Mental Health Equity and the Power of Self-Care

Transcript

MIA ROCHELLE LOWDEN: The 8 Changes for Racial Equity, which is a group that proposed eight strategies that our agency can use to help improve our workplace culture. And we have partnered with the National Institute of Mental Health (NIMH) as well as other institutes of the NIH to observe Juneteenth with a 19 days of wellness celebration, and this is our kick-off event. So I'm so happy you could join us today.

Just to give you a little background, Juneteenth commemorates the date that slavery in the United States was considered officially over as Union troops marched into Galveston, Texas, and ensured enslaved black people there were freed on June 19th, 1865, which was more than two years after they truly would have been freed. With the signing of the Juneteenth National Independence Day Act in 2021, Juneteenth became a federal holiday. And we invite you to practice 19 days of wellness and observance of Juneteenth, 2023.

Next slide. So some housekeeping. Please use the Q&A function for any questions and comments that you may want to submit. Attendees may submit questions and there's an option to submit anonymously. Please avoid using the chat box for questions related to today's presentation. Again, we want to use the Q&A function. And a view showing the ASL interpreter will work best on a laptop rather than an iPad or a mobile device.

Next slide. So today we're going to be hearing from the director of NIMH, Dr. Joshua Gordon, as well as one of our NIMH clinical psychologists, Dr. Krystal Lewis, and we'll leave time at the end for Q&A. So please submit your questions as we go along, and we'll get to as many as possible at the end. Dr. Gordon, I'll hand it over to you.

JOSHUA A. GORDON: Thank you very much, Mia, for inviting NIMH to participate in these 19 days of self-care and to help launch it with this discussion today, which is really two parts: one on NIMH efforts to address mental health disparity, and another on mental health equity and the power of self-care. And so we're really pleased to be able to participate as an institute and looking forward to taking questions and having some discussion towards the end.

Next slide, please. This is my agenda for this portion of today's talk. I'm going to talk to you briefly-- sorry, Mia Rochelle. I'm going to talk to you briefly about the burden of mental illnesses, disparities in prevalence treatment and outcomes, and our efforts from a research perspective to address these disparities. And then finally, I'll close with, of course, as we emerge from the worst parts of the COVID-19 pandemic, we have to recognize the impact on those existing disparities was pretty significant. So I'll talk some about that as well. Next slide.

Starting with the burden of mental illnesses, next slide. Many people don't recognize that mental illnesses are tremendously burdensome in our society. Collectively, mental and substance use disorders account for the third largest cause of disability in the United States. And of any single diagnosis in medicine, major depressive disorder is the single largest cause of disability worldwide.

Next slide. If those facts are surprising to you, it is likely because there isn't enough recognition and talk around this burden. One, if one looks at the most serious mental illnesses, schizophrenia, bipolar disorder, depression, causing occupational and scholarship disability, any one point in time, about 14 million adults in the US are experiencing a serious mental illness. And by a serious mental illness, we mean they're experiencing functional impairments and disabilities that make it difficult for them to work, to learn, to care for their loved ones. They also, in addition to these mental illness disabilities, they face a higher risk of other health conditions, everything from infectious diseases to hypertension, and like in many areas of medicine, underserved populations, discriminated and minoritized populations are disproportionately impacted. Next slide.

The economic burden of the health inequities themselves can be estimated as we learned in this work that was done by National Institute of Minority Health Disparities in other colleagues have tremendous cost above and beyond the burdens of the illnesses themselves. And this landmark study, which was the first to estimate the total economic burden of health disparities demonstrates that the greatest burden was born by people who are black or African-American and people with only a high school diploma or GED. And this burden, the article makes the point, that this burden could be reduced if structural contributors to inequities, including racism and socioeconomic inequalities could be addressed. Next slide.

So let's focus in on disparities and focus in on mental illness. Next slide.

Disparities in prevalence treatment and outcomes of mental illnesses exist really throughout the United States, and indeed, worldwide, if one thinks about globally underserved populations. Health disparities are often experienced by marginalized and minoritized populations, including people from racial, ethnic, and sexual, and gender minorities, socioeconomically disadvantaged populations, populations such as those in rural areas that are underserved by mental healthcare. And we recognize also that people with serious mental illness also experience health disparities in other areas of their health. Next slide.

We also know that the role of social determinants of health in the mental health drive mental health disparities, which include reduced access to evidence-based mental health services, lower levels of treatment engagement. So once treatment is available, the treatment is not tailored sufficiently to these groups to be able to keep them in care, and that leads to fewer follow-ups across a variety of provider settings.

Next slide. One of the easiest ways statistically to demonstrate this is to just ask what percentage of US adults have received mental health services in the past year. Consistent with the burden, nearly half of US adults with any mental illness will have received care in the past year. That is a pretty scary figure in and of itself. That means half of the people with a mental health diagnosis are not receiving care in any given year. And the fact that these are chronic illnesses means that people who need care are likely not getting it. But that story is even more concerning when one breaks out that percentage by racial and ethnic category, and it shows that individuals who are black or African-American or Asian or Hispanic have dramatically lower rates of receiving any care for mental health in the past year. Next slide.

