I have no conflict of interest to report. For any of you who know me, you may know that many years ago I started a software company which is in health informatics. This talk has nothing to do with that, and actually I'm no longer in that enterprise. But it did give me a perspective on the use of technology as applied to this area of mental health. Anybody want to identify what this is? A swamp. So if you get nothing else from my talk about the more than 10,000 mental health apps that are available to us today to address mental health, and you think of this as the body of research, you're going to have to search long and hard for a body of quality research. Now it doesn't mean that there isn't good stuff happening in the world of technology. Just by a show of hands, and don't raise your hand if you think it's TMI or PHI, but how many of you have on your person, your phone, your wrist, somewhere, an app that purports to help you address your mental health? That could be a sleep app. It could be something that reminds you to breathe. It could be telling you to take breaks from your computer. Many of us have those today. I had one, but I actually don't use it anymore, which is actually part of the problem. There's sometimes initial engagement but not sustained engagement, but we'll come back to that later. So just be aware that you have to find your way through this swamp if you're going to use these apps, especially if you are in a healthcare organization and you're asked to identify what are the best apps for us to offer to our employees, which many of you are probably part of organizations that offer one or more technology solutions. So our objective is to understand some of the considerations in selecting and implementing these technology solutions because you can't just rely on high-quality published research. So what I'm going to do is offer you a framework or a number of frameworks and some sources to go to, to help identify what might lead you in a better direction than another. And just as a takeaway, if you're going to enter that swamp of selecting digital technologies, I'm sure that there are some good ones out there, and some of them are benefiting people, but again, it's just the evidence basis that's lacking. So what's our job? Our job, your all's job is, if you're going to use them, to set up a plan for evaluating them. Collect the data that's going to tell you whether they're achieving what you hope they achieve. And that would be my takeaway message for you all this afternoon. So the headlines, there are many, many tech solutions. The science is limited. Apps and companies that offer them themselves come and go. The best of them are offering some new tools, skills, and resources to workers. And imagine a world where we really had apps that could extend what's needed to our colleagues and ourselves. Because we can't see everyone in EAP, we can't see everybody in mental health treatment. If we can find a way to help get upstream of some of these problems and give people technology solutions that are in their hand, that's a great dream. But the other headlines are, one size does not fit all. Engagement problems are typically one of the things that you have to consider. Even if an app has efficacy, is it sustainable? One major takeaway for you today is that, largely, these are patient. And in the case of a health care organization, if they're offered by an employer, they're going to be worker-patient focused. And mostly about secondary prevention. So think of mindfulness apps that are out there today. And many of them are also related to treatment. Technology that supports coaching in between sessions, for example. That ties into licensed clinicians. So there clearly are some niches where there's a place for technology. And we're still in an exploratory phase of understanding where this can take us all in the future. This is my other big take-home message. Rarely do we focus on what employers can and should be doing to not be part of the problem. I won't ask for a show of hands, because it's embarrassing. But how many of you work for RVUs? Don't raise your hand. If you work for RVUs, you're driven in part by a need to produce. Your productivity is being measured. The EHR is one of the ways in which that's being measured. And frankly, in my opinion, this is part of the problem that we have. So consider what can employers be doing, and how could technology actually help employers do a better job of not being part of the mental health problems of health care workers? So that would be my question that I pose back to you. So there are lots of different types and features of digital mental health technologies. Digital wearables and digital biomarker apps are typical that collect physiologic data about us. There are those that are about prevention and treatment solutions. There are chatbots, where you're with an automated voice on the other end of the line, which actually turns out, in some cases, to be pretty successful in engaging with people. There are virtual and in-person methods, where apps are delivering cognitive behavioral therapy, hypnosis, meditation. Some of them are customizable. And then the other type and feature is around the analytic tools. Some of them are really collecting the data in order to be able to integrate the data to alert you as an individual, and sometimes your employer or a third party, about your need for help or clinical referral. So this is brave new world stuff. There are opportunities for this to be used well. And time is going to tell us how and when we can best apply these technologies. The challenges that we have is that