Dr Daniel Knoepflmacher (Host): Hello and welcome to On the Mind, the official podcast of the Weill Cornell Medicine Department of Psychiatry. I'm your host, Dr. Daniel Khel Mocker. In each episode, I'll be engaging in thought-provoking conversations with experts on mental health, neuroscience, and other important topics on the mind.

Today we'll be discussing structural inequities in mental healthcare and ways to create a more just system for those who are unable to access it. The COVID 19 pandemic and national social justice movements of the past few years have heightened public awareness of entrenched problems with health equity in the United States.

 Despite the fact that in our country we spend more money on healthcare than any other country in the world, our overall health outcomes in the US consistently fall below those of other comparable developed countries.

These inherent disparities hold true especially for the treatment of mental illness, where some receive comprehensive high quality care, while many others are unable to access any services at all. Why does our system consistently fail to provide the same quality of mental healthcare to individuals from all backgrounds, socioeconomic statuses, and geographic locations?

What are the steps necessary to improve access to care, address the needs of diverse populations, and ultimately make our system more just in fair? These are difficult questions without easy answers. But today we're joined by someone who I'm hoping can help us wade through these deeply entrenched problems and shine light on potential solutions.

I'm thrilled to welcome Dr. Justin Chen to the podcast. Dr. Chen has a dual role as the Vice-Chair for Ambulatory Services and Vice-Chair for Health Justice in the Weill Cornell Medicine Department of Psychiatry. In this latter role, he'll be spearheading efforts to provide more equitable delivery of care and oversee our community's efforts to promote diversity, belonging, and inclusion.

Justin, thank you for joining us today.

Dr Justin Chen: Thanks so much for having me, Daniel. I first have to say how delighted I am to be here and excited about what you've created with this podcast.

Host: Thank you. Well, we have a lot to tackle. So before we jump in, I'd like to learn more about you. Can you share your story with us and how you developed into your current roles here in our department?

Dr Justin Chen: Definitely. I'm happy to share a little bit about my own journey into psychiatry and into these roles. So, as you know, I actually very recently joined the Department of Psychiatry at Weill Cornell just a few months ago, February 1st, 2023. And prior to that, I had spent my entire career in Boston first as a psychiatry resident at Mass General and McLean Hospitals and then as faculty at Mass General where I had been serving as the medical director of the Outpatient Psychiatry Division and Co-director of Medical Student Education and Psychiatry at Harvard Medical School.

So, I did do my homework. I listened to prior episodes of this podcast. And unlike your other guests, I actually did not know I was going to become a psychiatrist until relatively late in the game. In fact, it was actually during my third year of med school, when you have to choose kind of rotations and the order of rotations and I requested psychiatry as my first rotation, because I figured it would be sort of an easy warmup to the hospital, so to speak. But to my surprise, I quickly fell in love with it. I absolutely fell in love with the field.

I think, in addition to really enjoying speaking with patients and the people that I was working with, who I felt were addressing the problems in a different way, I found I was actually drawn to the stigma of these illnesses. There was no brain scan. There was no blood tests that would diagnose someone. And yet, the suffering was very obvious and very real, and actually often more devastating to patients and their families than many of the physical illnesses that I had encountered.

And so as I went through the other rotations, I kept a very open mind. I found each one fascinating and engaging in their own way, but I kept being drawn back to psychiatry and to the fundamental challenge and mystery of human behavior, which seemed to me to contribute to many of the illnesses that we were managing in healthcare.

However, even with all of that, that great story I just told you, I still had to overcome my own internalized stigma. So, I identify as the child of immigrants from Taiwan. And growing up, I actually had never really heard of psychiatry or the concept of mental health at all. And frankly, my family was horrified when I told them about my decision. And for a while, they tried to persuade me to switch to a different field. So, it took a lot of my own personal reflection, discussion with trusted mentors, even my first experience with psychotherapy, to help me to realize that I should stick with this. This was something that really called to me. And I'm happy to say that my parents now, many years later, I think get it, and they're very happy that I found a career that I love and find extremely rewarding. So, that's kind of how I entered into psychiatry to begin with.

