Hello and welcome. I'm Dr. Donna Roland, Director of the Psychiatric Mental Health Nurse Practitioner Program at UT Austin, and the nursing expert for SMI Advisor. I'm pleased that you're joining us today for our SMI Advisor webinar, Culturally Informed Psychopharmacology for Patients with Mood Disorders. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Today's webinar has been designated for one AMA PRA Category 1 Credit for Physicians and one Nursing Continuing Professional Development Psychopharmacology Contact Hour. Credit for participating in today's webinar will be available until October 10th. Slides from the presentation today are available in the handouts area found in the lower portion of your control panel. Select the link to download the PDF. Please feel free to submit your questions throughout the presentation by typing them into the question area found in the lower portion of your control panel. We'll reserve 10 to 15 minutes at the end of the presentation for Q&A. Now I'd like to introduce you to the faculty for today's webinar, Dr. Eugenia Millender. Dr. Millender is currently the Co-Founder and Associate Director of the Center for Population Sciences and Health Equity and Associate Professor at Florida State University College of Nursing. As an indigenous Afro-Caribbean Latina nurse scientist, Dr. Millender's career has been dedicated to increasing access to mental health equity and providing culturally appropriate care. Dr. Millender, thank you for leading today's webinar. Thank you so much, Donna. I had to find the mute button. As always, it's always a problem here when you're doing this kind of meeting. Thank you so much for having me and inviting me to be a part of this wonderful presentation here today. I have no disclosures to disclaim at this point. The learned objectives for today's presentation are to identify mental health disparities when prescribing for patients from diverse populations who have mood disorders, to demonstrate culturally sensitive techniques when prescribing for patients from diverse populations who have mood disorders, and to access opportunities for utilization of culturally sensitive approaches to achieve pursued equity and prescribing. I want to start by providing land acknowledgement. This is a powerful way of showing respect and honoring indigenous people of the land of which we live and work. I acknowledge and pay respect to all Native American and indigenous peoples, traditional custodian of the lands and pay respect to the elders past and present. I also acknowledge all Native American and indigenous people who have been or have become part of this lands and territories throughout Mother Earth. Thank you so much. I'm going to start by just giving you a little story about who I am. And for that reason, that will give you a little idea of how I came up with this presentation and this concept, which is very true to who I am and where I have come from, and how I take care of my patients, how to research and how I also teach. We all come from different backgrounds and can share different lived experiences with each other. These experiences make us unique. They also allow us to see the same world in different colors and different shapes. They give us purpose and diversity of thought, as well as put these diversities at the table when decisions are made. Respecting these thoughts can foster a sense of belonging and work to a more equitable system by creating innovative solutions to increase the quality of mental health services. So let me tell you a little bit about me. I was born and raised in the Republic of Panama. My father was indigenous Kuna from Panama. My mother is Afro-Latina from Panama. I came to the United States when I was 12 years old, and I only spoke English in my native indigenous language. My mother was a single mom working with four children. We lived in a severe poverty and drug-infested neighborhood. I did six years in the army. I was air sold with the 101st Airborne Division in Fort Campbell, Kentucky. I was part of the storm. I am now married almost 30 years and have three sons, two living with mental illness. My initial exposure to the mental health system revolved around my family trying to get the best care for the two of my sons. I now have a hybrid telehealth practice, and my clients are mostly homeless individuals or individuals that recently out of prison, out of jail, and also refugee immigrants youth. It is this life experience that allows me to think differently, see the world differently, and allows me to be able to put myself in some of my own experiences. And I also have to say, identify some of my own biases when it comes to take care of different populations. But I think it's these experiences that make all of us very unique to be able to provide the best care that we can for our diverse populations. Before I get more in-depth into actual hands-on activities, I have to provide some background information. It might be a little boring, but I think it also provides the essence of why what we have to do about creating a more inclusive and respectful environment in our clinical settings is very important. In developing a more equitable mental health system, we have to assess mental health among diverse populations. The Kaiser Family Foundation showed that COVID and socioeconomic hardship negatively affect the people, mental health, and exacerbated symptoms of people already suffering from mental illness and substance use disorder. During COVID pandemic, four in 10 adults in the United States reported symptoms of anxiety or depression disorder up from one in 10 before the pandemic. Furthermore, when it comes to our healthcare workforce heroes, a recent study showed that worldwide, one in five healthcare worker experienced anxiety, depression, or PTSD. Yes, the pandemic has impacted us all, but it also has disproportionately affected the health of communities of color. Non-Hispanic Black adults and Hispanic or Latino adults are more likely to report symptoms of anxiety and or depression disorder than non-Hispanic white adults. Historically, these communities of color have and continue to face challenges assessing mental health care. And when they do receive care, often it is not quality care. It is important for us to first understand some of these disparities. Unequal distribution of social gradients such as poverty and education lead to unequal distribution of poor health, morbidity, and mortality. Different populations face toxic combinations such as marginalization, conflict, lack of healthcare access, education, and employment. Therefore, when we encounter our patients, we must gather social cultural information that is relevant to them. We must utilize innovative ways to achieve conversations around social and cultural determinants, such as normal times and before the crisis and during