you can go out there, and you can find top 10 mental health apps of 2022. If you Google that, they'll pop up, and they're all the favorites. It starts off with a kind of a disclosure that many of these are evidence-based, which means there's some research, but a lot of the research may be done by the company. It's in the gray literature. It's not published in peer-reviewed. So they're all pretty quick to disclose that these are our favorites, but the rationale for why those are the favorites has probably a lot to do with the marketing as much as anything. So popular well-known does not necessarily equal effective. Understanding the quality and reliability of specific options is complicated. Vetting tech is a complicated thing to do. And having started a health information technology company and then been CEO of it for over eight years, I can tell you that even with being well-intentioned to communicate what technology can and cannot do for a health care organization is a complicated process, because there's a process of sharing information and making sure that it's understood, et cetera. This is a fast-paced area. The software is updating. It's changing. These are just some of our challenges. There has been some work done to try to evaluate the digital mental health tech in the workplace. And I say in the workplace because you can find precious little addressing it specifically in the health care workspace. There's a little bit out there, but not a lot. Actually, a couple of the best studies are out of the VA, the U.S. Ventures Administration, looking at CBT, cognitive behavioral therapy for insomnia, for example. So there are some shining examples. But for the most part, there's relatively little written. And the meta-analyses are showing promising preliminary results for some conditions. But they're also quick to point out that there are evaluation issues. There is not a uniform regulation over mental health apps, digital technologies. Where there are studies, there's heterogeneity in study design and study quality, a lack of research similar to what Kent Anger presented this morning for interventions to help health workers, mental health. There's a lack of research on long-term health effects. Most studies, if they're done, look for effects at three months or six months and rarely go out to a year. And there's even a lack of an agreed-upon taxonomy. How do we even think about how to judge the good, the bad, and the evil of a particular app is messy business. There have been already, we counted, more than 45 evaluation frameworks for health apps that have been proposed. So even from the research standpoint, just trying to wrap our heads around how to even think about how to tell you what's a good one and what's a not-so-good one turns out to be pretty challenging. I'm going to point you to some frameworks that are out there, though, just so you can start to think about where can I go to get help. And this is actually from a paper which tries to articulate from the American Psychiatric Association's standpoint what makes for a framework just to organize our thinking around these apps. And it includes issues like how accessible are the technologies? Is there adequate privacy and security? Is it clinically well-founded? What about the engagement style? How does it engage with our audience? And I'll just add to that, does it in fact reach all of the audience that we need to reach? This morning we heard about how even above and beyond the impacts, the mental health impacts of COVID on health workers like nurses and doctors, even more impacted have been the other health ancillary staff, for example. Are they finding engagement? And is it achieving the therapeutic goals that we hope? So this is at least one useful way of thinking about how to make decisions about the selection of apps for an organization. Another really, and this is a place where you can be contributing, there's a very interesting site put together by MindApps, the people at Deaconess in Boston, put together a fabulous open source library of these approximately 10,000 apps. And you can actually contribute to this. If you have experience working with certain technologies for mental health, you can go to this site, you can see information about what the cost is, the developers, what kinds of supported health conditions are being addressed, what functionality does it have, what kind of uses does it have, what are its features, et cetera. And you can also contribute to this site to build the community of knowledge about the value of these tools. They're searchable and they're current. And so I encourage people to be aware of this as one very interesting tool to use. And there are others. There is an ANSI ISO document that actually looks at health software broadly and there's part two of this document which addresses health and wellness apps and their quality and reliability. So for those of you who want to drill into what's, you know, you want to do a deep dive, you know, go to this part two section. And there's also some information on the U.S. FDA website about device software functions. Well, you know, so when counted in 2017, there were over 325,000 digital health applications in healthcare broadly, of which I said there may be 10,000 or so today that we know of that are specifically focusing on things like wellness and mental health. But, you know, go to the FDA. You can find there that there have been thus far, I haven't checked recently, but the last time I checked, five apps for mental health that are actually FDA approved. So, you know, among those are, there are ones that are used as supplements