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Transcript: Mental health and well-being in America

On Wednesday, June 13, The Washington Post convened policymakers, health-care experts and advocates to discuss the state of mental health care in the U.S., strategies for addressing the country’s mental health concerns and links between technology use and mental well-being.

Mental Health and Well-Being in America: A view from Capitol Hill:

Cunningham:   I’m Paige Winfield Cunningham, health policy reporter and author of The Post’s Health 202 newsletter.  And I’m pleased to be joined this morning by Senator Brian Schatz, a Democrat from Hawaii, and Senator Thom Tillis, Republican from North Carolina.  Thanks for being here.

Schatz:            Thank you.

Tillis:               Thanks for having us.

Cunningham:   So this morning, we’ll be talking about the government’s role in promoting mental healthcare.  And before we get started, I’d like to remind our audience that you can tweet questions to us using the hashtag #PostLive and we’ll try to fit some of those in near the end of the discussion.  We’ve got a lot of ground to cover, so let’s get started.

Over the last couple of years I’ve done some writing about mental healthcare and I’ve really seen some of the stigma start to come away.  And I know there’s been more public discussion about just the problem of mental illness.  Just to quickly put the problem in perspective, 1 in 5 adults in the U.S. experience a mental illness, and 1 in 25 adults live with a serious mental illness.  And yet, just 41% of adults with mental illness received professional help in the past year.  Of course, last week we had a CDC report talking about the rise in suicides, which is up 30% in the last two decades.  And then, of course, some celebrity suicides last week as well.

Can you share a little bit about your reaction when you hear stats like that, when you hear news like that?

Schatz:            Well, I think—but first of all, thank you for having us and thank you for focusing on this issue.  You know, I used to run a social service agency that focused on adults with severe and persistent mental illness.  And we talked a lot about stigma.  We are making progress on de-stigmatization.  And we’re making progress on understanding that mental health is health and trying to integrate the way we think about that.

But the problem is we have this sort of labyrinthian system that has to catch up with some of our more advanced thinking around mental health.  So it’s one thing to say we need to destigmatize, it’s another thing to say mental health and physical health are interconnected.  But now we have a system which means reimbursements, billing, processing, auditing, statutes, rules, laws, training, availability of care.  All of those are kind of systems issues that have to flow from the sort of premise that mental health is health.  But then you have to get into the details about how systems work and that’s sort of the hard work of making mental health available for everybody.

Cunningham:   Senator Tillis?

Tillis:               Well, I do think the—when I was thinking about this conference, I thought about a personal experience I had about 10 years ago when I was diagnosed with an incurable, potentially fatal disease.  And I was put on high-dose steroids for several months.  And I experienced pharmacologically induced mania.  And then after I came off of the steroids, I experienced clinical depression for nearly two months.  And I realized that even I struggled.  I was a partner at IBM, I was a state legislator, and even I struggled with the idea of recognizing that there was something going on.  It was most likely associated with the drugs that I needed to take to prevent me from getting more ill.

And so it really hits home at a personal level that we have to—I really do believe that we have to make sure that people understand that today’s society views this as if it’s an illness on par with a physical illness.  It is a physiological challenge that I happen to have, that went away after I lost the drugs.  And I, for one, think it was one of the great blessings in my life to really see it from the perspective of somebody who wants to see a doctor but doesn’t want to admit they need help, then wants to go through the whole process of finding a qualified professional to help me.

And I think those are things that we have to continue.  Those who have done it need to be prepared to talk about it.  I have some staff say, “Why on Earth would you talk about your personal experience?” I said, “That’s a part of the problem, people not doing that.”  And recognizing there’s a path to getting well for many, not all, but for many.

Cunningham:   Right.  So let’s talk a little bit about underserved populations.  Who comes to mind when you kind of worry about which Americans are getting access to healthcare—[OVERLAPPING]

Tillis:               I worry a lot.  I worry a lot about people in the prison population.  We did what we called “Justice Reinvestment Act” in North Carolina, when I was speaker, to try and identify that population that we could possibly release from prison.  But not just let them on their own, vector them into various treatment programs.

You know, you got to understand the sources of behavioral and mental health.  They could be substance abuse, some other physiological driver.  So it’s really understanding the nature of the mental health challenge and trying to get resources.  I worry about the poor population in North Carolina.  You know, we’re a state of 10 million people.  Half live in the cities.  Half live in the outreaches of North Carolina.  So I worry about those who are in the rural areas where I actually think the stigma is even a greater driver and they have a disproportionately lower number of options for treatment.

Schatz:            So one thing I think provides a real opportunity is telehealth for a couple of reasons.  First of all, this is bipartisan, and that’s a big deal when it comes to healthcare.  We are trying to find common ground and we were able to enact legislation that did a couple of things.  First, Medicare now reimburses for telehealth within ACOs and within in certain contexts.  Yesterday—or maybe this morning—the VA is implementing a law that allows VA doctors to work across a state line as it relates to telehealth.

Now, telehealth provides access to people, especially in rural areas.  But when it comes to mental health treatment, there are a lot of things that you can do telephonically, you know, through a phone, to decrease the discomfort that individuals feel in accessing care.  I think about the case management that we used to do in Hawaii where half of the time we were actually trying to physically locate the consumers.  And then we were trying to representative payee services.  In other words, trying to manage the individual’s money.  A lot of that can be done with a smart phone nowadays.  So we can articulate a kind of new social safety net using tech.  But it also helps with medication management.

But in the end, people want to have a relationship with their clinician.  Once that clinical relationship is established, once that trust is established, using a phone is not a bad way to increase the quality and access, and actually decrease the cost.

Cunningham:   So what kind of levers do you think Congress should be pulling here?  Because there are sort of many layers of reason why people aren’t getting the mental healthcare that they need.  There’s the stigma about seeking care.  There’s the uninsured rate, which is still relatively high in the U.S.  And of course, lots of fights in Congress about kind of what to do about that.  Could each of you kind of describe what you would like to see, you know, you and your colleagues do legislatively to take on this problem?

Tillis:               Well, you know, I think what we have to do is look at the broader framework that we should go about solving the problems or the gaps in the system.  And if you do that, you have to take a look at city, county, state, federal engagement.  I, for one, think that we should, at the federal level, provide some incentive for the states to take a look at their scope-of-practice laws.  You made me think about it when you were talking about telemedicine.

The other issue that we have in the rural areas is you simply have areas that don’t have access to, say, the highest certified practitioner.  So then you’ve got to get into scope of practice.

Cunningham:   I think like 60% of Americans in rural areas live in these, like, shortage areas.

Tillis:               Right.  And so, you know, when I was speaker of the House—when I first came into the legislature I thought all the healthcare providers were just one big happy family until I learned about scope of practice.  And then I realized they back up and each one of them wants to expand their scope, but they think it’s crazy talk to let some other colleague in a different area of the field.  We’ve got to look at that hole and see how we plug the gap.

Of course, if you could have a psychiatrist in the outreaches of western North Carolina that would probably be ideal because the education, the scope of supervision that they have.  But we’ve got to take a look at how states are actually dealing with their scope of practice laws, how they’re actually allowing us to go over state lines, beyond just the federal purview—like we’re trying to do with the VA—and sit down and really find the gaps and start filling them in a systematic way.  And the federal government should play some role in encouraging the state and local entities to really help us come up with solutions that can become models that other states can follow.

Cunningham:   Senator Schatz, do you agree with that?

Schatz:            I absolutely agree with that.  I was thinking about when I was in the legislature and I was talking to a friend of mine who is a psychiatrist who didn’t want us to expand the scope of practice for psychologists.  And I said, “Great, you want to work in Kailua [ph] as a psychiatrist?”  And they said, “No, thank you.”  I said, “Well, then we’re going to take whoever is willing to provide that kind of care.”

So Thom makes a really good point.  I just want to thank Thom for his courage in talking about his personal experience.  I think, frankly, that’s one of the most important things that public leaders can do in talking about mental illness.  I’ve been noticing, you know, NBA players talking about their anxiety.  I’ve been noticing stars talking about the difficulty that they’ve had with mental illness.  And I think all of that lends itself towards people accessing care and us expecting a system that actually takes care of people.

On what we should do next, I’m just totally evangelical about telehealth.  It is one of the bright bipartisan spots when it comes to healthcare.  And even though we’re not arguing about it, it might be the most important thing that we’re doing when it comes to improving our system of healthcare.

And one final thought, harm reduction, as it relates to drug abuse and drug use, we have an inverse correlation between the availability of medical marijuana and opioid use.  Now, I’m not a clinician and I’m not prepared to assert that marijuana is medicine.  I am just saying that there is a correlation, which is inverse, which is where medical marijuana is available.  You have fewer people using opioids and fewer people dying of opioids.  And so what we have right now is this kind of co-occurring mental health and substance abuse problem.  And we have to look, frankly, outside of the box when it comes to drug policy, criminal justice reform, and criminal justice policy.

So we have to, you know, engage in a kind of straightforward bipartisan discussion about what’s going to solve this problem.  And frankly, I’m the son of a principal investigator, son of a doctor, and I was pretty skeptical about marijuana as medicine.  I continue to be skeptical about marijuana as medicine, but I am very skeptical about the idea that we prescribe opioids to the extent that we do.  And whatever works to reduce the incidents of death, accidental or suicidal, we should pursue as aggressively as we can.

Cunningham:   I want to—sorry.

Tillis:               If I can touch on just one other piece.  First, I agree, and I’ve never really understood a society that thinks it’s all right to prescribe an opioid, a product of opioids, but have some problem with even considering the possibility of prescribing something that’s derived from cannabinoid.  So on the medical, to me, it’s the thing that produces the greatest efficacy for the least risk to the patient.  So I think that’s something we have to keep talking about.  Not the Wild, Wild West that we’re seeing in some states, but treat it on par with other treatment options.

But there is one other thing that I think we also have to do.  And better educate—with my own personal experience—better educate caregivers and family members.  I remember when I was going through this, and I did share it with some of my family members, what I was dealing with.  You know, they have these platitude sort of solutions, like go fishing, or go surfing.  I wake surf.  I don’t surf on the big waves.  They scare me.  [LAUGHTER] But you know, just do that, or if you know somebody, go shopping.  And that really—you have the same challenge for dealing with people with Alzheimer’s and dementia.

We need to better educate the population on how they can help get people who are suffering with mental illness to someone who can help them.  And there’s a lot to be done on the caregiver side.

Cunningham:   I wanted to go back real quickly to the telehealth thing.  I want to talk more about opioids.  But can you explain a little bit more why you think telehealth, telemedicine has so much promise in this area because, as you probably know, providers have been pretty slow to adapt to this, discouragingly so.

Schatz:            Well, I think they are going to adapt to it.  Some of that was the economics of Medicare not reimbursing, right?  So if, say, 20 to 40% of your payer mix won’t reimburse for telehealth services, it’s really hard to have parallel system.  One that’s sort of Medicare-oriented and one that is VA, and private pay, and everything else.  This Medicare change will, I think, change the view of private hospital systems, doctor’s groups, and others.

