All right. Thank you. Good afternoon. Thank you for joining us. My name is Elian. I'm a psychiatrist in New York City and faculty at Columbia. And I have the pleasure of having the easy job of being the moderator for this discussion rather than being the panelist. We have two great panelists, Dr. Dolores Malaspina and Dr. Paul Rosenfield. Dr. Malaspina is a psychiatrist. She's also an epidemiologist, geneticist, and she's conducting translational research on the antecedents and neurobiology of psychiatric disorders. She chaired the Research and Education Committee for the Presidential Committee on Social Determinants of Mental Health. And she also serves on the APA Research Council and the DSM Steering Committee. And she's on faculty at Sinai. And then Dr. Paul Rosenfield is the Director of Psychiatry Education and Training at Mount Sinai Morningside and Sinai West. And he's an Associate Professor of Psychiatry at the Mount Sinai School of Medicine. He attended Columbia and completed residency at UCSF and then did a public psychiatry fellowship at Columbia. And now we're going to start the discussion. So to guide the discussion, Elvis was super helpful in providing us with a set of questions to think about, but also would love to get some feedback and more questions from the audience so that we can keep this conversation going. So the first question that I'm going to ask our panelists is actually going to be directed at Paul Rosenfield first with input from Dr. Malaspina. When you think about the social determinants of mental health, in your perspective, how can they be effectively introduced in psychiatric curricula to build a foundational understanding of social determinants of mental health? Thanks, Elia. And thanks for having me on this panel. And I really apologize for not being able to join the rest of the afternoon. We had an interview day today. I was interviewing applicants for the program and just got to join in for just a couple minutes and now I'm back. But such great people here doing this amazing work. Pleasure to be here. So I think one of the things just in terms of introducing this topic to residents and training is having a place that values it, that recognizes the importance of understanding the social factors in mental health. And so building up a case for its importance through all the things that you've been talking about. I got to see a little bit of Dr. Jesse's talk and just sort of establishing epidemiology and the case for the importance of social determinants. And then finding spaces in the didactic curriculum to introduce these concepts and then to make it real in practice as well. And I think one of the ways that we do this, and I know other programs talk about the biopsychosocial formulation as a foundational way of putting together a holistic view of our patients. And that social piece is sometimes passed over. But I think if you really emphasize the relevance and importance, then the residents get an understanding through that introduction. And then also doing it in the clinical space. Doing a formulation of a patient that you're taking care of or using that in your case conferences where there's a discussant addressing those things. And also finding creative ways to teach about it and engage people going on field trips and seeing where people are living in a shelter or in a jail or getting services at a clubhouse or a residential program. Like those really introduce, okay, what's the living situation of our patients? And I can now picture them more fully in their social context. Well, I'm curious, in your experience, how have the residents accepted and how have the residents received the concept of social determinants of mental health? Have you gotten any pushback, any denial? I think what I've seen over the last, I've been program director eight years, I've seen more and more already pre-existing knowledge about it. They're learning about this in medical school now. So they are coming in with some, some of them have done research on social determinants of health and have an MPH from during medical school time. So there's a range of different levels of expertise, but people are more open and recognizing the importance of this. I think of that, I found the same, Ellie and Paul. I like to give the students or the residents that I teach an understanding that a hundred years ago, we were appreciative of the large increase in the risk for mental illness incidents in crowded inner city areas. Work was going on to understand the social forces that could cause psychiatric illness. Then after World War II, it became abundantly clear that this level of trauma was related to psychiatric outcomes. All of that changed though, with the new administration about 40 years ago and Ronald Reagan really redirected attention away from social forces toward the individual's brain and toward the individual's genetics. And I think we've proceeded along that direction for quite a while. I was glad Vivian Pender mentioned the book that that's been written by our real leader, Tom Insull of NIMH for a long time, who came to say, gee, we've studied so much about neurobiology and so much about genetics, but where are these diseases coming from? What's actually happening? What are these mechanisms? What can we do about? I would think that the horror of COVID, of the racist murders, of the outrage of people gave us a