to therapy is pretty much where they, where those approved ones go. I think limiting ourselves to what the FDA approves for those of us in the U.S. would be a mistake. As I said, there are others out there that are in common use in health settings, in healthcare settings. But, you know, just to be aware of somebody says, well, is this FDA approved? Was the FDA think about it? You can go to the FDA website and you can also, you know, then kind of appreciate what are the criteria they use. And mostly they're focused on the ones that are going to tie into therapy. When we talk about the considerations that you should be using, if somebody asks you, should we keep using the apps we have or should we add some new ones or should we spend the money as a health organization to provide apps, the kinds of things that you want to be considering are the kinds of things that the Minds app people on their website describe. And so I'm not going to spend much time on this because I'd be repeating myself. But it is important to realize that, you know, as was described this morning, depending upon what taxonomy you use, you know, just mental health itself is too global a term. What part of mental health are you trying to address? Are we focused on mindfulness? Do we want people breathing? Do we want people to be aware of their physiologic state? Do we want to help them with insomnia? You know, you can go down the list. Are we addressing stress? Are we addressing depression, anxiety, post-traumatic stress disorder? There's an app for everything on the list. So starting with a consideration of what are we trying, you know, what are the conditions that we're most concerned about in our workforce? And then trying to find the best fit for what's available to us. And like I said earlier, evaluation. The one of the last points that I want to make sure I talk about because I want to leave time for the other speakers and maybe we'll have time at the end of the session for some questions to come back to this because I find when it comes to the apps topic, everyone's got an opinion. Everyone's got a favorite. Everyone's had experiences. But engagement is a big deal. So when I think about design and intervention, I think about, first of all, we want to know does it work, right? Does it have effectiveness? Does it have efficacy? And if you get that, even in a short-term study, the next thing I want to know is, you know, is it going to reach the audience, the people who I'm trying to reach? Is it something that's easily adoptable? Is it something that can be readily implemented? Will it engage people in a sustained way? Can we maintain, if there's a benefit, can we maintain that benefit? And what I just described to you is actually one of the models for dissemination and implementation evaluation called RE-AIM. So when you think about in that context, one of the places where the literature is starting to say that we fall short is we may demonstrate short-term efficacy, but engagement, sustained engagement, getting people to even sign on to an app for the first time, even if we think they might benefit from it, is a challenge, and getting them to keep using it becomes a second challenge. So if you're going to evaluate the utility of these instruments, one of the things you have to evaluate along the way is the process of adoption and how many people who sign on to it keep going with it. So good tech is not enough. We need to focus on engagement efforts, and it's well-documented that with, like many well-being and wellness apps, mental health is no exception. Sustained engagement tends to be fairly low. A few parting comments, some of which deliberately kind of overlap with each other but have different ways of triangulating on some of the recommendations. Choose options that fit employee-specific needs. Vet the tech before you make a final choice, or if you've already got them in place, persuade somebody who paid for that contract to let you evaluate whether your group of employees is getting the benefit that you hope they're getting. Things like convenience and ease of use and anonymity are highly prized. And then when you're communicating with employees about the use of these apps, consider it from – you know, this is practicing empathy. Consider from their perspective what they might be hearing from you. So how you frame this. Is there actually a positive language that you can use? Are you interested in helping people boost their well-being? Are you making efforts in sharing this app to help reduce and not contribute to stigma? So thinking hard about how you communicate with the workforce where you're introducing these kinds of apps is very important. We think that having an orientation towards well-being, towards wellness, is a helpful way to go, but we're in a stage where the only way to address stigma is actually to acknowledge that we are having struggles with our mental health, whether it's depression or anxiety, stress, PTSD, what have you, insomnia-related health problems, et cetera. Realizing that participation is voluntary is extremely important and how do you balance that against promoting engagement is you know I can't solve for you today but but the the worst thing you can probably do is place expectations or in my opinion incentives positive or negative placing incentives on the use of a product would be a bad idea and explaining where the data are going to go and who's going to have access to the data is extremely important and so as you go through some of the references that I gave you and some of those sites this will come up time and again I don't have time here to