A Deep Look into Mental Health: On Campus, In Our Community and Around the World

A Deep Look into Mental Health: On Campus, In Our Community and Around the World

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[MUSIC] Welcome everyone. I'm Kit Pogliano, Dean of the School of Biological Sciences at UC San Diego. I'd like to thank each of you for joining us for today's deep look into the future of biology event, which is our first since we've become a school of biological sciences. Today, along with our partners at UCTV, we turn our attention to a subject that's critically important in our daily lives.

Mental health has long been dismissed and undervalued in society, but thankfully, long ignored concerns related to mental health have now come to the forefront of our collective consciousness and are becoming much less stigmatized. With that in mind, joining us to help us understand some of the key issues involved in mental health, I'm thrilled to welcome today's three presenters. They're joining us here today to help us understand mental health at the university level, in our communities in the San Diego region and on a global scale and locations around the globe.

Following their presentations, we welcome questions from the audience. Our first speaker is Dr. Savita Bhakta, a board certified psychiatrist. She's been a faculty member at the UC San Diego School of Medicine since 2015, working in the Department of Psychiatry as an associate clinical professor. She's the interim director of the UC San Diego Health College Mental Health Program, which provides comprehensive mental health care for UC San Diego students.

She also serves as a department of psychiatry physician wellness director. Please join me in welcoming Dr. Bhatka. Thank you Dean Pogliano for the kind introduction and for hosting this deep look mental health event.

I'm honored to be part of this event and share about the mental health crisis in college students, the unique factors contributing to this crisis and what we at UC San Diego have done to address this crisis. What is youth mental health crisis? It can be defined as a mental state in which college students could endangered or harm themselves or others are unable to care for themselves. This could happen when the student is experiencing depression, mania, or psychosis, or under the influence of substances.

At a systems level, this term is also used when the disproportionate increase in mental health needs on college campuses out pieces that capacity. At a national level, it is also used to describe the rapid rise in the number of youths experiencing mental health crisis over time. In this data from the National College Health Assessment Survey in spring 2019, that is pre-pandemic, you can appreciate a two-fold increase in the rates of anxiety and four-fold increase in the rates of depression. Post pandemic, the Center for Collegiate Mental Health surveyed 43,000 students across 137 campuses and found that about 80 percent of students reported impact on mental health. A deeper dive into the mental health impact shows significant increase in depression, anxiety, social anxiety, eating disorder, and distress index about the 2019 national average.

Here's a bird's eye view of the rising trends seen since 2009, showing a peak post-pandemic. The US Department of Health issued youth mental health crisis as a health advisory in December last year. In May of this year, President Biden and Vice President Kamala Harris, pledged support to address this crisis and schools and colleges. At UC San Diego, we have seen a 30 percent increase in student body over the past decade. Importantly, the mental health needs have increased 90 percent over the past decade.

This increased demand in part could be attributed in a positive way to the early identification and treatment of mental illness in children and adolescents allowing students with mental health issues to graduate high school and enroll in colleges. It is also due to the increased awareness and efforts to reduce stigma of mental illness on college campuses, thanks to our campus student health and well-being, team and social media, of course, like TikTok, etc. However, we have seen a rising trend in emergency room visits, pre versus post pandemic.

In the table we show percentages of the primary concern for the emergency room visits. It is important to note that the cumulative ER visits during the academic year 2017, 2018 and 2018, 2019 were 231. Whereas the ER visits for last year was 183 visits and this year, 2022, 2023, in just four months, we have had 626 ER visits. You can see that while suicidal ideations is still the most common reason for ER visits, there has been a significant increase in the rates of psychosis, anxiety, and depression followed by overdose. Sadly, majority of students seen in the ER or at college mental health program have suffered from mental health issues for months to years prior to seeking treatment for crisis.

Student mental health is influenced by a wide assortment of factors. These factors used to be referred to as the biopsychosocial model, but it is clearly more complex than that. College students come from diverse backgrounds. They could be first-gen, from LGBTQI plus community, from marginalized and underrepresented minorities, or those who have had adverse childhood experiences, and all of those students are trying to succeed academically in a highly rigorous, competitive environment while trying to create their own identity, developing new friendships or romantic relationships, managing finances, basic needs, in the context of separating from parents, being far away from home for many, strong influence of social media, news, peer pressure, polarized political climate, climate change, and the list goes on. At UC San Diego, we understand the complex factors that influence student mental health and therefore in partnership with the on-campus student health and well-being team, we have developed a multi-pronged stepped approach to provide comprehensive mental health care for our students. This makes us unique within the 10 UC campus system, and one of only a few such comprehensive and coordinated college mental health programs in the nation.

It begins with prevention and well-being for all students offered by the health promotion services and counseling and psychological services, and providing targeted and intensive interventions at our college mental health program and sub-specialty programs within the Department of Psychiatry. In the next few slides, I'll go over each of these depth approach. Prevention is always better than cure. College students often sacrifice their physical and mental well-being to meet the academic demands. At UCSD, we are committed to every aspect of student well-being.

We have partnered with the UC San Diego Recreation Center to promote well-being. Students can access exercise classes, yoga, health coaching, nutrition counseling, health promotion services, and the counseling and psychological services conduct several events throughout the year on campus, such as the wellness pop-up tents, the zone, which is an area for students to come and de-stress and do wellness activities. Let's talk events to get the students started on talking with a counselor. Workshops and community forums as well as the robust pure support program to address the needs of diverse student population,for example, international students, students belonging to the LGBTQ community, and those students who are struggling with substance use or academics are adjusting to UC San Diego. Students can also use self-help tools such as the Headspace app for mindfulness, which is available for free.