chance to be more holistic. It's not a swinging pendulum. It's not just genetics or just the environment, but both. And I think that students can really appreciate that. And maybe for their patients, don't start out so-and-so presented to the hospital with the following symptoms, where his HPI is just how many weeks since his last hospitalization. Tell us about a human being, right? Begin with a bit of a context. Who is this person? What is a little bit about their lived experience? Then maybe symptoms and diagnosis, but informed by it. So it really is a perspective that can illuminate so many things. And as you said, Paul, bringing people to the environment, to the community, I mean, that sounds so key to me. Thank you. Paul, any additional thoughts? Yeah, no, I was just thinking as Dolores was giving a historical overview, NIMH, I believe, started in that context of social research and sort of shifted as the brain took dominance and as the, also as the psychoanalysts were kicked out of the leadership roles in hospitals in the 80s and biological psychiatry took over. And, you know, so there has been that pendulum, but also, but I think that people, and actually I was thinking about Tanya Lerman's book she wrote in the early 2000s about psychiatric training and how even if they tried to integrate the biological and psychological, they were still separate sort of domains and they didn't really talk to one another. But she didn't even recognize the, you know, the social piece. So I think we have a more holistic view now, and I think there is more consensus on a holistic view. So we need to sort of develop our abilities to teach that and really use that in our work. Sorry, Ellie, I know you've got the most pressing question. I was just going to build a teeny bit further on what Paul said, and that is, you know, we escape from the nature versus nurture controversy finally, when we all said, well, there's epigenetics, you know, and that pushed people forward for a while. But I think what's even more compelling is that so much of the effect of early adversity in humans and across species is really a pro-inflammatory push, as if evolution decided if you're going to be a subordinate, you know, or not have access to the same resources, let me do you another favor. You know, maybe giving you a pro-inflammatory phenotype will cause some disorders later on, but you'll survive long enough. And I think understanding that trauma changes the expression of inflammatory genes, produces the array of the metabolic dysfunction, can help persons understand this shared biology as we see more and more psychiatric diseases having inflammatory underpinnings. And going back to what you were saying earlier with regards to the historical perspective, when you think about the ways psychiatric and mental health treatments were being offered in the past, it addressed a lot of the social determinants of health without calling them this way. But then with the advent of biological psychiatry and modern therapeutics, there's been a shift away from that. And now the thought is, if we're bringing that back into education and psychiatric residency training, it's not just about understanding why the person is who they are today, and then they're presenting with the symptoms that they're presenting with, but really how do we conceptualize their treatment, then formulating their treatment in a way that will be effective, not just to deal with the acute symptoms, but to kind of prevent further symptoms down the line. Yeah, there are the, you know, when we talk about the social determinants, on the one hand, we're thinking about early exposures that disadvantage this person, in many, many ways. But then we also, as clinicians, need to understand their current circumstances. You know, and I think Alan was talking nicely, and earlier, Vivian and Dilip as well, about like the person with cancer has to get to the clinic to be treated. And I know we prescribe medications, it's not that common that a psychiatrist asks, are you having trouble getting your medication, which would be the structural issue. Instead, are you taking them, which is asked in a more, you know, authoritarian, diminishing way. Yeah, but also like housing, you know, do you have housing available? Is your housing compromised? Do you have enough money to buy food? Do you have enough food till next week? Do you have access to fresh food and vegetables? You know, we talked, or I kind of went on and on again about inflammation as a result of early adversity. We have only one system in our body that's anti-inflammatory, and that is our gut microbiome. And persons who are disadvantaged from fresh fruit and vegetables in early life can have a dysbiosis that can drive other chronic conditions. So, fresh food now, but what about the food deserts? What's the lasting impact on the health of this generation and the next generation? I'm curious to see what direction is research going into now in terms of better understanding the social determinants of health and how they affect outcomes. Yeah, well, I think, you know, Dilip introduced a little of this, but, you know, certainly there is epigenetics, so that if I talk about changes in the production of expression of certain pro-inflammatory genes, that would be epigenetic changing their expression. But we also know the bone marrow shifts and produces more types