Yale Psychiatry Grand Rounds: September 8, 2023

September 08, 2023

Information

Global Mental Health and Health Equity

Speakers: Sirikanya Chiraroekmongkon, MD; Yang Jae Lee, MD; Marcos Moreno, MD; and Matthew Basilico, MD, PhD

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00:00To be here today and let me just start
00:04by sharing my screen and then I'll,
00:06I guess I'll introduce people.
00:08So my name is Sonia.
00:10My full name is Sierra Ganya Girala Monkon.
00:12I'm a fourth year psychiatry resident here.
00:15I've been the resident leader of
00:17the global mental health program for
00:19three years and I'm stepping down.
00:22And the three resident leaders
00:24coming up are Marcos, Jay and Matt,
00:26who are all presenting today.
00:28And they're really, really spectacular
00:31and wonderful and compassionate.
00:33So very excited to have
00:34them on the leadership.
00:36And I will start with our presentation.
00:41All right. If there's any hiccups,
00:44please let me know because
00:46I won't be able to see us.
00:50All right.
00:52So the table of contents today I'll
00:55be introducing the Yale Global of the
00:58introduction to global mental Health,
01:00spending about 20 minutes on
01:01that briefly going over the Yale
01:02Global Mental Health Program.
01:04And then the three residents will be
01:06talking about their capstone projects.
01:08So our objectives today,
01:09we want to define global mental
01:11health and HealthEquity.
01:13We want to discuss some key principles
01:15in bidirectional learning and global
01:17mental health and then we'll be
01:19discussing the wonderful academic projects,
01:22no disclosures for any of us.
01:24And so we're getting started with
01:26the introduction global Mental
01:28Health and HealthEquity.
01:29I want to let you guys know that I'm taking
01:33you guys on a little bit of a journey,
01:35a little bit of a story this morning.
01:37So I want us to to hopefully
01:41have our minds open and sort of
01:43take us where the journey goes.
01:45And I'm going to pose a lot of questions
01:47and unfortunately due to time constraints,
01:49I won't be able to get audience answers.
01:52But these questions are not by all
01:55means limited to just this talk,
01:57but continued discussion,
01:59hopefully for the future as well.
02:03So global mental health,
02:04it's an area for study,
02:06research and practice that places
02:08a priority on improving mental
02:10health and achieving equity in
02:12health for all people worldwide.
02:14That's The Lancet definition.
02:18In our history,
02:19there's been significant changes that's
02:21been made in the world's mental health care.
02:23So I do want to acknowledge
02:25that that we've come a long way.
02:26Even in my lifetime alone,
02:28we've certainly come a long way.
02:30And a big part of that is how much
02:32we care about our mental health now
02:35and how much is talked about now.
02:37So this is a quote from a current
02:40psychiatric mental health practitioner
02:43I knew.
02:44My father was hospitalized for
02:45mental health issues in the 1970s.
02:48He's passed now.
02:49We didn't talk about it back then.
02:51It's still weird for me to talk about it now.
02:53There was so much shame and guilt.
02:56I knew that he was hospitalized
02:58for mental health reasons,
02:59but I didn't know anything else.
03:02So I think this is beautiful quote
03:05that really depicts how mental
03:08illness was really not talked about
03:11and how even family members who love
03:14individuals suffering so much are
03:17were unable to help them in the
03:20way that they really wanted to.
03:23So our present, you know,
03:24there's certainly still a way to go
03:27in our world's mental health care.
03:29This is by The Who.
03:31One in eight individuals live
03:33with a mental health condition.
03:3571% of people with psychosis do
03:37not receive mental health services
03:39and only 2% of health budgets.
03:41So 2% of the health budgets,
03:44not the whole budget,
03:45but the health budgets on
03:47average go to mental health.
03:49So it's certainly widespread,
03:51undertreated and under resourced.
03:54And this is a term that's been
03:57coined a failure of humanity
04:00not only on a systemic level,
04:01but certainly on a 1 to 1 interaction
04:04and every day especially on a
04:07everyday life interaction as well.
04:10So when we think of global mental health,
04:13I think we normally think about going
04:16internationally and practicing in
04:17a low middle income country to help
04:21and to save and to create systemic
04:23changes in those countries that we
04:25think of as having less resources.
04:28So more than 85% of the world's
04:31population do live in a low and
04:33middle income country and more than
04:3580% of people who do have mental
04:37disorders are residing in low and
04:40middle income country just by virtue
04:42of having higher population alone.
04:44And by Doctor Patel,
04:46the most striking in equity is
04:48that concerning the disparities in
04:51provision of care and respect for
04:53human rights of people living in
04:56with mental disorders between high
04:58and low and middle income countries.
05:00So certainly there is a huge in
05:03equity and disparity in the care
05:06and the services that are able
05:08to be provided between high and
05:10low and middle income countries.
05:12So when I show these kind of statistics
05:14or when these kind of statistics are shown,
05:16I think it easily leads us to
05:19believe that oh,
05:20maybe we're doing better off
05:21in the United States or maybe,
05:24oh,
05:24at least we're doing better than
05:26in low and middle income country.
05:28So that could be a very common
05:30perception and that certainly
05:32was my own perception as well.
05:34So I just wanted to dive a
05:36little bit more into that.
05:37More than 70% of Americans say that
05:40the US stand above all other countries
05:42in the world or is one of the greatest
05:45countries along with some other countries,
05:47a U.S.
05:48Department of Defense News article noted.
05:51A number of African countries are
05:52among the most fragile in the world.
05:55These countries have ungoverned or
05:57little governed areas and that attracts
06:00violent extremist organizations which
06:02capitalize on economic and political
06:05dysfunction to extend their reach.
06:07These governments are in are in need of help,
06:11so I want to highlight these
06:14very common statements.
06:15the US stand above all other countries.
06:18Africa countries are most
06:19fragile and they need help.
06:21So this view is certainly pervasive
06:24in almost every area of practice
06:27we have and certainly extensively
06:29pervasive in global mental health
06:32whether consciously or unconsciously.
06:35And I am posing and many others that
06:38this may be rooted in white supremacy
06:41and white savior complex and this is
06:44certainly a mindset that I had coming
06:47into the residency program that oh I need
06:49to go to someone somewhere in Africa
06:52to help them because they need help.
06:55So I'm certainly this is this was certainly
06:59pervasive in my thought process as well
07:02some more statistics for you guys.
07:04So they did an analysis of over
07:0675,000 research grants 90 more than
07:1098% of mental research.
07:11Mental health research is funded by
07:14high income countries and less than
07:165% of research funding is conducted
07:18in low and middle income country.
07:20So you know this high discrepancy of
07:23where research is actually being funded.
07:26And even when the research is funded
07:28in a low middle income country,
07:30it's usually led by researchers from
07:32or based in high income countries.
07:34And certainly this father reinforces the
07:39power asymmetry that currently exists today.
07:43So I did a dive of a basic Google search
07:45and I just wrote in Google Mental Health
07:48and and I put in a name of a country.
07:50So this list is a high income country.
07:53So like Australia, the UK,
07:54the US, New Zealand,
07:56and these were the pictures that
07:59came up in my Google searches.
08:01They're all numbers,
08:02they're all words and they're all statistics.
08:05And when I did the same thing and I
08:08did a Google search of mental health
08:10in and I put in a low income country,
08:12So South Africa,
08:13which is not exactly a low income country,
08:17Bangladesh and Nigeria.
08:20So this is the images that are
08:25pervasive when we're thinking about
08:27mental health in low income countries.
08:29And it may invoke us to think, wow,
08:31they're really suffering over there,
08:34they really need our help.
08:37How can this happen to someone else?
08:39How can we do something like this, right?
08:41Whereas when we're looking at these
08:43kind of images, it can show, oh, maybe,
08:48you know, they do have struggles,
08:50but maybe, like,
08:51they're really addressing these struggles.