For our international students and students from out of state, we have the, My Student Support Program that offers counseling services while the students are in their home over break. The average age of undergraduate students is 21. Seventy five percent of mental health disorders begin before the age of 25, with 50 percent of all cases beginning by age 14. However, there's good news that early identification and early intervention specifically intensive psychiatric treatments followed by continued care and transition age youth has been shown to significantly change the life course and impact of mental illness. Therefore, every member in the UCSD community, be it student, faculty, or staff can help identify at-risk students to mitigate the crisis. There are several trainings available for staff, faculty, and students to understand how to identify students at risk, check with the students and get them connected with mental health care team.

Although there is a long way to go, we are making strides. The UCSD HEAR Program is one such innovation that provides screening and counseling for graduate students, specifically medical students and students from the School of Pharmacy, faculty staff, residents. Our plan is to leverage technologies such as mobile apps. Since 96 percent of students use cell phones, it makes sense to use an app to screen and diagnose and predict the level of mental health care needs that the student needs, and then make appropriate referrals. Students with mild to moderate mental health symptoms are initially seen at CAPS and student health service.

The primary modality of treatment at CAPS and SHS is therapy followed by medication management. If the student needs a higher level of care and continued care, then they're referred to our College Mental Health Program. Our College Mental Health Program is a multidisciplinary team with psychiatrists, psychologists, and social workers, and we are trained to meet the needs of our diverse student body.

In addition to medication management and individual psychotherapy, we provide state of the art therapy such as virtual reality therapy for specific phobias, dialectical behavior therapy group for emotion regulation and distress tolerance. We plan on launching a digital based therapist assisted therapy, such as cognitive behavioral therapy with mindfulness meditation. To ensure that our students have easy access to care, we have a hybrid model of care and provide telehealth services. We collaborate with student affairs, deans and case managers, as well as the office of students with disabilities upon obtaining consent from our students to provide them campus support to participate in treatment and succeed academically.

We collaborate with our specialty diversion partners to manage co-morbid conditions and provide targeted intervention, such as students with treatment resistant depression with active suicidal ideations are referred to our interventional psychiatry clinic to provide novel life-saving treatments such as repetitive transcranial, magnetic stimulation, and ketamine treatment. For students with comorbid substance use disorders, we partner with our addictions program, and for students with prodromal or first episode psychosis, we refer them to our early psychosis care program. Similarly, for students with eating disorder, we refer them to our eating disorders center. The students maintain their care with their college mental health provider even while receiving care at one of these specialty clinics to maintain continuity of care. We use the integrated care model while treating our students in crisis to ensure their safety and well-being. A student in crisis can reach out to CAPS urgent care or College Mental Health Program or go to the ER by calling 911.

You'll soon have a dedicated psychiatric emergency response team called the Triton Core, who will be able to evaluate the student in crisis and determine the need for an ER visit. We ensure that a student discharged either from an emergency department or from inpatient psychiatric hospitals is seen by a college mental health provider within five business days and receives a safety check-in call from our social worker within 72 hours. This approach is critical in managing students in crisis. It improves patient outcomes and patient experience and provides opportunities for research and innovation. On the right-hand side, I have listed down a list of crisis resources.

What can a student do when they find themselves in crisis? They can call the crisis hotline, as well as text the crisis text line, there is the San Diego Suicide Prevention Line, as well as for LGBTQ community, there is TrevorLifeline, TrevorChat, and the Talkline. If you are a parent or faculty member or a friend and you are concerned about a student, you can use the UCSD Triton concern line as well as the UCSD Triton consent form, and one of the social workers and case managers will be able to reach out to the student. The seamless integration of our college mental health program within our campus mental health ecosystem is crucial in reducing crisis, offering warm care handovers and care continuity. This integration provides student visibility and access to care innovation happening now within our department of psychiatry.

To summarize, I showed you the national and the UC San Diego data suggesting the rise in youth mental health crisis, pre-pandemic, that only got worse with pandemic. The wide assortment of factors that influence youth mental health and how we at UC San Diego have taken a stepped approach to address this crisis and provide student-centered mental health care. Finally, I'll urge the viewers; students, faculty, staff, parents to ask your peer or a child or student if they are doing okay. When you notice they are grades are falling, or they seem distant, just engage and connect them with a mental health provider. We still have a long road to go. But this is a beginning and our next steps are to leverage the technology such as mobile apps, digital therapy, and predictive analytics to reduce crisis.

Here are various resources on campus. You can use the URL and contact information for our college mental health program. Thank you for listening and for your time. Kristin Brownell is a UC San Diego alumni who received her bachelor's degree from biological sciences and her medical degree from the School of Medicine. She also received her Masters in Public Health from the joint doctoral program with San Diego State University. She's now a core faculty member with a family health centers of San Diego and the family medicine residency, and she's past president of the San Diego Academy of Family Physicians.

