Expanding mental
health resources

Speaker 1:

B is for believing mental healthcare is healthcare. That's why we have more options, like remote therapy visits, self-guided programs, and wellness offerings. Find the support you need at bluecrossma.org.

Andrew Dreyfus:

Good after, I'm Andrew Dreyfus, the CEO of Blue Cross Blue Shield of Massachusetts. On behalf of Blue Cross, and the Boston Globe, thank you for joining us today on this important and timely conversation about mental health. If you have anxiety or depression, you're not alone. More than 40% of Americans are experiencing some form of mental health or behavioral health challenge related to the COVID pandemic. The rates of anxiety and depression for example, are almost 400% higher than they were just a year ago. I've seen it in my own circle of family and friends, and it's challenging to deal with mental health issues. Clearly Americans are worried, and rightly so, about COVID-19.

Andrew Dreyfus:

We're separated from friends and family, many of us have lost friends or loved ones, we're grappling with financial challenge as a result of the changes of the economy, job losses. And clinicians are seeing mental health issues and mental health challenges in patients that they have never experienced before. And they're seeing deepening mental health issues in those who have long struggled with the problem. At Blue Cross, access to mental healthcare has always been a priority, and today we're engaging in a number of new initiatives to address mental health needs in creative ways.

Andrew Dreyfus:

We're offering webinars to thousands of our members, on depression, on anxiety, on the stress caused by social injustice, and racism, and many other issues. We've vastly expanded the availability of telehealth, which in some ways has kind of revolutionized the mental health field over the last six to nine months. And we're working with child psychiatrists with primary care physicians and others to make treatment more accessible to even broader populations. We're very fortunate here in Massachusetts to have brilliant and compassionate clinicians with whom we can work. You're going to hear from a few of these clinicians today.

Andrew Dreyfus:

I'm happy to introduce one of them to you, Dr. Ken Duckworth. He's going to moderate today's session. He is the Senior Director of Behavioral Health here at Blue Cross, and he also serves as the Chief Medical Officer of the National Alliance of Mental Illness. So, Ken, I'm going to hand this over to you.

Ken Duckworth:

Thank you, Andrew. I want to salute The Globe for taking this topic. Mental health is an important wave of this pandemic. And I think you can sense that this is being felt in a lot of different quarters, and the research is backing that up. Today we have three superb panelists to ask questions that you've submitted, and I would like to introduce them now. And after I introduce them, I'm going to develop the questions that were sent in by Globe readers and participants in this event.

Ken Duckworth:

Our first person I'd like to introduce is Christine Crawford. Christine, can you put your camera on? Christine is a child and adolescent psychiatrist. Also, has a master's in public health from the BU School of Public Health. And Christine is the Associate Director of Medical Student Education at the BU School of Medicine. Deirdre Calvert is a licensed clinical social worker, and now the Director of the Bureau of Substance Addiction Services here in Massachusetts. And Irene Falgas Bague, who trained in Spain, and has an international perspective. She's a psychiatrist who does work on disparities in the Latino community in particular at the Disparities Research Unit at the Mass General Hospital.

Ken Duckworth:

So, these are all remarkable local leaders and clinicians. And I want to start by asking each of you what you are seeing from the perspective that you're at. Christine, could you please begin?

Christine Crawford:

Thanks so much for having me, Ken, I'm so happy to be a part of this event today about this such important topic. Now, in terms of what I'm seeing as a child psychiatrist in my day-to-day, is soaring rates of anxiety, depression, and behavioral issues in the children that I'm treating. One thing that we know to be true over the course of this pandemic is that rates of anxiety and depression have tripled during this time period, and have been so largely affected by the black population and the Hispanic population, in which we see much higher increases in the rates of depression and anxiety. So, that's data that we're seeing with the adults, so you can imagine that if adults are struggling emotionally, if they're struggling physically, and financially, that's going to have a tremendous impact on the emotional well-being of the children that I see at my clinic.

Christine Crawford:

The other thing about kids who have been going through this pandemic is that there is a tremendous sense of isolation. They're not able to attend school, and to be around their peers, and to get the emotional support that they had access to so readily. And we're seeing those contributing to more bouts of depression, more bouts of anxiety. And it can also expose children to more difficulties within the home, because they're spending more time with family members that they weren't previously around prior to this pandemic. And then additionally with the way that remote schooling has been going, it is not an easy task for our children and for our parents to manage. So, you can imagine the amount of tension and conflict that are within some of these homes, that is further contributing to some of the emotional distress that our children are experiencing.

