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The NIMH Director’s Innovation Speaker Series: Addressing Ethnoracial Disparities in Mental Health Risk, Assessment, and Service Delivery


Joshua Gordon: All right. Welcome everyone to this edition of the NIMH Director's Innovation Speaker series. I am Joshua Gordon, director of the National Institute of Mental Health. And it's my pleasure to host this talk which will be given by Roberto Lewis-Fernández, whom I will introduce in just a moment. Before I do so, let me remind everyone that there is an ASL interpreter. And if you can't see her on your screen, find her video and pin it, and that will help. There's also captioning available by the closed caption capabilities of Zoom, and you should be able to find that on the bottom of your screen. Finally, one more housekeeping note, you may ask questions for Dr. Lewis-Fernández to answer at any point during the presentation by using the Q&A function, and Alex Denker will moderate the Q&A at the end of the talk. All right. So without further ado, we'll get started.

Joshua Gordon: Again, it's really my pleasure to have Dr. Roberto Lewis-Fernández here. Roberto is really an outstanding scientist, a wonderful clinician, and I know from personal experience a fantastic teacher. He's a professor of clinical psychiatry at Columbia College of Physicians and Surgeons and the director of the New York State Center of Excellence for Cultural Competence and the Hispanic Treatment Program, as well as being the co-director of the Anxiety Disorders Clinic. All of these things taking place at the New York State Psychiatric Institute, which is, as many of you may know, a joint effort between New York State and the Columbia University. Roberto also teaches, I assume, but certainly taught cultural psychiatry and cultural competence to psychiatry residents, and that's where I first got to know him as a resident at Columbia.

Joshua Gordon: Dr. Lewis-Fernández research focuses on developing culturally-valid clinical interventions and novel service delivery approaches to help overcome disparities in the care of underserved cultural groups. His work centers on improving treatment engagement and retention in mental health and physical health care by persons with a variety of mental illnesses. He also studies the way culture affects individuals' experiences of mental disorders and their help-seeking expectations, including how to explore this cultural variation using the psychiatric evaluation. In fact, he led the development of the DSM-5 Cultural Formulation Interview, a standardized method for cultural assessment for use in mental health practice, and was the principal investigator of its international field trial in multiple countries. Roberto, welcome. So glad you're here with us today, and I'm really looking forward to your talk.

Roberto Lewis-Fernández: Thank you very much, Josh. Sorry, I hit the wrong button here on my timer. There it is. You sure brought me back there with the memory of me being your teacher in residency. I want to appreciate very much NIMH including ethnoracial disparities in this Director's Innovation Series and asking me to present. There's a lot of exciting work in this area that I'm happy to share with you. And first, I want to thank Micaela Rodriguez and Dolly John, who are colleagues of mine at the Cultural Competence Center at the New York State Psychiatric Institute who helped put this all together along with other colleagues. So one of the takeaways - there's two that I want to share with you; I hope it comes across in the talk - is that causes in these pathways of ethnoracial disparities in mental health are quite complex and that we need multilevel studies and strategies to address disparities in the risk of mental disorders, access to and use-- access to and use quality and outcomes of mental health care.

Roberto Lewis-Fernández: The timeliness of the topic ethnoracial disparities in mental health is very good because of the growing awareness of structural racism and ethnic discrimination that has been manifested in episodes of police violence and in disparities related to the COVID infection and death and ethnoracial disparities in that. And you see here some of those terrible statistics about age-adjusted COVID-19 deaths showing the ethnoracial disparities in the country as of August 2020 in COVID-related deaths. So one would expect from this also a differential rate of mental health consequence. We'll come to that in a minute. First, this is the outline of the talk. The conceptual basis of disparities will be covered first, following by promising topics for research on disparities in mental health, risk assessment, service access, and delivery. These topics actually are very important for NIMH because the social conditions that lead to disparities affect all aspects of mental health, including neurobiology. They are often poorly measured, and if unaddressed, will continue to interfere with mental health care.

Roberto Lewis-Fernández: First, a definition of disparities. This is taken from paraphrasing several existing definitions. Health disparities are preventable and unjust differences in health status, outcomes, and burden of disease that adversely affect socially-disadvantaged populations. Ethnoracial disparities are only one of many kinds of disparities. I will not address those disparities directly in the talk, but many of the points I raise, I hope will apply. This slide is here as one of the many schematics on the causes and pathways of health and mental health disparities. The main point of the slide, if you will, is just how complicated it is. I will not go through the slide of the many causes on this graphic. I just wanted to show it to you to tell you how many levels and elements and components there are of causes and pathways of disparities. These causes and pathways are not only present at the individual level but they're also at systemic or institutional levels and at larger societal and structural levels as well, and we need to include all of these levels in our models of disparities if we are to understand them. We also need to address all these levels in the interventions we design and implement, but too often, our research is focused only on individual-level variables.