Another important aspect of my background that I think is relevant to today's conversation is after residency training and psychiatry. I think I was always very interested in thinking about the ways that illness and disease doesn't just live in a vacuum, but it's influenced by much larger systems, including culture and society and healthcare policies, things like that. And so, all these interests led me to pursue actually a master of public health degree following my training. And I focused my research at that time on the Chinese immigrant community in Boston, and I was looking at the impact of stigmatizing beliefs about depression on depression outcomes over time. And along the way during that degree program, I strengthened my understanding of the healthcare system and the methods that researchers used to study it.

And so then, you had asked how I ended up in sort of a leadership position in outpatient. So, I had never been particularly aware of or interested in administrative leadership. But when the opportunity came along to take on the outpatient medical director role at Mass General, I decided to really push myself out of my comfort zone and apply because it really appealed to my interest in understanding and solving problems and applying some of that systems thinking I've been learning. So, I was fortunate to receive the role and I was in that role for over four years. At the same time, I was responsible for helping to direct the largest outpatient clinical program in the psychiatry department at Mass General. So during those years, I really cut my teeth and learned a tremendous amount. I didn't know what I didn't know, but I learned a lot.

And so finally, that brings us to today. After 13 years in the same institution, as you might imagine, it was really hard to leave MGH. h But I was drawn to Weill Cornell because of the dedication of the leadership actually jumped out to me. They were so invested in outpatient mental healthcare and really trying new things to address the tremendous challenges that we're going to be discussing today.

I was also really excited about this unique combination of leadership in ambulatory services and health justice, which I do think are tied. It relates to health equity, access to care, et cetera. So ultimately, I made another huge leap and moved from Boston to New York City just this past January. And so far, I'm really loving it.

Host: Well, we're thrilled that you made that shift. It's been wonderful working with you and it's clear in listening, your life experiences, your training, all of this was really excellent preparation for your current job. And I'd like to focus specifically on that second role, your role as the Vice Chair for Health Justice, which you brought up in the end. Justice in the context of medicine broadly and in psychiatry specifically refers to a basic ethical concept that we all should be upholding as healthcare providers. Can you explain in plain words what health justice means?

Dr Justin Chen: So in brief, I would say that I think health justice refers to two related, but almost reverse concepts. The importance of having a just or ethical and fair healthcare system, and as well the role of health and healthcare in creating a just world. So, my actual role title, Vice Chair for Health Justice, is directly adapted from a larger initiative at New York Presbyterian that I'm sure you're aware of, called the Dalio Center for Health Justice. This center was established a few years ago, thanks to a generous gift from Ray and Barbara Dalio. And the mission of that center, which I will be closely collaborating with in my role, is to address health disparities in health justice through research, education, advocacy and investment in communities, including with a focus on reducing disparities that disproportionately affects communities of color.

So, you might be familiar with the really famous Martin Luther King quote where he says, "Of all the forms of inequality, injustice in healthcare is the most shocking and inhumane." And by the way, I recently read the actual quote. It's likely to have actually been, "Of all the forms of inequality, injustice and health is the most shocking and the most inhuman because it often results in physical death." So, he is really underscoring, you know, sort of the stark outcomes of this injustice. But the point remains that problems of health and healthcare reflect fundamental injustices in our society. And so, for example, we know that black Americans have had a lower life expectancy than white Americans for as long as records tracking these outcomes have existed in this country. And they fare worse than any other racial group across a wide range of medical conditions. So, these healthcare disparities track with so many other societal inequities, facing this group in particular that was brought to this country through violence and continues to suffer from the long legacy of systemic racism, both historical and ongoing.

So, the healthcare system, like so many other systems in this country, can and does perpetuate injustice. And part of our job as those interested in health justice is to identify and find ways to address and fix that. And then, for the other meaning of health justice around building a more just society, I want to share another important quote by Rudolph Virchow. So as you may know, Virchow was a German physician. He's known as the father of modern pathology, and his name is known to all medical students because of his famous Virchow's triad, which are the three factors that contribute to the formation of thrombosis or blood clots.

But what many medical students may not know is that Virchow was also an anthropologist. He's someone who studied culture and he's clearly a very broad thinker. So in his investigation of the typhus epidemic in Germany in the mid-1800s, he actually demonstrated that the typhus epidemic had a lot of social contributions, including inequities and the availability of resources and how infectious diseases flowed and ultimately created epidemics. And through this research, he laid the foundation for public health in Germany. So, a lot of these concepts might be familiar to our listeners because of COVID, right? We saw how COVID and these infectious disease epidemics kind of lay bare fundamental structural inequity.

