Hello and welcome. I'm Dr. Amy Cohen, a clinical psychologist and director for SMI Advisor. I am pleased that you're joining us for today's SMI Advisor webinar, Zip Code and Mental Health, Where You Live Matters for Individuals with Serious Mental Illness. Next slide. 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. Next slide. Today's webinar has been designated for one AMA PRA Category 1 credit for physicians, one CE credit for psychologists, one CE credit for social workers, and one nursing continuing professional development contact hour. Credit for participating in today's webinar will be available until November 22nd, 2022. Next slide. 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. Next slide. Please feel free to submit your questions throughout the presentation by typing them into the questionnaire 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. And now I'd like to introduce you to the faculty for today's webinar, Dr. Benson Kuh. Dr. Kuh is an attending psychiatrist in the Achieving Recovery Through Resilience, Optimism, and Wellness Clinic at Grady Health System in Atlanta, Georgia. He provides clinical care for young adults experiencing first episode psychosis. He completed his residency and fellowship training in psychiatry at Emory after receiving his medical degree at Hofstra. His research, which was recently funded by an NIMH K23 award, focuses on the impact of neighborhood characteristics on conversion to psychosis among youth at high risk, which provides a novel integration of multiple levels of investigation, including public health, neuroscience, and developmental studies in humans to discover novel targets for intervention, both at the individual and the neighborhood levels to prevent or mitigate psychosis. Thank you, Dr. Kuh, for leading today's webinar. Great. Thank you so much for the introduction, Dr. Amy Cohen. And thank you for this opportunity for presenting at this webinar today. I'm very excited to be talking about some of my research findings, as well as how it can be used in the clinical settings. First, I just wanted to report that I have no conflicts, no relationships or conflicts of interest related to the subject matter of this presentation. And the learning objectives of today's talk is to first explain how neighborhood factors, neighborhoods impact mental health among individuals with serious mental illnesses. Number two, analyze the research findings on the association between neighborhood characteristics and mental health outcomes. And I'll be focusing on three particular neighborhood characteristics. One is food deserts. The second is a neighborhood poverty, and the third is neighborhood residential instability. And then the third objective is to apply research findings on neighborhood factors and mental health outcomes to clinical practice. So first, I just wanted to start with this slide, which is a picture of Elmhurst in Queens, New York. This is where I was born and raised. I grew up in poverty and lived with my parents and brother. I remember there was such a lack of resources in my elementary school and sitting in the back of the classroom packed with 40 kids with one teacher. I performed pretty poorly in school and almost failed third grade. And remember my parents' disappointing faces when they received the Jeopardy letter from the principal. I was also pretty socially engaged and I felt like I didn't fit in with the other kids. And the reason why I'm sharing my personal story is because my experience is growing up in my neighborhood has inspired my clinical and research interests in investigating the relationship between place and health, the relationship between neighborhood and mental health, which is part of a broader topic, the social determinants of mental health. And I just wanted to first put this in context of the larger picture here. According to doctors Michael Compton and Ruth Shim, the social determinants of mental health are the conditions into which people are born, live, and age that are shaped by policy decisions and distribution of opportunity within societies. Social determinants are primarily responsible for the health disparities and health inequities that exist between population groups and are akin to the concept of fundamental causes of disease, first described by Link and Phelan, and the causes of the causes. So shown here is a diagram that conceptualizes the various social determinants. Although you can see these are grouped into four boxes here of various social determinants of health, like homelessness, housing instability, food insecurity, adverse early life experiences, to name a few. And these social determinants often drive what appears to be individual level behavioral patterns, including high risk behaviors and seemingly poor choices, which can lead to increased risk factors for mental illnesses and substance use disorders, and ultimately contribute to early mortality for individuals with serious mental illnesses. Now this is a picture of Grady Hospital. This is where I worked as a resident. I currently work there as an attending. I remember coming in as an incoming first-year resident. I felt overwhelmed working in the emergency room, seeing such high volumes of patients presenting with suicidal ideations, acute psychosis, substance use disorders. However, I began to learn and appreciate the upstream structural factors such as homelessness and housing instability that might have led to and exacerbated their presentation to the emergency room. And with this greater appreciation and understanding, I've been able to picture myself in their shoes. Maybe if I were in their situation, I might be presenting with similar concerns. But these experiences also motivated me to pull the thread and conduct research to better understand the mechanisms of how social determinants and structural issues impact mental health. My hope is to develop effective interventions to relieve the suffering of these individuals. And I focused on one particular social