As you will hear, she is passionate about addressing health disparities and urban under-served patients, and especially newcomers to our community and immigrants where mental health and wellness have become a growing important theme for patients and the medical community. Kristin, thank you so much for joining us. Thank you for inviting me. It's wonderful to have you here. Could you please tell us a little bit about the spark that led you to where you are today in your career path? The spark is a little bit of upbringing in the Central Valley with parents who were social justice minded, a federal defender and a nurse midwife. I had Latino roots, so my aunts didn't speak English, so I had some connection to the immigrant experience.

Then I was really fascinated with other cultures and look to UCSD near the border for my undergraduate experience after City College, when I transferred there and had already been speaking Spanish and had visited Mexico before. It's just intrigued with the region and just delve into the culture in UCSD. I enjoyed just exploring the clubs, found the Amnesty International, found the school radio station, the mere college biology department. I had a minor in healthcare and social issues and I think Dr. Lola Romanucci-Ross [LAUGHTER] taught medical anthropology, which I loved and just followed my passions and ended up in working with human rights issues with the field workers at North County. Then met some physicians there when I was working with the Amnesty International and then got connected to some lawyers helping folks supply for political asylum and used my Spanish skills, translating, and then fell in love with medicine.

Like the biology spark, figuring out how the body works and how fascinating it is. Then the other like social justice and that all came together there in undergrads. That's great. Thank you for telling us about that. Can you tell us a little bit more about what you're doing today and how you're putting those skills and passions to work. Yeah.

Fast forward, Peace Corps in South America came back straight to medical school at UCSD, Northern California for residency, back for underserved medicine fellowship where I got to work with the student-run free clinic project that got started my first year of medical school and I was actively involved with just access to care. There are a lot of folks who didn't have access to care. It's important to me to work in the safety net. I'm working now in federally qualified health center, Family Health Centers of San Diego, where I've been since 2007, so long time. It's in the heart of urban, under-served San Diego. City Heights, where a lot of our immigrants and refugees first resettle.

But then it's also near San Diego state and it's near a bunch of things. We have a wide diverse patient panel. I have folks who are also working but maybe underinsured, over 40 languages being spoken. Now we have teaching health center graduate medical education. We've graduated six classes of family medicine residents training in the site, working at a local hospital, and doing some electives even with UCSD, but also within the script system and Family Health Centers. I do primary care, family medicine.

Newborn, OB, adults, geriatric and then I also work with a Refugee Health Assessment Program, where we do assessments for the county and the state for families when they first arrive in the first 90 days of arrival and screen them for illnesses and refer and connect them to the community. Very impressive. Can you tell us a little bit more about the most critical mental health-related issues you see in this diverse community that you serve.

We're serving those who are more vulnerable. Those who may be homeless, those who may be living under the poverty level and struggling with their basic needs. UCLA just released a policy brief, I believe yesterday, with the California Health Information Survey in 2020, saying those who have a harder time meeting their needs during COVID had significantly higher at least one in four stress level. Then our local San Diego refugee community groups also organized during COVID. They formed a San Diego refugee community coalition and they produced a report about the refugees and city heights and alcohol and just in the San Diego Community and said that their mental health needs were high. They decided to work together.

There's over 60 groups, I believe, and are offering community warm lines and different languages. Then our clinic, we have mental health embedded within the clinic. But the wait time is to see folks are high. It can be a couple of months to get in to see a therapist. As primary care doctors were trained to do basic mental health care. Like depression, anxiety, we can treat common things.

Then we have a behavioralist psychologist who works with us in our residency and we have a behavioral health clinic to supplement the mental health system. But if somebody is in crisis, we can do a warm hand-off to our mental health professionals within our clinic, which is very nice because the needs have skyrocketed. Can you tell us a little bit more about what a warm hand-off is? Yeah. Warm hand-off. Basically, the other thing is we're screening for depression. At most of our visits, we have what's called a PHQ-2, a Patient Health Questionnaire-2.

It's like two questions about how you're doing with your mental wellness. If you're positive for either, it triggers a further screening. It's a nine-question, the PHQ-9 questionnaire. If number nine is suicidality risk, and if you're scoring anything in that line, we need to really assess safer for safety.

If we have concern for safety or if people are having more severe symptoms like hearing or seeing things that other people don't see in here, then we call for our mental health folks to come down and assess with us so we can decide the next steps in this safe plan. Great, Thank you. Can you tell us a little bit about how the mental health issues might differ between or among the different groups that you serve? Yeah. The folks that live

in the US who maybe haven't lived in a war-torn country and haven't fled, maybe have different life experiences. Our new arrivals or folks who've been here for 20 years, but they lived through a war, whether it's from Cambodia or Somalia or most recently, we've had a large number of new arrivals from Afghanistan they're at higher risk for PTSD and some other issues just like adjusting to life here, not speaking the language, having extra barriers, maybe being separated from friends and family. There is a special screening tool that we use for our refugee community called the Refugee Health Screener-15. It asks other questions in a different way. It's been validated and some of the newcomer arrival said it started out of Washington. But it goes through symptoms of PTSD a few of those a few symptoms of depression and some more physical symptoms about maybe heart racing or body aches, stomach pain, and if you're getting symptoms in a lot of different body parts that can be related to it as well and then there's like this Distress Thermometer at the end is an overall sense of how they're feeling.

Zero being not doing well, and 10 being they're feeling full. But there's a picture because some folks may be fully educated and professionals coming here, college graduates and some may be illiterate and don't read or write in their own language so there are some visuals to help us screen and we use those. Wow, that's great thank you. Can you tell us about the impacts of COVID on mental health and how it's affecting your patients? Yeah, I mean, so many different ways.