Listen, you know, some of these docs have been trained in a certain way of delivering services and that’s part of the issue.  But in the long run, look, 10 years ago, 15 years ago, if you told a patient that they were going to interact with their clinician via a laptop or a smart phone, they would have been insulted and irritated.  Now, if they can’t interact with their clinician—

Tillis:               They’ll be insulted and irritated.

Schatz:            —they will be insulted and irritated.  [LAUGHTER] And that’s an absolute transformation in the way that we all expect to be delivered services.  And you know, from Orrin Hatch, and John Thune, Thom Tillis, to myself, and Ben Cardin, and Mark Warner, others, I mean, we’re moving as aggressively as we can because this is the one space where everyone seems to agree we’re going to increase the availability and the quality and decrease the cost.  And as we fight like cats and dogs over the ACA and everything else, this is a space where we can really institute some significant changes.

Tillis:               Also, I think the other thing that’s caught up is that we’re not any longer talking about technology that’s like a Skype experience.  I was just at Vidant Health [ph] care, one of the largest healthcare providers in North Carolina, visiting three weeks ago.  They just stood up a new system that really makes you feel like you’re interacting with a doctor, you’re not just a head on the screen.  So the user experience, the patient experience, is vastly different than 10 years ago.  And I think that it’s time for it to become ubiquitous.  And I also think it’s time to measure reimbursement on the basis of the outcome, not the manner in which the care was provided.

Cunningham:   So let’s talk about, just briefly, something that’s not so bipartisan.  I don’t want this to devolve into a discussion about Medicaid expansion and all of that.  However, I do want to ask you, Senator Tillis, Medicaid is the single largest payer of behavioral health services in the U.S., so how do you respond to the arguments that rolling back expansion would hurt people’s coverage and therefore their access to mental health services?

Tillis:               Well, you know, in North Carolina, as speaker, we didn’t expand Medicaid under Obamacare.  And the reason that we didn’t is I wasn’t quite sure what Congress was going to offer the states at some point in the future.  Because, again, when measures get passed that are purely on partisan lines then they’re always subject to some kind of change going forward.  So I told my team that if we wanted to look at populations, we needed to expand Medicaid, then let’s do it under the current reimbursement rules so that we don’t suddenly create a system that could be a financial risk should the rules change.  And they almost changed last year.

But what we also did is start working on expansion of accountable care organizations.  Now we’ve got some of the best examples of capitated models that are working, that the healthcare providers.  We went through a lot of challenges to get them going, to where we’re driving down the cost of care and freeing up those resources to expand services.  So at some point, we have to recognize there’s a lot of inefficiencies in the Medicaid system that should be driven out so that we’re getting better quality care, more access to the population.

And I think that right now it’s just become an either-or.  I think there’s something in the middle that would probably address the fundamental concerns of all the people—on either side of the aisle that just want a political win—that there’s a way to do it to where you can expand care, but you do it and bend the curve.  When I came in as speaker, I had a $750 million shortfall in the year that had to actually be paid for with next year’s dollars.  And we could not afford to sustain that because it was putting at risk.

When you have a Medicaid shortfall—you’ve been in the legislature, you know how this works—you usually cut provider rates.  And then that actually causes a number of issues that are, at the end of the day, harming the patients.  So you’ve got to be—you’ve got to go in with your eyes wide open.  If you’re going to expand it, make sure it’s sustainable.

Cunningham:   Of course, we also have the private coverage, and most Americans are covered by employer-sponsored plans.  And we have the Mental Health Parity law, which it was passed, I think, in 2008 or 2009, but then the ACA strengthened.  But there’s been quite a lot of reporting on how implementation of that law has been pretty slow among insurers.  Of course, the law requires them to cover mental health services sort of on par with other health services.  And I believe the labor secretary has asked Congress on numerous occasions for more authority to kind of crack down on these insurers, to implement the law, and put its provisions in place.

Are you aware of that?  Do you have any thoughts about how we could kind of speed up this provision of mental health services among private plans?

Schatz:            Well, part of it is just the availability of clinicians.  You know, we were talking about psychologists and psychiatrists.  I’m thinking of east Hawaii, Hilo town, our perennial challenge with the agency that I ran was we just couldn’t get a psychiatric nurse who could last on the Big Island.  And it was an incredible challenge.

So we, you know, in the State of Hawaii, we have the Prepaid Health Care Act, which is actually something we should do nationally.  You’ll hate it, Thom.  [LAUGHTER] But anyone who works 20 hours gets healthcare.  And it’s clean.  The business community likes it.  And everything is more expensive in Hawaii except for healthcare, even on the private side, even on the Blue Cross Blue Shield side.  It is the cleanest way to do it.  It is a mandate.  It’s you work 20 hours, you get healthcare.

And we have very aggressive parity laws.  A Democratic legislature and a strong advocacy community.  But the challenge in terms of parity, in my view, is not purely at the reimbursement side and the way that insurance companies operate, but it’s just the availability of clinicians, which is why I’m evangelical about telehealth.  I’ll say it again.  But also, we need to do more training and to be adults about scopes of practice.  I came in—as I just mentioned—a doctor’s son, kind of a hard-nosed guy about doctors versus nurses, and psychiatrists versus psychologists.  And over time, I just realized that that is a theoretical exercise when nobody is willing to care for people in rural communities.

And so it’s about getting providers out there.  Sure, you’d always rather have a more well-trained individual wherever you can, but you just have to deploy people who can provide care wherever they can.

Cunningham:   Senator Tillis, do you have any thoughts on mental health parity or is something you’ve—

Tillis:               I agree with him.  I hate the one option, but everything else he said I agree.  [LAUGHTER] I think what it comes down—and this is really where I think reasonable people need to sit down and say, “Instead of this either-or.”  I mean, I think we all ultimately want everyone to have broad access to healthcare.  But we have to get to the sustainability question, and it has to be the whole of government.  It can’t just be a federal solution.  As a state legislature, I think we can play a role.  A lot of our urban leaders would play a different role than our rural leaders.  But if we really want to solve this and make it less of a political lightning rod on how you solve it and sustain it, we have to people sit down and even recognize what may work for Hawaii—with a very different industrial and business mix—may not work in North Carolina.

So we start looking at how we come up with enablers from the federal government that let the states execute these with the ultimate goal of everybody having access to whatever healthcare service they need.  If they can pay for it through a private employer, great.  If they can’t, then the safety net exists to help the others.

Cunningham:   Now, Congress did pass some mental health reforms, I think a year-and-a-half ago, as part of the 21st Century Cures Act, which was kind of widely seen as, like, doing some—making some modest reforms, but nothing very sweeping.  Do you think there’s any energy in Congress to kind of have another go at this?  Is there an obligation on lawmakers to act?

Schatz:            My instinct is that where this will fly is in the context of our continuing efforts to address the opioid crisis.  And I think there continues to be an appetite.  But frankly, because of the bipartisan leadership of people like Thom, who are willing to talk about mental health as health.

I just want to add one little thing, which is that we really have to talk about the homeless population.  We have to talk about meeting people’s basic needs.  Because, you know, you have really no prospect of getting better if you’re sleeping on the street.  And so we just have to prioritize housing people and meeting their most basic needs because it’s morally correct, but also because it’s clinically indicated.  We know that now.  And we spend so much money servicing people’s problems, and it would be literally cheaper to put them in a hotel, and let them get some rest, and let them get clean, and be safe than to either require that they get clean before they get shelter, which is counterintuitive.

But that is the way most homeless shelters work.  That is the way our social service community is forced to work.  So we really have to think about housing first.  But more generally, we have to understand these are people, and what would you do if one of your friends or family members was mentally ill, probably physically sick, and out on the street?  You would prioritize housing, food, being safe.  And we don’t do that in the social service community.  We prioritize servicing the illness at the back end and people have very little chance of getting better if they’re in danger or deeply physically uncomfortable.

Cunningham:   One of the—sorry, go ahead.

Tillis:               I think, actually, Senator Franken and I were working on this before he left the Senate.  We’re trying to pick it up with other members to try and take a look at, again, steps.  Nothing really big happens here.  When it does, it’s usually not good.  But there’s a number of steps that we can take.  I think we have to look at the prison population and the veteran’s population.  If you take a look at—I mean, even if you take a look at traumatic brain injury or post-traumatic stress, those are other mental health challenges that we need to work on, particularly for our nation’s veterans.

So I think if we start with these very focused, very narrow populations, then they can also be adapted to the remaining population.  That’s the way that you actually get things done in Congress.  Where you can scope it in on a population where there’s virtually no daylight between Democrats and Republicans, say on the veteran’s population.  There’s a large number of people, like me, who are prepared to talk about criminal justice reform and targeting the prison population, the way that we did in North Carolina.  Those are the kind of positive steps I think we can take, and look to producing an outcome versus trying to hit a ball out of the park.

Cunningham:   I think you make a really good point on how you can achieve more bipartisanship on sort of smaller issues or smaller populations.  But what’s sort of unique about our system in the U.S., of course, is that we have such a complicated health coverage system, unlike many other countries.  And this makes it really hard to achieve any kind of consensus on how to expand care because we have Medicare, Medicaid, private coverage.  Are there any big levers that Congress can pull to really expand mental healthcare access?  Or is this just this  necessarily have to be sort of an incremental thing because of the way our system is set up?

Schatz:            I think this does have to be incremental, but I think one of the beauties of being in the United States Senate is even the small things are actually enormous.  There’s a saying in Hawaii, “You have to go slow to go fast,” and I think that we have to go slow to go fast.  We have to not try to hit homeruns.  You can score a lot of runs with a lot of singles and doubles.  And again, if you’re talking about federal legislation, you can make an enormous difference kind of below the radar in the areas where we’re not in disagreement.

Cunningham:   Any final thoughts, Senator Tillis?

Tillis:               If I answered I’d be over time.  [LAUGHTER]

Cunningham:   Well, that is all the time we have for today.  Thank you so much for joining us this morning.

Schatz:            Thank you.

Tillis:               Thank you.

Cunningham:   And now I’d like to welcome my colleague Amy Ellis Nutt to the stage.

Mental Health and Well-Being in America: On the front lines:

Nutt:                Good morning.  My name is Amy Ellis Nutt.  I’m the neuroscience and mental health reporter at the Washington Post.  I am joined here today by Mary Giliberti, the CEO of the National Alliance on Mental Illness, and Joshua Gordon, the director of the National Institute of Mental Health.

We are going to be talking about some of the more specific and pressing issues in mental health today.  Some of these issues, we hope, will generate some answers or at least avenues to answers, but we’ll see.  I want to remind the audience that you can tweet questions to @PostLive and feel free at any time during this section.