This lack of care, even amongst those individuals who need mental healthcare results in disparate outcomes. For example, in the blue line at the top, you can see that individuals who are identified as American-Indian or Alaska Native have dramatically higher rates of death by suicide than individuals who are white and the light gray line. And although other racial or ethnic minorities have historically been protected against suicide for reasons that we don't fully understand, we've seen that change in recent times, especially among youth. Next slide. Sorry, I don't have the slide, but among youth, where we see the rates of death by suicide, particularly amongst black youth, but in other minoritized youth as well, dramatically increasing over the last five years. So that in the preteen and teen ages, black children are dying by suicide at equal or higher rates compared to white children. How can NIMH help in terms of addressing these disparities? What are we doing and what do we want to try to expand? Next slide.

We have a strategic plan for mental health research that asks all of our researchers in all of the areas of research to pay attention to disparities. So disparities are a cross-cutting goal that go across multiple focuses for the plan.

But particularly, in areas such as examining mental illness trajectories across the lifespan and developing novel treatments, we've emphasized NIMH's commitment to funding research that aims to reduce mental health disparities and promote health equity. With that, especially, is a renewed interest on understanding and importantly mitigating the impact of social determinants of health on mental illness trajectories. In particular, we have a focus on children. We have a focus on development because mental illnesses have their roots in early development, whether we're talking about genetic causes, environmental causes, or social causes. And so we need to understand and mitigate those impacts early in life. Next slide.

Our approach to mental health disparities is also outlined in a separate strategic framework focusing on youth mental health. It identifies five priority research areas, including multi-stake or collaborative and integrated research approaches to reduce disparities of mental illness and the access to and use of mental healthcare. And with youth in particular, we're focused on racial and ethnic health disparities that impact mental health needs and impact mental health access.

Next slide. What are some of the things we're doing now? Well, we have a range of projects that we are supporting to test innovative strategies to enhance mental healthcare and reduce disparities. These include, for example, the use of telehealth to increase access to care for disadvantaged, minoritized, and rural populations. A novel telemedicine tool, for example, to identify autism spectrum disorder that's tailored to children from traditionally underserved groups where the diagnoses of autism have historically been made later and the outcomes are historically worse than the majority population. A video-based therapy for mothers with perinatal depressive symptoms who live in rural communities is another project that we're studying. And an intervention to encourage family medicine providers to offer HIV prevention services in the Deep South, focusing on minoritized and underserved populations that are at the greatest risk for HIV. Next slide.

Those are just some of the research highlights that NIMH is engaged in on its own. But as many of you know, NIMH is one of several Institutes leading an NIH common fund effort called the Community Partnerships to Advance Science for Society. The ComPASS Program is built on the notion, number one, that social determinants of health have wide-ranging effects, and number two, that interventions that attack those social determinants of health can have wide-ranging benefits from a health perspective. Therefore, it makes sense to try to address these social determinants of health with interventions in a collaborative way that measures the effects across many different health outcomes in a standardized, harmonized way.

Importantly, like much of the NIMH's focus on disparities research, the ComPASS program will involve community-led partners. I shouldn't say partners. The grants go to community-based organizations that will design and then implement in a research study structural interventions, leveraging partnerships across multiple sectors aimed at reducing health disparities. They will be united by a common data center. They will also be aided by research hubs so that these community partners can learn how to conduct the research properly while they're doing it.

This whole project is not just aimed at uncovering and mitigating the social determinants of health through interventions. It's also aimed at developing a new health equity research model for community-led multi-sectoral structural intervention research that can be used by NIH Institutes and other federal agencies moving forward.

Next slide. Finally, I want to close with some discussion of the impact of the COVID-19 pandemic on the disparities that I've been talking about so far. Most of the data of which I've shown came before the pandemic.

Next slide. We knew before the pandemic about disparities and mental health outcomes driven by social determinants of health, as I mentioned before, including racism, housing, and food insecurity, access to, and quality of care. During the pandemic, we also knew that some populations were particularly vulnerable. These include the same populations that were suffering mental health disparities, people with preexisting mental and substance use disorders, and the healthcare workforce. Why? Because these were the individuals who were faced with the brunt of the pandemic. They were the ones who had to go to work regardless of the need to protect themselves. They were the ones who had the least capacity to engage in and take advantage of opportunities to protect themselves. And so their communities were hardest hit by the pandemic. And we know that those who are hardest hit by any disaster are the most likely to develop mental health consequences. Next slide.

We also saw their direct associations between rising symptoms of depression and suicidal ideation and experiences of discrimination, and that was shown through studies that were funded by NIMH, all of us, and other organizations examining the mental health impact of the pandemic. This was true whether you looked at depression symptoms or suicidal ideation. The impact of discrimination raised these symptoms higher in the context of the pandemic.

Next slide. We also learned some potential mitigation efforts that had direct impacts on mental health. For example, through studies funded by the NIH and NIMH, we learned that the state eviction moratoriums that were put in place across the United States were associated with improvements of health, of mental health. Such that in the 30 days after the inaction of a state moratorium, or the 30 days after its withdrawal, the data would indicate that those moratoriums reduce the number of days not in good mental health and reduce the likelihood of an individual to experience frequent mental distress. Next slide.

