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What do you mean? So by the end of this session, participants will be able to explain how disparities in depression treatment and identify at least two strategies to promote health equity in the treatment of major depressive disorders across diverse populations. So to start, I think it is often helpful to have some definitions so that we're having a shared understanding of what do I mean when I talk about health equity? So first, it's important to define health inequity. This definition comes from the World Health Organization and defines health inequities as differences in health status or in the distribution of health resources between different population groups that come from the social conditions in which people are born, grow, live, work and age. In this definition, it's understood that health inequities are unfair and that they could be reduced by the right mix of governmental policies. So the main thinking is that we're not talking about the choices that an individual would make. We're talking about something that's broader and structural, that is explaining the differences in the individual health outcome. Another definition really helps to delineate this. When you look at the difference between the quality of health care between a minority or nonminority group. This is based in the United States. It describes disparities in healthcare as differences in treatment or a sets of population groups that are not justified by differences in health status or the preferences of the groups. So we're not talking about the difference that's driven by what's clinically appropriate or what's needed in that situation or even patient preference. Disparity is the difference that is driven by the way that the healthcare system operates, the legal and regulatory climate or outright discrimination, which includes biases, stereotyping or other factors. I also really like this definition from the centers of disease control that talks about mental health disparities. I'm gonna come back to refer to these examples of these definitions in a little bit. So it talks about mental health disparities that fall into one of three categories, public health health systems and society. The first is the disparity between the attention that's given mental health and that is given to other public health issues of comparable magnitude. An example here would be the suicide epidemic even though especially since the whole pandemic, more and more attention has been given to mental health. There has been a suicide epidemic for decades with person dying by suicide once every 14 minutes and yet we just weren't talking about it even though it was a massive driver of death and disability worldwide. So that would be described as a disparity in attention. The second is what we might think of normally, which is the disparity of the health of a person with mental illness compared to those without. It's well known that people with serious mental illness are dying 25 years sooner than those that do not have a serious mental illness that have the same medical problem. That's, that's another really important mental health disparity and then finally, disparities that is between populations with respect to mental health, which we'll talk about a little bit in terms of the quality accessibility and outcomes when you are actually trying to get mental health care. So let's look at this a little bit more. Um There was a recent report which I've referenced here and I highly recommend you go back and read just came out from the Meer School of Global Health and they actually put a cost around the economic impact of mental health in, in the United States and they forecast so that you can s uh really understand the scope of this inequity and the negative impact that it has on our society. So this estimate said that the projected cumulative cost of mental health inequities is estimated to amount to $14 trillion by the year 2040. And currently the United States spends an estimated $477 billion annually in avoidable and unnecessary expenses related to mental health inequities. The report goes into a lot more detail about what that looks like if you just wanna point out the emergency department utilization is one very large driver because when someone doesn't have access to preventive care or when they're not understanding how to detect their mental health problems, they're more likely to seek care in an emergency department. And that alone is an estimated cost of $5.3 billion annually with a projection if that, that might balloon all the way up to $17 billion if it's left unaddressed. So there is a huge economic imperative to try to turn the tide for mental health inequities when we look specifically at depression care disparities in the United States. Um This was a recent report from Blue Cross Blue Shield which just confirmed what had been demonstrated time and time again. Anytime we look at data, trying to understand these health disparities is that the first hurdle is actually getting diagnosed, major depression goes undiagnosed and untreated at disproportionately greater rates in majority Black and Hispanic communities. And then if you are lucky enough to manage to get to get diagnosed when treated black and Hispanic communities have lower frequency of both prescription drug treatment and counseling, so they're less likely to actually get treatment if you have a diagnosis and you might ask yourself what can be done about that. We do have consistent data that having racial concordance or recruiting um for the workforce to reflect the population that they serve does help and that's associated with higher diagnosis rates So it's well understood that having an adverse workforce is one of those solutions to improve access to care and eliminating depression care disparities. There's also a global disparity in just data. There's kind of a um a saying what gets measured gets treasured. And if you apply that to this global map, you see that there's a clear difference with the darkest colors, having the largest numbers of studies looking at depression care. And there's a lot of countries that don't have any studies at all. And quite a number of them that just have only one or two studies looking at depression care. So this next report that was uh published in 2022 looking at the global gap and treatment coverage for major depressive disorder did look at the 84 countries that had at least one study and it showed that there's just a gap in treatment coverage. So this is really a fundamental issue of, do you have access to basic health