The first question, unfortunately, I am going to begin with because it has been so much in the news and that’s suicide.  Not only the very public suicides of Kate Spade and Anthony Bourdain, but the very recent, in between those two deaths, the CDC report on suicide in this country with the alarming statistics of the increase in 49 out of 50 states with Nevada being the one that didn’t but already having a high rate. I wanted to also make a reference to depression and the fact that diagnoses of depression have increased rapidly and the use of antidepressants has increased some 400% since the 1980’s.  It would seem that we are doing something wrong.

Dr. Gordon, if you would begin, are we doing something wrong?  What do we need to make sense of those numbers?

Gordon:           First we have to acknowledge that this is a big problem that we are not addressing.  The rates have been going up consistently.  That is not news.  It has not been news since 1999.  That’s tragic, not only for the individuals who are losing their lives to suicide, but for their families, for the community, and for the country as a whole.

We, on the one hand, are doing a lot of things right now.  We’re talking about it more.  Those diagnoses going up?  As best as we can tell that’s because people are going to their doctors more.  And the prescriptions for antidepressants going up?  That’s because people are getting better treatment.  But treatment doesn’t always work, and when the base rate of depression goes up and other mental illnesses that are associated with suicide then deaths by suicide will go up as well.

What are we doing wrong?  Well, I think one of the most telling things in the CDC report that was released last week was the fact that over 50% of those who completed suicide had no known mental health diagnoses.  Now we know from years of research that if you go in and really look hard at those who have died by suicide, you talk to their family members, you look at their medical records, you find evidence for a mental health condition in over 90%.  So that means to me that it is quite likely that the majority of those who complete suicide in the United States, the majority of those 54%, have an undiagnosed, untreated mental health condition, and I think that is one of the big things we’re doing wrong is we’re not discovering these cases.

Giliberti:          This area is very personal to me because during college I lost a dear friend and suitemate to suicide.  She had major depression.  So when I think about this I think about it in two different ways.

One is what we need to be doing as friends, as colleagues of people who have these conditions, and that is don’t do what I did, which was say, “Cheer up, look on the bright side,” things like that that were totally unhelpful.  What you want to do is really express empathy and say, “I’m there for you.  I’m here for you.  I care about you,” and help that person get connected to the right help.

The second part of this is that it’s difficult to find the right help, to find evidence based treatments for things like depression.  I think that’s an area where we’re not doing enough, to make sure people have access to the therapies that we know work: evidence based therapies, cognitive behavioral therapy, dialectical behavioral therapy, different kinds of therapies.

If you also look at the fact that, of people who die by suicide, 10% were released from an institutional setting, that could be a psychiatric hospital or hospital.  So there are things we could be doing and follow-up care to make sure that those people have access to the best that we know to make sure we reduce the risk.

I think there are things that we could be doing as the public, as colleagues, friends, family members, teachers, I think there is a role for all of us and we’re doing education in schools around that.  And then I think there is a role for the mental health system to step up and do better in terms of reducing risk.

Nutt:                You bring up access, which is frequently noted as being one of the main problems in addressing these mental health issues.  More than half the counties in the United States do not have a psychiatrist, psychologist, or social worker, so how do we address that problem of getting more professionals and getting them into the right places?

Gordon:           I think there is some data to help guide us.  We know that coordinating mental healthcare and physical healthcare can really help, actually, both mental health and physical health.  But I think starting with the healthcare practitioners who are in that area, training them, but also teaming them up with health professionals, is a great idea and has an evidence base behind it.

In the previous conversation the senators mentioned telehealth, and I think that’s another great way to bring mental healthcare to rural settings.  I do think we also have to look at task shifting, that is having people who aren’t traditional mental health professionals play a role.  We have lots of evidence that in under-resourced settings that can work.

In the United States, though, we have lots of mental healthcare providers.  Probably not enough, but we have lots of them.  Getting them to the patients who need it in the places that they live, we can do that with modern technology, and so I think we really ought to give that a try.

Nutt:                One of the things that I’ve come across with regard to telepsychiatry and telehealth is, obviously, rural areas, and rural areas that sometimes do not have internet access so telepsychiatry is not going to work for them.  How do we reach those people in those rural areas?

Gordon:           Well, people have telephones.

Nutt:                Yeah.

Gordon:           That’s one way to do it, but it’s a real challenge, right?  That’s one of the reasons why you have to look at things like task shifting and training the providers who are in those areas now.  We need to make investments in areas to make sure that we can reach everyone.

Giliberti:          I think when you talk about the financing, that’s something that is important to be thinking about because the shortage of providers at least, in some ways, is linked also to the fact that payment rates are not the same in mental healthcare as physical healthcare.  There was a study last fall that showed when a psychiatrist and a general practitioner did the exact same thing, same code, the psychiatrist actually got paid less, which makes no sense at all.  Hospital care, same thing.  You see in our hospitals, including rural hospitals, beds being shut down because cardiac care pays more than psychiatric care.  We have a real problem when it comes to financing.

We have pilots going on in some areas, something that is called a Certified Community Behavioral Health Center.  That’s a mouthful, but it’s basically like federally qualified health centers for mental healthcare.  We have pilots going on in eight states including Missouri, so states with rural populations, where these centers are paid like the FQHCs so they’re actually paid at cost.  Which would seem kind of logical, but in mental healthcare our payment systems are anything but logical.

Early outcomes are good.  They’re held to high quality standards.  In mental health we have very little quality standards and very little measurement of care, so that’s another benefit in these pilots.  That’s an area that I think we’re making some progress, but we’d like to see that across the country.  No more pilots.  Let’s let everybody have access to well financed mental healthcare.


Nutt:                Nice shout out.  [LAUGHTER] I’d like to ask a few questions about the most seriously mentally ill.  These are people that seem to really be caught in the system.  I know, Mary, you’ll address the paper coming out on parity.  But I wonder, Dr. Gordon, if you could first address inpatient beds.  This is a real problem for the most seriously mentally ill.  I think we’re down to about 11 per 100,000 people in this country.  That’s the same number as in 1850.

At the same time these most seriously mentally ill, because there is no community healthcare or there is not enough community healthcare, are going to emergency departments and are being boarded, sometimes for days at a time.  What can we do for the most seriously mentally ill?

Gordon:           We’ve got a system that is at its breaking point in terms of capacity.  I’m not 100% sure—as a research institution I abide by the data—I’m not 100% sure the data would say that inpatient beds is where we need to go.  I think if we had better outpatient care, better community mental health centers, et cetera, we can keep people well in the community, but they need more than that, right?

The best evidence, for example, in first episode psychosis, in individuals who are coming down with their first serious expression of schizophrenia and other psychotic disorders, that coordinated care, looking not just at stopping their psychosis but also helping them with social issues, helping them with cognitive issues, giving them assistance with vocational help, that a combination of that care leads to the best outcomes.

Coordinated special care, fortunately, is on the rise thanks to the research that we have taken out, thanks to our sister agency the Substance Abuse and Mental Health Services Administration promulgating coordinated special care as an evidence based care practice for the centers that they fund.  It’s on the rise, but it’s really, really inadequate.  So if we could address the needs of those with a serious mental illness we would maximize their potential.

I would still assert that’s not enough.  We are not going to get enough people to full recovery, to full integration in the community, until we come up with really transformative treatments, and we’re hard at work at that at the NIMH, but it’s a good start.  If we could now give everyone the treatments that we know work best we would make a lot of people’s lives a lot better.

Giliberti:          Amy, this is sometimes referred to as the greatest health disparity that nobody is talking about, serious mental illness.  The lack of urgency, many times, to address what are just incredible disparities in access to not only mental healthcare, which is part of it, and physical healthcare.

People with serious mental illness die at least 10 years earlier than people who don’t have these conditions largely for health conditions that are treatable, but they don’t get access to the screening, to the treatments.  A lot of times providers don’t think that what they are complaining about is real, and because of this lack of integrated care people don’t get that physical healthcare, either.

On the mental health side, people can’t get access to really good evidence based care.  People want to work?  They can’t get supported employment services.  People want supported housing?  It’s not there.  The evidence based care is not there on the mental health side.

The Post reported of a woman who was discharged from the hospital in a gown, really, after an acute psychiatric episode, and there was outrage.  But there should be outrage about the fact that every day, in every area that I know, people are discharged from acute circumstances with no follow-up care.  You don’t do that when someone has hip surgery, you don’t do that when they have cardiac care, why do we keep doing it when people have serious mental illness?

That lack of coordination is really a tremendous problem for people with serious mental illness and for their families.  As we said, the financing is terrible.  There is discriminatory policies that prevent payment for certain inpatient care.  As Dr. Gordon was saying there is not enough financing for coordinated specialty care, which we know works.  We know it works.  We’ve seen it work.  There is a lot of research showing that for young people, they go from, in New York for example, 40% working to 80% working, 70% having rehospitalizations to 10%.  These are huge changes.  In any other condition everybody would have access to that, but we don’t.

So when you think about it, people with mental illness, and particularly the most serious conditions, we always lag behind.  We’re always at the end of the line.  We don’t know why we’re at the end of the line because if you look at our numbers we should be at the front of the line.  If you look at that disparity, that we’re dying earlier, we’ve got the highest readmission rates, we should be at the front of the line and yet we’re always at the back of the line.  We say if you look at marriage equality it was love is love, well we think care is care and people with serious mental illness aren’t getting much of it, physical or mental.


Nutt:                Before we came out we were talking about how since 1971 there has been a war on cancer, there has been a war on drugs, a war on AIDS, a war on Alzheimer’s, a moon shot for cancer, but nothing for mental illness.  You had a great line.

Giliberti:          Yeah.  People always talk about the moon shot and cancer, and I think that’s a very accurate portrayal because we’ve been to the moon and we know something about the moon, and certainly there is more we need to know, but it is something that we’ve done.  In mental illness we need a Mars shot.  We need to go where we haven’t gone before because the brain is very difficult and we need newer and better treatments.

So working with NIMH and Dr.  Gordon, working with the Stanley Center at Broad, my organization, a lot of academics, the pharmaceutical industry, we’re all getting together to talk about what do we need to do next?  How do we get that Mars shot?  How do we get public/private partnerships?  I like the Dr.  Gordon because he’s the expert.  I’m just the person who knows we need this, but he is going to hopefully get us there.

Gordon:           So.  [LAUGHTER] Let’s hope.

Nutt:                No pressure.

Giliberti:          No pressure.

Gordon:           No, I think there are a lot of opportunities, and Mary knows this because of the conversations that we have been having over time.  There are a lot of opportunities now that we didn’t have before.

For example, in schizophrenia.  As little as five years ago we had no known identified bona fide genetic causes.  Now we have probably close to 250.  These are each biological clues, they are not treatment targets just yet.  We can’t design drugs, necessarily, against those and help folks, but they’re biological clues now that we didn’t have before.  We hope to be able to use that information to engage with pharmaceutical companies, with academics, to try.  It’s worth a try.  It doesn’t take that much to see how many of those 250 places in the genome that are associated with schizophrenia, how many of them might lead to new treatments.  But it is going to take concerted effort.  That is just one example of, I think, the new opportunities that we have in neuroscience.  There’s lots of other causes of schizophrenia besides those genes, but these are hard biological clues that are potentially actionable.