determinant, the geographical area and neighborhood characteristics, which is also known as the socio-spatial determinants of health. The predominant literature on investigating geographic area level characteristics and health has been in epidemiology. For example, in the beginning of the pandemic, the COVID-19 pandemic, it was important to describe COVID-19 infections, mortality rate, hotspots, which counties in the US had higher rates of infection and mortality due to COVID-19. And so this is something we here show the unadjusted and adjusted infection rates and models A and B. And we show the unadjusted and adjusted mortality rates in model C and D. And we see that the hardest hit counties were those that had primary care provider shortages highlighted here in red, even after controlling for various socioeconomic indices. And this was important to see where cases were highest and where a lot of people were dying due to COVID during this time that aligned with places with shortages in primary care providers. We use similar approaches to identify hotspots for suicide rates in our country. This was a study that examined the relationship between mental health provider shortage areas and suicide rates from 2010 to 2018 in the US. Suicide rates were derived from the CDC Wonder database. And we found that at the county level, mental health shortage areas were significantly associated with suicide rates during this time. Also highlighted here in red. And the relationship remains significant even after accounting for age, gender, rurality, various socioeconomic indices, social capital, insurance status, et cetera. In fact, there was a significant interaction between time and mental health shortage areas and predicting suicide rates, such that we see increases in suicide rates only predominantly among mental health shortage areas shown here in the blue line, but not among counties with adequate mental health providers shown in orange line. And this is the incident rate ratio after adjusting for the potential confounders, what we've talked about before. And we see increases in magnitude of the incident rates over time. This is another way to depict the data. Here's the map of where mental health shortage areas are. Red highlighted areas represent counties with whole mental health shortage areas. And blue highlighted areas represent counties without shortage areas. You see that the darker colors represent higher suicide rates. So in this map, we see that counties in the Western and Central part of America have more mental health shortage areas, and these counties also have higher suicide rates. And the study's findings suggest that communities in the US are likely facing simultaneous challenges of limited access to mental health care and high burden of suicide. Furthermore, it might be possible that reduced access to mental health providers in shortage areas can lead to greater under-treated and untreated mental illnesses, leading to higher suicide rates due to delays in diagnosis, resource shortages. So this epidemiological type of study can help us see the big picture and help us see where suicides are clustering, as well as certain patterns in respect to county-level characteristics such as shortage areas or in respect to time. However, there are several limitations to these types of studies, mainly regarding the mechanisms and causal directionality of relationships. The mental health shortage area term also does not tease apart inadequate supply and demand of mental health providers, and it's still unclear how living in certain areas will lead to suicide. It would also be important to look at smaller areas at the neighborhood level, as well as a better understanding the living circumstances at the individual level. And one way to further explore this is to investigate outcomes at the individual level as opposed to the aggregate level. So the next part of my talk will focus on some examples of how the relationship between place and health has been explored in greater detail. I'll be talking about the association between three neighborhood characteristics listed here and mental health outcomes among individuals with SMI, including schizophrenia. So first, I wanted to talk about food deserts, the prevalence of food insecurity and living in food deserts among individuals with SMI in public health clinics. This was recently published in the Community Mental Health Journal, and this is a very important topic since such very little research has been conducted to date about this. This is a study that was conducted with 300 patients with a psychotic or mood disorder receiving outpatient services at five community mental health agencies in Washington, D.C. And what we found was that the prevalences of low food security and very low food security among individuals with SMI were 68.9% and 46.8% compared to the national rates of 13.7% and 5.4%. In addition, 50% of these participants lived in food deserts, census tracts. In this study, living in food deserts was more common among female patients associated with self-reported poor access to grocery store, and was associated with both severe and morbid obesity. In other studies, food insecurity is linked to depression, poor mental health outcomes, and poor physical health outcomes, including chronic diseases known to be disproportionately common among persons with SMI and likely associated with early mortality. Not to mention having to deal with food insecurity is a serious stressor for individuals already struggling with unemployment, low income, and having SMI requiring ongoing treatment. And although our study was quite limited in understanding the mechanisms of these associations, our findings suggest a need for greater clinical and research attention to food insecurity and residing in food deserts among those with SMI. In addition, there's a serious need for public behavioral health policy and service systems to pay increasing attention to the social determinants of physical and mental health. The next factor I'll