Major Depressive Disorder

New research provides further evidence that a high body mass index (BMI) leads to depressed mood and poor well-being via social and physical factors.

Obesity and depression are “major global health challenges; our findings suggest that reducing obesity will lower depression and improve well-being,” co–lead author Jessica O’Loughlin, PhD student, University of Exeter Medical School, United Kingdom, told this news organization.

“Doctors should consider both the biological consequences of having a higher BMI as well as the social implications when treating patients with obesity in order to help reduce the odds of them developing depression,” Ms. O’Loughlin added.

The study was published online July 16 in Human Molecular Genetics.
 

Large body of evidence

A large body of evidence indicates that higher BMI leads to depression.

Ms. O’Loughlin and colleagues leveraged genetic data from more than 145,000 individuals in the UK Biobank and Mendelian randomization to determine whether the causal link between high BMI and depression is the result of psychosocial pathways, physical pathways, or both.

The analysis showed that a genetically determined 1 standard deviation higher BMI (4.6 kg/m²) was associated with higher likelihood of depression (odds ratio, 1.50; 95% confidence interval, 1.15-1.95) and lower well-being (beta, -0.15; 95% CI, -0.26 to -0.04).

Using genetics to distinguish metabolic and psychosocial effects, the results also indicate that, even in the absence of adverse metabolic effects, “higher adiposity remains causal to depression and lowers wellbeing,” the researchers report.

“We showed similar findings when looking at genetically predicted BMI and when using genetic variants that make you fatter but metabolically healthier (favorable adiposity genetic variants),” said Ms. O’Loughlin.

“Although we can’t tell which factor plays a bigger role in the adiposity-depression relationship, our analysis suggests that both physical and social factors (e.g., social stigma) play a role in the relationship between higher BMI and higher odds of depression,” she added.

In contrast, there was little evidence that higher BMI in the presence or absence of adverse metabolic consequences causes generalized anxiety disorder.

“Finding ways to support people to lose weight could benefit their mental health as well as their physical health,” co–lead author Francesco Casanova, PhD, with the University of Exeter, said in a statement.
 

Unexpected finding

Reached for comment, Samoon Ahmad, MD, professor, department of psychiatry, New York University, said that “multiple studies have shown a correlation between stress, obesity, inflammation, overall well-being, and psychiatric disorders, particularly depressive and anxiety disorders.”

He said this new study is important for three reasons.

“The first is the cohort size. There were over 145,000 participants involved in the study, which is significant and serves to make its conclusions stronger,” Dr. Ahmad noted.

“The second point is that the authors found that the correlation between higher adiposity and depression and lower well-being scores occurred even in patients without adverse metabolic effects,” he said in an interview.

“Of note, obesity significantly increases the risk of developing type 2 diabetes, hypertension, and a host of other illnesses as well as inflammatory conditions, which can all have a negative impact on quality of life. Consequently, these can contribute to depression as well as anxiety,” Dr. Ahmad added.

“Interestingly, what this study suggests is that even people without these additional stressors are reporting higher rates of depression and lower scores of well-being, while higher adiposity is the common denominator,” he noted.

“Third, the paper found little to no correlation between higher adiposity and generalized anxiety disorder. This comes as a complete surprise because anxiety and depression are very common comorbidities,” Dr. Ahmad said.

“Moreover, numerous studies as well as clinical data suggest that obesity leads to chronic inflammation, which in turn is associated with less favorable metabolic profiles, and that anxiety and depressive disorders may in some way be psychiatric manifestations of inflammation. To see one but not the other was quite an unexpected finding,” Dr. Ahmad said.

The study was funded by the Academy of Medical Sciences. Ms. O’Loughlin, Dr. Casanova, and Dr. Ahmad have disclosed no relevant conflicts of interest.

A version of this article first appeared on Medscape.com.

New research provides further evidence that a high body mass index (BMI) leads to depressed mood and poor well-being via social and physical factors.

Obesity and depression are “major global health challenges; our findings suggest that reducing obesity will lower depression and improve well-being,” co–lead author Jessica O’Loughlin, PhD student, University of Exeter Medical School, United Kingdom, told this news organization.

“Doctors should consider both the biological consequences of having a higher BMI as well as the social implications when treating patients with obesity in order to help reduce the odds of them developing depression,” Ms. O’Loughlin added.

The study was published online July 16 in Human Molecular Genetics.
 

Large body of evidence

A large body of evidence indicates that higher BMI leads to depression.

Ms. O’Loughlin and colleagues leveraged genetic data from more than 145,000 individuals in the UK Biobank and Mendelian randomization to determine whether the causal link between high BMI and depression is the result of psychosocial pathways, physical pathways, or both.

The analysis showed that a genetically determined 1 standard deviation higher BMI (4.6 kg/m²) was associated with higher likelihood of depression (odds ratio, 1.50; 95% confidence interval, 1.15-1.95) and lower well-being (beta, -0.15; 95% CI, -0.26 to -0.04).

Using genetics to distinguish metabolic and psychosocial effects, the results also indicate that, even in the absence of adverse metabolic effects, “higher adiposity remains causal to depression and lowers wellbeing,” the researchers report.

“We showed similar findings when looking at genetically predicted BMI and when using genetic variants that make you fatter but metabolically healthier (favorable adiposity genetic variants),” said Ms. O’Loughlin.

“Although we can’t tell which factor plays a bigger role in the adiposity-depression relationship, our analysis suggests that both physical and social factors (e.g., social stigma) play a role in the relationship between higher BMI and higher odds of depression,” she added.

In contrast, there was little evidence that higher BMI in the presence or absence of adverse metabolic consequences causes generalized anxiety disorder.

“Finding ways to support people to lose weight could benefit their mental health as well as their physical health,” co–lead author Francesco Casanova, PhD, with the University of Exeter, said in a statement.
 

Unexpected finding

Reached for comment, Samoon Ahmad, MD, professor, department of psychiatry, New York University, said that “multiple studies have shown a correlation between stress, obesity, inflammation, overall well-being, and psychiatric disorders, particularly depressive and anxiety disorders.”

He said this new study is important for three reasons.

“The first is the cohort size. There were over 145,000 participants involved in the study, which is significant and serves to make its conclusions stronger,” Dr. Ahmad noted.

“The second point is that the authors found that the correlation between higher adiposity and depression and lower well-being scores occurred even in patients without adverse metabolic effects,” he said in an interview.

“Of note, obesity significantly increases the risk of developing type 2 diabetes, hypertension, and a host of other illnesses as well as inflammatory conditions, which can all have a negative impact on quality of life. Consequently, these can contribute to depression as well as anxiety,” Dr. Ahmad added.

“Interestingly, what this study suggests is that even people without these additional stressors are reporting higher rates of depression and lower scores of well-being, while higher adiposity is the common denominator,” he noted.

“Third, the paper found little to no correlation between higher adiposity and generalized anxiety disorder. This comes as a complete surprise because anxiety and depression are very common comorbidities,” Dr. Ahmad said.

“Moreover, numerous studies as well as clinical data suggest that obesity leads to chronic inflammation, which in turn is associated with less favorable metabolic profiles, and that anxiety and depressive disorders may in some way be psychiatric manifestations of inflammation. To see one but not the other was quite an unexpected finding,” Dr. Ahmad said.

The study was funded by the Academy of Medical Sciences. Ms. O’Loughlin, Dr. Casanova, and Dr. Ahmad have disclosed no relevant conflicts of interest.

A version of this article first appeared on Medscape.com.

New research provides further evidence that a high body mass index (BMI) leads to depressed mood and poor well-being via social and physical factors.

Obesity and depression are “major global health challenges; our findings suggest that reducing obesity will lower depression and improve well-being,” co–lead author Jessica O’Loughlin, PhD student, University of Exeter Medical School, United Kingdom, told this news organization.

“Doctors should consider both the biological consequences of having a higher BMI as well as the social implications when treating patients with obesity in order to help reduce the odds of them developing depression,” Ms. O’Loughlin added.

The study was published online July 16 in Human Molecular Genetics.
 

Large body of evidence

A large body of evidence indicates that higher BMI leads to depression.

Ms. O’Loughlin and colleagues leveraged genetic data from more than 145,000 individuals in the UK Biobank and Mendelian randomization to determine whether the causal link between high BMI and depression is the result of psychosocial pathways, physical pathways, or both.

The analysis showed that a genetically determined 1 standard deviation higher BMI (4.6 kg/m²) was associated with higher likelihood of depression (odds ratio, 1.50; 95% confidence interval, 1.15-1.95) and lower well-being (beta, -0.15; 95% CI, -0.26 to -0.04).

Using genetics to distinguish metabolic and psychosocial effects, the results also indicate that, even in the absence of adverse metabolic effects, “higher adiposity remains causal to depression and lowers wellbeing,” the researchers report.

“We showed similar findings when looking at genetically predicted BMI and when using genetic variants that make you fatter but metabolically healthier (favorable adiposity genetic variants),” said Ms. O’Loughlin.

“Although we can’t tell which factor plays a bigger role in the adiposity-depression relationship, our analysis suggests that both physical and social factors (e.g., social stigma) play a role in the relationship between higher BMI and higher odds of depression,” she added.

In contrast, there was little evidence that higher BMI in the presence or absence of adverse metabolic consequences causes generalized anxiety disorder.

“Finding ways to support people to lose weight could benefit their mental health as well as their physical health,” co–lead author Francesco Casanova, PhD, with the University of Exeter, said in a statement.
 

Unexpected finding

Reached for comment, Samoon Ahmad, MD, professor, department of psychiatry, New York University, said that “multiple studies have shown a correlation between stress, obesity, inflammation, overall well-being, and psychiatric disorders, particularly depressive and anxiety disorders.”

He said this new study is important for three reasons.

“The first is the cohort size. There were over 145,000 participants involved in the study, which is significant and serves to make its conclusions stronger,” Dr. Ahmad noted.

“The second point is that the authors found that the correlation between higher adiposity and depression and lower well-being scores occurred even in patients without adverse metabolic effects,” he said in an interview.

“Of note, obesity significantly increases the risk of developing type 2 diabetes, hypertension, and a host of other illnesses as well as inflammatory conditions, which can all have a negative impact on quality of life. Consequently, these can contribute to depression as well as anxiety,” Dr. Ahmad added.

“Interestingly, what this study suggests is that even people without these additional stressors are reporting higher rates of depression and lower scores of well-being, while higher adiposity is the common denominator,” he noted.

“Third, the paper found little to no correlation between higher adiposity and generalized anxiety disorder. This comes as a complete surprise because anxiety and depression are very common comorbidities,” Dr. Ahmad said.

“Moreover, numerous studies as well as clinical data suggest that obesity leads to chronic inflammation, which in turn is associated with less favorable metabolic profiles, and that anxiety and depressive disorders may in some way be psychiatric manifestations of inflammation. To see one but not the other was quite an unexpected finding,” Dr. Ahmad said.

The study was funded by the Academy of Medical Sciences. Ms. O’Loughlin, Dr. Casanova, and Dr. Ahmad have disclosed no relevant conflicts of interest.

A version of this article first appeared on Medscape.com.

Although a novel investigational drug that combines dextromethorphan and bupropion (AXS-05, Axsome Therapeutics) met its primary and key secondary endpoints in a phase 2 trial of patients with treatment-resistant depression (TRD), the U.S. Food and Drug Administration has voiced some concerns.

In the MERIT study, AXS-05 significantly delayed time to depression relapse compared with placebo (primary endpoint) – with no relapses observed for at least 6 months. It also significantly prevented depression relapse (secondary endpoint), the company said in a news release announcing the topline results.

The drug has been granted breakthrough therapy designations by the FDA for the treatment of major depressive disorder (MDD) and agitation associated with Alzheimer’s disease.

In addition, the agency is currently reviewing a new drug application (NDA) for AXS-05 for the treatment of MDD, with a target action date of August 22.

However, Axsome stated that the FDA has identified “deficiencies that preclude labeling discussions at this time.”

The company is “attempting to learn the nature of these deficiencies with the goal of addressing them,” Herriot Tabuteau, MD, chief executive officer of Axsome, said in a statement.

However, Dr. Tabuteau acknowledged that this development “may lead to a delay in the potential approval of AXS-05.”
 

‘Well tolerated’

A total of 44 adults with TRD were enrolled into the MERIT study from the long-term, open-label phase 3 trial of AXS-05.

All patients were in stable remission after treatment with AXS-05 and were randomly assigned to continued treatment with AXS-05 (45 mg dextromethorphan/105 mg bupropion twice daily) or to switch to placebo.

Compared with placebo, AXS-05 significantly delayed time to depression relapse (P = .002) and prevented depression relapse (P = .004).

The novel drug was also well tolerated, with no treatment-emergent adverse events reported in more than one participant in the AXS-05 group, the company said.

One patient treated with AXS-05 did experience gout and bacteremia, but these incidents were deemed unrelated to the medication.

A version of this article first appeared on Medscape.com.

Although a novel investigational drug that combines dextromethorphan and bupropion (AXS-05, Axsome Therapeutics) met its primary and key secondary endpoints in a phase 2 trial of patients with treatment-resistant depression (TRD), the U.S. Food and Drug Administration has voiced some concerns.

In the MERIT study, AXS-05 significantly delayed time to depression relapse compared with placebo (primary endpoint) – with no relapses observed for at least 6 months. It also significantly prevented depression relapse (secondary endpoint), the company said in a news release announcing the topline results.

The drug has been granted breakthrough therapy designations by the FDA for the treatment of major depressive disorder (MDD) and agitation associated with Alzheimer’s disease.

In addition, the agency is currently reviewing a new drug application (NDA) for AXS-05 for the treatment of MDD, with a target action date of August 22.

However, Axsome stated that the FDA has identified “deficiencies that preclude labeling discussions at this time.”

The company is “attempting to learn the nature of these deficiencies with the goal of addressing them,” Herriot Tabuteau, MD, chief executive officer of Axsome, said in a statement.

However, Dr. Tabuteau acknowledged that this development “may lead to a delay in the potential approval of AXS-05.”
 

‘Well tolerated’

A total of 44 adults with TRD were enrolled into the MERIT study from the long-term, open-label phase 3 trial of AXS-05.

All patients were in stable remission after treatment with AXS-05 and were randomly assigned to continued treatment with AXS-05 (45 mg dextromethorphan/105 mg bupropion twice daily) or to switch to placebo.

Compared with placebo, AXS-05 significantly delayed time to depression relapse (P = .002) and prevented depression relapse (P = .004).

The novel drug was also well tolerated, with no treatment-emergent adverse events reported in more than one participant in the AXS-05 group, the company said.

One patient treated with AXS-05 did experience gout and bacteremia, but these incidents were deemed unrelated to the medication.

A version of this article first appeared on Medscape.com.

Although a novel investigational drug that combines dextromethorphan and bupropion (AXS-05, Axsome Therapeutics) met its primary and key secondary endpoints in a phase 2 trial of patients with treatment-resistant depression (TRD), the U.S. Food and Drug Administration has voiced some concerns.

In the MERIT study, AXS-05 significantly delayed time to depression relapse compared with placebo (primary endpoint) – with no relapses observed for at least 6 months. It also significantly prevented depression relapse (secondary endpoint), the company said in a news release announcing the topline results.

The drug has been granted breakthrough therapy designations by the FDA for the treatment of major depressive disorder (MDD) and agitation associated with Alzheimer’s disease.

In addition, the agency is currently reviewing a new drug application (NDA) for AXS-05 for the treatment of MDD, with a target action date of August 22.

However, Axsome stated that the FDA has identified “deficiencies that preclude labeling discussions at this time.”

The company is “attempting to learn the nature of these deficiencies with the goal of addressing them,” Herriot Tabuteau, MD, chief executive officer of Axsome, said in a statement.

However, Dr. Tabuteau acknowledged that this development “may lead to a delay in the potential approval of AXS-05.”
 

‘Well tolerated’

A total of 44 adults with TRD were enrolled into the MERIT study from the long-term, open-label phase 3 trial of AXS-05.

All patients were in stable remission after treatment with AXS-05 and were randomly assigned to continued treatment with AXS-05 (45 mg dextromethorphan/105 mg bupropion twice daily) or to switch to placebo.

Compared with placebo, AXS-05 significantly delayed time to depression relapse (P = .002) and prevented depression relapse (P = .004).

The novel drug was also well tolerated, with no treatment-emergent adverse events reported in more than one participant in the AXS-05 group, the company said.

One patient treated with AXS-05 did experience gout and bacteremia, but these incidents were deemed unrelated to the medication.

A version of this article first appeared on Medscape.com.

The United States of America is home to a rapidly growing population of more than 3.5 million Muslims. The American Muslim population is a microcosm of global Islamic culture and religious practice, with heterogeneity across age, sex, ethnic origin, immigration status, socioeconomic background, and religiosity. Muslims in America face stressors, including challenges with migration, language barriers, and acculturation.

Some Muslim subgroups (for example, Black Muslims) face additional, intersectional struggles, such as racial discrimination and multigenerational trauma. These challenges may lead to the onset or exacerbation of psychopathology. Nevertheless, the mental health needs of this segment of the American population remain unmet.

Among mental health problems, suicide is inadequately researched among American Muslims. Global studies from both Muslim majority and non-Muslim majority countries consistently indicate that Muslims have among the lowest rates of suicide in comparison with other religious and nonreligious groups. Overall, this body of literature alludes to suicide resiliency in Muslim populations.

However, these studies may not depict the reality for American Muslims. A new research letter, published by two of us (R.A. and B.Z.) and other colleagues at Stanford (Calif.) University’s Muslim Mental Health and Islamic Psychology Lab, highlights the possibility of risk rather than resilience among American Muslims.

In a widely sampled population-based poll, we found that across religious groups in America, Muslims were up to twice as likely to endorse a lifetime history of suicide attempt than other religious or nonreligious groups.

Because of the paucity of suicide research, further inquiry is needed to explain American Muslim evident suicide risk. Nevertheless, our research shows that discrimination and marginalization, both religious and racial, are prominent suicide risk factors in the American Muslim narrative. From 2016 to 2020, almost two-thirds of American Muslims reported facing religious discrimination every year. In 2020, Muslim children in public K-12 systems were twice as likely to face bullying, a third of whom indicated that their bully was a school staff member. While the suicide literature has yet to explore Islamophobia in depth, marginalization and discrimination are demonstrably linked to suicide.

Here are a few clinical pearls that we think will help clinicians meet the needs of these patients:

1. Emphasize the basics. Muslims may be hesitant to engage with mental health practitioners and are often unfamiliar with confidentiality standards. Some may have experience with paternalistic health care cultures where patient privacy is violated. Consequently, some Muslim patients may have concerns that medical professionals can share personal medical history with family members or allied health professionals without obtaining consent. They may worry that private matters will be spread in their community, resulting in stigmatization or discrimination.

Providers should clearly communicate the terms of confidentiality and emphasize patient autonomy over information disclosed outside of the therapeutic partnership.

2. Develop a therapeutic alliance with cultural humility. Since Muslim patients have likely witnessed discrimination, either directly or indirectly, clinicians must adopt a nonjudgmental stance when discussing cultural, religious, or moral values different from their own. Muslim patients may find defending their faith and cultural norms stigmatizing, when faced with clinicians’ assumptions.

Providers should be transparent about their knowledge limitations, ask humbly for a partnership of shared learning, and allow the patient to lead where appropriate. Clinicians should develop a working understanding of Islamic values and cultural norms. See below for Muslim Mental Health resources.

3. Assess suicide risk and ask follow-up questions. Some clinicians may not deem suicide assessments valuable for Muslim patients, believing that strong religious values may preclude them from suicide risk. New findings that suicide risk is prominent among American Muslims highlights the necessity for assessment.

Practitioners should conduct thorough suicide risk assessments, including: past and present ideation, plan, intent, means, relevant risk, and resilience factors. Muslims may be culturally inclined to deny ideation, especially when accompanied by family members. Providers should be on alert for incongruent cues in patient affect and behavior.

4. Accommodate inpatient religious practice. Muslims navigate daily religious choices, from prayers at prescribed times to observing Islamic dietary guidelines. During psychiatric admissions, many of these norms are suspended temporarily. Treatments that do not include the flexibility to address these concerns may mirror patients’ experiences with Islamophobia. For example, being asked to remove the hijab, even with good cause (that is, self-harm precautions), may trigger familiar discriminatory threats to safety and belonging.

Religious accommodations should be addressed in rounds so that all interacting staff maintain collective accountability for religious needs. Accommodations may require adaptive solutions, such as one-piece pull-on–style hijabs as safer alternatives to rectangular wraps. To prevent pathologizing religious observance, providers should consider meeting with Muslim chaplains and patient advocates, including family members or religious care providers, where appropriate.