08:54There's models of care,
08:55there's logic models,
08:57there's all these beautiful bar graphs.
09:00So they're really actively trying
09:02to address this concern.
09:04So it could seem you can really
09:06seem that way.
09:09So I did another Google search and this time
09:11I put life in rather than mental health,
09:14justice, overall life, life in Bangladesh.
09:18This is the first image that comes
09:20up children next to garbage.
09:22And one might evoke from this emotion that,
09:28wow, how can these kids be
09:29living in such a poor condition?
09:32It's so dirty, it's so impoverished.
09:35This is a picture in Laos.
09:37This little girl's cute and smiling.
09:40Laos is a neighboring country
09:42to Thailand where I'm from,
09:43and so this picture reminds me of myself.
09:47But this is the little girl is in
09:49mud and you know, she's so cute.
09:51Maybe she needs our help.
09:53And actually, when I looked on the website,
09:56it was of of an American going to
09:59Laos and listing all the things,
10:02all the statistics of Laos and how
10:05one man can truly change the world
10:08and really help alleviate poverty
10:10by changes in policy and changes
10:14in implementation worldwide.
10:16This is the first picture that
10:18pops up life in Chad.
10:19So this one is still of children.
10:23Something about children being
10:24depicted in images for some reason.
10:26And you may think, wow,
10:28they don't have a toilet,
10:29they don't have functioning
10:31bathroom and they're outside the
10:33Hut like washing their hands,
10:36you know, this is the hot sun.
10:38Oh my goodness, like these these poor kids.
10:43And then this one is life in America.
10:46So again,
10:48a child smiling child,
10:52which is different from the other photos
10:56and really industrialized well manicured
10:59houses and fences and properties.
11:02So this website was actually
11:05a website that said, oh,
11:08this is how you can immigrate to America,
11:11come live with us.
11:12Life in America is really wonderful.
11:14These are all the wonderful
11:16things about America.
11:17And this is how you can get a visa.
11:19So that was the first Google image search.
11:24So, you know, power and privilege
11:28is certainly the current state
11:29of things in today's world.
11:31And I want to emphasize that that doesn't
11:36only come from the high income countries.
11:39And so it's not only the US that's
11:41saying we need to go to these other
11:44countries and really help them and
11:46really build up their capacity,
11:48but it also comes from low income
11:50countries who have internalized,
11:52oh, maybe I am worse off and I do
11:55need help and I really do need,
11:58you know, the technological advances
12:00or the medical advances of the
12:02Western world to to bring that in,
12:05to really help us go to the next level.
12:08So that's certainly the current
12:11thought process that's pervasive
12:12in a lot of us today.
12:15And that may be rude in white
12:19supremacy and saviorism,
12:20lack of diversity, equity and inclusion,
12:23the history of colonialism,
12:26the forever foreign gays that you
12:28can never really be one of us.
12:29Patriarchy and racism.
12:33Because I think, you know,
12:37we all know as mental healthcare
12:39practitioners that there is another
12:41important reality in the United
12:43States that is certainly not widely
12:45advertised or not widely depicted.
12:49And this is something that makes
12:51us feel really uncomfortable.
12:53So this is a prison in the United States.
12:57This is an individual with homelessness.
13:00In Chicago,
13:01I had to do a really,
13:04really specific Google search
13:06to find these images.
13:08This is actually a woman in New
13:11Haven struggling with homelessness.
13:13And this is actually a picture
13:15from my personal archive.
13:17We don't see a lot of pictures
13:20of Asian Americans struggling,
13:22and I think it really further contributes
13:25to the invisibility that we have.
13:28So this picture is actually of my mom
13:31in the hospital with schizophrenia.
13:35This is in the New Haven Green.
13:38This is in the prison in Kentucky.
13:42This is also in the prison in Kentucky,
13:47and a statistic is that at any given time,
13:52there are many more people with
13:55untreated severe psychiatric illnesses
13:57living on America's streets than
13:59are receiving care in hospitals.
14:02And over 1/3 of individuals
14:05in prisons and experiencing
14:07homelessness have a mental illness.
14:10And sometimes we may want
14:13to comfort ourselves with,
14:15oh at least we're better off than
14:18individuals in those other countries.
14:20But I want to ask you guys, are we really?
14:24Is that the the whole story?
14:28So another important reality
14:31in low middle income countries.
14:35This is a really beautiful picture.
14:38It's a power of the community in Nigeria.
14:41This one is in Bangladesh again,
14:44the power of the community.
14:47And this one is my personal favorite.
14:49This one is in Laos.
14:51Certainly reminds me of how I grew
14:54up and the childhood that I had
14:58there in Thailand close to Laos.
15:00And then I just, I'm such a proud big sister,
15:03and this is my little sister.
15:05She's so unapologically herself
15:07and she I think really has taught
15:09me to be more that way and she's
15:12my role model in many ways.
15:13So this is certainly another
15:17reality that's not often depicted
15:19in low middle income countries.
15:23And then these are some last slides
15:26with statistics for all of us.
15:28So the global prevalence of mental disorders,
15:31this was published by The Who in 2019.
15:34So 13% of global population is
15:37living with mental disorders.
15:39And when we zoom in by economic growth,
15:43it's interesting because more than 15%
15:48this is the high income country and
15:51then a little bit over 10% that's the
15:54prevalence in the low income country.
15:56So actually, you know high income countries
15:59have a higher prevalence in mental
16:02disorders than low income countries do.
16:05And why might that be and what
16:08might explain this difference?
16:10Perhaps there's under diagnosis
16:13in low low income countries due
16:16to less accessible services.
16:19And then the WH O's also notes that
16:22maybe their demographic factors like
16:24low income country tends to have higher
16:27population proportion of children under
16:29the age of 10 and in that population
16:32mental disorders are less common.
16:34And then this is something I would
16:37like to ask all of us is what about
16:40factors in high income countries
16:42that could contribute to higher
16:44prevalence of mental disorders?
16:46Are there factors and if
16:48So what are the factors?
16:52This is prevalence again,
16:54but this time by regions.
16:57Notice again in the Americas we have
17:00the highest prevalence and then Africa
17:04has the lowest prevalence and for some
17:08reason this statistic is in the 100
17:11page WHO report and not easily found,
17:14not found in a Google image search actually.
17:18And this is this is also another
17:22statistic and reality that that is
17:24true that in America we have a higher
17:27prevalence whatever the reason may be
17:29and in Africa they have the lowest,
17:31lowest prevalence of all regions.
17:34So I'm asking us have we been
17:36telling ourselves the whole story.
17:41So I haven't been able to test this yet
17:43but some of the hypothesis that I have
17:46is that there may be factors in high
17:48income countries that contribute to
17:50higher prevalence of mental disorders.
17:52So things like need and drive for
17:54productivity and equating one's
17:56value and one's self worth with
17:58one's job and productivity.
18:00And then the other side to that
18:02is with the lower prevalence in
18:04Africa and low income countries,
18:06is there prevention?
18:07I don't believe that there is a cure,
18:11but I really do think there is
18:15prevention there and prevention
18:17to mental disorders makes this,
18:19but perhaps it is not yet quantified
18:21or perhaps it's not something
18:24that's even quantifiable.
18:25So maybe that's why it's not so
18:28advertised or so acknowledged.
18:31And some of these factors that are
18:33preventative to mental disorders,
18:35maybe community and family,
18:37sense of interconnectedness and
18:39responsibility to another's wellbeing,
18:42sense of belonging,
18:44lack of the need for urgency,
18:46living more in the moment,
18:49and maybe even dealing with
18:51life's inconveniences like hand
18:53washing your clothes.
18:54Like it's actually one of my
18:57favorite memories growing up in
18:58Thailand was hand washing my clothes.
19:00And I think when I tell
19:02that story to people here,
19:03it it just brings an image
19:05of them being like, oh,
19:06you must have been poor and struggling.
