My name is Kate Hardy, and I'm the co-director of PetNet based at Stanford University. I'm absolutely delighted to moderate today's session, Racial and Cultural Mental Health Disparities, Early Psychosis, and the Effects of COVID-19 on Mental Health. Now, I would like to introduce you to our faculty for this session, Dr. Maxie Gordon. Dr. Gordon completed medical school in Nashville, Tennessee, and a combined psychiatry and internal medicine residency in Greenville, North Carolina, where he served as assistant professor and founding director of the Medicine Psychiatry Unit. Dr. Gordon moved to Mississippi, where he served as a National Health Service core scholar. He later joined the faculty of the University of Mississippi. There he became the associate professor and director of medical student education. Dr. Gordon is experienced in both institutional and community psychiatry, where he works as an activist. He reads and speaks widely on health disparities and has a weekly radio show. This radio show, called HealthWise with the Health Spurts, targets black and brown audiences with the aim of educating people in their own language and is award-winning. Dr. Gordon reports the following relationships, the Speakers Bureau of Neurocrine, Janssen, Alchemids, Synovian, and Intracellular. And I will now turn the presentation over to Dr. Gordon. Thank you. Thank you, Dr. Hardy. Good morning, everyone. I guess it's evening, afternoon on the East Coast. Thank you all for joining us today as we talk about this important topic. Our objectives today, we're going to explain the role that lack of financial resources, as well as discrimination and inequalities play in increasing poor outcomes, poor health outcomes for minorities. We're going to discuss the role of early intervention in improving outcomes in minority populations, and discuss ways that proper intervention by law enforcement may lead to better strategies in early psychosis. Finally, we're going to end by discussing how COVID-19 complicates the treatment of mental illness. Next slide. Now, it's well known that in the United States, minority populations have experienced numerous instances of social injustice. Minority groups are often seen as inferior and receive differential access and treatment to mental health resources. Next slide. In the early days for minorities, African-American ancestors, of course, were forced to leave their native land and were brought to America as slaves. Native Americans were forced off their land and placed in the reservations where there are few natural resources or opportunities for financial gain. And that, of course, was the Indian Removal Act of 1830. And Chinese-Americans, and we still see some things regarding Chinese-Americans. Recently, there was a convention and the COVID-19 situation was described as the China flu. But Chinese-Americans were denied access for immigrating to America and a path to citizenship, the Chinese Exclusion Act of 1882. Ancestors of Hispanic and Latino descent were able to become U.S. citizens through acts of conquest. However, they continued to face discrimination because the Jim Crow laws early in the century actually caused these individuals to have many instances of discrimination. People who were Hispanic were, you know, forced off their property. They were sometimes lynched, and a lot of times they were raided and sent back to their country. Even citizens of the country who were Hispanic were sometimes arrested. Next slide. Okay, let's go to the next slide. Now, the common thing among these racial groups is they've not been given a place easily in American society. In fact, they have to gain it. There are many social injustices and hardships that minorities went through before there ever any justice for having a place in American society. Now, this is not just a U.S. problem. We see that in lots of countries where there's a minority community. Next slide. Now, one of the earlier things, as we go to the next slide, is for minorities, especially African Americans, people would make up situations and they would use medicine to kind of justify the way things were. There was a doctor, Samuel A. Cartwright, who came up with a disease called Drapetomania. Drapetomania was a mental illness that caused blacks to want to run away from slavery. So, if you're enslaved and people are beating you every day, and you're being poorly treated, if you run away from that situation for a better life, then you're having mental illness. It's called Drapetomania. Now, there was a cure. He not only came up with the disease process, but he came up with a cure. Next slide. The treatment was either whipping the devil out of them or removing both big toes. Next slide. Now, Dr. Cartwright was at the Medical University of Louisiana. He held the title as an expert in the diseases of the Negro. Now, at one time, I was at the University of Mississippi and asked for that title, but they kept asking me, what do you know about black people? So, I didn't get that title in Mississippi. Next slide. So, discrimination has been a primary form of injustice among racial and ethnic minorities for centuries. Now, this applies to a lot of different situations. Housing rentals, there are certain housing, there are certain neighborhoods that minority people could not move into. Employment opportunities was a really big one because these individuals were not allowed to have certain jobs or work in certain situations that may have been management. There was a thought at one time that people of color, black and brown people, that these individuals didn't have the intellectual wherewithal to have management potential or have opportunities to actually give directions to other people. Medical care has also been a big one. There was an Institute of Medicine Studies not long ago that demonstrated that regardless of your insurance, if you were a person of color, you were less likely to receive the best forms of health care. So, acts of discrimination and perceived discrimination cause distress for minorities, which is distress that is not normally experienced by white Americans. Discrimination is felt by 25% of African Americans in a day-to-day life and 3% of individuals who are a non-minority. The other thing is that being discriminated against can cause depressive symptoms for many people of racial and ethnic groups. And the reason is, is that being denied all the time, being denied opportunity, being