the crisis, such as COVID that will have implemented to us. This is the only way to provide whole health experience. This will require for us to go beyond our comfortable zone to have difficult conversations to reach mental health equity. We have to start understanding that we have to come comfortable in being and feeling uncomfortable. In addition to the constant social cultural determinants of health we just discussed, we have to add the impact of the COVID pandemic as an additional stressor. The pandemic has both short and long-term implications for mental health and substance use, particularly for those groups that we just have discussed. They have associated with mental health disorders and those facing barriers in obtaining mental health services. Towards this, we have to be able to understand again how those experiences affect them. Here in this picture, you're going to see that you have different realms of what we call adverse childhood experiences. You have to go sometimes very deep into what has happened before because that is what matters now and where they are. In the first realm here, we talk about household. What has happened in the household? You have parents or family members that have been incarcerated. You have divorce experiences. Some people live in homeless situations. You have parents with mental illness and alcohol use problem, as well as experience emotional, physical, and sexual abuse, domestic violence, maternal depression, bullying. How is that impacting the individual? These are some of the questions we have to ask. Those questions may be very difficult for you and or the patient. You also have to assess the community and the environment. When we talk about community environment, those are the questions we don't necessarily often discuss. But in community, again, what kind of poverty are you experiencing? What kind of housing you have? Is it quality or not quality? What about lack of jobs, food security? What about the school system? What about structural racism? What about the history of trauma, discrimination, lack of social capital and mobility, social support, quality of water? Nowadays, we are definitely paying more attention to the third realm, which is environment. More specifically, things like pandemic, earthquake, natural disasters, wildfires, heat, droughts, severe level of water. How is this impacting your own patients, your own experiences, your community? Because that is what's going to advise them or educate them or inform them and sometimes make them afraid of coming to us for services and care. As we see, there are several social cultural considerations we must address when dealing with diverse, and for that matter, any population. The accumulation of these social cultural factors over the lifespan of a person can result in cumulative stress, trauma, and impact the mental health fitness, increasing risk for mental disorder. The mental health fitness discussion has taken place as far back as 1964, but McCarthy, he used this terminology to avoid negative conversation of mental illness. Today, this term is even more relevant and valuable given that communities distrust the healthcare system and have negative view of mental disorder. Here, we are not only discussing illness, but more importantly, prevention and building resilience with the concept of mental fitness, a concept that is often more relevant to Black, Brown, and Indigenous peoples, because this builds on the historical trauma experience of survival and overcoming incredible obstacles. So now what? Now that we have discussed some of the social cultural stressors and traumas that impact mental fitness or exacerbate mental illness or places certain groups at higher risk for mental illness, how do we go about breaking this cycle of disparity and inquiring more about these social cultural factors in manners where we can all learn? First, we have to master some essential tools when working with diverse populations. This includes, one, being open-minded. We all think differently. We all have different languages. You might be able to hear my accent. If I get too excited, I might speak a little faster. You may be able to see and understand and hear some of my perspective, my passion. We all have different ages, skills, culture, nationality, ancestry, religion, and all those things make us have different perspectives and point of view, and therefore, for that reason, you have to be open-minded to other individuals' perspectives and views. This allows us to create a more holistic and inclusive treatment plan. How can we be able to ask for individual stressors when we are not even able to be open-minded to hear what they have to say? Do not take things personally. When someone does not agree with you, it's not because they necessarily are telling you that. It's because of their own experiences, where they came from, and where sometimes they see themselves going, sometimes hopeless. You have to respect the person and the experiences. It may not make sense to you, but it is real to them. Sometimes, I know growing up, and I always share to individuals saying that, you know, poverty is different for different individuals, and even now, when I go back to the Republic of Panama, poverty in Panama cannot be compared to poverty in the United States. Poverty in Brooklyn can be compared to poverty in Florida and vice versa, so when you talk about poverty, you have to be a little bit more understanding that it all means different things for different individuals. These essential tools and others will help us to get to a brave space of discussion and developing shared decision that is culturally sensitive to decrease mental health disparities and increase mental health equity, and this is where I start getting to the nitty-gritty of developing a bright space, but first, we have to talk about other things. In my own process of growing and gathering authentic experiences in what matters most to individuals, I always want to have conversations about what it is to be who you are in the moment, and I start looking at the literature and the concept of safe space first came, and that is which the initial conversation around it creating a place to talk about difficult things and difficult issues came to be. Safe spaces where people with similar interests or ideology come together to talk. This is a space for people to necessarily come to not disagree but just to talk. The problem with safe spaces is that sometimes a comfortable space is not possible and can create isolation of thought as well as groups, creating more problems than solutions, so what does that mean? That you come to a safe space the way it was created in the literature is that you come because you all have the same ideology and you want to talk about the same things because you agree on the same things, but that's not always the