*Re-release* Minority Mental Health Care

Hello everyone and welcome to Culture of Health. I show that zero's in on healthcare matters that disproportionately affect our community. And we highlight ways to break down systemic barriers to quality care. On this podcast, we will talk with healthcare professionals and hear stories that inspire and inform the listeners to bravely navigate healthcare with dignity, care and humanity in order to achieve equity. I'm your host, Dr. Wanda Wanyoku, I'm Chief Health Equity and Clinical Innovation Officer for Providence. And here with me today is Dr. Arpan Wai Gray, President and CEO of Providence's Well-being Trust, the past chair of the Behavioral Health Committee of the American Hospital Association and a dear friend of mine. I invited Dr. Wai Gray to the show to help us understand why good mental health is so important to our overall health and some of the issues facing minority communities when it comes to mental health. We will also talk about some of the programs he's working with to help close health equity gaps in mental healthcare. Hello and welcome Dr. Wai Gray. It is so great to speak with you today. Thank you so much for having me, Dr. Wanyoku. This is such a joy. This is a topic that is very dear to my heart and I am always just so grateful for the opportunity to listen to you and learn from you and I hope that we're able to have a meaningful discussion and try to help the audience understand the importance of what we're talking about over here in the context of mental health and equity. So really excited to be a part of this conversation. Thank you. I appreciate you so much. Can you tell us a little bit about yourself a little bit about the work you're doing at the well-being trust just to set some context for our listeners? For sure. So I am a son of immigrant parents from southern India was born in Charleston, South Carolina but then moved you know back and forth between India and in the United States over the course of growing up. In my psychiatrist by training and fellowship trained in geriatric psychiatry so really enjoyed that intersection of medicine and neurosciences and psychiatry and have been with the Providence family of organizations for almost 17 years now in different roles so really enjoyed being a part of this and for the past 18 months have had the great privilege of serving as the chief executive for Providence's well-being trust. So this is a foundation that was created by the sisters of Providence and the St. Joseph Orange when we came together with a very bold goal and the goal was to advance the mental, social and spiritual health of the nation and this was supported by a very generous endowment by the sisters of a hundred million dollars and we're really privileged to be stewards of these resources and trying to drive change through our communities. That is so awesome. I know this stuff but every time I hear it it just lifts my spirit so thank you for sharing. Let's dive into mental health a little bit and starting with what is mental health literacy? How does it contribute to a person's overall well-being? Yeah such such an important question. I think you know there's health literacy itself is such an important topic for us to be able to be well. We need to understand what are the factors that drive from promote wellness? What are the risk factors? What are the protective factors and so on? It's even more pertinent in the mental health field because there's so much subjectivity to mental illness. There's no clear blood test that we can draw that would define and tell us that we have illness A versus B. It's a cluster of symptoms that are reported subjectively by an individual that then lead to a diagnosis. So it becomes even more important for us to be well informed. So what mental health literacy is is the understanding of signs and symptoms of what we describe as mental illness. It's such a range so it's okay for us to be sad and down when things are not going well. I mean we all wear human beings. We're going to have those emotional appropriate emotional responses. That's not all mental illness. That's normal human behavior and responses. So understanding that versus when things are falling into the category where they become of concern that we need to pay attention. What is feeling down, feeling blue versus being clinically depressed? What is bipolar disorder? What is schizophrenic illness? When is drinking alcohol or using some substances problematic enough that it is now classified as a substance use disorder. So understanding those differences is important. So that's a core part of mental health literacy. I would also say the ability of an individual to not only understand what those symptoms are but what drives the symptoms, what are the protective factors. And also I would add how does one understand how to access the appropriate support and services. I would put all of that in the bucket of mental health literacy and our strong goal as people of providence to make sure that we are democratizing knowledge. We are demystifying things. We're getting to the heart of stigma that holds people back and where everyone is well informed so that they can flourish and they can realize their fullest potential of well-being. It's so incredibly important. I mean, I'm a pediatrician by training and we know that especially for young, for children and young adults, this has become a really challenging situation. It always was but post-pandemic it seems to have taken on new proportions. What can we tell people what to look out for? Where, how do we know when we're no longer sad but we're now dealing with depression. What do we do? What do we tell us? No, that's such a great question. It's when we all kind of wrestle with, right? You have family members, friends asking us these questions. I would say trying to keep it fairly simple and high level. One of the core things that we look at when we're clinically diagnosing people and we're coming to some recommendations where we want people to get more professional help are the symptoms. You're experiencing impacting your ability to function socially or occupational. I think that becomes a very important guiding force to say, well, if