19:08But for me it was actually something
19:10like I love doing and it was a
19:13responsibility that I felt that
19:15I was really proud of because
19:16I was helping my household.
19:21So this is a quote that I heard a long time
19:24ago that still stays with me to today.
19:26Make what is important measurable and
19:29not what is measurable, important.
19:33And some last food for thought going back
19:36to these pictures of the statistics is,
19:38you know, I discussed with you guys
19:40about the potential harm that's done
19:42when we're only focusing on the
19:44bad in low middle income countries.
19:46So potential harm like further
19:49oppression and further devaluation.
19:51But with us having mainly these pictures,
19:55is there also harm done to
19:58us by thinking this way?
20:01And if so, what is the harm?
20:03And why might we have depicted mental
20:07health as statistics rather than personhood?
20:12So also another hypothesis is just that
20:15it makes our humanity less acknowledged.
20:19Certainly in the US,
20:20and it makes our suffering and our
20:23clients and our family members
20:25and our patients or ourselves.
20:27It makes our sufferings less acknowledged.
20:30And these statistics may be
20:32because they help ease our
20:34uncomfortability with human suffering.
20:39So our future, you know,
20:40if we can conceptualize that there are
20:42things in the US that we're good at
20:44and there are things in low and middle
20:46income countries that they excel at,
20:48then we might be able to benefit
20:50and really truly learn from one
20:52another a bidirectional partnership
20:54rooted in mutual respect and value.
21:00I know I'm running out of time,
21:01but these are some really amazing programs.
21:04This one is the friendship bench in
21:06Zimbabwe and it's a task sharing approach.
21:08Basically, these grandmothers sit in
21:10front of a bench right in front of
21:12a community Health Center where they
21:13can provide mental health services and
21:15the grandmothers are trained in basic
21:17CBT and anyone in the community can
21:20sit on the bench to provide this care.
21:23And the numbers are 14% of patients in
21:26friendship bench experience symptoms
21:28of depression after six months
21:29compared to 50% standard of care.
21:31And with standard of care means they
21:33went into the community Health Center
21:36themselves and either had medication or
21:39treatment by a trained psychologist or both.
21:42So 12% with anxiety compared to 48% in
21:46standard of care and 2% with suicidal
21:48thoughts compared to 12% in standard of care.
21:51So what is going on that these
21:54grandmothers are doing such an amazing
21:57job and perhaps even more improvement
22:00than community health infrastructure?
22:02And the other interesting thing is
22:05that they actually did this study with
22:09grandfathers sitting on the bench and
22:11the numbers were not as good when the
22:15grandfathers were sitting on the bench.
22:17So something about grandmothers
22:19and community this one is a dream
22:22of world Jamaica.
22:23They went to the school,
22:24did a multimodal therapy intervention,
22:28training both teachers and children,
22:31and actually the primary school they
22:33piloted out went from being the worst
22:35to being one of the best programs,
22:37the best schools in the country.
22:39Then this is the last statistics,
22:42mental health research.
22:44The majority of our funding goes into
22:47basic research at theology and underpinning,
22:50and only 7% goes into prevention.
22:54So why might be that we want to invest
22:56so much of it into basic research?
23:02So a brief overview of our
23:06global mental health program.
23:07We have two arms, the Resident Distinction
23:09Pathway and the Seminar Series.
23:11With our seminar series,
23:13I think we've been extremely successful.
23:15They've been zoom and hybrid.
23:17We've been trying to really emphasize
23:19community health leaders from their home
23:22country rather than the traditional
23:23model of someone in the US going abroad.
23:25So we had, you know, doctors,
23:27Banda from the friendship bench along
23:31with many other wonderful speakers.
23:33We also had cosponsored the Muslim
23:36Mental Health Conference in 2022.
23:37That was also very successful
23:39as well and highly educational.
23:41Our inaugural resident distinction
23:43pathway has four residents in it,
23:46Yvonne, Paul, myself and Enoch.
23:49And then this year of course is our
23:52three residents that we presenting
23:54today and this is our leadership
23:55team for the last three years.
23:57I just want to say they've been amazing
23:59and wonderful and such a pleasure to work
24:02with and I'm so grateful for the experience.
24:05And our acknowledgement,
24:06of course is to our former faculty leaders,
24:10resident leaders,
24:11school of public health leaders
24:13and community volunteers.
24:14We certainly could not have done any of this
24:16without you guys and growing the program,
24:19you know,
24:19since Doctor Robot started in 2008.
24:22So without further ado,
24:24I will stop my share and hand it over to Max.
24:31Thank you so much, Sonia.
24:33Just going to pull up my slides quickly.
24:44So really honored to to speak with all
24:47of you today and follows the incredible
24:50work that Sonya and and others have done
24:54at Yale and and to build presence of of
24:56gold mental health here which we think
24:58of the definition of global health.
25:00It probably extends to essentially every
25:03activity that that our department does.
25:06But I'm going to offer just a flavor
25:09of some things that I've been working,
25:12working on, thinking about and we were
25:14asked to give just a little bit of history
25:16into what brought us into this field,
25:18how we kind of came to identify with
25:20with with global health and my story.
25:24I would I would take back to when I was
25:2718 and I actually had decided not to
25:30go straight to college and to pursue
25:32a career as a professional athletes.
25:34But I was, I was also in a jazz band
25:36in that that Jasmine we were on tour
25:39in South Africa and it was actually
25:41at this particular place which is
25:43a casino called Sun City.
25:45And we've been mostly improvising with
25:48local groups and Township schools etcetera.
25:52And despite language barriers you
25:55know jazz music offers a chance for
25:58your human connection that that can
26:01kind of transcend a you know many
26:03many other types of social barriers.
26:06And so kind of recognizing that all
26:08at once you know the just incredible
26:10similarities that we share while these
26:13just unbelievable economic and health
26:15inequalities that that related on top.
26:18So it was actually right here at
26:20this casino that the just.
26:22The overwhelming level of inequality
26:26in health and economic outcomes
26:29really struck me.
26:30And I decided to,
26:32on that day become a doctor and if I could.
26:35And so it kind of ended up shifting
26:37my career towards medicine and ended
26:38up pursuing a PhD in economics to
26:40try to understand inequality better.
26:45So I I ended up spending a
26:48couple of years living in Malawi,
26:49spent my my summers working with partners
26:52in Health and which is a group like
26:55Doctors at Borders in in Haiti and Rwanda.
26:58I work for the president of the
27:00World Bank for a couple years and
27:02like I said it kind of develops
27:06expertise in history of science,
27:08medicine and and economics.
27:10Doing a piece in Economics at Harvard.
27:15Currently I serve on 2 faculties
27:18at Harvard in a parttime role,
27:20one at the Department of Global
27:21Health and Social Medicine,
27:22the other in Department Economics.
27:24I had the privilege of writing a
27:27textbook when I was just out of college
27:30with Paul Farmer who's passed away.
27:31Jim Kim who is the former president
27:33of the World Bank and Arthur Kleinman
27:35who's a well known psychiatrist
27:38trying to kind of reintroduce the
27:41field along several the the the
27:43lines of post colonial thinking
27:45that Sonia mentioned and that's you
27:48know continue to be a either number
27:51one or two most used textbook in
27:54in the field of global health.
27:56I also teach a lecture course between
27:59100 and 200 students on the economics
28:01of development and global health,
28:02kind of taking a deep historical
28:04look at why we have the types
28:06of inequalities that we have.
28:07And also as as Sonia mentioned
28:09that the levels of happiness,
28:11the types of,
28:12you know,
28:13social outcomes,
28:14I think economists expected haven't really
28:17kept pace with with with economic models.
28:21I mentioned all this is by way of saying
28:23that I I come as well from a kind of
28:25general global health orientation.
28:26And I I think it's more and more
28:29true that the types of problems
28:30and questions that we ask in
28:32global mental health are really
28:34the questions of global health and
28:36and global policy in the future.