Roberto Lewis-Fernández: I will now turn to very briefly noting some ethnoracial disparities in mental health and the mental health care continuum. I will use the term BIPOC in the talk to denote black, indigenous, and people of color individuals. Despite a higher exposure to social adversity and discrimination than non-Latino white Americans, BIPOC individuals tend not to have higher prevalence of psychopathology. So it's important also to focus on resilience factors as we go along, not just problems that cause worsenings in disparities but also factors that protect different population. In addition to the BIPOC groups, most of them not having higher indices on many disorders, psychopathology prevalence varies substantially both across and within ethnoracial minoritized groups. What BIPOC groups do generally tend to have are more persistent, severe, and impairing mental and emotional disorders. And one major contribution to this is the consistently worse indices of mental healthcare they receive across the full continuum of service access and delivery. As noted in the graph, you see there the various examples of disparities in access and quality of care in the different boxes that are listed that are present here along this loop of care.

Roberto Lewis-Fernández: And the loop is there to denote how this worse access in services of care and outcomes have an impact on the severity, impairment, and persistence of psychopathology, which is one of the main reasons people tend to agree that despite not having higher prevalence, the disorders are worse in these characteristics. Now, it's still somewhat unclear why BIPOC groups, many BIPOC groups, do not have higher prevalence of psychopathology. And this is illustrated here. It's considered a paradox. And it's included here, is seen here, in the prevalence of meeting a cutoff score in symptoms of anxiety or depressive disorders on the leftmost graph, or of trauma and stress-related disorders in the rightmost graph in the spring of 2020. The one on trauma and stressor disorders are symptoms related to COVID-19 related from a stressor disorder. Despite BIPOC individuals having higher death rates from COVID, as I showed you earlier, as much as 3.5 times higher than black Americans, for example, this CDC data shows only small elevations, at least cutoff scores, in black individuals compared to whites and lower rates of cutoff scores in Asian Americans, especially for anxiety and depressive symptoms. Latinx Americans have, in this sample, somewhat higher scores that is commensurate with their higher death rates.

Roberto Lewis-Fernández: Why this variation in symptom reports? There are many explanations which have to do with artifacts of measurement or sampling which I won't address in the talk, but I will focus instead on some other multilevel processes that contribute to these findings and that we need to understand in order to address disparities. So now, I'm going to turn to contributions to disparities in risk of mental disorders. And this part of the presentation has three sections: intersectionality, subjective appraisal, and societal structure. I will take each one in turn. First, intersectionality. This is a major contributor to the complexity of the evidence on risk in ethnoracial disparities. Intersectionality can be defined briefly as the simultaneous impact of multiple aspects of identity or social position. And these different aspects of identity are associated with different social statuses, adverse exposures, and access to resources. And the relationship between these multiple aspects is not additive. It's not simple. It's multiplicative, complex. They yield emergent effects from different combinations of social statuses and identities. And intersectionality compounds and modifies the effect of risk and protective factors.

Roberto Lewis-Fernández: I'll provide you with an illustration here in this graph, classic graph of an interaction. This study examines the impact of, the study done by Leo and colleagues, subjective social status, meaning where the person thinks they fall in the social hierarchy. The contribution of this status to probability of mood or anxiety disorder here on the Y-axis in two groups of Asian immigrants, one who migrated at an earlier age between lower than age 25 and another set, another group, that migrated at age 25 or older. In the graph, we see that subjective social status only impacts probability of mental disorders for Asian-Americans who migrated at an older age. Subjective social status did not impact the probability for those who migrated at a younger age, despite them having greater education and income gains than those who migrated at younger ages-- at older ages, sorry. This shows the intergroup heterogeneity and the need to disaggregate ethnoracial groups to identify intergroup disparities. Intersectionality helps to explain intra and intergroup disparities, and these disparity differences will remain unclear if we don't take into account factors like intersectionality in our analysis.

Roberto Lewis-Fernández: There are several methods statistically to examine intersectionality. However, they're often not used in analysis. When they are used, the most often is interaction analyses or ethnographic-- sorry, ethnoracial group stratification. But interaction analyses require large sample sizes and are often not performed. Several other alternatives exist for how to examine intersectionality. One is to take a life course approach and compare trajectories of psychopathology over time. That is, examine whether risk factors accumulate and interact longitudinally in different ways across ethnoracial groups or subgroups to yield distinct mental health outcomes. A life course approach can also identify specific life periods of relative vulnerability or resilience, so-called critical periods, and test whether these coincide or differ across ethnoracial groups or specific subgroups, such as by gender or socioeconomic status. Network analyses can compare the evolving interconnections among symptoms over time, examining whether these networks vary across ethnoracial groups or subgroups. Latent class models may identify specific clusters of identity characteristics that are associated with a given mental health outcome. This may simplify the search for relevant aspects of intersectionality. Commonalities and differences can then be identified across intra-ethnoracial subgroups, possibly creating typologies that can be tested in other data sets.