denied jobs, being denied fair housing, may lead some people to develop depression or a sense of hopelessness or helplessness. They feel as though things won't get any better. A lot of times, we just had an election and one of the things that we used to talk about during elections is people feeling as though their vote didn't count, that nothing was going to change for their particular group, regardless of how active they were in terms of voting. Next slide. Next slide. Dr. David Satcher, who was formerly Surgeon General, talked about the fact that racial and ethnic minorities have less access to needed care. And not only if they were to get care, they're likely to receive a poorer quality of care. And let's kind of expound on that. Next slide. So, Blacks versus white or people of color versus white, and this is true across the board in terms of people of color, they tend to have less personal or less parental education, which means that a lot of times they don't have a lot in the way of health literacy. It's hard to know what to ask for when you go to a hospital or to a medical clinic. If you're not informed of what's out there and what's available. We know that these individuals may have a poorer quality of life. They're more likely to be homeless. And they're less likely to have private insurance. And private insurance may be a big marker for a lot of practices, because people who don't have private insurance, there are some practices in my area that don't take publicly issued insurance programs. They only take private insurance or they take people with private pay. So, some of the super specialists, a lot of these individuals don't have access to. Next slide. In continuing with the branding of people and the labeling of people, in the 1960s, both the ICD and the DSM included a category of mental retardation caused by deprivation. Meaning if you grew up in a home and there weren't many books and your parents weren't educated, then you don't have as much capacity to do the things that you want to do. These guys were given a diagnosis of mild mental retardation. If you look at some of the charts in the southern areas of the country, you'll see that a lot of people have this diagnosis of minimal brain dysfunction. That's what they called it. That if you didn't grow up in a neighborhood or in a situation where you had enrichments or culture, then you were perceived to have mild mental retardation or difficulties in terms of brain dysfunction. Next slide. Next slide. And this continues. You know, people of color also have behavioral issues blamed on character flaws. For example, a young person of color who may present to an emergency room or present to a clinic, if they're having difficulty sitting still in class, difficulty obeying the teacher, difficulty with focus, if they want to ask questions during the lecture, then they're likely to get the diagnosis of oppositional defiant disorder. Okay. And this happens to people of color primarily. Oppositional defiant disorder, which is considered more of a character flaw than an actual illness that can be treated or that's amenable to medication. The other thing I talked about was minimal brain dysfunction. A lot of students were dismissed early on because they felt like, well, they came from homes where there's no books, there's no culture. The parents are not educated. Parents are not learned individuals. So what do you expect? So those are the types of things that happen with people of color. And a lot of times when people of color go to emergency rooms, not to disparage any emergency room personnel, a lot of times they will get these types of diagnoses. I get them in the office all the time with the diagnosis based on one visit of having oppositional defiant disorder. And whether this is through emergency rooms, through other institutions, through schools who want them evaluated, this is a thing that happens. Next slide. I wanted to briefly mention this book and I'm not endorsing the book or not reviewing the book here, but this is what Protest Psychosis is. It's a book about the fact that African Americans during one period of time, if they protested racial inequality, if they protested their treatment by authorities or by medical workers or by the government, the diagnosis of schizophrenia was rewritten to include those individuals who were protesters as having schizophrenia. So it talks about the fact that schizophrenia went from one group of people to these inner city black males. And you see that, we still see that, that black males and people of color are more likely to be diagnosed with schizophrenia, even if they don't have schizophrenia. And that's one of the unfortunate things about diagnosing and the people who are doing the diagnosis. Next slide, please. Next slide, please. So regardless of a person's background, people who live in poverty usually experience poor health. And those in the lowest socioeconomic classes are more likely to suffer from a mental disorder. Of course, wealthier communities, we know, have greater access to mental health services when compared to communities of poverty. Okay? The rate of use of mental health care services is much lower for adults who live in poverty. One of the interesting things that is important to note that minorities, minority populations of all kinds, are more likely to live in communities that have an increased susceptibility for experiencing mental health issues. Now, what does that mean? That means if I'm a minority or if I have minority status, I'm more likely to live in the community, especially if I'm impoverished. I'm more likely to live in a neighborhood where there's violence. Does violence keep me up at night? Is there shooting in my community? Am I afraid to go for a walk in my community because someone may shoot at me or I may get robbed? Do I live near dumps? Do I live near some, you know, big area where they built, you know, a waste storage place or something of that sort? Do I live in an area where there's lots of power line? The other thing is, do I live in a food desert? Do I live where I can't go to a grocery store because there's not one that's open, but I can get fast food, I can get food that may be less healthy for me, and it's fairly cheap. I have to admit that there is this place that sells two chili dogs at a dollar a piece. I love that place. There's not a grocery store anywhere near, but two big chili dogs for $2 sounds