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    Transcript for The Case for Bringing Your Mental Health to Work


    DAVID J. SKORTON, MD: To our listeners and viewers, I just wanted to mention that on this episode of “Beyond the White Coat,” we’re going to be talking about some difficult issues related to mental health, including suicide. I just want you to be aware of that as you think about joining us. Thank you.

    RACHEL BUNN: Welcome back to “Beyond the White Coat” where we convene authentic conversations between members of the academic medical community, AAMC leaders, other health professionals, and other experts on timely issues. I’m your producer this week, Rachel Bunn.

    This week, we’re talking about the stigma that surrounds mental health care in the medical community and how it can be vitally important to treat patients. As always, I’m joined by our host and CEO, Dr. David Skorton. David, I was Googling you the other day, and I saw on Wikipedia that you actually have a bachelor’s degree in psychology. Do you think having that background in psychology affected how you treat your patients?

    SKORTON: Well, Rachel, I’ll tell you the truth. I was very undecided in college. I was an undecided major for two years. I was proud. I had a T-shirt that said, I’m undecided and I’m proud. And the third year, they forced you to declare a major so that you could continue your registration. And so, I picked the most general major that I could think of that had, you know, some parts of social sciences, some parts humanities, some parts of biological sciences. And that’s how I did it. So, as you know, Rachel, I had a funny nonlinear career path, and that was the beginning of it. But thanks for trying to make me seem more organized than I really am.

    BUNN: We’re all disorganized, so don’t ... yeah. But with that, I think this is going to be a really great conversation with our guests about just their backgrounds, their careers, and how they are both tackling this issue. So, with that, I will introduce our guest this week. We have Dr. Yunyu Xiao, who is an assistant professor of population health sciences in the health informatics division of the Department of Population Health Sciences at Weill Cornell Medicine. Joining us too is Dr. Justin Bullock, who is a fellow in nephrology at the University of Washington School of Medicine. We’re excited to have both of you join us today. And with that, David, I’m gonna turn it back over to you.

    SKORTON: Thanks, Rachel. Welcome, everybody, to another episode of “Beyond the White Coat.” And Dr. Xiao and Dr. Bullock, it’s a great honor to have you here today. I’m very excited to talk about this. Why am I excited? Because I’ve thought for a long time, as a doc and just as another person, that we have a hill to climb in terms of mental health in the country at large, in the world at large, and in the medicine community.

    So, what I’d like to start out is asking each of you to tell our listeners and viewers a little bit about your background and about what you think about that question — How are we doing in the medical community about mental health? Are we doing a good job? Are we missing the mark? Where do you think we are on our collective journey? And Dr. Xiao, we’ll start with you, please.

    YUNYU XIAO, PHD: Sure. Thank you, David, for inviting me. And I am actually, my career is also like you, it's very nonlinear. I actually got very interested in mental health during the last year of my undergraduate. And believe it or not, my undergraduate, it was majored in political science. And it was, and also I had econometrics, like minor degrees. And back to then, one and year two, my dream job is to become a UN ambassador and then to be the lobbyist or to be at the negotiations tables and talking about like security assemblies and how to help with children living in poverty.

    But in my last year, I recognized that there, when I was preparing my thesis, I found that in China, there was like, there hasn't been a mental health laws and mental health policies implemented and especially for people who were diagnosed with severe mental illnesses when they are sent to the hospitals and afterwards, there is no kind of like rehabilitations systems established. So that got me very interested in how these structure factors, policy factors, could be associated with different domains and help with people who are suffering from mental health.

    So then when I'm doing my master's degree, I shifted to the degree of social work, where we are constantly very interested in how community-based social workers and also how social workers can bridge the gap between the hospitals and individual level of care. And then I got very interested in how to use data to illustrate why it is important because we find that there has been increasing need and demand of data and data-driven evidence. And also, right now in this year or so, we have been also seeing a lot of growth of available data from all sorts of domains, like from the hospitals, from the communities, social determinants of health, social media, mobile phones like passive monitoring, everything can be implemented and also encoded as data. So then when I was doing my PhD, I became a PhD student in social work. But then at that time I have been really digging into this data science subject, and that established my field of linking the data science and social science together to study the social determinants of health regarding mental health.

    So that's why I think that this episode's topic really attracts my interest because one of my recent research really finds that although we have been advocating for reducing stigma of mental health, and particularly my area in suicide prevention, we haven't done a really good job in terms of reaching out and to do the public awareness. Like there are still a lot of stigma and the stigma is also unequally distributed among certain amounts of subgroups among the populations, such as the racial and ethnic minorities, immigrants, and as well as today's topics about the health care workers.