be discussing will be neighborhood poverty and its relationship with social engagement and schizophrenia. To give a brief background about the relationship between place and psychosis, we have long known that urban upbringing or being born in the city is one of the biggest environmental risk factors for the development of schizophrenia. And this paper by Marge and colleagues does a wonderful job reviewing the literature on this topic. If you're born in the city, your risk for schizophrenia increases about threefolds. However, if you currently live in a city, your risk for schizophrenia does not considerably increase. The risk for anxiety and depression increases. But it's still unclear what aspects of the urban environment explains this relationship. And more recent studies conducted mainly in Europe have explored neighborhood level factors that may explain the association between urban upbringing and schizophrenia. Actually, the first researchers to explore neighborhood factors and its relationship to schizophrenia are Ferris and Dunham in 1939 in Chicago. They demonstrated an association between high rates of schizophrenia and city zones in Chicago characterized by poverty, residential instability, and low ethnic density, which they hypothesized may be due to social disorder or lack of cohesion. They argue that those who resided in these disorganized communities found it difficult to foster and maintain positive affiliations with local institutions, neighbors, and family members, thus increasing these residents' sense of social isolation, which was deemed significant to the onset and the course of mental illnesses. However, their work was criticized for lack of rigorous statistical methods as well as the social drift hypothesis, which postulates perhaps the association between place and schizophrenia may be due to people with schizophrenia who moved to these disorganized communities as opposed to exposure of neighborhood characteristics causing schizophrenia. Since then, most literature regarding neighborhood and schizophrenia has been conducted in Europe and Australia, and this topic has not been as popular in the US. However, I was quite fascinated by these findings from Ferris and Dunham when I learned about this in medical school at Hofstra, and it was around the time I was working as an emergency medical technician as part of my medical school curriculum where I transported patients from their homes to the hospital and saw their living conditions in neighborhoods. I reflected on the relationship between place and mental health and thought back to the neighborhood I grew up. And although I grew up in a poor neighborhood, there was this magic shop in Queens Boulevard called Rogers Magic Fun Shop, which I used to go to and hang out. I used to work there during the summers, and I found community there, and people were supportive when I was learning about how to do street magic and on rare occasions performed on stage. And no matter how the show went, we all went out and grabbed a late snack afterwards. Sadly, this magic shop went out of business during the pandemic. But my experiences growing up in poverty and being involved in this community have inspired research questions and interest in the interaction between neighborhood poverty and social engagement and predicting mental health outcomes. So this is a study which was pretty recently published in Schizophrenia Bulletin, which investigates the interaction of neighborhood poverty and social engagement in relation to hippocampal volume. These findings were also recently featured in Medscape. What we found, you know, we focus on the hippocampus as an outcome because it is highly vulnerable to cumulative stress and rich with glucocorticoid receptors. The hippocampus is really important in the pathophysiology of psychotic disorders and schizophrenia as well as other psychiatric and neurologic disorders. For youth at clinical high risk for psychosis, which means that they haven't developed a psychotic disorder yet and they're at the prodromal stage, it has been shown that there is progressive decline in hippocampal subfield among those with persistent and progressive psychotic symptoms. And between those with schizophrenia and those without schizophrenia, we see that there is differences in hippocampal volume. What I'm showing here is a T1-weighted MRI of the brain and the free surface segmentation of the hippocampus. What also inspired the study was a paper that came out by Taylor et al. And they showed the inverse relationship between neighborhood poverty and right hippocampal volume in healthy children. They postulated that above and beyond the individual level, living in a poor neighborhood may be associated with exposure to greater cumulative stressors that may impact cognitive function and neurodevelopment of the hippocampus. This is another great paper by Davidson and McEwen. And their study suggested that in animal models, social enrichment and positive social interactions can actually preserve brain structure and prevent plasticity-related changes in the brain by buffering the adverse effects of stress. So we thought we would test this in another sample to see if our results may replicate in terms of the relationship between neighborhood poverty and hippocampal volume. But in addition, we wanted to also see if social engagement may interact or may modify this relationship. And so I'll go into a little bit about the study participants, which they were recruited as part of the larger multi-site study called the North American Prodrome Longitudinal Study, otherwise also known as NAPLS. And this was a larger multi-site longitudinal study of youth at clinical high risk for psychosis, and they follow participants to at least two years. And the goal of this larger study was aimed to identify biomarkers for conversion to psychosis. So who ends up developing psychotic disorder or who doesn't end up developing a psychotic disorder? What are some of the predictors of it with the hopes of