pretty tempting if you don't have a lot of other things going on there, so absolutely. You will see that African Americans are less likely to use mental health services versus other groups, and a lot of that has to do with distrust of the medical system. Now, most of us know about something called the Tuskegee Study, and the Tuskegee Study was a study which started in, I believe, the 1940s, but ended in 1972 during my lifetime, strangely enough. But this was a study in which people around the Tuskegee, Alabama area were being treated for syphilis, or so they thought. They thought that they were being treated for syphilis, but it turned out that they were not. They were allowing the public health service, which is a governmental agency, may I add, the public health service allowed these individuals to have their syphilis progress. So they gave syphilis to other people in the community, and their children were born with terrible birth defects, and the reason for that is so that they could see the long-term prognosis of the disease, even though the treatment for syphilis was readily available discontinued. So when you talk about distrust of the mental health system or the health system itself, people of color have a lot of reasons to be distrustful, especially if you go to some place where the people don't look like you, where the providers don't look like you. The other thing, of course, that's important is that there were a number of studies done with medications. There are another number of drug studies done with medications that involve people of color, usually prisoners, and it was colors that, it was medicines that they didn't agree to take. There was a situation in Kentucky that was sponsored partly by the public health service, and I think partly by the Central Intelligence Agency, in which African Americans thought that they were getting treatment for opiate dependence, but as a result, what was really going on with them is that they were getting LSD. They were given LSD to determine what the doses would do to them, the effective dose for what they wanted to achieve, as well as what the potential side effects were, and these individuals thought that they were being treated and that they were getting better, but they thought they were going to get better, but what happened is that they ended up having more illnesses or more problems related to these particular things. So what we've talked about up to this point is the fact that minorities and communities of color have always experienced discrimination, especially when it comes to health care, but not only in health care, but in job and work situations, in communities where they could live, and opportunities that were afforded to them, and these particular situations have caused these communities to suffer. They have poor quality of health care. They have less means for achieving health care, and they have less opportunities. So let's combine that with individuals who may become plagued with what is called early psychosis, and early psychosis psychosis is a brain and environmentally influenced condition that is present with many mental disorders. So what is early psychosis? We know that psychosis is something that can happen to individuals in kind of the prime of their life. One of the major theories behind psychosis is that individuals develop some type of brain dysfunction in which they have too much of a particular chemical, too much of a particular chemical called dopamine, in certain areas of the brain. One of the things that goes on is that many families and friends are unaware of the early signs of psychosis. They really don't know what the signs are, and it usually takes a while when there's a realization that something is wrong, and when they find out that something is wrong, people, the family members usually struggle with knowing what to do to receive treatment and care. A lot of times, minorities who experience the onset of mental illness are misdiagnosed. We had a lady who came into the emergency room once at a hospital where I worked, and she was talking with the resident who was on call. The resident was from, I think, an Eastern Bloc country or something at the time, and the patient was saying, I came in because Jesus told me that I needed to get some help. So the resident asked her, have you been talking to Jesus? She says, yes, and he's been talking to me. Now for a lot of people in the South, that means that Jesus talks to them in spirit, that it's a thing in their mind. But this lady got hospitalized with schizophrenia because the belief was that she was hearing voices and that she was responding to those voices, and that was one of the things. So a lot of things may be cultural. There are some people who have cultural beliefs about mental illness, about things that go wrong, and so once people realize that there really is a problem, there's difficulty in terms of deciding what to do. Some physicians who care for racial and ethnic minorities can fail to notice early warning signs that leads to misdiagnosis, and that can delay proper treatment. For example, when we don't take people to the proper types of doctor, when we take our psychotic patient to general practitioners and they get diagnosed with anxiety or something, or when we take children who are having mental health concerns to their pediatrician, and especially that pediatrician is not accustomed to those types of symptoms, they can actually become mislabeled, and that means that it's longer, it's a longer time for them to actually get the care that they need. Next slide, please. Now, when we talk about early psychosis, one of the things we're saying is that these psychotic symptoms are hallucinations. These are individuals that see things when nothing's there. Of course, delusions, delusions are false beliefs, disorganized thoughts, and disorganized thoughts are actually when people don't make sense. We used to teach the medical students that if you go out with someone and you have a conversation with them, and they don't make sense and they're disorganized, don't go out with them anymore, because it means there's a problem there. So these individuals can be quite disorganized once they're psychotic. Now, the negative symptoms, they can have decreased emotional expression, socialization, they can have lack of motivation, they can have decreased energy, and they can actually have decreased ability to initiate new things. Early