it is getting to a point where I am not able to maintain the fulfilling meaningful relationships in my life, I'm not able to function as a productive member of the society that I normally am accustomed to. Whatever context that might be and if it starts impacting your ability to function at work or at school, then that is a point where we should pause and we should try to get a little more understanding. In addition to that, I would say there are some symptoms that would warrant more immediate attention and one of them would be forever feeling or getting to a point where we feel life is not worth living and we were having thoughts of wanting to end our life or have diabetes suicide. Those are of course very, very concerning symptoms that need to be brought to someone's attention sooner up in the day. Absolutely. And the other challenge with mental health, mental illness is that there are a lot of misconceptions and myths. Can you talk about some of the most common ones and how they impact our ability to navigate this space? For sure. You know, it is interesting how we have historically thought about mental illness as being a sign of personal weakness or one's personal failing. And I think all of those misconceptions and myths perpetuated the stigma and have actually got us to this point where we're at today where it is different than any other illness that we treat. So, you know, those are very common misconceptions. You're thinking that these are very rare. I'm the only person who's experiencing this is also a myth. It's a very, fairly common disorders, one in, you know, by almost 20% of 20 to 25% of the US population. And even population across the world experience some level of mental illness through the course of their lifetime. So, these are fairly common illnesses and, you know, their combination of nature and nurtures. So, there could be genetics that's playing into it. But also life experiences, trauma, adverse childhood experiences and so many other things that go with it that could be contributing to these symptoms. Another common misperception, you know, when it comes to thinking about suicidality, which is, you know, unfortunately, one of those things that no one, we believe, no one should die alone and despair by suicide. And these are preventable deaths and fairly common when among the leading causes of death among our younger people. So, becomes even more concerning is that if, you know, the misperception is that if I were to see somebody's feeling down or depressed and if I were to ask them a question if they're feeling suicidal, I'm actually going to plant that thought in their mind. That is a myth. There's been a lot of studies to understand and dispel that and yet many of us hold on to those things. So, we don't ask those questions which can actually be the difference between life and death and people getting help in those moments. But, you know, the myths and the misperceptions come in the way. So, those are some that come to mind, right? Along those lines, I wonder how does this play out in under so minority and under so populations? I know there are some unique challenges in these communities. Can we talk about that? Yeah, no, that is such been important question. And I don't think people really appreciate the importance of that enough. So, you know, again, we started off by saying the difference between mental illness and what we talked about mental hook literacy is that a lot of the way we diagnose and we understand mental illnesses is through subjective reports of symptoms, not blood tests or other diagnostic tools that we have there more, you know, history taking and understanding that. Now, think about it, right? If you do not have a good understanding of one's cultural context, it is very, very easy for us to misinterpret what one is trying to tell us and not be able to give them the right diagnosis and support if we do not have the cultural humility and understanding and cultural responsiveness and what we're doing. So, when I think about examples, and this is true across so many different, you know, cultures, ethnic groups, and I was thinking about different groups that I worked with over the years. I so I used to work my training at the VA hospital, and I remember working in a clinic where I was working with elderly Japanese men. And it was a very interesting experience to me because I do not recall any of the patients coming and telling me that they had clinical depression or were feeling sad. They would always come and their presenting complaints and symptoms were abdominal pain or other physical symptoms. And, you know, unless you're looking for something, you can't really understand and help people. And, you know, I think it was a Canadian author, Matthew Davies, who said that the eyes see only what the mind is prepared to comprehend. And if we do not know what we're looking for, we do not understand, we're going to miss a lot of things. Now, this goes on in all different categories. You think about in minority groups, the stigma is even more prevalent than, then, you know, so many others. And that limits folks from trying to get the help and support they need. And so being able to understand that, understand where one is coming from. What is the context in which they're presenting these symptoms? Another thing that comes to mind is when people report symptoms and we're not, we do not have the cultural understanding, it is very likely that we also miss diagnosed. And one of the large meta-analysis, I think it was published, I mean, over many years, but there was a report from, it was a world congress on psychiatry. And this is not unique to the United States, but black individuals are twice as likely to be diagnosed with schizophrenia with the same presenting complaints than someone who's white and they're diagnosed with bipolar illness. It makes you pause, reflect and say what's going on here, right? There's something that's not adding up. There's something that we're missing. Now this has serious implications in how we design our treatment plan, what we're doing. And so we need to really understand and spend time. We also need to understand that are there certain groups that are not getting the help and