Culture of Health: Minority Mental Health Care Transcript
(Please note: this transcript was machine generated and may not be word for word perfect)

Dr. Nwando Anyaoku

Hello everyone and welcome to Culture of Health a show that zeroes in on healthcare matters that disproportionately affect our community, and we highlight ways to break down systemic barriers to quality care. On this podcast, we will talk with healthcare professionals and hear stories that inspire and inform listeners to bravely navigate healthcare with dignity, care, and humanity to achieve equity.

I'm your host, Dr. Nwando Anyaoku, Chief Health Equity and Clinical Innovation Officer for Providence. And here with me today is Dr Arpan Waghray, President and CEO of Providence well-being trust. The past chair of the Behavioral Health Committee of the American Hospital Association and a dear friend of mine.

I invited Dr. Waghray to the show to help us understand why good mental health is so important to our overall health and some of the issues facing minority communities when it comes to mental health. We will also talk about some of the programs he's working with to help close HealthEquity gaps in mental healthcare.

Hello and welcome Dr. Waghray, it is so great to speak with you today.

Dr. Arpan Waghray

Thank you so much for having me. Dr. Anyaoku, this is such a joy. This is a topic that is very dear to my heart, and I am always just so grateful for the opportunity to listen to you and learn from you. And I hope that we're able to have a meaningful discussion and try to help your audience understand the importance of what we're talking about over here in the context of mental health and equity. So really excited to be a part of this conversation. Thank you.

Dr. Nwando Anyaoku

I appreciate you so much. Can you tell us a little bit about yourself and a little bit about the work you're doing and the Well-Being Trust just to set some context for our listeners.

Dr. Arpan Waghray

For sure. So I am a son of immigrant parents from southern India. Was born in Charleston, SC, but then moved, you know, back and forth between India and the United States over the course of growing up in the psychiatrist by training and fellowship trained in geriatric psychiatry, so really enjoyed that intersection of medicine and neurosciences and psychiatry, and have been with the Providence family of organizations for almost 17 years now in different roles, so really enjoyed being a part of this and for the past 18 months have had the great privilege of serving as the chief executive for Providence's Well-Being Trust.

So, this is a foundation that was created by the Sisters of Providence and the Saint John and Saint Joseph Orange, when we came together with a very bold goal, and the goal was to advance the mental, social and spiritual health of the nation, and this was supported by a very generous endowment by the Sisters of $100 million. And we're really privileged to to be stewards of these resources and trying to drive change through our communities.

Dr. Nwando Anyaoku

That is so awesome. I you know, I know this stuff but every time I hear it, it just lifts my spirits, so thank you for sharing. Let's dive into mental health a little bit, starting with what is mental health literacy? How does it contribute to a person who's overall well-being.

Dr. Arpan Waghray

Yeah, such an important question. I think the, you know, there's health literacy itself is such an important topic for us to be able to be well.

We need to understand what are the factors that drive from promote wellness. What are the risk factors? What are the protective factors and so on? It's even more pertinent in the mental health field because there's so much subjectivity to mental illness. There's no clear blood test that we can draw that would define and tell us that we have illness A versus B. It's a cluster of symptoms that are reported subjective by an individual that then lead to a diagnosis.

So it becomes even more important for us to be well informed. So, what mental health literacy is? Is the understanding of signs and symptoms of what we describe as mental illness? There's it's such a range. So there it's OK for us to be sad and down when things are not going well, I mean, we all, we're human beings, we're going to have those emotional, appropriate emotional responses. That's not all mental illness.

That's normal human behavior and responses. So, understanding that versus when things are falling into the category, where they become of concern that we need to pay attention, what is feeling down feeling blue versus being clinically depressed, what is bipolar disorder? What is schizophrenic illness when is?
You know, drinking alcohol or using some substances problematic enough that it is now classified as substance use disorder. So, understanding those differences is important. So that's a core part of mental health literacy.

I would also say the ability of an individual to not only understand what those symptoms are, but what drives the symptoms, what are the protective factors, and also, I would add, how does one understand how to access the appropriate support and serve?

I would put all of that in the bucket of mental health literacy and our strong goal as people of Providence to make sure that we are democratizing knowledge. We are demystifying things. We're getting to the heart of stigma that holds people back and where everyone is well informed so that they can flourish, and they can realize their fullest potential of well.

Dr. Nwando Anyaoku

It's so incredibly important. I mean, I I'm a pediatrician by training, and we know that, especially for young, for children and young adults, this has become a really challenging situation. It always was. But post pandemic, it seems to have taken on new proportion. We tell people what to look out for here you know, how do we know when we're no longer sad, but we're now dealing with others?