Addressing the mental health needs of Muslim patients not only requires cultural humility but knowledge about unique challenges facing this diverse community.

To help further advance understanding of these issues, consider taking the American Psychiatric Association’s Muslim Mental Health CME course, which will be taught by Dr. Awaad. In addition, we have included a list of resources below.
 

Further reading

Moffic S et al. Islamophobia and Psychiatry: Recognition, Prevention and Treatment. New York: Springer, 2019.

Keshavarzi H et al. Applying Islamic Principles to Clinical Mental Health Care: Introducing Traditional Islamically Integrated Psychotherapy. New York: Routledge, 2020.

Ahmed S and MM Amer. Counseling Muslims: Handbook of Mental Health Issues and Interventions. New York: Routledge/Taylor & Francis Group, 2012.

American Psychiatric Association. Stress & Trauma Toolkit for Treating Muslims in a Changing Political and Social Environment, 2019.

American Psychiatric Association. Mental Health Disparities: Muslim Americans, 2019.

Awaad R et al. JAMA Psychiatry. 2021 Jul 21. doi: 10.1001/jamapsychiatry.2021.1813.

Baca-Garcia E et al. J Affect Disord. 2011;134(1-3):327-32.

Institute for Muslim Mental Health: https://muslimmentalhealth.com/

Institute for Social Policy and Understanding. “Religious Discrimination in Multiple Forms Impacts Muslims of All Ages: American Muslim Poll, 2020.

Silverman JJ et al. Am J Psychiatry. 2015 Aug 1;172(8):798-802.

Resources

Stanford Muslim Mental Health and Islamic Psychology Lab: http://med.stanford.edu/psychiatry/research/MuslimMHLab.html

Maristan: https://maristan.org/

Naseeha mental health hotline: https://naseeha.org/

Dr. Awaad is a clinical associate professor in the department of psychiatry and behavioral sciences at Stanford University. She also serves as associate division chief of public mental health and population sciences, and diversity section chief in the psychiatry department. In addition, Dr. Awaad is executive director of Maristan, an organization focused on using authentic traditions to meet the mental health needs of the Islamic community, and is affiliated with the department of psychiatry and behavioral sciences at Stanford. Dr. Awaad is coeditor of “Islamophobia and Psychiatry: Recognition, Prevention and Treatment” (New York: Springer, 2019), and “Applying Islamic Principles to Clinical Mental Health Care: Introducing Traditional Islamically Integrated Psychotherapy” (New York: Routledge/Taylor & Francis Group, 2020).

Dr. Husain completed her medical degree from St. George’s University in True Blue, Grenada; she is currently a graduate student in the department of public health concentrating on mental health parity in the United States. She also works as a researcher at the Stanford Muslim Mental Health & Islamic Psychology Lab and as an organizer for Team Liyna, a national effort aimed at diversifying the stem cell registry responsible for more than 10,000 new registrants since 2019.

Mr. Zia, who has been affiliated with the department of psychiatry and behavioral sciences at Stanford, is a PhD candidate and Canada-Vanier scholar in the department of clinical psychology at the University of Manitoba, Winnipeg. Mr. Zia is also a psychological associate at the New Leaf Psychology Centre in Milton, Ont. He has no relevant financial relationships.


 

The United States of America is home to a rapidly growing population of more than 3.5 million Muslims. The American Muslim population is a microcosm of global Islamic culture and religious practice, with heterogeneity across age, sex, ethnic origin, immigration status, socioeconomic background, and religiosity. Muslims in America face stressors, including challenges with migration, language barriers, and acculturation.

Some Muslim subgroups (for example, Black Muslims) face additional, intersectional struggles, such as racial discrimination and multigenerational trauma. These challenges may lead to the onset or exacerbation of psychopathology. Nevertheless, the mental health needs of this segment of the American population remain unmet.

Among mental health problems, suicide is inadequately researched among American Muslims. Global studies from both Muslim majority and non-Muslim majority countries consistently indicate that Muslims have among the lowest rates of suicide in comparison with other religious and nonreligious groups. Overall, this body of literature alludes to suicide resiliency in Muslim populations.

However, these studies may not depict the reality for American Muslims. A new research letter, published by two of us (R.A. and B.Z.) and other colleagues at Stanford (Calif.) University’s Muslim Mental Health and Islamic Psychology Lab, highlights the possibility of risk rather than resilience among American Muslims.

In a widely sampled population-based poll, we found that across religious groups in America, Muslims were up to twice as likely to endorse a lifetime history of suicide attempt than other religious or nonreligious groups.

Because of the paucity of suicide research, further inquiry is needed to explain American Muslim evident suicide risk. Nevertheless, our research shows that discrimination and marginalization, both religious and racial, are prominent suicide risk factors in the American Muslim narrative. From 2016 to 2020, almost two-thirds of American Muslims reported facing religious discrimination every year. In 2020, Muslim children in public K-12 systems were twice as likely to face bullying, a third of whom indicated that their bully was a school staff member. While the suicide literature has yet to explore Islamophobia in depth, marginalization and discrimination are demonstrably linked to suicide.

Here are a few clinical pearls that we think will help clinicians meet the needs of these patients:

1. Emphasize the basics. Muslims may be hesitant to engage with mental health practitioners and are often unfamiliar with confidentiality standards. Some may have experience with paternalistic health care cultures where patient privacy is violated. Consequently, some Muslim patients may have concerns that medical professionals can share personal medical history with family members or allied health professionals without obtaining consent. They may worry that private matters will be spread in their community, resulting in stigmatization or discrimination.

Providers should clearly communicate the terms of confidentiality and emphasize patient autonomy over information disclosed outside of the therapeutic partnership.

2. Develop a therapeutic alliance with cultural humility. Since Muslim patients have likely witnessed discrimination, either directly or indirectly, clinicians must adopt a nonjudgmental stance when discussing cultural, religious, or moral values different from their own. Muslim patients may find defending their faith and cultural norms stigmatizing, when faced with clinicians’ assumptions.

Providers should be transparent about their knowledge limitations, ask humbly for a partnership of shared learning, and allow the patient to lead where appropriate. Clinicians should develop a working understanding of Islamic values and cultural norms. See below for Muslim Mental Health resources.

3. Assess suicide risk and ask follow-up questions. Some clinicians may not deem suicide assessments valuable for Muslim patients, believing that strong religious values may preclude them from suicide risk. New findings that suicide risk is prominent among American Muslims highlights the necessity for assessment.

Practitioners should conduct thorough suicide risk assessments, including: past and present ideation, plan, intent, means, relevant risk, and resilience factors. Muslims may be culturally inclined to deny ideation, especially when accompanied by family members. Providers should be on alert for incongruent cues in patient affect and behavior.

4. Accommodate inpatient religious practice. Muslims navigate daily religious choices, from prayers at prescribed times to observing Islamic dietary guidelines. During psychiatric admissions, many of these norms are suspended temporarily. Treatments that do not include the flexibility to address these concerns may mirror patients’ experiences with Islamophobia. For example, being asked to remove the hijab, even with good cause (that is, self-harm precautions), may trigger familiar discriminatory threats to safety and belonging.

Religious accommodations should be addressed in rounds so that all interacting staff maintain collective accountability for religious needs. Accommodations may require adaptive solutions, such as one-piece pull-on–style hijabs as safer alternatives to rectangular wraps. To prevent pathologizing religious observance, providers should consider meeting with Muslim chaplains and patient advocates, including family members or religious care providers, where appropriate.

Addressing the mental health needs of Muslim patients not only requires cultural humility but knowledge about unique challenges facing this diverse community.

To help further advance understanding of these issues, consider taking the American Psychiatric Association’s Muslim Mental Health CME course, which will be taught by Dr. Awaad. In addition, we have included a list of resources below.
 

Further reading

Moffic S et al. Islamophobia and Psychiatry: Recognition, Prevention and Treatment. New York: Springer, 2019.

Keshavarzi H et al. Applying Islamic Principles to Clinical Mental Health Care: Introducing Traditional Islamically Integrated Psychotherapy. New York: Routledge, 2020.

Ahmed S and MM Amer. Counseling Muslims: Handbook of Mental Health Issues and Interventions. New York: Routledge/Taylor & Francis Group, 2012.

American Psychiatric Association. Stress & Trauma Toolkit for Treating Muslims in a Changing Political and Social Environment, 2019.

American Psychiatric Association. Mental Health Disparities: Muslim Americans, 2019.

Awaad R et al. JAMA Psychiatry. 2021 Jul 21. doi: 10.1001/jamapsychiatry.2021.1813.

Baca-Garcia E et al. J Affect Disord. 2011;134(1-3):327-32.

Institute for Muslim Mental Health: https://muslimmentalhealth.com/

Institute for Social Policy and Understanding. “Religious Discrimination in Multiple Forms Impacts Muslims of All Ages: American Muslim Poll, 2020.

Silverman JJ et al. Am J Psychiatry. 2015 Aug 1;172(8):798-802.

Resources

Stanford Muslim Mental Health and Islamic Psychology Lab: http://med.stanford.edu/psychiatry/research/MuslimMHLab.html

Maristan: https://maristan.org/

Naseeha mental health hotline: https://naseeha.org/

Dr. Awaad is a clinical associate professor in the department of psychiatry and behavioral sciences at Stanford University. She also serves as associate division chief of public mental health and population sciences, and diversity section chief in the psychiatry department. In addition, Dr. Awaad is executive director of Maristan, an organization focused on using authentic traditions to meet the mental health needs of the Islamic community, and is affiliated with the department of psychiatry and behavioral sciences at Stanford. Dr. Awaad is coeditor of “Islamophobia and Psychiatry: Recognition, Prevention and Treatment” (New York: Springer, 2019), and “Applying Islamic Principles to Clinical Mental Health Care: Introducing Traditional Islamically Integrated Psychotherapy” (New York: Routledge/Taylor & Francis Group, 2020).

Dr. Husain completed her medical degree from St. George’s University in True Blue, Grenada; she is currently a graduate student in the department of public health concentrating on mental health parity in the United States. She also works as a researcher at the Stanford Muslim Mental Health & Islamic Psychology Lab and as an organizer for Team Liyna, a national effort aimed at diversifying the stem cell registry responsible for more than 10,000 new registrants since 2019.

Mr. Zia, who has been affiliated with the department of psychiatry and behavioral sciences at Stanford, is a PhD candidate and Canada-Vanier scholar in the department of clinical psychology at the University of Manitoba, Winnipeg. Mr. Zia is also a psychological associate at the New Leaf Psychology Centre in Milton, Ont. He has no relevant financial relationships.


 

The United States of America is home to a rapidly growing population of more than 3.5 million Muslims. The American Muslim population is a microcosm of global Islamic culture and religious practice, with heterogeneity across age, sex, ethnic origin, immigration status, socioeconomic background, and religiosity. Muslims in America face stressors, including challenges with migration, language barriers, and acculturation.

Some Muslim subgroups (for example, Black Muslims) face additional, intersectional struggles, such as racial discrimination and multigenerational trauma. These challenges may lead to the onset or exacerbation of psychopathology. Nevertheless, the mental health needs of this segment of the American population remain unmet.

Among mental health problems, suicide is inadequately researched among American Muslims. Global studies from both Muslim majority and non-Muslim majority countries consistently indicate that Muslims have among the lowest rates of suicide in comparison with other religious and nonreligious groups. Overall, this body of literature alludes to suicide resiliency in Muslim populations.

However, these studies may not depict the reality for American Muslims. A new research letter, published by two of us (R.A. and B.Z.) and other colleagues at Stanford (Calif.) University’s Muslim Mental Health and Islamic Psychology Lab, highlights the possibility of risk rather than resilience among American Muslims.

In a widely sampled population-based poll, we found that across religious groups in America, Muslims were up to twice as likely to endorse a lifetime history of suicide attempt than other religious or nonreligious groups.

Because of the paucity of suicide research, further inquiry is needed to explain American Muslim evident suicide risk. Nevertheless, our research shows that discrimination and marginalization, both religious and racial, are prominent suicide risk factors in the American Muslim narrative. From 2016 to 2020, almost two-thirds of American Muslims reported facing religious discrimination every year. In 2020, Muslim children in public K-12 systems were twice as likely to face bullying, a third of whom indicated that their bully was a school staff member. While the suicide literature has yet to explore Islamophobia in depth, marginalization and discrimination are demonstrably linked to suicide.

Here are a few clinical pearls that we think will help clinicians meet the needs of these patients:

1. Emphasize the basics. Muslims may be hesitant to engage with mental health practitioners and are often unfamiliar with confidentiality standards. Some may have experience with paternalistic health care cultures where patient privacy is violated. Consequently, some Muslim patients may have concerns that medical professionals can share personal medical history with family members or allied health professionals without obtaining consent. They may worry that private matters will be spread in their community, resulting in stigmatization or discrimination.

Providers should clearly communicate the terms of confidentiality and emphasize patient autonomy over information disclosed outside of the therapeutic partnership.

2. Develop a therapeutic alliance with cultural humility. Since Muslim patients have likely witnessed discrimination, either directly or indirectly, clinicians must adopt a nonjudgmental stance when discussing cultural, religious, or moral values different from their own. Muslim patients may find defending their faith and cultural norms stigmatizing, when faced with clinicians’ assumptions.

Providers should be transparent about their knowledge limitations, ask humbly for a partnership of shared learning, and allow the patient to lead where appropriate. Clinicians should develop a working understanding of Islamic values and cultural norms. See below for Muslim Mental Health resources.

3. Assess suicide risk and ask follow-up questions. Some clinicians may not deem suicide assessments valuable for Muslim patients, believing that strong religious values may preclude them from suicide risk. New findings that suicide risk is prominent among American Muslims highlights the necessity for assessment.

Practitioners should conduct thorough suicide risk assessments, including: past and present ideation, plan, intent, means, relevant risk, and resilience factors. Muslims may be culturally inclined to deny ideation, especially when accompanied by family members. Providers should be on alert for incongruent cues in patient affect and behavior.

4. Accommodate inpatient religious practice. Muslims navigate daily religious choices, from prayers at prescribed times to observing Islamic dietary guidelines. During psychiatric admissions, many of these norms are suspended temporarily. Treatments that do not include the flexibility to address these concerns may mirror patients’ experiences with Islamophobia. For example, being asked to remove the hijab, even with good cause (that is, self-harm precautions), may trigger familiar discriminatory threats to safety and belonging.

Religious accommodations should be addressed in rounds so that all interacting staff maintain collective accountability for religious needs. Accommodations may require adaptive solutions, such as one-piece pull-on–style hijabs as safer alternatives to rectangular wraps. To prevent pathologizing religious observance, providers should consider meeting with Muslim chaplains and patient advocates, including family members or religious care providers, where appropriate.

Addressing the mental health needs of Muslim patients not only requires cultural humility but knowledge about unique challenges facing this diverse community.

To help further advance understanding of these issues, consider taking the American Psychiatric Association’s Muslim Mental Health CME course, which will be taught by Dr. Awaad. In addition, we have included a list of resources below.
 

Further reading

Moffic S et al. Islamophobia and Psychiatry: Recognition, Prevention and Treatment. New York: Springer, 2019.

Keshavarzi H et al. Applying Islamic Principles to Clinical Mental Health Care: Introducing Traditional Islamically Integrated Psychotherapy. New York: Routledge, 2020.

Ahmed S and MM Amer. Counseling Muslims: Handbook of Mental Health Issues and Interventions. New York: Routledge/Taylor & Francis Group, 2012.

American Psychiatric Association. Stress & Trauma Toolkit for Treating Muslims in a Changing Political and Social Environment, 2019.

American Psychiatric Association. Mental Health Disparities: Muslim Americans, 2019.

Awaad R et al. JAMA Psychiatry. 2021 Jul 21. doi: 10.1001/jamapsychiatry.2021.1813.

Baca-Garcia E et al. J Affect Disord. 2011;134(1-3):327-32.

Institute for Muslim Mental Health: https://muslimmentalhealth.com/

Institute for Social Policy and Understanding. “Religious Discrimination in Multiple Forms Impacts Muslims of All Ages: American Muslim Poll, 2020.

Silverman JJ et al. Am J Psychiatry. 2015 Aug 1;172(8):798-802.

Resources

Stanford Muslim Mental Health and Islamic Psychology Lab: http://med.stanford.edu/psychiatry/research/MuslimMHLab.html

Maristan: https://maristan.org/

Naseeha mental health hotline: https://naseeha.org/

Dr. Awaad is a clinical associate professor in the department of psychiatry and behavioral sciences at Stanford University. She also serves as associate division chief of public mental health and population sciences, and diversity section chief in the psychiatry department. In addition, Dr. Awaad is executive director of Maristan, an organization focused on using authentic traditions to meet the mental health needs of the Islamic community, and is affiliated with the department of psychiatry and behavioral sciences at Stanford. Dr. Awaad is coeditor of “Islamophobia and Psychiatry: Recognition, Prevention and Treatment” (New York: Springer, 2019), and “Applying Islamic Principles to Clinical Mental Health Care: Introducing Traditional Islamically Integrated Psychotherapy” (New York: Routledge/Taylor & Francis Group, 2020).

Dr. Husain completed her medical degree from St. George’s University in True Blue, Grenada; she is currently a graduate student in the department of public health concentrating on mental health parity in the United States. She also works as a researcher at the Stanford Muslim Mental Health & Islamic Psychology Lab and as an organizer for Team Liyna, a national effort aimed at diversifying the stem cell registry responsible for more than 10,000 new registrants since 2019.

Mr. Zia, who has been affiliated with the department of psychiatry and behavioral sciences at Stanford, is a PhD candidate and Canada-Vanier scholar in the department of clinical psychology at the University of Manitoba, Winnipeg. Mr. Zia is also a psychological associate at the New Leaf Psychology Centre in Milton, Ont. He has no relevant financial relationships.


 

On March 16, the world was witness to a horrific act of violence when a gunman killed six Asian American women and two others at spas in the Atlanta, Georgia area. The attack prompted a national outcry and protests against the rising levels of hate and violence directed at Asian Americans and Pacific Islanders (AAPI), a community that has experienced a profound and disturbing legacy of racism in American history.

Despite this fact, my own understanding and awareness of the hate and racism experienced by the AAPI community, then and now, would be described as limited at best. Was I aware on some level? Perhaps. But if I’m being honest, I have not fully appreciated the unique experiences of AAPI colleagues, friends, and students.

That changed when I attended a White Coats Against Asian Hate & Racism rally, held by the George Washington University School of Medicine and Health Sciences 2 months after the Atlanta killings. Hearing my colleagues speak of their personal experiences, I quickly realized my lack of education on the subject of how systemic racism has long affected Asian Americans in this country.
 

Measuring the alarming rise in anti-Asian hate

The data supporting a rise in anti-Asian hate crimes have been staring us in the face for decades but have drawn increasing attention since the beginning of the COVID-19 pandemic, when these already distressingly high numbers experienced a steep rise.

Before looking at these figures, though, we must begin by defining what is considered a hate crime versus a hate incident. The National Asian Pacific American Bar Association and Asian & Pacific Islander American Health Forum have produced a beneficial summary document on precisely what separates these terms:

• A hate crime is a crime committed on the basis of the victim’s perceived or actual race, color, religion, national origin, sexual orientation, gender identity, or disability. It differs from “regular” crime in that its victims include the immediate crime target and others like them. Hate crimes affect families, communities, and, at times, an entire nation.
• A hate incident describes acts of prejudice that are not crimes and do not involve violence, threats, or property damage. The most common examples are isolated forms of speech, such as racial slurs.

Stop AAPI Hate (SAH) was founded in March 2020 as a coalition to track and analyze incidents of hate against this community. SAH’s 2020-2021 national report details 3,795 hate incidents that occurred from March 19, 2020, to Feb. 28, 2021. In a notable parallel to the Georgia killings, SAH found that Asian American women reported hate incidents 2.3 times more often than men and that businesses were the primary site of discrimination.

This rise in hate incidents has occurred in parallel with an increase in Asian American hate crimes. Recently, the Center for the Study of Hate and Extremism (CSUSB) released its Report to the Nation: Anti-Asian Prejudice & Hate Crime. CSUSB found that anti-Asian hate crimes increased by 164% in the first quarter of 2021. I re-read that data point multiple times, thinking it must be in error. If you’re asking exactly why I was having difficulty accepting this data, you have to appreciate these two critical points:

• Per the CSUSB, anti-Asian hate crimes were already surging by 146% in 2020.
• This surge occurred while overall hate crimes dropped by 7%.