case, right? You sometimes disagree with your patients and your patients disagree with you. Therefore, we have to move on to another concept which we are now calling a brave space. This is not so much of a comfortable space, since we are voluntarily coming to know about something that we know nothing about or something that we already know might make us feel uncomfortable to talk about. You do not know how the conversation will go or how you feel about it. You also do not know necessarily that you have to agree with the individual of what they're saying, so what is the goal of a brave space? It is to listen, to understand, not necessarily to respond, to address the idea and not the person. While you listen, be mindful of everything and everyone's struggle, to unpack the tension and plant the seed of having social-cultural conversations in a clinical setting, so what am I saying? That this is not going to be comfortable, but it's necessary. Not every patient that you take care of agrees with you, probably the majority, but then you're going to have a few that do not agree with you, and the question is, if they disagree with you, why do they disagree with you? Is there some cultural, social-cultural issues or barriers that is preventing them from agreeing with you, and therefore we have to have those conversations. For me, integrating a brave space is just a beginning of being mindful about having social-cultural discussions with patients as a standard part of our assessment and follow-up visit. It is not perfect, but it is a good start. At the end of the day, we want to be aware of every individual's needs. Some of the critics are real about this concept because it can cause some discomfort. Some people may not necessarily want to do it, but I use brave space to create a culturally responsive evaluation and treatment plan. This includes integrating culturally relevant information and themes in our educational moments, creating a plan that is inclusive, that is also allowing the patient to voice their opinion. It has to make a major play in what will be done next or not. Gather culturally relevant, collaborative information to be able to educate and create a more specific treatment plan for them. The patient and I know what I'm saying. We need to, when I say we're going to need a brave space, excuse me, they know that we're going to have a discussion about social-cultural issues, right?, and things that may make either one of us uncomfortable. Please prepare us to be able to be open-minded and get ready for the discussion. So, these are different ways to be able to do this, but I know that, and I'll show you a little later, some of the things that I have put in the office in order to prepare the individual to not only to have this conversation but know that it's relevant at every single visit. So, before we could actually talk about little things that we can do to put brave spaces into play or how to integrate into our practice, we have to discuss bias, right? The first step towards having that brave space is to understand your own self and your own biases. Today's conversation is not about right or wrong but more about awareness of self, how those biases impact your thinking, decision-making, clinical suggestions, and interaction with your patients. Implicit bias happens when our brains make incredible but quick judgment and assessments of people and situations we are realizing it. We are not aware of this. It just happens. Implicit social bias are byproducts of our cognitive process and can be as simple as a flash. It doesn't necessarily mean something at the moment. You may not even know what it is. It can be a complicit of beliefs and expectations, can contain subtypes, numerous other, there are other many different types of content biases. Now, there are two main types of conscious biases, right, that we have to discuss here. You have the other one, which many of us are always discussing in literature and research. It's a conscious bias, right? This is where you actually know how you feel and why you're doing what you're doing. This is not what I'm talking about today. I'm talking about conscious today. Because if you already know how you feel and what you're doing, what you're doing, there's nothing I can do about that, because that is your own belief, and I have to respect that. Again, I have to live in that respect that I don't necessarily agree with what you're saying, but that is who you are, and I have to accept you for that. I'm talking today about the unconscious bias. You have to become aware of it. And so, for example, one of the things that I had to work very hard on was I am a victim of when, say, my mom suffered from domestic violence severely. So, as an adult and then a clinician, I became aware that when I was taking care of those clients who were the person who gave and, obviously, abused other children or women or whoever may be, there was some anxiety. And as part of my debriefing and chatting with my other collaborators and coworkers, I identified that I had an unconscious bias for such individuals, so I had to put certain things in play as to maybe changing my patient list or my visits and giving other providers certain patients, but I had to come to know myself. I had to come to know what that meant for me, but this is something I worked very hard for. So, this is the individual I'm talking about, individuals that may not necessarily know at the beginning that they have unconscious bias, but then they see flashes or symptoms or ideas or things that may be a problem, and this is when you have to debrief another provider to understand yourself and how does that impact your patients and the treatment that you're giving. This goes to the point that if you understand yourself now, you could develop a better relationship and trust with your clientele, right, with your patients. If we do not respect, if we do not understand and communicate effectively with our patients, why would they trust us? Why would they trust our recommendations? Why would they believe that what you're recommending is the best for them if you can't even communicate honestly and authentically with them? You have to respect and trust must be mutual. So, then this is a very simple question, but the answer may be very complex. What do you fall when it comes down to bias awareness? Are you in a denial phase? Are you in a defensive phase? Are you in a minimization phase? Are you in an acceptance phase? And then beyond that is where we are actually making changes, right, to make things better, not only for ourselves but for our clients in our community. That's when you begin to adopt some reductions in your own biases and in the integration. When it comes to unconscious bias awareness, we have to be aware of the full aspect of where we are. As you assess what category describes you best, implement