Nutt:                We have a great question from, on Twitter, Stephanie.  How do we get policy makers and healthcare providers to recognize the role of mental health in chronic diseases like obesity and heart disease?

Gordon:           I think healthcare providers actually do recognize it because they see it, they live with it every day, but they don’t necessarily, number one, know what to do about the mental health contributions to these chronic illnesses, and number two, as Mary was saying before, even if they know what to do or know where to send them, access to care is problematic.  So over and over again the data is very, very clear: you integrate mental health into traditional physical health settings and the care gets better both for mental illness and chronic disease.  So that is one way, in direct answer to the question, is get more providers who have the psychiatrist or social worker right next door to their offices.

Nutt:                Right.  Integrated healthcare is so important since we now know that about 70% of antidepressants, for instance, are prescribed by primary care doctors, even OBGYNs.  Even more reason why we need to have them all in one place.

Giliberti:          It’s a reason why I know we were going to talk about parity.  Parity is so important because people need mental health coverage.  If you have a mental health condition, or if you have a physical health condition that has mental health implications for you, you need to be able to access the mental healthcare.  And so for decades we have been fighting for parity which is equal coverage for mental healthcare and physical healthcare.  But there are some policies that people are talking about right now, lawsuits that are pending, that would get rid of, for example, the pre-existing condition protections.  So if you have a pre-existing condition currently you can still get insurance on the individual market.

If you had that chronic condition or you had a mental health aspect to it, a mental health condition with it, you can still get coverage today, but if that’s gone are you still going to be able to get coverage?  We also see people talking about plans that don’t have all the coverage that we currently have.  Under the Affordable Care Act we had protections against pre-existing conditions exclusions, and we have essential health benefits.  That means mental health and substance use has to be part of the plan and that it has to be covered at parity, meaning equality.

We have been looking at what it was like before these protections existed so people don’t forget, because if you don’t know your history you are destined to repeat it.  We released a report today with Georgetown University called “Mental Health Parity at Risk.”  And when we looked back at what it was like back then, let me tell you, it was rampant discrimination: people with mental illness not being able to get coverage at all, people getting exclusionary policies which says, “You can have coverage except for the thing you actually need it for,” higher premiums, 20-50% higher premiums, higher co-pays, you name it, difficulty accessing prescription drugs for psychiatric care.  That’s where we were.  We certainly do not want to return to the days of that kind of discrimination.  It’s not perfect today, but it’s a far cry from what we were experiencing then, and I urge people to check out the report on our website.

Gordon:           Let me just point out there is one fact about mental illness which makes the pre-existing condition issue all the more important, and that is that mental illness strikes young and it stays with you throughout your lifetime.  Most mental illnesses occur in late adolescence or early adulthood.

Imagine you were diagnosed with depression at age 19.  You are going to have chronic remitting depression, very, very likely, for most of your adult life.  You are going to have that as an active issue that needs management.  It doesn’t mean you are going to be suffering the whole time, fortunately we have good treatments, but you are going to have it as an active issue.  That is going to be a pre-existing condition.

Most other illnesses that afflict the young are acute illnesses that get better and then you don’t have to worry about it again.  Like diabetes, psychiatric diseases strike early, they stay with you throughout your lifetime, they are going to affect you in terms of pre-existing conditions for most, if not all, of your life.

Nutt:                I want to ask Dr. Gordon a question that you’re going to have to answer in a minute and nine seconds, and that’s specifically about ketamine.  ketamine is sort of the new Prozac, except the new super Prozac, and has been fast tracked, may well be approved, the nasal spray, by the FDA this year.  At the same time there are thousands of people already being treated because it is used in anesthesiology and there are clinics that are run by anesthesiologists giving this nasal spray to depressed people.  Where do you stand on ketamine as the next great drug?

Gordon:           A few things to point out about ketamine.  Number one, there is really good data, but from small numbers of people, that ketamine given intravenously works for what we call treatment resistant depression, people who have tried at least three antidepressant treatments, be they drugs or psychotherapy, and not responded.  In that case ketamine is probably a good option, at least given intravenously.

The data on intranasal ketamine look good, but is not yet FDA approved.  So I’d recommend that people hold off until the FDA approval.

Nutt:                I want to thank Mary Giliberti and Dr. Gordon.  We have to end now for the next panel.  Thanks again.

Content from Cigna: America’s Mental Health Crisis – The Growing Impact of Loneliness:

Mundy:           So good morning.  I’m Alicia Mundy.  I’m an author and a long-time editor and reporter on healthcare policy in Washington.  With me is Mr. David M. Cordani, and he is the CEO and president of Cigna, the global health service company.

Cordani:          Good morning.

Mundy:           I’m going to start you off with a—good morning to you.  I want to ask the most obvious question, but why is Cigna sponsoring an event on mental health and well-being?

Cordani:          Sure.  So to understand that, you have put it in the context of our mission.  We’re a global health service company and our mission is to improve the health, well-being, and sense of security of the people we serve.  We have the blessing and good fortune to have 95 million customer relationships around the world.  But we were early on to understand that the connection between mind and body, to get the total health equation to work together, was critical for the benefit of our customers, working with our healthcare professional partners.

So the whole notion of loneliness, mental health, mind-body connection is a critical part of how we orient their business.

Mundy:           Well, that brings us to the next question, which is, last month, Cigna launched kind of an unusual study.  It launched findings of its Loneliness Index.  What made you decide to actually take on this issue, loneliness, and where are you going with this with its contribution to mental illness and how we can deal with it for mental health and well-being.

Cordani:          So, I mean, it started with a hypothesis or hunch.  We believe that we were on the precipice of or confronting a loneliness epidemic in the United States.  We’ve seen pockets of that around the world as well, but specifically focusing on the United States.  You don’t leap in when you have a hunch or a hypothesis.  You have to better understand it.  So we partnered up with UCLA.  We fielded the largest study of its kind with UCLA in the proven methodology, surveying well over 20,000 individuals over the age of 18 to garner the insights, to take the hunch and determine whether or not the facts supported it.  And then with the design of the survey to be able to get some quite good insights to be able to guide action and behavior going forward.

Mundy:           So let me ask, I looked through the study.  I read the report.  There were some, again, unusual findings and a number of negative ones, a number of sad ones.  What was the most surprising findings for you?  Which ones were the major ones?  And what was the most surprising?

Cordani:          Yeah.  I guess, personalized a little bit in terms of the way I process the information.  As I said, we started with the hunch.  A bit astonished and breathtaking when about half of Americans correlate themselves in some way, shape, or form to being lonely.  So you kind of look left and right with your colleagues, your loved ones, your partners, et cetera and say, “Wow.”

Second is the hypothesis kind of validated back to the challenge in terms of today’s youth, or as the survey was looking at, since it started with people 18 years and older.  The 18- to 22-year-olds were the loneliest of everybody surveyed.  And the senior population was less lonely.  So that was a surprise.  That was a surprise.  But bringing back the two punchlines about one and two, just shy of one and two, and secondly the younger population feeling more lonely, more disconnected, even with that large base of one and two.  That’s pretty breathtaking.  So then you step back and determine what are you going to do about it.

Mundy:           There was another finding in there that I think correlated with the youngest group also being the loneliest, and that is that they are so involved in social media and yet one of your findings, it was kind of surprising on that score.  Can you talk about that for a second, the social media?

Cordani:          Yeah, I mean, the correlations in terms of the science or otherwise, there’s not a direct correlation that social media equals loneliness.  So more social equal media equals loneliness.  But there were correlations that the younger population were utilizing social media much more significantly and happen to be lonelier than the older population that used social media but much less comprehensively and happened to be less lonely.

And then ultimately you triangulate that back and look at what are the positives in terms of when loneliness doesn’t exist, what occurs from that standpoint.

Mundy:           That was pretty interesting because I expected a different answer on the social media outcome and it was not there.  You have talked before about the bright spots, the importance of community to humans, the importance of social action, the importance of balance.  Can you expound a little on that and why those are issues and concepts that a giant health service company would be actually throwing itself into studying?

Cordani:          Sure.  So, first, from a community standpoint, which I’ll come back to, as it relates to the United States, we actually believe that the employer creates these temporary virtual communities.  So bear with me for a second.  But you have a collection of individuals that come together around an employer.  They become a shared population with a mission, a strategy, goals, different communication, peer pressure, peer support, et cetera.

And as it relates to the bright spots or findings, it’s pretty clear that individuals who work versus don’t work, individual who has a best friend or best friend at work tend to be less lonely versus not.  Individuals who have more physical activity versus less tend to be less lonely versus not.  People who believe that they’re, obviously, contributing back to their community in some way, shape, or form.  The way community is defined is very personalized.  It could be your literal community, your virtual community, or otherwise.  It could be a faith-based community.

But again, having something to attach back to, that is important to one.  Having a best friend, there’s a direct correlation, if people have a best friend at work versus not.  Their level of happiness, satisfaction, et cetera versus loneliness that correlates up against it.  So the bright spots are not unique to the employer, but since half of all Americans get access to their healthcare through their employer, we see that as a bright spot opportunity to create more belonging, more support, less loneliness, et cetera.

And then beyond that, it’s the physical health, physical activity.  If people are more physically active, less lonely versus more.  Some semblance of balance.  There’s correlation to the amount of sleep people get to loneliness, et cetera.  And then back to being attached to something, belonging, be it faith-based, literal community, virtual community, or otherwise.

Mundy:           So you mentioned a number of things that the everyday man can basically do to try and be less lonely, including more activity.  Is there anything else that you want to add to this because it seems like such a big problem to conquer, loneliness.  It’s just a systemic concept.

Cordani:          Sure.

Mundy:           So what else can the everyday man do?

Cordani:          I mean, it’s obviously—we believe all healthcare is personal, all healthcare is local.  So there’s not an easy answer for just do X or just do Y.  When you break down the data, you look at the insights in it, it’s ultimately a lot of it comes back to more human interaction.  Societally, in many cases, there’s less human interaction by the day or more rushed human interaction.  And the human dimension and the social interaction that happens of truly sitting down and having a cup of coffee with somebody and having a conversation—truly a conversation, not distracted every 30 seconds with an electronic distraction or a partial dialogue—it’s powerful.  It’s powerful.

I think a prior individual may have made a reference to just listening.  Mental health professionals would demonstrate, the VA would demonstrate, recovery from surgery, chronic care patients demonstrate time and time again, having somebody who listens to understand—not to solve your problems, but just listens to understand—and feeling like there’s somebody there for you, it may sound extraordinarily soft for a global health service company to be oriented around that, but it’s the human interaction and the sincerity of it.  Which is why it requires somebody that you want to spend some time with or interact with at that level.

