Social determinants of mental health across the lifespan

Social determinants of mental health across the lifespan

Thank You Canada and Carl and good morning everybody it’s I’m so pleased to be here and to have the opportunity to talk about what is my favorite subject and the thing that I am most passionate about which is the social determinants of mental health so I think I have a lot to talk about because I’m here to set the stage the overview for the work that you’re going to be doing for the next day and a half and so I want to jump right into it but but I do think it’s a lot to cover and so we will take a little break and ask some questions while we go along this is Emory University Hospital it’s located in Atlanta Georgia I had the great fortune to go to medical school residency and do my fellowship in community psychiatry and get a masters in public health all at Emory University in Atlanta and I grew up in Virginia and I had parents who were immigrants from Jamaica and so moving to Atlanta and moving to this I was in the south but moving further south was a bit of an experience for me Emory is a beautiful beautiful institution it is located in the suburbs of Atlanta it’s located and probably the richest part of Atlanta and so the people who have the most amount of money and the nicest houses live right here where Emory University Hospital is based won one of the great things about Emory and the training that you get there is that you get a mix of working with patients at Emory University Hospital but also working with patients at Grady Hospital which is the large downtown hospital located in downtown Atlanta very different from the hospital at Emory University Hospital so Grady Memorial Hospital is located in the poorest parts of Atlanta and people that there’s a very high homeless population and very few people have access to any sort of care or services so I started noticing something really interesting when I got to medical school but specifically when I started residency because we rotated as residents in the inpatient hospital at Emory University Hospital and we rotated as residence at the inpatient hospital at Grady universe at Grady Memorial Hospital and whenever I had a patient who was admitted to Emory University Hospital for a psychiatric emergency or some type of crisis we would treat that patient we would provide all of the services that we had on that inpatient unit and they would get better and we would discharge them and I’d feel like I’m doing such a great job I’m making a difference this is why I went into this field and whenever I had a patient admitted to the inpatient hospital at Grady Memorial Hospital we would provide all of the same care the exact same care we would treat them I believed in the exact same way we provide all the same services and they did not get better and I could not figure out what was happening there if I’m doing the same thing it’s the same crisis it’s the same illness why is it that some people are improving and and my treatments are working and and why is it that some people are not and so I went on a journey to try and understand that and that’s how we got that’s how I got to looking more at the social determinants of health so let’s go ahead and define them the social determinants of health as defined by the World Health Organization are those factors that impact upon health and well-being and the circumstances into which we are born grow up live work and age including the health system that’s the first part of the definition the second part of the definition which we’re going to expand on more later today is that these circumstances are shaped by the distribution of money power and resources at global national and local levels which are themselves influenced by policy choices and there’s one last piece of the definition that I like to highlight and this gets to again the answer to why my patients at Grady we’re not doing as well as my patients at Emory and that is that the social determinants of health are prominently responsible for the health disparities he’s experienced both within and between countries so that explanation for that difference I found lots of people had tried to understand what is it that leads to inequities what is it that leads to disparities but actually the social determinants of health and the social determinants of mental health are most responsible so I just want to take a minute to define the difference between a health disparity and a health inequity because there’s a lot of confusion around that so health disparities are differences in health status among distinct segments of the population including differences that occur by gender race or ethnicity education or income disability or living in various Geographic locales or other things as well health and equity is a disparity in health that is the result of systemic avoidable and unjust social and economic policies and practices that create barriers to opportunity so the difference between an inequity and a disparity is there’s no real kind of value judgment on a disparity it’s just a difference it’s just a health difference of some kind whereas with a health inequity there is a moral difference there it is the result of systemic avoidable and unjust social economic policies and those policies create barriers to opportunity when I started looking at disparities in mental health reasons why for instance african-american males are more likely to be diagnosed with schizophrenia than white males and white males are more likely to be diagnosed with bipolar disorder when often it’s the same condition or for instance women tend to have higher rates of depression than men or any number of other