    Just two weeks ago, we were analyzing the data among people who died by suicide and divided by different kinds of essential workers, including the health care workers. And we did find that comparing with non-health care workers, health care workers have almost doubled or tripled of this suicide risk, and depending on whether they are physicians or nurses. And both of them are facing a lot of stigmas, and they are not having a high risk of seeking help. And in the meanwhile, we also find that these populations have better access, has more access to like medications or drugs, and they tend to reduce their stress over it. So, I think this is a continuous topic and it needs a holistic solution to address it. So, I really look forward to talk and this dialogue with you as well as Dr. Bullock.

    SKORTON: Thanks so much, Dr. Xiao. Dr. Bullock, a little bit about your background, if you don't mind, and what you think about where we are as a health care community regarding mental health.

    JUSTIN BULLOCK, MD, MPH: Thank you, also David, for inviting me. Thank you, Dr. Xiao, for starting us off. So, first of all, my background — So I'm originally from Detroit, Michigan. I went to MIT for college. I'm a former runner, kind of competitive runner. I'm still trying to run, but a lot more slowly now. And then did medical school and residency at UCSF. And now I'm a nephrology fellow at the University of Washington.

    And my sort of connection to this topic of mental illness and suicidality in medicine very much comes from my lived experience as someone who lived with bipolar disorder, and specifically someone who is visible with bipolar disorder within medicine. And, you know, it's something that I've become very passionate about both because it affects myself very intimately. But also, as I've had the opportunity to speak and write and talk and connect with people, I found there are so many people within medicine who live with mental illness, and particularly so many of whom do so sort of in the shadows, in the darkness, kind of hiding.

    And I think that relates to my second question, which is, how are we doing within medicine? And I would say my perspective depends on the day. But today I would say I think we're doing better than we have done in the past, but I think we are very, very far from a place that to me feels like where we should be. And my two intro reasons for why that is first, I would look at how medicine is doing with mental illness with respect to patients. And I identify as both a patient and a provider. And I found that my lived experience within the mental health system is actually one of a lot of trauma, of feeling very harmed by the system and feeling discouraged for seeking help at times. Not always, certainly. I'm happy to talk more about that as we go. I guess the one point that I'm making about that is I've had times where I've been hospitalized during training. And on Monday, I was writing orders for patients and it was considered a fully functional human society. And on Tuesday, I get hospitalized and I lose all agency and all ability to make any decisions about myself. And that's just a very dramatic contrast that has not always felt great as a patient.

    And then the second, I would say from the lens of the, no, as a provider with mental illness, I think there are efforts that are being made to try to change our relationship to people who live with mental illness or substance use disorders. You know, I think states are changing the licensure questions. This has been a big thing that people have been very afraid of seeking help because they're worried that they might put their license at risk and states are actually changing. And so that to me, that's one sign that things are getting better. But I still think you have a long way to go.

    SKORTON: Thank you both of you. Just a very, very meaningful and I agree with the general consensus that we've made progress but we're nowhere as near where we need to be. Dr. Bullock, I want to tell you that I very much appreciate your sharing your story. I too have a history of mental illness and I'll tell you the circumstance under which I decided to walk past the stigma and talk about it publicly, which I do regularly.

    When I was in my tenure as president of Cornell University, which was, unfortunately, I missed Dr. Xiao. I left before she came. But when I was there on the Ithaca campus, we had one year with six student suicides in one year. And it was very, very traumatic for everyone involved, other students, parents, and you, I'm sure you understand. And we decided that, there was even in that little microcosm, a very strong stigma against coming to the Student Health Service and asking for help or going to a resident's advisor and asking for help. And so, a group of us, mostly grad students, and I made little brief videos in which we told about our own history with mental illness and counseling. And I told them something, I don't remember the exact words, but something like, you know, if it wasn't for going to get help from mental health professionals, I wouldn't be where I am today. I told people what was wrong. I got help and here I am, I got a pretty good job. I'm your president. And I told them, if you learn one thing at Cornell, learn to ask for help. And so, I've been very willing to share my story as well. Partly to show that one can overcome it. And Dr. Bullock, nobody could do that more eloquently in my view than you just did. But also, I think it's important that the more of us in responsible positions as providers, leaders, bureaucrats, whatever it is that do this, the more everybody will understand that we just can't live in the shadows anymore because that's no way to do things better.

    And one more thing that you both may be aware of, my wonderful predecessor at the AAMC, Dr. Darrell Kirch, a very famous academic psychiatrist, had his own lifelong challenges with mental health and wrote a very moving piece in our journal, Academic Medicine. Pretty sure it was in 2021, pretty sure. And to our listeners, if you haven't had a chance to read Dr. Kirch's piece, check it out. Look it up. It goes right along with where the conversation is going today. So, I thank you both for kicking us off in such a fabulous and very, very important way.