Dr. Arpan Waghray

That's such a great question. It's when we all kind of wrestle with, right. You have family members, friends asking these questions. I would say trying to keep it fairly simple and high level one of the core things that we look at when we're clinically diagnosing.

People and we're coming to some recommendations where we want people to get more professional help. Are the symptoms your experience that are impacting your ability to function socially or occupationally?

I think that becomes a very important guiding force to say, well, if it is getting to a point where I am not able to maintain the fulfilling meaningful relationships in my life, I'm not able to function as a productive member of the society that I normally am accustomed to, whatever context that be and you know if it starts impacting your ability to function at work or at school, then that is a point where we should pause and we should try to get a little more understanding.

In addition to that, I would say you know, there's some symptoms that that would warrant more immediate attention. And one of them would be forever feeling we're getting to a point where we feel life is not worth living and we we're having thoughts of wanting to end our life or have, you know, die by suicide. And those are, of course, very, very concerning symptoms that need to be brought to someone's attention sooner rather than later.

Dr. Nwando Anyaoku

So the other challenge with mental health, mental illness. There's. But there are a lot of misconceptions and myths when we talk about some of the most common ones and how they impact our ability to navigate the space.

Dr. Arpan Waghray

For sure, you know it is. It's interesting how we have historically thought about mental illness as being a sign of personal weakness or personal failing. And I think all of those misconceptions and myths perpetuated the stigma and have actually got us to this point where we're at today where it is different than any other analysts that we treat. So, you know, those are very common misperceptions.

Your thinking that these are very rare or I'm the only person who's experiencing this. It's also a myth. They’re fairly common disorders. One in you know about almost 20% of 20 to 25% of the US population, and even population across the world experienced some level of mental illness through the course of their lifetime. So, these are fairly common illnesses.

And you know, they're a combination of nature and nurture. So there could be genetics that's playing into it, but also life experiences, trauma, adverse childhood experiences and so many other things that go with it that could be contributing to these symptoms. Another common misperception.

You know, when it comes to thinking about suicidality, which is unfortunately, one of those things that no one we believe no one should die alone in despair by suicide, and these are preventable deaths. And it's fairly common when among the leading causes of death among our younger people.

So, it becomes even more concerning is that if the misperception is that if I were to see somebody's feeling down or depressed, and if I were to ask them a question if they're feeling suicidal, I'm actually going to plant that thought in their mind. That is a myth. There's been a lot of studies to understand and dispel that. And yet many of us hold on to those things. So, we don't ask those questions, which can actually be the difference between life and death and people getting help in those moments. But you know the myths and the misperceptions come in the way. So those are some that come to mind, right?

Dr. Nwando Anyaoku

Along those lines, I wonder how does this play out in underserved minority and underserved populations? I know there are some unique challenges in this community. Can we talk about that?

Dr. Arpan Waghray

That that is such an important question. And I don't think people really appreciate the importance of that enough, so you know. Again, we started off by saying the difference between mental and lesson. We talked about mental health literacy. Is that a lot of the way we diagnose, and we understand mental illnesses is through a subjective reports of symptoms, not blood tests or other diagnostic tools that we have. They're more you know, history taking and understanding that.

Now think about it, right. If you do not have a good understanding of one's cultural context. It is very, very easy for us to misinterpret what one is trying to tell us and not be able to give them the right diagnosis and support. If we didn't. If we do not have the cultural humility and understanding and cultural responsiveness and what we're doing. So when I think about examples and this is true across so many different cultures, ethnic groups, and I was thinking about different groups that I worked with over the years.

I saw I used to work my sitting at the VA hospital, and I remember working in a clinic where I was working with elderly Japanese men and it was a very interesting experience to me because I do not recall any of the patients coming and telling me that they had clinical depression or were feeling sad. They would always come and their present team complaints and symptoms were abdominal pain. Other physical symptoms and you know, unless you're looking for something, you can't really understand and help people and you know.

I think it was Canadian author Matthew Davies said that the eyes see only what the mind is prepared to comprehend, and if we do not if we do not know what we're looking for? We do not understand. We're gonna miss a lot of things now. This goes on in all different categories. You think about in minority groups. The stigma is even more prevalent than you know, so many others. And and that limits folks and trying to get the help and support they need and so being able to understand that understand where one is coming from, what is the context in which they’re presenting these symptoms.