And so, Virchow famously said, this is another quote that I love, "Medicine is a social science and politics nothing but medicine on a grand scale. Medicine as a social science, as the science of human beings has the obligation to point out problems and to attempt their theoretical solution." And so, I think this quote, Virchow is sort of situating medicine as a tool, not just for helping individuals, but also society at large. Our task is not just individual.

So in addition to being the father of modern pathology, Rudolf Virchow has also been called the Father of Social Medicine. So in this regard, I think we can think of healthcare as a means toward creating a more just world for all of us. And so again, just to summarize, I think health justice really boils down to two things, kind of mirrored concepts, having a just or ethical healthcare system that's fair and then having a healthcare system that plays a role in creating a more just world.

Host: Thank you. I never knew that about Virchow. I didn't know of him as the Father of Public Health. But I really like how you crystallize that all down into these two missions behind health justice. And I want to go from the kind of wider level down to the more micro-experiences, real life experiences for, let's say, a person out there who's trying to get mental healthcare for themselves or for their loved one? What does the injustice of our current system look like to them?

Dr Justin Chen: Well, unfortunately, it's actually worse than many people are aware until they have to navigate it themselves. You and I are very familiar because we live in it, but many people don't know. I think, those of us who work in mental healthcare as clinicians, especially those in more acute settings, we find ourselves constantly apologizing on behalf of a totally broken system that none of us created.

So, as we all know, mental healthcare is literally overwhelmed. If it was hard to get a clinician before 2020, it's been way worse since the pandemic. Everyone is full, there's no room at the inn. And ironically, it's actually worse for those with more severe mental illnesses generally. And I think to understand that, we have to trace it back to, again, the systems and the structural roots.

Psychiatric services have been undervalued and basically under reimbursed for decades. And that's in part due to the stigma we discussed earlier where society just hasn't placed as much value on mental illnesses and their treatment as physical illnesses. And these disparities are evident in the fact that politicians have actually had to pass mental health parity laws to try to compel insurance companies that pay for services to cover mental health conditions equally to physical health conditions. And they and we are still fighting to get these laws correctly implemented even over a decade after they were first passed.

One way to understand the injustice of our system is to compare it to kind of a physical health condition. Let's say you caught a cold, which developed into fevers and chills, eventually shortens of breath. Basically, you have pneumonia, right? So, you'd generally expect that you could go to your primary care provider's office, the local emergency department somewhere, and eventually get funneled into the right type of care that you need, which probably involves some tests to identify the cause, antibiotic medications, IV fluids, et cetera, and all through your health insurance if you're lucky to have health insurance. And actually by the way, the more severe the illness, the more you kind of expect that the healthcare system might connect you to the right type of care. Whereas with mental health, it's almost the opposite.

Because of the longstanding undervaluing and under-reimbursement of our services, we have not just a two-tiered system, a multi-tiered system, which all in essence depends on the person's ability to pay. And indeed, with the lack of access, many desperate people are willing to pay top dollar essentially for a private practice clinician who has chosen not to accept insurance at all and sort of priced themselves out of the system. And so of course, when we think about who can afford these private practices, it's actually usually not those with severe mental illness, things like schizophrenia, severe bipolar disorder, substance use disorders, disabling depression. These individuals, because of their illnesses, actually ironically have the least access to high quality insurance, for example, through an employer. And even if they have that access, it's difficult to find clinicians willing to see them because they are more psychiatrically and medically complex and risky. So, our mental healthcare system basically has reverse incentives for clinicians to actually opt out of insurance, to only accept very mildly ill patients, et cetera. Thankfully, we do have many mission-driven clinicians who do want to accept insurance, but the fact remains, we do have this multi-tiered system.

And unfortunately, we also know that severe mental illnesses take a huge toll on multiple levels. So on the individual level, the person themselves who has a mental health diagnosis, they themselves are dealing daily with symptoms. They miss out on life chances because their illness is disabling. And they have huge gaps in mortality. People with severe mental illness live on average 10 to 25 years less long than the general population. Also, we shouldn't underestimate the toll that mental illness takes on families who often bear the brunt of these illnesses and struggle to keep their loved ones safe and healthy within a broken system. Finally, society faces significant loss of productivity. Again, psychiatric illnesses are disabling and chronic. They've been described as coming early and staying late. So, society and governments find themselves struggling to find an approach to managing mental illness, both from an economic perspective as well as within our public spaces, for instance, on the streets, in the prison system, on public transportation, as we've been hearing a lot about New York City of late. So, the bottom line is that people with more severe mental illnesses are paradoxically often the least well served by the mental healthcare system. And that is a serious injustice that requires significant financial investments to truly address.