developing strategies for early detection, intervention, and prevention of schizophrenia and psychotic disorders? And just to talk a little bit about this population, in the course of psychotic symptoms with the early stages in psychosis, this figure illustrates a typical emergence of the early stages of psychosis as it unfolds during adolescence and early adulthood. As clinicians, we usually encounter and treat patients well after the first episode when chronic deficits and functioning are already in place and positive symptoms wax and wane, sometimes depending on whether they're taking medications consistently. However, the emphasis needs to shift to the earliest stages of this process and on how antecedent developmental liability are initially expressed as psychopathology during the final major stage of neurodevelopment in adolescence and young adulthood. And as shown, premorbid normality gives way to declines in school, work, and social functioning. And soon thereafter, psychological symptoms emerge that are precursors to the positive symptoms that later become the basis of DSM diagnosis of schizophrenia and psychotic disorders. At this earliest stage, however, these symptoms are not as prominent or disabling as they are in full-blown psychosis. And typically, they're labeled as prodromal or clinical high risk for psychosis and these symptoms and functional deficits. And while other investigators have identified neuroimaging and inflammatory biomarkers from Naples, I've been spearheading the identification of area and neighborhood level characteristics at various times in their lives. So to meet criteria for clinical high risk, youth administer the structured interview for psychosis risk syndromes or otherwise known as the SIPs, which assesses five positive symptom domains, unusual thought content, suspiciousness, grandiose ideas, perceptual abnormalities, and disorganized communication. And within each domain, there is a list of questions we ask in a structured manner to assess the severity and timing of these positive symptoms. Raters need to pass a test to become certified to administer the SIPs, and the process is quite rigorous. Of note, youth who meet SIPs CHR clinical high risk criteria also have other comorbidities, including mood, anxiety disorders, and a history of ADHD or autism spectrum symptoms. So they or their parents are usually help-seeking. In this study, we have 104 participants at high risk who are included. And here, I'm showing the demographics of the participants. Most of the individuals were between 16 and 20, predominantly white, male, non-Hispanic, without family history of mental illness. Most did not experience poverty within the household they were growing up in. And later on, we looked at the relationship between neighborhood poverty and hippocampal volume. So neighborhood poverty, we derived from the US Census, the American Community Survey, linked with addresses that they provided at baseline, which was geocoded and to their respective census track and to the year of exposure. Hippocampal volume was derived from MRI sequencing imaging. And when we talk about social engagement, which I'll get to a little bit later, we measured it based on various factors such as making new friends, being part of organizations, communities, or churches, which we'll talk a little bit about later. So when we first looked at the relationship between neighborhood poverty and hippocampal volume, what we found was that we see that there is a negative association. So the greater level of poverty in the neighborhood, the smaller their hippocampal volume was. And this relationship was still significant even after controlling for age, sex, race, ethnicity, family history of mental illnesses, individual level household income, parental education, and life event stress. And we see here the scatterplot and the best fit line on the right side. We show similar results for also the right hippocampus, and we see that neighborhood poverty is negatively associated with volume, and the effect size is also pretty similar. After these results, we then wanted to see if social engagement was a significant moderator. So we ran a regression analysis looking at the interaction and we found that there was a regression analysis looking at the interaction, and it was significant. So we then stratified our analysis based on greater versus lower social engagement. And you see here on the right side that the dotted line represents those subgroup of participants with greater social engagement, and the black line shows participants with lower social engagement. And we see that the association between neighborhood poverty and left hippocampal volume was no longer significant among those with greater social engagement. However, among those with lower social engagement, the inverse relationship was even stronger and remained significant. And this was true for also the right hippocampal volume as well. So our findings replicate prior findings of the inverse relationship between neighborhood poverty and hippocampal volume, suggesting that beyond the individual level, broader neighborhood level poverty may impact hippocampus among adolescents and young adults. There may be structural issues that have chronic and cumulative impact on neurodevelopment, and these findings suggest that social engagement may be a potential buffer to the development of deleterious impact of neighborhood poverty on hippocampus. Several limitations are of note here, including pretty small sample size. The neighborhood poverty measure, does it actually reflect the social neighborhood and the smaller area in which the participant resides in? And that this is a cross-sectional design, limiting our ability to assess directionality or causal directionality of effects. Yeah, so in summary, we show the inverse relationship and the relationship between neighborhood poverty and hippocampal volumes, which was moderated by social engagement. But despite the limitations, these findings may have big