Christine Crawford:

And so it's hard for these kids to keep up with all of the online assignments, to know how to navigate various platforms, have access to their school work. And for parents who are now taking on the role as teacher, when before they were just used to parenting. And so, we're just seeing a tremendous amount of stressors that are impacting all people. But we know that particularly in communities of color, they've already been burdened by a number of issues prior to the onset of this pandemic. And so, that's why we're seeing much higher rates of various psychiatric symptoms within children, especially children of color.

Ken Duckworth:

Thank you, Christine. Deirdre, what from your perspective leading an addiction agency, the substance use disorder agency from the Commonwealth of Massachusetts, you worked a lot in the epidemic of the opiate crisis before the pandemic. How do you see substance use relating to this pandemic at this time?

Deirdre Calvert:

Thank you, Ken, and again I'd like to also say thank you for allowing me to be here, and to speak about this incredibly important subject. So, we know that recovery thrives with community, and we know that addiction thrives in isolation. And so this pandemic has thrown us a curve ball because we're asking folks to isolate for safety and for health. And yet, for the thousands and thousands of individuals who are suffering with addiction, this is a very difficult ask. So, the things that we are concerned about, and we have not taken our foot off the gas in terms of the opiate epidemic, is how do we keep people safe?

Deirdre Calvert:

And things that we're concerned about outside of the opiate epidemic, I just want to remind folks that 74,000 Americans died last year of alcohol related causes. And we're worried about increases in alcohol consumption during this time, so we're very concerned about that. We're concerned about the increased risk of overdose. Massachusetts is a high-risk state of opiate overdoses. And when we are alone, we are looking at people who are using alone. So, there's not somebody there to administer Naloxone as needed if somebody happens to overdose.

Deirdre Calvert:

We're looking at changes in drug supplies, maybe some certain drug dealers or paths the drug get into our state have changed, and we know the biggest risk of overdose is when somebody changes their dealer or their amount from where they're getting their drugs from. There's a reluctance for individuals to access treatment, because they're worried they're going to get COVID. So they don't want to go to a detox, or some other congregate setting where there might be a lot of people. They might be the single caretaker, and they can't access treatment. So to Dr. Crawford's point too, they're at home, and now they're doing much more on top of their daily routine anyways with parenting, and teaching, and things like that.

Deirdre Calvert:

We have the continued stigma of accessing treatment, so people don't want to access treatment. And COVID has also brought us along with we have seen an increase in homelessness and housing unstable. So, those are the concerns that we are facing. Those are for the individuals. For providers, we're very concerned about our providers, because we're also asking them to decrease their bed capacity to allow for social distancing. So in the areas where we do need capacity, we're asking people to reduce that. So, those are some of the-

Ken Duckworth:

But just has demand has increased, at the same time there's more pressure on supply because you can't have several people in a room. Is that what you're thinking of?

Deirdre Calvert:

That's exactly correct. That is exactly correct. So, those are just some of the concerns that we are actively and aggressively trying to mitigate in our work here at BSAS, at the Bureau of Substance Addiction Services.

Ken Duckworth:

Thank you, Deirdre. Irene, you're a leader in the cultural perspectives on mental health, and your work with the Latino population around Boston is something I'd like you to just describe what you've been seeing during this pandemic.

Irene Falgas Bague:

Yes, of course. Thank you so much first of all to have this opportunity to talk about this super important issue. So, basically I would just add I think that Christine and Deirdre have pointed very, very general points that we are all seeing. The people who are professionals who are trying to help, and deal with people who are facing depression, and anxiety, and substance use problems during this pandemic. But I would add that this has been a long run, and if we have seen different faces of it. So, it was very different when we first started in March, and we thought that that would be something about a month, and we were just going home for a month, and then we would come back, and how was our mental health, and our symptoms by then?

Irene Falgas Bague:

But then how we approached the summer, and how we spent our summer, and our population, and the people, and the professionals that we work with, how they were facing the summer without being able to travel to their countries for example, for immigrant populations without being able to ... Like seeing all these political changes that were impeding them to travel even. So, there's been a lot going on also within the immigrant population related to that, that has also affected their mental health. We have then seen all the stressors coming with the school, as Dr. Crawford was mentioning. Kids being at home, and dealing with your own necessities as an adult, having the kids at home, how can you get out and work?