A, just livelihood if they weren't able to work, they're having less income if they got sick. I had a patient who was working in a grocery store. She couldn't zoom in to the grocery store, a little local grocery store, where unfortunately, people weren't required to wear masks.

And she got COVID before the vaccine and ended up having long COVID on home oxygen and wasn't able to work for over six months. And she didn't have a large pot of money waiting for her and she was on oxygen at home for a while and had to wean and she was in her '40s, otherwise fairly healthy, just being overweight and then more at-risk community and hospital bills, all those things. But just even for the, I saw a child this week who came in actually with symptoms of COVID, we screened him [LAUGHTER] because he got sent home from school this week with a fever and I saw him with a resident and we screened them for COVID and flu and he ended up being flu positive. But we noticed his weight. He almost doubled his weight since we last saw him, which was before COVID and he's significantly overweight. So I think we're having a big obesity, we're going to find ourselves in a big obesity issue because they weren't moving a lot.

They weren't going to school, they weren't in PE and when you're short on food, there's food and security issues, cheaper foods. Cheaper foods you might go for the higher calorie ones, which might be less healthy. Anyway, [LAUGHTER] there's so many different ways you could take this, but mental health, social isolation. I have a few older adult patients like in their '70s who live alone and have declined significantly and I'm worried about them.

They're still too worried to leave the home. They're reliant on elder help and Jewish Family Services bringing them frozen foods. They're not eating their home foods and I'm trying to connect them to our pace program. I'm just like donate to your food [LAUGHTER]. Donate to hear local food banks, donate to your elder community support groups because they've been really socially isolated.

If people don't have the people who do better have a stronger family connection or friend connection. Thank you for caring for our most vulnerable members of our community and our new arrivals. How is COVID and the mental health crisis affecting health care professionals? Interesting [LAUGHTER] you say that. I think a lot of us right at the beginning, it was scary. We were worried could we die before the vaccine was out? Where we going to bring the virus home to our family.

Having to change clothes before coming in and take showers, then you're just really scared and we didn't know a lot about it so there's the stress of that and then just the increased needs for your patients, have increased and gotten complicated and the stress over the last couple of years like you power through it and I think we've lost some healthcare providers along the way because people are honestly getting burned out. Then there is a little disheartening to find folks who weren't willing to wear their masks when we're putting ourselves in harm's way. Just the politicization of things was challenging.

But you just powered through. But I know for myself making it through to the summer and you feel like things are getting better [LAUGHTER]. Then I slowed down and you start to feel wait, how do I feel? [LAUGHTER] Put everybody's needs before your own and then decide maybe you're not doing as well. Maybe health issues are becoming more of an issue or even mental health issues are becoming more of an issue, so over the summer, my good friends and I who were all alums from UCSD School of Medicine and we've actually been a good support system for each other decided to take our good friends coaching. There's empowering women physicians coaching over the summer to how to prioritize when there's all these demands on you as a physician, especially primary care.

If you happen to be a parent on top of that and all the demands, how do you have healthy boundaries? How do you make sure you're taking your lunches to? How do you make sure you're eating healthy yourself and you're sleeping and all these things because there aren't enough hours in the day. There's been a need and the increased awareness of the need and I wasn't aware of until the summer that physicians are higher risk of suicide than a lot of other professions and then women physicians are two times this higher at risk. Wow.

There may be some societal pressures, so there's a thought that we should be checking in on each other in general as colleagues and then being a teacher, I'm realizing I was working too much and but what am I modeling for my mentees? We all need to be healthy and well so looking back at saying yes to the things that are really important than not saying yes to everything and then looking at the model of the heart, going back to biology, what's the first artery off of the heart? It feeds itself. The coronary artery, you feed yourself first before you can feed other people so you can do sustained work and don't decide to leave the profession. Wow, thank you. Thank you so much for your inspiration and being such a fabulous role model for all of us and our trainees.

Do you have any advice for our audience and especially for our students? I guess my first advice would be, find your passion. Find someplace to get involved. Get your hands wet. Get in the thick of things, and also take good care of yourself in the meantime. Sometimes we think things have to happen in a certain way.

Maybe I have to graduate in four years or maybe I have to do whatever. I went to the pre-medical group and I honestly was intimidated by the group on campus [LAUGHTER] and I didn't go back, I was too scared so it's good to just find your people and ask your professors, ask your friends, look for mentors, and then find what helps you take care of you. My new wellness trained to practice is looking at gratitude or a little pieces of joy every day not postponing your joy. Like I'm going to work really hard now and I'll enjoy myself in three years.

Or we need to take care of ourselves now and then giving ourself time to reflect on how we're doing. Dr. Michelle Chestovich is the physician coach as well like Dr. Stephanie Smith and she shared just an easy way to think about how you're doing, check in on how you're doing is a smile, so S is let me see.

Sorry, I have it on here. S is sleep so sleep is really important. We need probably seven or eight hours a day. You want to prioritize that movement, some exercise that was my savior through medical school, through undergrad jogging.

Whether you surf, you jog, you paddle board, you do aerobics, you dance. We haven't had an Medical School, I think a salsa dancing night every Tuesday people would go, I, for the smile, is inhaling and exhaling. You almost want to trigger your parasympathetic system just to relax. Just take deep breaths if you're feeling like you're getting overwhelmed and just remembering to breathe.

