1. Presented by: William B. Lawson, MD, PhD, DLFAPA
Changing Paradigms of Mental Health: Implications for Vulnerable Populations
Presented by: William B. Lawson, MD, PhD, DLFAPA
This presentation is provided free-of-charge and is supported by Grant Number 1L1CMS from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. The contents provided in this webinar are solely the responsibility of the presenters and do not necessarily represent the official views of HHS or any of its agencies.

2. Speaker Notes: For today’s meeting:
Dr. William Lawson is Associate Dean for Health Disparities at the Dell Medical School and Director of Community Health Programs and Professor at Huston-Tillotson University, where he leads the Sandra Joy Anderson Community Health and Wellness Center. He is also UT Austin's institutional representative for the Health Disparities Education, Awareness, Research and Training (HDEART) Consortium. He received his MA from the University of Virginia, and PhD in Psychology from the University of New Hampshire. He received his MD from the Pritzker School of Medicine University of Chicago, did his residency at Stanford University and a fellowship at the National Institute of Mental Health. He has held several faculty positions at the illustrious universities including the University of Illinois, Urbana, University of California, Irvine, Vanderbilt University, University of Arkansas, and recently left after 15 years as Professor and Chairman of the Department of Psychiatry and Behavioral Sciences at Howard University. He has held numerous senior positions and received national recognition. He has received the American Psychiatric Foundation Award for Advancing Minority Mental Health, the 2014 Solomon Carter Fuller Award by the American Psychiatric Association, the Sigma XI the scientific honor society and Alpha Omega Alpha, the medical honor society, the National Alliance for the Mentally Ill Exemplary Psychiatrist Award and Outstanding Psychologist Award. the Jeanne Spurlock Award from the American Psychiatric Association, and he E.Y. Williams Clinical Scholar of Distinction Award from the NMA. He has over 200 publications and has continuously received federal, industry, and foundation funding to address mental and substance abuse disparities.
Speaker Notes:
For today’s meeting:
We will go over the MACRA legislation and the two pathways within the MACRA Quality Payment Programs. How you as a provider can prepare for these alternative payment programs under MACRA with TCPI, or The Transforming Clinical Practice Initiative.
We will provide an overview of the Transforming Clinical Practice Initiative and discuss the two key components to TCPI – Support and Alignment Networks (SAN) and the Practice Transforming Networks. The TCPI is critical as it ushers in a new era of practice that shifts its focus from “volume” to “value” and what does this new payment system mean.
We will discuss the criteria for TCPI participation and the benefits to doing so.
If time allows, we will take the opportunity to address your questions.

3. Polling Questions

4. Disparities In General and Mental Health
Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care—Report of the Institute of Medicine of the National Academies,1 2002
US racial and ethnic minorities are less likely to receive even routine medical procedures, and they experience a lower quality of health services
Supplemental Surgeon General’s report on mental health of minorities,2 2001
No substantial difference in prevalence
Significant illness burden: Lack of access

5. Chronic Disease
Heart disease is the leading cause of death for people of most ethnicities in the United States. Blacks have a higher prevalence of cardiovascular disease than Whites and Hispanics.
Diabetes mortality rates among Blacks (38 per 100,000) and Hispanics (25 per 100,000) are higher when compared with the rate for Whites (19 per 100,000).

6. Mental Health Affects general wellness 10 to 20 years
Shortened life span
Because of comorbidity of chronic diseases
Because of lack of access to primary care
Because of poor self care
Because of poor treatment adherence
Because of suicide
Poor outcomes
Poor treatment adherence

7. Reputation Vs. Reality
While mental health of the broader community is improving . . .
Mental health of communities-of-color are declining!

8. Percentages Meeting Criteria for Lifetime PTSD & MDD in a Primary Care Clinic
But only 17% were treated or referred for mental health treatment

9. Mental Health Impacts General Medical Conditions
Myocardial Infarction (MI) or heart attack
Depressed individuals far more likely to die from an MI
Treatment with antidepressants but NOT psychotherapy associated with improved outcome after MI
Occurs comorbidity in 40 % of individuals with Diabetes Mellitus
Common in obesity
Risk factor in breast cancer and other cancers
Research suggests that people who have depression and another medical illness tend to have more severe symptoms of both illnesses. They may have more difficulty adapting to their co-occurring illness and more medical costs than those who do not also have depression.

10. Addiction Medical Medical DRUGS Social Economic Neurotoxicity
AIDS
CANCER MENTAL ILLNESS
Neurotoxicity
AIDS, Cancer
Mental illness
DRUGS
The effects of drug abuse are wide ranging and affect people of all ages. Besides addiction, drug abuse is linked to a variety of health problems, including HIV/AIDS, cancer, heart disease and many more. It is costly to individuals and society, and is linked to homelessness, crime, and violence.
Social
Economic
Health care
Productivity
Accidents
Homelessness
Crime
Violence

11. Why Do Some People Use Drugs?
To feel good
To have novel:
feelings
sensations
experiences
AND
to share them
To feel better
To lessen:
anxiety
worries
fears
depression
hopelessness
Research has shown that people generally take drugs to either feel good (sensation seekers, or anyone wanting to experiment with feeling high or feeling different) or to feel better (self-medicators, or individuals who take drugs in an attempt to cope with difficult problems or situations, including stress, trauma, and symptoms of mental disorders).