So, if 2020 was a surge, the first quarter of 2021 is a hurricane. What’s perhaps most concerning is that these data only capture reported cases and therefore are a fraction of the total.

Undoubtedly, we are living through an unprecedented rise in anti-Asian hate incidents and hate crimes since the start of the pandemic. This rise in hate-related events paralleled the many pandemic-related stressors (disease, isolation, economics, mental health, etc.). Should anyone have been surprised when this most recent deadly spike of anti-Asian hate occurred in the first quarter of 2021?
 

Hate’s toll on mental health

As a psychiatrist, I’ve spent my entire career working with dedicated teams to treat patients with mental health disorders. Currently, hate is not classified by the Diagnostic and Statistical Manual of Mental Disorders as a mental illness. However, I can’t think of another emotion that is a better candidate for further research and scientific instigation, if for no other reason than to better understand when prejudice and bias transform into hatred and crime.

Surprisingly, there has been relatively little research on the topic of hate in the fields of psychology and psychiatry. I’d be willing to wager that if you asked a typical graduating class of medical students to give you an actual working definition of the emotion of hate, most would be at a loss for words.

Dr. Fischer and Dr. Halperin published a helpful article that gives a functional perspective on hate. The authors cover a great deal of research on hate and offer the following four starting points valuable in considering it:

• “Hate is different from anger because an anger target is appraised as someone whose behavior can be influenced and changed.”
• “A hate target, on the contrary, implies appraisals of the other’s malevolent nature and malicious intent.”
• “Hate is characterized by appraisals that imply a stable perception of a person or group and thus the incapability to change the extremely negative characteristics attributed to the target of hate.”
• “Everyday observations also suggest that hate is so powerful that it does, not just temporarily but permanently, destroy relations between individuals or groups.”

When I view hate with these insights in mind, it completely changes how I choose to utilize the word or concept. Hate is an emotion whose goal/action tendency is to eliminate groups (not just people or obstacles) and destroy any current or future relationships. We can take this a step further in noting that hate spreads, not only to the intended targets but potentially my “own” group. Similar to secondhand smoke, there is no risk-free exposure to hate or racism.

In the past decade, a robust body of evidence has emerged that clearly illustrates the negative health impacts of racism. Dr. Paradies and colleagues performed a systematic meta-analysis explicitly focused on racism as a determinant of health, finding that it was associated with poorer mental health, including depression, anxiety, and psychological distress. Over the past two decades, researchers have increasingly looked at the effects of racial discrimination on the AAPI community. In their 2009 review article, Dr. Gee and colleagues identified 62 empirical articles assessing the relation between discrimination and health among Asian Americans. Most of the studies found that discrimination was associated with poorer health. Of the 40 studies focused on mental health, 37 reported that discrimination was associated with poorer outcomes.

SAH recently released its very illuminating Mental Health Report. Among several key findings, two in particular caught my attention. First, Asian Americans who have experienced racism are more stressed by anti-Asian hate than the pandemic itself. Second, one in five Asian Americans who have experienced racism display racial trauma, the psychological and emotional harm caused by racism. Given the rise in hate crimes, there must be concern regarding the level of trauma being inflicted upon the Asian American community.

A complete review of the health effects of racism is beyond this article’s scope. Still, the previously mentioned studies further support the need to treat racism in general, and specifically anti-Asian hate, as the urgent public health concern that it truly is. The U.S. government recently outlined an action plan to respond to anti-Asian violence, xenophobia, and bias. These are helpful first steps, but much more is required on a societal and individual level, given the mental health disparities faced by the AAPI community.

Determining the best ways to address this urgent public health concern can be overwhelming, exhausting, and outright demoralizing. The bottom line is that if we do nothing, communities and groups will continue to suffer the effects of racial hatred. These consequences are severe and transgenerational.

But we must start somewhere. For me, that begins by gaining a better understanding of the emotion of hate and my role in either facilitating or stopping it, and by listening, listening, and listening some more to AAPI colleagues, friends, and family about their lived experience with anti-Asian hate.

A version of this article first appeared on Medscape.com.

On March 16, the world was witness to a horrific act of violence when a gunman killed six Asian American women and two others at spas in the Atlanta, Georgia area. The attack prompted a national outcry and protests against the rising levels of hate and violence directed at Asian Americans and Pacific Islanders (AAPI), a community that has experienced a profound and disturbing legacy of racism in American history.

Despite this fact, my own understanding and awareness of the hate and racism experienced by the AAPI community, then and now, would be described as limited at best. Was I aware on some level? Perhaps. But if I’m being honest, I have not fully appreciated the unique experiences of AAPI colleagues, friends, and students.

That changed when I attended a White Coats Against Asian Hate & Racism rally, held by the George Washington University School of Medicine and Health Sciences 2 months after the Atlanta killings. Hearing my colleagues speak of their personal experiences, I quickly realized my lack of education on the subject of how systemic racism has long affected Asian Americans in this country.
 

Measuring the alarming rise in anti-Asian hate

The data supporting a rise in anti-Asian hate crimes have been staring us in the face for decades but have drawn increasing attention since the beginning of the COVID-19 pandemic, when these already distressingly high numbers experienced a steep rise.

Before looking at these figures, though, we must begin by defining what is considered a hate crime versus a hate incident. The National Asian Pacific American Bar Association and Asian & Pacific Islander American Health Forum have produced a beneficial summary document on precisely what separates these terms:

• A hate crime is a crime committed on the basis of the victim’s perceived or actual race, color, religion, national origin, sexual orientation, gender identity, or disability. It differs from “regular” crime in that its victims include the immediate crime target and others like them. Hate crimes affect families, communities, and, at times, an entire nation.
• A hate incident describes acts of prejudice that are not crimes and do not involve violence, threats, or property damage. The most common examples are isolated forms of speech, such as racial slurs.

Stop AAPI Hate (SAH) was founded in March 2020 as a coalition to track and analyze incidents of hate against this community. SAH’s 2020-2021 national report details 3,795 hate incidents that occurred from March 19, 2020, to Feb. 28, 2021. In a notable parallel to the Georgia killings, SAH found that Asian American women reported hate incidents 2.3 times more often than men and that businesses were the primary site of discrimination.

This rise in hate incidents has occurred in parallel with an increase in Asian American hate crimes. Recently, the Center for the Study of Hate and Extremism (CSUSB) released its Report to the Nation: Anti-Asian Prejudice & Hate Crime. CSUSB found that anti-Asian hate crimes increased by 164% in the first quarter of 2021. I re-read that data point multiple times, thinking it must be in error. If you’re asking exactly why I was having difficulty accepting this data, you have to appreciate these two critical points:

• Per the CSUSB, anti-Asian hate crimes were already surging by 146% in 2020.
• This surge occurred while overall hate crimes dropped by 7%.

So, if 2020 was a surge, the first quarter of 2021 is a hurricane. What’s perhaps most concerning is that these data only capture reported cases and therefore are a fraction of the total.

Undoubtedly, we are living through an unprecedented rise in anti-Asian hate incidents and hate crimes since the start of the pandemic. This rise in hate-related events paralleled the many pandemic-related stressors (disease, isolation, economics, mental health, etc.). Should anyone have been surprised when this most recent deadly spike of anti-Asian hate occurred in the first quarter of 2021?
 

Hate’s toll on mental health

As a psychiatrist, I’ve spent my entire career working with dedicated teams to treat patients with mental health disorders. Currently, hate is not classified by the Diagnostic and Statistical Manual of Mental Disorders as a mental illness. However, I can’t think of another emotion that is a better candidate for further research and scientific instigation, if for no other reason than to better understand when prejudice and bias transform into hatred and crime.

Surprisingly, there has been relatively little research on the topic of hate in the fields of psychology and psychiatry. I’d be willing to wager that if you asked a typical graduating class of medical students to give you an actual working definition of the emotion of hate, most would be at a loss for words.

Dr. Fischer and Dr. Halperin published a helpful article that gives a functional perspective on hate. The authors cover a great deal of research on hate and offer the following four starting points valuable in considering it:

• “Hate is different from anger because an anger target is appraised as someone whose behavior can be influenced and changed.”
• “A hate target, on the contrary, implies appraisals of the other’s malevolent nature and malicious intent.”
• “Hate is characterized by appraisals that imply a stable perception of a person or group and thus the incapability to change the extremely negative characteristics attributed to the target of hate.”
• “Everyday observations also suggest that hate is so powerful that it does, not just temporarily but permanently, destroy relations between individuals or groups.”

When I view hate with these insights in mind, it completely changes how I choose to utilize the word or concept. Hate is an emotion whose goal/action tendency is to eliminate groups (not just people or obstacles) and destroy any current or future relationships. We can take this a step further in noting that hate spreads, not only to the intended targets but potentially my “own” group. Similar to secondhand smoke, there is no risk-free exposure to hate or racism.

In the past decade, a robust body of evidence has emerged that clearly illustrates the negative health impacts of racism. Dr. Paradies and colleagues performed a systematic meta-analysis explicitly focused on racism as a determinant of health, finding that it was associated with poorer mental health, including depression, anxiety, and psychological distress. Over the past two decades, researchers have increasingly looked at the effects of racial discrimination on the AAPI community. In their 2009 review article, Dr. Gee and colleagues identified 62 empirical articles assessing the relation between discrimination and health among Asian Americans. Most of the studies found that discrimination was associated with poorer health. Of the 40 studies focused on mental health, 37 reported that discrimination was associated with poorer outcomes.

SAH recently released its very illuminating Mental Health Report. Among several key findings, two in particular caught my attention. First, Asian Americans who have experienced racism are more stressed by anti-Asian hate than the pandemic itself. Second, one in five Asian Americans who have experienced racism display racial trauma, the psychological and emotional harm caused by racism. Given the rise in hate crimes, there must be concern regarding the level of trauma being inflicted upon the Asian American community.

A complete review of the health effects of racism is beyond this article’s scope. Still, the previously mentioned studies further support the need to treat racism in general, and specifically anti-Asian hate, as the urgent public health concern that it truly is. The U.S. government recently outlined an action plan to respond to anti-Asian violence, xenophobia, and bias. These are helpful first steps, but much more is required on a societal and individual level, given the mental health disparities faced by the AAPI community.

Determining the best ways to address this urgent public health concern can be overwhelming, exhausting, and outright demoralizing. The bottom line is that if we do nothing, communities and groups will continue to suffer the effects of racial hatred. These consequences are severe and transgenerational.

But we must start somewhere. For me, that begins by gaining a better understanding of the emotion of hate and my role in either facilitating or stopping it, and by listening, listening, and listening some more to AAPI colleagues, friends, and family about their lived experience with anti-Asian hate.

A version of this article first appeared on Medscape.com.

On March 16, the world was witness to a horrific act of violence when a gunman killed six Asian American women and two others at spas in the Atlanta, Georgia area. The attack prompted a national outcry and protests against the rising levels of hate and violence directed at Asian Americans and Pacific Islanders (AAPI), a community that has experienced a profound and disturbing legacy of racism in American history.

Despite this fact, my own understanding and awareness of the hate and racism experienced by the AAPI community, then and now, would be described as limited at best. Was I aware on some level? Perhaps. But if I’m being honest, I have not fully appreciated the unique experiences of AAPI colleagues, friends, and students.

That changed when I attended a White Coats Against Asian Hate & Racism rally, held by the George Washington University School of Medicine and Health Sciences 2 months after the Atlanta killings. Hearing my colleagues speak of their personal experiences, I quickly realized my lack of education on the subject of how systemic racism has long affected Asian Americans in this country.
 

Measuring the alarming rise in anti-Asian hate

The data supporting a rise in anti-Asian hate crimes have been staring us in the face for decades but have drawn increasing attention since the beginning of the COVID-19 pandemic, when these already distressingly high numbers experienced a steep rise.

Before looking at these figures, though, we must begin by defining what is considered a hate crime versus a hate incident. The National Asian Pacific American Bar Association and Asian & Pacific Islander American Health Forum have produced a beneficial summary document on precisely what separates these terms:

• A hate crime is a crime committed on the basis of the victim’s perceived or actual race, color, religion, national origin, sexual orientation, gender identity, or disability. It differs from “regular” crime in that its victims include the immediate crime target and others like them. Hate crimes affect families, communities, and, at times, an entire nation.
• A hate incident describes acts of prejudice that are not crimes and do not involve violence, threats, or property damage. The most common examples are isolated forms of speech, such as racial slurs.

Stop AAPI Hate (SAH) was founded in March 2020 as a coalition to track and analyze incidents of hate against this community. SAH’s 2020-2021 national report details 3,795 hate incidents that occurred from March 19, 2020, to Feb. 28, 2021. In a notable parallel to the Georgia killings, SAH found that Asian American women reported hate incidents 2.3 times more often than men and that businesses were the primary site of discrimination.

This rise in hate incidents has occurred in parallel with an increase in Asian American hate crimes. Recently, the Center for the Study of Hate and Extremism (CSUSB) released its Report to the Nation: Anti-Asian Prejudice & Hate Crime. CSUSB found that anti-Asian hate crimes increased by 164% in the first quarter of 2021. I re-read that data point multiple times, thinking it must be in error. If you’re asking exactly why I was having difficulty accepting this data, you have to appreciate these two critical points:

• Per the CSUSB, anti-Asian hate crimes were already surging by 146% in 2020.
• This surge occurred while overall hate crimes dropped by 7%.

So, if 2020 was a surge, the first quarter of 2021 is a hurricane. What’s perhaps most concerning is that these data only capture reported cases and therefore are a fraction of the total.

Undoubtedly, we are living through an unprecedented rise in anti-Asian hate incidents and hate crimes since the start of the pandemic. This rise in hate-related events paralleled the many pandemic-related stressors (disease, isolation, economics, mental health, etc.). Should anyone have been surprised when this most recent deadly spike of anti-Asian hate occurred in the first quarter of 2021?
 

Hate’s toll on mental health

As a psychiatrist, I’ve spent my entire career working with dedicated teams to treat patients with mental health disorders. Currently, hate is not classified by the Diagnostic and Statistical Manual of Mental Disorders as a mental illness. However, I can’t think of another emotion that is a better candidate for further research and scientific instigation, if for no other reason than to better understand when prejudice and bias transform into hatred and crime.

Surprisingly, there has been relatively little research on the topic of hate in the fields of psychology and psychiatry. I’d be willing to wager that if you asked a typical graduating class of medical students to give you an actual working definition of the emotion of hate, most would be at a loss for words.

Dr. Fischer and Dr. Halperin published a helpful article that gives a functional perspective on hate. The authors cover a great deal of research on hate and offer the following four starting points valuable in considering it:

• “Hate is different from anger because an anger target is appraised as someone whose behavior can be influenced and changed.”
• “A hate target, on the contrary, implies appraisals of the other’s malevolent nature and malicious intent.”
• “Hate is characterized by appraisals that imply a stable perception of a person or group and thus the incapability to change the extremely negative characteristics attributed to the target of hate.”
• “Everyday observations also suggest that hate is so powerful that it does, not just temporarily but permanently, destroy relations between individuals or groups.”

When I view hate with these insights in mind, it completely changes how I choose to utilize the word or concept. Hate is an emotion whose goal/action tendency is to eliminate groups (not just people or obstacles) and destroy any current or future relationships. We can take this a step further in noting that hate spreads, not only to the intended targets but potentially my “own” group. Similar to secondhand smoke, there is no risk-free exposure to hate or racism.

In the past decade, a robust body of evidence has emerged that clearly illustrates the negative health impacts of racism. Dr. Paradies and colleagues performed a systematic meta-analysis explicitly focused on racism as a determinant of health, finding that it was associated with poorer mental health, including depression, anxiety, and psychological distress. Over the past two decades, researchers have increasingly looked at the effects of racial discrimination on the AAPI community. In their 2009 review article, Dr. Gee and colleagues identified 62 empirical articles assessing the relation between discrimination and health among Asian Americans. Most of the studies found that discrimination was associated with poorer health. Of the 40 studies focused on mental health, 37 reported that discrimination was associated with poorer outcomes.

SAH recently released its very illuminating Mental Health Report. Among several key findings, two in particular caught my attention. First, Asian Americans who have experienced racism are more stressed by anti-Asian hate than the pandemic itself. Second, one in five Asian Americans who have experienced racism display racial trauma, the psychological and emotional harm caused by racism. Given the rise in hate crimes, there must be concern regarding the level of trauma being inflicted upon the Asian American community.

A complete review of the health effects of racism is beyond this article’s scope. Still, the previously mentioned studies further support the need to treat racism in general, and specifically anti-Asian hate, as the urgent public health concern that it truly is. The U.S. government recently outlined an action plan to respond to anti-Asian violence, xenophobia, and bias. These are helpful first steps, but much more is required on a societal and individual level, given the mental health disparities faced by the AAPI community.

Determining the best ways to address this urgent public health concern can be overwhelming, exhausting, and outright demoralizing. The bottom line is that if we do nothing, communities and groups will continue to suffer the effects of racial hatred. These consequences are severe and transgenerational.

But we must start somewhere. For me, that begins by gaining a better understanding of the emotion of hate and my role in either facilitating or stopping it, and by listening, listening, and listening some more to AAPI colleagues, friends, and family about their lived experience with anti-Asian hate.

A version of this article first appeared on Medscape.com.

The mental health toll from the Surfside, Fla., Champlain Tower collapse will be felt by our patients for years to come. As mental health professionals in Miami-Dade County, it has been difficult to deal with the catastrophe layered on the escalating COVID-19 crisis.

Courtesy Dr. Cassie Feldman

With each passing day after the June 24 incident, we all learned who the 98 victims were. In session after session, the enormous impact of this unfathomable tragedy unfolded. Some mental health care professionals were directly affected with the loss of family members; some lost patients, and a large number of our patients lost someone or knew someone who lost someone. It was reminiscent of our work during the COVID-19 crisis when we found that we were dealing with the same stressors as those of our patients. As it was said then, we were all in the same storm – just in very different boats.

It was heartening to see how many colleagues rushed to the site of the building where family waiting areas were established. So many professionals wanted to assist that some had to be turned away.

The days right after the collapse were agonizing for all as we waited and hoped for survivors to be found. Search teams from across the United States and from Mexico and Israel – specifically, Israeli Defense Forces personnel with experience conducting operations in the wake of earthquakes in both Haiti and Nepal, took on the dangerous work. When no one was recovered after the first day, hope faded, and after 10 days, the search and rescue efforts turned to search and recovery. We were indeed a county and community in mourning.

According to Lina Haji, PsyD, GIA Miami, in addition to the direct impact of loss, clinicians who engaged in crisis response and bereavement counseling with those affected by the Surfside tragedy were subjected to vicarious trauma. Vicarious trauma, also used interchangeably with secondary trauma, occurs when practitioners absorb and integrate the aspects of the traumatic experience into their own consciousness. Mental health care providers in the Miami area not only experienced the direct effect of this tragedy but have been hearing details and harrowing stories about the unimaginable experiences their patients endured over those critical weeks. Vicarious trauma can result in our own symptoms, compassion fatigue, or burnout as clinicians. This resulted in a call for mental health providers to come to the aid of their fellow colleagues.

So, on the 1-month anniversary of the initial collapse, at the urging of Patricia Stauber, RN, LCSW, a clinician with more than 30 years’ experience in providing grief counseling in hospital and private practice settings; Antonello Bonci, MD, the founder of GIA Miami; Charlotte Tomic, director of public relations for the Institute for the Study of Global Antisemitism; and I cohosted what we hope will be several Mental Health Appreciation retreats. Our goal was to create a space to focus on healing the healers. We had hoped to hold an in-person event, but at the last moment we opted for a Zoom-based event because COVID-19 cases were rising rapidly again.

Working on the front lines

Cassie Feldman, PsyD, a licensed clinical psychologist with extensive experience working with grief, loss, end of life, and responding to trauma-related consults, reflected on her experience responding to the collapse in the earliest days – first independently at the request of community religious leaders and then as part of CADENA Foundation, a nonprofit organization dedicated to rescue, humanitarian aid, and disaster response and prevention worldwide.

Dr. Feldman worked alongside other mental health professionals, local Miami-Dade police and fire officials, and the domestic and international rescue teams (CADENA’s Go Team from Mexico and the Israeli Defense Force’s Search and Rescue Delegation), providing Psychological First Aid, crisis intervention, and disaster response to the victims’ families and survivors.

This initially was a 24-hour coverage effort, requiring Dr. Feldman and her colleagues to clear their schedules, and at times to work 18-hour shifts in the early days of the crisis to address the need for consistency and continuity. Their commitment was to show up for the victims’ families and survivors, fully embracing the chaos and the demands of the situation. She noted that the disaster brought out the best of her and her colleagues.