spend more on it but I think we all go into this with a heightened sense of sensitivity about who in my organization could potentially have this information about me and what would they do with that information so both from the perspective of the employer as well as from the perspective of the employee there's a need for protections around privacy and I can tell you that not all of the technologies out there are equal when it comes to privacy it's a significant ongoing issue and one that you have to consider when you're vetting I'm going to just go ahead and wrap up with a few resources for you and with that thank you for your time hopefully we'll have some some time for questions later and hopefully we've got the rest of our team who's online back in and and are you all there and do you have voice we still can't hear you see that's going to share her screen we can we can see the slides can you test and see if we have audio the slides are coming up on the screen but no audio yet did I say something about not trusting technology can't where do you want to take it from here yeah I'm happy to take a few questions while and and Bernice if you get if you get audio just break in thank you for the presentation but a few things like we use apps on a regular basis you saw the number of apps that are out I think app fatigue probably is a definitely a thing sustainability is a question always most of the time the other day I was sitting with my five-year-old and I look at that ABC mouse dot-com right and you see that they're not at one point keep moving around same holds good with us if we have the same sustained the data that's coming out of that it's the same thing over and over it's likely they'll get the fatigue there has to be a change any of the social media apps that have gained momentum are typically the ones that change moment for example Facebook Twitters and everything your videos change constantly and that's what creates the interaction people would like to have the change and make sure that the conversation is ongoing and those apps are very limited yeah you know there's the gamification which it feels like a weird thing to say when we're talking about something as precious as our mental health but your gamification is certainly part of there's a segment of this technology market which which you know they use gamification because it's a way of continuing to engage people or or just simple even goal-setting you know just you know kind of triggering that you know you'll you'll keep coming back and changing something about the imagery one of the things that's that's kind of finding it's it's niche right now in early stages is is using virtual reality glasses for for mindfulness and you know that's a constantly changing image and and in fact you know intentionally keeps changing up in order to you know maintain you know the the therapeutic goals that they're setting and have you keep coming back and probably also adding a hybrid model where it's just not virtual but also in person yeah so to the point about about hybrid models one of the things that is often said in this in this literature in the meta-analyses have been done is that is that you know apps do not stand alone that for the most part if you're using them especially in secondary or tertiary prevention that it's app plus so having an app that connects you to a provider having to be something that helps bridge you know what you're working on between visits you know that seems to be you know and that's where the FDA kind of steps in and says you know these are the ones that we that we agree are worthwhile and and and yet when you when you dig into that literature you have to look long and hard to to find evidence that the addition of an app to traditional mental health therapy with a provider is actually superior to provider alone now again full you know my caveat is just because the science hasn't been done doesn't mean there isn't some potential benefit we just don't find that much in the literature yet to support it but so as a result the the the reaction in the literature that you'll find is if you're going to use you know apps that especially trying to address things like depression and anxiety your best your best position is to say this should be linked to to traditional therapy Lee can you hear me now yes Oh success all right thank you everyone for your patience now we can't see you yet that's cuz I know we can oh there we go I'm gonna get off the stage and turn it back to you welcome back so much Lee for moving things along really appreciate it let me share my screen okay where are the slot there they are Bernice I think let me just introduce you to everyone and Lee thank you so much for presenting and just so everyone knows dr. Newman is really an integral part of the NIOSH effort so we really appreciate what he and his team is doing for our initiative our next presentation will be from dr. Bernice Pesco Salido and Bernice if I mispronounced your last name I apologize I've been practicing all week she will be presenting a talk titled mental health stigma in the workplace targets levels and approaches to increasing awareness reducing stigma and lowering barriers to care dr. Pesco Salido is the distinguished and Chancellor's professor of sociology the director of the Indiana Consortium for Mental Health Services research and the director of the Irsay Family Research Institute for Sociomedical Sciences at Indiana University dr. Pesco Salido's research focuses broadly on how social networks and culture provide insights into health illness and healing phenomena and more specifically on four major areas