Host: Well, you're right that both of us, I know speaking for myself, have lots of firsthand experience in seeing people struggling with this and so many are trying to get care and not able to get it or getting insufficient care. So, I'm curious, you've alluded to some of this, but what are the actual things that are causing these gaps? Is it too many people that need services? Is it not enough service providers or is there a system that doesn't really connect people well, these patients to these clinicians?

Dr Justin Chen: It's actually I think all of the above. You're absolutely right. We haven't done, I think, a good job of parsing out the different levels of severity of mental health conditions and appropriately incentivizing care for the more serious illnesses. So, I was describing before, insurance companies generally pay a single rate for any medical service, like in the case of taking out your appendix, let's say, or providing your annual physical exam. In psychiatry, that rate gets applied to our two main treatments available, which are medication management or talk therapy, sometimes both are combined. But clearly, these treatments are not equally applied across all patients. So if you have an individual with complex trauma, multiple suicide attempts, active substance misuse, multiple hospitalizations, that's not the same as someone who is seeking help for mild anxiety. And yet, the care of these two individuals would generally be reimbursed at the same exact rate by the insurance company. These challenges are seen, by the way, also in primary care, which is also generally reimbursed per visit, regardless of the patient's complexity. So, that's sort of the misaligned incentives and then adds to the fact that we have huge shortages of mental health clinicians in this country, especially in more rural areas. We're just not training enough clinicians. And actually, we know now that many people are leaving the mental health professions because of burnout or moving into private practice as I described. And so, you now add to that the pandemic, which in a good way has actually helped to decrease stigma and shed light on the importance of mental health problems and their treatments. But you can see that we've had a perfect storm to overwhelm an already struggling system.

Dr Daniel Knoepflmacher (Host): It is a perfect storm, and you've described a mental healthcare system that's completely overwhelmed. How does this impact those people who already face structural disadvantages even before the pandemic?

Dr Justin Chen: I mean, one way to view that is to see how those who already have some privileges and advantages can navigate the system better, right? So if you have financial resources, you can get a private practice clinician, you're more likely to be able to have more options in terms of who you could find. If you do need to use your insurance for mental healthcare, that puts you in a different category, right? So, you need to find a clinician or a clinic that accepts your insurance. But again, even with the overwhelming demand for services, those who are better connected socially or financially are going to be more able to find kind of a backdoor into treatment since everyone's already full. But if you know a friend of a friend, you're more likely to have the person say, "Okay, I'll take you in." And then if you have a public insurance, like Medicare or Medicaid, rather than a private insurance like Aetna or Cigna or one of the other big payers, any provider that you get referred to or you find online is even less likely to accept your insurance. And then, you add to that racial and ethnic disparities, which often track with socioeconomic disparities. but these racial and ethnic differences may also be tied to other challenges in terms of fit with your provider. And you can see that there are entire segments of the population that are left out in the cold in the current system.

Host: Speaking of fit and background of both the patient and the clinician, in an earlier podcast, I spoke with Dr. Stephanie Cherestal. And we talked about the importance of culturally sensitive mental healthcare. I know you've done work in this area. In fact, I think I have a book on that shelf that has your name on it, because you were a co-editor of a book on sociocultural issues in psychiatry. How do cultural factors affect the ways different communities use our mental healthcare system?

Dr Justin Chen: So, let me just say that conversation with Dr. Cherestal was fantastic and it's definitely worth a listen for those who haven't already. So, I completely agree with Dr. Cherestal's description of the problem there, as well as the potential solutions. As I mentioned, I am the child of immigrants myself from Taiwan, who had very little concept of mental health. But what I've also learned is just cuz we don't talk about something doesn't mean it doesn't exist. These things absolutely exist in diverse populations and we need to understand that and find ways to address it. as Dral also mentioned, many cultures have very different ways of understanding behavioral symptoms.