support they need because we're not really paying attention to that. And so I believe it's almost 20 to 25 percent men, black men, over 70 who do not receive treatment for depression or are less likely to re-prescribe that to the press. We've seen from some of our own data that I think it was in one geography where if you happen to be Latinx and a young Latinx individual, you're over 30 percent or 38 percent less likely to be screened for depression. So there's a lot that's built into that that makes us want to pause, reflect, understand and then respond appropriately. I don't know if I answered your question. I kind of asked you absolutely did because I'm thinking about that. What is the role of bias? What is the role of systemic racism in mental health care in access and being believed? So have a lot of underserved populations who have a basic distrust of the healthcare system because of things like that. You come in and you end up with a diagnosis that doesn't quite gel. How do we even start to look at that? To heal that gap? It seems so big. Yeah, that's an important question. And one that I'm still wrestling and struggling with. I don't know if I have intelligent answers for that, but I feel like being able to heal and cross that gap where there is mistrust for a lot of good reasons that we should own and move past so that we're able to actually build bridges and actually get to a place where now there is a health system that works for everyone, not just for the particular group of people. And I think that's really important. I would say kind of the way Edward Demings had that in God we trust and all others must bring data. And I think that's probably the way I would think about us addressing this. So if we are very transparent and every time we look at outcomes, we need to make sure that we have an equity lens built into that. So if we have a dashboard, for example, the work we're trying to do with Providence, trying to identify some core metrics in the mental health space where we're able to address and alleviate the most common causes of human suffering and disability, address some of the most impactful areas where we have the greatest ability to save lives. So this would be around depression care, care for opioid use disorder, and suicide care. And so when we build these dashboards to try to understand how are we improving the quality? How do we understand that in a way that we are paying attention to which groups? Are there certain groups that are not responding well to the treatment that's being given? Are there certain groups that have a disproportionate impact? And they're not at the same level of clinical improvement? And then that informs how you design your quality improvement. And I think those are the kind of very fundamental things that if they're done with intentionality and humility, we will start making some progress. And I think we have a long way to go. I love it. And yet we must start, right? So how do we think? So do we think about having, I have two questions. One of them is working with mental health professionals, right? To help their professionals in general to, you know, build that muscle, to build the, to learning about providing culturally humble, culturally sensitive care for individuals of different backgrounds is I know that that's not something that was called out when I was going through medical school. But we learned that we really have to be intentional about it to your point. So are we putting things in place now to start building that muscle in our health care team? Yeah. So I have the privilege of serving on a health care systems committee with the American Psychiatric Association. And this is a topic that comes up quite a bit, you know, in our training of the new generation of residents. How are we bringing in tensionality? I mean, the one thing would be nice that if we had, you know, people who are providing care, be very representative of those who are getting care and have numbers. But we also recognize that there's a huge gap. And so we need to start doing something right now that allows people to build those competencies so that even if you don't exactly look like someone you're caring for, you have the ability to meaningfully care for them by your training and understanding. And I do feel that there's a lot of progress that's being made. I think just like you said, I never had that understanding when I went to medical school and residency training. There was barely anything. And that was a huge gap. And I also will say that I think this intentional training needs to happen at the residency level. And not just a Zoom that if you belong to a certain culture that you have the cultural humility and competence to care for it, I will give my own example from Indian background. And I remember when I was in practice, I started having a lot of patients being referred to me who were from an Indian background. And I hadn't lived in India for a very long time. And I didn't really understand a lot of what they were describing. But just because I'm of the same race ethnicity, you know, it was just a Zoom that I would be able to provide culturally competent and you, you know, care. And I wasn't able to do that. It took me some time to stop and learn and understand, you know, the symptoms. I'm so, I was trained in the United States. So understanding the DSM criteria and how symptoms are diagnosed. But I realized that many times patients would not present with those DSM symptoms and those criteria. It was a very different way in which they were, and I had to dig in deeper to understand. So I would just say that, you know, it's something that we all must take on. And we must all try to build our competencies because ultimately, this is our, it's not a job. If you go if you're a physician, it's not just a job, it's your vocation, it's your calling. You go into this because you want to make a difference, you want to support and care for everyone, not for one group or another group. And I think that is generally true. And we need to have those skills built in. And I think, you know, something that will require work. And for those who are in practice for a long time, I mean, I would encourage people to go back and