Sometimes another thing that comes to mind is when people report symptoms and we're not. We do not have the cultural understanding. It is very likely that we also misdiagnose and one of the large meta-analysis. I think it was published, I mean over many years, but there was a report from it was the World Congress and psychiatry. And this is not unique to the United States that black individuals are twice as likely to be diagnosed with schizophrenia, with the same presenting complex.

Means then someone who's white and they're diagnosed with bipolar unless it makes you pause, reflect and say what's going on here. Right, there's something that's not adding up. There's something that we're missing. Now. This has serious implications and how we design our treatment plan, what we're doing. And so we need to really understand and spend time. We also need to understand that are there.
Certain groups that are not getting the help and support they need because we're not really paying attention to that.

And so I believe it's almost 20 to 25% men, black men over 70 who did not receive treatment for depression or are less likely to be prescribed antidepressants. We've seen from some of our own data that I think it was in one geography where if you happen to be Latin X and a young LatinX Individual year or 30% or 38% less likely to be screened for depression so there's, there's a lot that's built into that that makes us want to pause, reflect, understand and respond appropriately.

I don't know if I answered your question. I kind of looked all over.

Dr. Nwando Anyaoku

Yes, you absolutely did because you know I'm thinking about that, right? How what is the role of bias? What is the role of systemic racism in mental health care in access? And you being believed, right. So have a lot of underserved populations who have a basic distrust of the healthcare system because of things like that, right? You come in and you end up with a diagnosis that doesn't quite gel.

How do how do we even start to look at that, to start to heal that gap it seems so big.
Yeah, that that's an important question and one that I'm still wrestling and struggling with. I don't know if I have intelligent answers.

Dr. Arpan Waghray

For that, but I feel like being able to heal and cross that path where there is mistrust for a lot of good reasons that. We should own and move past so that we're able to actually build bridges and actually get to a place where now. So there is a health system that works for everyone, not just for the particular group of people.

And I think that's really important. I would say, you know, kind of the way Edward Deming said that, you know, in God we trust and all others must bring data. And I think that's probably the way I would think about us addressing this. So if we are very transparent and every time we look at outcomes we need to make sure that we have an equity lens built into that.

So if we have a dashboard, for example, the work we're trying to do, you know with Providence trying to identify some core metrics in the mental health space where we're able to address and alleviate the most common causes of human suffering and disability issues. One of the most you know, impactful areas where we have the greatest ability to save lives, you know? So this would be around depression.

In care, care for opioid use disorder and suicide care. And so when we build these dashboards to try to understand how are we improving the quality. How do we understand that in a way that we are paying attention to which groups are there certain groups that are not responding well to the treatment that's been given? Are there certain groups that have a disproportionate impact and they're not at the same level of your clinical.

And then that informs how you design your quality improvement. And I think those are the kind of very fundamental things that if they're done with intentionality and humility, we will start making some progress and I think.

We have a long way to go it. And yet we must start, right. So how do we so do we think about having I have two questions. One of them is working with mental health professionals, right. The healthcare professionals in general.

Dr. Nwando Anyaoku

To, you know, build that muscle to build the learning about providing culturally humble, culturally sensitive care for individuals of different background is I know that that's not something that was called out when I was going through medical school, but we learned that we really have to be intentional about it, to your point. So are we putting things in place now to start building that muscle in our in our healthcare team?

Dr. Arpan Waghray

Yeah. So I had the privilege of serving on on a healthcare systems committee with the American Psychiatric Association. This is a topic that comes up quite a bit you know, in our training of the new generation of residents.

How are we bringing intentionality? I mean, the one thing would be nice that if we had, you know, people who are providing care, be very representative of those who are getting care and have numbers, but we also recognize that there's a huge gap and so we need to start doing something right now that allows people to build those competencies so that even if you don't exactly look like someone you're caring for and you have the ability to meaningfully care for them by your training and understanding.

And I do feel that there's a lot of progress that's being made. I think just like you said, I never had that understanding when I went to medical school and residency training, there was barely anything. And that was a huge gap.

And I also will say that I think this intentional training needs to happen at the residency level and not just a zoom that if you belong to a certain culture that you have the cultural humility and confidence to care for it. I will give my own example. And you know from in Indian background. And I remember when I was in practice, I started having a lot of patients.

You referred to me, who were from an Indian background and I hadn't lived in India for a long time and I didn't really understand a lot of what they were describing, but just because I'm of the same race, ethnicity, you know.

It was just doing that I would be able to provide culturally competent and, you know, care. And I wasn't able to do that. It took me some time to stop and learn and understand, you know, the symptoms. I'm so you. I was trained in in the United States. So understanding the DSM criteria and how symptoms are diagnosed. But I realized that many times patients would not present with those DSM symptoms and those criteria.