of monocytes, so we can start piecing together that inflammation. Also, the idea of allostatic load, you know, this was Bruce McEwen's really groundbreaking concept because not all stress is bad. Some amount of stress is essential for our thinking, our planning, our responsivity, but stress can be more than a person can bear. You know, if you have schizophrenia, that might be a single parking ticket that puts you in that spiral and lands you in the hospital, right? People have different thresholds, not only for reacting to a stress, but for achieving equilibrium after the stress, for getting back to baseline. So the idea of the stress model is important. And we have mindfulness, you know, we can actually begin psychotherapeutically to help people calm down more quickly, to teach them how to recognize stress and center from it. We have a big push on mindfulness, right? How do you get out of that to-do loop, you know, or a severe stressor might have just happened, you know, and you want to be able to function and regroup and not just pull away. So these are skills we can teach people psychotherapeutically. I mean, I have in my practice a big focus as well on nutrition for all my patients, on gut health, multivitamins with minerals, and a little list of things that I would suggest. Really one of the biggest things in the room about the social determinants is the preterm birth, low birth weight, and bad birth outcomes of women who are Black and Brown or otherwise disadvantaged. So that is really a U.S. phenomenon. You know, Black persons in Africa don't have these horrible rates of early infant mortality, preterm birth, and low birth weight. So how do we start to understand that? Well, finally, we have this much better focus by the people who are taking care of pregnant women, but it's the life course of the woman up to that point, right, that gives her the health, the resilience to really kind of endure and have a good outcome in the pregnancy. I, when I teach schizophrenia, I ask how many medical students have heard of fetal programming, and none of them have. And that's such a surprise to me. Fetal programming is the Barker hypothesis. Barker was the scientist trying to understand cardiovascular death and pondering, these are obese grownups, could they have been fat babies, and discovering quite to the contrary that it was low birth weight and tininess that predicted later life obesity and cardiovascular death. That takes us to understanding that there's programming of the baby's genes, and that's happening in response to the mother's milieu. So overstressing moms, and I don't mean like not having them work. I mean, that's healthy stress very often, but other times those types of stress and adversity can really have a negative outcome on infant birth, and that can reverberate for quite a while. Psychiatric risk, attention risk, learning disability, and metabolic things can all be tied to that fetal programming. Thank you. Paul, in your work with your residents, have you seen any residents being interested in working on research projects or quality improvement projects related to social determinants of health? Or I guess the question is, is there a way to foster that kind of research among residents? Sure. Just a word about what Dolores was just saying, which is so wonderfully eloquent about the connection of the scientific understanding of why social determinants make an impact, because I think we can do the epidemiology, which is very powerful, and see the impact of those experiences, but to understand the science behind it, and the explanatory models that she shares are really powerful, and it's really great. So I think, sure, there are opportunities for thinking about, one project that we did was just trying to understand the prevalence of ACEs in our population, in our clinic, and so residents were involved in collecting the data. We actually introduced ACEs as sort of a standard intake questionnaire, so we could just collect the data without a research consent, and then look at the prevalence, and sort of make a case for how prevalent this is, and the connections of adverse outcomes, and to increase our training, and to just show the importance of that exploration in our clinics. And then we built some education based on that, and I think there's opportunities for residents to get involved in lots of different ways, and actually, as I'm interviewing applicants, they're already doing great projects in medical school. One applicant I just interviewed did a project looking at a state hospital records to see, that was a segregated black hospital, to see sort of what kinds of treatment was provided, and sort of what she came up with was a lot of the erasure of the voice of these patients. And there were very few notes, and very few efforts to understand the patients as people. So yeah, there's certainly many projects we can do. One other project that we've worked on is one of our residents created an interactive experience or game to teach about social determinants, and I'll actually, if I can just share my screen for one sec. This is a game where people roll the dice at the beginning of the game to see how many aces you get in life, and then they get four different characters who have different life stories with different levels of aces, and then pick cards that are different social determinants through the course of