disparities and there’s a lot of them I really started to understand more clearly that none of these were actually disparities none of these were that the issue was kind of in the seat biologically of the person or the population that these groups were creating these differences but in actuality all of these things were the result of systemic avoidable and unjust social and economic policies and practices that create barriers to opportunity and I think we’re gonna spend some time talking about that a little bit more today as well okay so here’s just an example of how the social determinants of health work and this is an example from Health Canada and part of how to think about the social determinants of health is to think like a toddler and toddlers often ask why a lot so if we’re gonna play the toddler game we can say why is Jason in the hospital because he has a bad infection in his leg but why does he have an infection he has a cut on his leg and it got infected but why does he have a cut on his leg he was playing in his junk yard next to his apartment building and fell on some sharp jagged steel there but why was he playing in a junk yard his neighborhood has run down kids play there and there’s no one to supervise them but why does he live in that neighborhood his parents can’t afford a nicer place to live but why can’t his parents afford a nicer place to live his dad is unemployed and his mom is sick but why is his dad unemployed because he doesn’t have much education and he can’t find a job and so you see you can go on and ask why and why and why over and over and over again and ultimately the real reason that Jason is in the hospital has very little to do with the infection and much more to do with those social circumstances that led him to be in the situation that that resulted in him having that cut so I’m gonna talk about some morbid stuff for a little bit which is def and we’re gonna talk a little bit about what causes people to die early because if we’re thinking about markers of health and even markers of mental health I think it’s really important to look at kind of the ultimate marker of Health which is morbidity I’m sorry mortality so these are the reasons why people die early that could contribute the major contribute to premature death and as you can see there is a piece of that that relates to genetic predisposition so about 30 percent of the reason why people died prematurely has to do with family history has to do with if you have a family member with cancer or with cardiovascular disease you have a higher likelihood of developing that condition 15% has to do with social circumstances and as this as as the authors of this particular study we’re thinking this relates to the social determinants kind of purely as we have to find them so far environmental exposure which makes up 5% are things like exposure to toxins in the environment so so very clear things like pollutants LED other types of toxins in the environmental milieu healthcare makes up 10% and so that includes not being able to access medical care but also medical errors and I think it’s interesting that if we look at this figure that 10% of premature mortality is in the healthcare sector and yet we spend a lot of time and energy and resources trying to improve that particular sector when it’s a very small part of what contributes to premature death and then the overall 40% of the contribution to premature death is behavioral patterns and behavioral patterns are things like do you smoke do you drink do you exercise what’s your diet like those types of things and so if you are thinking about this particular graph and in the way that we think about the social determinants of health I would submit to you that about 70% of this graph is actually social determinants of health because often the behavioral patterns the choices that we seemingly make about whether to smoke or whether to drink or whether to exercise that many of those things are based on our social circumstances and there is a statement that David Williams said that the choices we make are based on the choices we have and so if if you have limited options if you don’t have a safe place to walk in your neighborhood then you’re not going to walk in your neighborhood because it’s not safe and then your physical activity decreases significantly as a result of that so if you think about this I’m saying 70% and I teach medical students and they often are very astute and they’ll say well isn’t there like things like historical trauma that can actually change your genetic makeup and epigenetics and how does that work and and I say well actually you’re right and probably it’s even more than 70% that actually contributes to this this this premature death that we’re talking about that has to do with social determinants so just an example again I said we’ll spend a little bit of time talking about morbidity and mortality this is Washington DC and this is a map that shows differences in life expectancy depending on where you live and this map is actually at the metro station and in DC and I took the Metro this morning and you can see that as on the red line or on the yellow line there’s very different huge gaps and mortality depending on what part of the the small area a very small radius of distance there are huge differences in outcomes so 86 years for Arlington County versus 78 years in District of Columbia proper and this relates to people with mental illness so individuals with serious mental illnesses die on average up to 25 years earlier than the general population and then when you ask well what are they dying of a lot of people think oh well of course suicide and violence and things like