They divided and conquered the work, alongside clinicians from Jewish Community Services and Project Chai intervening acutely where possible, and coordinating long-term care plans for those survivors and members of the victims’ support networks in need of consistent care.

Dr. Feldman reflected on the notion that we have all been processing losses prior to this – loss of normalcy because of the pandemic, loss of people we loved as a result, other personal losses – and that this community tragedy is yet another loss to disentangle. It didn’t feel good or natural for her to passively absorb the news knowing she had both the skill set and capacity to take on an active supportive role. The first days at the community center were disorganized; it was hard to know who was who and what was what. She described parents crying out for their children and children longing for their parents. Individuals were so overcome with emotion that they grew faint. Friends and families flooded in but were unaware of how to be fully supportive. The level of trauma was so high that the only interventions that were absorbed were those that were nonverbal or that fully addressed practical needs. People were frightened and in a state of shock.

Day by day, more order ensued and the efforts became more coordinated, but it became apparent to her that the “family reunification center” was devoid of reunification. She and her colleagues’ primary role became aiding the police department in making death notifications to the families and being supportive of the victims’ families and their loved ones during and in between the formal briefings, where so many concerned family members and friends gathered and waited.

“As the days went on, things became more structured and predictable,” Dr. Feldman noted. “We continued to connect with the victims’ families and survivors, [listened to] their stories, shared meals with them, spent downtime with them, began to intimately know their loved ones, and all the barriers they were now facing. We became invested in them, their unique intricacies, and to care deeply for them like our own families and loved ones. Small talk and conversation morphed into silent embraces where spoken words weren’t necessary.”

Dr. Feldman said some of her earliest memories were visiting ICU patients alongside her father, a critical care and ICU physician. Her father taught her that nonverbal communication and connection can be offered to patients in the most poignant moments of suffering.

Her “nascent experiences in the ICU,” she said, taught her that “the most useful of interventions was just being with people in their pain and bearing witness at times when there were just no words.”

Dr. Feldman said that when many of her colleagues learned about the switch from rescue to recovery, the pull was to jump in their cars and drive to the hotel where the families were based to offer support.

The unity she witnessed – from the disparate clinicians who were virtual strangers before the incident but a team afterward, from the families and the community, and from the first responders and rescue teams – was inspiring, Dr. Feldman said.

“We were all forced to think beyond ourselves, push ourselves past our limits, and unify in a way that remedied this period in history of deep fragmentation,” she said.
 

Understanding the role of psychoneuroimmunology

In another presentation during the Zoom event, Ms. Stauber offered her insights about the importance of support among mental health clinicians.

She cited research on women with HIV showing that those who are part of a support group had a stronger immune response than those who were not.

Ms. Stauber said the impact of COVID-19 and its ramifications – including fear, grief over losing loved ones, isolation from friends and family, and interference/cessation of normal routines – has put an enormous strain on clinicians and clients. One of her clients had to take her mother to the emergency room – never to see her again. She continues to ask: “If I’d been there, could I have saved her?”

Another client whose husband died of COVID-19–related illness agonizes over not being able to be at her husband’s side, not being able to hold his hand, not being able to say goodbye.

She said other cultures are more accepting of suffering as a condition of life and the acknowledgment that our time on earth is limited.

The “quick fix for everything” society carries over to people’s grief, said Ms. Stauber. As a result, many find it difficult to appreciate how much time it takes to heal.

Normal uncomplicated grief can take approximately 2-3 years, she said. By then, the shock has been wearing off, the emotional roller coaster of loss is calming down, coping skills are strengthened, and life can once again be more fulfilling or meaningful. Complicated grief or grief with trauma takes much longer, said Ms. Stauber, who is a consultant with a national crisis and debriefing company providing trauma and bereavement support to Fortune 500 companies.

Trauma adds another complexity to loss. To begin to appreciate the rough road ahead, Ms. Stauber said, it is important to understand the basic challenges facing grieving people.

“This is where our profession may be needed; we are providing support for those suffering the immense pain of loss in a world that often has difficulty being present or patient with loss,” she said. “We are indeed providing an emotional life raft.”

Ultimately, self-care is critical, Ms. Stauber said. “Consider self-care a job requirement” to be successful. She also offered the following tips for self-care:

1. Share your own loss experience with a caring and nonjudgmental person.

2. Consider ongoing supervision and consultation with colleagues who understand the nature of your work.

3. Be willing to ask for help.

4. Be aware of risks and countertransference in our work.

5. Attend workshops.

6. Remember that you do not have to and cannot do it all by yourself – we absolutely need more grief and trauma trained therapists.

7. Involve yourself in activities outside of work that feed your soul and nourish your spirit.

8. Schedule play.

9. Develop a healthy self-care regimen to remain present doing this work.

10. Consider the benefits of exercise.

11. Enjoy the beauty and wonder of nature.

12. Consider yoga, meditation, spa retreats – such as Kripalu, Miraval, and Canyon Ranch.

13. Spend time with loving family and friends.

14. Adopt a pet.

15. Eat healthy foods; get plenty of rest.

16. Walk in the rain.

17. Listen to music.

18. Enjoy a relaxing bubble bath.

19. Sing, dance, and enjoy the blessings of this life.

20. Love yourself; you truly can be your own best friend.

To advocate on behalf of mental health for patients, we must do the same for mental health professionals. The retreat was well received, and we learned a lot from our speakers. After the program, we offered a 45-minute yoga class and then 30-minute sound bowl meditation. We plan to repeat the event in September to help our community deal with the ongoing stress of such overwhelming loss.

While our community will never be the same, we hope that, by coming together, we can all find a way to support one another and strive to help ourselves and others manage as we navigate yet another unprecedented crisis.
 

Dr. Ritvo, who has more than 30 years’ experience in psychiatry, practices telemedicine. She is author of “BeKindr – The Transformative Power of Kindness” (Hellertown, Pa.: Momosa Publishing, 2018). Dr. Ritvo has no disclosures.

The mental health toll from the Surfside, Fla., Champlain Tower collapse will be felt by our patients for years to come. As mental health professionals in Miami-Dade County, it has been difficult to deal with the catastrophe layered on the escalating COVID-19 crisis.

Courtesy Dr. Cassie Feldman

With each passing day after the June 24 incident, we all learned who the 98 victims were. In session after session, the enormous impact of this unfathomable tragedy unfolded. Some mental health care professionals were directly affected with the loss of family members; some lost patients, and a large number of our patients lost someone or knew someone who lost someone. It was reminiscent of our work during the COVID-19 crisis when we found that we were dealing with the same stressors as those of our patients. As it was said then, we were all in the same storm – just in very different boats.

It was heartening to see how many colleagues rushed to the site of the building where family waiting areas were established. So many professionals wanted to assist that some had to be turned away.

The days right after the collapse were agonizing for all as we waited and hoped for survivors to be found. Search teams from across the United States and from Mexico and Israel – specifically, Israeli Defense Forces personnel with experience conducting operations in the wake of earthquakes in both Haiti and Nepal, took on the dangerous work. When no one was recovered after the first day, hope faded, and after 10 days, the search and rescue efforts turned to search and recovery. We were indeed a county and community in mourning.

According to Lina Haji, PsyD, GIA Miami, in addition to the direct impact of loss, clinicians who engaged in crisis response and bereavement counseling with those affected by the Surfside tragedy were subjected to vicarious trauma. Vicarious trauma, also used interchangeably with secondary trauma, occurs when practitioners absorb and integrate the aspects of the traumatic experience into their own consciousness. Mental health care providers in the Miami area not only experienced the direct effect of this tragedy but have been hearing details and harrowing stories about the unimaginable experiences their patients endured over those critical weeks. Vicarious trauma can result in our own symptoms, compassion fatigue, or burnout as clinicians. This resulted in a call for mental health providers to come to the aid of their fellow colleagues.

So, on the 1-month anniversary of the initial collapse, at the urging of Patricia Stauber, RN, LCSW, a clinician with more than 30 years’ experience in providing grief counseling in hospital and private practice settings; Antonello Bonci, MD, the founder of GIA Miami; Charlotte Tomic, director of public relations for the Institute for the Study of Global Antisemitism; and I cohosted what we hope will be several Mental Health Appreciation retreats. Our goal was to create a space to focus on healing the healers. We had hoped to hold an in-person event, but at the last moment we opted for a Zoom-based event because COVID-19 cases were rising rapidly again.

Working on the front lines

Cassie Feldman, PsyD, a licensed clinical psychologist with extensive experience working with grief, loss, end of life, and responding to trauma-related consults, reflected on her experience responding to the collapse in the earliest days – first independently at the request of community religious leaders and then as part of CADENA Foundation, a nonprofit organization dedicated to rescue, humanitarian aid, and disaster response and prevention worldwide.

Dr. Feldman worked alongside other mental health professionals, local Miami-Dade police and fire officials, and the domestic and international rescue teams (CADENA’s Go Team from Mexico and the Israeli Defense Force’s Search and Rescue Delegation), providing Psychological First Aid, crisis intervention, and disaster response to the victims’ families and survivors.

This initially was a 24-hour coverage effort, requiring Dr. Feldman and her colleagues to clear their schedules, and at times to work 18-hour shifts in the early days of the crisis to address the need for consistency and continuity. Their commitment was to show up for the victims’ families and survivors, fully embracing the chaos and the demands of the situation. She noted that the disaster brought out the best of her and her colleagues.

They divided and conquered the work, alongside clinicians from Jewish Community Services and Project Chai intervening acutely where possible, and coordinating long-term care plans for those survivors and members of the victims’ support networks in need of consistent care.

Dr. Feldman reflected on the notion that we have all been processing losses prior to this – loss of normalcy because of the pandemic, loss of people we loved as a result, other personal losses – and that this community tragedy is yet another loss to disentangle. It didn’t feel good or natural for her to passively absorb the news knowing she had both the skill set and capacity to take on an active supportive role. The first days at the community center were disorganized; it was hard to know who was who and what was what. She described parents crying out for their children and children longing for their parents. Individuals were so overcome with emotion that they grew faint. Friends and families flooded in but were unaware of how to be fully supportive. The level of trauma was so high that the only interventions that were absorbed were those that were nonverbal or that fully addressed practical needs. People were frightened and in a state of shock.

Day by day, more order ensued and the efforts became more coordinated, but it became apparent to her that the “family reunification center” was devoid of reunification. She and her colleagues’ primary role became aiding the police department in making death notifications to the families and being supportive of the victims’ families and their loved ones during and in between the formal briefings, where so many concerned family members and friends gathered and waited.

“As the days went on, things became more structured and predictable,” Dr. Feldman noted. “We continued to connect with the victims’ families and survivors, [listened to] their stories, shared meals with them, spent downtime with them, began to intimately know their loved ones, and all the barriers they were now facing. We became invested in them, their unique intricacies, and to care deeply for them like our own families and loved ones. Small talk and conversation morphed into silent embraces where spoken words weren’t necessary.”

Dr. Feldman said some of her earliest memories were visiting ICU patients alongside her father, a critical care and ICU physician. Her father taught her that nonverbal communication and connection can be offered to patients in the most poignant moments of suffering.

Her “nascent experiences in the ICU,” she said, taught her that “the most useful of interventions was just being with people in their pain and bearing witness at times when there were just no words.”

Dr. Feldman said that when many of her colleagues learned about the switch from rescue to recovery, the pull was to jump in their cars and drive to the hotel where the families were based to offer support.

The unity she witnessed – from the disparate clinicians who were virtual strangers before the incident but a team afterward, from the families and the community, and from the first responders and rescue teams – was inspiring, Dr. Feldman said.

“We were all forced to think beyond ourselves, push ourselves past our limits, and unify in a way that remedied this period in history of deep fragmentation,” she said.
 

Understanding the role of psychoneuroimmunology

In another presentation during the Zoom event, Ms. Stauber offered her insights about the importance of support among mental health clinicians.

She cited research on women with HIV showing that those who are part of a support group had a stronger immune response than those who were not.

Ms. Stauber said the impact of COVID-19 and its ramifications – including fear, grief over losing loved ones, isolation from friends and family, and interference/cessation of normal routines – has put an enormous strain on clinicians and clients. One of her clients had to take her mother to the emergency room – never to see her again. She continues to ask: “If I’d been there, could I have saved her?”

Another client whose husband died of COVID-19–related illness agonizes over not being able to be at her husband’s side, not being able to hold his hand, not being able to say goodbye.

She said other cultures are more accepting of suffering as a condition of life and the acknowledgment that our time on earth is limited.

The “quick fix for everything” society carries over to people’s grief, said Ms. Stauber. As a result, many find it difficult to appreciate how much time it takes to heal.

Normal uncomplicated grief can take approximately 2-3 years, she said. By then, the shock has been wearing off, the emotional roller coaster of loss is calming down, coping skills are strengthened, and life can once again be more fulfilling or meaningful. Complicated grief or grief with trauma takes much longer, said Ms. Stauber, who is a consultant with a national crisis and debriefing company providing trauma and bereavement support to Fortune 500 companies.

Trauma adds another complexity to loss. To begin to appreciate the rough road ahead, Ms. Stauber said, it is important to understand the basic challenges facing grieving people.

“This is where our profession may be needed; we are providing support for those suffering the immense pain of loss in a world that often has difficulty being present or patient with loss,” she said. “We are indeed providing an emotional life raft.”

Ultimately, self-care is critical, Ms. Stauber said. “Consider self-care a job requirement” to be successful. She also offered the following tips for self-care:

1. Share your own loss experience with a caring and nonjudgmental person.

2. Consider ongoing supervision and consultation with colleagues who understand the nature of your work.

3. Be willing to ask for help.

4. Be aware of risks and countertransference in our work.

5. Attend workshops.

6. Remember that you do not have to and cannot do it all by yourself – we absolutely need more grief and trauma trained therapists.

7. Involve yourself in activities outside of work that feed your soul and nourish your spirit.

8. Schedule play.

9. Develop a healthy self-care regimen to remain present doing this work.

10. Consider the benefits of exercise.

11. Enjoy the beauty and wonder of nature.

12. Consider yoga, meditation, spa retreats – such as Kripalu, Miraval, and Canyon Ranch.

13. Spend time with loving family and friends.

14. Adopt a pet.

15. Eat healthy foods; get plenty of rest.

16. Walk in the rain.

17. Listen to music.

18. Enjoy a relaxing bubble bath.

19. Sing, dance, and enjoy the blessings of this life.

20. Love yourself; you truly can be your own best friend.

To advocate on behalf of mental health for patients, we must do the same for mental health professionals. The retreat was well received, and we learned a lot from our speakers. After the program, we offered a 45-minute yoga class and then 30-minute sound bowl meditation. We plan to repeat the event in September to help our community deal with the ongoing stress of such overwhelming loss.

While our community will never be the same, we hope that, by coming together, we can all find a way to support one another and strive to help ourselves and others manage as we navigate yet another unprecedented crisis.
 

Dr. Ritvo, who has more than 30 years’ experience in psychiatry, practices telemedicine. She is author of “BeKindr – The Transformative Power of Kindness” (Hellertown, Pa.: Momosa Publishing, 2018). Dr. Ritvo has no disclosures.

The mental health toll from the Surfside, Fla., Champlain Tower collapse will be felt by our patients for years to come. As mental health professionals in Miami-Dade County, it has been difficult to deal with the catastrophe layered on the escalating COVID-19 crisis.

Courtesy Dr. Cassie Feldman

With each passing day after the June 24 incident, we all learned who the 98 victims were. In session after session, the enormous impact of this unfathomable tragedy unfolded. Some mental health care professionals were directly affected with the loss of family members; some lost patients, and a large number of our patients lost someone or knew someone who lost someone. It was reminiscent of our work during the COVID-19 crisis when we found that we were dealing with the same stressors as those of our patients. As it was said then, we were all in the same storm – just in very different boats.

It was heartening to see how many colleagues rushed to the site of the building where family waiting areas were established. So many professionals wanted to assist that some had to be turned away.

The days right after the collapse were agonizing for all as we waited and hoped for survivors to be found. Search teams from across the United States and from Mexico and Israel – specifically, Israeli Defense Forces personnel with experience conducting operations in the wake of earthquakes in both Haiti and Nepal, took on the dangerous work. When no one was recovered after the first day, hope faded, and after 10 days, the search and rescue efforts turned to search and recovery. We were indeed a county and community in mourning.

According to Lina Haji, PsyD, GIA Miami, in addition to the direct impact of loss, clinicians who engaged in crisis response and bereavement counseling with those affected by the Surfside tragedy were subjected to vicarious trauma. Vicarious trauma, also used interchangeably with secondary trauma, occurs when practitioners absorb and integrate the aspects of the traumatic experience into their own consciousness. Mental health care providers in the Miami area not only experienced the direct effect of this tragedy but have been hearing details and harrowing stories about the unimaginable experiences their patients endured over those critical weeks. Vicarious trauma can result in our own symptoms, compassion fatigue, or burnout as clinicians. This resulted in a call for mental health providers to come to the aid of their fellow colleagues.

So, on the 1-month anniversary of the initial collapse, at the urging of Patricia Stauber, RN, LCSW, a clinician with more than 30 years’ experience in providing grief counseling in hospital and private practice settings; Antonello Bonci, MD, the founder of GIA Miami; Charlotte Tomic, director of public relations for the Institute for the Study of Global Antisemitism; and I cohosted what we hope will be several Mental Health Appreciation retreats. Our goal was to create a space to focus on healing the healers. We had hoped to hold an in-person event, but at the last moment we opted for a Zoom-based event because COVID-19 cases were rising rapidly again.

Working on the front lines

Cassie Feldman, PsyD, a licensed clinical psychologist with extensive experience working with grief, loss, end of life, and responding to trauma-related consults, reflected on her experience responding to the collapse in the earliest days – first independently at the request of community religious leaders and then as part of CADENA Foundation, a nonprofit organization dedicated to rescue, humanitarian aid, and disaster response and prevention worldwide.

Dr. Feldman worked alongside other mental health professionals, local Miami-Dade police and fire officials, and the domestic and international rescue teams (CADENA’s Go Team from Mexico and the Israeli Defense Force’s Search and Rescue Delegation), providing Psychological First Aid, crisis intervention, and disaster response to the victims’ families and survivors.

This initially was a 24-hour coverage effort, requiring Dr. Feldman and her colleagues to clear their schedules, and at times to work 18-hour shifts in the early days of the crisis to address the need for consistency and continuity. Their commitment was to show up for the victims’ families and survivors, fully embracing the chaos and the demands of the situation. She noted that the disaster brought out the best of her and her colleagues.

They divided and conquered the work, alongside clinicians from Jewish Community Services and Project Chai intervening acutely where possible, and coordinating long-term care plans for those survivors and members of the victims’ support networks in need of consistent care.

Dr. Feldman reflected on the notion that we have all been processing losses prior to this – loss of normalcy because of the pandemic, loss of people we loved as a result, other personal losses – and that this community tragedy is yet another loss to disentangle. It didn’t feel good or natural for her to passively absorb the news knowing she had both the skill set and capacity to take on an active supportive role. The first days at the community center were disorganized; it was hard to know who was who and what was what. She described parents crying out for their children and children longing for their parents. Individuals were so overcome with emotion that they grew faint. Friends and families flooded in but were unaware of how to be fully supportive. The level of trauma was so high that the only interventions that were absorbed were those that were nonverbal or that fully addressed practical needs. People were frightened and in a state of shock.

Day by day, more order ensued and the efforts became more coordinated, but it became apparent to her that the “family reunification center” was devoid of reunification. She and her colleagues’ primary role became aiding the police department in making death notifications to the families and being supportive of the victims’ families and their loved ones during and in between the formal briefings, where so many concerned family members and friends gathered and waited.

“As the days went on, things became more structured and predictable,” Dr. Feldman noted. “We continued to connect with the victims’ families and survivors, [listened to] their stories, shared meals with them, spent downtime with them, began to intimately know their loved ones, and all the barriers they were now facing. We became invested in them, their unique intricacies, and to care deeply for them like our own families and loved ones. Small talk and conversation morphed into silent embraces where spoken words weren’t necessary.”

Dr. Feldman said some of her earliest memories were visiting ICU patients alongside her father, a critical care and ICU physician. Her father taught her that nonverbal communication and connection can be offered to patients in the most poignant moments of suffering.

Her “nascent experiences in the ICU,” she said, taught her that “the most useful of interventions was just being with people in their pain and bearing witness at times when there were just no words.”

Dr. Feldman said that when many of her colleagues learned about the switch from rescue to recovery, the pull was to jump in their cars and drive to the hotel where the families were based to offer support.