warning signs of psychosis, a lot of people miss. It can be changes in your sleep pattern, changes in concentration, disruptions in appetite, difficulty with decreased energy, perceptual abnormalities. When people tend to become focused on more unusual beliefs, they can have some mood swings, and of course, they can have speech that is disorganized, and they can have loosening of associations. Next slide. And of course, there's a lot of stigma associated with mental illness and mental disorders. When people become mentally ill, a lot of times it's the stigma that causes them not to seek proper care. They don't seek psychological care. Mental health isn't discussed among a lot of minority communities. I grew up in a community where people had mental illness, but it was never discussed. We had a lady across the street from us who always saw people trying to break in her house and saw Martians up and down the street. We as children thought it was odd, but obviously nobody else did because they didn't tell us that that was a thing, that that was not something that was normal. So a lot of times, individuals who have mental illness, they're just kind of put in the back rooms and they're not taken out because a lot of times, it puts a stereotypical thing on the family. The family thinks if somebody in the family has mental illness, then that shines a negative light. So a lot of times, they don't want that discovered. Next slide. So these individuals who have mental illness can internalize the stigma, meaning they can experience hopelessness and decrease self-esteem. They can say, hey, I have mental illness and something must be wrong with me. I've got to keep it to myself. I really just can't tell people that I'm seeing things or that I'm hearing things or that the CIA is coming to get me. So this can be harmful because it may delay treatment-seeking, especially in early psychosis. Next slide. So we talk about the negative attitudes and beliefs about mental illness and how they can become internalized. And we know that individuals who are in the early phase of psychosis, who internalize the stigma, they tend to suffer from greater depression compared to those who do not internalize the stigma, meaning the people who internalize it, they feel the sense of hopelessness. They feel the sense of depression. They don't reach out to other people. And that's one of the problems that we have in terms of getting these individuals to seek treatment, especially early on. Remember, one of the things is first recognizing the fact that you have these psychotic symptoms. The other thing is seeking treatment for them and overcoming things like stigma, overcoming mistrust of the health system, and overcoming the other barriers such as financial barriers. Do I have money? Can I go somewhere and see someone? Can I see a private psychiatrist or a private psychologist? Can I see a private therapist or do I have to go and stand in the mental health center where everybody can see me and know that there's something wrong with me? Next slide. So early psychosis, we talk about the fact that the duration of early psychosis is the time it takes from the moment where there are onset of symptoms to the time that there's proper treatment. Now, duration of early psychosis, how long this early psychosis goes on is important in terms of determining the outcome. Normally, although there have been some exceptions, normally the duration of untreated psychosis, the longer duration of untreated psychosis, the more, you know, the more harmful the outcome. You know, it pretends a poor prognosis. If I'm psychotic, if I'm psychotic for a long time, if I go untreated for a long time, then I may have a poor prognosis once treatment starts for me. So shortening the duration of early psychosis is an important point. And how do we figure this out? We try and see where these early psychotic people go, who do they interact with? How do they come to our attention? Next slide, please. These are, and this is one of the things in terms of criminal justice settings. We know that a lot of individuals who have early psychosis go through the criminal justice system. And I believe this is some, from some of our references, and a lot of it comes from the Bureau Institute, that 37% of participants in this particular study were incarcerated at some point during their duration of untreated psychosis. And during this point of incarceration, these individuals had a delay in terms of treatment. Because a lot of people who get incarcerated or who go through the criminal justice system are not properly screened for psychotic symptoms or mental health symptoms in general. A lot of times these patients are considered to be just bad people, or people who are breaking the law, or somebody who's out at night, you know, attacking cars and making noise, okay? So when we talk about early psychosis, we really have to address issues with the criminal justice system. Next slide. Okay, and we just, it reiterated the fact that, reiterates the fact that many individuals who suffer from early phase psychosis, they're admitted for treatment or cure after being arrested are injured, okay? People who have this early psychosis are more likely to be victimized. Absolutely. We see a lot of people who are homeless, who have psychotic disorders, who have mental disorders, who are on the street, and these individuals are sometimes robbed, they're sometimes beaten. A lot of times the authorities are called on them. They actually may be a nuisance in some communities. Instead of getting help or treatment for these individuals, the police is called, and that can sometimes lead to bad outcomes. Next slide. Other information from the Peer Institute, the Blacks are overrepresented in the criminal justice system. I guess that's not news to anybody. People of color are less likely to be screened for mental health issues while incarcerated, and we're just reiterating that. 25% of people in jails have mental illness, and this was a sample that was comprised mostly of African-American males, and according to the Veer Institute, this group is disproportionately arrested and incarcerated, and there's lots of information on the arrest of people of color. There have been lots of, a number of policies in cities where people of color or people in certain communities are stopped. They're searched. Their cars are searched, and they're arrested if there is any reason to take