Mundy:           That becomes one of the issues here, is what Cigna can do for that.  And I’m reminded earlier this year, the British Prime Minister Theresa May announced she was going to appoint a Minister of Loneliness.  She got a lot of flak for that being too touchy feely.  But you know, she was actually looking at the issue of we know what makes people lonely.  We know it affects mental health.  What can we do about it.  So I saw that Cigna had some kind of interesting ideas it was going to launch, plus some things it had in place.  Can you tell us more about what Cigna’s doing now?

Cordani:          Just a few.  So, one, we don’t think we have silver-bullet answer to anything.  Two, we orient a lot around public-private partnerships.  So you start with, when there’s an issue, trying to amplify the issue, expand the dialogue, be in a convening capacity.  Something like this changes the narrative and something like this transpiring in multiple forums.  Beyond that, we were quite early—from an innovation standpoint—of integrating mental health and behavior health resources with physical health resources.

For example, if somebody has a chronic illness—of which over 40% of Americans confront some form of a chronic illness—they’re six times more likely to be clinically depressed than somebody who doesn’t have chronic illness.  We now know that.  What do you do about it?  Well, you try to integrate or leverage health coaches, mental health, behavioral health professionals with the medical health professionals to treat the whole person.  And you see more positive outcomes.  More positive outcomes not just from an absence of loneliness or depression, but actually better physical health outcomes that correlate with it.

Second, we actually stood up a dedicated unit in our company to provide support to veterans.  So veterans could access us telephonically, digitally, or otherwise, whether you’re a customer or not, whether you have challenges with pain management, PTSD, depression, access to housing, food, clothing, et cetera, we’ll support you.  We’ll support you from that lens.

Integrating community services, working more collaboratively, of 500 collaborative accountable care relationships in the United States.  That means we work differently with medical professionals in a more aligned fashion.  In many cases, those are all independent organizations.  In many cases, we’re embedding physically at the direction and the decision-making of the practicing physicians, nurses, health coaches, behaviorists, social workers, et cetera to more comprehensively engage the individual to get a better overall health outcome.

Those are some examples.

Mundy:           I noticed one of the things you list in there is the call-in line, at least for employees, which goes to the issue of the role of telemedicine, addressing the big issue of can you get someone to listen to you, just having someone listen.  And it’s pretty clear that you’ve tried to incorporate that in some of the plans that you’re rolling out.

Cordani:          No doubt.  You need—you know, the technical term is “modalities.”  You need a bunch of different access points to be preference-centric.  So someone may want to interact digitally.  Someone may want to interact telephonically.  Somebody may want to interact eyeball to eyeball.  So you need to have the multiple access points.  But the common approach is understanding the individual and being present for them.  And telemedicine, tele-behavioral care, et cetera is quite powerful.

Mundy:           Okay.  I have one final question.  We’ve had government leaders here, public health officials, academics, and experts, and we have a lot of people who actually are very, very much involved in advocacy for mental health and for the health community.  What’s the takeaway you’d like today?  What would you like to suggest to some of the people to do that would help us succeed in addressing loneliness and could help you and other health service companies do the same?

Cordani:          I guess a couple points.  One is, a problem of this magnitude is not going to be solved by any one entity, or person, or otherwise.  Secondly, our country’s demonstrated massive power by pulling on the ingenuity and entrepreneurialism, the power of the community, and public and private partnerships, from that standpoint.  So this is a mechanism of amplifying that dialogue.

And then lastly, the ability to, again, bring this conversation more comprehensively into the community in terms of every person who’s in this room, every government official, and otherwise back to, what are the local communities doing about this?  This will not be solved federally.  It will not be solved at a state level.  It could be enabled.  All of this gets addressed at a localized level because all healthcare is local and all healthcare is personal.

So amplify the dialogue, understand the public-private partnership is powerful, be able to pull on some of the bright spots, whether it’s through the clinical community, the employer, evolving social programs, and then allow for broader access through—as you indicated—for example, digital health, ensuring that the regulation allows for more digital access and broader access to services.

Mundy:           This’ll be pretty interesting.  Thank you, Mr. Cordani.

Cordani:          Thank you.

Mundy:           And now I’d like to turn this back to The Washington Post.

Cordani:          Thank you.  Thank you all.

Mental Health and Well-Being in America: Youth of the nation:

Joyce:              Okay.  Good morning, everybody.  Thanks for being here.  I’m so excited for this conversation.  We’ve had a nice conversation in the back, and I hope to share a lot of the things we just talked about with all of you.  I am Amy Joyce, editor and reporter with the On Parenting blog here at The Washington Post, and we’re here to talk a bit about the social factors affecting the mental health of American youth, with a focus on media and technology.

So with me, we’ve got Dr. Robert Findling, who is the director of Child and Adolescent Psychiatry at the Johns Hopkins University School of Medicine.  We have Dr. Yalda Uhls, who conducts research at UCLA on how media affects the social behavior of children.  She also wrote a book that I’d love to talk about, called Media Moms & Digital Dads, and it’s about parenting in the digital age.  And finally, we have Dr. Primack, who’s the director of the Center for Technology, Media, and Health at the University of Pittsburgh.  Thank you all for being here today, and thank you all.

I want to remind our audience that you can ask your questions, tweet it at us here, using the hashtag #PostLive.  I look forward to those questions, so do send those on.

So we’re going to start with an easy one [LAUGHTER] for all of you.  I hope it’s an easy one.  What is your reaction to what you just heard?  How are media and technology impacting kids, teens, and college-aged students’ mental health?  Are you seeing that impacting their mental health?  Dr. Primack, why don’t we start with you?

Primack:          Sure.  So I do think that media and technology, social media, is impacting youth.  The question is in what ways and to what degree.  In other words, I think that we have a very classic double-edged sword here, where there certainly are things about media and technology that can be beneficial to young people.  Somebody who is very isolated might be able to make certain connections with others because of technologies like these.  One the other hand, there certainly are potential pitfalls.  And as an example, I think that there’s been a lot of promise held out that through these technologies, no one’s every going to be lonely again.  You know?  All I have to do is reach out.  I have 700 friends, I must be, you know, likeable, I must be connected.

But we recently did a large, nationally-representative study testing that hypothesis out, and we expected that people who had more social media exposure would be more connected, and we actually found exactly the opposite.  And it was a linear association.  Every amount of social media increase was associated with an increased feeling of loneliness.  And so that doesn’t mean that every single person who uses social media is going to be lonely.  And probably in these large, nationally-representative studies, there are pockets of individuals who are going to get a lot of benefit.  But it’s just a little bit of a cautionary tale for us to understand that just because you have an interaction on social media doesn’t mean that you’re really getting what we need as social animals who have developed to need human contact over millions of years of evolution.

Uhls:                Right.  Yeah.  And I would say there’s no question face-to-face communication is the gold standard of communication.  And we are just starting to figure out how social media and these devices—mobile technology—are affecting adolescents, children.  They’ve been around for only 10 years.  I mean the iPhone was invented in 2007.  Research moves very, very slowly.  Technology moves very, very quickly.

And there are mixed findings.  Some findings find positive findings, some findings are negative, and it’s very complex.  As a social scientist who studies research, as someone who speaks to parents, what I think is we need to get really deeper into this data, understand the individual differences, understand YouTube is very different than Instagram.  We are moving towards video chat.  There’s Houseparty now, where you can actually talk face to face through video with other people.  So we need to sort of get more nuanced with the way that we look at this, but it’s going to take time.

Joyce:              Right.  Okay, and Dr. Findling, we had talked a bit about what you’re actually seeing as far as the mental health in kids, teens these days.  The CDC numbers on teen suicide doesn’t look very good.  It’s up quite a bit.  Can you talk about that?

Findling:          So certainly, we’ve known for years, and it sadly hasn’t changed, that a leading cause of death in teenagers has been suicide.  I have the privilege of working in the state of Maryland, and a leading cause of death in 10 to 14-year-olds now is suicide.  Ultimately, suicide is the most catastrophic tip of an iceberg that’s really depression.  And throughout the high-tech world, including the United States—the affluent part of the world, the leading causes of disability in young people are psychiatric conditions.  And so in many ways, we’re not just talking about experiences of feelings, but we’re talking about things that disable people, and we’re talking about things that are lethal.  And that’s really, at the heart of it, why this actually needs to be thoughtfully considered seriously, and the reason the first question is actually answered by my colleagues here in a thoughtful, circumspect way, which is the areas are gray.  If the answers were simple, we would have solved them already.

Joyce:              Right.  Right.  Okay, so Dr. Primack, what new trends are you seeing?  What do you see emerging in the care community to treat and predict these problems of disconnection that you’ve seen in your own studies and that we’re talking about today?  How should we be looking at this, and as parents, what should we be doing?  And Dr. Uhls, maybe you can speak about the parenting side of that, although you also have children, so—[LAUGHTER]

Primack:          Yes.  Yes, I do have children, and so I am able to see this in a natural laboratory as well.

Uhls:                Exactly.  [LAUGHS]

Primack:          And I think that the trends are very complex and confusing.  I don’t think there is a primary trend because I think that some clinicians are very comfortable with new media.  And they’re very comfortable suggesting, “You know, it’s not so bad to use this.  You’re a parent, go ahead, take a shower.  Let them watch some television even if they are just one year old.”  Whereas other people read certain studies and say, “Oh my goodness.  I can’t let anyone near a screen before they’re two years old because there was a recommendation from the American Academy of Pediatrics long ago.”  And so I think that people really are very confused, and it comes back to what Dr. Uhls was saying in terms of we need to understand the nuances.  Because we’re only going to really be able to move forward if we have more evidence-based approaches.  And there are a lot of things that I think we need to understand better.

So for example, there are a lot of different ways of using social media.  Not every social media interaction is the same.  Sometimes you’re having very positive experiences, like clicking “like” on cute pictures of babies and puppies.  Other times, you might be using that same hour, but you might be having very angry confrontations around very hot-button issues.  And so we need to understand, are these different ways of using social media differently related to depression, for example?

And we just released a study last week that looked at this, and the results were actually surprising.  We found, like we hypothesized, that if you had more negative experiences, that was directly associated to higher levels of depression.  But if you had lots of positive experiences, it was not necessarily associated with lower levels of depression.  There was a slight tendency, but it wasn’t even statistically significant.  And so what this says to us is that we need to understand more of what those negative things are, and we need to understand more of what’s going on with those positives.  Because we don’t want to throw the baby out with the bath water.  We want to be able to use these technologies so that people can have positive experiences.  But I think right now, we’re just not there yet as a society.

Uhls:                One thing that we do know—well, I wouldn’t say we know it for sure, but there has been some evidence that passive use of social media can lead to more depression, mental health issues, while active—and this has been replicated a few times—somebody who actually posts, somebody who’s actually engaging with the social media, that can actually lead to less feelings of loneliness.  But when you’re just watching, when you’re just, it’s called “lurking,” that can lead to increased feelings of loneliness.

Joyce:              Because you’re on the outside and not interacting.