stigma suicide health care use and health care systems in the NIOSH initiative we have come to recognize the significance of these areas particularly the area of stigma which you've heard people refer to in different ways all kind of leading up to this presentation and she joins us today to contribute insights from the perspective of her substantial expertise in this area to provide us a further basis to discuss these problems I now ask dr. Pesco Salido to begin her talk thank you very much thank you Suda can you all hear me great okay oh no can you can't hear me Suda no I can I was just being impressed all right well I guess I'm here to talk about a word that we use a lot but that has means a lot of different things to a lot of different people and there's a reason for that so I have a number of objectives today and the first one really is to get a handle on what we mean by stigma and how we use it in the research context then I've tried to scrape together as much data as I could to look at the correlates and levels of stigma in the u.s. in the workplace and to offer a summary of the kind of myths surrounding stigma which are critical because they found the they they form the foundation for stigma change efforts and then to provide an overview of scientific findings so Suda can you go to that that's the slide of the of the objectives okay so next next slide so let's just start basically what do we mean when we say stigma well initially the word literally meant a physical mark on the body used from in ancient Greece to mark people who had become slaves because of the endless warfare and to differentiate the people who were citizens from the people who were slaves it has come now to really mean an attribute that is defined by a society in a particular time in a particular place to mark someone who is considered less than that they are reduced from a whole person to a person who is considered less than fully human stigma has a number of types which I'll talk about more in a few minutes but literally when we talk about stigma we're talking about a stereotype of attributions that are applied to individuals they're fixed there they absolutely obliterate individuality because these attributes are attributed to all members of the marked group stigma itself as the mark then produces prejudice and that prejudice is usually negative sometimes it's positive but usually negative attributes that negative attitudes that people hold it can be about the knowledge of what causes the mark it can be about beliefs surrounding the mark or it can be about attitudes towards the people who are so marked more importantly for some that this prejudice turns into discrimination and that discrimination is launched in behaviors where individuals with that mark are rejected excluded they're coerced they're restrained they are denied opportunities such as not being hired promoted dated or rented to so it's really a very large area that we're talking about next slide the other reason that it matters as a number of people with mental illness have told me I don't care if people like me but I would like them not to discriminate against me and the research literature is very clear that stigma does matter for many aspects of life because it affects whether or not people recognize mental health problems whether or not they seek help whether or not they'll use those apps that we just heard about whether or not there are limited treatment options compared to other kinds of disease problems that we face in the workplace they're denied opportunities there's a lot of isolation that's around it which itself produces more health problems and there's actually studies that document reduced life expectancy in the u.s. for people treated in the mental health system for about 15 years lowered life expectancy all of these things affect worker productivity and it also translates in the health sector itself into a mismatch between the problems that mental the challenges that mental health faces us in the United States and the number of medical professionals that are actually available to help solve those problems it also translates into the unwillingness of medical professionals to attend to their own mental health problems and the effects are magnified when this particular stigma comes with other stigmatized conditions or identities people face what we call the double hit or layered stigma which magnifies the kinds of challenges that they face the research on stigma has indicated that it's pretty stubbornly persistent and pernicious and that we actually have we do not have a suite of anti stigma efforts that have been shown to be measured as we heard about earlier in terms of efficacy studies that are sustainable and that are scalable so we have a lot of challenges that we face at this point next slide so when we think about stigma rather than sticking thinking about it as one word or one thing we have talked about the stigma complex in research and this is important because the different types of stigma that exist translate into there being very different targets for dealing with stigma in the workplace and different kinds of interventions that matter so for example we tend to think of stigma as something that one person does to another person but in fact the issue of structural stigma suggests that these kinds of stigmatized attitudes and behaviors are actually baked into certain kinds of organizations and policies that make it very hard for people to deal with their individual problems in dealing with mental illness and this matters in terms of whether or not we can just focus on individuals to eliminate