It was a very different way in which there and I had to dig in deeper to understand, so I would just say that you know, it's something that we all must take on and we must all try to build our competences because ultimately this is our it's not a job if you go, if you're a physician, it's not just a job, it's your vocation. It's your calling. You go into this because you want to make a difference. You want to support and care for everyone.

Not for one group or another group. And I think that is generally true and we need to have those those skills built in. And I think you know something that will require work and for those who are in practice for a long time.

And I mean, I would encourage people to go back and actually take some scenes and learn and and get some books, and we're always learning about so many new technologies and new things coming.
Why not spend and put some energy learning about something that really matters and can make a difference to somebody's life.

Dr. Nwando Anyaoku

Fantastic. I love it. And it's so interesting when we think about.

The value of having diversity of lived experience, background and lived experience cause to your point we may look similar but may not have the lived experience and we may look different and get share share that lived experience. So I I I think it's really important to your point to really think about how we enrich our teams not just with people of different backgrounds and lived experience but.

With each one of us building that competency, that muscle of learning how to care across cultures, because even if we try to match one-on-one, it would take a really long time for everybody to get a congruent provider. But if we have a diverse pool, then I think we all enrich one another. So I I really love that.

Dr. Nwando Anyaoku

I also wanted to talk about how your partner with the Community cause mental health is so personal and yet community, right? So how do we partner, how do we Co-create solutions with communities, especially underserved community that we're developing solutions out for this work.

Dr. Arpan Waghray

I think there there's so many levels to that question. I do think there are a lot of people who have described this, you know as a, as you know, psychiatric illnesses as medical problems that many times have societal solutions in psychiatry and in our training, we will always start to think about the diagnosis and treatment plan in the context of biological, psychological and social, and that was deeply ingrained in our training and how we thought about this. And I think that aspect of Community and that intersection of clinical and community is critical.

Probably more so than in many other areas, for all the reasons we discussed earlier in in, you know, mental health literacy, the lack of understanding the stigma and so on. You know, one of the things so some of the things we're trying to do is as we are trying to think about.

Creating a system that works for everyone in a way that we're filling gaps. Like if if someone needs help and support for themselves or their loved one, we need to make sure that we're always there for them now, sometimes that care is going to be delivered through the healthcare system and there are other times when it's going to be through community partnerships.

And when we think about this, it's not just about the clinical care and the tertiary care like, you know, the advanced care where you're having to give you know, hospitalization, hospital level care or medications. I'm actually thinking further upstream, you know, when and some of the work that we're trying to embark on is working with the faith-based community. When we think about the opportunities and we've looked around the country, use the example of cure for opioid use disorder, right we have some amazing treatments. We have medication assisted treatment and we wanted to put this in context to think of.

This the number needed to treat to save a life is so significant with medication, assisted treatment. So if you treat, you know, and I think the number if we compare this with say we needed to do 3000 mammograms to save one life from breast cancer. Critically important must do. You need to treat 20 people. You had an opioid overdose with medication assisted treatment. You have the likelihood of saving one life over the next year. So we have treatments that actually work. You can save a life, and yet there's this mismatch even when we have resources, people are not getting it.

So, you know, working with communities can actually be a game changer here. So one example that comes to mind is something we're trying to emulate in our footprint was work that happened in New Jersey, Cardinal Tobin, who trained the you know, faith-based communities and was all types of faiths in the understanding of what people might persent with when they're dealing with substance use disorder in use, focus on opioid use disorder and helping them overcome the stigma and try to get the support they need.

And all that happened outside the hospital system was in the community, and it was a game changer because people who were actually struggling, who would never make into the health system. Or if they made it to the healthcare system, made it after an opioid overdose, and are being resuscitated with naloxone and other things, we're actually getting the support earlier. So those are models we're trying to emulate and build.

In addition to that for children, for example, we're trying to really go outside of our four walls of healthcare and work with school districts In very, very meaningful ways and one of the partnerships we're very proud of is the work we're doing in Renton School District, where our corporate headquarters is. This is our backyard.

And So what we have done over here is we've partnered with this sports team. We've partnered with others and the idea really is to say there are 15,000 children in this school district that we're trying to support. Many of them come from underprivileged backgrounds.

We looked at the Community Health survey data and there was, you know, unfortunately a lot of depression, anxiety and things that we're seeing across the country. So how do we come together in a way that we're actually able to move outside our walls, go into the community and be supportive?
So in this partnership with this sports franchise, one of the first things we tried to do was to bring the athletes in, meet with the kids, and start normalizing, help seeking behavior, and when the athletes were role models for these kids start talking about, you know, their experiences. Each just took so much pressure off and we saw magic happen.