actually take some CMEs and learn and get some books. And we're always learning about so many new technologies and new things coming in. Why not spend and put some energy learning about something that really matters and can make a difference to somebody's life? Fantastic. I love it. And it's so interesting when we think about the value of having diversity of lived experience, background and lived experience. Because to your point, we may look similar, but may not have the lived experience. And we may look different and get share that lived experience. So I think it's really important to your point to really think about how we enrich our teams, not just with people of different backgrounds and lived experience, but with each one of us building that competency, that muscle of learning how to care across cultures. Because even if we try to match one on one, it'll take a really long time for everybody to get a congruent provider. But if we have a diverse pool, then I think we all enrich one another. So I really love that. I also wanted to talk about how you your partnering with the community. Because mental health is so personal and yet community, right? So how do we partner? How do we co-create solutions with communities, especially on this sort of community that's where developing solutions out for this work? - I think there's so many levels to that question. I do think there are a lot of people who have described this, you know, as you know, psychiatricalness is at medical problems that many times have societal solutions. In psychiatry and in our training, we were always taught to think about the diagnosis and treatment plan in the context of biological, psychological and social. And that was deeply ingrained in our training and how we thought about this. And I think that aspect of community and that intersection of clinical and community is critical, probably more so than in many other areas. For all the reasons we discussed earlier and you know, mental health literacy, the lack of understanding, the stigma and so on. You know, one of the things, so some of the things we're trying to do is as we are trying to think about creating a system that works for everyone in a way that we're filling gaps. Like if someone needs help and support for themselves or they're loved one, we need to make sure that we're always there for them. Now sometimes that care is gonna be delivered through the healthcare system and there are other times when it's gonna be through community partnerships. And when we think about this, it's not just about the clinical care and the tertiary care, like you know, the advanced care where you're having to give people, you know, hospitalization, hospital level care or medications. I'm actually thinking further upstream, you know, when and some of the work that we're trying to embark on is working with the faith-based community. When we think about the opportunities and we've looked around the country, I'll use the example of care for opioid use disorder, right? We have some amazing treatments. We have medication assisted treatment and no wonder to put this in context, to think about this, the number needed to treat to save a life is so significant with medications assisted treatment. So if you treat, you know, and I think the number, if we compared this, we'd say we needed to do 3000 mammograms to save one life from breast cancer. Critically important must do. You need to treat 20 people who had an opioid overdose with medications assisted treatment and you have a likelihood of saving one life over the next year. So you have treatments that actually work and can save a life. And yet there's this mismatch. Even when we have resources, people are not getting it. So, you know, working with communities can actually be a game changer here. So one example that comes to mind is something that we're trying to emulate in our footprint was work that happened in New Jersey, Cardinal Tobin, who trained the faith-based communities and was all types of faiths in the understanding of what people might present with when they're dealing with substance use disorder and we was focused on opioid use disorder and helping them overcome the stigma and try to get the support they need. And all that happened outside the hospital system was in the community and it was a game changer because people who were actually struggling would never make into the health system or if they made it to the healthcare system, made it after an opioid overdose and are being resuscitated with Naloxone and other things, we're actually getting the support earlier. So those are models we're trying to emulate and build. In addition to that for children, for example, we're trying to really go outside of our four walls of healthcare and work with school districts in very, very meaningful ways. And one of the partnerships we're very proud of is the work we're doing in Renton School District where our corporate headquarters is. This is our backyard. And so what we have done over here is we've partnered with the sports team, we've partnered with others. And the idea really is to say there are 58,000 children in the school district that we're trying to support. Many of them come from under-crived-led backgrounds. We looked at the community health survey data and there was unfortunately a lot of depression, anxiety and things that we're seeing across the country. So we said, well, how do we come together in a way that we're actually able to move outside our walls going to the community and be supportive? So in this partnership with the sports franchise, one of the first things we tried to do was to bring the athletes in, meet with the kids and start normalizing help seeking behavior. And when the athletes who are role models for these kids start talking about their experiences, it just took so much pressure off. And we saw magic happen. We saw kids start talking about it. So that to so many other things that started being brought in to empower kids to our talk of health care literacy, how do we support them? How do we give them the tools, the vocabulary, the understanding so that they're able to know what's going on? Now while doing this, we were also realized that we need to have safe places