Expanding cash assistance by easing the rules associated with that cash assistance led to similar improvements in mental health, again, decreasing the number of days not in good mental health. A number of different interventions were tried in different states. Each of them had benefit, such as giving emergency cash benefits to those who were not participating before the pandemic, subsidizing wages for people whose work hours were cut, wave work requirements for benefits waived or paused sanctions and automatically recertifying benefits. All of these reduced the number of days not in good mental health. Next slide.

So ongoing research is still looking at the effects of structural inequalities that contributed disparities in COVID-19-related mental health outcomes. These include how pandemic-related stressors and state-level policies jointly shape these disparities. The impact of COVID-19 and racial discrimination on health outcome in black, pregnant, and postpartum people is a particular interest. And a community-based intervention to address inequalities and disparate consequences of the pandemic on immigrants and refugees from ethnic minority populations. These are examples of ongoing research.

So if I could summarize the COVID-19 data, it's clear that COVID-19 increased the degree of mental health disparities in the United States, increased our attention on them, and provided opportunities to understand how to mitigate the determinants of these disparities that can be used in intervention studies moving forward aimed at reducing the disparities. Next slide.

I want to thank you for listening. NIMH envisions a world in which mental illnesses are prevented and cured, and our efforts to transform the understanding and treatment of mental illnesses through basic and clinical research paving the way for prevention, recovery, and cure. That's our vision and mission, and importantly, we want to make sure that this vision and mission is achieved for all Americans. And in doing so, we need to pay attention to these mental health disparities that I've been discussing today.

You can go to the next slide, and I'll introduce-- sorry, this is just extra stuff. Let's keep going. Keep going. Keep going. Keep going. Keep going. Keep going. Boy, I put in a lot of extra data. Now we'll move on to Krystal Lewis, a clinical psychologist with the National Institute of Mental Health, who's going to move from the research world into the more personal world as fitting with the theme of the Juneteenth moment. Krystal, please take it away.

KRYSTAL LEWIS: All right. Thank you so much for that introduction, Dr. Gordon. Good afternoon, everyone. I'm grateful to NIMH and 8CRE for the opportunity to join Dr. Gordon today to discuss mental health equity and self-care.

So I am a clinical psychologist here with the emotion and development branch. And the labs in our branch study, different mental health phenotypes, but all have the same goal of highlighting the neural underpinnings of emotion and identifying mechanisms of psychopathology and youth.

So in the work with my group, I provide cognitive behavioral therapy for all of the kids who have a clinical diagnosis of anxiety as well as related or comorbid disorders. So today I'll be focusing on identifying symptoms of mental health as well as very practical stress reduction tools and techniques that individuals can use.

So as Dr. Gordon noted in his presentation, we know that it is very important to address the structural contribution to be able to decrease disparities in mental health. However, another part of improving equity in healthcare involves education and dissemination of scientifically-supported information relevant for all. And so that's what I'll be talking about today.

Okay. So my overview here is I will briefly touch on mental health and Black Americans. I will identify some signs and symptoms of mental health disorders. I'll touch on maintaining mental health, and then talk about strategies for helping loved ones, family, and friends with mental illness.

So just to begin and not to be redundant to what Dr. Gordon has just reviewed. But we know that people of all ethnicities, cultures, and identities, experience, mental health, conditions. Black individuals experience mental health challenges at about the same rate as other groups, but that does vary. It depends on the disorder. Specific to trauma, we know that there's trauma in the black community. And what we need to focus on is the role of stigma in mental health treatment. We know that the role of stigma is long-standing. When considering the mental health of Black Americans, it's important to view the experience through historical and a cultural lens.

The black community has shown resilience in the face of adversity for many years, for centuries, but notwithstanding, we know that there are high rates of mental illness within the communities. And what is important to highlight here is there is a discrepancy between treatment-seeking behaviors. And so the numbers have crept up a little bit, but there's still that discrepancy between black people seeking treatment as compared to other groups.

And what we want to consider here are what are the barriers to care, right? What is getting in the way of individuals seeking treatment? We know that there-- we know that stigma, as I mentioned, comes into play. We know that there are resources that are needed in order to seek mental health treatment, not just finances, but also means, time, being able to take time off from work, I guess, to go seek therapy.

We have to consider the healthcare system in terms of providers and organizations. And we know that there's a lack of cultural sensitivity or a cultural humility as we call it. And so in order to really make sure that we are providing treatment widespread and considering cultural differences, it's important that providers do present with a sense of cultural humility. We know that there's unequal access, so there's a lot of barriers to care to consider when talking about mental health treatment. We also know that the CDC declared racism a serious threat to public health and has placed communities of color at greater risk for poor health outcomes and mental health outcomes. And we know that racism continues to have an impact on the general mental health of black and African-American people. And so oftentimes, mental health symptoms are compounded by the psychological stress and systemic racism.

So just to, again, review some stats that were already highlighted, but importantly, we must consider that African Americans living below the poverty line are two times more likely to report serious psychological distress. And so what that means is that there are these other factors we must consider.