Irene Falgas Bague:

Because as Dr. Crawford was saying, the problem that we've been seeing is that it's something that comes before the pandemic, that the baseline situation for Latinos and people of color communities were much worse than other communities. So, when the pandemic arrived, the capacity to cope was much more challenged. And we are talking about unemployment rate, we are talking about employment and stability, and where do you find your employment so you are much more exposed to the virus, you don't have the capacity to work from home, as other people may have. And then all the other things, the stable housing, the risk of eviction.

Irene Falgas Bague:

So, these are all the things that we've been dealing and trying to manage during these months. I would also add that at the Disparities Research Unit, we are focusing on research and trying to do research within the community. So, a big part of our job was to do outreach, trying to break down the stigma on talking about mental health, and seeking care for Latino, and Chinese, and non-white communities. So, it has been very hard also in terms of finding the people, where they are, because we are asking people to be isolated at home. We see on one side that the symptoms increased, but in the other side it's much more difficult to get to people and offer care.

Irene Falgas Bague:

So, that has been something that has been an important challenge. And last, I would end that we also are very interested on looking on resilience factors, because we know that these communities have been already through a lot of stressors before the pandemic, and we also want to learn from all these resilience skills that people develop through crisis like this one. So-

Ken Duckworth:

That's important, mental health is both symptoms and vulnerability, but it's also strengths, coping, and resilience. And it sounds like some of the work you're doing is to really better understand what helps people manage some of these stressors. I want to turn to questions from the Globe audience. Janet asks, "How do you tell somebody you're not okay when you have a roof over your head, money in the bank, and food on the table?" Deirdre, I want to start with you, because I know you're worked in every setting imaginable, including the homeless population to a private assertive community team. So, this person's saying I seem to look okay, and if you looked at my life from the outside, looks like I'm doing okay. How do I convey to people what I'm struggling with?

Deirdre Calvert:

That's a question I think all of us struggle with, and I think it's a really important question. And I always look to how we talk to ourselves, would we talk to another person that way? Would we discount their feelings or validity? And so I really look at how we would turn our focus towards what we can and cannot manage, and what we can and cannot control. And I look towards being understanding, and understanding that you can't compare and contrast. We'll always find people who have greener grass, or dead grass on their side of the fence. And so, what can we do in this moment? What are the challenges that you're facing? The human condition is for all of us, we're all trying to figure out this world, and this new world with the pandemic. And I would look towards those things. So, I would be understanding towards ourselves. I would look towards forgiveness, and I'd ask for help because there's no shame in asking for help. We're all trying to understand this. Nobody has ever had to deal with this pandemic, not in my 50 plus years, this type of crisis. So, we're all trying to learn as we go along.

Ken Duckworth:

It's all of our first pandemics, I've never been to a pandemic mental health class. Although undoubtedly at the American Psychiatric Association there will be dozens of them next year. One of the things I heard was self ... in your statement. That the person should be gentle with themselves as they're asking this same question. Stacy asked a question about shame, prejudice, stigma even within a family system. Christine, do you have thoughts about this particular challenge that people face, the internal wish to tell somebody and figuring out who you can talk to? And the question is asked by Stacy, "Who can you trust?"

Christine Crawford:

Yeah, no it's a wonderful question because what can be so incredibly challenging and frustrating is when you are experiencing emotional distress internally, and you want to connect with the people around you, your loved ones. And when you do try to make attempts to reach out, to convey what it is you're experiencing, you're often met with sometimes for some individuals, are met with comments that can be quite invalidating, and make it seem as though they're not going to get the support that they need, and the understanding that they need from the other people.

Christine Crawford:

And when that keeps happening, folks continue to keep all of that shame, that guilt inside, and feel as though they are alone, when it's already difficult enough to have a mental health condition, but to experience that alone without the supports of your loved ones can make it even more so difficult. And so, one thing that I encourage people to do is that it's so important to find even if it's one person, even if it's just your primary care doctor, to establish a relationship with someone who you can share your emotional experiences with, without the concern about being judged negatively. Because when we turn to family and friends, there's always this concern about negative judgment right?

Christine Crawford:

Going back to Janet's question, well you look fine, you have all your basic needs met, what is the big deal? When you meet with a mental health provider, they're able to acknowledge that it is a big deal. We know that mental health is directly connected to our physical health. That's why I tell patients, "We have a neck because your brain is attached to the rest of your body." So if you're not doing well emotionally, then physically you're not going to be able to do well. You're not going to be able to get out of bed, your appetite isn't going to be that great. You're not going to be able to have all of the energy that you need in order to maintain your relationships with everyone in your lives.