the game, and move forward or backwards, whether they have a good education or negative educational experience, bullying and discrimination in school versus positive role models, poor housing and, you know, a positive job, or, you know. So they move forward, backwards, and really get a very powerful telescope sort of version of understanding how social determinants of health and the background of aces impact the long-term course of the life of our patients, and they see these are like real patients from the clinic that they know and get to really get a personal experience with that. So yes, certainly other research and QI opportunities exist. Thank you. Yeah. I guess this kind of leads to the next question. The question is about the specific skills that the residents should learn that should be prioritized in psychiatric training, and this kind of relates to a question that we also got now from Ken Thompson, who says, given that the social drivers of our society produce psychiatric suffering, how might we imagine teaching psychiatrists how to take a public health approach to psychiatric challenges, including mental health promotion? Any questions on that? Yeah. So mental health promotion, yeah, I think we should be thinking about introducing public health and prevention, and what are the larger sort of ways that we can help improve the mental health? So I know like from Dolores' work, if you vaccinate for flu during pregnancy, you're going to decrease the risk of schizophrenia, so that's like a long-term preventive intervention. Maybe on Ken Thompson's work in creating community and creating social engagement and decreasing loneliness, certainly that's a huge impact on people's mental health, and as we saw in COVID, certainly the isolation of COVID has a big impact, and Vivek Murthy's work on this kind of impact of loneliness, I think we need to educate people about this and figure out ways to reduce that, lots of different ideas that he presents in his book and that we can think about together. And would this be the wellsprings of a national curriculum, Paul? Do people who are residency training directors, when they get together at their annual meetings, have they started sharing information on what the components of a national training program should be in psychiatry? So yeah, there's a lot of wonderful work at the residency directors' meetings, and Enrico has been a major figure in that and written really powerfully on sort of how we should be evaluating residents using a broader, you know, not just systems-based practice, but a broader understanding of how they think about social determinants. There have been, sort of, Adford has modeled curricula for different areas in psychiatry, including this, and actually the American Association of Community Psychiatry has put together sort of a model curriculum around community psychiatry, which includes structural competency, which includes social determinants of health, includes sort of learning about the different kinds of models of community care that are available, and so on. That are available as resources. But I think there's, I think there is room for making a more clear curriculum for social determinants and what we should all be learning, because I think there is a lot of variability in terms of the emphasis in different programs on more community and social psychiatry kinds of issues versus the more, you know, genetic and biological interventions and, you know, advances in psychiatry research on that level. Paul, are you aware of any movement towards, from the ACGME to integrate the social determinants of mental health in the milestones? So, as Enrico wrote about in a really great paper about this, you know, it's sort of touched on in systems-based practice, understanding how our patients interact with systems and how social factors influence them, but I think he convincedly argues that it's not really robust enough in terms of the expectation or the need to really understand the full context of social determinants of health. So, I don't believe there is any movement in ACGME to add a new competency. Enrico, maybe if he's here, could comment if there is any movement in sort of the RRC, which sometimes revises the milestones, which are the, you know, the different stages and expectations for training competencies. On that, you know, within the systems-based competency, that might be an area where there could be a compromise and adding more on that. So, I'm not sure if that's on the table right now. I'm sorry, Eli. But so much of this, you know, we're developing the physician competency to understand and consider it. It's separate, you know, first of all, from appreciating the cause of the causes. As I said, you know, how marginalization, racism, and certain policies can contribute to the disadvantage that we see in so many different ways. But then there's also the nature of the intervention for it. And someone pointed out that, you know, we as physicians, we're trained to work in multidisciplinary teams, you know, certainly on an inpatient unit. But addressing a person's social determinants might also take more of a multidisciplinary team than we have available to us as private practitioners or as residents in a clinic. So, I'm wondering, Paul, because you do such, you know, really a kind of a leader in trying to introduce this into training. Is there any way that