Socioeconomic status in terms of finances, and as we noted, the social determinants of health are all related into the experience and expression of mental health symptoms. There are greater reports of sadness, hopelessness, worthlessness, depression symptoms within the black community. And as Dr. Gordon showed, the graphs in terms of suicidal ideation and suicide behavior, we know that over the past few years, there has been an increase in suicidal thoughts at rates much higher than other groups for black individuals.

Moreover, we must consider where black individuals are going in terms of their expression of mental health symptomatology. So we know when we look at emergency visits for mental health-related concerns, the rate for black adults is nearly double, so twice, at the national average. So the manifestation of stress - and we'll touch on that in terms of chronic stress - and mental health symptomatology being expressed psychosomatically and physical symptoms in general impacts the experience of where individuals go to seek care.

So let's just move into identifying signs and symptoms of mental illness. So of course, this is not a comprehensive list. We're just going to touch on a couple of different areas today. But there are warning signs of potential mental illness or deteriorating mental health in adults as well as adolescents as listed here. And so what we might see is that individuals are displaying excessive worry in situations and have a negative or catastrophic outlook that bad things are going to happen. They might express a lot of fear, and it could be in relation to things that have already occurred as well, but the excessiveness of the worry and concern gets in the way of functioning. Rapid mood changes. So if we're looking at an individual who experiences a sudden change in mood, including significant highs, an elevated mood, excessive energy, kind of manic-like behaviors, oftentimes can be an indicator that there may be an underlying mental illness. Strong feelings of irritability or anger. And oftentimes, this anger, irritability may come about, it could be a very small trigger or out of the blue or just be out of proportion for the particular situation.

Behaviorally, we'll see individuals who might start avoiding social activities or there's a lack of social engagement, and so we look at what are the behavioral changes, as well as changes in maybe eating or sleeping.

Sometimes with individuals who are suffering from mental illness or changes in mental health in general, we might see changes in cognitive symptoms such as confused thinking or problems with remembering things, memory, or difficulties with learning. And we can also see an inability to just carry out daily tasks, so all of these symptoms that were just noted can impact an individual's ability to function on a daily basis. We know that there is a high correlation between substance use, substance abuse, and mental illness, and again, increases in thoughts or comments about death or suicide. So again, obviously, not being a comprehensive list, but looking at these different signs and symptoms can be an indication that someone may be struggling with their mental health.

So if we just go more into depth here, anxiety in terms of anxiety disorders are among the most common mental health disorders. And we know that there's an increased risk for anxiety, as well as depression, due to exposure to racism, trauma, and societal factors. Anxiety can start very early on in childhood as well, but we know anxiety left untreated often is associated with other disorders and can lead to substance misuse, substance abuse as well.

So it's important to look at what are some of these signs of anxiety. You might have an individual who presents with an anxious or fearful, kind of has an anxious or fearful presentation. Increased worry or concern, like I mentioned, about catastrophic or just bad things happening in a preoccupation with not being able to handle these things that may occur. But oftentimes, the concern is an unrealized future, so something that has not occurred. Individuals with anxiety could avoid people or places, start isolating, try to stay home. So there are changes in behavior as well.

Irritability or feeling unable to relax, individuals being on edge. This could be a sign or a symptom of anxiety. Decreases in decision-making abilities, decreasing incompetence. And so kind of struggling with being able to do certain things, whether it's work-related or at home personally. But you'll note that individuals may ask for a lot of reassurance or demonstrate that they're unable to handle things. Difficulty concentrating, and as well as a host of physiological symptoms, which can include headaches, stomachaches, or general just physical malaise. Again, related to we see an increase in individuals going to the ER for mental health-related concerns. Sometimes these might be related to physical. Physical symptoms might be related to kind of anxiety. So these symptoms can also be experienced when feeling stressed, right? But with anxiety, these symptoms tend to be long-lasting and have a significant impact on our daily functioning, causing overall impairment and distress.

Similarly, depression symptoms have increased significantly over the last few years. Of course, during the pandemic. But what we note here for a clinical diagnosis of depression, individuals must have one core symptom, and then at least five other symptoms that occur together. So the core symptoms could be sadness. It could be a low mood, irritability, loss of interest or pleasure in things that have once been enjoyed. And so if one of those core symptoms are met, then we look for these other symptoms, which could be changes in sleep pattern, as I mentioned, changes in appetite, leading to weight loss or weight gain, loss of energy, feeling just kind of physically or mentally exhausted, feeling restless or the opposite end, slowed down.

Individuals with depression may exhibit excessive guilt or feeling like their life is not worth living, right? So feeling worthless, they have no value, trouble concentrating, making decisions with depression as well as other disorders. There may be shifts in cognition and difficulties with concentrating. And then increases in thoughts of death, suicidal ideation, or suicide attempts. Importantly, to keep in mind, though, some individuals with depression may not exhibit suicidal ideation or thoughts of suicide. And so it's important to look for these other symptoms that one may be experiencing as it relates to depression.

Similarly here with posttraumatic stress disorders. S we do know that black communities experience traumatic events at a higher rate than other racial groups. As far as PTSD, PTSD is a mental health response to witnessing or experiencing one or several traumatic events. And so it is natural to feel afraid after and during a traumatic situation. The fear, essentially, that occurs is a fight or flight response, right? And that helps protect us, keep us safe. But people may experience a range of symptoms following a trauma, and most people recover from the initial symptoms over time. However, as listed here, those who continue to experience problems after a month, four weeks of time, in these different categories. 