Christine Crawford:

And also, in order to maintain your level of functioning, so that you could be a good parent, and so that you could be a good employee. So, talking to a mental health provider can be really helpful, and that mental health provider can also provide you with that support that you need in order to have these difficult conversations with your family. They can provide strategies for how you can navigate some of those conversations, so that you don't have to continue to live with fear of being judged, you don't have to live in this fear of people having negative attitudes or assumptions about you. And that can also in turn reduce some of the shame, which hopefully can also further make it such that you can heal from some of the emotional difficulties that you're experiencing.

Ken Duckworth:

This idea of going to your primary care doctor, I think it's been demonstrated in the literature that about half of mental health visits, medical visits to a primary care doctor, have a mental health dimension, or a substance use dimension. They're used to having this conversation, and so if you can't find somebody in your immediate family life, that is a place to turn. Irene, I wanted to ask you, you have an international background, you trained in Spain, I know you did some of your work in Montreal. Can you talk a little bit about attitudes and shame about seeking help from a different cultures that you've observed?

Irene Falgas Bague:

Yes. Of course, yes. I think that the view about talking about mental health is something pretty universal, and how this view is shaped it's different depending on the culture that you are from. But I would say that this is something very general. And we tend to think that our culture is special, and we hear that a lot, like well for us, for Latinas, it's for sure. This is true, we cannot talk about it. I cannot talk to my mom about that because she will judge me, and we have these assumptions for sure in our culture. But then when you ask that to someone who comes from a Chinese background, we'll tell you exactly the same, and will say, "Actually, it's even worse because mental health the world of mental health was taboo in China, and doesn't exist in our language." And we have to find other ways to translate.

Irene Falgas Bague:

For example, we do all of our interventions in Mandarin and Cantonese as well, so we need to find creative ways to talk about depression, because there's not an exact word to talk about it as we understand it in English. And so, I would say that this is a taboo all over, for a lot of cultures. But the way that it's expressed is different. And going to a psychotherapy and lying in a [inaudible 00:23:20] is something that is also cultural. So, I think that it's important to be aware of that, that it's something that is shaped by our culture, and how we seek help is also shaped.

Irene Falgas Bague:

So, it's very important to when we talk to someone who might be struggling with a mental health problem, what I always use is this four questions about cultural formulation that is asking, "What do you understand from what is happening to you? Why do you think it's happening? And how do you think you could improve?" Because these three questions brings you a lot of information on what are the strategies that may be useful for this person. Also, I would say that as you were saying, I would emphasize more and more the primary care provider role on it. And I don't want to over-burden more them, but I think if it's not the primary care physician, it might be the primary care nurse, the person who is there, the PA. Someone who will be in the community who will be there to hear you no matter what is your culture background. And that's very, very, very important to know that there's something near you, someone that can hear you, and be there.

Ken Duckworth:

Never worry alone is a universal concept, and really sounds like from your perspective this is a universal problem. So Patricia writes, "If you're having depression and you've never had it before, how do you know how bad it is, and where might you start to look for help?" And I know we've discussed primary care. Christine, do you want to start that question? How do you know when it's time to seek help, and where might you look?

Christine Crawford:

Yeah. And I think the reason why oftentimes people aren't quite sure about when to enter care is because we don't have open conversations about that. We're so eager and ready to have discussions about our headaches, and how we went to see the neurologist, or if we're having stomach issues, we saw a stomach specialist. We're so accustom to talking about all the other medical specialties, and the help that we sought out when we were experiencing symptoms. But it is very rare that you would encounter someone who would share with you, "I think I was experiencing depression. I had these thoughts, it was hard to get out of bed. And I talked to my primary care doctor, and they recommended I start medicines." We don't have those conversations. And I am so encouraged by the fact that we're having that discussion right now, so that people can walk away from this webinar and know when it is time for them to actually seek out help.

Christine Crawford:

So, there are a few things that I think would be important for people to keep in mind. If you notice that the mood that you're experiencing, whether it's feeling sad, whether it's feeling down in the dumps, or whether that's feeling constantly on edge, and having difficulties controlling your worry and shutting your mind off from thinking about a whole bunch of things at the same time. If it's getting to the point where you can't function, and what I mean by that is you can't work, you can't focus on your work, you can't maintain relationships in your life. If your performance in school is failing because of some of these symptoms, and your physical health is also deteriorating, meaning you're losing weight, you have aches and pains in your body, and you're not sleeping, that's a clear sign that you need to talk to a healthcare provider about what it is that you're experiencing.