that and that is a contributor but that’s actually not the number one reason why people are dying prematurely of serious mental illness they’re actually dying of cardiovascular disease and pulmonary disease and the very same things that everybody else is dying of they’re just dying earlier and we just talked about what is the driver of inequities health inequities that we see in Society and one of the main drivers is the social determinants of health and so it becomes very important when we’re talking about mental illness to focus on the social determinants of mental health as something that may be driving this large mortality gap that we see in patients with serious mental illness and then this is a report that came out in 2001 from the Surgeon General that just highlighted that there is an intersection here between mental health culture race and ethnicity and that racial and ethnic minority groups have less access to and availability of care received poor quality mental health services and experience a greater disability burden from unmet mental health needs so I’ve been dancing around the concept for the last 15 minutes and I might as well just kind of jump right into it and that is the concept of social justice and so social justice is a philosophical term and I did not take any Phylis philosophy classes at any point in my entire career so I’m not necessarily the most that the best person to discuss this philosophical concept but I want to take a minute to define it because it relates to what we’re thinking about when we think about these concepts so the distribution of good or advantages and bad or disadvantages in society and more specifically how these things should be distributed in society so social justice is concerned with the ways that resources are allocated to people by social institutions and this is the definition by David Miller and and if you’re thinking about what we said about what inequities are and what drives mental health inequities we said it had to do with unjust social and economic policies and practices and that really comes down to how we decide who is advantaged in our society and who is not and we make judgments on that as as a society we kind of collectively decide which people are worth advantages and which people are worth receiving good and which people are worth disadvantages being disadvantaged receiving bad and then I’ll add to that definition another definition by job by another philosopher John Rawls who said that social justice is assuring the protection of equal access to liberties rights and opportunities as well as taking care of the least advantaged members of society and oftentimes when we think of people with mental illness and substance use disorders for a variety of reasons which we are going to talk about later today they do in fact end up falling into this category of least advantaged members of society so one more concept around these things that we are discussing is the concept created by kimberlé crenshaw about intersectionality and this idea that you have a clustering of a lot of different [Music] experiences that often come and coexist in one person and and we often don’t think of the complexity of one person we kind of see one person even in medical school I was taught to kind of reduce somebody down to kind of one one individual one concept or one idea the problem with that is there are none of us that don’t have multiple identities multiple cultural identities multiple groups that we feel affiliated or connected to and so when we try to kind of separate those things out or create differences we run into problems and particularly when we think about things like racism and sexism and classism and ableism and I just like to add that for people with serious for people with mental illnesses and for substance use disorders there is a high degree of stigma and often you see a collection for people in particular with mental illnesses and substance use disorders clustering around all of these events and and then ultimately you see those differences those inequities seem to be larger in groups that share that share intersectional intersectional qualities I would say okay so this is a figure by the Robert Wood Johnson Foundation and it is describing the difference between equality and equity and I love this figure because it really just plainly states it here so a lot of times when we think about health care and we think about health care delivery and delivering services to people with mental illnesses we think about fairness we want to make sure everybody has access to treatment we want to make sure everybody gets the same kind of care and that if you’re if you’re striving for that you’re gonna you’re gonna meet the needs of the folks at the top everybody gets the same bicycle the problem is it’s very hard for everybody to get to the same place when when they are what everybody has the same bicycle because everybody has different needs and so the goal here is not to strive for equality the goal is to strive for equity that every person gets the the specific thing that they need to be successful so that everybody gets to the journey together but that there will be different needs for different people okay so Karl already mentioned this but I just want to highlight it again that the social determinants of mental health are not distinctly different from the social determinants of health however they deserve special emphasis because they are highly prevalent highly disabling because behavioral conditions are so high cost so high high in morbidity and mortality and because generally they have largely been neglected in conversations and interventions about social determinants