So the ongoing symptoms there are people may have re-experiencing symptoms. So that might be intrusive thoughts or nightmares, thinking about the traumatic event, avoidance symptoms, behaviorally trying to stay away from people or things that remind them of the trauma. Cognitive or mood symptoms. And so this might be kind of easily agitated or angry, difficulties kind of with memory and focusing, and arousal and reactivity symptoms. And so this might be being jumpy or easily startled. A lot of individuals have heard the term kind of being hypervigilant. And so just having that extreme alertness after a negative event occurs.

So you'll see there the numbers next to each category are just kind of what's required to get a diagnosis of PTSD. But trauma, we know is quite common, unfortunately, in the communities, and it's important to consider what contributes to trauma. And so several years ago, Robert Carter came up with the idea of race-based traumatic stress. And so we do know that those individuals who experience forms of racism have a similar traumatic response to those who have PTSD as it would be maybe from a domestic violence incident or so forth. And so it's important to consider the whole picture with trauma and not necessarily always focus on symptomatology and the clinical diagnosis. And as providers, we might say, well, we want to look at not what's wrong with the individual, but what happened to the individual. And so just kind of keeping that in mind.

All right. So here I'm just going to move into the maintenance of mental health, essentially. And we also know - just kind of backtracking a bit - but from the stress and anxiety, individuals feel chronic stress or activation of the limbic system as a result of racism and discrimination, can cause changes or alter brain circuitry. And so there is research and literature out there that looks at the impact of racism on development. And especially in kids, there's some literature that came out several years ago, looking at changes in the amygdala, the hippocampus, the prefrontal cortex, and what happens to individuals when they do experience this racism. And so this is why we're talking about this today, why it's important to just highlight these symptoms that individuals may experience in different contexts.

All right. So we're going to talk a bit about self-care and shift here. As 8CRE is jumping into their 16 days of wellness, it's important to figure out, well, what are ways that I can maintain, right, my own mental health? What are ways that I can potentially reduce stress?

We do know, given everything we were just talking about, that there is a need for change at the societal level. However, we can not wait until that change comes about, and so how do we care for our mental health, right? What are things that we can do? So there are several strategies that are effective for reducing stress, which we'll get into. Here are just some suggestions about how to kind of maintain our mental health and take care of self. As far as self-care, we know that self-care is just an intentional practice of really just focusing on our mental or physical well-being. So taking an active role in protecting and preserving our health, our physical and mental health, preventing illness, and coping with stress.

It's important that we have a social support network. And so reaching out and connecting with people who you trust, who can hold space for you, who you can show up and be your authentic self is important so that we can kind of express, just talk about things that might be weighing you down, being able to reflect on what you need and ask for it. We really want to make sure that you're being able to advocate for yourself, your needs, others, connecting with things that bring you joy and energy. With everything that's going on, we do want to make sure that we are finding the small things in life that bring us joy. It might be gardening, being outside.

How can we get away from kind of the stress of the world? Being able to transform feelings of frustration and hopelessness, and that might be by doing advocacy work or volunteer work. This is quite important. And so there may be situations whether that be in our work environment, whether that be kind of in the community, where we are feeling like our voice is not being heard, you might be feeling invalidated. A lot of times that can lead to anger and frustration. Are there ways that we can kind of channel that energy into advocacy or a volunteer event and really help us to feel more empowered?

It's important to create boundaries. This might be with your family, with friends, also in the work environment, but that is a good way as well to maintain mental health. And we want to make sure we're engaging in healthy coping strategies. So we do know that unhealthy coping includes excessive alcohol use, drug use, isolation. So reverting and not being around people. It could be sleeping too much, overeating, spending hours scrolling on social media, any behavior that can be detrimental to our general health.

So let's talk a little bit about healthy coping strategies. So last year, there was an NIH live stream, that event that I did, and we were talking a bit about how to manage stress and anxiety. And so you're trying to come up with a way to remember these practices, and essentially here, what we came up with was being great. How can we be great, engage in great practices?

G stands for gratitude. So what do you grateful for? Small moments of joy and gratitude across the day can go a long way in terms of managing mood and stress.

R is for relaxation. We can engage in relaxation in a variety of ways. However you choose to unwind, it's important that you do figure out how you're going to unwind. So we'll talk a bit about relaxation.

Exercise. We know that 30 minutes of moderate exercise daily is the recommended amount for our health and well-being. Are we able to exercise and move our bodies throughout the day?

A is for acknowledging feelings. We must acknowledge how we feel and allow ourselves to experience a range of emotions. We can sit with being sad, being angry, being scared, but we must be able to be aware that we are experiencing that, acknowledge that it's happening so then that we can either problem-solve if there's an issue, make a plan, or just kind of be aware about how that emotion, that feeling is impacting our functioning.