Christine Crawford:

Now, mental health conditions are medical conditions, and they respond to treatment. And we have a number of treatments that are available. And I think a lot of folks believe, "Well I'm feeling like this for the last couple weeks, or for the last month, I'll get through it, it won't be that bad." But then time continues to pass on and on. But if you were having a lung issue and you couldn't breathe, you wouldn't wait six or eight months to go and finally talk to someone if you couldn't walk three steps. And so, I encourage people if this has been going on for a couple of weeks, for more than a month, you should go and get help. What we see in child psychiatry is that there's often a significant delay between the child presenting with the symptoms, and the parent actually bring them into care.

Christine Crawford:

We see that it actually takes for some kids years before they first present to healthcare provider. And you can imagine the negative impact that that can have on a child's overall growth and development. So, I encourage people to be able to recognize those signs and symptoms, if it's getting in the way of your functioning, and to get help sooner rather than later, because there are treatments available and we wouldn't want people to continue to suffer without any great reason when we have relief available.

Ken Duckworth:

I agree with your emphasis on duration and functional capacity, your role as a parent or as an employee is getting impaired, and the duration piece is important. There's one thing to take a mental health day, but there's another thing if you're struggling for weeks. Dierdre, I want to ask you the related question, for a person who's in recovery from addiction during this period of isolation, and they're beginning to wonder if they're losing some of their capacity. How might you think about that with someone as a clinician and as a leader in this field?

Deirdre Calvert:

Thank you, that's an excellent question. I was really thinking a lot about what Christine was saying too, is how to maintain this. I want to back up a couple of steps and just think about the culture that we have right now, and the emphasis on relying on alcohol so to speak to soothe ourselves. We have it's wine thirty, or mommy's little helper, or the fact that the liquor stores stayed open during the pandemic. These contribute to what people might think is the normalcy of coping. And we forget that we're having our family and our children watch us as we learn to cope. And if we're turning to alcohol, marijuana, or illicit prescription drugs, they're learning from us. So somebody in early recovery, we're really emphasizing of reaching out.

Deirdre Calvert:

I have right now it's available, and we'll make sure it's available, 23 pages of online support for folks. And I think that's really hard because we also need to remember that many of the individuals struggling with addiction may not have access to computers, to data, to phones, to privacy to even talk to anybody in their homes if they're struggling. So, we are definitely sending out the message right now that you're not alone, and that we are here, and that there are multiple pathways to receiving support, and we encourage all that there's no right way to receive support, and there's no wrong way to receive support, and so whatever works for that person.

Deirdre Calvert:

And I think sometimes people feel like again comparison to the first question I had is, "I'm not that bad, I don't need detox, or I don't need x, y, and z, so I'm not nearly as bad." We need to remember that there's no comparison. If it's impacting your life, if addiction is impacting your life in any way where you can't be a good employee if you cannot raise your children, if you are unable to be present, those are concerning signs for individuals that they need to look at themselves. I would also encourage talking to the primary care doctor, if they're religious to reach out to any kind of religious support, to reach out to friends and family.

Deirdre Calvert:

As I said at the beginning, addiction thrives in isolation. And when we isolate, we get into our own head. And I remind people all the time of how many people reach out to be privately and say, "Please help me my mom, please help me my dad, please help me my child," and if people just started talking to each other, and started understanding this again is a human condition, I wonder where we'd be. There's a wonderful film called The Anonymous People, about whether or not anonymous has helped or hindered a lot of folks in recovery, because it has allowed stigma to kind of fester sometimes because of seeking privacy. Which people are entitled to, and we want them to have that, but we wonder if there was more acceptance and understanding that I think it's one in four people deal with addiction on any level. It might even be more, maybe one in three. That this is a human condition, and nobody's free from it.

Ken Duckworth:

Thank you. Odette asks the question, I'm thinking Christine and Irene, "Black, brown, and other patients of color often get worst care and discriminatory treatment within the mental health care system. Public discussion usually focuses on the attitudes or stigma within those cultures, but what about the quality of care?" And so we're getting closer to the systemic racism questions about care from this reader. Yeah, Christine, do you want to take that on first?