L is laughing, love. Making sure you're having connections with other people that you're not isolating. E is checking in on your eating and your energy. So if any of those things are really out of whack or out of balance maybe even seeking help. It's something I've done that something my colleagues have done, But we sometimes don't even realize when we're out of balance.

It's good to just check in and have a daily practice. Christine, could you please tell us about resources for individuals who might find themselves in need of mental health assistance or support? Yes. There's a new national mental health emergency line 988 instead of 911 that we're encouraging folks to use, and it should connect you wherever you are in the US to support. That being said for folks who maybe speak a language other than English if they're in San Diego, not if they're in crisis, crisis, but maybe having some mental health concerns. It's good to always go see your Dr. and maybe go through a triage line if you're needing to because you're not sure, but there are community support navigators that are supported by the San Diego refugee communities coalition, and they have folks who are on the line who speak a number of different languages, over 10 languages at least, which is great.

I had that number that (619)404-4322. Anyways, yes, please reach out, ask here. If you're on campus in the dorms, talk to your RA, talk to your parents, talk to each other, don't keep it in. It's not normal to be having thoughts of hurting yourself. Please reach out if you're feeling in crisis and called 988. Thanks.

Thank you. That's wonderful. Kristin, I will just pause for a moment and express my sincere gratitude for having you as a member of our community and for all of your amazing work taking care of the most vulnerable members of San Diego. Thank you so much for sharing so much of yourself today and for your fabulous advice.

Our final speaker is Dr. Bonnie Kaiser, who is jointly appointed in the UC San Diego Department of Anthropology and global health. Her research focuses on understanding cultural models of mental health and illness and exploring their connections to care-seeking. She also conducts research on how to develop, adapt, and validate mental health assessment tools for cross-cultural use, as well as a means to improve the adaptation of global mental health interventions in different cultures. Please join me in welcoming Dr. Kaiser.

Thank you so much for inviting me and for that introduction. I'm going to be talking today about global mental health, which is a field that's interested in identifying and addressing disparities in global mental health and particularly healthcare globally. My work is really focused on the ways that we can understand how people experience and conceptualized mental health and illness, and using that information to better match our treatment to those experiences. Things like motivating people to seek care, making sure that that care will work for them.

Today I'm going to talk about some of the key questions or challenges in the field of global mental health and the progress that we've made and addressing them. In about the '90s, people started to pay more attention to mental elements because we changed the way that we assess global burden of disease. We used to just focus on mortality, so you can see that when just looking at mortality or death caused by disease, mental disorders represented a really small fraction. But in the '90s when we changed to actually looking at disability caused by various diseases, we saw that mental disorders actually represent a much larger portion of the global burden of disease. Of course, we all know there's a really high personal cost from experiencing mental illness.

But we also realize there's a really high economic cost. This was the second thing that started to motivate more attention to global mental health, so the estimated cost of mental illness through both treatment, but also things like lost work is about two-and-a-half trillion dollars, and that's equivalent to the GDP of France. Through these realizations, governments and researchers really started to pay more attention to global mental health. I'm going to talk about some examples from my work today in the way that we really are trying to address the burden of disease and make sure that we're doing it in a way that really addresses how people experience and conceptualize mental illness.

I'll tell a couple stories. One is from my work in Haiti, and I started working there shortly after the 2010 earthquake. This is an image from a mobile clinic in a rural area. On this day, there was a Haitian American Dr. who was visiting. He spoke with a woman who had lost her husband and lost her mother in the earthquake. She described that she experienced profound sadness on the 12th of every month, which was the date of the earthquake.

She just really struggled to do anything but think about the earthquakes. She just cried uncontrollably. She's having trouble sleeping, trouble eating and the Dr. said you have depression, go to the Dr. and tell him that you have depression. Interestingly, there's a false cognate for depression in Creole, so it actually means something very different. There's not an equivalent term for the psychiatric concept of depression in Haitian Creole.

Basically, this label wouldn't mean much to this woman. It wouldn't make sense necessarily. It wouldn't motivate her to seek care. She did try to seek care. It would be at this clinic. This is the closest permanent clinic which is still quite a distance from where she lived and we spoke to the doctors and nurses here and they basically said, we don't get trained in medical school to address mental illness.

We don't feel that we can diagnose it. We don't feel like we can treat it so we don't put it on our differential diagnosis. Essentially, if this woman did try to seek care, and at least in biomedical settings, she wouldn't find that there was adequate care available to her. These are a couple of examples of what I'm going to talk about today, which is both identifying mismatches between how psychiatry talks about mental distress and how people globally experienced it, and how we can better match those, as well as the disparities in care that's actually available and how we're working to address that.

I'll focus on three fundamental questions that are facing the field of global mental health. First is how can we best communicate about mental distress? Again, trying to match the way that people conceptualize and experience illness. How can we best measure it? Which is a really closely related question. This is like assessment tools and how they can match people's experiences. Then finally, how can we fill these gaps in care that I've mentioned? I'll start with how can we best communicate about mental distress and I'll start with an example from Nepal. This is an example of the way that people conceptualize the person in Nepal.