And lastly, T is for tracking thoughts. And so if we are feeling anxious or stressed, it's very likely that our thought patterns are along those same lines. So our thoughts aren't going to be very helpful. So being able to track what you're thinking and write out, and that might be journaling or just noting in your phone. Getting out some of those negative thoughts can be helpful so you're aware of when they're interfering and when they're kind of causing you to feel a certain way.

So engaging in GREAT practices is a good way to just kind of manage low levels of stress and make sure that you're caring for your mental health. So as I noted with relaxation here, it's important to find what works for you. Many different ways, and I'm sure most of us have seen, suggestions for how we can relax our body or our mind.

As you see listed on the slide, there are different ways that we can engage in relaxation. What's important here is relaxation really can help us to have the ability to think more clearly, to access our cognitive resources, to make better decisions. And potentially, staying in a relaxed state can help us to maybe resist kind of future stressors or just have a little bit more resilience. Relaxation can lead to just a more positive outlook and essentially, physically, a healthier body, slowing down our rate of breathing, having more relaxed muscles, reduce blood pressure. It's linked to better physical health. So there are a lot of reasons why we should engage in relaxation. So here on the slide are just kind of different things that we can do to help relax our mind and our bodies.

And so another tool we like to teach is called grounding. And essentially, grounding is a self-soothing skill that we like individuals to use if you're having an intense moment of an emotion. It could be anxiety. It could be frustration. But essentially, in dealing with that stress, using a grounding strategy could help. It is increasing your awareness in the present moment.

And so we want to do this because when we are activated in any way-- and so it might be a strong fear or anxious response and our amygdala is active. Being able to kind of use, say, cortical areas, different parts of the brain can down-regulate the amygdala. So when we're grounding, what we want to do is focus on our current situation. Here, what we would do is use what's called our five senses. Five things that you can see immediately around you, right? So I might, as I'm sitting here, look at-- I can see a picture on the wall. I'm looking at my keyboard. You want to identify in your physical environment five things you can see, or things that you can touch, paying attention to, is it hard? Is it soft, hot, or cold? What does it feel like? So you're really engaging your senses. Three things you can hear, two things you can smell. And what you're doing is bringing your awareness back to that moment and out of that, if it's an anxious moment or anger moment.

This is a great strategy to use. Oftentimes, we could be triggered very easily. Might be in work meetings. It might be at home with your child, and you can kind of engage in this as a very quick way to kind of bring yourself down and be able to think through and make more helpful, I'll say, decisions in the moment. And really just shift your attention away from the uncomfortable feelings that you might be experiencing, physical feelings.

Visualization is another strategy we could use. And so, again, this is something that I teach to adolescents, to children, also for my adults, easy to use, and you can do it anywhere. You can do it sitting in your car before you walk through the doors at work. You can do it at home. You can do it at bedtime, right? Maybe when you're putting your kids to sleep. But visualizing a place that you really enjoy or a relaxing place, or it could be a place you'd love to visit.

For me, it's anything tropical, and so as long as there's a beach there, warm weather, the sun, I'm good. So I use this image. It used to be, for me, going to Manuel Antonio Beach in Costa Rica, right? Gorgeous. And so I'm thinking of this place. I'm closing my eyes, engaging in some deep breathing. And here, I'm also using my five senses to bring myself to that place. So this is more imaginal in that when your eyes are close and you're picturing this place, while you're picturing it, then you can say, "Okay, what are things I see in this environment? I feel the sand on my feet. So you're doing this, it's all imaginable though. So it's not bringing you back to the present moment. You're more so imagining yourself, you're visualizing yourself in that location. This is quite effective as a way to relax the body physically, and again, can use it at any time.

So I'm just going to move into here ways that you can help loved ones. And so again, you can teach these strategies. You can use them yourself. You can also teach them to your loved ones. So in terms of supporting your family, friends, other people who may have, it could be your mental illness or it could just be symptoms of stress and anxiety, we don't want to perpetuate the stigma around mental health.

And so it's really important that we're able to have the conversation, be open and honest about what you may be observing. You can ask your-- it's a relative, a colleague at work. "Hey, so I noticed your mood has been pretty low these past few days. Everything good?" You notice someone's missing work for several days, kind of reaching out, putting it out there, and say, "What's happening?" Give them the opportunity to talk. It's important that we use validating statements. 

And so if someone is expressing to you, they have a frustrating situation at work or they're feeling really sad, you want to respond more so with, "Wow, that sounds really frustrating," or, "I can't imagine how difficult that has been." Our first instinct sometimes is, "You're fine, cheer up, you'll be okay," in an effort to make someone feel better, right? But what it can do is cause them to feel invalidated or minimize their experience of what they're going through.

Encouraging self-care and opportunities to engage in activities together. And so this could be, again, sharing some strategies that they could use. Self-care, it could be something that you do together. You go home and you say, "You know what? Let's just go for a walk around the block," right? So it's good to get out, exercise, be in nature, figuring out things you can do together with people or for them. A lot of times people with mental illness may have trouble with doing daily tasks. So here you can, "You know what? I'm going to go to the grocery store. Let me pick up-- let me pick up food for the week for you," right? Do something that they're struggling to do. This might be an individual who has significant depression and is having trouble getting out of the house or even kind of go on an app to order food. You can do that for them.