self-compassion tools, and what I mean by this is that sometimes we may be hard on ourselves because we don't think or we don't believe that we have unconscious bias or we have biases, so that's what I say. It's self-compassion because we are all not perfect, but we do have biases. The question is, do you want to identify them and do something about it, or you are very comfortable with the biases that you have identified already? We all have ways of improving, so therefore this is not a bad thing, meaning that you have just identified them for the first time. The question is, do you want to do something about it? So, for here, for the purpose of this presentation, I'm not going to go into detail about this, but I just want you to take a moment to really take time to see and understand yourself, because if you don't understand yourself, you're not going to be able to understand others and be open-minded to what they have to say, so if you're in a denial phase where you're not aware of any biases, I want you to start moving up the ladder and identify, at least be able to go into acceptance that we do have biases, and then what can we do about those individual biases, and how does that affect our patient? Once you identify where you fall, then the question is, what experiences have you implemented or you can implement to move you from one level to the other, right?, talking to another colleague, maybe reading a little bit more and identifying things that you can do. Is there anything that you have learned so far to move you to the next level and to help you gain greater awareness of yourself, greater awareness of our different populations that we care for, why it is so important to have those conversations in a clinical setting? Which of the bias reduction strategies that I'm going to share talks most to you, right?, and identify two specific strategies that you can use as a clinician in your own setting for your own population. I would disclose that you will not be able to move into creating a brave space if you have not identified your unconscious bias. It is going to take courage, and I say courage, to agree to be open to being uncomfortable about a certain conversation. In a brave space, you will ask questions to inform you about social cultural events that the patient, or even more important, their family have experienced that impacts their mental health and mental fitness. You want to discuss their beliefs, perception, understanding of the mental health care system, whether they distrust the health care system, whether they distrust the mental health care provider. You may or may not agree, and it's okay, and you have to understand that it's okay not to agree. The goal here is to get to know the person and their beliefs and how that impacts their whole health, so, again, it's understanding to have those five elements of civility, have conversation with civility, disagree with civility on the intentions and the impacts, so make sure that they know that you're asking this question, because you want to know who they are and how their role affects who they are, and also how best can you help them. Challenge the choice, so I have many individuals that refuse medications or refuse therapy, and it's because their family refuses the concept of mental illness, so many of those conversations have always been about culture and explaining how things are beneficial for them in a culture-centric moment of conversation. You have to respect, so when you are disagreeing, you're not putting that person down and their beliefs and their family, but you tell them, I respect your perspective, but this is what is good for you because of this, and this is how we can incorporate some potentially your holistic approaches. There's no attacks. There's no ill-feeling here, but you have to let them know, and families and individuals are able to sense and smell and see your authentic being, and it is that that makes them move into a more acceptable way of understanding mental illness and being open-minded to different treatments. So, here, I dare to be powerful, to use my strength in the service of my vision. Then, it becomes less and less important if I'm afraid, and this speaks to the bright space, right?, where you have to be daring. You have to be confident. You have to be conscious of yourself and your weakness and your strength in order to go into this space and be able to talk to other individuals about things that may make you feel uncomfortable, right?, and also how we, too, react when they feel uncomfortable, so we have to be able to see the greater good in things and how we have these conversations, and developing a clinical space can be very difficult. I'm not telling you that it's easy and that we all could do this. It took me some time, but I know that it's meaningful, and I see the difference that it has made. It can be used without fear in some parts when you become comfortable, but then it's very fearful at the beginning, but once your patients see what you're doing and you're consistent with it and the work is consistent, they'll become more open, and the walls start coming down. The ideas and the experiences they share with you are also going to move you, but we all must dare to be a little daring, go outside our comfort zone, and be able to be agents of change, so what can we do to do and create a bright space?, and these are some of the things that I have done slowly and surely. It has taken me years, but make sure that when you start the conversation about culture and economic status or anything else that you let the patient know that this information is confidential and it's important to create the best treatment plan for them individually. This is something that you will have to be able to share a few times, because, again, the first or second time, they may not trust you because they're saying, You're telling me the same thing that I have heard many other times, but then the other provider or clinician is not necessarily here for me. They're not listening to me. They're just talking at me. Show them that you're authentic, that you really care. Your authentic actions and break space will have to be consistent to develop trust in authentic communication. After your first tries, ask yourself, What is challenging about this moment or was it challenging at all? How do you feel in the moment of being in a break space and asking these very intimate questions that sometimes you haven't asked before or maybe you already have and you feel more and more comfortable? What is the learning goal for the conversation? So, if you have a patient that is coming in and, again, for the first time, you do the assessment and they may need either medication or therapy, and they refuse, even though you know they need it, but they refuse for cultural reasons. Just continue to have those conversations