28:38We just unfortunately lost Paul Farmer,
28:41who is the chair of the Department
28:43Health and global part of global
28:44health and social Medicine,
28:45a real pioneer in the field.
28:47And there was a kind of long extensive
28:51search and real soul search to see
28:53kind of who would be the future
28:56leader of this department and in a
28:58lot of kind of the the top names
29:00and global health considered and
29:01and the community really landed on
29:04a psychiatrist Vikram Patel who has
29:06been a real pioneer in in the global
29:09mental health space asking you know
29:11exactly the type of questions that
29:12that Sonia covered in in terms of
29:14you know community based supports
29:16you know treatment of common mental
29:18health disorders and and and how
29:19do we really understand you know
29:21the the relationships between power
29:23equity access and and mental health.
29:25And so I I think that you know certainly the,
29:28the,
29:28the words I get from my my colleagues
29:30are that this,
29:31this which often considered a small
29:33field in psychiatry department is
29:35really kind of the future of a lot
29:37of these these big questions
29:39and and and health and as you'll see
29:41hopefully in this brief talk of the economy.
29:44So I'll just check briefly about a couple
29:47presentations I did at the American
29:49Psychiatric Association last year,
29:51which are taking on a question that's
29:55very well known in macroeconomics
29:57called the Eastern paradox.
29:59And it's simply the finding that mean
30:02country income does not increase as,
30:06sorry, mean country wellbeing does not
30:08increase as mean country income increases.
30:10And that might sound like a simple statement,
30:13but it's it's pretty shocking in
30:15regards to most macroeconomic models.
30:17We assume that increasing income
30:19should make people feel better,
30:21should pay people better off
30:22on a country level.
30:23We do see that income
30:25correlates with wellbeing,
30:26but unfortunately we see that as
30:28countries grow they tend to not,
30:30you know, be on average better off.
30:32And so this has been implications for
30:34global health, for mental health.
30:35It's often pointed this is maybe one of the
30:38the key questions environmental economics,
30:40because we are essentially
30:42destroying the environment as an
30:44externality of economic growth,
30:45but that growth is not
30:48really producing well-being.
30:49It leaves a lot of questions in tow.
30:52It's related to a similar puzzle
30:54on the attack that I'm gonna take
30:57which is economists that have gone
30:59in search for explanations for the
31:01modern opioid epidemic and increase
31:03in all cause mortality have really
31:04landed back in the mule.
31:06Durkheim's theory of anime essentially
31:09saying there seems to be something
31:11that goes wrong when when society
31:14has some type of fracture to its
31:16core notions of identity.
31:18And this is seen not just in the
31:20prevalence of particular disorder,
31:21but several things happening
31:22at the same time.
31:24Whether that's deaths of despair,
31:26this, you know, alcohol, liver disease,
31:28suicide overdose, death,
31:29but also changes in political psychology,
31:31increases in authoritarianism,
31:32which is what the Frankfort
31:34school was very focused on,
31:35was not Sierra.
31:36But essentially the hypothesis is that this
31:38has been seeing you in the Weimar Republic.
31:40This Soviet Russian's been seen in the
31:43United States for the past two decades.
31:45So my approach to this puzzle,
31:48Eastern paradox,
31:49is to say potentially this is
31:51what's called a Simpsons paradox.
31:54You know as well,
31:55correlation doesn't equal causation,
31:56and in fact,
31:57sometimes you can have a trend that's
32:00the average of two opposing trends.
32:02So perhaps in fact,
32:03income increasing security does
32:05lead to a better wellbeing.
32:07But there's something that's
32:08been happening at the same time,
32:09along with economic change on
32:11the past 300 years.
32:12It's making
32:16wellbeing and mental health worse.
32:18So establishing causation on a
32:19question like this is challenging.
32:21We certainly can't run an RCT on, you know,
32:24these are the change in the last 300 years.
32:26So instead what we do in economics
32:28typically look for natural experiments.
32:30And so the framework for these should be,
32:34you know, very natural.
32:35Just as in a treatment assignment,
32:37say like a variable D,
32:39which could be your your
32:42ketamine to an outcome,
32:43say depression, right.
32:44Z would be your random assignment
32:46of you know patients to to ketamine
32:48and the the keys are you know
32:51Z is as if randomly assigned.
32:53Z has a sizable effect on the
32:55distribution of medication and
32:56there's an exclusion restriction,
32:58which is random assignments only affecting
33:01the outcome of interest through your
33:06predictor variable thing.
33:07So that's the same framework that it
33:10that's used for natural experiments.
33:12In this case, we're going to use,
33:15you know, geoclimactic instability
33:17as an instrument for tradition
33:20over the past 2000 years.
33:23So this came from a now very
33:25influential article Giuliano and None.
33:26This was also presented at 2023
33:29American Economic Association plenary
33:32session which is essentially seen as
33:34the biggest lecture in our field both
33:36presenting a model of of mismatch
33:38really one of the first evolutionary
33:39models to take off in the field as
33:42well as the result that exposure to
33:46historical geoclimactic instability
33:49predicts society level tradition.
33:53And the the essentially link
33:56there is that where there's been
33:59more climactic instability,
34:02groups will go in search of new
34:04explanations for what's happening
34:06and essentially lose are more likely
34:07to to lose such of their tradition.
34:09And we see that in in the
34:10results of of Giuliano and None.
34:12And so these are 50 year increments
34:15just on the the variance of of six
34:18different geoclimactic measures.
34:20Here's essentially a distribution
34:21of that predictor variable.
34:23And so essentially the hypothesis is
34:25that that these 50 year increments of
34:27variance in Geo collecting stability
34:29are only influencing our outcomes of
34:31interest through this loss of tradition.
34:33And so I'm curious if this is affecting
34:35essentially mental health outcomes and
34:37my initial results I won't kind of bore
34:40you with the data matching process.
34:42But essentially in brief overview what
34:44happens is we have the ethnographic
34:46Atlas from Murdoch where we can
34:49characterize the location and and
34:51several features of of ancestral groups.
34:53We can then match them linguistically
34:57to essentially give a waiting score
35:00to to any variable of interest in
35:04in modern geographic populations.
35:05So I'll just start with my my Table 2,
35:08which is the,
35:09the essentially reduced form of
35:11the sorry the the ordinary least
35:13squares just as you say,
35:15we do see the tradition has a has an
35:19impact on suicide rates and when we
35:22instrument for that in table one by
35:25asking it does geoclimactic instability
35:28in fact predict global suicide rates today,
35:31we do see a very positive
35:33and significant effect.
35:35So the essentially the the,
35:38the mechanism here,
35:39the hypothesis again is that
35:41geoclimactic instability is leading
35:43to a loss of tradition and then
35:47that's increasing suicide rates at
35:49a country level around the globe.
35:52So this would be kind of one
35:54example of the type of,
35:55you know,
35:55historical evidence or you know plausibly
35:57causal evidence that we could bring to
35:59bear with that kind of common set of
36:02covariates included for
36:04various robustness checks.
36:07And that's kind of adjunct to this
36:09is what this is actually saying
36:10is that the loss of tradition in,
36:12you know, the several 1000 years
36:15from zero 80 to 1900 is is you know,
36:19predicts modern variations in the
36:22suicide rate across countries.
36:24I also look at other notions
36:26of cultural persistence on.
36:27This comes from another famous paper
36:30in economics literature essentially
36:32showing that historical plow use
36:35predicts modern gender norms.
36:37So I instrument Using historical
36:40plow use for gender norms to find
36:43that depressive disorders for both
36:45males and females are higher in
36:48countries that have historically,
36:50you know,
36:51had more on equal gender norms through
36:53this different mode of production.
36:55All these findings suggest that
36:57there's kind of deep transmission
37:01from these core cultural notions
37:05of power and order and identity
37:09to modern mental health outcomes.