Roberto Lewis-Fernández: Finally, decomposition analyses are counterfactual experiments with the data in which one aspect of intersectionality, such as income, is artifactually altered at a time-- one at a time, is altered to observe its effect on other variables, such as mental health outcome. You change one variable, and you see how it affects an outcome variable. This process can reveal that certain aspects of identity or social position play a particularly important role in the risk of psychopathology identifying ways in which ethnoracial subgroups differ or are similar, depending on how the changing variable affects the outcome in different groups. These are all ways to examine data in order to clarify the contributions to psychopathology risk from specific interrelationships among intersectional characteristics. A second contribution to the complexity of risk across ethnoracial groups is the person's own interpretation of experience called subjective appraisal. This is central to classic stress theories as appraisal modifies the impact of objectively-assessed stressors. Subjective appraisal helps explain why there is so much intra- and inter-ethnoracial group variability in the association between objective measures of adversity and mental health disparities.

Roberto Lewis-Fernández: The example is in the next slide. This shows that subjective appraisal can have an even greater effect on psychopathology than objectively-defined risk factors. For example, the study by Sidra Goldman-Mellor's group involving an ethnoracially diverse representative sample of adolescents in California, the California Health Interview Survey, examined the relationship of the person's own perception of the safety of their neighborhood compared to an objectively-defined measure of neighborhood safety, which is composed of the violent crime rate obtained from law enforcement data geocoded to the participant's address. The subjective measures here and the objective measure of crime rate is here. And the study used the Kessler 6 scale as a measure of serious psychological distress. What the graph shows is that adjusting for individual, family, and other neighborhood-level covariates, both subjective and objective measures, had an effect on the prevalence of serious psychological disorder. But the impact of the perceived safety was greater and statistically significant. This one was not.

Roberto Lewis-Fernández: The effect of perceived safety remains unchanged when the analysis was adjusted by objectively-measured neighborhood violence, was included as a covariate. Perception still remained equally significant, even when the objective measure was added as a covariate. A different study, not the one I'm showing you but just to tell you-- a different study found similarly independent effects of perceived neighborhood safety and neurohormonal and inflammatory markers of stress, independent of neighborhood income and individual income. So again, using a biological biomarker in this case, they found the same effect in a different study of the importance of subjective appraisal. A third contributor to the complexity of ethnoracial disparities is the way societies are organized and how this differentially affects ethnoracial groups and subgroups with reference to the various social determinants of health and mental health that have become a very important aspect of disparity research. These are manifestations of the social forces in the ways societies are organized. For example, foundational social forces such as laws and policies, built environments such as access to transportation, the safety of buildings, social environments such as social contact.

Roberto Lewis-Fernández: In particular, disparity work has been pointing to the key role of structural racism in patterning this access to resources and social determinants. In particular, the central importance of racialized residential segregation, which was defined by David Williams - I like this quote - as the physical separation of racialized groups by enforced residents in certain areas, which is an institutional mechanism of racism. Residential segregation patterns the exposures, not only to everyday stressors but also to major adverse events like violence as well as the exposure, the availability of opportunities. Therefore, social structure helps explain the impact of social position on intra- and intergroup disparities by virtue of the relative relationship with these different social determinants of health, depending on the multiple ways that different ethnoracial groups and subgroups interact with these ways that societies are organized.

Roberto Lewis-Fernández: Here's the example for the impact of racialized residential segregation. This is a study by Phuong Do's groups with a nationally representative sample of black and white participants, the National Health Interview Survey. It examines the relationship between geocoded, neighborhood-level index of residential segregation, in this case, how even the racial distribution is of the geographic area, and self-reported K6 data, shown in the bars, as a measure of serious psychological distress. And the investigators stratified the sample by high here and low neighborhood poverty level using census data. What it shows is that after adjusting for individual characteristics, including family income, residential segregation impacted the probability of serious psychological distress only in high-income areas. We see it in-- this is all in the black moiety, the black component of this nationally representative sample. You see the impact of segregation only in the high-income areas and not in the low-income areas, pointing out, again, the variability of effects depending on your position in the social hierarchy. So essentially, this shows the importance of two structural variables, residential segregation and neighborhood poverty, which are often correlated in American cities and many other places as well.

Roberto Lewis-Fernández: In the non-white-- sorry, in the white sample, in the non-Latinx white sample, there was no association between residential segregation and psychological distress, either overall or by neighborhood poverty level. Again, another study also found a biological effect over 10 years of neighborhood-level socioeconomic status and a biomarker of aging telomere shortening that was also independent of individual SES. These findings highlight the need to include structural-level data to clarify ethnoracial disparities in psychopathology risk. So I'm going to wrap up this first part of the talk by discussing very briefly-- listing, really, some of the future directions for mental health research that NIMH and other funders and agencies could focus on. One is longitudinal multilevel examinations in diverse populations, emphasis on the longitudinal and multilevel that I have been showing are important, and diverse populations in terms of intersectionality and every other subgroup possibility there. We need both population-level designs and tailored approaches to follow up the population level to get the big picture, but then following up with tailored designs of specific ethnoracial groups to avoid missing ways in which risks of psychopathology affect specific subgroups that can cause disparities to worsen if left unattended.