the trainees kind of interact more with the social workers or, you know, try to take these on and solve these issues for patients? Um, yeah, I think, I think, in a hospital setting, in a residency training program, there is really an emphasis on teams. And, you know, an inpatient unit, you're working with social workers and other colleagues. And so that really is emphasized that collaboration and not just like, okay, how the social work stuff, but I, I think it's really important to work as a team to value what they, the knowledge that they have to learn about the resources oneself as a psychiatrist. I think that's, that's really essential. And, you know, I think like studies like NAVIGATE and RAISE show the importance of a team-based model for early psychosis treatment, right? And so we're not on our own doing this work. We should be working in collaboration. And I think residency training is a great opportunity to demonstrate that and to build that skill and get, you know, we have social workers do some of the teaching and have, learn about the resources. And, you know, we, we bring in as part of our like public psychiatry introduction, people who are working in the field of homeless outreach or care in forensic facilities or, you know, diversion from, from incarceration, if you have a mental illness and committed a crime. So lots of ways to think about all the different people that are working in a field where, you know, in addiction, KSAC workers or peers in, you know, peers have been really valued in much more in psychiatry. Now people with lived experience who provide support and guidance to other patients. I see we have a lot of, we have a lot of questions building up in our chat. Should we try to tackle it? Eric, Eric sent, Eric Rafayuan sent a question that's relevant to what we're talking about. He's saying that he's noticed that there's a lot of interest from trainees, but the problem is that the interest from the trainees is not matched by the availability or expertise of the faculty. And many times psychiatry departments do not have a deep faculty bench with expertise on these topics. So what can the APA do to help? Is the APA well positioned to help support departments to develop or retain faculty with this expertise and provide some offset on its own? Yeah, I would respond to that. You know, we need to train our field. We have an annual meeting. It needs to have some time dedicated to teaching the social determinants, to focus on the education only of the young, but of the clinicians themselves, right? Many were trained when the pendulum was just geared toward the diagnosis and the pill, you know, or the analysis of the person as opposed to more of the community. Maybe in some ways we need to take some of the silos away from the different subspecialties in psychiatry and have them all come together around the social determinants. That would be one way. But if we can lift the knowledge of our practitioners, that will influence the department. You know, when I hear it asked that way, I'm thinking, well, will there be a grant to departments to, you know, support an educator with more of an expertise in this area? I mean, how have you managed it, Paul, in your program? Yeah, just on the topic of the conferences, I think APA has done more with this. I mean, with this initiative and with Dr. Pender's work, and I mean, I think valuing that, I've seen it certainly more in conferences, even at the main APA conference, and of course, at the Mental Health Services Conference, that's much more of a focus. So I think that's great, but, you know, the full packed talks are the ones with like the latest drug and, you know, sometimes we need to make it more appealing somehow for people to learn and get excited about the role of social determinants so they can really do their best at their work. In terms of other ways of training and engaging faculty, I think it depends if you are at a more research-based institution where that is faculty that are more primary versus a more community-based institution, like where the faculty are joining a hospital because they're providing frontline community psychiatry care. So I think there's a range of different programs, but even at any of them, there's not enough depth in this, and I think so having grand rounds, having APA-sponsored, you know, meetings that focus on this, I think is really important. Perhaps, you know, MOC can do more with this, the topics, you know, of social determinants. I don't recall if there is specifically a social determinants topic in the MOC. I don't think so. I think they're mostly diagnosis-based, so that would be a really helpful way to add, you know, an opportunity to learn more. Read the papers as, you know, you have to read those and take some tests on that, and that would be a big advance. I wanted to ask you both on the use of real-life examples and teaching social determinants of health, and Vivian Penders asked a question related to this. She said, are you aware of any training programs that rely on home visits, especially for child and adolescent patients? How is that integrated in training? I think not so common from my understanding, but certainly a possibility. I think at Mount Sinai, there's actually a well-developed visiting doctors program, for mostly geriatric patients, I think, where the primary care doctors actually go to their home as