Uhls:                I think you’re just—yeah.  I mean if you think about it, if you’re just sitting there watching other people have these curated, perfect lives—and especially tweens—preteens and teens, they don’t yet understand that these lives are created—they’re curated, they’re always positive.  They’re learning these things, so they often have fear of missing out, the often have downward social comparison, so some of these are the negative feelings that arise when a young person is first getting engaged with social media.  On the other hand, they’re very excited.  There is a theory called “rich get richer,” which, if you’re an extroverted kid, you actually use the media to connect with more people, and you have a lot of fun with it.  So as we keep saying, it’s very, very nuanced.

Parents are terrified.  [LAUGHTER] I’m a parent.  I was terrified when my kids were tweens.  They’re now 15 and 18.  I’ve seen them sort of cycle through, and they’re turning out just fine [LAUGHTER].  And they are media kids.  But every time I talk to parents—and I do a lot of panels, I do a lot of speaking—they are really, really scared.  You know, the latest thing—and we didn’t even talk about video games.  Video games are also social, and I consider video games social media.  So now everybody’s scared of Fortnight.  [LAUGHS] You know, there’s always something to freak us out, but this is normal.  There’s always a moral panic around media.  We’ve had moral panics around books.  We’ve had moral panics around the telephone.  And then we sort of adjust.  And we’re in the adjustment phase.

Joyce:              We are.  We’re the first generation of parents dealing with this.

Uhls:                Exactly.

Joyce:              And so I do think there has been a lot of blame and a lot of conversation around, is this an actual addiction— are there addictions to screens?  Can we talk about that a little bit?  You are seeing an increase in depression and suicide, so what’s the connection there?  Are screens the connection?  And can we talk a little bit about whether screen addiction is a real thing?

Findling:          So I’ll just talk about, since my colleagues to my left are social scientists—I know patients as I see them, one at the time.  [LAUGHTER] And so what I would tell folks is really simply, I’ve never seen a youngster who had a completely well-functioning life who was drawn to something terrible solely as a result of a screen.  And so ultimately, the screen may be part of a larger, complicated picture that can be driven by a variety of different things.  It may not be the only problem, but it may be a symptom of other things to consider.  Because ultimately, our patients aren’t quite neatly categorized, and we take them as they come.  So I certainly have patients who have had positive interactions and get a lot of support from social media, and I’ve seen youngsters who have been horribly victimized.

You know, when I grew up, as you can perhaps see from the gray hair [LAUGHTER], you know, when you were being bullied, it was somebody, you know, intimidating you for your lunch money.  Well, now if you’re shamed, it’s not just a physical aggression, it’s really a relational aggression and a shaming—not just between you and perhaps your victimizer, but with thousands and thousands of thousands of other people watching, perhaps even ganging up.  So at the end of all of this, it’s still, again, a mixed blessing, and every individual youngster is impacted potentially differently.  But to your question, have I ever seen somebody who was doing well in school, well with peers, well with their family—

F:                     Sleeping.

Findling:          —doing all those good things, and yet their one albatross in life is they couldn’t get off the screen?  I’ve never seen such a thing.  And so the point is, but when I’ve seen kids who’ve had these things, there are other things.  It’s a wonderful distraction to immerse oneself if one doesn’t have a sense of belonging and if one doesn’t feel as if their future holds a lot of promise for them.  So again, it’s a place to begin, but it’s not necessarily the place to end if this is a concern for any youngster out there.

Uhls:                I agree with that.

Joyce:              And can we talk a little bit more, too, about with kids how to introduce screens and at what age?  I have a child [LAUGHTER] who’s going to middle school, and the parents are all up in arms.  They have, you know, contracts that their kids are signing, and they’re asking other parents what they’re doing because they want all the kids to be on the same page, with the same rules.  Are we freaking out a little bit too much?  What kind of rules, from your experience and what you all know, should we be putting in place as parents?

Findling:          My kids are adults.  I’ll have to—[LAUGHTER]

Joyce:              You’re good, right?

Uhls:                I mean, every single parent talk, I get asked what’s the right age for a phone, what’s the right age for social media?  My answer is every family is different.  Every child is different.  I have a friend who was a single mother with three kids, right here in D.C.  She had to give her daughter a phone at a very young age, eight years old, because she had to keep track of them.  Most families do it from the transition from elementary school to middle school.  That’s when I did it.

I do agree that giving media contracts or device contracts actually work, mainly because when you give those kind of contract—and that’s a family thing, not a school thing.  When you’re sitting at home—and you yourself are agreeing to the same things—you know, no phones at the dinner table, we charge it downstairs—that’s a really good time to discuss all of the issues around media.  Because you are giving them a tool that gives them a lot of power, a lot of connection that can be used for positive and negative, and you want to maximize the positive, minimize the harm, and a family media agreement can help with that.

Primack:          I completely agree, and I would add that in addition to figuring out the specific differences about timing, it’s also really important to pair that with empowerment and education.  So you don’t just give a teenager at age 16 a car and say, “Okay, enjoy.”  You know?  You take courses.  You talk about responsibility.  You go through an entire process.  And I think that in this case, it’s maybe even more so.  I mean I probably went a little bit extreme.  I made my 14-year-old, before he got his phone, he had to learn how to program.  I said, “Look, [LAUGHTER] these things are either program or be programmed,” right?

Uhls:                Now he has a job.  [LAUGHS]

Primack:          And so he had to learn HTML and JavaScript, and you know, that was maybe a little bit extreme.  [LAUGHTER]

Uhls:                I love that idea.  [LAUGHTER]

Primack:          But the idea, I think did actually work in the sense that he looks at this in a different way.  Every time he sees a message on there, he sort of knows how that was created.  And he knows that that was created by people, and that this was not created, you know, by some divine force that is always right.  And so I think that that whole idea of media literacy—understanding how to not just access this tool, but to analyze and evaluate everything that we see on it is going to be crucial.  And if we as a society can integrate media literacy around these devices as well as other media, I think we’re really going to be able to maximize the positive things we can do with them and minimize some of those concerns.

Uhls:                And I would say, you know, there are a lot of schools that are integrating this kind of teaching into their classrooms, and any of us who are parents can talk to our teachers about it.  We can do that kind of teaching at home, but we should be asking our schools to do it as well.

Joyce:              Okay.  And Dr. Findling, can you talk a little bit about the loneliness factor?  How much does that play a part in the patients that you see, and what can we do as parents, as teachers to mitigate that, if that is a big reason for a lot of the depression and anxiety you’re seeing yourself?

Findling:          So I think the most important part—just like screens, loneliness is really nonspecific.  So we may see a youngster who has a hard time relating to people in a social way.  And so getting him in with the right people and help them socialize is part of it.  Some of them may be very, very anxious and helping them through their anxiety.  Like so many other things, when we have one, clear symptom, it may not be the way to solve it by just focusing on the symptom itself, but looking at what the determinants are of there and addressing it.

So for example, one of the more recent youngsters I saw has a low IQ and was in a class that was far too accelerated for him, and he was having a hard time relating to his peers.  And he just had to be with the right peer group, and he was a lovely young man.  So all things being considered, when faced with an issue, just don’t stop there, but dig a little deeper.  As a general rule of thumb, the answers will actually reveal themselves to you with a little bit of treasure hunting.

Joyce:              Okay.  And how do we know when our children are depressed or anxious and they’re not just going through moody teenager?

Findling:          Ah.  [LAUGHTER] So anyone who’s ever been with teenagers—I mean we were all teenagers at one point.  I raised adults who were teenagers not so long ago.  Look, life has its challenges.  Being an adolescent has its challenges.  But being a young adult first out has its challenges.  Transitioning further and being a parent has its challenges for the first time.  Life has its challenges and adolescence is no different than any others.

Thankfully, about 85% of teenagers go through their adolescent years, maintaining their grades, not getting caught up in drugs, keeping their friends, getting involved in extracurricular activities, and not feeling terribly overwhelmed and miserable.  However, there’s about 15% of folks who might start hanging out with the wrong crowd, watch their grades go down, get involved with drugs.  And so what I tell parents is to step back, and forgetting about the independent strivings that you’re now challenged with, if there’s a problem, there’s a problem.  And if there’s a problem, ask about it.  Talk to your pediatrician or your family doctor and say, “I’m worried about this.  This is not my child.”

But if there’s no problems and you’re just really grappling with the development and maturation that we all actually grapple with throughout our entire lives, then you’re okay.  And remember, 85% of teenagers do just fine, thank you so much.  So let’s not pathologize [LAUGHTER] adolescence, but rather recognize that it’s part of life.

Joyce:              Okay.  Great.  And can we talk briefly—how do we raise responsible digital kids?  It’s a whole new world.  Like I said, we’re the first generation of parents dealing with this—doctors, pediatricians.  What can we do to sort of make it okay?  What can we do to raise smart digital kids?

Uhls:                Well, as Dr. Primark said—

Joyce:              Have them learn HTML.  [LAUGHTER]

Uhls:                —you know, you don’t hand them the keys to the car.  And actually you spend 50 hours—I have a teenager who learned how to drive—with them in the car.  So you actually join them.  You role-model.  You make sure that you’re talking the talk, walking the walk that you’re asking your kids to do.  you friend them on social media.  You talk to them positively about their experiences.  If you’re always negative, they’re going to tune you out.  You do family media agreements.  And you promote digital citizenship in the classroom as well.  All of these things, it’s just like parenting offline—parenting online.  Just be confident in your own ability to parent and believe in yourself and trust your kid.  Until there’s a problem.  [LAUGHTER]

Joyce:              Until there’s a problem.

Uhls:                Do you have more?

Primack:          No, I completely agree with that.  I would add co-viewing to the list.  In other words, you know, let’s look at some of these social media things together.  And, you know, it’s the same kind of media literacy concept that we have with advertising and with movies and things like that, but again, a lot of those things are transferrable into the social media world.

Uhls:                Absolutely.

Joyce:              Okay.  Alright.  Well, on that note—that flew by very quickly.  [LAUGHTER] Unfortunately, that’s all the time we have today.  So thank you, Drs. Findling and Uhls for joining us.  And I’d like to hand things over now to my colleague Libby Casey, who will lead the final interview of the program with the First Lady of New York, Chirlane McCray.  Thank you all very much.  Thanks for coming.

Mental Health and Well-Being in America: One-on-one with the First Lady of New York City:

Casey:             Good morning.  I’m Libby Casey.  I’m a politics and accountability video anchor here at The Washington Post, and I’m pleased to be joined onstage by the First Lady of New York, Chirlane McCray.  And, among many things that you’re doing, she’s the creator of ThriveNYC, which is an initiative aimed at creating a model behavioral health system in New York City, and Thrive has expanded to more than 200 cities across the country through the city’s Thrive Coalition of mayors.  Thank you so much for being here.

McCray:          Thank you, Libby.