Roberto Lewis-Fernández: If you just look at the overall population and assume that if you just treat the overall average of problems, you will quickly discover that some populations are left behind. Essentially, the boats rise, but not all boats rise equally. Some actually sink by virtue of the differential risks that are worsened or taken care of, improved, by the interventions. It's also important to notice that most of these studies I showed focused on symptoms. It's important to move beyond symptoms to also examine disorders. We need innovative methods in addition to the ones I already mentioned, such as, for example-- an example could be machine learning to derive novel structural targets from large linked databases such as the US Census and Medicaid data, looking for specific structural-related issues that are pointed out by that intersection of data. A final point I want to make is about intergenerational effects. That's another way I didn't mention much-- that I didn't mention at all. The disparities manifest and this is a way in which adversity experienced by the parents is transmitted to their offspring, both epigenetically and via parenting effects. This is an important contribution. A colleague, Cristiane Duarte, and Jonathan Posner, and others at Columbia and Puerto Rico are working on this topic. Myrna Weissman, of course. Many others.

Roberto Lewis-Fernández: The second area that I wanted to bring up has to do with mental health assessment. I've already given examples about how to measure intersectionality, subjective appraisal, structural factors from the research already presented. Now, I want to focus on how to assess these important variables in clinical research and how to include in mental health care as well. This section is two parts, person-centered contextual assessment, and communication and implicit bias. Person-centered contextual assessment includes a person's wants, needs, abilities, and circumstances in the process of assessment. It goes beyond just clinical, if you will, symptom level, if you like. And it's obtained from the perspective of the person and their significant others. That's a usual part of person-centered contextual assessment often includes the perspectives of others as well. It obtains information on multiple aspects of what I've described so far. You can obtain information on intersectionality, appraisal, and the impact of societal structure from person-centered assessment.

Roberto Lewis-Fernández: And it complements generic, I'm going to call them, assessments in research and clinical work. Here is what I'm calling a generic assessment essentially about intersect-- tag to each of the three kinds of major contributors to ethnoracial disparities and the complexity of ethnoracial disparities that I was pointing out earlier. For intersectionality, your generic assessment will ask demographic indicators, symptom experience for essentially as close as it typically gets often to a symptom experience, and then rather generic assessments of living arrangements and food insecurity. These are necessary. I don't want to give you the impression only person-centered is needed. It's just these generic data are a baseline, a beginning, but not enough. When person-centered assessment takes the place-- when you do a person-centered assessment, there are many other things that you can ask about the person's own experience, the relevant aspects of identity, the most troubling aspects of a problem, not just the symptoms, their experience of discrimination, and so on. You can read them there. And these are actually literal examples taken from two instruments of person-centered assessment, the cultural formulation interview and the structural vulnerability questionnaire that focuses on structural factors.

Roberto Lewis-Fernández: I will now turn to the cultural formulation interview. It's a sociocultural assessment for evaluation and treatment planning. It's one example of a person-centered contextual assessment that was developed for DSM-5 based on the cultural formulation framework that had appeared in DSM-4, which is the cultural formulation framework is a way of organizing and interpreting information, a method on the impact of cultural and social contexts, on the experience of mental and emotional distress, based on the views and practices of the person and their social network. Was developed, as Josh kindly said, by an international group of developers that my center led. And it can be used for initial evaluation and treatment planning with any patient, by any provider, in any care setting. It has three components: a core CFI, we call it, that is 16 questions asked of the person themselves; an informant version, we call it, that asks for collateral information; and 12 supplementary modules that can deepen the assessment that's needed. And here are the four domains of the cultural formulation interview, the core version. I won't go through them in detail.

Roberto Lewis-Fernández: First, find out about the person's definition of the problem. The ABC are the subunits of the large domains. Each one has several questions. The first one, for example, is three questions, like that. But the first domain is what does the person and their social network think is happening? The second one is what do they think is causing it? What makes it better or worse? What aspects of cultural identity are involved? The third section has to do with what they've done in the past to cope, and what got in the way of seeking help or coping. And the fourth section focuses on current help-seeking. What is it they want now, and how does it relate to the care they're about to receive? This CFI can be used at the beginning of any initial clinical evaluation or at any point in care where people think it's useful to assess the impact of sociocultural issues. Josh mentioned the field trial. These are the countries and sites where it was held. It was five countries-- sorry, six countries, and 11 sites, with 318 patients, 75 clinicians, and 86 relatives. And it essentially found that the CFI was perceived by all three of those groups, patients, clinicians, and relatives, as feasible, acceptable, and useful, and that it enhanced the rapport, communication, and expressions of caring in the patient-clinician relationship.

Roberto Lewis-Fernández: There's also been research on the CFI that shows how it advances the cultural competence of psychiatric trainees. This wasn't part of the field trial, but rather, it has been conducted in different parts of the US and elsewhere internationally over the years since the CFI came out. Another piece of information that the person-- another aspect of care that the person-centered cultural contextual assessment can be useful for is improving the accuracy and completeness of diagnostic evaluation. This slide refers to research on a different operationalization of the cultural formulation framework. Remember, there was a narrative framework in DSM-4 that has been operationalized by different groups internationally. This is work in Canada, at McGill, in Montreal by Laurence Kirmayer and other folks there in which they run a Cultural Consultation Service which uses a cultural formulation approach to receive referrals across the city of Montreal from people, patients whom providers feel there's some conflict or difficulty in their care that has something to do with culture. Most of the people referred were refugees, immigrants often from sub-Saharan Africa and many other parts of the world, East Asia, and many other parts of the world.