of health and so it’s important that we emphasize these things so this figure is my colleague Michael Compton and my conceptualization of the social determinants of mental health and if you start at the very bottom of this figure this is kind of the things that drive the social determinants these are things like public policies and social norms and we’ll talk a little bit more about that and that leads to unfair and unjust distribution of opportunity which we’ve already discussed that unfair and unjust distribution of opportunity leads to the development of these social determinants of mental health and there’s a few of them here I could spend a minute talking about some of them but for instance adverse early life experience experiences or adverse childhood experiences have been strongly connected to poor poor physical and mental health outcomes for for about twenty years now and the data is very concerning the more child adverse childhood experiences you have the higher your rates of suicide attempts in adulthood and that’s actually on an almost exponential scale so that by the time you have seven or more adverse childhood experiences you have a risk that’s 30 times greater than someone without any adverse childhood experiences of attempting suicide in adulthood discrimination is an extremely strong social determinant of mental health um it actually leads to more problems with mental health and physical health and those problems just the experience of perceiving discrimination can lead to higher rates of major depressive disorder extremely high rates of generalized anxiety disorder increased alcohol use disorder risk as well as a number of other outcomes like poor self rated mental health we do have enough data to know that poverty and income inequality and unemployment and underemployment often do lead to poor outcomes and in mental health and we have a lot of data around homelessness and housing we are getting more data around food insecurity and the fact that people with poor access to food tend to have worse mental health outcomes and particularly for children children who have food insecurity often have higher rates of anxiety and higher rates of behavioral disruption in school so we have epidemic rates of diagnosing children with ADHD and other types of behavioral disruptions in school but often times food insecurity is the driver of those conditions and then the environment kind of quite literally so the the built environment how disordered your neighborhood is the exposure to pollution and climate change we’re starting to see more and more data around how those things lead to poor mental health outcomes ultimately we end up with those social determinants leading to reduced options poor choices again we said the choices we make are based on the choices we have behavioral risk factors physiologic stress responses and psychological stress then that ultimately leads to the adverse mental health outcomes that we see so we’re gonna pause for a second I’ll let that sink in and maybe take a few questions are there any questions so I’d like to just ask ah we do have a question yes thank you very much you mentioned that children with food and secured these have a greater degree of mental health disorders I’m wondering if they have a greater a greater degree of mental health disorders are greater degree of diagnosis and and and I want to emphasize the difference there because sometimes I think that people children are diagnosed with this orders and they’re it’s really more an issue of social determinants yeah that’s a great another yeah biological disorder there are something we can absolutely so that that’s a great question and there’s layers and layers and layers of complexity within that within that question because to answer it properly we have to kind of go deeply into the criteria and the diagnosis of the condition of attention deficit hyperactivity disorder I’m going to just put that to the side for a minute and just say because the the challenge and I think what makes the social determinants of mental health and thinking about psychiatric conditions so much more complicated is the fact that psychiatric conditions are filtered through the lens of society we define them we create them a small group of people kind of sit in a room and create the the DSM that leads to the diagnosis of these conditions so there so there and it’s it’s usually a common language by which to describe something so we can’t say that these are necessarily at least ADHD like a biological disorder but what we can say is that there is a language of behaviors that is used to define a certain aspect of children who are hyperactive and disruptive in class and that often is that language is often ADHD do those do those children have ADHD my thought is is that those children who are food insecure are being disruptive in class and maybe being hyperactive and maybe being anxious and often we are diagnosing that condition without asking about whether somebody has access to food so I so I don’t I don’t I don’t know if I can state whether the illness is greater because that’s not what I’m saying I’m just saying that the behavior is there and the thing about it is is how do we treat attention deficit hyperactivity disorder we give stimulant medication right which is interesting because it’s an appetite suppressant so we’re actually kind of treating a little bit food insecurity when we treat young people with medication is that the right way to solve this problem no probably much easier to go ahead and address the food insecurity and not go down this route so a lot I have a lot to say about this but we we can continue to talk about it more as the day goes