So, for example, I've done a lot of work in the Asian community and Asian American community. And in many Asian cultures, traditionally psychiatric symptoms are not really seen as a medical problem at all, but instead might be considered a weakness of personality, maybe even just laziness, right? If you're depressed, you're not working. So, the solution is you should work harder. That's an extreme, but I think that's something that folks from the community may recognize.

And you can imagine that for someone holding these beliefs, they would never seek help for those symptoms, right? They wouldn't see it as a symptom at all. Instead, they would try to suppress or hide it, and that's kind of the definition of stigma. But what we know about stigma is that it just drives illnesses underground. And in many cases, it delays care, needed care, and makes them worse over time. If you had pneumonia, you wouldn't say, you know, "Just suck it up and work harder." You would say you need to take time off and address it and rest, and then you're more likely to recover.

But again, I think because there's different ways of understanding these illnesses, clinicians from outside of a patient's culture who attempt to address psychiatric symptoms through sort of a more Western biomedical perspective might as well be speaking a different language and the patient is unlikely to return, right? So, it's important for healthcare systems to understand this and to have some humility about the diversity of ways that patients understand their symptoms, and find innovative ways of addressing those problems, including training as Dr. Cherestal mentioned on the diversity of beliefs that we'll encounter in our patients.

Host: We're focused on mental health in this discussion. And as clinicians, we know that social factors have to be taken into account when you're helping someone who's struggling with an illness. I learned that in medical school, even when it wasn't psychiatry that was being taught. So, can you describe the main social determinants of mental health and how these play into the inequities in our care?

Dr Justin Chen: Absolutely. And I think we had just started talking about that in the prior discussion, kind of expanding our concept of illness. So, there's a long tradition, of course, at least in the west, of thinking of illness as the product of disease. That is a specific pathogen or mechanism that's gone awry within our body and that's the cause and the solution is probably a biological one as well. And this is sort of what's known as a reductionist approach. And that approach has been challenged, you know, over years, over decades by different models. The most famous of which is probably the biopsychosocial model, which was popularized by the internist, George Engel, among others. But it's been around much longer than him. But the point is that this is an idea that illnesses result from multiple intersecting systems and frameworks, including in that case, biological, psychological and social, and you could even add cultural or spiritual.

Let's take the example of diabetes. Someone might be at risk for developing diabetes because of genetic factors from their parents, so that's obviously a biological contribution. But they may also use eating sweet foods as a coping mechanism for having a very stressful life. And that might be seen as sort of a psychological mechanism, a coping skill. And that same person might have extremely limited access to fresh fruits and vegetables. And so, they mainly eat sort of processed sugary foods. They may also have very limited access to safe places to exercise because of where they live. And all of those are social determinants. So, it's that third category that we're talking about when we talk about social determinants of health.

So again, in healthcare, we focused on biological causes, but I think we are expanding into that latter category, which as Virchow pointed out to pull it back to that, exerts significant impacts as well. And I think in a positive way, we're really starting to pay much more attention to that, including at New York Presbyterian. So, social factors include access to resources, including financial resources, health insurance, safe neighborhoods, healthy foods, transportation. All of these factors intersect with and significantly affect both the likelihood of developing a physical or mental illness, as well as our ability to cope with or recover from that illness.

Host: So, you brought up the social determinants of health and of mental health and how we must take these into account, how we are taking these into account and how that's becoming part of the care that we provide at institutions like ours, here at Presbyterian, Weill Cornell. Can you give us some examples of what clinicians can do to address social determinants of mental health?

Dr Justin Chen: Yeah. On a very basic level, just as Dr. Cherestal said, ask about it. So if we assume every patient coming through is sort of the mean or modal patient that we've learned about in a textbook, I think we're going to be missing a tremendous amount of nuance. And not just nuance, but these are actually tremendously important.

So, a very obvious example is when we discharge a patient from the hospital with sort of a chronic severe mental illness, let's say schizophrenia, one of the biggest predictors of whether they end up back in the hospital is whether they take their medicine. And some of that, some small percentage of that is the person's interest in taking their medicine. But other humongous aspects include do they have a health insurance? Do they have a pharmacy? Can they get to that pharmacy? Do they have people in their lives who are going to assist them if they have trouble and also make sure that they are taking their medicine if they need to. So, all of these things are things we need to ask about. And then, you could apply that to any of the other items I mentioned. Again, we know that, let's say, physical exercise is a huge part of many people's mental health. And yet for many people, it's basically inaccessible because of social factors. So, we should be asking about it and then helping our patients understand that and brainstorm solutions.