The unity she witnessed – from the disparate clinicians who were virtual strangers before the incident but a team afterward, from the families and the community, and from the first responders and rescue teams – was inspiring, Dr. Feldman said.

“We were all forced to think beyond ourselves, push ourselves past our limits, and unify in a way that remedied this period in history of deep fragmentation,” she said.
 

Understanding the role of psychoneuroimmunology

In another presentation during the Zoom event, Ms. Stauber offered her insights about the importance of support among mental health clinicians.

She cited research on women with HIV showing that those who are part of a support group had a stronger immune response than those who were not.

Ms. Stauber said the impact of COVID-19 and its ramifications – including fear, grief over losing loved ones, isolation from friends and family, and interference/cessation of normal routines – has put an enormous strain on clinicians and clients. One of her clients had to take her mother to the emergency room – never to see her again. She continues to ask: “If I’d been there, could I have saved her?”

Another client whose husband died of COVID-19–related illness agonizes over not being able to be at her husband’s side, not being able to hold his hand, not being able to say goodbye.

She said other cultures are more accepting of suffering as a condition of life and the acknowledgment that our time on earth is limited.

The “quick fix for everything” society carries over to people’s grief, said Ms. Stauber. As a result, many find it difficult to appreciate how much time it takes to heal.

Normal uncomplicated grief can take approximately 2-3 years, she said. By then, the shock has been wearing off, the emotional roller coaster of loss is calming down, coping skills are strengthened, and life can once again be more fulfilling or meaningful. Complicated grief or grief with trauma takes much longer, said Ms. Stauber, who is a consultant with a national crisis and debriefing company providing trauma and bereavement support to Fortune 500 companies.

Trauma adds another complexity to loss. To begin to appreciate the rough road ahead, Ms. Stauber said, it is important to understand the basic challenges facing grieving people.

“This is where our profession may be needed; we are providing support for those suffering the immense pain of loss in a world that often has difficulty being present or patient with loss,” she said. “We are indeed providing an emotional life raft.”

Ultimately, self-care is critical, Ms. Stauber said. “Consider self-care a job requirement” to be successful. She also offered the following tips for self-care:

1. Share your own loss experience with a caring and nonjudgmental person.

2. Consider ongoing supervision and consultation with colleagues who understand the nature of your work.

3. Be willing to ask for help.

4. Be aware of risks and countertransference in our work.

5. Attend workshops.

6. Remember that you do not have to and cannot do it all by yourself – we absolutely need more grief and trauma trained therapists.

7. Involve yourself in activities outside of work that feed your soul and nourish your spirit.

8. Schedule play.

9. Develop a healthy self-care regimen to remain present doing this work.

10. Consider the benefits of exercise.

11. Enjoy the beauty and wonder of nature.

12. Consider yoga, meditation, spa retreats – such as Kripalu, Miraval, and Canyon Ranch.

13. Spend time with loving family and friends.

14. Adopt a pet.

15. Eat healthy foods; get plenty of rest.

16. Walk in the rain.

17. Listen to music.

18. Enjoy a relaxing bubble bath.

19. Sing, dance, and enjoy the blessings of this life.

20. Love yourself; you truly can be your own best friend.

To advocate on behalf of mental health for patients, we must do the same for mental health professionals. The retreat was well received, and we learned a lot from our speakers. After the program, we offered a 45-minute yoga class and then 30-minute sound bowl meditation. We plan to repeat the event in September to help our community deal with the ongoing stress of such overwhelming loss.

While our community will never be the same, we hope that, by coming together, we can all find a way to support one another and strive to help ourselves and others manage as we navigate yet another unprecedented crisis.
 

Dr. Ritvo, who has more than 30 years’ experience in psychiatry, practices telemedicine. She is author of “BeKindr – The Transformative Power of Kindness” (Hellertown, Pa.: Momosa Publishing, 2018). Dr. Ritvo has no disclosures.

After Sept. 11, 2001, and the subsequent long war in Iraq and Afghanistan, both mental health providers and the general public focused on posttraumatic stress disorder (PTSD). However, after almost 20 years of war and the COVID-19 epidemic, attention waned away from military service members and PTSD.

COVID-19–related PTSD and the hearings on the Jan. 6 attack on the Capitol have reignited interest in PTSD diagnosis and treatment. Testimony from police officers at the House select committee hearing about their experiences during the assault and PTSD was harrowing. One of the police officers had also served in Iraq, perhaps leading to “layered PTSD” – symptoms from war abroad and at home.

Thus, I thought a brief review of updates about diagnosis and treatment would be useful. Note: These are my opinions based on my extensive experience and do not represent the official opinion of my employer (MedStar Health).

PTSD was first classified as a disorder in 1980, based mainly on the experiences of military service members in Vietnam, as well as sexual assault victims and disaster survivors. Readers may look elsewhere for a fuller history of the disorder.

However, in brief, we have evolved from strict reliance on a variety of symptoms in the DSM (Diagnostic and Statistical Manual of Mental Disorders) to a more global determination of the experience of trauma and related symptoms of distress. We still rely for diagnosis on trauma-related anxiety and depression symptoms, such as nightmare, flashbacks, numbness, and disassociation.

Treatment has evolved. Patients may benefit from treatment even if they do not meet all the PTSD criteria. As many of my colleagues who treat patients have said, “if it smells like PTSD, treat it like PTSD.”

What is the most effective treatment? The literature declares that evidence-based treatments include two selective serotonin reuptake inhibitors (Zoloft and Paxil) and several psychotherapies. The psychotherapies include cognitive-behavioral therapies, exposure therapy, and EMDR (eye movement desensitization reprocessing).

The problem is that many patients cannot tolerate these therapies. SSRIs do have side effects, the most distressing being sexual dysfunction. Many service members do not enter the psychotherapies, or they drop out of trials, because they cannot tolerate the reimagining of their trauma.

I now counsel patients about the “three buckets” of treatment. The first bucket is medication, which as a psychiatrist is what I focus on. The second bucket is psychotherapy as discussed above. The third bucket is “everything else.”

“Everything else” includes a variety of methods the patients can use to reduce symptoms of anxiety, depression, and PTSD symptoms: exercising; deep breathing through the nose; doing yoga; doing meditation; playing or working with animals; gardening; and engaging in other activities that “self sooth.” I also recommend always doing “small acts of kindness” for others. I myself contribute to food banks and bring cookies or watermelons to the staff at my hospital.

Why is this approach useful? A menu of options gives control back to the patient. It provides activities that can reduce anxiety. Thinking about caring for others helps patients get out of their own “swamp of distress.”

We do live in very difficult times. We’re coping with COVID-19 Delta variant, attacks on the Capitol, and gun violence. I have not yet mentioned climate change, which is extremely frightening to many of us. So all providers need to be aware of all the strategies at our disposal to treat anxiety, depression, and PTSD.
 

Dr. Ritchie is chair of psychiatry at Medstar Washington (D.C.) Hospital Center. She has no conflicts of interest.

After Sept. 11, 2001, and the subsequent long war in Iraq and Afghanistan, both mental health providers and the general public focused on posttraumatic stress disorder (PTSD). However, after almost 20 years of war and the COVID-19 epidemic, attention waned away from military service members and PTSD.

COVID-19–related PTSD and the hearings on the Jan. 6 attack on the Capitol have reignited interest in PTSD diagnosis and treatment. Testimony from police officers at the House select committee hearing about their experiences during the assault and PTSD was harrowing. One of the police officers had also served in Iraq, perhaps leading to “layered PTSD” – symptoms from war abroad and at home.

Thus, I thought a brief review of updates about diagnosis and treatment would be useful. Note: These are my opinions based on my extensive experience and do not represent the official opinion of my employer (MedStar Health).

PTSD was first classified as a disorder in 1980, based mainly on the experiences of military service members in Vietnam, as well as sexual assault victims and disaster survivors. Readers may look elsewhere for a fuller history of the disorder.

However, in brief, we have evolved from strict reliance on a variety of symptoms in the DSM (Diagnostic and Statistical Manual of Mental Disorders) to a more global determination of the experience of trauma and related symptoms of distress. We still rely for diagnosis on trauma-related anxiety and depression symptoms, such as nightmare, flashbacks, numbness, and disassociation.

Treatment has evolved. Patients may benefit from treatment even if they do not meet all the PTSD criteria. As many of my colleagues who treat patients have said, “if it smells like PTSD, treat it like PTSD.”

What is the most effective treatment? The literature declares that evidence-based treatments include two selective serotonin reuptake inhibitors (Zoloft and Paxil) and several psychotherapies. The psychotherapies include cognitive-behavioral therapies, exposure therapy, and EMDR (eye movement desensitization reprocessing).

The problem is that many patients cannot tolerate these therapies. SSRIs do have side effects, the most distressing being sexual dysfunction. Many service members do not enter the psychotherapies, or they drop out of trials, because they cannot tolerate the reimagining of their trauma.

I now counsel patients about the “three buckets” of treatment. The first bucket is medication, which as a psychiatrist is what I focus on. The second bucket is psychotherapy as discussed above. The third bucket is “everything else.”

“Everything else” includes a variety of methods the patients can use to reduce symptoms of anxiety, depression, and PTSD symptoms: exercising; deep breathing through the nose; doing yoga; doing meditation; playing or working with animals; gardening; and engaging in other activities that “self sooth.” I also recommend always doing “small acts of kindness” for others. I myself contribute to food banks and bring cookies or watermelons to the staff at my hospital.

Why is this approach useful? A menu of options gives control back to the patient. It provides activities that can reduce anxiety. Thinking about caring for others helps patients get out of their own “swamp of distress.”

We do live in very difficult times. We’re coping with COVID-19 Delta variant, attacks on the Capitol, and gun violence. I have not yet mentioned climate change, which is extremely frightening to many of us. So all providers need to be aware of all the strategies at our disposal to treat anxiety, depression, and PTSD.
 

Dr. Ritchie is chair of psychiatry at Medstar Washington (D.C.) Hospital Center. She has no conflicts of interest.

After Sept. 11, 2001, and the subsequent long war in Iraq and Afghanistan, both mental health providers and the general public focused on posttraumatic stress disorder (PTSD). However, after almost 20 years of war and the COVID-19 epidemic, attention waned away from military service members and PTSD.

COVID-19–related PTSD and the hearings on the Jan. 6 attack on the Capitol have reignited interest in PTSD diagnosis and treatment. Testimony from police officers at the House select committee hearing about their experiences during the assault and PTSD was harrowing. One of the police officers had also served in Iraq, perhaps leading to “layered PTSD” – symptoms from war abroad and at home.

Thus, I thought a brief review of updates about diagnosis and treatment would be useful. Note: These are my opinions based on my extensive experience and do not represent the official opinion of my employer (MedStar Health).

PTSD was first classified as a disorder in 1980, based mainly on the experiences of military service members in Vietnam, as well as sexual assault victims and disaster survivors. Readers may look elsewhere for a fuller history of the disorder.

However, in brief, we have evolved from strict reliance on a variety of symptoms in the DSM (Diagnostic and Statistical Manual of Mental Disorders) to a more global determination of the experience of trauma and related symptoms of distress. We still rely for diagnosis on trauma-related anxiety and depression symptoms, such as nightmare, flashbacks, numbness, and disassociation.

Treatment has evolved. Patients may benefit from treatment even if they do not meet all the PTSD criteria. As many of my colleagues who treat patients have said, “if it smells like PTSD, treat it like PTSD.”

What is the most effective treatment? The literature declares that evidence-based treatments include two selective serotonin reuptake inhibitors (Zoloft and Paxil) and several psychotherapies. The psychotherapies include cognitive-behavioral therapies, exposure therapy, and EMDR (eye movement desensitization reprocessing).

The problem is that many patients cannot tolerate these therapies. SSRIs do have side effects, the most distressing being sexual dysfunction. Many service members do not enter the psychotherapies, or they drop out of trials, because they cannot tolerate the reimagining of their trauma.

I now counsel patients about the “three buckets” of treatment. The first bucket is medication, which as a psychiatrist is what I focus on. The second bucket is psychotherapy as discussed above. The third bucket is “everything else.”

“Everything else” includes a variety of methods the patients can use to reduce symptoms of anxiety, depression, and PTSD symptoms: exercising; deep breathing through the nose; doing yoga; doing meditation; playing or working with animals; gardening; and engaging in other activities that “self sooth.” I also recommend always doing “small acts of kindness” for others. I myself contribute to food banks and bring cookies or watermelons to the staff at my hospital.

Why is this approach useful? A menu of options gives control back to the patient. It provides activities that can reduce anxiety. Thinking about caring for others helps patients get out of their own “swamp of distress.”

We do live in very difficult times. We’re coping with COVID-19 Delta variant, attacks on the Capitol, and gun violence. I have not yet mentioned climate change, which is extremely frightening to many of us. So all providers need to be aware of all the strategies at our disposal to treat anxiety, depression, and PTSD.
 

Dr. Ritchie is chair of psychiatry at Medstar Washington (D.C.) Hospital Center. She has no conflicts of interest.

“I feel like my aggression is being racialized.” “Of course I wouldn’t call the cops if I felt like hurting myself. I’m Black.”

Those statements represent the heightened trauma our Black and Brown patients with mental health issues have been experiencing. In the wake of increasingly publicized police brutality against Black and Brown communities, the role race plays in mental health decompensation is evident. At this moment in time, we must continue to improve our understanding of the role race plays in psychiatric disorders. We must also ask ourselves: At times, does psychiatry worsen the traumas of the communities we serve?

Some psychiatrists are afraid to speak about race. They may believe it to be too “political.” But avoiding these necessary conversations perpetuates the trauma of those we treat. It suggests that physicians are ignorant of an issue at the forefront of patients’ mental health. Psychiatry, today, is primarily focused on the biological aspects of disease. We must not forget that psychiatry is biopsychosocial. It is imperative that psychiatrists have conversations about race – and its significance to our patients and their care.

Our difficulty in discussing race in part comes from the lack of representation by Black and Brown psychiatrists. Only 10.4% of psychiatrists in the United States comprise those considered underrepresented in medicine (URM). Yet, those very groups make up 32.6% of the U.S. population and are overrepresented in psychiatric hospitals.¹ Many studies have shown that concordant racial backgrounds between patient and physician lead to a more positive patient experience² and arguably, the subsequent potential for better health outcomes. Our efforts in addressing this disparity often fall short. URM applicants may be hesitant to join an institution where diversity is lacking or where they may be the only minority.³ While there is no simple solution, I propose that psychiatrists promote the importance of mental health to Black and Brown students of all ages by collaborating with schools and community leaders.

It is important to acknowledge that the lack of diversity within psychiatry is reflective of that among all physicians. This in part stems from the barriers to medical education that Black and Brown communities face. Those who start off with more resources or have parents who are physicians are at an advantage when trying to get into medical school. In fact, one in five medical students have a parent who is a physician⁴ and about three-fourths of students come from families whose income falls among the top two quintiles.⁵ Impoverished communities, which have a disproportionate share of Black and Brown people, cannot afford to take MCAT preparatory classes or to accept unpaid “resume building” opportunities. Many medical schools continue to place more weight on test scores and research/medical experiences, despite a shift to a more holistic review process. Institutions that have tried a different approach and accepted students from more diverse backgrounds may often overlook the challenges that URM students face while in medical school and fail to provide appropriate support resources.

The result is a failure to retain such students. A study conducted at Stony Brook (N.Y.) University showed that those underrepresented in medicine were six times more likely to get dismissed from medical school, and three times more likely to both withdraw or graduate beyond 4 years, compared with their White counterparts.⁶ This is a serious issue that needs to change on a structural and systemic level.

Any discussion of race and psychiatry must acknowledge psychiatry’s history of racism against Black and Brown communities to engage in racially informed discussions with our patients. Only then can we play a better role advocating against racism within the field in the future. Dating back to the 18th century, psychiatry has promoted ideologies that promote racism. Benjamin Rush, considered the “father of American Psychiatry,” believed that Black skin was a disease derived from leprosy called “negritude.” In the late 19th century, this twisted ideology continued with the invention of the term “drapetomania,” which was used to describe enslaved people who ran away as having a mental disorder.⁷ Black prisoners were subjected to experimental treatment with substances such as LSD and bulbocapnine to subdue them.⁸ This idea that minorities were dangerous and needed to be subdued translated into a higher number of schizophrenia diagnoses, particularly among Black men, as it was used as a tool to vilify them in the 1970s. Although schizophrenia is equally prevalent among Whites and non-Whites, Black people are four times more likely to be diagnosed, compared with their White counterparts, while Hispanics are three times more likely. Studies have shown that Black and Brown men are also more likely to receive higher doses of antipsychotics.⁹

Given this history, it is not surprising that Black and Brown representation within the field is lacking and that patients may be hesitant to share their feelings about race with us. While we can’t change history, we can take a stance condemning the harmful behavior of the past. The American Psychiatric Association issued an apology earlier this year to Black, Indigenous, and People of Color for its support in structural racism.¹⁰ This is a step in the right direction, but we need more than statements or performative actions. We need to amplify the voices of Black and Brown psychiatrists and patients, as well as highlight their current and past contributions to the field. While my educational experiences focused on the work of prominent White scholars, medical curricula should showcase the work of people like Solomon Carter Fuller, MD, a Black psychiatrist who was essential to understanding Alzheimer’s, or Joseph White, PhD, sometimes referred to as the “godfather of Black psychology.”¹¹

At times, I have found myself witness to situations where colleagues make statements that not only do not condemn racism, but in fact encourage it. I have unfortunately heard some use the all-too-familiar rhetoric of reverse racism, such as: “They just assume I am racist because I am a White male” or “They’re being racist against me” or statements like “Don’t you think it is far-fetched to believe she was just sitting on a college campus doing nothing when the police were called?” Rhetoric such as this is problematic to the field of psychiatry and medicine as a whole – and only serves to further invalidate the feelings of our Black and Brown patients. We must increase exposure and education regarding racism to address this, especially the meaning of microaggressions, a concept many fail to understand.

Attention to the subject of racism has increased within medical schools and residency training programs in the wake of George Floyd’s death. However, most programs often make these lectures optional or only have one to two limited sessions. Furthermore, many do not make it mandatory for faculty to attend; they are arguably the most in need of this training given that they set the precedent of how to practice psychiatry. Some institutions have incorporated comprehensive antiracist curriculums into medical training. One model that has been successful is the Social Justice and Health Equity program within Yale University’s psychiatry residency. The curriculum has four tracks:

• Structural competency, which focuses on the mental health impact of extraclinical structures, for example a patient’s neighborhood and associated barriers of access.
• Human experience, which explores the interaction of patients and providers and how biases play a role.
• Advocacy, which teaches residents the written and oral skills to lobby for patient interests on a community and legislative level.
• History of psychiatry, which focuses on understanding psychiatry’s prior role in racism.

In each track, there are group discussions, cases led by faculty, and meetings with community leaders. Through this curriculum, residents learn about power, privilege, and how to interact with and advocate for patients in a way that promotes equity, rather than racial disparity.^12,13 This is a model that other psychiatric residency programs can promote, emulate, and benefit from.

Educating ourselves will hopefully lead to a deeper introspection of how we interact with patients and if we are promoting antiracism through our attitude and actions. Reflecting on my own personal practice, I have noted that the interplay of race, mental health, and provider decision-making becomes particularly complex when dealing with situations in which a patient exhibits increased aggression or agitation. As a second-year psychiatric resident immersed in the inpatient world, I have become familiar with patients at higher risk and greater need. The first attempt toward de-escalation involves verbal cues without any other more intrusive measures. If that fails, intramuscular (IM) medications are typically considered. If a patient has a history of aggressive behavior, the threshold to use IM medications can decrease dramatically. This is mainly to protect ourselves and our nursing staff and to prioritize safety. While I understand this rationale, I wonder about the patient’s experience. What constitutes “aggressive” behavior? For patients who have had violence used against them because of their race or who have suffered from police brutality, having police present or threatening IM medications will increasingly trigger them and escalate the situation. The aftermath can deepen the distrust of psychiatry by Black and Brown people.

How do we then handle such situations in a way that both protects our staff from physical harm and protects our patients from racial trauma? While I don’t have a great answer, I think we can benefit from standardizing what we consider aggressive behavior and have specific criteria that patients need to exhibit before administering an IM medication. In addition, discussions with the team, including residents, nurses, and attending physicians, about how to address an emergent situation before it actually happens are essential. Specifically discussing the patient’s history and race and how it may affect the situation is not something to be shied away from. Lastly, in the event that an IM medication is administered and police are present, debriefing with the patient afterward is necessary. The patient may not be willing or able to listen to you or trust you, but taking accountability and acknowledging what happened, justified or not, is a part of the process of rebuilding rapport.