There are elements of the person like the man, which is the heart-mind and the demagogue, which is the brain mind and then after a civil war and Nepal, several humanitarian groups came in to try to provide mental healthcare and they communicated what they were providing as helping to address problems with the demogrant the brain-mind. Unfortunately, in Nepal, this is actually considered a really stigmatized part of the body or the person to have problems with. It's associated with lack of social control, anger, aggression. People did not want to seek care for problems with a democracy.

They did not want to be seen as having that problem. They didn't try to engage with that care when it was provided. Instead, anthropologists said, you should really communicate about this as saying it's problems with a man or the heart-mind. This is considered appropriate for discussion.

It's not considered permanent to have problems with them on and so when they shifted to presenting mental healthcare by talking about problems with the man or the heart-mind, it was much more acceptable for people to seek care. Another example that I really like is called Khyal attack. This is common in Cambodia in populations.

The way that it starts is if you imagine when you stand up too quickly and you feel a bit light-headed, maybe your vision blacks out a bit. This can happen if you're dehydrated. But in a Khyal attack, it is understood to be the start of a process and so this happens because when link channels that Khyal moves through in your body become blocked and so you have this upsurge of Khyal this wind-like substance and it can lead to various things like burst blood vessels, heart attack, and even death. If someone has that lightheadedness and they think, I'm dehydrated and they brush it off.

That's the end of that experience. If someone has lightheadedness and says, Oh no, this could be a Khyal attack they really pay attention to those symptoms. They get worse. They add on anxiety and panic-like symptoms, catastrophic cognitions. The experience of what's happening in the body and that distress is fundamentally different because the meaning that's associated with that lightheadedness is different. Khyal attack is a great example of where in global mental health we're not just trying to find what's the best term for depression, but we're really paying attention to how people conceptualize the person and how that relates to experiences of mental distress.

We want to make sure we communicate in a way that makes sense to people and matches those experiences because that's what they care about having improved. Really closely related to communicating about mental distress is measuring it. In global mental health, both research and practice, we often want to answer questions like, who needs to be referred for care? How well does that care work? Why are some people who are "vulnerable", "resilient" to mental distress? Before we can answer any of these questions, we have to step back and ask, how can we best measure mental distress? When I talk about measurement, I'm talking about examples like the screener that I'm sure you're very familiar with, that just asked you to report on symptoms like nervousness and hopelessness.

Do you experience this all the time? None of the time in the past two weeks or the past month. These are the kinds of screening tools or measurement tools that I'm talking about. Typically these tools just get translated when they're used cross-culturally.

What happens, though, if you only use translation, is we have these weird findings, like one study found 97 percent of people had PTSD. We don't really expect that that's valid. That seems really unreasonable.

So instead we have to ask, was there something wrong with the assessment tool that was used to produce these data? When we only translate our tools, we can't be very confident that we're measuring what we want to measure. When we think about measurement and global mental health, we have to balance both cross-cultural comparison. I'm showing an image of a Partners in Health Hospital in Haiti. They have to go to donors and governments and say, we're seeing this amount of depression or this amount of anxiety; please fund our work so that we can provide treatment. But as the examples I've shown demonstrate, we also have to match people's lived experience.

In places like Haiti, that experience is very different than where most of our screening tools were developed in the US and Europe. We want to try to balance these goals of cross-cultural comparison, but also matching people's lived experience. The way that I do that in my work is through a really rigorous adaptation process that goes beyond just translation to really look at how people make sense of these screening tool questions and how it matches their lived experience. I'll give a couple of examples of some of the problems that we find in this work. In Nigeria, we tried to translate a depression screening tool item about feeling lonely and we found that it wasn't conceptually understood the way that we wanted it to be.

It was initially translated to feeling there's only you in this life, and people said, oh, that means you're rich. If there's only you, you live in a gated community because you're wealthy. Obviously, that's not what we're trying to ask about. We had to re-translate it to feeling you don't have anyone in life. That worked well to get at what we were trying to measure.

In Nepal, when trying to adapt the item, lack of strong feelings, which is another depression item, what we found in how people talked about it is that it really reflected value that's applied to different emotional states and particularly expectations around appropriate emotions. People would say strong feelings are bad, so no children should have strong feelings. Everyone should say, yep, I lack strong feelings. What we had to do to adapt to this screening tool item in working with kids we say, when you're in a sad situation but you don't feel sadness. You're not feeling happy when your friends are happy. Trying to show, it's when it's okay to have emotions but even those emotions you don't have.

These are just a couple of examples where, if we had only translated these tools and hadn't done anything else, we would have ended up asking people like, are you rich? Do you have inappropriate emotions, and not really getting experiences of depression? The third thing I'll talk about is what is the progress that we're making in filling gaps in care? Specifically, there's an estimated shortage of about one million people to address the global burden of mental illness. This is showing the number of psychiatrists per 100,000 population. So you can see that particularly the shortage is, I'm focused in low and middle-income countries. A lot of them have fewer than one psychiatrist per 100,000 population. One of the main things that we're doing to address the shortage of specialists is called task shifting.

That consists of taking the kind of tasks that would normally be done by a psychiatrist or a psychologist, like counseling and training non-specialists to deliver that care. It might be a primary care provider, or it might be a community health worker, or a teacher, or someone else in a community. This helps to provide care through human resources that are already there in communities and providing training and some mental health treatment skills. These task-shifting programs have just taken off globally.