part of the program, and I think in psychiatry, we're familiar with this, with ACT teams going out to people's homes and with, you know, case management going out to people's homes, mobile crisis going out to people's homes, and so to have residents and other trainees get involved in that, I think is a great way to give them that experience. Going with a mobile crisis to see someone's home, rather than just waiting until they come to the emergency room, seeing what their home looks like, seeing who else is in the home is a very powerful experience, and, you know, ACT teams are a great way to see where people are actually living and going out to meet them where they're at is, I think, really powerful. I'm not sure about the child and adolescent opportunities. I'm not as hooked into that world, but certainly a great idea to see the family in its own context, yeah. I think it also can be the culture of a department that every case conference include, you know, by the expert or the faculty member introducing or discussing a case, the social determinants. You know, we're used to giving a couple of small lines. What should the minimum be there? You know, we need to know what needs to be in those few sentences that are essential in introducing a person and then discussing their case and their interventions, and then to think of interventions beyond medication, right? Is it that another therapy is needed, that a home visit is needed, but we can model that, and I think we could get our faculty to model that even without bringing in an expert. So it's not as special as Vivian's suggestion of getting into the home, but we can at least try to understand the home from the person's perspective. I also see so often someone will present, you know, maybe in their twenties with some cognitive issues. A trainee and some faculty rarely will tell you if there's been a decline in this person's overall functioning. You know, you can see two people who look pretty much the same. One never graduated from high school and the other was in a PhD program, right? How do we understand deterioration and course and how does it fit in with social determinants? We're still just learning that. Maybe another area for a research study, Paul. I think just a really basic way to address this is if we utilize the biopsychosocial formulation in all presentations that, I mean, it's not perfect and, you know, there've been critiques of it, but I think it at least highlights the need to address the data from all those different domains. And if you're then addressing the domains in your formulation, then you have to address those domains in your treatment plan. It's not just, okay, medicine therapy, but medicine therapy and like, what's going on? Is this person, you know, have housing or food insecurity? Do they have, you know, interpersonal, all kinds of different things that we've been talking about and addressing those and not necessarily the psychiatrist has to solve all those problems. They might be able to refer them to resources and think about different options. But if we're not even thinking about it, we're gonna miss out on a lot of important pieces. So yeah, just, and just another point on the context, I always ask people to ask, you know, in the introduction to their interview, rather than, you know, what's your problem? What brought you here? Start with, you know, who are you? Where do you live? Who do you live with? What do you do during the day? How do you spend your time? And how do you support yourself? Because I think getting that context as the initial introduction to a person, A, reduces your focus on their pathology and more on their healthy aspects of them. And B, gives you a context for understanding who they are in their life. And, you know, just getting symptoms of, I feel depressed or anxious or whatever, like there's no context to put that in until you have a sense of who they are, where they're living, you know, are they stably housed and in a high-powered job? And are they living on the streets and, you know, living hand to mouth? So those are really helpful in getting towards this goal. Did it just ask an interesting question? He's asking about like, because the two of you are talking about training for residents, Dolores, you talked a little bit about medical students, but what about in a psychiatric fellowship training? What's happening there as far as you know? Yeah, I think, I mean, I think some are naturally inclined to think about this. Forensics and addiction in particular are really very attuned to these issues because those are the populations they're working with and they know that this is not just a, you know, straightforward diagnosis that you need to make and then that's all you need to do. They're caught up in a web of, you know, forensic, you know, incarceration and addiction has so many different factors. And I think also geriatric, like awareness of loneliness as one of the major risk factors has increased and child psych, I think people really get a sense of families is so important and adverse experiences and school environment and all that. So I think there is, certainly part of the work requires that and I think maybe more naturally included, although certainly some places probably do it more and better than others. Yeah, one thing I can say about this is at Columbia, both in the, I'm involved both with the addiction