Both in the purview of the individual psychiatrist and the field of psychiatry as a whole, we need to examine our behavior and not be afraid to make changes for the betterment of our patients. We must learn to talk about race with our patients and in the process, advocate for more representation of Black and Brown psychiatrists, understanding the barriers faced by these communities when pursuing the medical field. We must educate ourselves on psychiatry’s history, and equip ourselves with knowledge and tools to promote antiracism and shape psychiatry’s future. We can then apply these very tools to challenging situations we may encounter daily with the ultimate goal of improving the mental health of our patients. This is the only way we will progress and ensure that psychiatry is an equitable, antiracist field. As Ibram X. Kendi, PhD, has written, “The heartbeat of antiracism is self-reflection, recognition, admission, and fundamentally self-critique.”
 

Dr. Malik is a second-year psychiatry resident at the University of California, San Diego. She has a background in policy and grassroots organizing through her time working at the National Coalition for the Homeless and the Women’s Law Project. Dr. Malik has no disclosures.

References

1. Wyse R et al. Acad Psychiatry. 2020 Oct;44(5):523-30.

2. Cooper LA et al. Ann Intern Med. 2003;139:907-15.

3. Pierre JM et al. Acad Psychiatry. 2017;41:226-32.

4. Hartocollis A. “Getting into med school without hard sciences.” New York Times. 2010 Jul 29.

5. AAMC. An updated look at the economic diversity of U.S. medical students. Analysis in Brief. 2018 Oct;18(5).

6. Rainey ML. How do we retain minority health professions students. In: Smedley BD et al. The right thing to do, the smart thing to do: Enhancing diversity in the health professions: Summary of the Symposium on Diversity in Health Professions in Honor of Herbert W. Nickens, M.D. Institute of Medicine. National Academies Press. 2001.

7. Geller J. “Structural racism in American psychiatry and APA: Part 1.” Psychiatric News. 2020 Jun 23.

8. Mohr CL and Gordon JE. Tulane: The emergence of a modern university, 1945-1980. Louisiana State University Press, Baton Rouge. 2001.

9. Metzl JM. The protest psychosis: How schizophrenia became a Black disease. Beacon Press. 2010.

10. APA’s apology to Black, indigenous and people of color for its support of structural racism in psychiatry. American Psychiatric Association. 2021 Jan 18.

11. Black pioneers in mental health. Mental Health America. 2021.

12. Belli B. For Yale’s emerging psychiatrists, confronting racism is in the curriculum. Yale News. 2020 Jul 30.

13. Jordan A and Jackson D. Social justice and health equity curriculum. Yale School of Medicine. 2019 Sep 24.

“I feel like my aggression is being racialized.” “Of course I wouldn’t call the cops if I felt like hurting myself. I’m Black.”

Those statements represent the heightened trauma our Black and Brown patients with mental health issues have been experiencing. In the wake of increasingly publicized police brutality against Black and Brown communities, the role race plays in mental health decompensation is evident. At this moment in time, we must continue to improve our understanding of the role race plays in psychiatric disorders. We must also ask ourselves: At times, does psychiatry worsen the traumas of the communities we serve?

Some psychiatrists are afraid to speak about race. They may believe it to be too “political.” But avoiding these necessary conversations perpetuates the trauma of those we treat. It suggests that physicians are ignorant of an issue at the forefront of patients’ mental health. Psychiatry, today, is primarily focused on the biological aspects of disease. We must not forget that psychiatry is biopsychosocial. It is imperative that psychiatrists have conversations about race – and its significance to our patients and their care.

Our difficulty in discussing race in part comes from the lack of representation by Black and Brown psychiatrists. Only 10.4% of psychiatrists in the United States comprise those considered underrepresented in medicine (URM). Yet, those very groups make up 32.6% of the U.S. population and are overrepresented in psychiatric hospitals.¹ Many studies have shown that concordant racial backgrounds between patient and physician lead to a more positive patient experience² and arguably, the subsequent potential for better health outcomes. Our efforts in addressing this disparity often fall short. URM applicants may be hesitant to join an institution where diversity is lacking or where they may be the only minority.³ While there is no simple solution, I propose that psychiatrists promote the importance of mental health to Black and Brown students of all ages by collaborating with schools and community leaders.

It is important to acknowledge that the lack of diversity within psychiatry is reflective of that among all physicians. This in part stems from the barriers to medical education that Black and Brown communities face. Those who start off with more resources or have parents who are physicians are at an advantage when trying to get into medical school. In fact, one in five medical students have a parent who is a physician⁴ and about three-fourths of students come from families whose income falls among the top two quintiles.⁵ Impoverished communities, which have a disproportionate share of Black and Brown people, cannot afford to take MCAT preparatory classes or to accept unpaid “resume building” opportunities. Many medical schools continue to place more weight on test scores and research/medical experiences, despite a shift to a more holistic review process. Institutions that have tried a different approach and accepted students from more diverse backgrounds may often overlook the challenges that URM students face while in medical school and fail to provide appropriate support resources.

The result is a failure to retain such students. A study conducted at Stony Brook (N.Y.) University showed that those underrepresented in medicine were six times more likely to get dismissed from medical school, and three times more likely to both withdraw or graduate beyond 4 years, compared with their White counterparts.⁶ This is a serious issue that needs to change on a structural and systemic level.

Any discussion of race and psychiatry must acknowledge psychiatry’s history of racism against Black and Brown communities to engage in racially informed discussions with our patients. Only then can we play a better role advocating against racism within the field in the future. Dating back to the 18th century, psychiatry has promoted ideologies that promote racism. Benjamin Rush, considered the “father of American Psychiatry,” believed that Black skin was a disease derived from leprosy called “negritude.” In the late 19th century, this twisted ideology continued with the invention of the term “drapetomania,” which was used to describe enslaved people who ran away as having a mental disorder.⁷ Black prisoners were subjected to experimental treatment with substances such as LSD and bulbocapnine to subdue them.⁸ This idea that minorities were dangerous and needed to be subdued translated into a higher number of schizophrenia diagnoses, particularly among Black men, as it was used as a tool to vilify them in the 1970s. Although schizophrenia is equally prevalent among Whites and non-Whites, Black people are four times more likely to be diagnosed, compared with their White counterparts, while Hispanics are three times more likely. Studies have shown that Black and Brown men are also more likely to receive higher doses of antipsychotics.⁹

Given this history, it is not surprising that Black and Brown representation within the field is lacking and that patients may be hesitant to share their feelings about race with us. While we can’t change history, we can take a stance condemning the harmful behavior of the past. The American Psychiatric Association issued an apology earlier this year to Black, Indigenous, and People of Color for its support in structural racism.¹⁰ This is a step in the right direction, but we need more than statements or performative actions. We need to amplify the voices of Black and Brown psychiatrists and patients, as well as highlight their current and past contributions to the field. While my educational experiences focused on the work of prominent White scholars, medical curricula should showcase the work of people like Solomon Carter Fuller, MD, a Black psychiatrist who was essential to understanding Alzheimer’s, or Joseph White, PhD, sometimes referred to as the “godfather of Black psychology.”¹¹

At times, I have found myself witness to situations where colleagues make statements that not only do not condemn racism, but in fact encourage it. I have unfortunately heard some use the all-too-familiar rhetoric of reverse racism, such as: “They just assume I am racist because I am a White male” or “They’re being racist against me” or statements like “Don’t you think it is far-fetched to believe she was just sitting on a college campus doing nothing when the police were called?” Rhetoric such as this is problematic to the field of psychiatry and medicine as a whole – and only serves to further invalidate the feelings of our Black and Brown patients. We must increase exposure and education regarding racism to address this, especially the meaning of microaggressions, a concept many fail to understand.

Attention to the subject of racism has increased within medical schools and residency training programs in the wake of George Floyd’s death. However, most programs often make these lectures optional or only have one to two limited sessions. Furthermore, many do not make it mandatory for faculty to attend; they are arguably the most in need of this training given that they set the precedent of how to practice psychiatry. Some institutions have incorporated comprehensive antiracist curriculums into medical training. One model that has been successful is the Social Justice and Health Equity program within Yale University’s psychiatry residency. The curriculum has four tracks:

• Structural competency, which focuses on the mental health impact of extraclinical structures, for example a patient’s neighborhood and associated barriers of access.
• Human experience, which explores the interaction of patients and providers and how biases play a role.
• Advocacy, which teaches residents the written and oral skills to lobby for patient interests on a community and legislative level.
• History of psychiatry, which focuses on understanding psychiatry’s prior role in racism.

In each track, there are group discussions, cases led by faculty, and meetings with community leaders. Through this curriculum, residents learn about power, privilege, and how to interact with and advocate for patients in a way that promotes equity, rather than racial disparity.^12,13 This is a model that other psychiatric residency programs can promote, emulate, and benefit from.

Educating ourselves will hopefully lead to a deeper introspection of how we interact with patients and if we are promoting antiracism through our attitude and actions. Reflecting on my own personal practice, I have noted that the interplay of race, mental health, and provider decision-making becomes particularly complex when dealing with situations in which a patient exhibits increased aggression or agitation. As a second-year psychiatric resident immersed in the inpatient world, I have become familiar with patients at higher risk and greater need. The first attempt toward de-escalation involves verbal cues without any other more intrusive measures. If that fails, intramuscular (IM) medications are typically considered. If a patient has a history of aggressive behavior, the threshold to use IM medications can decrease dramatically. This is mainly to protect ourselves and our nursing staff and to prioritize safety. While I understand this rationale, I wonder about the patient’s experience. What constitutes “aggressive” behavior? For patients who have had violence used against them because of their race or who have suffered from police brutality, having police present or threatening IM medications will increasingly trigger them and escalate the situation. The aftermath can deepen the distrust of psychiatry by Black and Brown people.

How do we then handle such situations in a way that both protects our staff from physical harm and protects our patients from racial trauma? While I don’t have a great answer, I think we can benefit from standardizing what we consider aggressive behavior and have specific criteria that patients need to exhibit before administering an IM medication. In addition, discussions with the team, including residents, nurses, and attending physicians, about how to address an emergent situation before it actually happens are essential. Specifically discussing the patient’s history and race and how it may affect the situation is not something to be shied away from. Lastly, in the event that an IM medication is administered and police are present, debriefing with the patient afterward is necessary. The patient may not be willing or able to listen to you or trust you, but taking accountability and acknowledging what happened, justified or not, is a part of the process of rebuilding rapport.

Both in the purview of the individual psychiatrist and the field of psychiatry as a whole, we need to examine our behavior and not be afraid to make changes for the betterment of our patients. We must learn to talk about race with our patients and in the process, advocate for more representation of Black and Brown psychiatrists, understanding the barriers faced by these communities when pursuing the medical field. We must educate ourselves on psychiatry’s history, and equip ourselves with knowledge and tools to promote antiracism and shape psychiatry’s future. We can then apply these very tools to challenging situations we may encounter daily with the ultimate goal of improving the mental health of our patients. This is the only way we will progress and ensure that psychiatry is an equitable, antiracist field. As Ibram X. Kendi, PhD, has written, “The heartbeat of antiracism is self-reflection, recognition, admission, and fundamentally self-critique.”
 

Dr. Malik is a second-year psychiatry resident at the University of California, San Diego. She has a background in policy and grassroots organizing through her time working at the National Coalition for the Homeless and the Women’s Law Project. Dr. Malik has no disclosures.

References

1. Wyse R et al. Acad Psychiatry. 2020 Oct;44(5):523-30.

2. Cooper LA et al. Ann Intern Med. 2003;139:907-15.

3. Pierre JM et al. Acad Psychiatry. 2017;41:226-32.

4. Hartocollis A. “Getting into med school without hard sciences.” New York Times. 2010 Jul 29.

5. AAMC. An updated look at the economic diversity of U.S. medical students. Analysis in Brief. 2018 Oct;18(5).

6. Rainey ML. How do we retain minority health professions students. In: Smedley BD et al. The right thing to do, the smart thing to do: Enhancing diversity in the health professions: Summary of the Symposium on Diversity in Health Professions in Honor of Herbert W. Nickens, M.D. Institute of Medicine. National Academies Press. 2001.

7. Geller J. “Structural racism in American psychiatry and APA: Part 1.” Psychiatric News. 2020 Jun 23.

8. Mohr CL and Gordon JE. Tulane: The emergence of a modern university, 1945-1980. Louisiana State University Press, Baton Rouge. 2001.

9. Metzl JM. The protest psychosis: How schizophrenia became a Black disease. Beacon Press. 2010.

10. APA’s apology to Black, indigenous and people of color for its support of structural racism in psychiatry. American Psychiatric Association. 2021 Jan 18.

11. Black pioneers in mental health. Mental Health America. 2021.

12. Belli B. For Yale’s emerging psychiatrists, confronting racism is in the curriculum. Yale News. 2020 Jul 30.

13. Jordan A and Jackson D. Social justice and health equity curriculum. Yale School of Medicine. 2019 Sep 24.

“I feel like my aggression is being racialized.” “Of course I wouldn’t call the cops if I felt like hurting myself. I’m Black.”

Those statements represent the heightened trauma our Black and Brown patients with mental health issues have been experiencing. In the wake of increasingly publicized police brutality against Black and Brown communities, the role race plays in mental health decompensation is evident. At this moment in time, we must continue to improve our understanding of the role race plays in psychiatric disorders. We must also ask ourselves: At times, does psychiatry worsen the traumas of the communities we serve?

Some psychiatrists are afraid to speak about race. They may believe it to be too “political.” But avoiding these necessary conversations perpetuates the trauma of those we treat. It suggests that physicians are ignorant of an issue at the forefront of patients’ mental health. Psychiatry, today, is primarily focused on the biological aspects of disease. We must not forget that psychiatry is biopsychosocial. It is imperative that psychiatrists have conversations about race – and its significance to our patients and their care.

Our difficulty in discussing race in part comes from the lack of representation by Black and Brown psychiatrists. Only 10.4% of psychiatrists in the United States comprise those considered underrepresented in medicine (URM). Yet, those very groups make up 32.6% of the U.S. population and are overrepresented in psychiatric hospitals.¹ Many studies have shown that concordant racial backgrounds between patient and physician lead to a more positive patient experience² and arguably, the subsequent potential for better health outcomes. Our efforts in addressing this disparity often fall short. URM applicants may be hesitant to join an institution where diversity is lacking or where they may be the only minority.³ While there is no simple solution, I propose that psychiatrists promote the importance of mental health to Black and Brown students of all ages by collaborating with schools and community leaders.

It is important to acknowledge that the lack of diversity within psychiatry is reflective of that among all physicians. This in part stems from the barriers to medical education that Black and Brown communities face. Those who start off with more resources or have parents who are physicians are at an advantage when trying to get into medical school. In fact, one in five medical students have a parent who is a physician⁴ and about three-fourths of students come from families whose income falls among the top two quintiles.⁵ Impoverished communities, which have a disproportionate share of Black and Brown people, cannot afford to take MCAT preparatory classes or to accept unpaid “resume building” opportunities. Many medical schools continue to place more weight on test scores and research/medical experiences, despite a shift to a more holistic review process. Institutions that have tried a different approach and accepted students from more diverse backgrounds may often overlook the challenges that URM students face while in medical school and fail to provide appropriate support resources.

The result is a failure to retain such students. A study conducted at Stony Brook (N.Y.) University showed that those underrepresented in medicine were six times more likely to get dismissed from medical school, and three times more likely to both withdraw or graduate beyond 4 years, compared with their White counterparts.⁶ This is a serious issue that needs to change on a structural and systemic level.

Any discussion of race and psychiatry must acknowledge psychiatry’s history of racism against Black and Brown communities to engage in racially informed discussions with our patients. Only then can we play a better role advocating against racism within the field in the future. Dating back to the 18th century, psychiatry has promoted ideologies that promote racism. Benjamin Rush, considered the “father of American Psychiatry,” believed that Black skin was a disease derived from leprosy called “negritude.” In the late 19th century, this twisted ideology continued with the invention of the term “drapetomania,” which was used to describe enslaved people who ran away as having a mental disorder.⁷ Black prisoners were subjected to experimental treatment with substances such as LSD and bulbocapnine to subdue them.⁸ This idea that minorities were dangerous and needed to be subdued translated into a higher number of schizophrenia diagnoses, particularly among Black men, as it was used as a tool to vilify them in the 1970s. Although schizophrenia is equally prevalent among Whites and non-Whites, Black people are four times more likely to be diagnosed, compared with their White counterparts, while Hispanics are three times more likely. Studies have shown that Black and Brown men are also more likely to receive higher doses of antipsychotics.⁹

Given this history, it is not surprising that Black and Brown representation within the field is lacking and that patients may be hesitant to share their feelings about race with us. While we can’t change history, we can take a stance condemning the harmful behavior of the past. The American Psychiatric Association issued an apology earlier this year to Black, Indigenous, and People of Color for its support in structural racism.¹⁰ This is a step in the right direction, but we need more than statements or performative actions. We need to amplify the voices of Black and Brown psychiatrists and patients, as well as highlight their current and past contributions to the field. While my educational experiences focused on the work of prominent White scholars, medical curricula should showcase the work of people like Solomon Carter Fuller, MD, a Black psychiatrist who was essential to understanding Alzheimer’s, or Joseph White, PhD, sometimes referred to as the “godfather of Black psychology.”¹¹

At times, I have found myself witness to situations where colleagues make statements that not only do not condemn racism, but in fact encourage it. I have unfortunately heard some use the all-too-familiar rhetoric of reverse racism, such as: “They just assume I am racist because I am a White male” or “They’re being racist against me” or statements like “Don’t you think it is far-fetched to believe she was just sitting on a college campus doing nothing when the police were called?” Rhetoric such as this is problematic to the field of psychiatry and medicine as a whole – and only serves to further invalidate the feelings of our Black and Brown patients. We must increase exposure and education regarding racism to address this, especially the meaning of microaggressions, a concept many fail to understand.

Attention to the subject of racism has increased within medical schools and residency training programs in the wake of George Floyd’s death. However, most programs often make these lectures optional or only have one to two limited sessions. Furthermore, many do not make it mandatory for faculty to attend; they are arguably the most in need of this training given that they set the precedent of how to practice psychiatry. Some institutions have incorporated comprehensive antiracist curriculums into medical training. One model that has been successful is the Social Justice and Health Equity program within Yale University’s psychiatry residency. The curriculum has four tracks:

• Structural competency, which focuses on the mental health impact of extraclinical structures, for example a patient’s neighborhood and associated barriers of access.
• Human experience, which explores the interaction of patients and providers and how biases play a role.
• Advocacy, which teaches residents the written and oral skills to lobby for patient interests on a community and legislative level.
• History of psychiatry, which focuses on understanding psychiatry’s prior role in racism.

In each track, there are group discussions, cases led by faculty, and meetings with community leaders. Through this curriculum, residents learn about power, privilege, and how to interact with and advocate for patients in a way that promotes equity, rather than racial disparity.^12,13 This is a model that other psychiatric residency programs can promote, emulate, and benefit from.

Educating ourselves will hopefully lead to a deeper introspection of how we interact with patients and if we are promoting antiracism through our attitude and actions. Reflecting on my own personal practice, I have noted that the interplay of race, mental health, and provider decision-making becomes particularly complex when dealing with situations in which a patient exhibits increased aggression or agitation. As a second-year psychiatric resident immersed in the inpatient world, I have become familiar with patients at higher risk and greater need. The first attempt toward de-escalation involves verbal cues without any other more intrusive measures. If that fails, intramuscular (IM) medications are typically considered. If a patient has a history of aggressive behavior, the threshold to use IM medications can decrease dramatically. This is mainly to protect ourselves and our nursing staff and to prioritize safety. While I understand this rationale, I wonder about the patient’s experience. What constitutes “aggressive” behavior? For patients who have had violence used against them because of their race or who have suffered from police brutality, having police present or threatening IM medications will increasingly trigger them and escalate the situation. The aftermath can deepen the distrust of psychiatry by Black and Brown people.

How do we then handle such situations in a way that both protects our staff from physical harm and protects our patients from racial trauma? While I don’t have a great answer, I think we can benefit from standardizing what we consider aggressive behavior and have specific criteria that patients need to exhibit before administering an IM medication. In addition, discussions with the team, including residents, nurses, and attending physicians, about how to address an emergent situation before it actually happens are essential. Specifically discussing the patient’s history and race and how it may affect the situation is not something to be shied away from. Lastly, in the event that an IM medication is administered and police are present, debriefing with the patient afterward is necessary. The patient may not be willing or able to listen to you or trust you, but taking accountability and acknowledging what happened, justified or not, is a part of the process of rebuilding rapport.