implications, meaning that if social engagement may buffer adverse effects of the environment on the brain, then potential interventions at the individual and neighborhood levels could be designed for prevention, mitigation of adverse dysfunctional behaviors or symptomatology or cognitive dysfunction as a result of lower hippocampal volume. If this relationship is replicated in larger samples, this may have clinical implications. For example, if we ask patients about their living situations and they talk about living in a poor neighborhood, I may also want to ask about their level of social engagement, whether they are making friends or being part of communities, churches, to evaluate and prognosticate the risk for mental illness, severity, and cognitive functioning. I'm fascinated by the prospects of how social engagement may potentially play a role in buffering the adverse effects of poor neighborhood on neurobiology. And I've had a long been interested in how social interactions or lack thereof may be related to psychosis risk and how this social interaction can be measured at the neighborhood level. Are there features, in other words, are there features of neighborhood characteristics that may contribute to greater social cohesion of a community or social fragmentation? This is something that I also thought about with respect to potential interventions at the community level that could be designed. In fact, this was actually how I first became interested in neighborhoods and psychosis, which leads to the next neighborhood characteristic which leads to the next neighborhood characteristic I'll be talking about, which is neighborhood residential instability. This term, neighborhood residential stability, this characteristic has been used to measure social fragmentation of the community, and it is defined as the percentage of the people in a given area, typically census tract, who have changed their addresses or moved. In this paper, we explored the association of 13 different neighborhood characteristics and the age onset of psychosis among first episode of psychosis patients from Grady Hospital. These are the neighborhoods where patients resided in Atlanta, Georgia. And this is where we recruited patients mainly from Grady Hospital. We looked at these 13 neighborhood characteristics and conducted a factor analysis. And interesting enough, only residential instability at the neighborhood level was significantly predicted the earlier age onset of psychosis. And the association between neighborhood residential instability and earlier age onset of psychosis remains significant, even after controlling for all known risk factors for earlier age onset, including male gender, family history of psychosis, individual level, as well as individual residential stability defined by the number of moves by the individual. We later replicated in a larger study as part of the Naples state participants, the relationship between area level residential instability and onset of psychosis. And this was really interesting to see from a multi-site study. And this relationship remains significant among participants who they themselves never moved, even after controlling for various socioeconomic indices shown here. This was another study that showed the association of neighborhood residential mobility or instability. Those terms are interchangeable with fewer outpatient visits among individuals with SMI and chronic medical conditions. So, what exactly is this area level residential instability? I've talked about it being used to measure social fragmentation. But upon conducting a larger systematic review of the topic, we ended up finding out that 14 out of 19 studies from the whole world found social fragmentation as measured by residential instability to be associated with higher incidence and prevalence of schizophrenia and non-affective psychotic disorders. And the term social fragmentation has a very interesting history. The way that it's been indexed was created by a geospatial statistician, Peter Cognon from London, who created this based on a study of the who created this based on theory from Durkheim. Durkheim was a French sociologist born in 1858. In his influential book, Suicide, published in 1897, he outlined the social and not individual causes of suicide, characterized by a rapid change of the standards or values of societies referred to as enemy and an associated feeling of alienation and purposelessness. Reachers have tried to quantify this social fragmentation term at the neighborhood level using neighborhood residential instability, which I mentioned before was defined as percentages of people in that community who had moved. In fact, places where there is high residential instability, there's also less pro-community action. What does that mean? So what I'm showing here is demonstrated by the attendance to baseball games. Places where there is higher residential instability, more people tend to show up to these baseball games when their local team was winning. And this is called conditional identification, which then leads to less pro-community action. In fact, these authors have also shown that places where there's high residential stability, there tends to be more chain restaurants like Starbucks, because they think that moving leads to more familiar seek-liking behavior through the mediating effects of anxiety. This is important to know, for example, in clinical practice, let's say if you have a patient presenting with greater anxiety, and then you later on find out that the patient recently moved, well, this anxiety may be partly explained or exacerbated by the recent move. So back to the relationship between area-level residential instability and psychosis, this influential paper by Zamet in 2010 suggests that social fragmentation or the movement that population turnover at the school level actually may partly explain the relationship between urban upbringing and non-effective psychotic disorders. Andreas Meyer-Lindenburg, their group in Germany, they