Christine Crawford:

Yeah, and I believe that this question already brings us to the issue of systemic racism and institutional racism. Because Odette, you're right, there's been so much conversations about what it is the communities of color can do to dismantle stigma around mental health, but what is it that mental health providers can do to also dismantle the racism that has been in existence for many years within our field? I think one thing that's important to note is that in recent months, I would say especially given the national reckoning around race, given all the protests and what's been happening during this period of time, is that there have been more open discussions within the field of mental health about the role that clinicians have played in perpetuating the ongoing systemic racism that exists within mental health.

Christine Crawford:

I think it's important for clinicians to understand the historical context of mental healthcare within our country. We know that going all the way back to times of slavery, that there were psychiatric conditions that were specific to slaves, to slaves who ran away or tried to escape from their slave owners. That was an actual psychiatric condition. And the treatment that was prescribed by the psychiatrist was to whip the slave in the hot sun, and that will cure them of their ailment. And then as we moved closer to the 19th century, we know that certain conditions like depression and anxiety were thought to not be experienced by black people because there was this assumption that the black mind wasn't sophisticated enough to experience some of these conditions.

Christine Crawford:

And so if we have that historical context within psychiatry already, and it's already been quite challenging for people of color, black people, to enter into the mental health field, you can imagine that there is a lot of ongoing concerns about whether or not people of color can trust their clinicians. That they have an understanding about this history, and how it has impacted and influenced the way in which we treat certain conditions, and the way in which we diagnose them. When it comes to certain diagnosis, there's been a lot of talk within the field about the DSM5, which is the guide book that clinicians use to diagnose certain conditions.

Christine Crawford:

Now, what we know to be true is that depression, anxiety, trauma symptoms may present differently from folks who are from different cultural backgrounds. And there's no growing recognition of the fact that that is true. And that may have contributed to a number of people of color who are misdiagnosed, and as a result receive the wrong form of treatment, or it could have contributed to a delay in them receiving treatment. The other thing that we see, especially for individuals who are experiencing significant emotional distress, and that's being manifested as being agitated, or experiencing difficulties in terms of the way that they are perceiving information from reality, and the way that they're thinking through things.

Christine Crawford:

When they present to an emergency room setting, or if they're in the midst of a crisis, it is often assumed that if this individual is a black man, that they may have a psychotic disorder, or they may have some other condition when in reality it may be an individual who's experiencing depression. And the way in which they manifest that is through being agitated. And so as a result, we have seen increased rates of black men being misappropriately diagnosed with psychotic disorders, and receiving the wrong sorts of medication treatment for that. And so, I'm encouraged by the fact that my field is now talking about this, looking inward to see how it is that we are further contributing to some of the issues, some of disparities that we see within the mental health when it comes to communities of color. And how we can change our prescribing practices, our diagnostic practices, to be more reflective of a diverse community. The [crosstalk 00:38:55]-

Ken Duckworth:

[inaudible 00:38:57] reassuring to hear the Associate Director of Medical Student Education, I have stumbled upon Drapetomania, which was the name of the diagnosis for escaped slaves, on my own. But it wasn't part of a systemic education, how do race and culture really impact how you do your work? And it just gives me great comfort to know that the students graduating from the Boston University School of Medicine are exposed to you, and to other leaders like you. Irene, do you want to offer a perspective on this question about disparities and systemic racism in terms of the caregivers?

Irene Falgas Bague:

Yeah, I was thinking about what is the best thing I can talk about to optimize the time that we have. But so we did this very specifically, just to bring some very specific information. We asked Latino immigrants both in Spain, living in Spain and in Boston, what were the barriers they were facing to access behavioral health services. And we gathered a lot of different barriers, and then we put them together, we classified them. So, the most important one was related to mistrust on behavioral health services, and it was much bigger here in the US compared to Spain, and there's a lot of things that we could discuss and why, but the language is a big piece as you can imagine. But just so it's very interesting to see that the mistrust, even though they have access, there's a mistrust. And this is very important to know that calls into what Christine was saying about training the professionals on cultural competence, and in being more open to any kinds of emotional distress, and not just use their assumptions as a tool for diagnosing. So, I think that's very, very, very important.

Irene Falgas Bague:

But I think that it's very important to know that the most important barrier that people reported was mistrust on the system. And then the other thing that I wanted to mention is that that was part of a big clinical trial where we were testing an intervention, psychotherapy intervention, provided by community health workers, people who spoke the same language, who came from the same background, who shared a lot of things with the people, with the Latino immigrants. We saw that people with the highest number of barriers, and people who had high levels of mistrust with the systems were the people who were more engaged, and retained to the treatment that we were offering.