We saw kids start talking about it. So you know that to so many other things that started being brought in to empower kids, you know, through our talk of healthcare literacy, how do we support them? How do we give them the tools, the vocabulary, the understanding so that they're able to, you know, know what's going on now while doing this. We're also realize that we need to have safe places for the kids to play, so it's not just about the healthcare delivery aspect.

What other things can be done? So that's where the sports team was building these pitches, where in many places where children do not have space spaces to play, they have soccer fields now so they can play and now while doing all of this, we brought in virtual therapy.

So that any of these children who wanted to support, whether they're choosing to get help, whether their parent wants them to get help, whether the teacher thinks that they might need help, we made confidential virtual care available at no cost for these 15,000 kids.

So that's one example of, like, moving outside of our walls, our comfort zone, to go into the community to drive real change.

Dr. Nwando Anyaoku

Oh my word. Yes you are. You are speaking my language right there. Thank you. That is such a powerful program and You know, you and I can talk for the whole day, but I'm going to start. I will start to come to the end of our time together. I want to ask 2 two more questions.

One of them is you know, to the point we talk about building resiliency right in the community and the children and all of us, what steps can we take to think about self-care. Self-mental health care to build our own resiliency and our own support. What can we share as one or two tips for our listeners to think about that?

Dr. Arpan Waghray

There definitely going to be so many different things that might work for different people. I will say that you know from and maybe I'll start with examples and things that work for me. One of the things that has been most impactful for me for my own mental health and self-care has been the practice of attitude. I cannot even begin to express how much of an impact this has had on my life.

I practice some code called the three good things. You know, what are the really good things have happened and you can journal that and you start implementing some of that in your life. That helps. I will say that routine and physical exercise and healthy diet. You know, it sounds very basic but it goes such a long way if you have some structure to your day another thing that we found that started off after the pandemic and some of the work from home and you know other things that are happening is that the bound ways between your work and your life have somewhat become blurred.

So another thing for self-care that actually I found helpful and something that we had done work with, which was not, I cannot take credit for the idea came out of the National Health services in the United Kingdom was something called a going home checklist. So irrespective of where you're working from, there are few things you can do and the idea really is to be able to meaningfully separate and disconnect between your work life and your personal life.

So those are some immediate thoughts that come to mind. I'm sure there's so much more. Yeah.

Dr. Nwando Anyaoku

I love those. I I like the going home checklist idea because the work from home thing, I think it's been very challenging for a lot of people. So before we go, is there anything we haven't discussed? You want our listeners to know?

Dr. Arpan Waghray

There's something that I've been thinking about a lot and I've talked to some folks about this. You know, I was going back and reading some, some of the historic some archives and think about mental illness. And it was 1963 w1hen for the very first time, a sitting United States President addressed Congress on mental illness, it was the very first time in part to that nothing like this had happened.

President John F Kennedy and in his speech, something that has stuck with me very, very dearly, is he actually called out. And, you know, 60 plus years ago saying that those living with mental illnesses and disability should no longer be aliens to our affection and beyond the reach of our community.
I think about this and 60 years later, we we're having these conversations, we're seeing the struggles we're seeing deaths of despair related to suicide, drug overdose. We haven't been able to make meaningful progress. I think for our audiences to listen and to stop and say that this is no longer acceptable. It is no longer OK.

I think the change will happen only when people demand that they get the care and support for mental illness, just like they would for any physical illness, and we need to make this front and center. And I think this is the time and if there's a silver lining from the pandemic, you know, I would say that it's the awareness around mental illness that has actually improved and normalizing of help seeking behavior.

So I I urge the audience and those listening say, everybody has a role to play. You could talk to someone in your community. You could ask someone how they're doing from that depending on what your role is. If you're in the healthcare delivery system, you can do more. You can get trained. I think everyone of us has a role and let's try to really come together to drive some real change.

Dr. Nwando Anyaoku

It's such a powerful call to action. In the role of advocacy from home, from the community, even elected officials. Dr. Wagner, you're amazing as always. And thank you so much for sharing your time and your wisdom with us today. I know our listeners have been enriched and given tools to start to make a difference and this really challenging you.

But I'm grateful that you're here in our organization leading this charge and I'm grateful to work with you every day. Thank you everyone for joining us today on culture of health. We look forward to continuing the important conversations about Health Equity issues with more experts from Providence in future episodes.

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