care and in many parts of the world, despite the fact that major depression is a major contributor to global disability, there's still a huge gap in treatment coverage. And to point that out, I pulled out two little facts that emphasize that if you look at mental health service use in the high income countries, it's still pretty low 33% using services. But in low and middle, lower middle income countries, it's as low as 8%. And then he might say, well, that could be different uh and based off like who needs services, well, for those that have been identified as needing services when they look at minimally adequate treatment, that was also pretty low, just 23% in high-income countries and as low as 3% in low and lower middle-income countries. So quite a lot of work to be done here in response to this and uh which is, you know, the study was in 2022 but we've known for a long time that there's been global depression care and mental health disparities. So in 2019, there was a special initiative for mental health that was launched investing $60 million over five years in 12 countries to try to address the service and treatment gap and move people with mental health conditions towards universal health coverage. Recognizing the importance of health care access as a first step to ensuring quality and affordable mental health care. So you can follow them along. They do periodically put out proper supports. They have a goal to achieve those outcomes by 2030. So what are some of the barriers? Um This Kaiser Family Foundation survey took a look at race and discrimination in health and recently reported on barriers access to mental health care. It's not just about access to healthcare in terms of insurance, which is a big part. Even if you have insurance, there are still differences in costs. Um specifically with a lot of insurance providers. Uh A lot of providers may not even accept insurance when it comes to mental health. Some estimates suggest it can be like a 5050 split. So if you're deciding I need mental health care, can you a or the provider that's in your area? Do they accept the insurance that you have? Are you going to have an out of pocket cost that makes it difficult for you to engage in carefully? And a lot of this is just not even knowing where to start because of some of those complexities and then being limited. So if you do have a preference in your provider type gender, race, cultural background, you might be very constrained in terms of being able to access the type of provider that you feel can help you and people of color do face increased access barriers due to those issues including a lack of a diverse mental healthcare workforce, which in part leads to an absence of culturally informed treatment options and stereotypes and discrimination that are also associated with poor mental health. We'll talk about a case that kind of really highlights the ways in which this gap in culturally centric care can drive poor outcomes. So enough doom and gloom, what can you do to promote depression care equity? The first is to participate in any effort that helps to ensure timely and accurate diagnosis. I like to think about this from a public health perspective in terms of primary prevention efforts that include educating young students in schools um about the signs and symptoms of depression, familiarizing community with evidence-based treatment options so that it's not so much a mystery. Um And I do think that there has been some success now with social emotional learning and other school based efforts to try to educate the community so that it might make it more likely that you could get an accurate diagnosis earlier in the course of depression as opposed to waiting until it's been many, many years or even decades. When you look at the national comorbidity study, the average length of time for diagnosis can be measured in the magnitude of decades, not just months or uh one or two years. Other efforts that are grounded in the community include the use of community health workers or tourists for support. This helps to address the challenges with not having a diverse workforce. So as you know, it's many years to become a therapist or psychiatrist or even a nurse practitioner. And the uh there are some pipeline programs that are working to increase diversity in the workforce, but it's a lot um it's a more shorter course to engage in community health workers or train a peer support workforce. Those are people from the community that have trust that have a knowledge, cultural knowledge and you can educate and train them around the signs and symptoms of depression, educate them around treatment options, help them to be members of the community to help identify symptoms and helping people get care. The third important aspect is just ensuring access to affordable treatment. So those are policy efforts that are trying to advance universal health coverage and also improving reimbursement. Um In the United States, we have an issue with a lack of parity. Even though there is a federal parity law, there still is a lack of parity in terms of how um care for mental health is reimbursed compared to comparable physical health conditions, which is in part causing that problem that I mentioned earlier where you have providers that are just opting out of the insurance process because there are still people who can pay what we would call a market rate for care. So as we work to enforcing the federal parity law to make sure we don't have denials of coverage or um unfair barriers to getting care for insured populations that also makes it affordable as you can then have more providers that are opting in to the insurance network and that makes it um more accessible to get mental health care. Um Speaking to those of us that are clinicians, it's important to make sure that those populations are offered both medication management and psychotherapy, that they have information that can engage in shared decision making and informed decision making about these treatment approaches to have accurate information about what to be, what's to be expected and that you can have that conversation in a culturally centered way to try to uncover any types of um misinformation or biases against one form of treatment or the next. There's a lot of resources that you can uh get to help you get more training on culturally centered care. Um The diagnostic and statistical manual DSM five has a cultural interview in the appendix that if you're just not comfortable with asking those questions, it can provide a structured, some structured tool for you to start to explore these