stigma because if it's baked into the organization and the structure and its policies if it's baked into the culture and climate of an organization then changing individuals is not going to give us the effects that we want in terms of worker health whether that's mental health workers or any kind of workers and the productivity that well we hope will come from that next slide so what does stigma look like well if there's very little data out there about workplace based stigma but we have done the national stigma studies in 1996 2000 2018 and we use it in a methodology here where we present people in the public with a nationally representative sample studies with we describe an individual who's facing a problem we don't tell them what that problem is we give them what they face in the workplace which is what is a person like how are they behaving and then we use a number of these that that meet criteria for alcohol-dependent schizophrenia major depression or just problems of daily living that don't meet criteria for anything what this graph shows you is the level of stigma expressed or endorsed by the American public in the workplace so the question that I'm focusing on here is a classic social distance question of would you be unwilling to work closely on the job with this person that we're describing and what we see here is a real consistency in the unwillingness very high levels most Americans are unwilling to work closely on the job with somebody who has or has been treated for alcohol dependence the levels are lower for schizophrenia even lower for depression and 20% of Americans are unwilling to work closely on the job for someone who has no psychiatric disorder but has problems of daily living we often refer to these people as the Mikey's if those of you of a certain age remember a life commercial cereal a cereal commercial where a mother brings home a new cereal life cereal and the two older brothers say we don't want it we don't want it we'll give it to Mikey he doesn't like anybody apparently 20% of American workers only want to work with people who have absolutely no problems so the level of stigma in the workplace around mental health issues and problems of daily living is actually quite high the one good news I can bring here is that if you notice on this graph the one bar that has decreased significantly over time is the gray bar which is we're actually moving the needle in the United States for stigma in the workplace around issues of depression so the good news is we can move the needle we are moving it for depression but we have still a lot of work to do next slide so we could also use these these surveys these national stigma studies because they represent a national sample of Americans to to pull out the people who are actually health workers that either that their industry code is this is something I think that Suzanne talked about earlier that either is an industry code that indicates a health workplace or an occupational code that indicates that and so what we did was we compared those levels that we talked about earlier in terms of stigma to work closely on unwilling to work closely on the job with between individuals in the general population versus those that are actually in medical occupations and what this shows the blue bar are the general public and the red bar are those people in medical occupations and we see absolutely no difference between people in medical occupations where you would hope there would be more of an understanding of mental health and the stigma associated with it compared to the general population but in fact there is no difference so you might say well there are a lot of people in medical occupations what about the people in the high-level medical occupations where you would hope that training in medical school in nursing school would affect that next slide Suda we pulled out individuals who were only did we are we on the same slide Suda I think we need to advance one do we need to advance one more yes I think so no no sorry go back I thought we were on the correct one yep you're right you're right okay I think yeah this is the higher yes what we did then was we pulled out just in the in the National Studies MDs nurse practitioners RNs to see if there was any difference there and again we see no difference between the stigma held toward mental illnesses by the general population compared to those in the workplace. Okay, next one. But just to make sure that we're not having some unusual findings, I bring in some data from Johns Hopkins University where they looked at primary care physicians, compared their levels of stigma with the public on the issue of opioids. And we find if you look at that second bar, we see no difference in their willingness to work closely on the job with a person who's using opioids. So the kinds of things that we're seeing seem to be fairly generalizable. Certainly they're nationally generalizable, but they seem to work the same way across all of the mental health problems. Next slide. So how do we understand this? And one of the studies that really was a very insightful study done during COVID looked at ER physicians and mental health issues. And so with regard to issues of mental health problems, we see among ER physicians that it's not a question of recognition. The graph on the left shows you that during COVID, people who worked in the ER understood that they were under a great deal of stress and they were facing mental health problems. And on the right, we see the graph that indicates that these physicians really understood that they had access to care. They knew where to get it, okay? So