them in. Next slide. So let's do a couple of patient things, and this is a patient that I'd followed for a long time, and she was a young lady who developed an early psychosis. It was a while before she came to my attention. At first, she started believing that she was dying and that her flesh was rotting, so she came to the mental health system after she had gotten fired from several jobs, and she'd gotten fired from several jobs because she believed that the people at her job could smell her rotting flesh. So at first, she would put on lots of cologne and perfumes and everything like that, and they told her, hey, you're wearing too much perfume in the workplace or people with allergies, you know, just kind of tone it down. After she stopped wearing as much perfume, if people were standing around the workplace, she worked at a factory that made furniture here in Mississippi, but after she's toned down the perfume, if she saw people standing around talking, she could actually hear them talking about her and saying that she was rotting and that they could smell her rotting flesh and that certain parts of her body was rotting. So she came to our attention after she had lost several jobs in the family, after they just thought she had a body odor problem, even though they couldn't tell she did, they decided to bring her to the mental health center. It was determined that she was psychotic. Later she was diagnosed with schizophrenia. There was a crisis call about six or seven months into my treating her, and she called the mental health crisis line and said that she was in our house because there are lots of demons outside and those demons were coming in to get her. And she said the demons look like soldiers and some of them look like policemen and some of them look like ambulance workers. But at the time, there was nobody at her door, there was nobody outside her house. So the mental health crisis worker decided, well, I can't get there right now. So what I'd like to do is I'm going to call the local police and just ask them to go by and do a welfare check. So the local police go to her house and they, of course, knock on the door and nobody comes to the door. So then they beat on the door and nobody comes to the door, but they can look inside and see that she was there in one of the corners. So they decided to break the door down to go in and check on her. When they went in to break the door down, she started to fight. She called back and said that the demons were coming inside and that they were going to kill her. And that's when about the time the police broke down the door and they went inside to take her for an evaluation. After her interaction with the police, she was taken to the crisis center. The doctor at the crisis center noted that she had multiple bruises and lacerations and referred her for medical care and then brought her back to the crisis center. This lady actually was charged with assault on a police officer. She was she was taken to court in that local town. She was fined and given supervised probation. So this is a situation where the lady was obviously psychotic and there should have been some other intervention. And I think at the time that was the best intervention possible, maybe, but certainly not the right ones. Now, I'm going to show you one from the national media. And I'm going to warn you, for some people, this video may be graphic. It involves a young man who was suffering from a mental health crisis and the police was called. And I believe this was outside of Dallas. And this video is on public media. It comes from CNN. And I think we're going to show it now. So this is a gentleman who was having a mental health crisis, and I think he was with his grandmother. His mother had called first and says, my son is having a mental health crisis. He's at his grandmother's house. He has schizophrenia or he has bipolar. And he's acting out and we need somebody to go and help him. Can you send an ambulance by? I think that's the way it went. And instead of an ambulance, of course, the police went first. So a lot of times when and a lot of times when we're having situations where the police are the people that are called to help out with individuals who have mental illness, a lot of times we have bad outcomes. And unfortunately, when people are at their, you know, people are at their, you know, most needy point. This is from the Vera Institute. It says people are police are often called to help people who are at their most vulnerable and don't think that they have anywhere else to turn for that interaction to end and gunfire death is deplorable. People should not be forced to call police, which can lead to further involvement in the criminal justice system in order to get care, attention or support for a sick family member. So one of the things, of course, is involving law enforcement. Now, I know that law enforcement is sometimes necessary, but I think the proper thing would be to involve to have crisis teams and the community and a lot of mental health centers do have. Next slide. OK, 60 percent of people in jail reported having symptoms of mental health disorder 12, 12 months prior to the study. Next slide. And this is just a thing from Massachusetts that talked about the fact that a third of all police shootings involved individuals who were having a mental health crisis. So not to disparage the police in any way, but to help people who are having with these individuals who have early psychosis or having difficulties, there need to be a plan in terms of caring for them. Next slide. Interventions that we can intervene early and early in untreated psychosis, these individuals will have a better outcome. We know that there is more research that's needed in order to understand these individuals and what the barriers are to effective treatment and engagement. Next slide. There is cognitive remediation that has been shown to improve the treatment of patients with early phase psychosis. There have been some successes in intervention that helps people to dispel the stigma associated with early psychosis or being psychotic or having mental illness by itself. Next slide. OK, we know that young adults with early psychosis, they need to have an access point that they can, you know, that they can access or a place that they can go prior to reaching a crisis point. And remember, a lot of times these individuals, it's not known that they have a psychosis