Roberto Lewis-Fernández: What this study found is that they followed 323 patients who were referred to their service. And what they found is that the group that was referred with a psychotic disorder-- remember, these are people referred by clinicians to a consultation. So the 70 patients who were referred with a referral diagnosis of psychosis, about half of them had their psychosis diagnosis re-diagnosed using a cultural formulation approach. The opposite only happened in 5%. That is, of the 253 who came in without a psychotic diagnosis, only five were re-diagnosed after a cultural formulation and more in-depth assessment as having a diagnosis of psychosis. So you can see that there's, number one, an overdiagnosis of psychosis much of the time when presentations come in that are unclear, and also, the importance basically of some of the missed diagnosis that were included in refugees and immigrants, probably PTSD and a few others that were unearthed, if you will, by a person-centered contextual assessment. The next point I want to make has to do with the fact of subjective appraisal. Earlier, I said that subjective appraisal can have a major impact on ethnoracial disparities in mental health outcomes.

Roberto Lewis-Fernández: Here, I focus on the fact that subjective appraisal is not just idiosyncratic to the individual but emerges from cultural traditions of what symptoms mean, how they are experienced, and how they are reported to clinicians, researchers, family, etc. These traditions are transmitted by ethnoracial groups and subgroups from generation to generation, including with great intergroup variation and change over time. This list here on the right illustrates the folk nosology, if you will, of cultural concepts of distress, idioms or expressions of distress, cultural syndromes in the Latinx Caribbean. And some of these are held very widely by many people in the community. Others are specific to subgroups. Now, on the left, you see DSM-5 diagnosis. These are here to show you that the relationship between-- as soon as I get my animation to work. There. I think there's one before. Yes, the relationship between the psychiatric diagnoses and the folk diagnoses or idioms, if you will, are never one to one. They're always one to many. They're always complex. What makes a category like major depression hang together is not what makes these cultural concept-- it's not exactly the same as what makes these cultural concepts hang together. And the same is true vice versa. What makes the category in the Latinx cultural groups hang together is considered heterogeneous from the professional nosology.

Roberto Lewis-Fernández: This variety affects not only clinical care but anything that depends on asking people about their symptoms of experience, including most mental health research. It means that in mental health assessment, we cannot assume a universalism in the relationship between symptom reports and disorders. We must consider the complexity of their relationship in a process of translation as if we were talking, as we are often, different languages. Now, I'm going to turn to factors that impair the process of communication, including clinician bias, which can affect many clinicians seeing BIPOC patients. Implicit biases are unconscious, automatic mental associations between a social group, stereotypes, and forms of prejudice. Anti-black implicit bias is particularly prominent in the US due to structural racism. Poor communication and implicit bias affect the rapport and exchange of information in clinical care and research, including the quality of the data obtained on intersectionality appraisal and structural factors. Importantly, interference in communication is associated with lower quality of care and patient disengagement. However, community-- sorry, communication processes may respond to intervention. Research on implicit bias is ongoing on whether it's amenable to intervention, but so far, brief interventions do not appear very effective. Longer interventions may be more effective but require institutional buying.

Roberto Lewis-Fernández: So now, I'm going to round out this section by talking about future research directions. We should continue to study the impact of assessment on information exchange and processes of care. These are different ways. For example, studying the association between implicit bias, observed clinician behavior, and patient outcomes-- much of the research doesn't do the observed clinician behavior and connect with the patient outcomes as a function of implicit bias. We also need to look at the impact of sociocultural assessment of all kinds on longitudinal patient outcomes. We need to find the best implementation strategies in routine care. For example, in terms of assessment, during a clinical assessment or other kinds, one could program an electronic health record to automatically present community-level data that is geocoded to the patient's address and is relevant to the symptoms or diagnosis entered by the clinician. For example, if you're entering information on PTSD, the EHR, and the EHR has your ad, the address of the person may bring up the crime rates of that area or other possible elements that could worsen or precipitate a PTSD-like situation. We also need study on longitudinal effects of clinician training, especially with respect to implicit bias reduction and how it can be used in routine clinical and research settings.

Roberto Lewis-Fernández: And then the fifth bullet about testing alternative approaches for improving clinician behavior. Many interesting ideas here about using value-based care, not just trying-- don't only try to change their behavior. Change how they're paid by virtue of the way the outcomes happen. Or address the biases that structure the work environment. For example, improve the ethnoracial representation in the leadership or the equity in pay, and then see what downstream effects this has on implicit bias. The third and final section of my presentation has to do with strategies to eliminate ethnoracial disparities in service access and delivery. There are five subtopics. I will cover these five strategies: engaging with communities-- I won't read them now because each one will actually be-- you will see them, each one at a time. But for each strategy, I will present the primary target or targeted addresses among the ones I've mentioned, intersectionality, and so on, what approach it followed, and then give an example illustrating the strategy. And for each example, I try to say the problem it's addressing and then how it's going about it, and if there are any results so far, what it has achieved.