There's a lot of these programs being developed and delivered around the world. At the same time, remember the example I gave in Haiti where at the clinic, the doctors and nurses would tell us we aren't trained in mental health care in medical school. We also need to address this problem not only through the task shifting approach but through building broader systems of training specialists. In Haiti, Partners in Health, which is an an international NGO, in all of their clinics and hospitals, has a system that combines community health workers being trained in task-shifting approaches, as well as training the doctors and providing specialist mental health care. So psychologists and mental health clinicians. This is a combined approach of continuing to train specialists as well as using a task-shifting approach to make sure that we can start to fill that gap in care.

Thinking back on the three key questions that I raised, and what are some of the answers that we've seen today, first, we really need to make sure that we communicate about mental distress in ways that match people's perceptions and experiences. That's the best way to make sure that we can motivate people to seek care and make sure that that care is going to work for them. Our measurement tools really need rigorous adaptation, not just simple translation, to make sure that we're actually measuring what we want to measure. Instead of a weird finding, like 97 percent of people had PTSD, we can actually feel confident in our data and that they are really valid. Finally, we're making progress on filling the treatment gap in global mental health, and really making sure that huge global burden of disease that we saw at the beginning is starting to be addressed through care provision globally. Thank you so much for your attention.

Hi, everyone. I hope you-all enjoyed the presentation and our three terrific speakers today. Before the Q&A session, we wanted to share a list of mental health resources with you. Some of these were mentioned by our speakers during their presentation. First we'll start with those available to UC San Diego students. We have CAPs Urgent Care.

I'm not going to read all of these. As well as if for individuals who are in crisis, please call the campus police. There's also the Crisis Text Line and the Tritone Concern Line that can be very useful to you. Next, for members of the San Diego Community, 988 is the equivalent of 911.

But for mental health crisis and we also have community lines and substance abuse lines and a mobile crisis response team. Number is shown here, as well as additional resources for the LGBTQ plus community, both on campus and in the community. Thank you so much. Now we're about to enter the Q&A session.

I would like to invite our speakers to please join me here on the panel. First of all, thanks to each of you for your really outstanding presentations today. It was so interesting to hear what's happening on campus in the community, and from a global perspective. I'd like to start with a question for Dr. Bhatka.

Could you please tell me or how UC San Diego's plan for addressing mental health on campus differs from the strategies that other campuses or how it compares? Thank you for that great question. How you see San Diego has addressed this is by creating ecosystem. We have our department of psychiatry, that has the College Mental Health Program.

Then on campus we have the counseling and psychological services and the student health service. In most universities you have the counseling and psychological services and the student health service, but they do not have an integrated system along with the Department of Psychiatry as such as the college mental health program. Therefore, the students there in other universities, once they are seeing the mild and moderate is managed by the counseling and psychological services, they need to be referred out to the community and find psychiatrist in the community for continued care or for much moderate to severe conditions. Because we have this integrated with the Department of Psychiatry, those two things don't have to worry about the continuity of care and have to read for a long period of time to find a psychiatrist.

They can easily be connected with a provider within our College Mental Health Program. Fabulous. Thank you. Next I have a question for Dr. Brownell. What are the biggest needs for mental health care in your community and also among clinical caregivers? Thank you for that question. The biggest need in my community, I guess there's a lot of different needs. One is culturally competent care.

Dr. Kaiser mentions being able to connect with the patients so that they can share what's going on with them. If we have culturally competent providers, if we have clinicians, psychiatrists, primary care doctors, community health workers who are from the community ideally, but if not, maybe trained to have the community teach them about themselves, and then we need more resources. We have open spots at our family health centers in mental health. I think we had 20 open spots last month.

We are building, not me personally, but the organization is planning on having a psychiatry residency housed within family health centers to try to help meet the needs they'll train, working with those folks and then needs for the healthcare providers themselves, physicians, nurse practitioners, PAs, nursing, everyone. I think a multi-pronged approach is good. Looking at systems factors that might be not sustainable, in primary care [LAUGHTER]. Looking at systems factors, but then triage ways and then coaching ways, and having access that you feel safe. There's EAP lines where you can call, first psychiatry mental health support. I think in some states, some physicians don't feel comfortable using those lines because they're worried their license might get pulled.

We need safe spaces for people to share what they're struggling with, so they're not alone in general. I love the diversity of care providers. Maybe having psychiatrists consult for the physicians that you can consult for the community health workers, and having our community tell us what they need. I have noticed, I've been getting a lot more questionnaires from the AMA and my organization on how we're doing.

I think it's great. There's some raised awareness, and there's been the great resignation. Hopefully, we're going to stop that if we can address some of the issues that are making it hard to stay in.

Thank you. I have a question for Dr. Kaiser. During your studies of mental health in other countries, what has been the most surprising thing to you, that you've found? Thanks, that mean a lot, and they are surprises, I guess. I guess, one thing at least I didn't expect when I started doing this work, is how much of my time, and effort, and communication is actually less focused on other cultures or communities, but really more about communicating with folks in the US or US providers, bio-medical providers, and psychiatrists, talking about when we're trying to provide care in other cultural contexts, here's how to think about it, here's some things to do or not to do. A lot of my communication is really focused in that direction about here ways that we want to make sure we're avoiding unintentionally doing harm.