    So, staying with the stigma, staying with the stigma topic. What ideas do you have, Dr. Xiao based on data, Dr. Bullock based on experience, and your own academic knowledge — What sort of things should we be doing? And I'd like to separate if we could, somewhat artificially, during the period of training and education, college students, medical students, residents, fellows, and the practicing physician where state medical boards get involved and so on and so forth. So, any thoughts you have about how we could move forward on this is particularly separating the sort of learner part of our professional lifetimes and then the longer part of our professional lifetimes when all that formal learning is done and we're practicing whatever it is that we're doing. Dr. Bullock, maybe you don't want to kick us off on this one.

    BULLOCK: Sure. First, I want to express my gratitude for you sharing and to acknowledge the vulnerability that it takes to be in a position of really significant power and be open and sharing about your own journey and struggle. And I very much believe in the power of disclosure. I've seen myself benefit very deeply from it. I've seen other people benefit from it. I've had many people connect in various ways. I think one of the narratives that I hope to sort of push within medicine is so many people feel afraid of sharing about their own struggles with mental illness until they've made it.

    And this, for me, this is important because first honoring the people who have, like, you know, who have sort of hidden in the shadows for a long time and then finally, you know, made it to a powerful position in some form and then disclosed. I think those people sort of hold open the door for everyone else and take the first step. But I think then what's lost is like this very like unglamorous journey of struggling with mental illness of like, you know, just like you're a lowly resident just like on, you know, on the wards who's suffering. And you look at these people who are, who've done these amazing things and there's this immense like, valley between you and them. And I want to push this like, there's so many people who are just walking around doing their normal job, you know, who are still in training, who are, you know, who are regular people who live with mental illness. And so first for me, that's one thing is like that it's a common thing. It's not like, you don't have to be exceptional for your narrative of mental illness to be worthy. And I think we in society convince ourselves that the only stories that are worthy are those of people who are great. But everyone is great in unique, different ways. So that's the first thing.

    And the second thing I would say is I think my journey of mental illness is one of having to deal with my own internalized ableism of the ways that like I learned from society to look at these parts of myself as bad as weak, you know as less than. And having to become, having to really challenge those things because something that I found is as I became very visible and I'm someone who I'm visible, I try to be visible about my messiness, about like the parts of Justin that are really like Justin hurting himself, Justin like attempting suicide, Justin like struggling and not, no one likes to think of their doctor as someone who struggles, who is like, who maybe is like kind of messy and not like always together every single day of the year. And so, there's this really big like actual personal battle.

    And I feel like you can't fight systems until you've done that work within yourself. Because that stigma, it just comes out naturally through interactions. And so, for me, what that looks like is learning to advocate for the things that I need for myself. And having to push against the feeling bad that I'm going to be a burden, that I need support and help. But actually, just saying that, no, I'm a, there are many people in the world who have bipolar disorder. I can give you statistics, but there are a lot of people in the world. I think 2% is the number that I've heard. So, 1 in 50 people have bipolar disorder. And our society should be able to accommodate those people or be supportive of those people. So that's the first portion. I would say those are the kind of, yeah. I'm happy to give more specific actions that one could take.

    And then on the sort of larger level. I believe that our sort of systems for supporting people who are struggling in various ways come from a very punitive nature. I believe that there is this default to leave of absence. You know, Dr. Lisa Meeks, who's a big disabilities researcher, she always talks about the default to leave of absence, where basically institutions say, you're not doing well, like, go leave. Go get better, and when you're better, come back and we will welcome you. And the problem with this, and sometimes that welcoming whether or not that actually happens, but the problem with this is that, one, it doesn't hold any institutional or structural accountability for the ways that the systems might be contributing to a person with mental illness. So, for me with bipolar disorder, nights are very well documented as a cause of sort of mood dysregulation. And there is, and you know, I would disclose that I have bipolar disorder when I went into training. And early on, until my very last sort of segment of training where I am now, early on, no one ever said, Justin, we know that night's going to be triggering for you. Here are some alternatives that we can sort of work with you, that they proactively do these things. Instead, it's this system where I have to ask for the things that I need as opposed to them being offered. And to me, I would say, we work in health systems and they have like health care providers who are creating these systems. So, we should know that, especially if someone is willing to disclose whatever mental health condition they have, we should proactively be creating, offering them solutions.

    And finally, from the state structural level, I think one of the arguments that's often made around sort of accommodating and supporting people in various ways is this notion that, oh, like in the real world, people can't do that, or people that you won't get this in the real world, once you're out of training, you won't get the support, you're being coddled when you're in training. And what I would say is, if you actually look in practice, people have all sorts of jobs that have all sorts of just like natural accommodations, people take jobs that allow them to like be the most well that they can be, or some people do.