about why they need the help, and then you may understand how to integrate some of the cultural beliefs into your education on why they need this help, but if you don't ask the question of what beliefs they have, you're not going to be able to integrate those things into your education plan or your treatment plan. Remember to ask small bits at a time. You are not going to get all this information in one visit, and usually we don't have that much time, but the more that you ask every single visit, the more you're going to get to know this individual. Do not try to figure it all out and then be able to understand that you're not going to get all your answers, and then you may not even agree with the answers, so this will take time and patience in both parts of you and the client. Here are some additional tips that are often not mentioned. Make sure that they understand HIPAA and how things are shared or not shared with family members, with community members, because many individuals that are from underserved populations believe that the information is going to be shared with every single person, that they have no say-so, they have no control, and therefore they are very skeptical of giving you information, so I always make it a point to talk about HIPAA, what does that mean, who I could give information to, and when I do not, that you understand that this conversation can be uncomfortable for them as much as it is for you, and you understand if they are not ready to have those conversations right now. Today may not be the day. It may be tomorrow. It may be the next visit, so both of you have to understand that, and both of you have to understand that each one of you have control over this, especially the patient. We, the clinicians, kind of already know that, right?, but not so much the patient. You let them know that you care. Share with your patients and remind yourself that the conversation is actually about intellect and getting to know versus feelings. It's not about putting you down. It's not about disagreeing with your own personal views about what recommendations you have for the person or for the individual. It's about getting intellect. You will not and should not make the conversation personal. We are here to challenge the conversation with care, so the patient may be able to disagree with you and tell you why they disagree with you, especially if this is a very constant conversation here with COVID vaccination versus not having it or not having it, so it's the same way that we should have those conversations with our patients in our clinical sites. Give shared decision-making as much as possible. At least allow them to understand that that is an option that they have every single time, that they are the keeper of their own body, and they should be able to provide and share how they feel about certain things, side effects, but as much as we know that this is something that we always talk about, our patients that are Black and Brown Indigenous do not understand this, and it has to be repeated over and over again. It has to be explained in different concepts and perspectives for them to be able to really truly own it. Understand that this conversation will have no closure. It will be ongoing. This is just the beginning, and many conversations can take place over many, many, many, many visits over many, many years, which it has been for me as well because things do change. Some of the long-term strategies to develop a clinical break space has been to me about integrating this from the moment that a patient walks through the door to the moment that they leave and even with every single call that may take place in between. You must have meaningful and authentic conversations with your patients from the beginning to the end. It's very sensitive that you do this because, again, individuals who do not trust the system are looking for a reason not to come back, and part of that is not being consistent because when you are not consistent, it shows, again, our skeptical view of looking at the world. They might be hesitant to trust, but if you continue to do this, you will see more and more people that are going to put the guard down, and I'm not going to say that every single individual is going to do this because you're going to always have those that are very resistant to change, so ask yourself to have, and what have you done in your practice to make it more inclusive? I put posters from the very beginning indicating shared decision-making and what does that mean, and I include it in different languages. You integrate this concept within your front desk staff, so they make sure that they reinforce this when the patients come in in their own languages. Create reminders for yourself in your notes. Did you ask something about the sociocultural perspective that you did not know or maybe that we have asked ourselves when we are doing our notes after we see our patients? Look for trends in the sociocultural barriers of the individual, and part of this also, maybe integrate a piece of a note or have an area within your note that talks about sociocultural in every single case. It could be as simple as one line. It doesn't have to be anything that is over something to do, but it is important to do for our diverse populations, and within these conversations, I always try to integrate what is new and the latest things out there that are important for these patients to know, and within that, I do talk about pharmacogenetics, and there was a new concept, especially when this population, number one, does not want to take medications, and number two, they feel that you are just like a guinea pig, a rat trial, that you're just trying things on them and things don't work and you don't know what you're doing, so I have always introduced in these conversations the pharmacogenetics concept, and I talked about how is it that the right medication potentially can be identified earlier if we do this specific test. I also talked about the cultural values about the medications. I talked about the health beliefs about the family beliefs about the medication or even treatment plan or even them coming to see a mental health provider, what does that mean to them, so when they go back home and they talk to their family member, what is the reaction, because if the family is looking at them in a worse manner because they're seeing a mental health provider, then we need to start discussing things differently, and sometimes they do share most of the time what this means to them, and also talk about, again, would you be able to go against your family's perspective and view for your own well-being, so this is, again, another hard conversation to have, but this is a conversation that must be had, and while in the brain space, again, you discuss these things, and they will help you identify how the patient