and the forensic fellowship and social determinants of health have been a, I don't wanna say a major part of our fellowship training, but a significant part, it's coming up in all sorts of didactics and it's coming up in forensic evaluations, especially in mitigation types of evaluation when we have a criminal defendant who develops an addiction or who's engaging in criminal behaviors and there's a mental health component to it. What we're seeing, I personally have used social determinants of health in forensic evaluation in these kinds of contexts and we've been talking about them with the fellows. It's received pretty well so far. The other fellowship that I think would benefit a lot from a focus on social determinants of health is child and adolescent fellowships. Dolores, are you aware of anything that's happening there? Did you say adolescent fellowships, Ellie? I missed the word. Child and adolescent. Yeah, yeah. I can't say specifically, but it did bring to mind even the clinical research fellowships in schizophrenia, right? And I'm thinking of different grants that I've seen go by when I've been a grant reviewer and the bias that we've had toward the very biological quantitative information where we're always limited by the scale we're going to use or the assessment instrument and less qualitative work. I would like to think that that is changing, that there is more appreciated value to people who are talking about microaggression and its erosion of health, which is so, so key. Maybe then previously, you could talk about a hit on the head, but not a hit on the heart or soul, you know? So we're moving to this broader spectrum. The child and adolescent research fellowship would probably be different than child and adolescent training, but I do have an optimistic view that we're appreciating that the science of social determinants is real science. It's not some squishy little thing we can't describe or we can explain away. And I think the more we study human responses to trauma, we see that a lot of them are conserved all the way down to vertebrate fissures. This is real biology of how a group of conspecifics survives adversity, you know? And I hope that brings it much more to knowing we can do things. Of course, we can prevent things, but what might be new interventions that can target particular epigenetics or target some master inflammatory pathway? You know, there can be new interventions, even if the horse is out of the barn already by the time we understand someone's suffering. So that makes me optimistic. I do hear more of that language from people who previously would only have a gene in mind. I have another question from Eric, roughly one. He's saying that there's a general consensus on the importance of translational research and applying findings to clinical practice, but this has been much slower in the social determinants of health area where research on various factors is much more robust than how to intervene on them in an evidence-based way. And Eric is asking about what kind of support would be helpful for this kind of research to move forward, specifically whether the APA can support trainees and in what ways the APA could support trainees interested in these areas. I would say, Pat, that translational research does also include findings from epidemiology that can be brought to the clinical interface. So I think there's room in that model to understand what a trauma does to a cell circuit or to brain development, to understand the age of the trauma and its relevance. So maybe we're not yet at the clinical interface to treat people, but we're seeing more and more like what is the result of repeated early trauma? It has some effect on white matter, depending on the age. It has some effect even on bone density, probably if there's a lot of glucocorticoids. So we're starting to see what does the evidence at the individual reflect about those exposures. But, Elie, you're thinking more of bringing it to a person and intervening, which sounds much more exciting. I wonder if you ever thought about that. Elie or me? Elie, but Paul, you can respond as well. I mean, because these are the exciting next ideas. So we're thinking about training, but we're also thinking about themes to train our research awardees. Say about like intervention programs is the application of the sequential intercept model to the social determinants of health. So sequential intercept model is a model that is focused on finding different intercept points for people who are involved in the justice systems and offering different types of interventions at different levels. So at the community level before any criminal exposure or at the police level, at the court level, at the re-entry in jail or incarceration. And a lot of these interventions were capturing individuals who otherwise would not enter our clinics otherwise. A lot of these interventions are not straightforward medicating the person or hospitalizing them, but it involves addressing the social determinants that shape the health differentials they experience and their likelihood of engaging in criminal recidivism. Obviously that's a much more forensically focused type of intervention, but there certainly is a lot more room for research in that area. Yeah, I think in terms of supporting trainees, the fellowships that the APA provides, I think it's a really powerful way, even