    And so, I think we create this false fixed mindset that you must be able to suffer. If you can't tolerate the suffering, then you're not worthy of being a doctor. And I think that there's no sort of bigger picture of structural accountability for institutions to prevent them from doing things like this.

    SKORTON: Thank you for that and I'm old enough that I remember the days where it was felt to be a badge of courage to be 36 on, 12 off, 36 on, 12 off, 36 on, 12 off and how clearly I remember whispering a little prayer toward the end of that 12 hours where I couldn't really sleep because I was so anxious, I hope I don’t hurt somebody. Because I’m so exhausted. So, it's important. And thank you for mentioning the intersectionality between mental illness that we're talking about and ableism as a general. And programming note, cheap pitch. We do have Dr. Meeks on another episode of “Beyond the White Coat.” So, if everybody would just sign up for “Beyond the White Coat” and make it the first thing they do every day is listen to it, you would also hear from Dr. Meeks. So, thanks, Dr. Bullock. Dr. Xiao. Please tell us your thoughts about this. Thank you.

    XIAO: Yeah, sure, I'd love to. And I really appreciate Dr. Bullock sharing personal experiences, and especially your individual levels of how you feel. Sharing is very important. And as a researcher, I'd love to maybe share some of this, our research results, or maybe from the academic researchers' findings perspective.

    SKORTON: That would be great. Yep.

    XIAO: And especially, as I mentioned that I come up from a background that has integrated different kinds of policies, data-driven analysis, to understand mental health, especially suicide prevention disparities. And for me, I always think about like, for reducing suicide, for reducing the stigma around mental health care, and especially for health care workers, I think we should really do a multifaceted approach. Imagine that there are different circles and from an ecological perspective, then we need to think about the systematic efforts, the community efforts, peer efforts, and also narrowing down to the individual efforts. For example, David, you mentioned that, talking about from a trainee's perspective and then moving to when people become graduated and then study their physicians and nurses of practices jobs. I'm thinking like at the trainee's perspective, it is not too late, it's never too late to really start the education about awareness. I think educational campaigns in schools and in communities can really be helpful.

    Like two weeks ago I just came back from Vienna, which is this World Congress of Psychiatrists, and their government really supports campaigns about raising awareness of mental health importance, mental health stigma. And then to open the discussion about mental health because right now the stigma is really preventing, like the societal stigma will prevent people from seeking help. So, if we can, through these campaigns at the society level, to normalize these issues and to encourage just sharing these experiences, either in person or media or social platforms, can really support these understandings.

    And in Hong Kong, where I previously come from, we also have, for example, we engage celebrities, even, to say there's an open up. You need to open up your thoughts on your struggles and then to share that actually you are never alone. And those kinds of awareness can really encourage seeking help behavior. So that is at the societal level is what we can do.

    And in terms of policies, there are also policies regarding, for example, laws and also like, like legislations to promote like mental health parities to protect even also individuals with mental health conditions from discriminations, right? And also, from also funding for mental health researchers like us to understand — how do we design this mental health treatment and services that can better reach the person who may not actually want it to disclose? Or we do better in terms of the screening as well. One of our research also finds that for people who are suffering from mental health or especially for suicide intent, some of them died from, many of the persons died by suicide, died by their first attempt. And we need to do better in terms of screening and maybe finding out what is the warning signs, especially like beyond like mental health, maybe people suffering from comorbid physical health that is also warning signs. And we should encourage people to, we should encourage everyone to do the screening of their mental health as well as exactly directly talking about, for example, asking, have you ever think about like kill yourself? And those kind of words should be really encouraged to build up this like normalized environment.

    And I also wanted to highlight that narrowing it down from a community level and where everyone right now is actually in the social networks. Like, since I was doing my PhD years ago, I was very interested in social network analysis. My thesis was on social network and suicide prevention. And we did find that, for example, for children, for young adults, their social networks especially tied to their families. And then to the adults, like middle adults, when they are moving to the workplace, having a support group at the workplace can really help like reducing the feelings of isolation and promoting acceptance. So, peer support is very important. And we can see that at Cornell, actually, I've also engaged in some of these peer support groups, learning that actually the peer support group can, not only from a senior to mentors, but also there are people who are in the same rankings. Then they can gather together and to do this, to do group interventions and then to, no, maybe just to gather and to share what do you feel? So having this peer support and a supportive network is very important.