Roberto Lewis-Fernández: The first strategy has to do with engaging with communities. And it can be useful for any of the targets that we have discussed so far. It involves organizing how researchers or clinicians engage with communities to implement a given intervention in a real-world setting. And these can be pitched-- these interventions at any level, individual, interpersonal, etc., organizational, even societal and policy levels. This approach ensures engagement with community partners is authentic, not superficial. And according to a Cochrane 2015 review on these kinds of interventions and strategies, it consists of three main approaches listed here: to be aware of multiple forces at all levels, such as the ones I've been describing, to invest in community participation in the process of care or research, and to prioritize community-defined mental health and social outcomes, or at least community mental health and social outcomes, if not defined by themselves. There are seven main areas that a recent literature review yielded were typically used with this type of approach: collaborative care and multi-sector, early psychosis, school. You can read them there. There are various kinds of community sectors where this kind of community approach is being used. There are others. These are just some of the most used ones.

Roberto Lewis-Fernández: Here's an example of this kind of strategy or intervention. It's called Community Partners in Care: Ken Wells, Loretta Jones, Felicia Jones, and so on in the LA area. The problem they're trying to address is limited access to major depression care in low-income communities. They're working in LA. And their approach consists of coalition building of multisectoral community-based organizations to engage stakeholders in a collaborative care model that includes providing depression services in primary care. There are many sectors in addition to primary care, including substance, homeless services, and other community programs such as faith-based, and so on. The coalition, importantly, is co-led, implemented, and monitored the services-- actually, what is leading, implementing, and monitoring is the coalition, not the researchers alone. And this particular study they've been following for a number of years now was a randomized controlled trial that compared regular implementation of a toolkit and technical assistance with and without this coalition-type building process. They had a lot of programs and people in two communities in LA. At six months, they found improved clinically- and community-defined outcomes. But I wanted to prioritize here the follow-up at four years, which is unusual to have an intervention that is able to be followed this long. It's fantastic, at least in mental health. It's fantastic.

Roberto Lewis-Fernández: And you see here some of the clinically-defined and community-defined type of remissions and outcomes that they study. Community-defined remission had to do with wellness indicators, not just symptom indicators. And essentially, what this shows, these numbers show the ORs and they reduce the bad things and increase the good things. The idea being that this coalition-building approach is more useful than simple program implementation, which is what typically happens even in the best of circumstances. So it's good to do this community type of work. A second intervention strategy, if you will, has to do with tailoring interventions for particular subgroups. Typically, this kind of intervention is a subtype of community-based implementation strategies covered in the previous slides. And what makes this one unique is that the primary target is precisely the intersectionality of the community participants. And the approach, you see, is to tailor the services for a specific community subgroup, typically organize their own aspects of identity or social or structural position, like being in a faith-based community or school or the criminal justice system, and so on. And what it does is leverage the subgroup commonalities to address disparities.

Roberto Lewis-Fernández: For example, the work of Sydney Hankerson here in New York on church-based mental health services. The problem that his group is trying to address is that black Americans in New York with major depression were less likely, 30 to 50 percent as likely as whites, to receive treatment for their depression. And he was basically basing that there's so many barriers to care in this community, including lack of access, and so on. And so what the group is doing is using screening and referral services in a trusted setting, community settings such as churches, faith-based community, and partnering with the church-based group in order to use this to bring out depression services to the community, particularly given the importance of the black church in the black community. The approach, the specific thing they've done is to screen in a number of New York City churches. That's a number of people who participated, and they found a very high rate of problem MDD using the PHQ. But none of the participants, zero, accepted mental health treatment referral, indicating an access and trust, and so on, problem in the sense that the services were not trusted or there was a lot of stigma or there were other interpretations, for example, appraisal with respect to what should be done with these problems.

Roberto Lewis-Fernández: So what currently NIMH-funded R01 is doing is testing, in different groups of churches, how to have community health workers who are church-based act as interventionists to conduct SBIRT, the screening, brief intervention, and referral to treatment modality, to see if that allows for better enrolment and participation and quality of life and reduction in symptoms in this community compared to a slightly enhanced usual care with cycle education and the list of referrals and so on. And there's also a process evaluation going on. So this is great that NIMH has funded this project. It should fund more projects like this. A third strategy has to do with leveraging technology to reduce disparities. And the primary target are structural barriers to accessing care and appraisal, for example, stigma, as I mentioned before, by facilitating remote access and engagement in services and self-help using technological modalities. You can see several of them here, either remote delivery of traditional services or technology-mediated self-help or technological actions, like the one that I'm going to describe in a minute, in which intervention reminders were sent and mood scales were obtained.

Roberto Lewis-Fernández: These interventions have been found to be clinically effective. They can reduce the barriers that we were discussing. There is the issue of the digital divide which people bring up, and it's something definitely to consider. At the same time, sometimes, the digital divide is presented too simply because it's a complex issue. For example, US Latinx communities are similar to whites in their use of smartphones. It's just that there are certain financial barriers that are more high in the Latinx community having to do with not having home broadband or data caps and so on. So the modality to be used depends on the type of intervention that-- the type of community that is being accessed and other factors such as age. So here, this study that I am discussing, presenting to you as an example, is one in which text messaging was used to increase engagement. And the problem that it's addressing is the poor BIPOC engagement in CBT treatment, limiting effectiveness. And the solution attempted, technological solution, was to automate text messages to increase engagement in CBT effects in Latinx with MDD. An RCT was done during 16 group CBT of people participating Latinx who are depressed with or without text messaging. And you see from these numbers that the mean time in CBT treatment increased fairly dramatically from 3 weeks to almost 14 weeks out of the 16 with the use of these text messages.