Host: I'd like you to speak to how the work that needs to be done to promote more diversity, inclusion and belonging within our own professional community relates to these overall goals of health justice for the wider community that we serve.

Dr Justin Chen: I had shared earlier about the significant race-based disparities in access to healthcare as well as health outcomes. Well, it turns out there's actually a body of literature to suggest that having a more diverse workforce can address some of those issues. Racial minorities often report greater trusts and therapeutic alliance with clinicians of the same race, and we know that these factors are critical for improving outcomes, perhaps in part through greater adherence to recommended treatments because of that trust. Racial minority clinicians have also been shown to be more likely to work in medically underserved areas than white clinicians.

So, we think about disparities. One of the solutions that the healthcare system can engage in and is engaged in is to increase diversity of the mental health workforce, as you mentioned. And this has been identified as a priority by almost every professional organization. So here at Weill Cornell, we are very much aligned. We're working on developing, for example, pipeline programs to expose younger students from diverse backgrounds that are traditionally underrepresented in our fields to careers in mental health, and provide opportunities for them to pursue such a career, to gain access to opportunities for research, et cetera.

And in terms of, as you said, diversity, inclusion, and belonging. I think we're working very hard to ensure that our department culture is one where all of our clinicians feel they can bring their full and authentic selves to work every day, where people's diverse backgrounds are seen actually as a strength and an asset that enrich the community as a whole. So those are some of the ways that I think the priorities of our department very much match those of the wider community.

Host: So in some ways increasing diversity and having inclusion in our department is part of the solution and I want to try to move towards solutions because we've talked a lot about these barriers and massive problems that lead to inequities in our system. So thinking about solutions, this is a massive, complex system and I know there's no single answer or simple fixes, but could you describe some basic principles that can be considered when working towards a more just future for mental healthcare?

Dr Justin Chen: I really appreciate the way you framed this question, Daniel. Because you're right, this is not going to be solved by any one single institution or person, right? And I think if we think in those ways, we quickly get overwhelmed. So, it is about all of us coming together across multiple stakeholders and systems. And we can be unified by principles exactly as you're saying. And so, we know there are certain fundamentals about our system that are not going to change, right? Money is always going to be part of the equation, as are these different tiers of insurance. And that's true in medical care too. And so, it's inevitable that there will be different experiences to a certain extent.

But fundamentally, if we go back to first principles, if we believe former Surgeon General David Satcher, who said there is no health without mental health. And we also believe that health is an important part of creating a more just society, then I think we need to work towards a system where everyone has at least access to basic good enough treatment, including mental health treatment, regardless of ability to pay. So just as we think of education as a public good, you can get higher tiers if you want, but there's some basic level that everyone's entitled to. I think we could think of mental healthcare in that same way. So for me, access is sort of an important foundational bedrock principle. Those who prioritize mental health and have the means to do so can invest more heavily in more specialized or longer term care, just to some people choose to invest in private schools for their children or a graduate degree for themselves, but we still need a comprehensive high quality mental health safety akin to public education. So, that's number one is access.

We also need to build systems that recognize that not all Americans will have the same needs or life experiences. So, we need to be ready for a range of patients and be trained in cultural awareness and humility. So, that's another important principle.

And then finally, I think just this idea of the right care at the right time. If someone's in crisis, they can't be waiting for six months, which is unfortunately often the reality. And same for the health systems, if you're providing outstanding care, but no one can get in for six months, it's not really meeting the need. So, we need to work with clinics, with other practices, with other organizations that provide care and health systems to ensure that patients can gain timely access to the expertise available at a place like Weill Cornell and New York Presbyterian and then, maybe have other options for much longer term care that might be in the community.

Host: So in this, I imagine partnerships being really important. And I'd love it if you could speak more about how partnerships could make a difference in this.

Dr Justin Chen: Academic medical centers like Weill Cornell have traditionally played a very large role in providing community mental health care, including the patients with public insurances and those with limited financial means. Other partners in this space that we've long collaborated with include federally-qualified community health centers, social service agencies, community-based group, mental health practices, and other community-based organizations. Many of these entities are under-resourced, but we've long worked together to provide sort of a safety net for some of society's most vulnerable.