because it's not recognized. Either it's missed by their mental health, either missed by their medical provider or family members. They attribute it a lot of times to other things. Next slide. So there's research that's ongoing trying to understand the biological context of racial and ethnic minority groups and understand that mental illness may be a personal or a group thing. I mean, the way that African-Americans experience mental illness may be different from Asian-Americans, may be different for Hispanics, may be different from Native Americans, or from people of European descent. So a lot of times it's a cultural thing. Next slide. So there are several approaches, there's effectiveness-based approach, efficacy-based approach, and of course there are psychosocial interventions. Next slide. This is just something also by the Vera Institute that says a lot of times if there's not health care or mental health care in the community, a lot of these people are rounded up. Sometimes a lot of homeless, psychotic people may be arrested, may be put in the medical, I mean, in the criminal justice system. And sometimes they get out because the criminal justice system just cannot support the cost of maintaining these people and providing them the help that they need. Next slide. So lack of health insurance may be a barrier. We talked about that earlier. A lot of people who have mental illness may want to avoid the mental health system because of the stigma associated with going there. A lot of people don't want to go to a community health system and stand in the lobby and let all of their neighbors and friends know that they have some type of mental illness. So lack of health insurance may be a treatment barrier. Next slide. First episode psychosis, there is some information on first episode psychosis, and there is a number of things that may shorten the path or lengthen the path. Go to the next slide for me. And I was just there. I think it should be a diagram. And this is a nice diagram actually from an online source. And I think it's Kibasa and others who actually came up with this. But just to just give you the gist of this, there are some individual factors and health service factors that may help. We know that misattribution of symptoms, people who hear voices. I know in my neighborhood, people would become psychotic and they would have schizophrenia. I see that in retrospect. But people would say, oh, somebody, he went to a party and somebody put something in his drink and he's been crazy ever since. And they would blame it on the fact that he got some bad drink or some bad Kool-Aid or something. That's the thing. The other thing, of course, is stigma. The other thing is self-reliance. If the individual is relying on himself or if the family members are not informed, then that actually prohibits care and creates this cloud of uncertainty. But some of the quality factors includes interpersonal connections. If mental health centers connect with people, if they give good quality care, if the family has good education about mental illness, there is a way of helping these individuals improve. Now, there is a question here in terms of white providers can better support black patients. Is there a practical way to get whites or cashers to check their biases? You know, I think more training in terms of biases. I think, you know, and now that you've mentioned that, I always wondered about residency programs in psychiatry. If I have a residency program in psychiatry, I would certainly want it to be at a place that was inclusive in terms of having a number of psychiatrists of all groups and all strata to help people understand. When you've got just one race treating other races, that may be okay, but I think you have to have a deep understanding of the cultural mores and norms of those people in order to actually appreciate them. Another one is African-American professionals underrepresented, if absolutely. In lots of places there, African-Americans are underrepresented in terms of healthcare. They are less likely, and there was a study done a few years ago. Well, there was an attempt a few years ago to increase the number of African-American males in the medical profession. I don't know how that's going, but not only that, Hispanic doctors, people of Asian backgrounds, all of those individuals may provide a more cohesive system of care. Okay, all right. Next slide, please. So, decision-making, remember that these individuals who've been given this early diagnosis of early psychosis, the longer it's untreated, the more likely they are to have difficulty. When we involve the criminal justice system, when we involve emergency rooms, we're really not doing these individuals justice. Now, I know the police do a great job and I know the police do the best job that they can, but they do not understand early psychosis. I think policemen are good for the most part. I think they're given lots of duties and lots of responsibilities. And a lot of times they don't have the training for these individuals who have these mental health concerns. Next slide. So, finally, let's end in the last few minutes that we have and talk about the pandemic. Let's talk about COVID-19 and mental health. Okay, next slide. So, coronavirus has provoked a lot of fear and anxiety and many other uncomfortable emotions. And why is that? There's no vaccine or treatment for it. There are more unknowns about it than there are knowns regarding coronavirus. It's especially stressful for vulnerable populations who are homeless, okay, if they have homelessness, if they have mental illness, if people who have difficulty with employment, who haven't been employed, and also people who have some health problems such as smoking or COPD. The other thing is that in my practice, personally, I've had a lot of families who have been stuck together in the house working together because of coronavirus. And I've had a lot of people consider splitting up after spending so much time with their spouse. I was home with my children for a few days and decided that I would set up a tent outside in the yard in order to, you know, outside in the yard in order to keep the relationship harmonious. But one of the interesting things about the pandemic is something that was recently published in the American Journal of Medicine. And it talked about the fact that as of April 14, 2020 in the United States, 32% of the deaths from COVID-19 are