37:11And you know potentially if we
37:13think that the loss of some of these
37:16identities is is meaningful for for
37:18wellbeing and mental health outcomes
37:21that this can begin to give us some
37:23purchase on why it is that as income
37:26increases these other changes in
37:28society in particular the labor
37:30market sending people you know very
37:33far from their close contacts and you
37:36know other types of cultural changes
37:38have been disruptive in a way that's
37:40counteracted some of the gains materially.
37:44Just my final piece is almost
37:46a plea I'd say you know their
37:49clinical mental health and then the
37:51institutions very influenced by
37:52economists are are are quite different.
37:55There are is a vascerative discussion
37:57some which I was privileged to
38:01observe it at the the World Bank
38:02that I think have a very big impact
38:04on on essentially the the future
38:06trajectory of of global mental health.
38:08And this used to be an argument for
38:11kind of my career and now it's almost
38:13a plea which is to say I'm as far as
38:15I understand the only person is there
38:1810 MDP issues in economics and the
38:19seven have done residency so far of all done.
38:21I am so there there,
38:23there are really very few people
38:24that are in the space of translating
38:26between these these two spheres.
38:28So I would,
38:29you know,
38:29welcome you know anyone's input
38:31thoughts as I do this.
38:33I'm currently teaching a seminar
38:34on the economics of mental health
38:36at Harvard on this this fall,
38:39which was apparently the most subscribed to.
38:42And if anything,
38:43I feel like there there's just so many
38:46connections here to make some really
38:48important ideas between economic change,
38:50mental health and homelessness
38:51that I would really appreciate any
38:54and all thoughts that folks have.
38:56But thank you so much for the
38:58time and really appreciate just
39:00the incredible community here.
39:05I'll pass off to Jay.
39:08Hi,
39:14everybody. Can you see my slides now? Just
39:19need to put it into the slide
39:22show mode. Okay. Sounds good.
39:26Perfect. Perfect. All
39:28right, awesome. So my name is Jay.
39:31I'm a 30 year resident with Marcos and Matt,
39:34and today I'm going to be talking about
39:37mental stigma and Uganda and the work that
39:39we've been doing there for almost a decade.
39:43So this is a map of the world and
39:45these are the places that I've lived.
39:47So I was born in South Korea.
39:49I lived there until I was 9.
39:51My father passed away when I was 5,
39:53and then my mom married an American
39:55soldier and he ended up coming to
39:57America and being a part of a military
39:59family in the USI moved around a lot,
40:02meaning the Deep South,
40:03where I was the only Asian person
40:06in the vast majority of places.
40:09And you know, this needs me.
40:12Like a bit of loss of community
40:15and there was some kind of pretty
40:18explicit other racism that happens
40:21and that happens deeps out.
40:24So it made me feel not very American.
40:27And when I go back to Korea,
40:28it also make me not feel Korean because,
40:31you know, now I'm like an American kid
40:33but like trying to go back to Korea.
40:35And you know, so.
40:36So I kind of felt at a loss of community.
40:38And, you know, I felt like I I quite
40:40know where I belong in the world.
40:42And I felt kind of lost,
40:44frankly, after high school.
40:46So I took,
40:48but I worked some jobs in high school
40:51and then I used that money to go
40:53live in Ghana and go live in China.
40:55And the idea is that, you know,
40:57I'm trying to broaden my horizons.
40:59I'm trying to learn more about the
41:01world and try to find my place or try
41:03to makes sense of to try to make sense
41:06of the world that makes sense and
41:08throughout this experience really need
41:11me question a definition of community.
41:14So what do you mean when you
41:16say my community?
41:16Does that mean that we value our
41:19community to be more to be more
41:22valuable than outside of our community?
41:24How do we even define community
41:26and the relationships that I mean,
41:29you know,
41:30in Ghana and the warmth of community,
41:32you know,
41:33that really welcomes me And like a lot
41:35of places that travels to meet me,
41:38meet me made me embrace the
41:42idea that community is global.
41:44You know, community is humanity.
41:46And you know,
41:47I care about people regardless
41:48of like where they're from.
41:49You know, like my mission is to care
41:52for people and that's my community.
41:54So with this mindset, you know,
41:56I started college and I've always
41:58been pretty curious about the world.
42:00So I look for opportunities to be
42:02involved in global development.
42:05So in 2015,
42:06I first went to Uganda for like the
42:09journalism project as well as some
42:12mentored the research project as well.
42:14And during that summer I
42:18made like really close,
42:19you know,
42:20friendships with people like
42:21around my age or Uganda and that,
42:23you know, I still like very close friends
42:26to friends with to the to this day.
42:28And this made me keep coming back.
42:30So the relationships and gone to the adult
42:32kept making me come back And you know,
42:34as I've been able to you know,
42:36see these guys, you know,
42:37like have have kids, you know both families
42:39and you know for the past decade or so.
42:42And, you know, they've gotten to
42:43meet my fiance and my parents.
42:45So it's, you know, the sense of community
42:48in Uganda kept kept me coming back.
42:50So you can see some pictures here.
42:53So on the far right is Doctor Weissman,
42:55one of my earliest mentors.
42:58He's a professor at Monterrey
43:00University in Carlin Institute.
43:01You know,
43:02he's been like a really great mentor to me.
43:05And in the middle picture,
43:06you see my friends Peter and Kazungu,
43:08you know, we both each other and about
43:11our families and you know, we just,
43:13you know, have like a very close
43:15kind of connection with each other.
43:17So these relationships that make me
43:18wanting to come back to Uganda and do more,
43:20do more there.
43:23So in about 5 years ago,
43:27you know,
43:27I had an opportunity to,
43:29I got some funding to start an organization
43:31by helping power through health.
43:33So it's a final C3 organization
43:36that's based in the US and Uganda.
43:37So there's the ETH Uganda also.
43:40And so you know,
43:41I asked some of my colleagues in Uganda
43:43if they're interested in doing this and
43:45they enthusiastically have jumped on board.
43:47So we've been operating since
43:50we're all over five years now,
43:53not over 99 like 99% of the money that
43:56we raised goes straight to Uganda
43:59to pay staff to provide healthcare.
44:01So we're very proud of this progress so far.
44:03It's grown every year since since started
44:07and one of the main focuses that,
44:10you know I've been working on in
44:11the context of this organization
44:13is reducing mental illness stigma
44:15and providing mental healthcare and
44:16and studying in a way that that
44:18makes sense in Uganda.
44:21So a little bit of context of where we work.
44:25So it's one of the most impoverished
44:27rural regions of Uganda.
44:29So there's just as in America,
44:30there's a lot of intraregional
44:32variety or diversity in terms
44:34of ECONSOCI economic status.
44:36You can take them.
44:37This happens to be like one of the most,
44:40one of the worst outcomes region and
44:42healthcare in terms of our infrastructure.
44:45So 414,600 people with one tax in position.
44:49I think this is going to change soon,
44:51but that's where it was when
44:53we started working.
44:55The majority of the population
44:57of subsistence farmers,
44:5945% illiteracy rate and there is no
45:03previous mental healthcare available.
45:04So you know people would see your
45:06schizophrenia or the manic and they
45:09didn't likely have somewhere to go.
45:11You know that there are some community
45:14structures but no medications and also
45:17no paid rates or for the electricity either.
45:21So what do you do?
45:22We generally do,
45:23we do three things with healthcare,
45:25education and research.
45:26So we provide essential healthcare
45:28services to the most vulnerable
45:31populations through Antunde health centers.
45:33We provide, we give healthcare to
45:35approximately over 10,000 people a
45:37year and that's including primary care,
45:39maternal care, mental healthcare
45:42innovations we can check up and urgent
45:46visits and we also are the mental
45:48healthcare providers for this district.
45:50So we work with the DHO District
45:52Health officer and the district
45:54leadership to to provide mental
45:56health care about the district,
45:58mainly severe mental illnesses,
46:00you know with medications so far.
46:04And another large part of
46:05what we do is education.
46:07So you know we have a fellowship.