Roberto Lewis-Fernández: And another important element was that the daily self-rated moods were sent out to patients. They responded via text. And these mood scores, simple mood scores, correlated significantly with PHQ-9 measures and significantly predicted the next day's CBT session attendance, the self-reported simple mood score, which means that this is very helpful for scaling up because you can automate either text reminders to people who are particularly depressed, or you can automate reminders about CBT to people whose mood is worse, and so on. Very useful. The next intervention that I will target - and I realize time is running out or has run out; I will more briefly say this - have to do with improving patient communication, patient-provider communication, and this can take the place of addressing both communication content and context. You can see content being exchange of ideas and context being the interpersonal, situational influences affecting this exchange, including, for example-- here are examples from a systematic lit review that my colleague Neil Aggarwal in our center did. These are a couple of examples - there are others, but - of content, patient concerns about useful, or unuseful, or inappropriate treatment for mental health not being useful, or appropriate, or stigma, or discord and community styles in the way people expect to be treated by their clinicians, whether exploratory or telling people what to do.

Roberto Lewis-Fernández: So there are all these concerns about communication and different strategies for how to improve communication. One of them that's particularly interesting is addressing the poor participatory nature of BIPOC mental health treatment that leads to poor care and outcomes, meaning BIPOC care is often not as participatory as care of other communities. And what this group led by Maggie Alegria and others is doing is trying to enhance patient activation and clinician and patient-shared decision-making through these coaching techniques designed for both patients and clinicians. And what they found in their most recent study is that if you have any patient coaching of the clinician and blinded shared decision-making assessments, you have a Cohen's d that's almost 0.3. And if you have maximal coaching, it approaches 0.8. And this is from blinded coded of the interactions-- blinded coding. But if you do maximal coaching for both patients and clinicians, you can increase patient quality of care by a lot, at least according to patients' perceptions. The final intervention has to do with the type of intervention. Intervening on social inequities, and this addresses social structural factors.

Roberto Lewis-Fernández: For example, connecting the person directly to resources, thinking outside the box, outside of the clinical box, if you will, of what is usually considered clinical, by removing barriers or training people how to access these different types of resources. They partner with stakeholders to identify the best targets. It's important to assess mechanisms and process factors so that when they get used in the real world, we don't get confused by the messiness of the many processes, many factors that are involved. So we keep track of what processes and mechanisms are most important. And it's important to include longitudinal evaluation sustainability because often, this kind of intervention takes a long time. And part of it has to be built into the intervention is how to make it last. An example of this is work that my colleague Oscar Jiménez-Solomon is conducting where he tackles-- he and his group tackled the problem of high objective financial hardship in BIPOC communities, and the fact that higher objective financial hardship is essentially higher debt and an inability to meet basic needs, and so on. How this is affected-- how this is connected to suicide-related outcomes.

Roberto Lewis-Fernández: Interestingly, there is elevated suicidal ideation and attempts, awfully. But interestingly, it's not suicide death that is elevated in some BIPOC groups, many, but rather, it's suicidal ideation and attempts is elevated relative to whites in some BIPOC groups, which also speaks about resilience to actual death by suicide but a certain risk to suicidal ideation and attempts. And so the intervention, what it does is empower people to access these resources through these mechanisms of peer-led interventions, and so on, to tackle objective hardship by improving wellness, both objectively and subjectively. Here, hope and shame are very important in order to reduce suicidal ideation and behavior. This has been funded by the American Foundation for Suicide Prevention, but it's just starting. So we don't have outcome data yet, but it's very exciting.

Roberto Lewis-Fernández: So future directions for this last section then I'll turn to conclusions. These are aspects of research that could be emphasized going forward. We need more research on implementation strategies to reconcile community and academic views of primary targets for intervention, how to bring those two together, optimally identify the best partnership structures for multisector collaboration, address the risks of diverse that-- sorry, address the diverse risks [laughter] - there's a typo there - within population-wide interventions, what I was mentioning before. You need both a population-wide and you need the specific risk for subgroups to assemble parsimonious but multilevel intervention. [inaudible] is hard to do in the real world but very important, and to balance scalability and effectiveness when first designing an intervention. It's wonderful to have a very complicated intervention that works, but how do you get it out into the world?

Roberto Lewis-Fernández: So in conclusion, in this talk, I intended to show you that causes and pathways of ethnoracial disparities are complex and are affected by these multiple factors I mentioned. We need research designs in partnership with communities that are longitudinal, multilevel, and multisectoral that target community plus individual and objective plus subjective factors that tailor interventions and implementation strategies to specific contexts, and that assess mechanisms and processes to guide replicability and sustainability. We also need to implement what is known. We know a lot already. We need to implement what is known, feel the knowledge gaps, and intractably reassess the test causes and pathways of disparities and ways to eliminate them. This points to the importance of leadership and institutional will to achieve this. So I'm very glad to be speaking to you about this. I want to thank everybody who contributed to the task. These are some of the members of the Cultural Competence Center on the top right, and that's our website below. Thank you also for your attention. I'll stop here.