Irene Falgas Bague:

So, that's just something to think about that maybe people who should be treating people of color is people from color, or people who really understand and shares a similar background. And this is just a discussion, and it's a result of what we have been finding that when it's someone from the community providing the treatment, the retention to the behavioral health treatment is much higher.

Ken Duckworth:

Thank you, Irene. Let's talk a little bit about January and February. I think all of us on a gray day in November have a sense of dread about our shortened days that are upcoming. And I do want to mention for people who have active seasonal components to their depression, that's happened in prior winters, do not expect it to pass you by this winter. Light boxes, 10,000 [inaudible 00:42:57] it's a very specific intervention, very commonly paid for by health plans. So, if you and your clinician have identified that you have a seasonal component to your depression that is treatable, and the treatment is the use of light boxes. Deirdre, how are you thinking about January and February?

Irene Falgas Bague:

Oh goodness. So, we are working really hard, we've been actually as a team been really thinking about this second surge, and how we are going to engage folks during this time. So, we are continuing to outreach to communities and to providers to ensure access to telehealth. To ensure that our individuals have access to this flexibility that's been offered through the federal government, and now through the state. We are, in fact for some, OBATP, which is Office Based Addiction Treatment Programs, we are reimbursing for phones and data plans, so folks can get inducted onto life saving medications. So, we are planning for that. We are working with our 26 recovery support centers to ensure that we have access, so folks who are struggling have a place to drop in, and to be able to receive support from people.

Irene Falgas Bague:

We are actively, this year alone since January, we've distributed 75,000 Naloxone kits, and we are going to continue to keep flooding the area with Naloxone kits. We are going to ensure that folks who are receiving the evidence based medications of Methadone, Suboxone, Vivitrol, and any other psychiatric or anxiety or depression med that they need, that they can continue to access. We are being as pro-active as we possibly can to ensure safety, and to ensure support for all of our individuals and families.

Ken Duckworth:

Richard and Robin are asking variations on a similar question, this is about isolation during the pandemic, connection being an intervention for mental health. And I want to add the twist of the upcoming Thanksgiving holiday. So, how might you think about this, families and connections are good as a resilience strength concept. Christine, do you want to take that one?

Christine Crawford:

Yeah. What we do know is that when it comes to the holidays, they could be a joyous occasion for all, and we know that it could be a very stressful time for a number of individuals as well. But nonetheless, being able to have access to our loved ones is incredibly important. And I think that there is a significant amount of fatigue around certain social distancing practices that have made it such that people are taking matters into their own hands, and still connecting with loved ones even though the risk of the transmission of this virus still remains quite high.

Christine Crawford:

And so what I've been suggesting to some of my patients about how it is they can navigate the upcoming holidays and the upcoming winter months, is to get creative. And so, ways in which folks can get creative and still be able to maintain that sense of connection with their loved ones, is doing what we're doing right now, using technology, using Zoom, and FaceTime. However, there are a number of communities that do not have access to some of these technologies that make it easy for folks to remain connected. And so, finding ways to call each other on the phone for certain periods of time, or to come up with a plan to make the same recipe together, and share what your experience was like making that recipe with other people.

Christine Crawford:

Finding activities that you can connect with remotely, or at an appropriate physical distance, is something to think about. The idea here is just finding ways to be connected with people, however knowing that connection doesn't always have to be sitting side-by-side with someone, someone right there with you. But being able to have someone you can speak to, someone you can share experiences with, whether it's on the phone, whether it's over the computer, that's the main thing. And we know that it can also reduce some of the anxiety and depression that people can experience if they don't have adequate social supports.

Ken Duckworth:

Irene, how are you thinking about January and February, a predictable challenge for us all?

Irene Falgas Bague:

Yeah, I think that I would draw on what Christine was saying, that it's very important that we get creative, and we really trust on human capacity of adapting, and adjusting to difficulties. Because we know we can go through difficulties, and we can thrive on difficulties, and learn, and adjust, and be even better after that. So, I think that it's very important that we are kind of ourself and we say, "Is this normal?" That will be a tough winter, but I'm going to try to make it as mild as possible in my head. And be creative, so go outside as much as you can, that is something that we are always encouraging. Try to put your gloves, and your scarf, and go outside, and try to plan it so it's something regular, and it's kind of a routine.