46:09We have a summer fellowship called
46:11Global Health Experiential Fellowship
46:13that's open to both Ugandan and American.
46:15So it's a five to six week
46:18experience where you know people
46:20were students pre doctoral students
46:22including medical students,
46:23masters students and undergrads from
46:25both Uganda and America can work
46:28together and an intercultural team to
46:30work on a project in global medical health.
46:33So the American students pay a
46:35tuition and this helps you know fund
46:36it and you know it also helps fund
46:38you know like a lot of our research
46:40and a lot of our healthcare also and
46:42Ugandan students are 10 for free
46:45to the summer. We hosted 2 sessions
46:47of 29 three doctoral students each
46:49that are about 58 and total And
46:52we also have a university chapter
46:54system where you know where you
46:57know American students can engage in
46:59learning about global mental health.
47:00We have speakers from Uganda and from
47:03other global health experts and also in
47:06helps us fund for this and for research.
47:09You know we I've been focusing on
47:122 main areas of research here.
47:15One is reducing mental illness stigma
47:16and the other one's working with
47:19existing community structures to
47:20deliver effective mental healthcare.
47:22So mental health stigma is very you know,
47:25multilayered, you know,
47:27offers the structural level,
47:29you know, could explain that,
47:30you know,
47:31like partially explained that less
47:33than 1% of Ugandan's Ugandan healthcare
47:36expenditure goes towards healthcare
47:38or goes towards mental healthcare.
47:42And you know it results in lowers
47:44treatment seeking behaviors for people also.
47:47So it seemed like a pretty fundamental
47:49problem to you know,
47:51try to try to address right there
47:54to improve mental healthcare.
47:56So I'm going to be talking about
47:58an example project that we've done
47:59in the past just just briefly.
48:03So we attempted a pilot community to
48:06add mental illness E stigma station,
48:08the other intervention in the role
48:10of Uganda and this is inspired
48:13by HIV AIDS interventions.
48:15And you know I I see a lot of parallels
48:17between HIV AIDS and senior chronic
48:18mental illness and that both are very
48:21stigmatized and that they're both chronic.
48:22So I saw a lot of parallels and you know,
48:25we we came up with this project where
48:28we are using like a lot of lessons
48:31learned from HIV AIDS epidemic or
48:32addressing HIV AIDS to mental health.
48:35So the steps that we took was we
48:37did 4 focus groups to examine the
48:39current beliefs and attitudes for
48:41severe mental illness.
48:43And then we utilize those findings
48:45to provide guidelines for community
48:47members to participate in a
48:50competition for the other skill.
48:53So we have about four teams compete
48:56to we have four teams compete to
48:58see who has the best play and he
49:00knows and and the voters were you
49:02know people in the community who
49:03they thought was what was like the
49:05best way but they had a criteria
49:07that they had to meet basically that
49:09mental illness can be treatable.
49:11That people with mental illness should
49:13be treated with respect and that
49:15that they should be treated nicely.
49:17And so we had like a winner and and
49:19then we evaluated the effectiveness
49:21of intervention by serving people
49:23before they watched intervention
49:24and after they watched intervention
49:26with one week apart between watching
49:29the intervention and asking them,
49:32you know, asking about the results.
49:37So this is a flow chart.
49:38101 participants were initially
49:41administered initial questionnaire.
49:426 weeks later 77 of 101 attended
49:45the other intervention.
49:46One week later,
49:4757 of the 77 were administered
49:49questionnaire to value short term
49:50effects and one year later 46
49:52of the 57 were administered questionnaire
49:54to value long term effects.
49:56So you can see the results and you
49:58know as you can see it's very,
50:00very physically significant and you
50:02know large effect size for both
50:05broad and personal acceptance scale.
50:07So broad acceptance scale is roughly
50:10structural stigma and personal acceptance
50:12scale is roughly interpersonal
50:14stigma and these are some projects
50:16that we are working on right now.
50:19So data collection is fully
50:21complete for these.
50:22So most of this happened during the summer.
50:26So thank you Dr.
50:28Orba and in the department for
50:31generous funding and time to
50:33you know help work on this.
50:35We conduct so we conducted cluster
50:37randomized control trial on
50:38the effectiveness of the radio,
50:40the other program to be stigmatized
50:42mental illness.
50:43So we converted the other program
50:45into radio show into audio show and
50:48then we showed it to people and yeah,
50:50that's quite before and after and
50:52the control group that that have
50:55an audio intervention that's not
50:56related to mental illness.
50:57And then we also examine stigma for
50:59suicide defense survivors in the
51:01community through mixed methods.
51:02We surveyed with survivors,
51:04family members,
51:05healthcare workers and community
51:06health workers.
51:07So we're excited for data there
51:09also evaluated the different levels
51:13of stigma that people might have
51:14towards different mental health
51:16conditions and whether the gender
51:17of the person with mental illness
51:20affects affects the level of stigma
51:23expressed or is that person And
51:26so those are some of the projects
51:28that might have worked on and for
51:30community structures you know it's
51:32important to work with existing
51:34structures that are in place other
51:36people use that people trust and
51:38that that you know have been around
51:40for such a long time.
51:41So,
51:42so we we've done two projects
51:45regarding that regarding that in that
51:47just and one is like pathways here.
51:49So what do people do like if they
51:51have a city or mental illness
51:53like whether to people that they
51:54go seek and why do we seek those
51:56people and like what happens
51:57after they go seek those people.
51:58So another mixed method study
52:00and another study evaluating the
52:02feasibility of collaborations among
52:03individuals in the back case of
52:05care includes traditional healers,
52:07religious leaders,
52:08biomedical providers who need health workers,
52:10local leaders.
52:11So you know seeing if this is you
52:14know what people think about the
52:15other party to see like what types of
52:18collaboration are happening already
52:19and to see what types that they think
52:21would be helpful in the future perhaps.
52:27So in terms of like future career goals,
52:30in terms of like where I hope to
52:32take my career and I want to continue
52:34addressing the health needs of the local
52:36community in Uganda collaboratively
52:38with the team there and like the
52:41local community leaders and and so on.
52:43And I would also,
52:44you know and we recently started a
52:46scholarship program for our team in
52:48Uganda to go on to get their masters.
52:50So the organization provides
52:52a tuition for their masters.
52:55So to build capacity build and
52:57to and to develop help develop
53:00leaders locally in Ubanka.
53:02I'm applying for a K23 October of next year.
53:05So my teacher by 4 year through the
53:08Center for Global Mental Health
53:09Research And you know so with the
53:12goal of eventually developing an
53:14independent physician scientists career
53:15in addressing global mental health needs.
53:21So here are my acknowledgements.
53:24So you know first the entire empower
53:27to help team who you know who you know
53:29we've been working on this project
53:31together for you know like almost
53:33for five years in the organization
53:35but like a lot a lot of them working
53:37on different projects and you've
53:38end up almost affecting the end of
53:41community health workers were you
53:42know very instrumental in gaining the
53:44trust of the community and also also
53:46showing the you know also teaching
53:48us you know what's being done and
53:50what they think would be helpful.
53:52And doctor Weissman my career.
53:54Ibrahims my long time colleague
53:58a long time partner in Uganda he was
54:00the executive director of ETH Uganda as
54:02executive director of ETH and now he's
54:05getting a PhD at the University of firm
54:07Bob Rosenak Bob Orba Alex Sign Donaldson.
54:11So I really appreciate and you know I
54:15have like so many people to thank for
54:17this work and it can't cover everything,
54:19but but I really appreciate
54:23all their help and thank you,
54:25thank you all for your time.
54:45I will our last piece of
54:49the today's presentation,
54:56so happy to be with you guys here
54:59today and discuss this project.
55:01I will try to be brief and leave some
55:04time for questions for all of us.
55:06Hopefully at the end
55:08today for my presentation,
55:10we'll be talking about a project that
55:12I completed with a community in Arizona
55:15known as the New Possible Reservation,
55:17affectionately referred to by me
55:19as a country within a country.