And more recently, there's actually been a new entrant into this space. These are so-called telehealth companies or digital mental health companies. I'm sure you've seen or heard their names on the radio or on social media with advertisements. I'm not going to name any because there are so many. These companies have entered the space because they've seen an opportunity in the tremendous demand for outpatient mental healthcare and just the shortage of available, clinicians and resources. And their arrival into the space, by the way, was turbocharged by the pandemic, which resulted in loosening of many restrictions on telehealth. And so from where I sit right now at Cornell, I'm thinking very carefully about how all of these different players can and should come together to meet some of those ideals that I described around providing access to the right type of care at the right time for all patients.

Host: So, these are some of the stakeholders that are going to help us achieve change in this system. What are some of the most important changes that can occur with individuals and local communities to create more effective care? And then, also thinking about on the macro level with like the government, state governments, federal laws, what can be done on all levels to create this change?

Dr Justin Chen: This is a great question too, because we always want to leave with a practical tool, right? What can all of us do? So, I think individuals and local communities can destigmatize mental health issues. If we're honest, all of us have either struggled personally or know someone who has. I think this is the case nationwide. And I also strongly believe that the antidote to stigma and shame is vulnerability and self-disclosure. So, everyone listening to this podcast can share their own story. Talk about their own struggles and how you overcame them, and then also treat others challenges with empathy and understanding. I truly believe these small actions can save lives. And then, I also think what individuals and communities can do is to educate themselves about the system that we're describing and advocate.

We need to be changing, structures, payment structures, and we need to go to our lawmakers and our insurance companies who, at the end of the day, are working for us, right? And speak up about needed changes. And so, that leads to the macro level you described. We do need policy makers, insurance companies, those who wield power to understand, again, that there is no health without mental health, and this underinvestment is only going to come back and bite us in the butt.

So even though the causes of mental illness are seemingly invisible for now, I think we're making great strides in understanding what causes these illnesses. The impacts are enduring and far reaching and costly. We need to fund treatments accordingly. We have to pay, not just for treatments that we have, but much more comprehensive types of care, expansion of the idea of what is care, so beyond just medication management and psychotherapy. But what are the other important services that we're currently neglecting? coordination of care is a huge one, picking up the phone and calling the other treaters. Occupational and vocational therapy, peer specialists who are individuals with lived experience with mental illness and substance use disorders, as well as just more in general recovery oriented programs that help people who've, been diagnosed with mental illness to reintegrate back into society.

Host: Well, Justin, thank you so much. You're leaving us with some hope and some actionable items thinking about destigmatization, about advocacy. It just was so great to be able to speak with you here today on this podcast. You brought clarity to a topic that is not easy to tackle, obviously.

And I want to end by asking you a question that I pose to every guest who comes on this podcast, because I believe it's important for us to all think about and I think it personalizes the wonderful guests that we have on this podcast. So, the question is, what are the most important things you do in your life to help maintain your own mental health?

Dr Justin Chen: Well, I'm a big believer in the idea that before we are humans, we are animals. So, all of us like animals need sleep, food, exercise, and social connection. And unfortunately, those are the exact things that go when we are stressed out. On a personal anecdote, it actually wasn't until I finished residency and was in my first few years as an attending that I made a very obvious realization that I am just not as good of a therapist if I haven't had enough sleep. Like I just can't concentrate, I'm more irritable, which doesn't do well for the treatment. And so for me, I absolutely think prioritizing these things that seem so obvious and fundamental, but are actual building blocks of wellness. And then speaking of animals, occasionally, just a snuggle with a cat can get me back on track.

Host: Those simple things make such a big difference. And it's just so wonderful, Justin, to have you on our podcast today. Thank you so much for bringing clarity to really complicated problems that vex our mental healthcare system, and I think providing us with some hope with your ideas about how we can begin to address the inequities that affect so many struggling with mental illness in our country. Maybe we'll check in with you again later and we'll continue this important discussion. But again, thank you so much for joining us

Dr Justin Chen: Thank you so much. This was a pleasure and you asked really good and important questions.

Host: And you gave great and important answers. So, thank thank you to all who listen to this episode of On the Mind, the official podcast of the Weill Cornell Medicine Department of Psychiatry. Our podcast is available on all major audio streaming platforms, including Spotify, apple Podcasts and iHeartRadio. If you like what you heard today, please give us a five-star rating and subscribe, so you can stay up-to-date with all of our latest episodes.

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