Try not to take it personally. Again, those with mental illness sometimes get to the point where they're either socially isolating, they may not be returning your phone calls, they may be extremely angry or irritable and lash out at you. So keeping in mind that this is mental illness and that it's not specific to you, and it could be very hard and frustrating to deal with, but knowing that, again, it's not personal.

And again, suggest seeking professional help. And so if you do notice any signs and symptoms, either ones that went through, right, or anything else of mental illness, is suggesting maybe they speak to someone, a professional person, get some help, be evaluated. Ideally, what we're looking to do is increase the conversation about the importance of mental health and therapy. So here on the slide is just listed treatment options, which most of us are well aware of, that individuals can seek out if they are struggling with mental illness, and keeping in mind with therapy, there are different, what's called, kind of orientations for a therapist to utilize. Cognitive behavioral therapy. It can be trauma-focused, interpersonal therapy. And so oftentimes, it might take a few attempts to find a provider that's a good fit, and also utilizing an orientation that is a good match for you.

So here are some providers, ways to find providers, rather. Contacting your primary care doctor, going online, and utilizing kind of professional organizations or national agencies. There are crisis resources, having these handy, especially if you do know a family member, you live with someone who has mental illness. These resources could be helpful.

And so this slide here just has some websites that you can go to that has great information for black individuals, people with mental disorders. Please note that NIMH is a research funding agency, and so the resources on this page are not endorsed by NIMH and are provided just for informational purposes. But I can say that they have really great information that individuals can use. And with that, I will stop here, and thank you for your attention.

MIA ROCHELLE LOWDEN: Thank you so much, Dr. Lewis and Dr. Gordon. I really enjoyed hearing from both of you today. And thank you so much to our audience, for the questions that you have been submitting. I will read a few of them out. So one question, I believe, came during your talk, Dr. Gordon. Do colleges and universities qualify as community-led agencies?

JOSHUA A. GORDON: No, actually. Purposefully not. So we certainly do support lots of research done by colleges and universities. But for the purposes of the ComPASS Initiative, which is where I emphasize the grants are being given to community-based organizations, we excluded academic organizations from that.

Now, those community organizations are, in general, partnering with academic investigators, but in a twist of the usual case. So usually at NIH, when we fund something like this, we'll fund a university and they might subcontract to a community-based organization. And we really wanted the power dynamic to be switched in this case. We wanted the community organization to be the one driving the research question, and so that's why we chose to give the primary grant to the community-based organization.

MIA ROCHELLE LOWDEN: Thank you. I will go on to the next question. This is from an audience member with the initials E.T.: “Hi, I'm an undergrad psychology student from suburban, Georgia. One thing I'm interested in, it's advocating for greater access and quality of mental health care because I have seen and heard a lot of harm from the few services in our area. I've tried to look into this myself, but I haven't found an answer. How exactly is quality of care by mental health providers measured and upheld?”

JOSHUA A. GORDON: That's a great question, and it really depends upon the provider. And Krystal, you should feel free to jump in if you have a different perspective. But in general, providers are held to quality standards by a variety of different entities, including the professional organizations that oversee them, whether it be a State Department of Mental Health or the American Psychiatric Association or the Psychological Association.

But in general, quality measures are usually done by the payers. So that might be the health insurance companies, it might be the clinics or the hospitals that they belong to. And not a lot is done in routine practice to measure quality of care.

So one of the things we pay a lot of attention to in our services research portfolio is ensuring that we are measuring the quality of care delivered. And how do we do that? Well, we do it in a number of different ways. First, we ask whether an evidence-based practice is being used. So, for example, if you're going to use psychotherapy for depression, is it one of the recognized evidence-based approaches: cognitive behavioral therapy, interpersonal therapy? Or is it a non-manualized or non-evidence-based approach?

We also look at the fidelity of care within a research project. So, we can measure how much a provider sticks to an evidence-based approach or how much a clinic includes the full package for an evidence-based package of approaches for mental health. So those are some of the ways that quality can be measured. But in general, in everyday practice, quality of care for mental health is something that's not measured well enough and often enough.

MIA ROCHELLE LOWDEN: Thank you so much for that response. Please, Dr. Lewis, if you'd like to jump in for any of these, you're more than welcome to add your thoughts as well or jump in as you wish. I'm going to pull more from the Q&A. Please continue putting your questions in. Thank you to those who are putting in positive comments. I'm glad that you're liking the questions and that you're attending. 

The next question is from Dr. Trance: “Hello. I'm working in a small, rural community on issues of mental health and suicide prevention. Where might I learn more about the grants that Dr. Gordon mentioned, and/or how might I contact him for information on collaboration or engagement with community health and the NIMH? Thanks, Tamra Turner.”

JOSHUA A. GORDON: Well, thank you, Dr. Turner. I really appreciate your query. The ComPASS Program is administered by the NIH common fund. And so you can visit the common fund website and find contact information or you can email me at joshua.gordon@nih.gov, and I'll try to send you in the right place if that's what you're talking about.

If you're more interested in our overall health disparities approach, Dr. Christina Borba is the director of the Office for Disparities Research and Workforce Diversity. And she's a good contact at NIMH to start, and then she can send you to the right person if you're interested in engaging in research yourself or you have a research partner that you'd like to work with to be able to ask research questions in your setting.