55:21The reason being for that
55:23just fun little factoid.
55:24For those of you who don't know,
55:26Native American tribes in the
55:29United States are in this kind of
55:31on a political space where they
55:33are viewed by the United States
55:35as distinct sovereign entities
55:36in the United States negotiates
55:38with them as foreign entities.
55:41So the the group that I worked with
55:43is known as the Fosquiaqui Tribe.
55:44There,
55:45indigenous peoples in southern Arizona,
55:49but also have members on the
55:50Mexican side of the border,
55:52and that's primarily where most of
55:54the tribe membership is busted.
55:56Along the eight villages in one
55:58of the historical homelands there,
56:00There's roughly 10,000 members
56:02in the United States,
56:035000 of which are located on the
56:05Bosqueyaki Reservation just out of Tucson,
56:07AZ.
56:08It's roughly half hour away
56:10from the US Mexico border,
56:12but there are other communities
56:14in the southern Arizona region.
56:16So in the Tucson metro area as
56:18well as in the Phoenix metro area,
56:20there's a number of smaller Yaki
56:23communities where over hundreds of
56:25years groups have kind of migrated
56:27towards for jobs and maintained
56:30a significant cultural presence.
56:33So my motivation for collaborating
56:35with this group is this is my group,
56:37I was born and raised on the
56:39Foski Yaki reservation.
56:40I still have majority of my family there.
56:44All my friends who I grew up with this
56:46woman down here in the lower left hand.
56:48Here's my grandmother that's a
56:50woman who raised me very prominent
56:52figure in the community still
56:53and actually part of the first
56:55tribal council way back when
56:58friends and things that go back
57:00regularly and see but I've I've
57:02also maintained a a really close
57:05working relationship with the
57:06tribe for a number of years now.
57:08So one of the first projects that we
57:13were initially working on together
57:16was community health assessments.
57:18So this was something that we
57:22started in 2014 to achieve a national
57:25public public accreditation.
57:27But one of the areas that was always
57:29frustrating was we could never really
57:31gather good mental health data.
57:33And we weren't really sure why
57:35because we captured a lot of data for
57:37essentially every other facet of health.
57:39But you know kind of to to Max
57:42point about his discussion on on
57:44these like deaths of despair.
57:46Myself and other health oriented
57:48people in the community were always
57:50very suspicious that there was a high
57:53rate of mental illness that was just
57:55essentially not being captured or
57:57not being treated in the community
57:59because of the types of that causes of
58:00death and things that we were seeing.
58:02So like you know liver cirrhosis
58:04cracking the you know top one of the
58:07causes of death for the community.
58:09Obviously that will suggest substance
58:11abuse being significant.
58:13You know,
58:15component things like assault
58:17from firearm is like a surrogate
58:18for trauma within the community.
58:20But the the frustrating piece of it,
58:22even you know,
58:23to add another layer was when we asked
58:25the community about their thoughts
58:27on mental health and substance abuse.
58:29For the most part,
58:31everyone kind of gave the same feedback.
58:33They were very much, you know,
58:35of the belief that mental health
58:38and things like depression,
58:40anxiety, even,
58:40you know some people throwing out terms
58:43like generational trauma are are big deals.
58:45But nobody talks about the community
58:47and prior surveys even had mentioned,
58:50you know,
58:51we really think alcohol and drug
58:53use are big health problems.
58:54And and they rank them #2 and
58:56#3 for physical health problems,
58:58rank substance abuse,
58:59the number one community problem.
59:02But overwhelmingly a lot of people
59:03were saying, you know,
59:05it doesn't feel like we can talk
59:07about this or just feels too taboo.
59:09It doesn't feel like a health problem.
59:11So a lot of stigma regarding mental health.
59:13And you know,
59:14overwhelmingly people saying that
59:16the needs from a mental health and
59:18substance abuse standpoint aren't being met.
59:20So with that as the premise,
59:23one of the projects that I completed
59:25over the last year with with the
59:27tribe was essentially looking at
59:29how do we gather more quantitative
59:32data on conditions in the community.
59:35So, you know, looking at just general things,
59:36but also wanting to look at who's
59:38using mental health services and and
59:40looking at does it make a difference
59:42for people from the tribe who
59:44live on the reservation community
59:45versus those who live outside of
59:48the reservation community.
59:50The other thing we looked at,
59:51and this was with big help from the
59:54health IT department within the tribe,
59:57through our electronic health data,
59:59we were able to see that we
01:00:02essentially were under diagnosing
01:00:03or just not diagnosing people,
01:00:05not seeing people for for mental health
01:00:08conditions within the population at
01:00:10within our population it was like within
01:00:12the single digits that were, you know,
01:00:14having these diagnosis come back.
01:00:15But nationally,
01:00:16just looking at data objectively,
01:00:19that doesn't really make sense.
01:00:20Native Americans have the highest
01:00:22rates of substance disorders
01:00:24of any ethnic group in the US,
01:00:25highest rates of trauma disorders
01:00:27of any ethnic group in the US.
01:00:29Also one of the highest rates of
01:00:31suicide and completion of any.
01:00:32So it's something that we
01:00:33obviously want to stay on top of,
01:00:35but we're not seeing them,
01:00:37we're not seeing them in a number
01:00:39of like the alternative health
01:00:41options that we have available.
01:00:42So why and like what's what's the
01:00:44true kind of prevalence or how much
01:00:48is this really out in the community,
01:00:50the question.
01:00:50So what I wanted to just generally
01:00:53look at were this positive screening
01:00:55rate because it was something that
01:00:56seemed like an easy fix to be able to
01:00:58implement across our health system.
01:01:00Things like screening for depression,
01:01:02anxiety, PTSD,
01:01:03substance use,
01:01:04distorted among the tribal members
01:01:06among all the communities,
01:01:08not just within the reservation.
01:01:10Also wanted to again look at that
01:01:12relationship between those who live
01:01:14on the reservation and those who
01:01:15live outside of the reservation
01:01:17as far as you know,
01:01:19health utilization and also
01:01:20rates of screening.
01:01:21The other thing that we wanted to look at,
01:01:24and this was in large part at
01:01:27the request of the community,
01:01:29there's this inventory called
01:01:30the Wellness inventory,
01:01:31essentially an alternative to an
01:01:35alternative type of screening that
01:01:38looks more concretely at essentially
01:01:40like how people are functioning
01:01:42and they wanted me to compare
01:01:44that to more validated scales.
01:01:46So I went throughout the community.
01:01:49We had these QR codes up everywhere.
01:01:51We put them in tribal buildings,
01:01:52offices at the boys and Girls Club,
01:01:54at the middle school,
01:01:56at the high school facilities,
01:01:58the Wellness Center everywhere.
01:02:00I had like people from the
01:02:03health department put these in
01:02:04like the waiting room lobbies.
01:02:05We had our primary care physician kind of
01:02:08handing these out everywhere they could.
01:02:10And at the end we had just like
01:02:12a brief little snippet about the
01:02:13behavioral health crisis lines that
01:02:15we have in addition to just some
01:02:17of the services that we offer and
01:02:19kind of how to triage people to
01:02:20care if they were looking for it.
01:02:24The survey scales were pretty simple
01:02:26and I intentionally kind of kept
01:02:28them short just because I wanted
01:02:30something that can be completed.
01:02:32You know in theory while people are
01:02:33in the waiting room and just did a pH.
01:02:37Q4PC5 for trauma screening,
01:02:39audit C for alcohol use,
01:02:41DAS 10 for other substance of abuse,
01:02:44and then this Wellness inventory
01:02:46for the you know purposes of time.
01:02:49And also just simply,
01:02:51I'll primarily be talking
01:02:53about the adult survey results,
01:02:55but the youth one had some
01:02:58different scales only because
01:02:59of the validation reasons for
01:03:03the Wellness inventory is the item
01:03:07that they wanted me to include
01:03:09to kind of compare to like pH,
01:03:11Q4 and other screening that are available.