12. Jackson Hypothesis to Explain Self Medication
Individuals who are exposed to chronic stress and live in poor environments will be more likely to engage in poor health behaviors (PHB), such as smoking, alcohol use, drug use, and overeating, because they are the most environmentally accessible coping strategies for socially disadvantaged groups.
These behaviors act on common biologic structures and processes associated with pleasure and reward systems .
These behaviors alleviate, or interrupt, the physiological and psychological consequences of stress and reduce reported or measured depression and other mental disorders

13. Community and Family Issues Related to Stigma
Related to attitudes like:
“Keep it in the family”
‘People will talk’
‘Its not from my side of the family’
The shame
Religious beliefs
“You will go to hell”
“ Unforgiveable sin”
Causation of mental health
We are a strong people
African American resilience
Weak stock

14. Contributing Factors to Disparities Among Minorities and Increased incidence of Mental Health Problems
Lack of Access
Continuum of psychiatric care leaves many individuals, particularly African Americans, with poor-quality treatment.
Culturally appropriate interventions are often lacking
Poor integration of follow-up treatment that link individuals in inpatient settings to outpatient follow-up are needed to reduce racial-ethnic disparities in outpatient mental health treatment following acute treatment. (Carson et al Psychiatric Services 65:888–896,2014)
Lack of Proper Screening Tools
Use of tools like the PHQ-9 and M-3 diagnostic helps providers understand treatment needs better in order to connect community members to services.
It is important to implement a comprehensive mental and behavior healthcare model that creates interventions before mental health conditions become chronic and lead to poor outcome (eg. job loss, poor relationships, poor health)
Lack of Supported Education and Employment
Helping persons who have experienced an initial psychotic episode continue in or return to school or work is key to their social and developmental progress and, ultimately, recovering from their illness.
Little to no participation in clinical trials and education around experimental treatment options
Specifically, the Individual Placement and Support (IPS) model is recommended to assist participants get back
To or start work.

15. Barriers to Adequate Treatment of Mental Disorders in Primary Care Setting
Clinical presentation with somatization
Stigma about diagnosis
Competing clinical demands of comorbid general medical problems
Problems with the physician-patient relationship
Lack of comprehensive primary care services.
Das et al 2006 Depression in African Americans: breaking barriers to detection and treatment.

16. Provider Factors Stereotypes & biases Lack of cultural sensitivity
Failure to communicate
Do not listen
Monopolize conversation
Lack of perceived respect
Failure to involve in decision making
Failure to engage
With engagement reported ethnic differences in prescribing disappear
Failure to get adequate information
Often does not use family, collateral resources
Socio-economic distance
Different income, education, race or ethnicity
Cooper LA, et al. J Gen Intern Med Jan;21 Suppl 1:S21-7. Review.
Segal SP, Bola JR, Watson MA.Related Articles, Psychiatr Serv Mar;47(3):282-6.

17. Disparity Among How Racial Groups Are Treated
Providers provide a sense of Hope (optimistic)
More likely to receive Rehabilitation referrals
Belief that each person, regardless of the severity of their condition, was capable of living a full and independent life in the community
Providers are more pessimistic
Less likely to be referred to aftercare programs
Belief that social dependency is inevitable
VS.
In African Americans Treatment is delayed
More symptomatic
More likely to be admitted to inpatient care
More likely to be referred to the correctional system
More likely to be involuntarily committed
More likely to leave against medical advice
More likely to be readmitted
More likely to end up homeless
Less likely to gain stable employment
More likely to be referred for medication only or to the emergency room
More likely to be terminated early
African-Americans (in general) receive:
More, but shorter, hospitalizations
Fewer privileges as inpatients
Less OT, psychotherapy
More medication
More likely to receive antipsychotics
More involuntary admissions
Fewer differences among other ethnic groups

18. Current System Mental Health Clinic
Long-term Dependency/ Dropout from Care
Mental Health Clinic
Help seeking
Referral from GP
Lack of Access
Unaffordability and Inefficiency of health care
Stigma
Lack of Knowledge
Distrust
Insidious Onset
Police
ER/IP
May not receive treatment for a decade after diagnosis
Compton M, Broussard B: Current Psych Reviews 2011, 7, 1-11

19. Roadmap for Pathway to Care
Onset of Symptoms
Help Seeking
Referral to Mental Health Services
Referral to Early Intervention Service
Previously gap between onset and treatment might be weeks to years especially
for racial and ethnic minorities

20. Specific Approach to Psychopharmacologic Treatment
Antipsychotic medications are a mainstay of treatment
increased sensitivity to adverse effects
more likely to respond to lower doses
efficacy is similar, side effect profiles vary
For FEP:
Select medication with most benign and tolerable side effects at lowest effective doses

21. Minority Representation in Clinical Trials of Recently Approved Drugs
Little data available for clinical trials of recently approved drugs
Minorities account for fewer than 10 percent of patients enrolled in clinical trials, according to the National Institutes of Health (NIH) National Institute on Minority Health and Health Disparities.
Estimated to average substantially less than 5% in pivotal trials supporting drug safety and efficacy
< 1% of studies in biological psychiatry when ethnicity is identified
(Lawson, 1990,2010)

22. Steps to a Healthier Patients
Establish a trajectory for additional education including rehabilitation, criminal justice, psychology and social work
Use mental health screening and stigma reduction in the primary care clinic and the community
Conduct research and outreach into mental and behavioral health needs

23. Treat the Whole Person!
No single Treatment is appropriate for all individual
Treatment must attend to multiple needs of the individual
Remaining in treatment for adequate time is vital for success
Treatment should be readily available no matter race, gender, orientation, or socio-economic status

24. Bottom line Treatment works Recovery is possible
Early treatment interventions can improve the quality of life, increase employability, prevent substance abuse, and reduce mortality
Racial and ethnic disparities may be reduced

25. We Are Getting There Slowly but Surely!

26. Polling Questions

27. Questions & Comments

28. William B. Lawson, MD, PhD, DLFAPA
Contact Information
William B. Lawson, MD, PhD, DLFAPA
>Dr. Janice Bray
Dr. Carolyn Brown
Denise Dodd