Both in the purview of the individual psychiatrist and the field of psychiatry as a whole, we need to examine our behavior and not be afraid to make changes for the betterment of our patients. We must learn to talk about race with our patients and in the process, advocate for more representation of Black and Brown psychiatrists, understanding the barriers faced by these communities when pursuing the medical field. We must educate ourselves on psychiatry’s history, and equip ourselves with knowledge and tools to promote antiracism and shape psychiatry’s future. We can then apply these very tools to challenging situations we may encounter daily with the ultimate goal of improving the mental health of our patients. This is the only way we will progress and ensure that psychiatry is an equitable, antiracist field. As Ibram X. Kendi, PhD, has written, “The heartbeat of antiracism is self-reflection, recognition, admission, and fundamentally self-critique.”
 

Dr. Malik is a second-year psychiatry resident at the University of California, San Diego. She has a background in policy and grassroots organizing through her time working at the National Coalition for the Homeless and the Women’s Law Project. Dr. Malik has no disclosures.

References

1. Wyse R et al. Acad Psychiatry. 2020 Oct;44(5):523-30.

2. Cooper LA et al. Ann Intern Med. 2003;139:907-15.

3. Pierre JM et al. Acad Psychiatry. 2017;41:226-32.

4. Hartocollis A. “Getting into med school without hard sciences.” New York Times. 2010 Jul 29.

5. AAMC. An updated look at the economic diversity of U.S. medical students. Analysis in Brief. 2018 Oct;18(5).

6. Rainey ML. How do we retain minority health professions students. In: Smedley BD et al. The right thing to do, the smart thing to do: Enhancing diversity in the health professions: Summary of the Symposium on Diversity in Health Professions in Honor of Herbert W. Nickens, M.D. Institute of Medicine. National Academies Press. 2001.

7. Geller J. “Structural racism in American psychiatry and APA: Part 1.” Psychiatric News. 2020 Jun 23.

8. Mohr CL and Gordon JE. Tulane: The emergence of a modern university, 1945-1980. Louisiana State University Press, Baton Rouge. 2001.

9. Metzl JM. The protest psychosis: How schizophrenia became a Black disease. Beacon Press. 2010.

10. APA’s apology to Black, indigenous and people of color for its support of structural racism in psychiatry. American Psychiatric Association. 2021 Jan 18.

11. Black pioneers in mental health. Mental Health America. 2021.

12. Belli B. For Yale’s emerging psychiatrists, confronting racism is in the curriculum. Yale News. 2020 Jul 30.

13. Jordan A and Jackson D. Social justice and health equity curriculum. Yale School of Medicine. 2019 Sep 24.

The tragic loss of three medical residents in our beloved South Bronx hospital shook us to the core. They were our colleagues and friends – promising young physicians whose lives and contributions to our hospital family will never be forgotten. We miss them and we grieve them.

We have been keenly aware of the growing trend of physician suicides across the country. That’s one of the reasons why, years ago, we established the nationally recognized Helping Healers Heal program across our health system and more recently expanded other mental health counseling and support to our frontline clinicians.

Our focus is wellness and prevention, as well as helping address the sadness, anxiety, and depression that so many of us experience after a traumatic event. During the surge of the COVID pandemic, these programs proved to be essential, as we expanded these services to all staff, not just those on the frontlines of patient care.

We share Dr. Pamela Wible’s concerns about the physician suicide crisis in this country. However, she misrepresented our residency program and made numerous statements that are false and simply hurtful.

Out of respect for our colleagues and their families, we cannot share everything that we know about this tragic and irreparable loss. But we must set the record straight about a number of incorrect references made by Dr. Wible:

1. We lost two residents to suicide. Though no less horrific, the third death was investigated and declared an accident by the police department.

2. Resident work hours and workload are closely monitored to follow guidance set by the New York State Department of Health and by ACGME. In fact, at the peak of the COVID pandemic, when we were caring for nearly 130 intubated patients at a time, we adopted a strict residency program schedule with built-in breaks and reduced shifts and hours. Even at that tasking time, no one worked more than 80 hours. Although the maximum number of patients assigned to an intern allowed by ACGME is 10, we rarely have more than five or six patients assigned to each of our interns.

A version of this article first appeared on Medscape.com.

The tragic loss of three medical residents in our beloved South Bronx hospital shook us to the core. They were our colleagues and friends – promising young physicians whose lives and contributions to our hospital family will never be forgotten. We miss them and we grieve them.

We have been keenly aware of the growing trend of physician suicides across the country. That’s one of the reasons why, years ago, we established the nationally recognized Helping Healers Heal program across our health system and more recently expanded other mental health counseling and support to our frontline clinicians.

Our focus is wellness and prevention, as well as helping address the sadness, anxiety, and depression that so many of us experience after a traumatic event. During the surge of the COVID pandemic, these programs proved to be essential, as we expanded these services to all staff, not just those on the frontlines of patient care.

We share Dr. Pamela Wible’s concerns about the physician suicide crisis in this country. However, she misrepresented our residency program and made numerous statements that are false and simply hurtful.

Out of respect for our colleagues and their families, we cannot share everything that we know about this tragic and irreparable loss. But we must set the record straight about a number of incorrect references made by Dr. Wible:

1. We lost two residents to suicide. Though no less horrific, the third death was investigated and declared an accident by the police department.

2. Resident work hours and workload are closely monitored to follow guidance set by the New York State Department of Health and by ACGME. In fact, at the peak of the COVID pandemic, when we were caring for nearly 130 intubated patients at a time, we adopted a strict residency program schedule with built-in breaks and reduced shifts and hours. Even at that tasking time, no one worked more than 80 hours. Although the maximum number of patients assigned to an intern allowed by ACGME is 10, we rarely have more than five or six patients assigned to each of our interns.

A version of this article first appeared on Medscape.com.

The tragic loss of three medical residents in our beloved South Bronx hospital shook us to the core. They were our colleagues and friends – promising young physicians whose lives and contributions to our hospital family will never be forgotten. We miss them and we grieve them.

We have been keenly aware of the growing trend of physician suicides across the country. That’s one of the reasons why, years ago, we established the nationally recognized Helping Healers Heal program across our health system and more recently expanded other mental health counseling and support to our frontline clinicians.

Our focus is wellness and prevention, as well as helping address the sadness, anxiety, and depression that so many of us experience after a traumatic event. During the surge of the COVID pandemic, these programs proved to be essential, as we expanded these services to all staff, not just those on the frontlines of patient care.

We share Dr. Pamela Wible’s concerns about the physician suicide crisis in this country. However, she misrepresented our residency program and made numerous statements that are false and simply hurtful.

Out of respect for our colleagues and their families, we cannot share everything that we know about this tragic and irreparable loss. But we must set the record straight about a number of incorrect references made by Dr. Wible:

1. We lost two residents to suicide. Though no less horrific, the third death was investigated and declared an accident by the police department.

2. Resident work hours and workload are closely monitored to follow guidance set by the New York State Department of Health and by ACGME. In fact, at the peak of the COVID pandemic, when we were caring for nearly 130 intubated patients at a time, we adopted a strict residency program schedule with built-in breaks and reduced shifts and hours. Even at that tasking time, no one worked more than 80 hours. Although the maximum number of patients assigned to an intern allowed by ACGME is 10, we rarely have more than five or six patients assigned to each of our interns.

A version of this article first appeared on Medscape.com.

Ketamine used to treat severe depression in patients with a history of psychosis does not exacerbate psychosis risk, new research suggests.

A meta-analysis of nine studies, encompassing 41 patients with TRD and a history of psychosis, suggests ketamine is safe and effective and did not exacerbate psychotic symptoms in this patient population.

“We believe our findings could encourage clinicians and researchers to examine a broadened indication for ketamine treatment in individual patients with high levels of treatment resistance, carefully monitoring both clinical response and side effects, specifically looking at possible increases in psychotic symptoms,” study investigator Jolien K. E. Veraart, MD, University of Groningen, University Medical Center Groningen, the Netherlands, told this news organization.

The study was published online July 13 in the Journal of Clinical Psychiatry.
 

Rapid, robust effects

Ketamine has shown “rapid and robust antidepressant effects” in clinical studies. However, this research has not included patients with past or current psychosis, based on the assumption that psychosis will increase with ketamine administration, since side effects of ketamine can include transient “schizophrenia-like” psychotomimetic phenomena, including perceptual disorders and hallucinations in healthy individuals, the investigators note.

Dr. Veraart said psychotic symptoms are “common in people with severe depression,” and these patients have poorer outcomes with pharmacotherapy, psychotherapy, and electroconvulsive therapy.

Additionally, up to 60% of patients with schizophrenia experience negative symptomatology, including loss of motivation, affective blunting, and anhedonia, which “has a clear phenomenological overlap with depression,” the authors write. They also note anti-anhedonic effects of subanesthetic ketamine doses have been reported, without adversely impacting long-term psychotic symptoms in patients with schizophrenia.

“Positive results from carefully monitored trials with ketamine treatment in these patients have motivated us to summarize the currently available knowledge to inform our colleagues,” she said.

To investigate, the researchers conducted a literature search and selected 9 articles (N = 41 patients) that reported on ketamine treatment in patients with a history of psychosis or current psychotic symptoms.

All studies were either case reports or pilot studies, the authors report. Types of patients included those with bipolar or unipolar depression, or depression in schizoaffective disorder , or patients with schizophrenia and concurrent depression. Depressive symptomatology was the treatment target in eight studies, and one study targeted negative symptoms in patients with schizophrenia.

Dosing, frequency, and types of administration (ketamine IV, esketamine IV, or esketamine subcutaneous) varied from study to study.

In seven studies, ketamine was found to improve depressive symptoms, and in two studies, improvement in psychotic symptoms was also shown. Two studies revealed improvement in symptoms of suicidality. Results of the study that measured negative symptoms showed “significant improvement” in five of six patients, with a -37.3% decrease in mean Brief Negative Symptoms Scale (BNSS) from the baseline to the end of four infusions.

“Ketamine showed good antidepressant effects, and, in some cases, the comorbid symptoms even improved or disappeared after ketamine treatment,” Dr. Veraart summarized. However, the effect size of ketamine might be lower in those with a history of psychosis, she added.

She also noted that ketamine administration did not negatively influence the course of psychotic illness or induce psychotic exacerbations in patients.

She pointed to one study limitation, which is that only small, uncontrolled trials were included and that there is a risk for publication bias.
 

Larger trials needed

Commenting on the study, Dan Iosifescu, MD, MSc, associate professor of psychiatry, New York University School of Medicine, said that if the finding “were based on a larger study it would be very important, as a theoretical risk of psychosis is preventing such patients from access to an otherwise beneficial treatment.”

However, “since the review is based on a small sample, a low risk of psychosis exacerbation after IV ketamine is still possible,” said Dr. Iosifescu, who is also the director of clinical research at the Kline Institute for Psychiatric Research in Orangeburg, New York, and was not involved with the study.

Dr. Veraart agreed, adding that the “efficacy, safety, and tolerability of ketamine in depressed patients with a vulnerability to psychosis should be investigated in well-designed randomized controlled trials before application on a large scale is promoted.”

The study had no specific funding. Dr. Veraart has received speaker honoraria from Janssen outside of the submitted work. The other authors’ disclosures are listed in the original article. Dr. Iosifescu has been a consultant to the Centers of Psychiatric Excellence, advising clinics on the best methods of providing treatment with IV ketamine.

A version of this article first appeared on Medscape.com.

Ketamine used to treat severe depression in patients with a history of psychosis does not exacerbate psychosis risk, new research suggests.

A meta-analysis of nine studies, encompassing 41 patients with TRD and a history of psychosis, suggests ketamine is safe and effective and did not exacerbate psychotic symptoms in this patient population.

“We believe our findings could encourage clinicians and researchers to examine a broadened indication for ketamine treatment in individual patients with high levels of treatment resistance, carefully monitoring both clinical response and side effects, specifically looking at possible increases in psychotic symptoms,” study investigator Jolien K. E. Veraart, MD, University of Groningen, University Medical Center Groningen, the Netherlands, told this news organization.

The study was published online July 13 in the Journal of Clinical Psychiatry.
 

Rapid, robust effects

Ketamine has shown “rapid and robust antidepressant effects” in clinical studies. However, this research has not included patients with past or current psychosis, based on the assumption that psychosis will increase with ketamine administration, since side effects of ketamine can include transient “schizophrenia-like” psychotomimetic phenomena, including perceptual disorders and hallucinations in healthy individuals, the investigators note.

Dr. Veraart said psychotic symptoms are “common in people with severe depression,” and these patients have poorer outcomes with pharmacotherapy, psychotherapy, and electroconvulsive therapy.

Additionally, up to 60% of patients with schizophrenia experience negative symptomatology, including loss of motivation, affective blunting, and anhedonia, which “has a clear phenomenological overlap with depression,” the authors write. They also note anti-anhedonic effects of subanesthetic ketamine doses have been reported, without adversely impacting long-term psychotic symptoms in patients with schizophrenia.

“Positive results from carefully monitored trials with ketamine treatment in these patients have motivated us to summarize the currently available knowledge to inform our colleagues,” she said.

To investigate, the researchers conducted a literature search and selected 9 articles (N = 41 patients) that reported on ketamine treatment in patients with a history of psychosis or current psychotic symptoms.

All studies were either case reports or pilot studies, the authors report. Types of patients included those with bipolar or unipolar depression, or depression in schizoaffective disorder , or patients with schizophrenia and concurrent depression. Depressive symptomatology was the treatment target in eight studies, and one study targeted negative symptoms in patients with schizophrenia.

Dosing, frequency, and types of administration (ketamine IV, esketamine IV, or esketamine subcutaneous) varied from study to study.

In seven studies, ketamine was found to improve depressive symptoms, and in two studies, improvement in psychotic symptoms was also shown. Two studies revealed improvement in symptoms of suicidality. Results of the study that measured negative symptoms showed “significant improvement” in five of six patients, with a -37.3% decrease in mean Brief Negative Symptoms Scale (BNSS) from the baseline to the end of four infusions.

“Ketamine showed good antidepressant effects, and, in some cases, the comorbid symptoms even improved or disappeared after ketamine treatment,” Dr. Veraart summarized. However, the effect size of ketamine might be lower in those with a history of psychosis, she added.

She also noted that ketamine administration did not negatively influence the course of psychotic illness or induce psychotic exacerbations in patients.

She pointed to one study limitation, which is that only small, uncontrolled trials were included and that there is a risk for publication bias.
 

Larger trials needed

Commenting on the study, Dan Iosifescu, MD, MSc, associate professor of psychiatry, New York University School of Medicine, said that if the finding “were based on a larger study it would be very important, as a theoretical risk of psychosis is preventing such patients from access to an otherwise beneficial treatment.”

However, “since the review is based on a small sample, a low risk of psychosis exacerbation after IV ketamine is still possible,” said Dr. Iosifescu, who is also the director of clinical research at the Kline Institute for Psychiatric Research in Orangeburg, New York, and was not involved with the study.

Dr. Veraart agreed, adding that the “efficacy, safety, and tolerability of ketamine in depressed patients with a vulnerability to psychosis should be investigated in well-designed randomized controlled trials before application on a large scale is promoted.”

The study had no specific funding. Dr. Veraart has received speaker honoraria from Janssen outside of the submitted work. The other authors’ disclosures are listed in the original article. Dr. Iosifescu has been a consultant to the Centers of Psychiatric Excellence, advising clinics on the best methods of providing treatment with IV ketamine.

A version of this article first appeared on Medscape.com.

Ketamine used to treat severe depression in patients with a history of psychosis does not exacerbate psychosis risk, new research suggests.

A meta-analysis of nine studies, encompassing 41 patients with TRD and a history of psychosis, suggests ketamine is safe and effective and did not exacerbate psychotic symptoms in this patient population.

“We believe our findings could encourage clinicians and researchers to examine a broadened indication for ketamine treatment in individual patients with high levels of treatment resistance, carefully monitoring both clinical response and side effects, specifically looking at possible increases in psychotic symptoms,” study investigator Jolien K. E. Veraart, MD, University of Groningen, University Medical Center Groningen, the Netherlands, told this news organization.

The study was published online July 13 in the Journal of Clinical Psychiatry.
 

Rapid, robust effects

Ketamine has shown “rapid and robust antidepressant effects” in clinical studies. However, this research has not included patients with past or current psychosis, based on the assumption that psychosis will increase with ketamine administration, since side effects of ketamine can include transient “schizophrenia-like” psychotomimetic phenomena, including perceptual disorders and hallucinations in healthy individuals, the investigators note.

Dr. Veraart said psychotic symptoms are “common in people with severe depression,” and these patients have poorer outcomes with pharmacotherapy, psychotherapy, and electroconvulsive therapy.

Additionally, up to 60% of patients with schizophrenia experience negative symptomatology, including loss of motivation, affective blunting, and anhedonia, which “has a clear phenomenological overlap with depression,” the authors write. They also note anti-anhedonic effects of subanesthetic ketamine doses have been reported, without adversely impacting long-term psychotic symptoms in patients with schizophrenia.

“Positive results from carefully monitored trials with ketamine treatment in these patients have motivated us to summarize the currently available knowledge to inform our colleagues,” she said.

To investigate, the researchers conducted a literature search and selected 9 articles (N = 41 patients) that reported on ketamine treatment in patients with a history of psychosis or current psychotic symptoms.

All studies were either case reports or pilot studies, the authors report. Types of patients included those with bipolar or unipolar depression, or depression in schizoaffective disorder , or patients with schizophrenia and concurrent depression. Depressive symptomatology was the treatment target in eight studies, and one study targeted negative symptoms in patients with schizophrenia.

Dosing, frequency, and types of administration (ketamine IV, esketamine IV, or esketamine subcutaneous) varied from study to study.

In seven studies, ketamine was found to improve depressive symptoms, and in two studies, improvement in psychotic symptoms was also shown. Two studies revealed improvement in symptoms of suicidality. Results of the study that measured negative symptoms showed “significant improvement” in five of six patients, with a -37.3% decrease in mean Brief Negative Symptoms Scale (BNSS) from the baseline to the end of four infusions.

“Ketamine showed good antidepressant effects, and, in some cases, the comorbid symptoms even improved or disappeared after ketamine treatment,” Dr. Veraart summarized. However, the effect size of ketamine might be lower in those with a history of psychosis, she added.

She also noted that ketamine administration did not negatively influence the course of psychotic illness or induce psychotic exacerbations in patients.

She pointed to one study limitation, which is that only small, uncontrolled trials were included and that there is a risk for publication bias.
 

Larger trials needed

Commenting on the study, Dan Iosifescu, MD, MSc, associate professor of psychiatry, New York University School of Medicine, said that if the finding “were based on a larger study it would be very important, as a theoretical risk of psychosis is preventing such patients from access to an otherwise beneficial treatment.”

However, “since the review is based on a small sample, a low risk of psychosis exacerbation after IV ketamine is still possible,” said Dr. Iosifescu, who is also the director of clinical research at the Kline Institute for Psychiatric Research in Orangeburg, New York, and was not involved with the study.

Dr. Veraart agreed, adding that the “efficacy, safety, and tolerability of ketamine in depressed patients with a vulnerability to psychosis should be investigated in well-designed randomized controlled trials before application on a large scale is promoted.”

The study had no specific funding. Dr. Veraart has received speaker honoraria from Janssen outside of the submitted work. The other authors’ disclosures are listed in the original article. Dr. Iosifescu has been a consultant to the Centers of Psychiatric Excellence, advising clinics on the best methods of providing treatment with IV ketamine.

A version of this article first appeared on Medscape.com.

Black individuals who received mental health services through a church-based program reported high levels of satisfaction, data from a small, qualitative study show.

“This model of providing mental health services adjacent to or supported by a trusted institution, with providers who may have a more nuanced and intimate knowledge of the experiences of and perceptions held by community members, may facilitate important therapy-mediating factors, such as trust,” wrote Angela Coombs, MD, of Columbia University, New York, and colleagues.

Black Americans continue to face barriers to mental health services, and fewer than one-third of Black Americans with a mental health condition receive formal mental health care, Dr. Coombs and colleagues reported. Barriers to treatment include stigma and distrust of medical institutions, and strategies are needed to address these barriers to improve access. Consequently, “one approach includes the development of mental health programming and supports with trusted institutions, such as churches,” they said. Data are limited, however, on the perspectives of individuals who have used church-based services.

In the study, published in Psychiatric Services, Dr. Coombs and colleagues recruited 15 adults aged 27-69 years who were receiving or had received mental health services at the HOPE (Healing On Purpose and Evolving) Center, a freestanding mental health clinic affiliated with the First Corinthian Baptist Church in Harlem, New York. At the time of the study in 2019, those attending the center (referred to as “innovators” rather than patients or clients to reduce stigma) received 10 free sessions of evidence-based psychotherapy.