though it's only a few people, but it demonstrates that value and allows people who are really interested to have exposure and be supported and mentored. I think if we could bring more trainees to the APA, I think that would be a great way to get them involved or the Mental Health Services Conference. Maybe connecting mentors. If someone doesn't have a mentor in their own institution, APA could be a clearinghouse for mentorship in these areas. Just a couple of thoughts. We've talked about education at different levels, right? Medical school, residency, fellowship, but what about psychiatrists who are not in training anymore? What are your thoughts on continuing medical education to help psychiatrists be informed of a social determinants of health? Yeah, I think we touched on maybe the maintenance of certification as one avenue because everyone has to do that and whether they take the test or do the articles. I think, I don't know actually what the numbers are, what people decide for their renewals, but I'm doing the articles and there are a lot of great things in there, but I think if I recall that I don't think that's a specific category of a topic of social determinants so I think that would be really a great way. And what else? Well, we talked about the national meetings. Yeah. Oh, and really we could highlight in our program book, you know, more important than a gene for the average person are these life course exposures, you know, how do you assess it? What can you do about it? You know, so we could try to make that one of the themes I know that get illuminated of different talks that resonate on it. They may already be so, but I hadn't noticed that. So it really stands out as an area of expertise people should aspire to. Thank you. Any more questions, Elie, that you wanna take? Okay. A lot of questions, but I really appreciate everything that the two of you shared with us. Did you have any closing? Yeah, just one thought, one of the questions that Elvis had shared was just what challenges have you encountered and how to overcome those? And I think one challenge in this area really is the demoralization that people can feel when they are confronted with all these social determinants that they do not have much control over. And so, you know, if it's overwhelming and they don't have a way to address it, then they might not ask for much about it because they don't wanna know or they don't wanna have to feel impotent in their role if they can, you know, give a medication for depression or have a treatment plan for a particular diagnosis that's much more in the standard, you know, textbook. But I think that's why we need to equip them with better understanding and understanding of the resources that are available. There are a bunch of different resources that are available. And then I think some places do this really well in terms of advocacy, thinking about how can they feel more empowered by having an advocacy role, whether going to lobby in front of a, you know, political party or whether to do research that is advocacy, whether to work on a particular project that increases access to care. So doing asylum work, which is, you know, asylum evaluations, which is a way of addressing, you know, the person's problem is their inability to live safely in their country of origin. And so that is a huge social determinant, the war or whatever is going on, or the discrimination or sexual orientation or whatever the different things are. And I think people doing that kind of work can really make a big impact. So I think feeling like we can empower our trainees to have an impact on social determinants is really crucial and needs to be on top of just learning about them and how they impact our patients. Thank you. Dolores, did you have any closing thoughts? No, I think that was so well said because ultimately, you know, it really takes policy changes for the cause of the causes. And we're making our trainees and our fellow psychiatrists much more aware of the impact of these adversities, but the solutions to them will be bigger. They will be the community or the state or advocating for other changes. Yeah, and I love, I always show when I'm teaching about this, the table or diagram that Uru Shim and Michael Compton have about sort of social determinants and the outcomes, but underlying all that is policies and social norms that drive those and whether it's racism or whether it's, you know, the child tax credit or redlining or, you know, all the different policies that have huge, tremendous downstream impact on our patients' wellbeing and mental health and physical health. We're actually gonna have one of our pulmonary colleagues give a grand rounds coming up. She's looked at redlining and how it impacts breath, like, you know, air pollution impacts health and nutrition access. And so she's gonna apply that to mental health as well. And I think how redlining sort of overlays all these different outcomes in health and even after years of, since that was done, those neighborhoods still remain. And so really a lot of creative ways to teach this and empower the trainees to feel like they can make a difference, I should say. Well, thank you both. Elvis, back to you.

psychiatric education

social determinants

biopsychosocial model

clinical practice

genetics

residency programs

advocacy

community contexts

evolutionary biology