on we have another question I just want to piggyback on the last point I’m from Syracuse New York and we’ve got a major analysis we’re doing with community members on gun violence and in the past three years we’ve had among and one year the highest rate of murders in New York State which are concentrated in the poor communities which for us our communities of because of segregation and we did an analysis of the third grade reading and math scores on standardized tests and mapped it onto a map of all the gun shots in a six year period and the lowest scores this is no surprise were in the schools that had the most gun shots around the schools we found out that the teachers when there’s a an active shooter outside the schools because this is neighborhood murders they make the kids climb under their desks and then when the police say that the person was caught they say okay come on let’s start reading again so obviously that’s part of school failure but also in those schools that have the high have around which there’s the high rate of gunshots there’s the most kids who have what’s called disabilities and when I first looked at that not being a mental health professional I thought oh that might be mobility or vision disabilities but it’s almost all behavioral disabilities they use the Vanderburgh scale in the schools to diagnose kids who have potential ADHD but we’ve talked about it and we think it’s quite likely it’s PTSD mm-hmm absolutely and and in in fact complex PTSD which is a again I said you know the field comes together and makes a determination about conditions but that those those conditions are filtered through the lens of those experts experiences and so if they’re not familiar with the type of experiences that these children have then they’re not going to be able to appropriately define this condition and so there is a lot of movement now to say okay there is this complex PTSD that most that many children in this country face from constant trauma that is a constant exposure to trauma and that we just kind of generally have not acknowledged that and have not the impacts and the mental health impacts of those conditions so so thank you for highlighting that thank you so we’re going to move on there will be a Q&A session at the end okay just a quick check on how much time I have left I don’t have any do I go I do okay good okay okay so I just wanted to take a second to highlight in my last 15 minutes the the piece that drives all of this so the public policies and the social norms and so as I said there is a distribution of opportunity that’s shaped by the laws that we as a society create and also are our own values that the things the values we put on certain people and again it’s interesting that we’ve had these questions we’re focusing on certain children that I think often times as a society these are children that we have kind of as a society written off and said that somehow their lives are not as valuable as other people’s lives and then that results in policies and laws and practices that just kind of perpetuate that that type of situation so the pathologist Rudolph Virchow said that medicine is a social science and politics is nothing else but medicine on a large scale and so when we think about how are we going to address the social determinants of mental health we need to think about public policies and we need to think about laws so a couple of ideas and I think we’re gonna spend the rest of the day and tomorrow thinking more deeply about what we cat we all can do but I think one of the most important things is to start thinking outside of the medical structure so outside of the formal mental healthcare system and again I could give another hour long discussion about the problems with with our current mental healthcare system but that is not this talk for today and so instead I would just say that some of the solutions may lie many of the solutions lie outside of the of the mental health care system and the formalized mental healthcare system that we have in society so starting to think about moving our interventions and while we still need good public mental health interventions we also need to be able to think about interventions that happen outside in communities in neighborhoods and then all of us have a responsibility to advocate for policies that increase or improve all of these social determinants that we’re talking about and another quote by David Williams excuse me is that all policies our health policies and we can extend that out to all health policies our mental health policies and so when you think about it all policies are mental health policies so when we’re talking about education policy or employment policy or housing policies neighborhood zoning laws all of those things have an impact on mental health and yet we don’t always consider what that impact is before we have Act laws so before we enact policies so it becomes very important for all of us both in kind of our own communities but also on on state and on national levels to start thinking about how these policies how we can help shape policies that really start to address these issues and related to that I think it’s really important to get political these are these are political issues and and if you really want to move the needle on social determinants of mental health it requires developing relationships with elected officials or using your organization’s to connect with people around policies and laws and then the most important thing I think is forming cross-sector collaboration so I often find that there are particularly in my profession a lot of psychiatrists that tend to kind of want to stay in their group and build work