feels about potentially pharmacogenetics, which could help them later on, especially if they're having a hard time identifying the best medication for them. And here, I always integrate precision health meets social-cultural conversations. Persons living with or at risk for mental illness often undergo multiple trials of medications, as I mentioned before, and experience negative side effects before arriving to the right medication. Given this disparity, is it more important for minorities under certain populations to be included in pharmacogenetic testing and in identifying different markers? This is also going to help us narrow the health disparity gap, because most diverse populations are not included in this type of research, and we all know that one size does not fit all, so why do we keep trying it, and sometimes, obviously, the social part is going to play a big part in pharmacogenetic testing, because most clients are not able to afford it, but I have been lucky enough to have some of the companies provide pro bono free services for this population, especially if they have Medicaid or if they're uninsured or if they are undershored, like with Medicaid. Obviously, the difficult conversation comes with those who have private insurance and they are billed, but then when the billing comes back, we are able to somehow adjust it to zero with the assistance of the company, and I do use multiple companies, so if we know that one size does not fit all, why do we not have these conversations with underserved populations? Again, it's because we are already seeing and thinking that we already have one barrier, which is the socioeconomic status that we know about. They may not afford it, and then, number two, we have the cultural barrier. They may not trust genetic testing in general, but therefore, this is why even more of a reason to have those conversations, because we don't know enough about different populations because those populations are not included in this type of research and implementations. Excuse me. Just for a second. Hold on. When every trial on new medication, the response rate decreases. By the time we are in one, on the fourth trial, we have 70% non-adherence and 60% treatment response. This is not a good combination to have. And if you add, in addition to this percentage of non-adherence and treatment response, hesitancy of pharmacogenetics, hesitancy of medications, we even have a more difficult time for underserved and vulnerable populations. So one of the reasons that I use pharmacogenetics in the population, because it actually kind of gives me something to discuss with them that is black and white. As we know that it's very difficult to medicate our patients because it's not like diabetes that you have insulin. You see the numbers come down immediately. This is not so with our practices, right? So therefore, this has come to be one of the closest thing to actually black and white. We have this test that gives us an idea of what medications potentially can be best for you, because guess what? You may be an ultra-rapid metabolizer. What does that mean, they ask? Or you may be an intermediate metabolizer or poor metabolizer. What does that mean? So when I start explaining those things in detail and indicate that now medications have a label and this label have to tell you exactly what genes they target. And with that information, now we could take a saliva test and pair both the drug and your genes together to come up with this result that tells me if you are going to burn this medication faster, or you're not going to burn it so fast, you're going to be slower. So I talked about, again, how do you burn calories, how somebody goes from skinny to fat. And that seems to be working. And actually, those individuals are a little skeptical about our medication are more likely to engage in the conversation about having medication because we talk about homogenetics. So it is actually a very powerful tool. But this conversation has to be inclusive and come in the moment we're talking about sociocultural factors, because again, a lot of barriers will be, I don't want to do this because I know what has happened before. You know, I always get this, I remember Tuskegee study or I hear about all these different kind of studies, and I don't want to be one of those. But when you talk about it, and you actually explain it, take the time, it may not be you that has the time, maybe a social worker that you work with, maybe another, you know, medical assistant, it could be a nurse, could be somebody in your team that does education. But this education is crucial if we want to be more inclusive, and be able to engage all populations in all different types of services that are available for every single person. So within that, this is another concept of endocyclopharmacology, which is a little different. So the significant differences in response to psychotropic drugs are observed in various ethnic and sociocultural groups. So endocyclopharmacology is the study of how culture, culture is being the key word here, and genetic differences in humans groups is determined and influence the response of psychotropic agents. So again, here we're looking at how culture influences genetic differences, while pharmacogenetics by itself just studies the influence of genetic variants in the response of patients to different drugs. So here we have to understand that pharmacogenetic tests are used to predict drug responses, and the potential for adverse effects, but there are important genetic variations that influence the metabolism and action of psychotropic drugs in different ethnic groups. And this is how this is a little different. Now the study about different groups and how different groups are affected by different medications, right? As an example of this, it's a frequency of the CYP2D6, which we all have heard, we have read. So this polymorphism depends upon race, ethnicity, or region, and it's well established. We have seen this. Now the prevalence for poor metabolizer, in another example of talking about ethnicity and groups, right? A prevalence of poor metabolizer in Black population has been estimated to be from zero to 19 percent, compared with consistent reports of poor metabolizer status in Caucasians, which is 5 to 10 percent, and Asians from zero to 2 percent. Within the extensive metabolizer category, Asians have higher metabolism ratios. This is a slow metabolism, right, than Caucasians who are extensive metabolizer. So here we see that there's a variance in the alleles, which is a different version of the CYP2D6. And here a higher frequency of mutation gene has been seen in Asian populations, which is the Y, the CYP2D6 number 10 allele, which is the most common allele in the Asian population. So this is just an example of how ethnicity and genes can be different for