Casey:             We want to talk about Thrive this morning and also how you help populations get care, especially at-risk populations, and how to combat the stigma of mental illness.  We’ll be continuing a lot of the conversations that have been going on this morning.  You can join the conversation yourself by writing in to us on Twitter using the hashtag #PostLive, and we can share those with the first lady.  So first of all, what was the inspiration for Thrive and what are its goals?

McCray:          Well, mental health, mental illness, substance use disorders, these are issues that are very deeply personal to me.  My parents suffered from depression.  Our daughter came to us when she was a teen and said that she was suffering from anxiety and depression.  So, it’s very personal.  I’ve seen so much in my life—so much that has gone wrong for people who have suffered from untreated mental illness and addiction, and it’s something I felt like I had to do something.  I had to.  Because I saw how it was connected to people’s inability to work and take care of themselves, their inability to have healthy relationships, or do well in school.  I think that too often we do not connect the dots when it comes to mental health that if we don’t deal with it, people cannot have healthy and productive lives.

Casey:             You talk about your own personal story, and that’s how a lot of us outside of New York got to know you.  I mean we heard about your personal story.  Does that help in combating stigma?  What has the reaction been as you’ve shared your story and as you’ve heard feedback from people, both in a very personal one-to-one level as well as a larger level?

McCray:          Oh, it’s been amazing.  Every time I tell my story, people come up to me and tell their stories.  They feel much more comfortable sharing what has happened to them, what has happened to their families, and I think that’s the best thing that anyone can actually do to combat stigma is to tell their own personal mental health story.

Casey:             And we saw two very high-profile New Yorkers, loved by many not just in New York, but around the country, kill themselves last week—Kate Spade and Anthony Bourdain.

McCray:          Yes.

Casey:             How does that enter this conversation right now?

McCray:          Well, obviously it’s been a very painful and tragic week for so many people.  These situations triggered memories for people who have had suicides in their own families.  And I think that—

Casey:             Your family had a suicide in it—your husband’s family.

McCray:          Yes.  That’s right.  That’s right.  And my family as well.  We don’t talk about this enough, and the reality is is that we can prevent so much of this death by suicide.  You know, sadly, these deaths have reminded us that people can appear to have it all—wealth, happy families—but still, there’s this invisible disease going on inside that needs treatment.  So this has been a reminder to all of us that we have to reach out to our friends, our family, our coworkers, and ask them, “How are you doing?”  You know, not superficially, but really, “How are you doing?” and pay attention to how they are connecting with other people and if they have had depression in the past, to know that people can relapse.  It is not uncommon for people to have a relapse.

Casey:             So, Ms. McCray, if you’re living in New York City and you’re having a personal crisis or you feel like you need help, what is the ideal set of steps that would happen?  You’ve tried to get people to know they can truly pick up the phone.  But what is there available in the short term, and what do you want to grow?

McCray:          Well, in New York City, we believe that there should be no wrong door—that people should have a variety of places to turn.  And that is why working in partnership with our communities is so important.  We do have a 24/7 helpline called NYC Well that anyone can call any time of day or night and talk to a trained counselor or a peer counselor, someone who has lived experience with addiction.  And we are pushing that word out—advertising, making as many people know about it as possible.  So that is one thing that people can do.

But you know, family—we want family members to be the first first responders.  Family members are often the first ones to notice, well, my son or my daughter, they’re not acting the same way.  They’re isolating themselves.  Or they’re agitated.  They are using more drugs or alcohol than before.  And this is something that a parent or a friend—anyone can call this number and say, “Look, I’ve got a friend.  I don’t know what to do,” and the trained counselor will help walk them through the steps of what they can do, depending on the situation.

Casey:             And then what should happen next in terms of what the city is responsible for versus the state versus the federal government?

McCray:          [LAUGHS]

Casey:             Because you make the call—you might be taken out of that immediate crisis, but then there’s the next day.

McCray:          Yeah, well, the wonderful thing about this call is that people can actually get connected to care, just by making this free phone call—this free and confidential phone call.  They can actually make an appointment with a therapist or a psychologist or a psychiatrist—it depends on what is appropriate.  And then, if the caller wants, the counselor will call back and see if it worked, if it was alright.  If need be, the counselor can send a mobile crisis team to the home and evaluate the situation.  So there’s no one answer.  There are many ways to connect to care.

We are employing our faith communities, we’re training them—our faith leaders in Mental Health First Aid and psychoeducation, motivational interviewing—whatever they want, whatever they need.  Because we know that people often go to their faith leader.  They turn to them if they need help because they trust them.

We know that people have trusting relationships with leaders in their communities, so we have a program called Connections to Care, where we train staff at community organizations and partner these organizations with a mental health partner for higher-level care.  And so when people walk through the door to get employment training or daycare or some other type of service, they can actually be screened, so if they need other kinds of care, they can be connected to it.  And we have 15 organizations—again, it’s called Connections to Care—15 organizations are in this program, and we have found that one out of every three people who walks through the doors actually needs some type of mental healthcare.  Now that’s pretty amazing.  That’s like 30%.

And we have found that the outcomes for these programs, the community programs, are much better, in addition to the individuals obviously getting the help they need.  And this is saving lives.  This is saving a lot of lives.  We’ve served more than 16,000 people this way.

Casey:             I want to get back to this question of sort of city versus state versus federal, but—

McCray:          Yes.

Casey:             —first, you brought up something so important, which was just being able to find someone who is a trained therapist, counselor, a psychiatrist if that’s needed.  And one of my colleagues sort of bravely tweeted out last week—she’s an African American young woman here in the city—about how hard it is to find care.  And that if you can find a therapist that you feel like relates to you—and I’ll point out here that the American Psychological Association reports that only 5% of the country’s psychologists identify as black.

McCray:          That’s right.

Casey:             If you can find a therapist that relates to you, your insurance may not cover it.

McCray:          That’s right.

Casey:             If you have insurance.  So how do you deal with this need for care so people can have that long-term, ongoing, developed relationship with someone who’s trained and knows how to help them through what they’re dealing with?

McCray:          Well, in New York City, we have this helpline, 1-888-NYC-WELL, and anyone who calls that number is provided with some kind of appropriate care that is convenient for them.  We don’t turn anyone away.  It doesn’t matter whether they have insurance or not.  We know how important this is.  It has to be a priority.  And you asked about the federal, the state, the cities—we all have to make this a priority.  We have to find ways that people can connect to care.  If we don’t, it can have lifelong consequences.  It can result in someone’s death or the devastation of a family.  We have to find ways to connect people to care.

And when it comes to populations like the African American population, the LGBTQ population, Latinos, so many, we do not have the culturally competent care that we need.  We just don’t.  That statistic, 5% of the mental health professionals in our country are African American, just imagine what it is for other ethnic groups.  So we need to create a pipeline of care.  We need to get more African Americans and other ethnicities involved in the mental health workforce, but we also have to employ task shifting.  And we have to train people who are already doing this work, like our clergy, like community organization leaders—we have to train them to do some of this work as well.

Casey:             So whose responsibility is it to tie it all together, to bring all those communities together?  And why do you hope that it works at the city-wide level?

McCray:          Well, the problem is is we’ve never had a coordinated behavioral health system in our country, ever.  I mean I just find that astounding.  This is 2018 and we have so many issues that relate directly back to the fact that we don’t have this system, and no one has really taken responsibility.  There are many good services, and many of our elected officials are doing amazing things, but there is no national will to get this done.  I think that everyone has to do their part.  As individuals, people can volunteer, they can pressure their candidates—people who are running for office to make this a priority.  We all have to do that, otherwise it will not happen.

And we have this coalition called Cities Thrive, where we’re talking every month to mayors all around the country and sharing best practices—sharing what we’re doing in New York with ThriveNYC and best practices in other places, whether it’s New Hampshire or Kentucky or Seattle.  Sharing really innovative solutions to what is really a mental health crisis.

Casey:             Can you share with us anything you’ve learned from some of those other communities that maybe surprised you or inspired you or you realized was a good takeaway that you could then apply to New York?

McCray:          One of my favorites is in New Hampshire, they are actually using their firehouses in response to the opioid epidemic.  Anyone—a loved one, a friend, can bring anyone who has survived an overdose or someone who is addicted to a fire station, and they get connected within 11 minutes to an opioid treatment program—recovery program.  I love the way these communities are using their assets—you know, preexisting structures and services in a new and innovative way.  Everyone thinks of the firehouse as a safe place—you know, firefighters are seen as lifesavers, and I thought that was a really good idea to use the fire stations as a place that anyone could go, any time of day or night, and get this kind of care.

Casey:             So what do you want to see happen at the state-wide level and the federal level?  Do you feel like New York can be sort of a cauldron, a place to create a model program?  But then how do you expand that out?

McCray:          I think our cities can model solutions.  That’s what we’re doing in New York, and it has been picked up by other cities.  And even in London, you know, Mayor Sadiq Khan has a London Thrive program inspired by what we’re doing.  I think that it has to be the priority of the elected officials.  The candidates have to have mental health in their platforms.  It is the ultimate intersectional issue.  You deal with mental health and substance use disorders, and you deal with a host of other issues, like domestic violence, like gun violence, like our schools and why so many children aren’t performing as well as they should.  It has to be part of everyone’s platform if they want to run for office.  Again, this is a crisis, [LAUGHS] so we have to do something on the higher levels if we’re going to get it solved.

Casey:             In working with some of the communities of New York, you’ve created Sisters Thrive?

McCray:          That’s right.

Casey:             You’ve created other programs, or sort of subsets of the bigger Thrive network.  Tell us about how the programs are different and why you’re really targeting certain communities.

McCray:          Well, we’re targeting specific communities because, as I say to everyone, there is no one solution.  And because the stigma is so great, it is helpful to have people reach those people who are closest to them, in their own communities.  So we launched Sisters Thrive, which is a collaboration between government and the traditional, service-led organizations—the sororities, like the Alphas and the Deltas and the Sigma Gamma Rhos, and we’re training them in Mental Health First Aid.

Mental Health First Aid is an eight-hour program.  It is amazing.  None of us grows up understanding mental illness and substance use disorders.  We don’t get that kind of education growing up.  We all know what to do when someone’s bleeding, but we don’t know what to do if someone has a panic attack or if someone’s suffering from depression.  Mental Health First Aid actually teaches people the skills to recognize, to identify the signs and symptoms of mental illness, but also how to respond appropriately.  So working with these sister organizations—we’re working with the brothers as well, which is so important, because men often have a harder time dealing with these issues.

Casey:             So there’s Brothers Thrive as well?

McCray:          Yes.  And working with our clergy.  They help us, as government, to penetrate communities where it’s harder for us to reach.  You know, we’re not always as trusted as someone who actually lives in the community and works with them every day.

Casey:             When you hear from people, why are they afraid to pick up the phone and either call the helpline that New York has established or—what’s the fear about having a mental health team come to your house and stage an intervention?  I mean what are you hearing that gives people pause—not just because perhaps of their depression or they can’t quite get to that place, but what’s some of the holdback?