    And then if we are further narrowing down to the individual levels, I think for the individual levels is also to enabling them, to giving them the tools to seek and help. And I'm — during the pandemic, it is a very stressful moment. But from our research, we also find that, using the electronic health records, we find there are increasing rates of telepsychiatric services use. So, we found that also after the increase of telepsychiatry services, it actually sustained even after the pandemic. And I think that is like a bright side of like, right now we have been enabled by the technologies. And so, I think that is a good sign that we can utilize these technologies to further enable and to improve the accessibility of individuals to these tools. And for example, there are also apps that you can do.

    And also, like right now, I think there, instead of just talking about mental illnesses, I think another part is like, especially when we're moving to like, we should move from just talking about mental illnesses to talk about maybe mental wellnesses. And I think in terms of mental wellness, we also have more and more lifestyle interventions that I have been always wanting to improve, to promote that, for example, exercise, diet, and also meditations. Those sort of tools can also help in terms of at the individual levels to improve self-care, especially for health care workers, physicians, nurses, they are actually the ones that care for the others, for the patients. But sometimes we neglect of caring about ourselves. But I think the languages should be framed as like, if the physicians can take care of themselves to emphasize it's like their self-care actually, they are further helping their patients because if they are happy, their patients are also happier.

    And I'd like to end with one of the last points that is also related to research that we have done about shifting the paradigms of studying mental health. There is a study we published in this scientific report saying that actually, we have been spending a lot of time reducing risk factors in terms of suicide interventions. But in that study, we flipped this kind of like normative statement to focusing on protective factors. And then we’re focusing on the term called flourishing. It's kind of like flourishing to help people to learn how to be hopeful, how to in terms of their lifestyles, to talking about how can they thrive and how can they flourish even during a stressful moment. So instead of teaching people how not to die and how not to suffer from mental illnesses, I think flourishing-based and flourishing-focused interventions of mental health or suicide prevention can teach us how to live. And when we change what we think about mental illnesses, these kind of languages, these linguistic changes, can also help us to reduce the stigma and I think that is what it is, what might be very useful for the health care workers field as well.

    SKORTON: Yes. Yeah, thank you so much. Wouldn't it be great if all of us in the health care professions and people in general, wouldn't it be great if we stopped thinking about self-care as some sort of luxury or a crutch that only weak people need or something like that? I mean, it's a necessity of life for sure.

    So, you two being together bring this wonderful combination of data, experience, all kinds of different things. And so, I want to learn from you. It seems to me, it feels to me, like these problems are getting more prevalent. And I don't follow the data carefully. I'm not an expert in the area, but it feels like they're becoming more prevalent both in the general population and in the health care provider population. Is that just my imagination or is there evidence that mental health challenges are getting more and more prevalent? I felt that at first during COVID. But honestly, I felt it before COVID, and I still feel it now. So, what do you think about that? Is this becoming a bigger deal?

    BULLOCK: I have no statistics to cite for you, so I cannot answer your question. But what I would like to highlight, and as Dr. Xiao was talking, was making me reflect. So, the type of research, I'm a medical education researcher and actually study identity and safety related to our identities in the learning environment. And so, I'll get to sort of answering your question. So, the first thing I would say is the process of becoming a health care professional is one of identity formation, where you come in with one identity and you leave with often a different identity, you know, like in sort of medicine, physicians, it's come in as a lay person, you leave as a physician. And this process of identity formation, one, it involves who we are as people coming into medicine and our experiences, our histories, etc. And in medicine, there's this, because it's so intense, you really become very reliant on your social network, often within medicine, and sometimes at the cost of your social network outside of medicine. And as a result, what happens is for many people, being a physician, I'm just gonna stick with physician, but this would apply to any health care professional, becomes so core to one's identity of how they see themselves in the world. And like not being able to be that thing becomes this sort of identity sacrifice that becomes impossible to conceptualize.

    And you all mentioned sort of Cornell, where I was at MIT, it's an institution that also has to really struggle with suicides. And also, when I was at UCSF, that was true as well. And I think what happens, I think there is a very significant identity component because we become, we know ourselves as these people who are sort of like academically achieving, who are aligning to work towards like, you know, very like sort of lofty goals, etc. And I think many people's mental health is worsened when like, their relationship to that identity becomes damaged or threatened in some way. And we know there are people who have died by suicide after not matching. And also, I think there's oftentimes this, for me personally, there's been this inability to step away from medicine. I mentioned this default to leave of absence, so that's what institutions pushing people out. But there's also this personal, inside thing where I feel like I don't wanna take a break because if I take a break, then I might not ever be able to get back in. And so, there's so much important identity dynamics that are happening in this space.