And Dr. Borba may or may not send you to someone else either in her office or in another division, depending upon the questions that you're interested in asking. So it's best if you want to get in touch with her to sort of frame what questions you're interested in asking, and that can help us get you to the right person.

MIA ROCHELLE LOWDEN: Great. I put in a few links in the chat to the ComPASS Program, NIMH funding opportunities, as well as the NIH guide, which is a great resource to understand what funding opportunities are there for NIH, as well as other agencies. So please check those out. There's also NIH Reporter if you want to learn more about what we've already funded and how we're using your wonderful taxpayer dollars.

We have a comment that came in: “This is so beneficial to see the numbers supporting the data.” And another question. I think this is a typo: “Are tribal governments and communities included as a community-led organization?”

JOSHUA A. GORDON: So they were certainly eligible. We haven't made the awards yet, so I can't tell you who we've funded, but they were certainly eligible to apply. I'm not 100% sure about the government piece. I think so, but certainly, tribal organizations were eligible to apply to ComPASS.

MIA ROCHELLE LOWDEN: Great. And again, please check out that link to ComPASS. I can't really see what it looks like on the audience side, but hopefully those links are coming through. Another positive comment: “Excellent talk and resources. Thanks.” Thank you, Beverly. And another question: “How well is racial-based trauma known and communicated?”

JOSHUA A. GORDON: Interesting. I'll choose to answer it the way I can, and then maybe Dr. Lewis, you might want to add. From a research standpoint, there is a lot of data showing that racial discrimination and other forms of what you might be meaning by racial-based trauma definitively play a role in mental health and mental health disparities.

So absolutely, that is known and appreciated. I don't know how well it's communicated to the public at large, the tremendous impact of racial discrimination and racial trauma on mental health, but certainly, it is known.

I think what we don't yet know really is how to mitigate, how to build resilience, etc. Though we're starting to learn some about the factors that lead to resilience to race-based trauma and racial discrimination. Krystal, do you have anything to add to that?

KRYSTAL LEWIS: I would just say in terms of race-based trauma, in the research world, there's a lot more that's being done to look at the experiences of racial trauma and discrimination and what that looks like in communities of color.

I will say that in the general population, it's less known as a concept. And so I think communities who have been experiencing racism and trauma over the past several years, it's kind of just the norm of how individuals may kind of respond to discrimination.

And so I do think that there is a need for a lot more, I would say, just kind of education and awareness about the stress response, stress and trauma, what it looks like, and how that fits into mental health in general in our communities.

To Dr. Gordon's point, there are groups that have been kind of highlighting what race-based traumatic stress looks like, how it's related to the concept of PTSD. But keep in mind that race-based trauma is not a DSM-5 diagnosis. And so it is something that is now being looked into as to how that relates to PTSD and experiences for individuals who have been exposed to racism and discrimination.

MIA ROCHELLE LOWDEN: Thank you for that question and those responses. So another question. Sorry, I need to clear a few of these that I finished already. And we're getting close to the end. So this will be the last one for now, but thank you for all that submitted questions: “What can we do to promote community education about mental health and disparities? What should we do with the info that we learned during this meeting?”

JOSHUA A. GORDON: Great question. I think the more that we can communicate this, particularly to groups that you participate in, whether they be clubs or houses of worship or discussion groups or other community groups, the more that you can communicate this information to the more people, I think that the greater the recognition that disparities exist and that they need to be addressed, whether it be addressed from a research perspective or addressed from a policy and care provision perspective, I think it would be important. Again, I might ask Dr. Lewis, if you have anything to add.

KRYSTAL LEWIS: Yeah. I mean, I am very passionate about disseminating information. And I think just kind of utilizing these resources. So being able to look up any of the information, access to the journal articles, anything that Dr. Gordon presented in terms of kind of the graphs about disparities, mental health disparities. It's important to use that and promote that in local communities.

So if you are in the field and you're able to offer your services once in a while to different community organizations, I will reach out and try to partner with different groups to share this information just to start to have the discussion around what we were talking about today. I think it's very important just to disseminate this information, have a list of resources that you can provide to maybe individual groups that you're working with, or individuals themselves.

And for those of you out there who might be in academia, you might be professors, kind of utilizing this information in classes to talk about mental health disparities and make it part of, I think, the normative in terms of training and education so we can make sure that we're disseminating this information.

JOSHUA A. GORDON: And in the spirit of dissemination, I want to let you know we have two more webinars coming up this month, one on black women's health and one on black men's health, and you can find that information on the 8CRE website. I understand some of the links aren't coming through, so you can always start at nimh.nih.gov. That's a good place to find out more about what we're doing, or commonfund.nih.gov/comPASS if you want to find out more about the ComPASS Program.

MIA ROCHELLE LOWDEN: Thank you so much, everyone, for attending. Thank you so much to our speakers, Dr. Gordon and Dr. Lewis. I appreciate the time that all of you shared today and hope that you will continue to practice wellness and observance of Juneteenth, thinking about yourself, your family and friends, and your community. Have a wonderful afternoon.