Irene Falgas Bague:

And for celebration and for trying to be with the people that you care, and that support you, try to be online, and make it regular. Not wait for them to call you, and then be increase your sadness because they didn't call you, which is something that we see very often. And a lot of conflicts that come because of these lack of planning on the social support. Make it something that is planned, and you know that every day at 8:00 PM you have this conversation with your loved ones that are far away, or that you cannot see. So, make it something regular that you can plan ahead on, and it's part of your life because you know that this is something that will help you cope with the winter, and the season.

Ken Duckworth:

Thank you. Carol asks a very specific question about a subpopulation. "The CDC report that Andrew Dreyfus mentioned at the top of the hour noted that young adults are having particular difficulties right now." Carol's question is about college-age kids, and what they're going through. But first, I just want to acknowledge that the numbers of college-age kids and young adults who are struggling is very high. And that number was impressive, especially compared to older people. And as I think about it, it's hitting people at their developmental moments, when they're starting out, when they're trying to develop an identity, figure out who they are in some ways. Christine, you're a child and adolescent psychiatrist, do you have any thoughts about this developmental disproportionate impact across the lifespan?

Christine Crawford:

Yeah. It's really challenging because we know that young people within this age group, it is developmentally appropriate for them to want to be connected to their peers, to want to have a sense of independence, and to want to have the ability to explore their interests, and have access to things that bring them joy to their lives. And as a result of this pandemic, all of those things have been limited. And then on top of that, there's tremendous sense of peer pressure that is being experienced by these young people when they're on the college campus and they're seeing some of their friends not adhere to certain social distancing practices. And so, there is some difficulty around wanting to be accepted by your peer group, but also knowing that sometimes it's not the best idea to follow the crowd. And so it was a very confusing time. And then you're receiving phone calls from your parents, from your family members, telling you to do x, y, z, and you're not doing it. So, it's really difficult.

Christine Crawford:

Now, on top of that, a rather concrete thing too is that mental health services, behavioral health services on campus and beyond are just overwhelmed, and inundated right now with referrals. And so, we have seen that there is limited capacity onsite to be able to provide counseling and guidance for these young people for how to navigate some of these challenges that may be further contributing to her anxiety and depression. As a child psychiatrist in the clinic right now, we're pretty much full to capacity. We've been receiving so many referrals. And I know earlier we talked about the importance of the primary care physician, but I cannot emphasize enough how important it is to reach out to hem, because there's only 8,000 of us child psychiatrists in the entire country. And so, everyone's capacity to be able to meet the needs of our young people has really been stretched thin. So Carol, I hear you. I hear you, Carol.

Ken Duckworth:

Thank you, Christine. We're just about to close. Final thoughts, Deirdre?

Deirdre Calvert:

So thank you so much for letting me participate. I think that this is the pandemic that we're learning as we go, and we all have fatigue. That's all I kept thinking as Christine and Irene were talking, is that there's so much fatigue. But we're not alone, and I think you said Ken, "Nobody should be worrying alone." There are people, and there are supports, and there's advocates in your corner, and to reach out to those people.

Ken Duckworth:

Irene, final thoughts.

Irene Falgas Bague:

Yeah, I would just emphasize the community where we are part of, and reach to the community based organizations that are around the corner as Deirdre was saying. And look for what are the opportunities that we may have, because also the pandemic has brought new ways of learning, and being treated. And so, that's something that explore what are the things that we can do to get help, because this is very important.

Ken Duckworth:

A lot of resources will be coming to people who signed up for this webinar. I know each of you has submitted resources that could be relevant to more specific questions. Christine, any final thoughts today?

Christine Crawford:

It's okay to not be okay. We're in the midst of a pandemic, and it's incredibly challenging for everyone. And so if there is a day in which you are not able to operate at 100%, have some forgiveness and compassion for yourselves, because this is incredibly difficult for us all.

Ken Duckworth:

Thank you, Christine. We're going to turn it back to Andrew Dreyfus, and I want to thank all of you for participating in this important conversation.

Andrew Dreyfus:

I'm going to start again by thanking Ken, and thanking Christine, and Deirdre, and Irene. We appreciate the insights you brought to the conversation today, and the work you and your colleagues are doing every day to help those experiencing mental health challenges. I want to thank The Boston Globe for its partnership today in these sessions, and on the pages of the newspaper. Every day The Globe is helping the community understand mental health issues better, and some of the resources that are available. Finally, I just want to join all the panelists in saying if you or someone you care about is experiencing mental health challenges, please know you're not alone. As our panelists today shared, there's always someone available to listen, to help. We have a lot of resources in our community, take advantage of them please. So, we appreciate you all joining us today, please stay well. Thank you.