for the kids to play. So it's not just about the health care delivery aspect. What other things can be done? So that's where the sports team was building these pitches where in many places where children do not have space spaces to play, they have soccer field styles. So they can play. And now while doing all of this, we brought in virtual therapy so that any of these children who wanted support, whether they're choosing to get help, whether their parent wants them to get help, whether the teacher thinks that they might need help, we made confidential virtual care available at no cost for these 15,000 kids. So that's one example of like moving outside of our walls, our comfort zone to go into the community to drive real change. Oh my word. Yes, you are speaking my language right there. Thank you. That is such a powerful program. And you know, you and I can talk for the whole day. But as we start to come to the end of our time together, I want to ask two more questions. One of them is, you know, to the point we talk about building resiliency, right? And the community, the children, and all of us, what steps can we take to think about self-care, our self-mental healthcare, to build our own resiliency and our own support? What can we share as one or two tips for our listeners to think about that? There definitely are going to be so many different things that might work for different people. I will say that, you know, and maybe I'll start with examples and things that work for me. One of the things that has been most impactful for me for my own mental health and self-care has been the practice of gratitude. I cannot even begin to express how much of an impact this has had on my life. I practice some called the three good things, you know, what are the three good things that happened and you kind of journal that and you start implementing some of that in your life that helps. I will say that routine and physical exercise and healthy diet, you know, it sounds very basic, but it goes such a long way if you have some structure to your day. Another thing that we found that started off after the pandemic and some of the work from home and you know, other things that are happening is that the boundaries between your work and your life have somewhat become blurred. So another thing for self-care that actually I found helpful and something that we had done work, which was not, I cannot take credit for the idea. That came out of the National Health Services and the United Kingdom was something called a going home checklist. So irrespective of where you're working from, there are few things you can do. And the idea really is to be able to meaningfully separate and disconnect between your work life and your personal life. So those are some immediate thoughts that come to mind. I'm sure there's a bunch more. Yeah. I love those. I like the going home checklist idea because the work from home, I think it's been very challenging for a lot of people. So before we go, is there anything we haven't discussed you want to listen to now? There's something that I've been thinking about a lot and I've talked to some folks about this. You know, I was going back and reading some of the historic, some archives and think about mental illness. And it was 1963 when, for the very first time, a sitting United States president addressed Congress on mental illness. It was the very first time and part of that, nothing like this had happened. That was President John F. Kennedy. And in his speech, something that has stuck with me very, very dearly, is he actually called out and 60 plus years ago saying that those living with mental illnesses and disabilities should no longer be aliens to our affection and beyond the reach of our communities. And as I think about this and 60 years later, we're having these conversations, we're seeing the struggles, we're seeing debts of despair related to suicide, drug overdose, we haven't been able to make meaningful progress. I think for our audiences to listen and to stop and say that this is no longer acceptable. It is no longer OK. And I think the change will happen only when people demand that they get the care and support, for mental illness, just like they would for any physical illness. And we need to make this front and center. And I think this is the time. And if there's a silver lining from the pandemic, I would say that it's the awareness around mental illness that has actually improved the normalizing of help seeking behavior. So I urge the audience in those listening to say everybody has a role to play. You could talk to someone in your community. You could ask someone how they're doing. From that to, depending on what your role is, if you're in the healthcare delivery system, you can do more, you can get trained. I think everyone of us has a role. And let's try to really come together to drive some real change. It's such a powerful call to action. The role of advocacy from home, from the community, even elected officials. Dr. Wagner, you're amazing as always. And thank you so much for sharing your time and your wisdom with us today. I know that listeners have been enriched. [BLANK_AUDIO] given tools to start to make a difference on this really challenging view. But I'm grateful that you are here in our organization leading this chart and grateful to work with you every day. Thank you everyone for joining us today on Culture of Health. We look forward to continuing the important conversations of health equity issues with more experts and providence in future episodes. Make sure to listen to all our shows on LitLive Radio, on the Future of Health Radio, or your favorite podcast platform, and follow us on social media. We can be found on X and Facebook at Providence and on Instagram on the Providence Health Systems. To learn more about our mission programs and services, please go to Providence.org. And please remember, the information provider during this program is for educational purposes only. We should always consult with your healthcare provider if you have any questions regarding a medical condition or mental health condition and treatment. Thank you for listening. And remember, at Providence, we see the light in you. (upbeat music)