different groups. But if we do not talk about pharmacogenesis, we do not do pharmacogenetic testing, or even interventions with our patients who are from different backgrounds, they're not going to be included in studies for us to be able to identify the differences in how things work or do not work for them. So I am a huge proponent of making sure that all my patients understand that this is an option. I don't try to force them into it, but I do tell them there is an option and why it is important, right? And with this, as well as our diets, how our diets affect, you know, our well-being, our medications, and as well as comorbidities. We have different groups that have different comorbidities that, again, can affect the kind of medications that we give or do not give. So one of the benefits, and as I mentioned, utilization of all these wonderful things is that it gives objective data to decrease mistrust in the healthcare system. I can't tell you how many times my patients are so happy and delighted to know that there's actually a test that will help. And I am very clear that this is not going to tell me specifically about any medications as if it's going to be a perfect fit. No. This is the combination. This is just a piece of the pie when it comes down to complete assessment to try to select the best medication. It's a piece of the pie, but they just happen to have that small piece compared to before never having it. You have less trust and errors to increase adherence and decreasing side effects. You have more information and shared decision-making that allows these patients to feel more inclusive and increase diversity in pharmacogenic evaluation and research, which is huge. I'm definitely a big proponent of this. This also gives you a holistic approach. You know, to me, providing the best care is also listening to what the client wants. One thing that I should have mentioned a little earlier, I do have, obviously, a half-Indigenous background, and my family definitely believes in the medicine man. And if the medicine man comes back and tells you that you need a leaf from this, a leaf from that, and you drink this tea, my family is going to do that. And I have to respect, and I cannot talk down at that. But what I have done to include this in my practice is that I always try to address those questions or even ask them, is this something that you believe? Is this something that you want to integrate into your practice? It does take some time for my practice to research the interactions between potentially what they're drinking or trying to drink or take, but sometimes they come back and say, you know what, I tried this on my own, and it does not work, and I'm ready for medications now. So again, you have to have this holistic approach mentality and respect their perspective, their views, because you don't know how strong their background is when it comes down to the perspective of mental illness versus mental fitness, or even if you are opening the door, closing the door by not having those conversations. So one scenario that I'm going to share, actually, I'm going to share two scenarios. One is an adult. This was a young man who went into prison when he was about 15 years old. I don't remember quite sure why he did, but he wasn't, I want to say murdered, because he was sentenced to 20, 25 years, and he was sentenced as an adult, but he was released 15 years later because in Florida, some kind of law came out that if you were, no, he was sentenced to life. He was sentenced to life as a minor. That was not legal. Therefore, you could do, I think, 15, 20 years, and then you have to release, and he was released on that technicality, and this young man suffered from severe bipolar and sometimes with psychosis. He did not want medications, and for the first two, three times that we met, he refused medications. He didn't want to talk to me, but everyone who was part of the care team, including social workers, psychologists, nurses, peer specialists, you name it, knew that he needed something, and after having some conversations, nothing related to mental illness, because he would not see me if I talked about that, realized that this young man was severely abused as a child. He was homeless. He was in the foster care system, and then when he was in prison, he was forced to take medications, and while taking those medications, he had severe side effects, and that also make him vulnerable for other inmates to take advantage of him because he was so sedated. For that reason, he didn't want nothing to do with medications, so I discussed pharmacogenetics, saying, number one, this will just give me an idea of where we are, where we could start, and I'm not going to do anything with you. You tell me. We will always start at a lower dose. We will start with one medication at a time, but you do need some help if you want to be a productive and independent citizen and get out of this, what we were, which was a homeless shelter, and I want to say I worked with this young man for about three years, and eventually he was able to share a whole lot more information about his culture. I believe he was a Rasta as well, and how he came to be that, and part of those conversations included coming with the best treatment plan for him, and finally, he was able to take some medications. He was, he went on his own. Next thing you know, I understand he ended up in Hawaii right before the COVID pandemic, and he was shipped back because he didn't have a place to live, but it was just happy to see that he was able to move on from not being, and refusing medication to taking medications, but again, that required a lot of conversation about social and cultural perspective, nothing to do necessarily with his mental illness because he didn't want to have those conversations, but when the wall came down, I have to say that he was probably one of the most, the movement the most, and I think that I have learned a lot about, you never judge a book by its cover, right, because you never know where these individuals came from and why the experiences that they have had have placed them where they are, so. My next scenario had to do with a child, a mother, divorced family. Mother was Latina from Puerto Rico, and the father was Haitian, but he was well-to-do. He was a pro, ex-pro basketball player, and the child, who had experienced severe verbal and emotional abuse, was suffering from depression and some ADHD as well. The family could not agree on a treatment plan, and after being evaluated, I want to say, I don't know how many times, but all the evaluations came back positive for depression as well as ADHD, and the father, who was the biggest refuser of medication, I had to spend a lot of time with him as well, and his background came more because people were giving people medications or things where he came from