found that urban upbringing was associated with deficits in two brain regions, the posterior dorsolateral prefrontal cortex and the perigenital anterior cingulate cortex in both structural and functional brain imaging. And interestingly, we also found that area-level residential stability was associated with decreased brain volumes in specifically these same two brain regions, suggesting that perhaps social fragmentation growing up in social fragmented or isolated places may partially explain the relationship between urbanicity and schizophrenia. And social fragmentation may also contribute not only to the onset of illness, but perhaps also to symptomatology, social functioning and recovery among individuals with SMI in general. So with what I've shown so far, I've demonstrated how certain and specific neighborhood characteristics matter for individuals with schizophrenia and serious mental illnesses. But what can we do about these findings as clinicians? I think greater awareness of the patient's neighborhood is important, but I think there's a little bit more to that. There was recently a really great New York Times article that talked about, it was called, Do You Need a Correct Attitude to Understand Your Mind by Rachel Aviv. I highly suggest that you check it out. There's currently a very popular trend in mental health to view mental illness as a neurobiological problem and chemical imbalance that patients would have insight if they understood that they had disorders of the brain. But this biological framework is quite limited and mental illness is more complicated and involving interactions of biology, genetics and environment. In fact, people who saw, there's a recent meta-analysis of 26 studies that concluded that people who saw mental illness as fundamentally biological or genetic were less likely to blame mental conditions on re-character or respond in punitive ways, but more likely to view a person's illness as uncontrollable, alienating and dangerous. But illness is much more complicated than just a chemical imbalance or neurobiological problem. Mental illness can be shaped by where you live, food, deserts, poverty, residential stability, as well as social connections. So, and although I've shown a handful of pretty small preliminary findings and studies, we still know very little about why some people with mental illnesses can lead full, fulfilling, functional lives and others with the same diagnosis feel as if they are defined and disabled by illness. So, you know, I really encourage you all to be curious about where patients where they're coming from. I certainly have been asking about where my patients are coming from, and asking this has also helped me talk in a shared language that makes frightening experiences of psychiatric illnesses more communicable, but also has allowed me to put myself in my patient's shoes and help me pay more attention to my patient's perspectives. I think that larger perspective longitudinal studies still need to be conducted for clearer clinical implications as to how, and a better understanding of how neighborhood factors lead to certain mental illnesses and certain mental health outcomes. But in the time being, I think I've seen this clinically asking and being curious about where patients are coming from has been able to not only help me see where they're coming from, but also build a really strong rapport and trust among my patients. So I think that is my last, well, this is a summary slide showing that kind of what we talked about with the three neighborhood characteristics associated with poor mental health and the associations between neighborhood characteristics, mental health outcomes may be partly explained by social factors and the social determinants of mental health, especially where you live, have clinical relevance for individuals with serious mental illnesses. I think that is my last slide. And thank you for listening to my presentation and for your attention. Thank you so much for such an interesting presentation, Dr. Koo. I just wanted to also add that your focus at the beginning and framing of this talk with your interests and your career focus in a personal context really was both helpful and powerful to me and to our audience. So I thank you for that. Before we shift into Q&A, I wanna take a moment and let our listeners know that SMI Advisor is accessible from your mobile device. Use the SMI Advisor app to access resources, education, upcoming events, complete mental health rating scales, and even submit questions directly to our team of SMI experts. The app is available now at smiadvisor.org forward slash app. So I wanna turn it now over to you and I to talk a little bit about the questions coming in. So let me see what we've got here. I will turn on my camera so we can see. One of the first questions, good to see you. One of the first questions that was asked kind of mid-talk was can you talk a little bit more about who administered the SIPs in the study that you talked about and also how can someone become certified in delivering the SIPs, the Structured Interview of Psychosis Risk Syndromes? Great. At the time that that study was conducted, oh, by the way, before I answer this question, is it a way? Yeah, we can take down the slide so you and I can see each other. Yeah, that'd be great. Yeah. Is there someone? Just a few seconds to do that. Yeah, they're gonna do that. Great. Sorry about that. All right. I know it's a little pause here while they do that. While they're taking down the slides, I Googled while you were talking the SIPs and found a website called thesipstraining.com. Is that the right place where people can go to find out more about it? Yes, that is a good place to learn more about the SIPs and at the time that it was administered, there was clinicians, students who received training. I went through the training as well, but it was for a different study. It was a two-day training where we learned about the different questions to ask as well as how patients