Treatment included cognitive-behavioral therapy (CBT), religiously integrated CBT, and interpersonal psychotherapy (IPT) to individuals, couples, and families. Group psychotherapy also was an option. Clinicians at the HOPE Center included licensed social workers with doctoral and master’s-level degrees, as well as supervised social work student interns.

Study participants took part in a 30-minute interview, in person or by phone, with a female psychiatrist who was not employed by the HOPE Center or involved in treating the patients. There were 15 participants: 13 women and 2 men, with mean ages of 48 and 51 years, respectively; 14 identified as Black, non-Hispanic. Most (13 individuals) identified as heterosexual, 11 had never married, and 14 had some college or technical school education.

Notably, 11 participants reported attending church once a week, and 13 said they considered religion or spirituality highly important. Participants “reported that services that could integrate their spiritual beliefs with their current mental health challenges enhanced the therapeutic experience,” the researchers said.

Positive messaging about mental health care from the church and senior pastor also encouraged the participants to take advantage of the HOPE Center services.

As one participant said, “I’ve always believed that I can handle my own issues ... but listening to the pastor always talking about the [HOPE] Center and not to be ashamed if you have weaknesses, that’s when I said, ‘You know what, let me just start seeking mental health services because I really need [them].’ ”

Overall, study participants said that they learned skills during their therapy that they could apply in daily life, including recognizing cycles of unproductive behavior, processing traumatic experiences and learning self-love, and embracing meditation at home.

“A common theme among participants was that the HOPE Center provided them with tools to destress, process trauma, and manage anxiety,” the researchers wrote. In particular, several participants cited group sessions on teaching and practicing mindfulness as their favorite services. They described the HOPE Center as a positive, peaceful, and welcoming environment where they felt safe.

Cost issues were important as well. Participants noted that the HOPE Center’s ability to provide services that were free made it easier for them to attend. “Although participants said that it was helpful that the HOPE Center provided referrals to external providers and agencies for additional services, some said they wished that the HOPE Center would provide long-term therapy,” the researchers noted.

Overall, “most participants said that establishing more mental health resources within faith-based spaces could accelerate normalization of seeking and receiving mental health care within religious Black communities,” they said.

The study findings were limited by the absence of clinical data – and data on participants’ frequency and location of church attendance, the researchers noted. In addition, the positive results could be tied to selection bias, Dr. Coombs and colleagues said. Another possible limitation is the overrepresentation of cisgender women among the participants. Still, “the perspectives shared by participants suggest that this model of care may address several important barriers to care faced by some Black American populations,” the researchers wrote.
 

Bridging gap between spirituality and mental health

In an interview, Atasha Jordan, MD, said Black Americans with mental illnesses have long lacked equal access to mental health services. “However, in light of the COVID-19 pandemic, published studies have shown that rates of mental illness increased concurrently with a rise in spirituality and faith. That said, we currently live in a time where mental health and spirituality are more likely to intersect,” noted Dr. Jordan, of the University of Pennsylvania, Philadelphia.

She said it is not surprising that the study participants felt more comfortable receiving mental health services at a clinic that was church affiliated.

“We have known for years that people of faith are more likely to seek comfort for psychological distress from clergy, rather than mental health professionals. Providing a more familiar entry point to mental health services through a church-affiliated mental health clinic helps to bridge the existing gap between spirituality and mental health,” Dr. Jordan said. “For many Black Americans, spirituality is a central component of culturally-informed mental health care.

“Mental health providers may find improved service utilization and outcomes for their patients by collaborating with faith-based organizations or investing time to learn spiritually-based psychotherapies.”

Recently published data, notably a study published May 1, 2021, in Psychiatric Services, continue to support the existing knowledge “that many patients with psychiatric illnesses want increased attention paid to spirituality during their mental health care,” Dr. Jordan noted. “Moreover, they showed that nonreligious clinicians may be more apt than religious clinicians to provide objective, spiritually-oriented mental health care. In this vein, further research aimed at understanding the most effective methods to address spiritual health in times of mental distress can help all mental health providers better meet their patients’ psychiatric and psychological needs.”
 

Overcoming stigma, mistrust

During the pandemic, clinicians have seen an increase in mental health distress in the form of anxiety, depression, and trauma symptoms, Lorenzo Norris, MD, of George Washington University, Washington, said in an interview.

“Historically, African Americans have faced numerous barriers to mental health care, including stigma and mistrust of medical institutions,” Dr. Norris said. “At this time, perhaps more than in recent decades, novel ways of eliminating and navigating these barriers must be explored in an evidence-based fashion that will inform future interventions.”

Dr. Norris also found that the study findings make sense.

“Historically, the Black church has been a central institution in the community,” he said. “In my personal experience, the church served in a variety of roles, including but not limited to advocacy, employment, social services, peer support, and notably a trusted source of advice pertaining to health. In addition, Black churches may be in an ideal position to serve as culturally sensitive facilitators to build trust,” he said.

The study’s message for clinicians, according to Dr. Norris, is to “carefully consider partnering with faith-based organizations and community leaders if you want to supplement your efforts at decreasing mental health care disparities in the African American community.”

He pointed out, however, that in addition to the small number of participants, the study did not examine clinical outcomes. “So we must be careful how much we take from the initial conclusions,” Dr. Norris said.

Additional research is needed on a much larger scale to add support to the study findings, he said. “This study focused on one church and its particular program,” Dr. Norris noted. “There is likely a great deal of heterogeneity with Black churches and definitely among church members they serve,” he said. “Although it may be tempting to go with an ‘of course it will work’ approach, it is best to have additional qualitative and quantitative research of a much larger scale, with clinical controls that examine the ability of Black churches to address barriers African Americans face in receiving and utilizing mental health services,” he concluded.

Dr. Jordan disclosed receiving a 2021-2022 American Psychiatric Association/Substance Abuse and Mental Health Services Administration Minority Fellowship Program grant to study mental health literacy in the Black church. Dr. Norris disclosed serving as CEO of the Cleveland Clergy Alliance, a nonprofit organization providing outreach assistance as a mechanism to help seniors and the disabled population through community programming. The study authors reported no disclosures.

Black individuals who received mental health services through a church-based program reported high levels of satisfaction, data from a small, qualitative study show.

“This model of providing mental health services adjacent to or supported by a trusted institution, with providers who may have a more nuanced and intimate knowledge of the experiences of and perceptions held by community members, may facilitate important therapy-mediating factors, such as trust,” wrote Angela Coombs, MD, of Columbia University, New York, and colleagues.

Black Americans continue to face barriers to mental health services, and fewer than one-third of Black Americans with a mental health condition receive formal mental health care, Dr. Coombs and colleagues reported. Barriers to treatment include stigma and distrust of medical institutions, and strategies are needed to address these barriers to improve access. Consequently, “one approach includes the development of mental health programming and supports with trusted institutions, such as churches,” they said. Data are limited, however, on the perspectives of individuals who have used church-based services.

In the study, published in Psychiatric Services, Dr. Coombs and colleagues recruited 15 adults aged 27-69 years who were receiving or had received mental health services at the HOPE (Healing On Purpose and Evolving) Center, a freestanding mental health clinic affiliated with the First Corinthian Baptist Church in Harlem, New York. At the time of the study in 2019, those attending the center (referred to as “innovators” rather than patients or clients to reduce stigma) received 10 free sessions of evidence-based psychotherapy.

Treatment included cognitive-behavioral therapy (CBT), religiously integrated CBT, and interpersonal psychotherapy (IPT) to individuals, couples, and families. Group psychotherapy also was an option. Clinicians at the HOPE Center included licensed social workers with doctoral and master’s-level degrees, as well as supervised social work student interns.

Study participants took part in a 30-minute interview, in person or by phone, with a female psychiatrist who was not employed by the HOPE Center or involved in treating the patients. There were 15 participants: 13 women and 2 men, with mean ages of 48 and 51 years, respectively; 14 identified as Black, non-Hispanic. Most (13 individuals) identified as heterosexual, 11 had never married, and 14 had some college or technical school education.

Notably, 11 participants reported attending church once a week, and 13 said they considered religion or spirituality highly important. Participants “reported that services that could integrate their spiritual beliefs with their current mental health challenges enhanced the therapeutic experience,” the researchers said.

Positive messaging about mental health care from the church and senior pastor also encouraged the participants to take advantage of the HOPE Center services.

As one participant said, “I’ve always believed that I can handle my own issues ... but listening to the pastor always talking about the [HOPE] Center and not to be ashamed if you have weaknesses, that’s when I said, ‘You know what, let me just start seeking mental health services because I really need [them].’ ”

Overall, study participants said that they learned skills during their therapy that they could apply in daily life, including recognizing cycles of unproductive behavior, processing traumatic experiences and learning self-love, and embracing meditation at home.

“A common theme among participants was that the HOPE Center provided them with tools to destress, process trauma, and manage anxiety,” the researchers wrote. In particular, several participants cited group sessions on teaching and practicing mindfulness as their favorite services. They described the HOPE Center as a positive, peaceful, and welcoming environment where they felt safe.

Cost issues were important as well. Participants noted that the HOPE Center’s ability to provide services that were free made it easier for them to attend. “Although participants said that it was helpful that the HOPE Center provided referrals to external providers and agencies for additional services, some said they wished that the HOPE Center would provide long-term therapy,” the researchers noted.

Overall, “most participants said that establishing more mental health resources within faith-based spaces could accelerate normalization of seeking and receiving mental health care within religious Black communities,” they said.

The study findings were limited by the absence of clinical data – and data on participants’ frequency and location of church attendance, the researchers noted. In addition, the positive results could be tied to selection bias, Dr. Coombs and colleagues said. Another possible limitation is the overrepresentation of cisgender women among the participants. Still, “the perspectives shared by participants suggest that this model of care may address several important barriers to care faced by some Black American populations,” the researchers wrote.
 

Bridging gap between spirituality and mental health

In an interview, Atasha Jordan, MD, said Black Americans with mental illnesses have long lacked equal access to mental health services. “However, in light of the COVID-19 pandemic, published studies have shown that rates of mental illness increased concurrently with a rise in spirituality and faith. That said, we currently live in a time where mental health and spirituality are more likely to intersect,” noted Dr. Jordan, of the University of Pennsylvania, Philadelphia.

She said it is not surprising that the study participants felt more comfortable receiving mental health services at a clinic that was church affiliated.

“We have known for years that people of faith are more likely to seek comfort for psychological distress from clergy, rather than mental health professionals. Providing a more familiar entry point to mental health services through a church-affiliated mental health clinic helps to bridge the existing gap between spirituality and mental health,” Dr. Jordan said. “For many Black Americans, spirituality is a central component of culturally-informed mental health care.

“Mental health providers may find improved service utilization and outcomes for their patients by collaborating with faith-based organizations or investing time to learn spiritually-based psychotherapies.”

Recently published data, notably a study published May 1, 2021, in Psychiatric Services, continue to support the existing knowledge “that many patients with psychiatric illnesses want increased attention paid to spirituality during their mental health care,” Dr. Jordan noted. “Moreover, they showed that nonreligious clinicians may be more apt than religious clinicians to provide objective, spiritually-oriented mental health care. In this vein, further research aimed at understanding the most effective methods to address spiritual health in times of mental distress can help all mental health providers better meet their patients’ psychiatric and psychological needs.”
 

Overcoming stigma, mistrust

During the pandemic, clinicians have seen an increase in mental health distress in the form of anxiety, depression, and trauma symptoms, Lorenzo Norris, MD, of George Washington University, Washington, said in an interview.

“Historically, African Americans have faced numerous barriers to mental health care, including stigma and mistrust of medical institutions,” Dr. Norris said. “At this time, perhaps more than in recent decades, novel ways of eliminating and navigating these barriers must be explored in an evidence-based fashion that will inform future interventions.”

Dr. Norris also found that the study findings make sense.

“Historically, the Black church has been a central institution in the community,” he said. “In my personal experience, the church served in a variety of roles, including but not limited to advocacy, employment, social services, peer support, and notably a trusted source of advice pertaining to health. In addition, Black churches may be in an ideal position to serve as culturally sensitive facilitators to build trust,” he said.

The study’s message for clinicians, according to Dr. Norris, is to “carefully consider partnering with faith-based organizations and community leaders if you want to supplement your efforts at decreasing mental health care disparities in the African American community.”

He pointed out, however, that in addition to the small number of participants, the study did not examine clinical outcomes. “So we must be careful how much we take from the initial conclusions,” Dr. Norris said.

Additional research is needed on a much larger scale to add support to the study findings, he said. “This study focused on one church and its particular program,” Dr. Norris noted. “There is likely a great deal of heterogeneity with Black churches and definitely among church members they serve,” he said. “Although it may be tempting to go with an ‘of course it will work’ approach, it is best to have additional qualitative and quantitative research of a much larger scale, with clinical controls that examine the ability of Black churches to address barriers African Americans face in receiving and utilizing mental health services,” he concluded.

Dr. Jordan disclosed receiving a 2021-2022 American Psychiatric Association/Substance Abuse and Mental Health Services Administration Minority Fellowship Program grant to study mental health literacy in the Black church. Dr. Norris disclosed serving as CEO of the Cleveland Clergy Alliance, a nonprofit organization providing outreach assistance as a mechanism to help seniors and the disabled population through community programming. The study authors reported no disclosures.

Black individuals who received mental health services through a church-based program reported high levels of satisfaction, data from a small, qualitative study show.

“This model of providing mental health services adjacent to or supported by a trusted institution, with providers who may have a more nuanced and intimate knowledge of the experiences of and perceptions held by community members, may facilitate important therapy-mediating factors, such as trust,” wrote Angela Coombs, MD, of Columbia University, New York, and colleagues.

Black Americans continue to face barriers to mental health services, and fewer than one-third of Black Americans with a mental health condition receive formal mental health care, Dr. Coombs and colleagues reported. Barriers to treatment include stigma and distrust of medical institutions, and strategies are needed to address these barriers to improve access. Consequently, “one approach includes the development of mental health programming and supports with trusted institutions, such as churches,” they said. Data are limited, however, on the perspectives of individuals who have used church-based services.

In the study, published in Psychiatric Services, Dr. Coombs and colleagues recruited 15 adults aged 27-69 years who were receiving or had received mental health services at the HOPE (Healing On Purpose and Evolving) Center, a freestanding mental health clinic affiliated with the First Corinthian Baptist Church in Harlem, New York. At the time of the study in 2019, those attending the center (referred to as “innovators” rather than patients or clients to reduce stigma) received 10 free sessions of evidence-based psychotherapy.

Treatment included cognitive-behavioral therapy (CBT), religiously integrated CBT, and interpersonal psychotherapy (IPT) to individuals, couples, and families. Group psychotherapy also was an option. Clinicians at the HOPE Center included licensed social workers with doctoral and master’s-level degrees, as well as supervised social work student interns.

Study participants took part in a 30-minute interview, in person or by phone, with a female psychiatrist who was not employed by the HOPE Center or involved in treating the patients. There were 15 participants: 13 women and 2 men, with mean ages of 48 and 51 years, respectively; 14 identified as Black, non-Hispanic. Most (13 individuals) identified as heterosexual, 11 had never married, and 14 had some college or technical school education.

Notably, 11 participants reported attending church once a week, and 13 said they considered religion or spirituality highly important. Participants “reported that services that could integrate their spiritual beliefs with their current mental health challenges enhanced the therapeutic experience,” the researchers said.

Positive messaging about mental health care from the church and senior pastor also encouraged the participants to take advantage of the HOPE Center services.

As one participant said, “I’ve always believed that I can handle my own issues ... but listening to the pastor always talking about the [HOPE] Center and not to be ashamed if you have weaknesses, that’s when I said, ‘You know what, let me just start seeking mental health services because I really need [them].’ ”

Overall, study participants said that they learned skills during their therapy that they could apply in daily life, including recognizing cycles of unproductive behavior, processing traumatic experiences and learning self-love, and embracing meditation at home.

“A common theme among participants was that the HOPE Center provided them with tools to destress, process trauma, and manage anxiety,” the researchers wrote. In particular, several participants cited group sessions on teaching and practicing mindfulness as their favorite services. They described the HOPE Center as a positive, peaceful, and welcoming environment where they felt safe.

Cost issues were important as well. Participants noted that the HOPE Center’s ability to provide services that were free made it easier for them to attend. “Although participants said that it was helpful that the HOPE Center provided referrals to external providers and agencies for additional services, some said they wished that the HOPE Center would provide long-term therapy,” the researchers noted.

Overall, “most participants said that establishing more mental health resources within faith-based spaces could accelerate normalization of seeking and receiving mental health care within religious Black communities,” they said.

The study findings were limited by the absence of clinical data – and data on participants’ frequency and location of church attendance, the researchers noted. In addition, the positive results could be tied to selection bias, Dr. Coombs and colleagues said. Another possible limitation is the overrepresentation of cisgender women among the participants. Still, “the perspectives shared by participants suggest that this model of care may address several important barriers to care faced by some Black American populations,” the researchers wrote.
 

Bridging gap between spirituality and mental health

In an interview, Atasha Jordan, MD, said Black Americans with mental illnesses have long lacked equal access to mental health services. “However, in light of the COVID-19 pandemic, published studies have shown that rates of mental illness increased concurrently with a rise in spirituality and faith. That said, we currently live in a time where mental health and spirituality are more likely to intersect,” noted Dr. Jordan, of the University of Pennsylvania, Philadelphia.

She said it is not surprising that the study participants felt more comfortable receiving mental health services at a clinic that was church affiliated.

“We have known for years that people of faith are more likely to seek comfort for psychological distress from clergy, rather than mental health professionals. Providing a more familiar entry point to mental health services through a church-affiliated mental health clinic helps to bridge the existing gap between spirituality and mental health,” Dr. Jordan said. “For many Black Americans, spirituality is a central component of culturally-informed mental health care.

“Mental health providers may find improved service utilization and outcomes for their patients by collaborating with faith-based organizations or investing time to learn spiritually-based psychotherapies.”

Recently published data, notably a study published May 1, 2021, in Psychiatric Services, continue to support the existing knowledge “that many patients with psychiatric illnesses want increased attention paid to spirituality during their mental health care,” Dr. Jordan noted. “Moreover, they showed that nonreligious clinicians may be more apt than religious clinicians to provide objective, spiritually-oriented mental health care. In this vein, further research aimed at understanding the most effective methods to address spiritual health in times of mental distress can help all mental health providers better meet their patients’ psychiatric and psychological needs.”
 

Overcoming stigma, mistrust

During the pandemic, clinicians have seen an increase in mental health distress in the form of anxiety, depression, and trauma symptoms, Lorenzo Norris, MD, of George Washington University, Washington, said in an interview.

“Historically, African Americans have faced numerous barriers to mental health care, including stigma and mistrust of medical institutions,” Dr. Norris said. “At this time, perhaps more than in recent decades, novel ways of eliminating and navigating these barriers must be explored in an evidence-based fashion that will inform future interventions.”

Dr. Norris also found that the study findings make sense.

“Historically, the Black church has been a central institution in the community,” he said. “In my personal experience, the church served in a variety of roles, including but not limited to advocacy, employment, social services, peer support, and notably a trusted source of advice pertaining to health. In addition, Black churches may be in an ideal position to serve as culturally sensitive facilitators to build trust,” he said.

The study’s message for clinicians, according to Dr. Norris, is to “carefully consider partnering with faith-based organizations and community leaders if you want to supplement your efforts at decreasing mental health care disparities in the African American community.”

He pointed out, however, that in addition to the small number of participants, the study did not examine clinical outcomes. “So we must be careful how much we take from the initial conclusions,” Dr. Norris said.

Additional research is needed on a much larger scale to add support to the study findings, he said. “This study focused on one church and its particular program,” Dr. Norris noted. “There is likely a great deal of heterogeneity with Black churches and definitely among church members they serve,” he said. “Although it may be tempting to go with an ‘of course it will work’ approach, it is best to have additional qualitative and quantitative research of a much larger scale, with clinical controls that examine the ability of Black churches to address barriers African Americans face in receiving and utilizing mental health services,” he concluded.

Dr. Jordan disclosed receiving a 2021-2022 American Psychiatric Association/Substance Abuse and Mental Health Services Administration Minority Fellowship Program grant to study mental health literacy in the Black church. Dr. Norris disclosed serving as CEO of the Cleveland Clergy Alliance, a nonprofit organization providing outreach assistance as a mechanism to help seniors and the disabled population through community programming. The study authors reported no disclosures.