that actually made them worse than better. He didn't want his daughter to be exposed to anything, and again, having those social cultural conversations, education, and he had the resources to get all the potential tests, pharmacogenic tests, and everything that you could possibly have, so we did that with him, and then we realized that, again, we're going to start small and slow. They both agree, and the young child, I want to say she's about 10 years old now, is doing much better, doing better in school, doing better at home, in the two different homes, and we also make sure we're integrating therapy as well for everybody in the family as well as the individual, so this is just some of the few things that I could share for you. Again, what is the endgame of this conversation? Implication for brain space decrease. You have to decrease your unconscious bias, so you have to become aware of it. Remove judgment. It can help you become more personalized with the individual. It allows for them to see you for who you are. It allows you, in a way, to be vulnerable to your own patients who, they think that you're untouchable, and for that reason, they don't think that they could open up to you, us. Reduce morbidity and mortality and improve whole health for every individual person. Help to improve the knowledge and attitudes about providing culture-sensitive care among diverse and underserved population, and I think there's one thing that I want to say that working with this population, diverse population, underserved population, homeless population, individuals out of prison, out of jail, who just seem that they themselves see themselves as the worst of the worst or maybe not being worth other people's perspective of attention. They see us as untouchable or that we know too much, or sometimes what they're saying is just may seem silly, so just by becoming vulnerable and open to them, they see you more of a human being able to share a little bit more. Embrace space, in summary, is the concept where people come together to understand and learn within a space, and those things have five elements, right? You have to be able to have controversy with civility, owning intentions and impacts, challenge by choice, respect everyone, and don't take it personal, do not attack one another. This is one of my last quotes, the most famous quotes that I have loved, all of the forms of inequality, injustice in health is both shocking and humane, and this is by Dr. Martin Luther King Jr., so you have to become aware of your biases. If you don't think biases, that is one of the major barriers you have to overcome. Know where you fall on your biases. How do you plan to use brave spaces or create your own? You don't have to call it brave spaces, create something, and how do you plan to increase the health equity one person at a time, and this is how I leave you, and I thank you so much for your time and here are the references. Thank you, Dr. Millender, for such an interesting presentation. Before we shift into Q&A, I want to take a moment to let you know that the SMI Advisor is accessible from your mobile device. Use the SMI Advisor app to access resources, education, and upcoming events, complete mental health reading skills, and even submit questions directly to our team of SMI experts. Download the app now at smiadvisor.org. And now we'll take just a few questions for Q&A for Dr. Millender. The first question, there continues to be a trend with African American males and acceptance of psychopharmacology supports based on community and cultural stigma as well as reduced libido. What is the best approach towards stability for this population? Thank you. One of the things that I always try to figure out is because sometimes this population have a lot of stress that they do not disclose, therefore I try to ask a lot of the questions about what is happening at the moment, because sometimes it's more than just the medications, but then I try to see if that is a medication and we definitely see the connection or correlation with the medication, I try to potentially just try to change to another medication. It seems that if it's antidepressant, some of those that work well for these populations are well-futuring, they normally, we change it too, and it has been so far so good for them. Great, thank you. And with our time, we just have time for one more. Do you have any recommendations on how to get clinicians on board to use Brave Spaces in their clinical and educational organizations? I have to say that I have not heard much about Brave Spaces until I started reading and discussing it more in different settings. So I would say trying to have more continuing education, sharing this idea and perspective in different settings, because I don't think too many clinicians know about it, and potentially creating something like bullet points or how to do that, like I just did, and sharing ideas. Great. Well, thank you for helping get the word out on this very important way to improve our care. Thank you so much. If you have a follow-up question about this or any topic related to evidence-based care for serious mental illness, our clinical experts are now available for online consultations. Any mental health clinicians can submit a question and receive a response from one of our SMI experts. Consultations are free and confidential. SMI Advisor is proud to partner with the American Psychiatric Association on the Mental Health Services Conference, which takes place on October 14th and 15th. The keynote address at this conference features Dr. Miriam Delfrin-Rittman, a newly appointed Assistant Secretary of Mental Health and Substance Use for HHS and Administrator of SAMHSA. The conference agenda features topics such as climate change and mental health, sociopolitical determinants, structural racism, mental health in rural and indigenous populations, and much more. I encourage you to learn more and register now at this URL. To claim credit for participating in today's webinar, you'll need to have met the requisite attendance threshold for your profession. Verification of attendance may take up to five minutes. You'll then be able to select Next to advance and complete the program evaluation before claiming your credit. Lastly, please join us next week on September 16th as Dr. Brian Hurley with the University of California at Los Angeles presents Treating Co-Occurring Opioid Use Disorder in Mental Health Settings. Again, this free webinar will run on September 16th from 3 to 4 p.m. Eastern. Thank you for joining us and until next time, take good care.

Dr. Donna Roland

Psychiatric Mental Health Nurse Practitioner Program

UT Austin

SMI Advisor

culturally informed psychopharmacology

serious mental illness

AMA PRA Category 1 Credit

Dr. Eugenia Millender

Center for Population Sciences and Health Equity

brave space