Alexander Denker: Thank you so much, Roberto, for an excellent talk. We have many questions, so I will do my best to combine and parse them as much as possible. And if you're available to go over by a couple minutes, we can do that, and then I'll hand it back over to Dr. Gordon at the end. Do you think it's accurate to assume that misdiagnosis of certain mental health disorders is higher in the BIPOC community? And similarly, have you seen if there are certain mental health disorders that are more likely to be diagnosed among individuals facing more social conflict?

Roberto Lewis-Fernández: Facing more social conflict?

Alexander Denker: Correct. Experience more social conflict.

Roberto Lewis-Fernández: There is a lot of evidence of misdiagnosis in BIPOC communities, for sure. There are certain presentations, if you will, that are particularly prone to misdiagnosis. Presentations in particularly African-Americans, black individuals who appear with mood disorders, with psychotic features or possibly psychotic features are routinely misdiagnosed as having schizophrenia. This has been shown for a few decades now. There's also misdiagnosis of conduct disorder and of oppositional defined disorder in BIPOC youth, particularly, again, black individuals. And there's also delays, substantial delays in diagnosis, for example, ADHD, in certain communities. So there-- forgive me. I have to turn off the phone. So these are just some of the examples. Misdiagnosis is very prevalent. And one big element that has been found, work of Stephen Strakowski and others, is the difference in the amount of information that is gathered. Essentially, some that comes to the topic of assessment, not enough information is gathered in some communities by virtue either of disparate care or the disparate services they have access to. So this is one of the main reasons of misdiagnosis. The other one is you're saying does it happen more in situations of social conflict. That was right?

Alexander Denker: Yeah, I believe the question is also are there are specific disorders expected to be seen more in those who've experienced social conflict?

Roberto Lewis-Fernández: I see. I see. I think that varies. I don't have an answer right at the tip of my tongue about exactly which, but there are some that are-- it depends. It depends on the extent of trauma. It depends also on the extent of access to certain things like substances in the community that actually can trigger that kind of response so that in areas of social conflict or social stress, some people have more access or there are more liquor stores, for example, in certain low-income communities so that you have a greater risk of substance disorders there, and so on. There are many socially structured reasons why certain disorders happen more than in other communities. There are also, as I mentioned, preferred ways of expressing distress in the sense of culturally-patterned expressions that could point people in one direction or another in terms of what is expressed, whether anxiety is more prevalent, depression, what type of depression, somatic symptoms, and so on. So all of these are at play at the same time.

Alexander Denker: So I think we have time for one more question. You said that we need to implement what is known. What would be your top three strategies to implement at a typical mental health program? And there've also been a couple of questions about how syndemic theory might play into this. So I don't know if that might be able to be integrated as well, but that's actually come up in quite a number of the questions.

Roberto Lewis-Fernández: I think syndemic theory could easily have been a big part of this presentation. It's - Merrill Singer and others have been working on this for some time - the idea that social health epidemics happen in synchrony. They don't happen isolated. It isn't like it-- people have multiple problems all at the same time by virtue of these social causations, essentially. And so that leads to an answer of-- I don't know about top three exactly, but the idea that you want multi-- the word multi has appeared a lot in the talk, multilevel, multisectoral, in some ways, multidisorder, distress focused, community definition of distress-focused interventions. And then which 3, if you will, or which 10 depend on the strategies-- this is what I'm trying to show, depends on the strategies that you want to implement in the problem that is in facing the community you're working with, and including stakeholders in it in order to determine the best approaches? So for example, that first one I mentioned, I mentioned it first, the authentic community partnerships, because those are extremely important to almost anything you do. You want to involve the stakeholders in not only the definition of the problem but the structuring of the solution so you can find together the best answers to the problems that you jointly identify.

Alexander Denker: Thank you. So I'll turn this back over to Dr. Gordon. Before he comes back on, I do want to wish to thank our interpreting team who stayed on a little late. They've done a real fantastic job today, so thank you to them.

Joshua Gordon: And thank you, Roberto, for visiting with us today and for this excellent talk. And thank you very much to the audience. We have lots and lots of questions. Would it be okay if we accumulate them and send them in an email and we can distribute them later to folks if you have anything, in particular, you'd like to answer?

Roberto Lewis-Fernández: Sure. I know people have time constraints. I'm able to stay a few more minutes if you're able to.

Joshua Gordon: I think, unfortunately, we do have to close because of interpreter issues, so.

Roberto Lewis-Fernández: Yeah. Okay.

Joshua Gordon: But thank you very, very much. And looking forward to our continuation of the series in the fall. Thanks all.

Roberto Lewis-Fernández: Take care.

Alexander Denker: Thank you.

Joshua Gordon: Bye-bye.

Roberto Lewis-Fernández: Thank you for having me.