within the field of Psychiatry and I think that’s one of the the least effective ways to make important strides and addressing social determinants of mental health because I think psychiatrists have to work with police officers and teachers and lawyers and people in the community and and probably every possible group that you can think of city planners and and every possible group in order to start thinking about this and you have examples of communities where success has happened in this place and so just I was just in Atlanta two weeks ago and had the the good fortune to tour a purpose-built community in East Lake Atlanta which really brought a lot of people from multiple sectors to design a neighborhood and take a neighborhood that had had failing school outcomes and the highest crime rates and and lots of homelessness and really turned that school at turned that neighborhood around dramatically to one of the top schools in in the state people are healthier and and safer and social determinants of mental health have improved dramatically in in that neighborhood so this is data from the American Public Health Association when we talk about policies so so a couple of things we say policies not programs we say a lot of people are thinking what is the program that I can I can do that will improve these things but really it’s not necessarily as a program it’s about laws and if you look at those countries that spend more money on social care programs compared to health care spending so things like education retirement benefits housing assistance employments programs disability benefits and food security if you invest in those things at a higher rate that you do your health care spending people live longer and do better from a health perspective so again if you’re if you if you’re using the marker of life expectancy we as a country are not investing in our social care programs the way that we need to be if we’re wanting to improve health outcomes and then the United States is the only developed country that spends actually the only country that spends more treating health issues versus more on social care and you can see our health outcomes compared to other countries and I would just add that prevention programs only get about 3 percent of US healthcare dollars so then the the last part of this piece is changing social norms and and you know the public policy part I kind of feel like that’s the easy one probably it’s not especially these days but it feels like it’s the easy one changing social norms is hard changing how people value each other how we feel about each other changing and trying to think kind of above maybe our nature and and thinking about how we can connect with people and and include people in society is much more difficult so first we have to create social norms of tolerance acceptance and inclusion and we have not done a good job of that traditionally we have examples upon examples of even in our current day of how we do really great a great job of excluding people socially from from society and so part of that work to build on that is to partner with communities and emphasize inclusion and mutual respect a last piece related to this is that to change norms we have to educate and legislate so some people exclude because they just don’t know because of ignorance and and those people need to be educated some people exclude because of hate and because of other kind of ingrained in grown ingrained qualities that cannot be educated away and for those people we need the laws and policies to help kind of adjust their impact in our society and then finally we need to cultivate a culture of social inclusion and most importantly speak up when this culture is not respected so I have I have started to notice that there are times when people are being exclusive exclusionary racist sexist homophobic transphobic any number of those things and a good people are sitting there as bystanders watching it happen and not saying anything and I think it’s on all of us to be the person that speaks up in those situations and so I will leave you with this quote from Audrey Lord when we speak we are afraid our words will not be heard or welcomed but when we are silent we are still afraid so it is better to speak thank you are there questions I just had a comment dr. Jim going back to the prevalence piece I and I think this relates to the social determinants of mental health and why we’re meeting today because we know in a lot of mental health disorders we could identify those disorders with tests like F MRIs or with genetics we could also even in some cases simply an EEG identify ADHD or autism but we don’t do those tests the standard diagnosis for diagnostic process for ADHD is a rating scale where you ask parents questions or observe a child and I think that speaks to the lack of attention we give and the lack of financial resource we give to mental health and I just wondered what your thoughts were about that yeah I tend to agree I think it’s really complicated so there are some diagnoses where you can do some type of biological tests to come close to a diagnosis but but then there’s others where there there’s not enough specificity in the test to be able to be certain of that diagnosis so for instance schizophrenia there are brain changes that happen when somebody has schizophrenia and and actually it’s interesting because those brain changes are different some of them happen at birth and some of them happen as people get older before they have symptoms some of them happen when actively they’re having symptoms but but there are nonspecific changes so there’s no like scan that we can do of somebody’s brain with schizophrenia and say