I think that's been where it feels like my effort is most helpful, I guess so, productive communicating or translating across cultures, and supporting providers like Dr. Brownell said, in terms of cultural competency. But yeah, that was, I guess not what I expected when I started work. But it's been really interesting. Great. Thank you. I have a question from the audience about whether help is available for our students who are enrolled at the UCSD Extended Studies? Dr. Bhatka.

I was just typing it in. Yes, we do have help for UCSD students who are in ordinary UCSD Extended Studies. I was going to menti0n that calling the call center for the psychiatry call center 858-534-7792, and then scheduling an appointment with one of the psychiatrist within the UCSC out-patient psychiatric services would be the best way to go about and seeking help for mental health needs. Fabulous. Thank you. Let's see. There's an interesting question from one of our panelists, I would like to answer it about what makes people more resistant to trauma? Why does some people overcome trauma better than others, and how can we truly heal from trauma? Or can we do so? Resiliency factors, and I think when folks have community, when they have connection, folks that I think have worked through things in the community. We have a number of them in San Diego, I believe over 60 expos ethnic-based organizations where they can reach out for support if you're coming from another country.

But within our country, having a family, or having a group, or having some connection to other people can help. There's been some work done and then their's for pediatrics, like the ACS screening is looking at what are the risk factors for doing quarterly. But there's been a movement through talks with the hope, we're looking at resiliency factors for the family, which is a whole different topic in and of itself. But I would love to see more research in this area.

Very interesting. I can add some to that. We have students who come from disadvantaged backgrounds with severe adverse childhood experiences. You can see that the resiliency also comes from this drive within to do something.

These students, at least the young generation, the young adults that we see in our clinic, have this increased drive to give back to the community, or do something for the younger generation that they don't go through this, or provide some mental health. They have this passion that they would want to be in a position where they want to help the others. That is one of the factors I feel like the internal motivation and the drive to help others also is a resiliency factor,which gets them through these circumstances. While they are also processing the trauma, they're able to compartmentalize that and still work on other aspects of their lives.

It is important that we connect these highly resilient students to mental health needs because they do need to care for themselves. As Dr. Bramble was saying, that we need to care for ourselves before we can provide to others,and so Important to take care of these students who have come through these difficult traumatic experiences because they have so much potential to give back to the community, and for themselves. Wonderful. Thank you so much. I have a question for Dr. Kaiser. A member of our audience is volunteering, and wonders if there's a place where providers can access culturally validated mental health questionnaires? That's a great question and I would say the answer is yes and no.

For example, we have a database that's called the Global Mental Health Assessment Database that collates a lot of these tools that have been culturally adapted and validated for cross-cultural use. I can put the link in the chat in a minute, that would be one starting point, but it's certainly not complete. I will say a lot of this work happens in a very hard hoc way when someone is starting to work in a new setting to provide mental health care. They'll reach out to listservs with providers, and researchers and ask, do you have tools been adapted and validated for this setting? Where can I find them? I don't think there's a great centralized way completely to find these. People will also look for where there's been publications that describe the validation processes.

Sometimes those include the actual assessment tools and sometimes they don't, but it is hard and I wish we did a better job of disseminating these. Thank you, so interesting. Let's see here.

I wanted to wrap up by asking each of our panelists to add or to tell us what their favorite tip is for maintaining mental health and wellness in really challenging times. World events and personal events can also stress us out. I would just like to ask each of you to say what's your favorite tip and then maybe what's the one go-to place or resource for people? I always like to say we need to be in the present. When we are flustered, we are either worried about the future or reminiscing about the past that has been somewhat negative and so we never take this moment to be in the present. Because if we are in the present moment, then we can see for what it is and then make the right decision. Simple acronym is STOP meaning S for stop.

Stop whatever you're doing. T is take a deep breath which means deep breath is always inhale like at the count of three and then exhale for the count of six. Always absorb around you, what it is, things around you. What can you here? Take this moment to observe around you. P, meaning proceed with thoughtful or mindful way.

Then you make the appropriate step. Doing that multiple times during the day, just to take a pause and bring yourself in this present moment is one of the ways you can overcome any anxieties or stressors. A resource would be headspace is a really good app for self-help app, and that could be accessed. For students at UCSD it is free subscription, but for people in the community, it is a very small subscription fee and it has great resources.

Wonderful. Thank you. I guess I'll go next. Talking about supporting the whole thing that help us.

The San Diego refugee communities coalition had a group of over 30 folks who work on the lines when people from different communities call in and who speak their language and wanted support for them. Because the secondary trauma of hearing things or seeing things on TVs, I am a big fan of turning the TV off or limiting your screen time. But I wanted to share some of the beauty of the wisdom of talking about what is health or wellness or mental wellness from that group when I zoomed in with them a couple of weeks ago. A person from Ethiopia shared that in Tigrigna, you say [FOREIGN] is spiritual soul and body in balance.

I just said wow. Or [FOREIGN] or there is life. [FOREIGN] is a wellness.

There's a sense of wealth, do they feel healthy is their wealth. Joy, Yoruba was said in Nigeria [FOREIGN] Lots of fun, different words, but let those around you see if they can reflect on how they're feeling. Getting in the moment and reflecting every day whether that's in the morning before you wake up just to have a sense of how you're doing and rebooting and they say you're living your life intentionally. Then if you're out of balance and you're not feeling like doing what you normally want do, reach out for help. Wonderful. Th

2023-01-03 13:17

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