    And first to this idea of mental wellnesses or the ways in which we benefit are — So for me, when I hear that, what I actually think about is the ways in which having mental illness makes people better providers. And I'm a kidney doctor now, and it's crazy how often I get to leverage my mental illness with my patients and how powerful it has been. And there's a journey of learning how to disclose and what to disclose with patients. But I had a patient once who attempted suicide in the same way that I did. And as a result, their kidneys were damaged. And like, you know, a few days into their stay, I like disclosed this to them. And they had gone from being very sort of closed down, immediately after saying that to like sort of opening up meaningfully, you know. And I guess I’d say like, that’s something that like, no one will ever measure. But in our, in my research world, we call this agency to serve, where people leverage their identities to help patients. But the person who's experiencing this agency, who's sort of showing agency to serve and helping patients, they know that they've helped that person. And so like, can I give you statistics and prove that this is actually helpful? No, but like, have I had my own providers do things like this for me? Absolutely. Has it been extremely helpful for me? Absolutely. And that's like in the social network, that's like creating a little connection to a human. And to me, that's actually how you fight suicide, is like when you feel a physical or an emotional connection to a person, like, you know.

    And so, returning to your initial question what I would say is, I think medicine is changing because historically, the narrative was personal and professional are completely separate. Like they should not be in any way, nothing of your personal life should come into medicine. But in reality, first, that was never actually true. That was always happening. But now it's becoming more acceptable that who people are outside the hospital, it does bleed with who they are inside the hospital. And actually, that might be a good thing. We have to learn how to do it well. But when it's done well, it actually can be really humanizing and really help patient care. And so, I bet what's happening is, I bet in the past, we just had doctors who were very angry and mean to people and yelled at people and did all these things. And that was mental illness manifesting, but we just didn't call it mental illness. We just said, this is doctor such and such and the way that they act. And now we have people who are starting to get treatment for these things and learning that they're actual diagnoses, that when they're really angry, it actually turns out that they're just very sad or they were like, anxious. And so that, and they were like, you know, and so I think we might just be getting cleaner with our language and identifying what's actually happening. And also accepting that like personal and professional, like I think they actually should blend. I think a lot of people, I think medicine is shifting that way too.

    SKORTON: They do blend whether we want them to or not. And so I think it's a very good point. And to your point about sometimes you can't measure a certain thing, especially researchers like both of you and Dr. Xiao, not everything is measurable by weights or wavelengths or whatever it is. There's qualitative research. There's all kinds of different things. And these observations, even the anecdotal ones, build and turn into major ways of understanding things that seem cloudy to us at first. Super helpful. Dr. Xiao, what do you think about the question? Is this set of issues becoming more prevalent for both the general public and for those of us in the healthcare fields?

    XIAO: Yeah, well, I would really share some, maybe I can share some statistics, especially, I think, among the suicide rates as well that from like the past years, we've seen that the suicide rates has been increasing, particularly before the COVID, it has been increased significantly, and then it dropped a little bit in 2020. But when we get the 2021 data, then the suicide rates further increased. And to — especially for health care workers, we also find that there are increasing suicide rates among the health care workers and that is underscored by the growth of like 3.8 million in 2008 to 6.6 million in 2021, which is the latest data we have. And that coincided with like the age of the U.S. population and also within the health care workers, we also find that there are also different distributions of this risk. And particularly we find that registered nurses, health technicians, and health care support workers, they themselves even have higher risk of suicide. And then in the data, it shows that is — and then the increasing rates was not significant for physicians. So, we have been really finding that different kinds of like health care workers have different struggles as well.

    And I also wanted to mention another part of like disparities among, like within, these health care workers is that the data shows that within health care workers also females having higher rates of suicide than the males. And there is so little research to be honest on why it happens and as David alluded, we need to understand more and we need to understand, for example, maybe do qualitative research or right now our group are also digging out the profiles of suicide deaths among these different occupations.

    And one of the points that maybe distinguish the risks among these health care workers versus the non-health care workers, is in terms of the burnout rates. That has been really highlighted during, especially we know that during COVID, the front-tier workers and then they have to — really dealing with and the balance between like their work-related stress as well as their home-related stress, like what we talk about childcare as well. So, we did find that especially during COVID there has been increasing rates of like the suicide risks among these populations. So, I think that health care workers as an occupation, and they have their own unique risks.

    And we need to really think about the priorities of creating a culture, maybe a culture of mental health well-being and mental health wellness. For example, there has been like protocols of well-cations. Like instead of, we talk about vacation, maybe we need to think about wellness and well-cations. And also to increase also to the intersectionality is like within these health care workers especially for females. They also maybe feel further in terms of like, the different barriers of childcare, so when you give more support for them to be thriving in these professional jobs as well as their homes. So, I think that the health care workers do feel more stress from different levels than the non-health care workers. And that reflects particularly among their suicide rates growth.