this is this is this is schizophrenic I can look at this and in the way that we can look at Alzheimer’s dementia and we can find you know actual neural fibers tangles for getting outside of my expertise but you can find you know actual evidence there is no evidence and a lot of people are working very very hard to get there and so we’re moving in that direction one of my fears though is that as we move in that direction there is a huge push in mental health to to biology’s mental illness and I think that’s helpful in some respects because it leads to decreased stigma and all of that but it’s also really problematic when you biologies a condition that is so conditions that are so predicated on how we interact in our society how we connect with other people which is what many mental illnesses that the impact that many mental illnesses have it’s how we move through society and I think that in in moving towards this biological perspective we’ve often come we’ve we’ve moved away from understanding how social factors and social circumstances have also contributed and how much impact they have on the development of mental illnesses as well oops sorry I’ve got my back to you but I got a second time so in a former life I’m I worked with a lot of individuals living in our community with chronic disabilities for example posed spinal cord injury from 20 years ago in an urban environment and what always struck me was when those individuals because of our education system and the way we silo how we deal with conditions when somebody with say a 20 year-old spinal cord injury was demonstrating symptoms of depression the Assumption by the providers was always well that’s due to their spinal cord injury right yet these individuals are living in public housing in an urban environment there are so many other issues so the immediate response was medication like nobody was thinking about that and I was struck by the example you gave him the school system but there are so many examples of that of individuals living with chronic disabilities in our community that we’re the assumptions being made and then I believe the way in which were educated in the first place I totally agree thank you for bringing up this question because disabilities is a really important piece when we talk about again the least advantaged members of our society and that idea of kind of who we place value on again as a society collectively we have decided to put less value on people with disabilities and so you see this interesting pattern so the way you’ve described that almost is exactly the way people educated people people I care about talk about people with serious mental illnesses they will say things like so for many years people with serious mental illness part of part of the reason why I think people with mental illness die early has to do with very very high rates of cigarette smoking and for many many years there was this idea that you could not when people would come into a psychiatric hospital you would not say oh this is a non-smoking facility like most hospitals because there was this thought that people with serious mental illness have such miserable lives that the only like piece of happiness that they have is to be able to smoke a cigarette and so would you deny them the one good thing in their life this thing that is very you know bad for their health would you deny them that thing and and to think about somebody in that like to have a perspective of a person that think the only thing that matters and in their life to kind of reduce somebody to the concept that their life has such little meaning when actually when interacting with people with serious mental illness it’s obvious that their lives have lots of great meaning and lots of value and most people don’t always do that and I think we do the same thing for people with disabilities we say oh they must live very miserable lives and so and and you know of course they would be depressed right of course so what are you gonna do about it really it’s and I feel we do that for a lot of mental health conditions well what can you do they live horrible lives so it’s a really depressing note to end on so maybe we’ll maybe maybe and we’re actually just at the top of the hour one quick question and hopefully we’ll end on it as you would like a positive happy question I do have a question I’m Tracy Morehead and I’m with the American Association opposed to queue care nursing we represent over twenty thousand nurses nationwide who are certified directors of nursing services social workers therapy speech and occupational therapists as well in post acute and long-term care we are very focused on developing continuing education that takes into account person-centered care including specifically now we’re working on trauma-informed care particularly to address some of the policy issues that you recognized I thank you so much for your comments particularly about children because obviously that does affect the lifespan and the elderly population that our members primarily serve who are by and large Medicaid recipients that payer population has a significantly higher incidence of mental illness as well and I would just thank this forum for the work that you’re doing but also encourage you to consider the role of continuing education providers such as a packet and the many other organizations out there we are your partners and we are here to help those practitioners who are in the field continue to incorporate new learning opportunities into their day-to-day practices and health care delivery so thank you for that thank you thank you please join me in thanking dr. Shen [Applause]

Ruth Shim, University of California, Davis