among black residents, despite the fact that blacks comprise only 13% of the population. So here again, you have a pandemic that is stressful for everyone, but it's especially stressful for people of color who don't have resources. Next slide. So minorities who are suffering from mental illness during the coronavirus should be provided with information and advice. They should have information in terms of, you know, maintaining distance, how to go about protecting themselves, no penalties or punishment for immigration status. Isn't that an interesting thing? We say, hey, look, during the time that COVID-19 is going on, why can't we all just get along and let all of these things that we fight about and worry about during the rest of the time, let's suspend those things so that we can all just get through this pandemic. So specialized and individualized treatment plans are also important for our patients who have mental illness. Next slide. One of the things that's interesting is there was an article in the Journal of the American Medical Association, and it was an opinion article regarding psychiatry and COVID-19. And it talks about the fact that for a lot of mental patients, this pandemic will cause a delay in seeking care, that it's likely to cause a delay in seeking care, not only for the reasons that we've mentioned, but because a lot of hospitals are closed, a lot of mental health centers for a long time did not give access. And if there are individuals who have had early psychosis, who have become psychotic, that actually made the duration of early psychosis longer, and which we already said lead to poor outcomes. So that's an important point. Next slide. So a couple of solutions here, and we'll close with this, okay? Next slide. So what do we do? Racial and ethnic minority populations are continuously increasing. So what do we need to do? We need to gain knowledge on how to best help racial populations that are different from ourselves. I think it creates a better path to the right type of mental health treatment and the right type of medical care altogether. We're looking at tactics that are, you know, that are successful in other facilities, and we're trying to apply those to facilities that have people of color. Next slide. And there has, in the past, been an under-representation of minorities in research. I know that there's a COVID-19 vaccine, and I think they're reaching out to various groups in order to have them participate, because we know that there's something called ethno-psychopharmacology, that different ethnicities may actually metabolize medicines differently. So understanding that and understanding what works best for one population versus another is a way to go about helping with disparities and care altogether. Next slide. Crisis intervention teams. We have a CIT training program here at the local mental health center in which we have police officers who come and they get a day of, they get a day of information about people with mentally ill and how to interact with them. And I think some of them have some ongoing training. One of the things also is something called jail diversion strategies. Before we take people to jail who have mental illness, really having them evaluated and understanding that there's a mental illness present. Next slide. Culture. We just talked about culture. We talked about understanding the norms and beliefs of people who are refugees and immigrants, people who are of different cultures. Understanding that language and talking with people in their own language and the language that they can understand. Some of you who have health literacy issues with patients, as an internal medicine doctor, I've asked patients, does anybody in your family have diabetes mellitus? No, nobody has that, but a lot of people have sugar. Well, it's the same thing for them. And my favorite one is, I don't have any other things. The only thing I have is Arthur. I said, who is Arthur, your husband? Oh no, Arthur is the stuff that goes in my joints. So what she was explaining to him is arthritis. So trying to make sure that health literacy is on the table. And a lot of times that involves talking with people in their own language and being aware of their culture. Next slide. We talked about these things, minorities being underrepresented in mental health research. And we're trying to make amends with that. Companies that manufacture medications are including more minority populations and more groups of all races and cultures. Usually it was just white males and sometimes prisoners, depending upon the type of treatment that was being researched. Next slide. Okay. This is Dr. Timothy Summers. I'm gonna make him famous. He's a community psychiatrist here in the Jackson area. And he'd been practicing about 40 odd years. And when asked about this topic, he said this, he says that people who are black and brown experience trauma every day, usually in the form of microtrauma or microaggressions. And, but they're not recognized as such. You know, microaggressions meaning, you know, for a black guy, you use language well, or, you know, for a black guy, you're as hairy as Kiki is, you know, it should be, or something of the sort, or you're pretty to be a Chinese girl, or you're pretty to be Hispanic, or those types of things. So this constant microtrauma may cause anxiety, depression, sense of hopelessness in the disparate communities. These may manifest themselves as difficulty with sleep. These people may have more anxiety and substance use. Okay, all right. Okay, the chronic effects may cause disruptions and emotional stability. And as a result, these individuals may have conflict, not only with family members, but when they go in the community, they may have conflict with police. But thank you guys so much. Next slide. And we'll entertain some questions here because we're getting to the end of the session. So this is what we said, and I'll leave this up as we answer questions. So let's talk about race and schizophrenia. Do stresses of being a minority make minorities more susceptible to schizophrenia? Now, there is information that says, if I live in an environment, if I have a propensity toward schizophrenia, if I have some type of genetic predisposition, and I live in an adverse environment, or I have childhood adversity, if I live in an adverse environment, I'm more likely to develop schizophrenia. Absolutely. So that's research that's