may respond and taking into consideration cultural formulations as well, which is really important. Yeah, right. And we had several test modules at the end to assess our understanding and we compared our ratings with the expert ratings and we discussed amongst ourselves. And sometimes it's, most of the time, there are these pretty good criterias to kind of rate the symptomatology of prodromal symptoms. They're not at the level of full-blown psychosis, but they may be things like, well, I have a feeling that other people are talking bad things about me or I don't have a good reason to believe that, but, or kinds of things about ideas of reference that are not kind of at the level of serious impairment yet but are very troubling. And so those are just examples of things that may present, but those are kinds of things that we are trained in and evaluating participants with a clinical high risk for psychosis. Do you think, is the SIPS training, does it cost? That, I'm not too sure about that. Okay, so they can go to the SIPStraining.com and kind of nose around. That was the website that I found while you were talking. I think that's the right place to go. Right now, a lot of the training and the administration of the SIPS is used mainly for research purposes. And so the clinical use of it has not really been that established as established yet. And so there's also questions of the criteria for a clinical high risk and whether that criteria may be expanding or what we can do to better prognosticate people before they develop schizophrenia or any other mental illnesses for that matter. I mean, I think one of the things that I'm thinking about in response to this question is, we're always wondering how to efficiently get to knowing this information about our clients, right? We all have very busy practices. We only have X amount of minutes with a client, but it seems from your talk today that it's really important for us to understand if they live in a food desert, if they're living in poverty, if they have residential instability. And so I think it's in an efficient way, how do we kind of ask people about this? And also, is it relevant for us to know if they had it as a child and they have it now, or is it just important if they're living in it now? Like talk to us a little bit about how we find out this about our clients. Great, well, first I just wanted to let you know that the information of the association of these neighborhood characteristics that I talked about and mental outcomes are very preliminary right now. And they just kind of point towards that these things matter in these associations. And it's still, and it could be, the directionality could go both ways, but further research would be needed to establish like, well, how exactly is this living in food deserts leading to obesity, for example, or other factors may be important as well. So I just wanted to kind of point that out that these are very preliminary things, but they point towards more of, it's kind of about the perspective as a clinician sitting down with a patient that they're presenting with greater anxiety or more symptoms that before jumping to increasing their medication to kind of consider what else is going on, what may be impacting some of the level of distress that they may be presenting. And it's being curious, and a lot of the times this is limited by the resources that we have, the time that we have, as you pointed out, but taking a step to kind of understand where the patients are coming from. And whenever I ask about where, especially in an initial interview, where are you from? Or tell me about your neighborhood. It kind of like light up, even a lot of patients who I don't really know, and they kind of talk about their experiences and what it's like to live in downtown Atlanta or grow up in a rural environment. And so understanding that, having them share their experiences, I can start talking with them and the interview questions that I end up using may contain some of the language that they're using. So building that trust and understanding of where they're coming from has also been an important part of interacting and having that shared language. I think for right now, it's important in that respect, but as to teasing apart at what developmental time period certain neighborhood characteristics is important, I think really varies on what type of neighborhood characteristic you're looking at. For example, for social fragmentation or neighborhood residential instability, we're seeing more and more how, and it's relation to the onset of schizophrenia, that exposure during childhood is actually really critical and important. There's a big study conducted with like, I think 1.4 million individuals in Europe that the individual moves of participants in childhood and adolescence is actually significantly associated with psychotic disorders. However, if they were moving a lot during a young adulthood, that was actually not associated. So it points to kind of developmental exposure at critical time periods may be really important. So I think that's what I'm doing further investigation actually and currently. I think that's great. And one of the things you are kind of touching upon and I think that I can feel from you as a clinician is for all of us to think about the whole person and their context and what they sit in, both their immediate context, their neighborhood, the United States, what's going on. And that leads to a question that somebody wrote in that they said, this seems like an amazing topic. And they were wondering how you think about this given COVID and they are wondering if, would you wonder about seeing large spikes in psychotic disorders due to the lack of social connection over that 2019, 2022 years? Do you feel like you've seen more, more symptomatology from clients than you would usually because of that? Do you see more new first episodes? I mean, we probably don't have the information yet. We need a little distance from it, but I think this person's