McCray:          Well, stigma.  We cannot underestimate the power of stigma.  First of all, most people, they don’t want to see themselves as that way, as someone who is broken or someone who is imperfect.  You know the stereotypes—that people just don’t have enough discipline or willpower, they’re crazy.  No one wants to be called crazy.  No one.  And so that can prevent somebody from picking up the phone.  They may feel like, oh, I’ll get better.  Or they may be in denial that there’s nothing wrong—nothing wrong at all.

I think that we can’t rely on people to pick up the phone when they need it all the time.  Many people do.  We get hundreds and hundreds of calls every day to our NYC Well helpline—sometimes as many as a thousand calls a day.  Our police respond to more than 400 mental health crises every day.  Those are astounding numbers.

We have to educate our families and our communities about mental illness and substance use disorders so that they can help people in a way that that phone number may not always be able to.  Because families see what the counselors who are sitting answering that helpline don’t.  We wouldn’t ask someone with a broken leg to run to the hospital [LAUGHS], right?  Hence, we should not expect someone who is in the throes of depression or someone who is suffering from any other mental illness to always be able to pick up the phone and call.  We just shouldn’t.  They don’t feel well.  They’re in a very vulnerable state.  We should not expect them to be able to pick up the phone.

Again, we can all be first responders.  We just have to learn how to be more observant, more sensitive.  And take Mental Health First Aid.  I took it and it’s an amazing course.  Anyone can go online and look it up—  I strongly advise anyone who’s listening to take that course.  It transformed my life.

Casey:             Really?

McCray:          That’s right.

Casey:             How so?

McCray:          Well, it just—because they really teach you about all the different mental illnesses and how to sort of put yourself in their shoes, understand what it feels like—as much as anyone can, and how to react appropriately.  I can’t emphasize that enough.  How to choose your words.  When someone’s having a panic attack, you don’t say, “Calm down.”  [LAUGHS] That’s not the right thing to say when someone in a panic attack.  So I advise everyone to take it because I think it’s very helpful in dealing with stigma and helping people feel comfortable around people who are suffering from a mental illness or substance use disorders, and it goes a long way to helping others.

Casey:             Let me remind you you can join this conversation by tweeting us with the hashtag #PostLive.  This is your opportunity to ask the First Lady of New York, Chirlane McCray, a question about Thrive, or about anything else.  Maybe we’ll talk politics in a few minutes.

McCray:          [LAUGHS]

Casey:             Can’t avoid it because you’re in Washington.  But I want to stay on this issue of what New York is doing and what your office is trying to do.  How are you talking with police and law enforcement and first responders about dealing with people who might be having a mental health episode, or might be, you know, on drugs, which they’re doing to self-medicate because of a mental health issue?

McCray:          Right.  Oh, it is so challenging for our police officers—for anyone who’s a first responder.  And what we’re doing with our police force is we’re training them in Crisis Intervention Training.  We’re teaching them to de-escalate situations where things may be getting out of hand.  We’re teaching them by using different scenarios.  We actually have actors.  We have a setup where they go through different scenarios.  We have them talking with people who have schizophrenia and who have bipolar disorder, who have actually had interactions with the police, because we want them to have first-hand experience with these situations so that when they actually get into a situation like that, they know what to do.  It’s tough, though.  It’s very tough, because everyone is different.  People are different.  They act out differently.  But it is so important that they have this training.

Many police forces all around the country are doing this.  Our training is four days long.  It is intense, and we think that it does so much to help them in these very unpredictable situations.  We’ve had more than 8,000 of our patrol officers trained, and we are going to do as much as possible.  Any recruit who comes in gets trained, and we are expanding this as fast as possible.  [LAUGHS]

Casey:             The money that it takes to launch a program like this, and you of course are working on partnerships with existing organizations, as you mentioned, faith-based groups, sororities and fraternities—how big should the budget for this be, and where should the funding come from?

McCray:          Well, I believe that a percentage of any government’s budget should be devoted to behavioral health services.  I know that we’re a long way from that, but that’s what I believe.  New York City has put nearly a billion dollars into these programs, but much of what we are doing is actually voluntary, because there’s great hunger, there’s a great need for these type of services.

Every year, the last three years, we have held a Weekend of Faith on Mental Health.  So we’ve worked with clergy members all around the city and around the country to get them to devote part of their service to talking about mental health or addiction.  We are getting them to tell their personal stories if they have a personal story to share, and we’re helping them to help their congregations feel more comfortable talking about these illnesses and giving them a way to direct them to resources.  So that’s something any city can participate in.  2,500 houses of worship participated in May this year, and all 50 states had at least one house of worship participate in our Weekend.  And we want to do more.  These are things that don’t really cost any money, that anyone can—it’s a little labor and of course communications, but we want everyone to be involved in any way that they can.  This is a crisis, which means that we need all hands on deck.

Casey:             I want to talk about children and the questions and concerns that have been swirling around, not only suicide by teenagers, but violence in the schools.  How are you looking at working with kids and working with their families, everything from preventing the next school shooting, on the mental health level, to talking to children about the fear they may have about going to school every day.

McCray:          Well, we’re big proponents of social-emotional learning.  We think that one has to look at the whole child and not just, you know, the reading, writing, and arithmetic.  That our children walk into the doors of the school, into the classrooms with so many emotional burdens, whether it’s trauma from domestic violence or drugs being used in the home—we don’t even know what our children are walking through the door with, so we really have to look at the whole child.

In New York, we are training our teachers in social-emotional learning so that they can help children identify their emotions—which so many children can’t do, they can’t even say what they’re feeling—identify the emotions, know what to do.  What do you do when you’re feeling sad?  What do you do if you’re feeling angry?  What is a constructive channel to focus that energy onto?  And we think this is a first step in getting our children the kind of support they need.

We now have some kind of mental health support in all 1,800 of our schools.  But that support, of course, varies.  Some schools have clinics.  Some schools have counselors who are available in organizations outside the school.  And we want to build on this.  This is kind of laying the foundation for what I think should be a truly holistic approach in the way we are raising our children and helping them learn.  When you have these type of services, the school climate tends to be much better, and children—it’s easier for them to learn.

And we have to make sure that they don’t have access to things that they can harm themselves with.  I mean, New York City’s suicide rate is less than half the national rate.  I believe one of the reasons for that is that we do have strong gun control.  The number one weapon for choice for most suicides is a gun.  Two-thirds of all suicides, firearms were used.  And we aren’t making those connections.  We’re very focused on the mass shootings, which is important because we certainly don’t want those to reoccur, but we have to realize that more people take their own lives using guns than perpetuate mass shootings.

Casey:             Ms. McCray, a question that’s coming in on social media—are you meeting with any lawmakers on these issues while you’re here in Washington?

McCray:          Yes, I’ll be meeting with some of our senators and representatives.  This is something—

Casey:             Both sides of the aisle?

McCray:          Both sides of the aisle.  Cities Thrive, our coalition of mayors, is a bipartisan coalition, and, you know, I say to everyone, this is a family issue.  This is a community issue.  We all have so much to lose or so much to gain by dealing with this appropriately.  We all have to do our part.

Casey:             What would you like to see legislators do on the national level?

McCray:          On the national level, I would like—we’re all pushing for more integrated care.  We’re pushing for a better funded mental healthcare system—well, that we don’t have.  [LAUGHS] More funding in mental health.  We have legislation that needs to go more directly—or the funding needs to go more directly to the cities and the counties.  You know, sometimes when it goes to the state, the cities don’t see as much of that funding as is needed.  So those are some of the things that we’ll be talking about these next couple of days.

Casey:             You’re obviously passionate about these issues and proposing solutions.  You’ve taken not only a very visible role, but an active role with this effort.  So one way to affect change is to run for office yourself.  [LAUGHTER] And you have said you could see yourself running in the future, perhaps in 2021 would be the soonest?

McCray:          That would be the soonest.

Casey:             Where do you see an avenue where you could be effective?  Is it at the local level?  Is it at the state or national level?

McCray:          I only said that I would think about running, [LAUGHTER] because as you know, the political landscape can change very quickly.  Like who knows what’s going to happen during the midterms, and who knows what will happen in 2020?  We’ll see.  But I will certainly be very focused on mental health and how I can have the greatest impact.  This is something I want to continue working on.  The need is great, and I’ll be looking for how I can do that.

Casey:             With your husband as the mayor, it’s given you the opportunity as a team to really dig into this and have the platform to create Thrive and to get it not only in New York City, but cities across this nation, and apparently in London as well.

McCray:          That’s right.

Casey:             So where do you see the power in serving in office as being appealing to you?  Is it at the local level?  Is it at the statewide level?  I mean do you see a road that looks like—you say, you know, that is a way where a lot of the sausage is made and so policy can really be created and then enacted and can impact the people I live with on the block.

McCray:          Look.  I’m first lady.  I’ve kind of created my path, and I’m having a tremendous impact.  I think that people can have a tremendous impact in whatever role they choose, and I don’t know where this path is going to lead me.  I will look at the landscape and figure out where that might be, but wherever I am, I’m going to be doing this work, and I will be looking for the place where I can do the most.

Casey:             What’s it been like having a strong role as the first lady, as the spouse of the mayor?  Because there was a tweet that came out from one of the staffers that sort of pushed back at someone saying that you were visible for policy announcements.  The staffer said, “She’s involved in the policy.  She’s helping to direct and create the policy.”

McCray:          Oh, yes.

Casey:             And your name is on press releases from the mayor’s office announcing personnel decisions.  So how has it been to chart that path in a role that has not traditionally had such a visibly active role?

McCray:          Well, I don’t think that what I’m doing is very different from what I’ve done over the decades leading up to being first lady.  I’m following my heart.  I’m working on issues that I care about passionately.  I like to be in the weeds.  I like to read everything—my team knows that.  And I’m just doing what I think is best for our families.  That’s my first priority, and I do what I can to help people understand the urgency and what I’m doing, and what we’re doing in New York City.

Casey:             Final thoughts?  Where do you go from here with this initiative?

McCray:          Where do we go?  Well, ThriveNYC is not that old.  We launched two years ago.  Not all of our programs launched two years ago, so we have a lot of building to do.  We have to expand our services.  We have to deepen our services, get them embedded in all of our agencies, because we know that—I know that we only have three and a half years left in this term, in this administration.  I want to make sure that it goes on, that all of these programs continue after we’re gone.  So that’s what I’ll be very focused on for the next few years, and making sure that everyone has an understanding of why we’re doing this, why the outcomes for everyone are better with these programs, so that they can continue after we’re gone.

Casey:             We’ll be watching for your visits here to Washington.  Thank you so much to the First Lady of New York, Chirlane McCray.  Thank you for joining us.  And thanks to all of you for coming.  That’s all we have time today for this event.  If you want to watch any of these interviews online afterwards, go to our website,  I’m Libby Casey.  Thank you so much for being a part of this.  Thank you.