been out there, and that's something, okay. So here's another question about a lack of knowledge about psychosis as one reason why black and brown individuals may not seek care. I think helping people to understand psychosis is an important thing because a lot of communities don't. For example, I treated a group of people who were very, very, they had a religion where they believed that God communicated with them directly. So when their daughter started saying that Jesus was in the room with her and had come and talked with her, or Jesus had told her certain things, they thought it was because she had received the Holy Spirit and there was nothing wrong with her. Well, when Jesus started giving her misinformation and telling her bad things about the family and to do to them, that brought her to the attention of a mental health provider. So absolutely, I think explaining to people what he is and what is not mental illness is important. I had a situation once where a lady who became manic, who was bipolar manic, who went and all of a sudden on a Sunday gave all of her money to the church. Well, she just wrote him a check for everything that was in her bank account. Nobody objected for a long time until her family member said, hey, no, that wasn't right, she was mentally ill. So lack of knowledge plays a big role. And we try to increase knowledge in other situations such as in treatment and information about diabetes and other health conditions. The more knowledge we give people, the better they are to manage their situation. So we have a radio show, myself and another guy, Greg Gordon, who's an internist psychiatrist, and it's a once weekly radio show. And in that radio show, we try and target primarily, we have a broad audience, we think, but we try and target primarily black and brown people in terms of helping them with health literacy, in terms of understanding their conditions, in terms of understanding medical people, medicines, and the way that you discuss your symptoms with your doctor. What is a serious symptom, what may not be a serious symptoms, what may not be a serious symptom. We got a lot of questions when COVID first came, because there were a lot of buzz in the community that it was a disease that targeted people of color, because in our state, at least, initially it was the people of color who were dying from it. And so there was a big thing that it was a way to eliminate people of color. And remember, people can be justified in having these beliefs based upon the history of medicine. People of color have been experimented with without their consent. And even in this, in the last century, and even in this century, people have been experimented with without their consent. There are a lot of safeguards in place, but people have a reason to be skeptical. The historical view, you know, medicalizing protest or the protest of abuse means that there's a questionnaire that talks about the fact that, how do we improve the situation? Because in the past, we've kind of medicalized abusive situations. When Dr. Cartwright said, if your slave runs away from picking cotton, that he must have a mental disorder. And people believe that, and that was the thing. And they would round up their slaves, and there were even hospitals. There was a hospital in one state that I worked at for a while that was a mental hospital for runaway slaves. And so how do we improve that type of stigma? It's by educating people. I think there needs to be transparency in the things that medical providers do for people of color. Making sure, first of all, that there is proper language translation, that we get the proper language translation so that people understand that we properly consent them, and make sure that they are stakeholders in what we're doing. How can we change the criminal justice system? That's a big one. It really, so we've got just a few more minutes, but when I was a kid growing up in Jackson, Mississippi, there was this lady who lived up the street from us, and this lady would always go downtown and protest, and she would always be on the front lines of protesting stuff. And they would issue a warrant for her, and at night, the police would come to her house, and they would get her, and they would bring her into the front yard, and they would tell her what they were arresting her for. And she was an older lady, and she probably weighed about 90 pounds of weight. And she would look at us, and she would say, children, I want you to bear witness to what's going on here so that you can do something about it. And I guess that's what we all do when we see all of the things that go on in the world with people who are mentally ill, and just people of color in general. And I think we all bear witness, but we bear witness so that we can do something, okay? So it's our job to take what we know and take what we learn and be agents of change. I think it was Gandhi who said, be the change that you wanna see in the world. So I think it starts with training police officers, training people in the criminal justice system, training people who look for immigrants to round up. I think training all of them and helping them understand the complexities of being a person of color, not only in this country, but in other countries where people are minorities in the population. Now, the name of the radio show again is Healthwise with the Health Spirits. It's on 90.1 WMDR. And I think most people can stream it online. And I think that's the end of my presentation. Thank you guys very much. One more. What can we do to change the perception of mental health issues? One thing I think is looking at mental health as a brain disease. I tell people just like diabetes, your pancreas may sometimes not produce enough insulin to control your blood sugars. In your brain, you sometimes don't produce enough chemicals to control your mood. And that's why we give medications to help with those mood. And so talking with people about the fact that this is a real illness, that these are real illnesses, just like physical illnesses, and there are proven treatments for them, and there's no need to be afraid of stigma or anything else in terms of getting treatment.

Dr. Maxie Gordon

racial and cultural mental health disparities

early psychosis

COVID-19 effects on mental health

financial resources

discrimination

inequalities

minority populations

stigma surrounding mental illness

cultural competence training