issues with your patients. I wanted to talk a little bit also about integrated care, which is another great way to promote equity and depression care. Integrated care is providing mental health services and care within primary care settings. Um This book improves access because patients are already getting primary care and they are, it also helps to reduce stigma because they're not asked to go outside of their comfort zone to get especially mental health care. Integrated care also involves the use of measurement based care so that both the provider and the patient can have um a shared information with respect to is treatment working or not. And it also allows for better use of a limited workforce. So one psychiatrist working in integrated care setting can support a whole primary care panel which is orders of magnitude more patients that they could ever care for in an individual treatment setting. And then there's also some research to support the involvement of family because of the way in which people make decisions about their mental health. As much as you can activate the support system in treatment, it will also help you get to better outcomes. So I have two cases. One is going to highlight some challenges. What what does it look like to um engage in behavior that is counter to equity. And then another case that showcases what you could do to promote health equity in clinical practice. So the first case is Isabel who was a 72 year old Mexican woman who presents to the heart failure clinic after hospitalization for a congestive heart failure exacerbation. She worked in agriculture for many years and she currently lives with her daughter and her grandchildren. She has been widowed for the past five years and had been prescribed medication briefly after what she calls a nervous breakdown, but she did not continue with medication. She did screen positive for depression at INTC, but she's not fluent in English relying on her granddaughter to assist her at the time. Her cardiologist makes a referral to the mental health clinic after noting that she looked attached and she told them that she was just waiting to die. The granddaughter took the referral information, placed it in her bag and she didn't seem that concerned. So let's talk about what's important about um what stands out in this this case. Um First, the first thing is that there was a failure to provide culturally and linguistically appropriate services. It's well known that relying on a family member or another staff member to provide interpretation services is highly variable and the place in which you work, whether it's a health system or an individual practice should be using professional medical translation services. Um It also you don't know whether or not she would even feel comfortable talking about her symptoms in front of her granddaughter. So that's another problem with using family members for transition services. Although this was a specialty healthcare setting, uh we have increasing data to support screening for social determinative health risk in all medical settings because we don't know whether or not she face housing insecurity. She's in a multigenerational home setting, whether they have any food security insecurity issues that is both gonna impact her health outcomes as well as her mental health outcomes. But there was no mention of inquiry into that area. And in my opinion, I think this is really not enough support in making the mental health referral. Um The granddaughter took the information, put it in a bag. Who knows if anybody's gonna take it back out? You didn't really have any types of conversation around. Um what was the action step or accountability there? And we I see this very often um It's a very low likelihood that Isabel is gonna actually call that number, make it to that first appointment. Does she even see that she has a problem and then finally a failure to explore potential suicide risk. I think this can happen also in older populations which, um, you know, I don't know, there's just a lot of biases that lead to minimizing a statement. Like I'm just waiting to die. I'm just old. My friends are all dying. We think of that. Oh, maybe, you know, her husband died. Well, that was five years ago. So that's well outside the realm of a typical grief process. So let's look at another case. Kamla is a 51 year old african-american woman who presents to her primary care physician for an annual visit. He notes that her diabetes is poorly controlled and she CS some stress after her son was murdered eight months ago. Her P HQ nine was 19 and she was offered a referral to the integrated behavioral health clinic. She was initially reluctant saying I'm not crazy, I'm just grieving, but she was glad that she could get help soon. Her doctor explained the P HQ nine results to her and recommended that she start an SSRI today and follow up with the behavioral health care manager within the next 48 hours. So she was also referred to a faith based grief support group and encouraged to bring her daughter who lives with her to the next appointment to answer any questions she or her loved 1 may have. So right away, you can see some differences here that as I mentioned, access to collaborative care, providing that low stigma treatment setting. She's also able to leave that appointment with a prescription for an SSRI prescribed by her trusted doctor. That's improving access, using measurement based care, ensures treatment to target. It also gives her a number to place to say this is a severe form of depression. It helps prevent her minimizing. And then she's also engaging in some culturally centered care to help the patient overcome self stigma and ensuring her assisting supports are activated. And by that, I'm referring to her being referred to the faith based grief Support group. Um and then finally engaging her family member in treatment prevents the likelihood of premature dropout and may improve the likelihood that she will take her medications. So I'll leave you with this quote by one of my mentors, Doctor David Thatcher, who was the 16th surgeon general, the founding Director of the Satcher Health Leadership Institute and well recognized global leader in health and mental health care. He challenges us as leaders to not just know enough care, enough, do enough, but most importantly, who will persist until the work is done. So, even though it's a big challenge to try to impact global mental health disparities, you can do something today and tomorrow to try to implement some of these strategies to improve health equity and depression care. Thank you.