getting at this lack of social connectedness we all felt during COVID and we couldn't even see our teams, we couldn't see anybody. And did you, are you feeling, are your clients talking about that when they're coming in, your first episode or your ongoing clients? Yeah, I think that this is a very complicated topic and something that can be really difficult to even talk about and remember. And the antecedents of what contributes to psychosis is, that's been a long area of investigation. And we're trying to capture some of that by going into neighborhoods with high residential stability or places that have more, have less social cohesion or things that may contribute to that. And really kind of to conduct qualitative analysis and interviews. And that's actually an ongoing project that I have currently and funded by the NIMH K23. But I hypothesize that the social isolation, that it may have cumulative impacts. It's not just, oh, that one day of feeling isolated may contribute to symptoms per se, but over time that kind of disconnection and feelings of isolation and lack of sense of belonging actually contribute. And then during a specific developmental period, I think during childhood where engagement is actually really important, it can actually contribute to adverse mental health outcomes. And I think that that feeling of belongingness has appeared in many other areas of my research, especially what I didn't go over today about there's another neighborhood factor called ethnic density or ethnic minority density where minorities who are, compared to those who are not minorities actually have a greater risk for psychotic disorders. But if they live in an area, in a neighborhood where there's greater percentage of people, of other minorities like them, that actually is a protective effect. So it kind of points more towards this sense of belonging and community that can be protective against mental illnesses. Yeah, it's interesting that you, I kind of had a chuckle when you had the slide about baseball, right? And about this feeling of community. I'm a big sports fan, so I get that. But I do think that this idea of community that you're talking about can be defined in so many ways. I mean, even when you think, when I think back to your slide about the magic shop, you found a community there and you said, you had people there who had similar interests and who, when you walked in there, people knew you. And there was something about that and there was a familiarity and a safety in that. And I think with our clients, for ourselves, et cetera, you're right that this sense of belonging in however you make it, and I think part of this is really, again, knowing our clients and knowing, what are their interests? Where, maybe it's a church group, maybe it's a Facebook group who loves anime. I mean, who knows what it is, but there's a lot of ways to make community. And it's part of our job to help think creatively about making community, because it may not be obvious, right? Like you said, it may not be community in the sense of me and my neighbor and my neighbor next to my neighbor. It might be something that we create. It might be online. It might be a place that we go to. It might be a magic shop. So I really resonated with your idea of community. Well, we had so many good questions today and there were so many more questions that we didn't get to. We may have to have you back sometime and we'll definitely be watching your research to see how your K23 turns out along with the other papers that you end up publishing. So thank you so much for joining us today. And we can go off camera as I finish off these last few slides here. Okay, great. Well, thank you so much for having me and I really enjoyed talking to you. Wonderful. So if the audience has any other topics covered, any other topics, either in this webinar or any other ones that you would like to discuss with colleagues in the mental health field, post a question or comment on SMI Advisor's Webinar Roundtable Topics Discussion Board. That's an easy way to network and share ideas with other clinicians who participated in this webinar or other similar webinars. And if you have any questions about this webinar or any other topic related to evidence-based care for serious mental illness, you can get an answer within one business day from the SMI Advisor National Experts in SMI. This service is available to all mental health clinicians, peer support specialists, administrators, and anyone else in the mental health field who works with individuals who have serious mental illness. This consultation service is completely free and confidential. SMI Advisor is just one of many SAMHSA initiatives that are designed to help clinicians implement evidence-based care. We'd encourage you to explore the resources available on the Mental Health, Addiction, and Prevention TTCs, as well as the National Center of Excellence for Eating Disorders and the Suicide Prevention Resource Center. These initiatives cover a broad range of topics from school-based mental health through the opioid epidemic. Just as a reminder 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 after we finish today. You'll then be able to select Next to advance and complete the program evaluation before claiming your credits. I want to thank you again for joining us today and invite you to join us on September 29th as Dr. Karen Fortuna presents the Digital Peer Support Specialist role in health and wellness. This free webinar will be held on September 29th from 3 to 4 p.m. Eastern time. I want to thank you again to Dr. Khoo, sorry, I lost myself there a little bit, for joining us today and for sharing his wisdom and expertise and we'll see you all next time. Until then, please take care. Thank you.

neighborhood characteristics

mental health outcomes

serious mental illnesses

food deserts

food insecurity

neighborhood poverty

neighborhood residential instability

hippocampal volume

psychotic disorders

social determinants of mental health