    SKORTON: Thank you. You know, one of the really important tools that I think it's important to use when thinking about any public health issue is to look at it through the equity lens, social determinants of health, you know, whatever you want to call it. And for a moment, focusing not on the health care professionals, but on the people we serve — not just the patients, but their families, the communities. I don't mean to be, you know, dramatic, but I'm terrified about the many people who don't have access to the internet and therefore even though you can have therapy, for example, over the wire, so to speak, they don't have access to broadband and they can't do it. And even in 2023 here in Washington where we fight all the time about everything, we're fighting again about mental health parity and we're still not there. We're not even close to being there.

    And so, to what extent do you think we're making any progress at all on the health inequity aspect of mental health care, both diagnosis and treatment? Because other problems that we've looked at in this program and just in general, whatever progress we're making and whatever it is we're talking about tends to lag, sometimes enormously, dramatically, because of social determinants of health, because of lack of access. And in the case of mental health, I'm sure you both know more about this than I do, but the availability of professionals to help is a big, big issue. Roughly half the counties in the U.S. don't have a single psychiatrist. And of course, much of this care is delivered by other terrific professionals that are not MD-psychiatrists. But there are big, big problems in that regard. So, tell me your thoughts about the health equity aspects of the battle that we're fighting. Dr. Xiao, maybe you could start this one.

    XIAO: Yeah, I'd love to share. I have been studying a lot, focusing on health disparities and promoting equities in different — especially in mental health and suicide prevention — that one of our previous research from a epidemiological perspective really shows that particularly for, there are racial and sex and also sexual and gender minorities really facing higher rates of suicide deaths, suicide ideation, and suicide attempts than their peers. And from my research, I also advocate a lot about studying suicide, studying mental health disparities from a social determinants of health perspective.

    Because as we find that many of these sensibilities to health care or like why a certain population has been systematically, always having higher suicide rates, is not just because of like the individual wills but it is a system levels issues that we need to — and also from my perspective it is not just about health care. Like health care is important in terms of like we need to advocate, and we did find that for people living in health care — like health service shortage, house areas, they have a higher rates of suicide. And also we find that in terms of rural versus urban populations like the rural and remote areas where there's health care resources hospitals psychiatric hospitals and when there is a lacking of this professional support, there are increasing rates of suicide showing in this data.

    At the same time, there are also non-health related issues, and particularly one of these publications we just published this week in the Journal of Pediatrics, we did find that, particularly for like even kids for the youth populations, if we think about social terms of health, we need to think it from a more broad perspective. And we need to not only think about health care, but also think about education, about physical infrastructure, natural environment, about their socioeconomic status, their social context, whether they are living in a place that is safe or having drugs sales or not. And those different kinds of environmental variables are equally important as the health care settings as well. And we did find that, for example, when children are living in the poverty and socioeconomically deprived areas, they also have higher rates of mental illnesses and suicide attempts. And that is exactly, I think, that is no, that have no difference in terms of like for people who are older like adults or moving to different kind of occupations. Like, the place you live characterized by the social determinants of health really shaped it in terms of the abilities, accessibilities, affordability of health care and also the norms, the social norms, or if there is a bias discriminations in the environment that would implicitly affect the mental health.

    So, I think that we have been seeing increasing amounts of the research started to understand not only at individual levels, not only just studying how psychiatric illnesses is associated with suicide risks among health care workers. But we also find that there are increasing emphasizes social determinants of health. And I think for example, the National Institute of Health, they are also emphasizing more right now on setting the social determinants of health as the goals. Healthy People 2030 also includes this SDOH, like social determinants of health, to target on how do we improve the conditions that people live, people grow, they work, and to improve the health care outcomes.

    And also, another note is about like, besides the quantity of health care, we also wanted to improve the quality of health care. And that would include the array of like culturally tailored mental health interventions as well. So, I think thinking about mental health from a social determinants perspective is actually very important. And the field is starting to pick it up, but we do need more research in this area.

    SKORTON: Thank you. Dr. Bullock, your observations from your patients and your experiences.

    BULLOCK: Yes. I completely agree with Dr. Xiao. I think what this topic brings up for me is the role of the physician or health professional in advocacy or sort of broader structural change, because if people don't have housing, they're not gonna go to therapy. It's much more challenging. you know, people don't have access to food, you know, like these very core, like basic fundamentals where like, you know, I very much am of the, like, for many sort of things in society, like housing is the cure. And I think this becomes interesting because when you look then at physicians who arguably, like, don't have like the same — they may have grown up in certain social constraints, but typically as once they're employed, don't have the same sort of needs that a lot of our patients do. Then there's sort of a question like, so what's happening in these populations? Because basically what everyone says, physicians, we're a very socioeconomically privileged group. And the suicide rate in physicians is remarkably high considering like, if you look at the other social determinants of health, like we just like don't represent like our patient population, which is much, much more privileged. And then I, you know, I think then this like, I think there is this human need for like belonging and safety and you know, all these other things and like sleep. And those things can get compromised by, you know, within medicine. But yeah, so one, I think there's, there's obviously a lot of interesting sort of academic things to think about.