01:03:14This one is it's interesting because
01:03:16it does address questions a little
01:03:19more on like the function of asking
01:03:20people like how they're sleeping,
01:03:22how they're eating.
01:03:23You feel connected to family,
01:03:25you enjoy creation or someone who
01:03:28laughs regularly, that kind of thing.
01:03:30And it scores it in a way that triages
01:03:33people to like the more they do those things,
01:03:36the higher their score.
01:03:37And you know it's supposed to be a
01:03:39clinical guide to say this person is fun,
01:03:41loving, healthy, balanced.
01:03:42We don't need to worry about them
01:03:44versus this person needs some
01:03:46appointment like today kind of thing.
01:03:47But the interesting thing to keep in mind,
01:03:51this survey does include a kind of loaded,
01:03:54ambiguous question about thoughts of like
01:03:58passive death wish versus self harm suicide.
01:04:01And I'll explain why I think it's
01:04:04a little ambiguous in a second.
01:04:06So obviously I'm not going to
01:04:07be able to go over everything,
01:04:08but just to give you guys a snippet
01:04:10of some of the highlights that
01:04:11were found in the survey.
01:04:12So you know,
01:04:13I think a couple of these statistics
01:04:16are a little inflated because
01:04:18unfortunately with like where
01:04:19some of these were located,
01:04:21it caters to people who are seeking care.
01:04:24But that being said what we found
01:04:26was majority of people are not
01:04:28reaching out for mental health
01:04:29care even less are receiving it.
01:04:31So that means some people reach
01:04:32out and are just not being seen for
01:04:34whatever reason over the past year
01:04:38trauma criteria on a exposure.
01:04:40So this is the requirement for PTSD
01:04:42diagnosis but also like to even
01:04:44continue on with the screening.
01:04:46You have to have a criteria on a 86%
01:04:49of the sample is or was endorsing that
01:04:52We we don't know about repeat traumas
01:04:54of potential that there's other people
01:04:56that had multiple and this is in line
01:04:58with what you'll see in literature.
01:04:59It's it's a very common kind of thing
01:05:02that happens to a lot of people.
01:05:03But what's uncommon or what was kind
01:05:06of surprising was like the rate at
01:05:08people screening positive for PTSD.
01:05:10Obviously this doesn't mean that
01:05:11all these people will have it,
01:05:12but it's still interesting that close
01:05:14to half of the sample population was
01:05:18essentially screening positive from
01:05:20the depression side of screening,
01:05:2228% of the sample was screening positive,
01:05:24anxiety side of screening 20%.
01:05:28The other thing we kind of uncovered
01:05:30when we parsed through the data was that
01:05:31there was a difference in community.
01:05:33So the community didn't matter.
01:05:35The reservation community family members
01:05:37who lived there were more likely to have
01:05:39at least one positive screen but less
01:05:41likely to reach out or receive care,
01:05:43which is kind of odd because that's where
01:05:45all of our health services offered from.
01:05:48It's headquartered from there.
01:05:49So you know, our behavioral Health Center,
01:05:51the alternative Med center, the sweat lodges,
01:05:54everything that people could get was there,
01:05:56but these are the people who are
01:05:57getting it less.
01:05:58The other thing was interesting.
01:06:00PTSD screening as well as audit
01:06:02screening had higher prevalences,
01:06:04significantly higher prevalences among
01:06:06people who live on the reservation
01:06:08versus people who live off the
01:06:10reservation but who are living in like
01:06:13the Tucson metro area or Phoenix metro,
01:06:15central Arizona, whatever.
01:06:18And it was so significant.
01:06:19So 53% screen positive for PTSD
01:06:22on the reservation versus 35% in
01:06:25all of the similar for the audit,
01:06:2755% in the reservation, 41%.
01:06:32The part that I want to touch on
01:06:35here about this suicidal ideation,
01:06:37passive death with self harm,
01:06:39I mentioned that it was a little bit of a
01:06:41loaded question and this is the one that
01:06:43was included in the Wellness inventory.
01:06:45And it's, it was interesting that what
01:06:49we found was a large percentage of
01:06:52the sample was endorsing, you know,
01:06:54at least having rare thoughts of this,
01:06:57but it's kind of hard to say what
01:06:58it is they're endorsing because
01:07:00it asks about all three.
01:07:01So do you think you're better off
01:07:03that you think you're purposely
01:07:04hurting yourself in some way?
01:07:06You can extrapolate that any other way.
01:07:08Reality is over a third of the sample
01:07:10is saying yes, I think about it.
01:07:12At least rarely,
01:07:13some people are saying they
01:07:14think about it daily,
01:07:15and this is over the last two weeks.
01:07:18The part when we looked at where
01:07:20these responses from that 34% came
01:07:23from shows a little bit of a cluster,
01:07:25again specific to the reservation community.
01:07:28So community members living here
01:07:29were five times more likely
01:07:31to endorse thoughts of this,
01:07:3380% who endorsed more than half of the
01:07:36time were residents of the reservation
01:07:38and 93% of those endorsing Daily
01:07:41Thoughts were residents of this community.
01:07:43And again these are the people
01:07:44not going to appointments,
01:07:46not receiving care,
01:07:47not going to alternative Med.
01:07:50It's it's it was a little shocking
01:07:53but I think it told us that we
01:07:56we have a lot of work to do and
01:07:58and I think we have some plans of
01:08:01action in place for next steps,
01:08:03one of which will be a pilot that
01:08:06I'll be running in collaboration
01:08:07with the trial moving forward.
01:08:09So I was fortunate enough to learn in
01:08:12the spring that I was awarded the APA
01:08:14SAMSA Fellowship and it's a smaller grant,
01:08:16but enough to kind of help us
01:08:19implement some efforts aimed at
01:08:20mental health STIMU reduction.
01:08:22And you know,
01:08:23we're planning on training community
01:08:25leaders and almost a a modest model
01:08:27similar to what Simon mentioned
01:08:29about the friendship pension,
01:08:31kind of incorporating the community
01:08:32into the healing process.
01:08:34But we're also going to focus on
01:08:36some town hall education series and
01:08:38just bringing this conversation to
01:08:40the forefront in the community.
01:08:42So it's we have work to do but we
01:08:44have some plans in place and and I
01:08:47think we'll we'll be able to make
01:08:49good on those brief acknowledgement.
01:08:52So this guy over on the left doctor,
01:08:55doctor R doctor and that he got this
01:08:57guy's been my mentor a long time.
01:08:58He was actually my primary care
01:09:00physician back in the day.
01:09:01He's the medical director for the tribe.
01:09:03Great guy, been with us forever.
01:09:05I'm really dreading the day and he
01:09:07has to leave and retire because
01:09:08I know it's coming soon.
01:09:09The health department really great in,
01:09:12you know,
01:09:13helping out with some of the manpower
01:09:14for these projects and you know,
01:09:16being all on board or helping
01:09:17get the word out.
01:09:18And really, really fortunate to
01:09:20have their support as well as
01:09:23support from private council
01:09:25who has been very supportive of,
01:09:27you know, all these ideas I've had
01:09:30and and are are working with us
01:09:32to continue making some progress.
01:09:35Lastly, our own Doctor Rohrbaugh
01:09:37very helpful in kind of helping
01:09:39me maneuver some of the logistical
01:09:42planning and funding for this project
01:09:44and also kind of started the pipeline.
01:09:47I'm not sure if people know this,
01:09:48but a number of years ago now,
01:09:50Doctor Rohrbaugh actually had another
01:09:53resident on their case project
01:09:54out in my community,
01:09:56and that was when I kind of first learned
01:09:58about Yale's novel approach to the
01:10:00residency program and put it on my radar.
01:10:04Big shout out to him starting that pipeline.
01:10:08I hope we have a little bit
01:10:10of time left for questions,
01:10:12but I'll stop screen sharing
01:10:15now and see if we have any.