    But things outside of very practical relevance because mental illness is, it does not discriminate. It impacts everyone. It doesn't matter how wealthy or privileged you are. Obviously, there are some risk factors that are related to one sort of socioeconomic status, but anyone can have mental illness. Yeah, I guess I'll just stop there.

    SKORTON: Yeah, this is so good to be able to get to know you, both of you, and to listen to you. It makes me more optimistic about the future in an area where I really haven't been very optimistic, because younger people, people who are devoting some aspect of their thinking and energy to this, just makes me feel more optimistic. And I really appreciate your wisdom, your sharing, and your willingness to come on “Beyond the White Coat.” Now we're gonna call our producer back for a little ending segment. Rachel, over to you.

    BUNN: Thank you, David. Thank you guys for this very enlightening conversation. We are gonna switch gears a little bit. And like I promised you, we always end with a fun question. So, it is now time for our favorite segment, which we like to call Prescription for Relaxation. I think it's very appropriate for this conversation because we know that life is challenging and we all have those really hard times where it can be really hard to find our joy and find the things that lift us up.

    So, we'd like to ask you, our guests, tell us what your prescription for relaxation is for us this week. And I'll give you guys a second to think and I'll pick on David first. David, what is your prescription for the week?

    SKORTON: So, our listeners know by now that my prescription always has to do with my dreams of being a successful musician, which never came through. Behind me in my office, over there is a little portable recording and composition area. And so, my prescription for this week's relaxation is to allow yourself to dream. And I sometimes dream that somehow, maybe even during recording of “Beyond the White Coat,” some famous act will break through and call me on my phone and say, We wanna take you away from all this and you go on tour with us. And so, dreaming is my prescription for relaxation for this week. Back to you, Rachel.

    BUNN: Thank you so much, David. Dr. Xiao, what is your prescription for us this week?

    XIAO: My prescription is a habit that I have been keeping for years, it is journalism, journaling. I really like waking up and then every day I think the first questions that I always ask myself is what are you grateful for? Because I think that everyone feels a lot of stress and you cannot always compare yourself to the others, but the most important thing is what do you feel? And what do you feel grateful for? And I feel like over the years, just since I started this habit, it really makes me happier because I realized that, wow, I have a lot of love in my words and I just need to focus on this and also focusing on doing this job that I really like, the research I really like and to support the others. And I think sharing is also an important — maybe another prescription, if I can? — that sharing love, sharing like what you have, and sharing and giving love to the others is also an important part because later on, you will feel that this gratefulness will last longer than anything else.

    BUNN: That's such a great prescription. Thank you so much. Dr. Bullock, what would you prescribe to us this week?

    BULLOCK: I have a book. This recently became my new favorite book of all time. So, this is like, and my old one had been for like a very, very long time. It's my favorite. It's called Faces at the Bottom of the Well by Derrick Bell. And it's, I will caveat that this is not really like a, it talks a lot — racism is a very sort of big part of the book and it's sort of, it's this kind of like historical fiction and it plays with these little stories of like sort of examining American society and sort of with this lens focusing kind of on racism. And so, it sounds very heavy, but it’s actually a very thought-provoking book that really like, tests sort of the bounds of like society in your head as you're reading. And it's just this really fun, like, I don't know. I just think it's a great — I would recommend that anyone read it. I think you'll have many different feelings, but I think it's very thought-provoking one.

    SKORTON: I’ll get that book today, this very day. This is so great. Before Rachel closes us, I just want to thank you two for your incredible insights and for all that you're doing. It's really been an honor.

    BUNN: Thank you both for joining us. We really appreciate your time and your thoughtful answers. Thank you as always to David for hosting and thank you to all of our listeners.

    “Beyond the White Coat” is hosted by David J. Skorton and our executive producer is Zenneia McClendon. Our project manager is Brittany Loca. This episode was produced by Rachel Bunn and edited and engineered by Laura Zelaya. Elena Marinaccio is our copy editor and De'Angello Powe made all of our graphics. Our sound design is by De'Angello Powe and David J. Skorton. Don't give up on your music dreams yet, David. And Aaron Dillard provided additional support for this episode.

    We will be back in a few weeks with another “Ask an Expert” mini episode featuring one of our wonderful AAMC experts. Thank you for listening.

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