in terms of dealing with mental health problems in the workplace, not a question of recognition, not a question of access to care. But if we go to the next slide, we see that in fact, it is a question of stigma. That in the mental health, in the emergency room during COVID, we see that 45% of emergency physicians in the left graph report that they are not comfortable seeking mental health treatment if needed. And on the right, they said that the reason for this is, is that 73% of them felt that there was stigma in their workplace and 71% feel that there is stigma among their colleagues that they work with in medical settings. Next slide. In addition, we feel that, in addition, ER physicians indicated that they fear reprisal for getting mental health treatment. And that 57%, so over half of physicians, emergency room physicians indicated that they would be concerned for their job if they were to seek mental health treatment. So if we wanna understand what to do about this, we really need to get a handle on the culture and climate of workplaces and look at the various kinds of stigma that health workers face. So I think one of the things that would be useful was to look at what we know from the research. And much of the research that we do really is about looking at assumptions about how we can change stigma in general, and then figure out from there how we can, in fact, change the workplace. So next slide, please. So one of the issues has to do with whether or not, and a typical awareness campaign focuses on the issue of mental health literacy, and that that should be the target. Education, awareness about underlying causes or about treatment options with the well-known tagline being mental illness is a disease like any other. I think, Sudha, you need to hit the slide button to, yeah, because what we see there is that that is actually false. That stigma, that the research is very clear that Americans really are fairly aware about underlying causes and about treatment options, not specifically, but in general, they know what to do or what to think about, but that has no relationship to how stigmatizing they are and how much stigma they endorse. The second myth is whether or not stigma is the same everywhere. One of the recommendations often that you hear when people talk about stigma is that in low and middle income societies that people seem to be more open and more accepting. We've also done a 16 country study that shows that in fact, that is not the case. Countries like Bangladesh, Cyprus, South Korea, actually have, the Philippines have the highest rates of stigma and the lowest rates are actually in the welfare state countries of Europe, where there is a lot of public health spending on issues of mental health. Next slide, next button, hit. Okay, the other thing that people tend to think is that stigma is a problem only among certain groups. Those who are less educated, certain we saw with the data on physicians and those in the medical sector, that is not true. Men are not more stigmatizing than women and people who are politically conservative are not more stigmatizing than those who are liberal. Another myth busted, next one. That we should target individuals for change because cultural climate doesn't matter, institutions don't matter, and that what we need to do are randomized clinical trial efforts to figure out what kinds of things work. But one of the things that we've discovered is that all of that is false, that in fact, the cultural climate in an area has a direct effect on the stigmatizing attitudes and behaviors that people hold. We find that institutions, as I said, bake in these things. One of the reasons that doctors are unwilling, have told me many times, that they're unwilling to seek care, to indicate that they have mental health problems is because in many states, their licensing asks them whether or not they've ever had a mental illness or have been treated for a mental illness. Not really clear why that is still on those licensing things. If somebody had a serious cancer, that would affect their work or productivity as well, but mental illness has that stigma that we don't see for other disorders that could affect productivity and the kinds of issues that we're talking about today. The other thing we find with randomized clinical trial research is that while they could show the effects of different kinds of anti-stigma efforts without a continual long-term effort, those effects extinguish, they go away. Stigma returns to the old levels. And finally, the issue of campaigns or public service announcements is the major vehicle for change. We find that, in fact, those only work if they are long-term, if they are long-term, and if they have certain characteristics, which I'm gonna talk about because I would like to end on a positive note. So let's talk about how we can change mental health stigma among workers in the health force. So next slide. Okay, the first thing we need to do is we need better research on what matters most in the workplace about their concerns for people with mental health problems. Are they concerned about their lack of productivity, which has been shown not to be true? Are they concerned about their penchant for violence, which has been shown not to be true? Are they concerned about feeling uncomfortable working with or talking to these individuals? We really don't have a good sense of that. The other thing that we need is that we need to change organizations, not even just or even primarily people, because if you change the culture and climate of an organization, people will come along. The other thing, the other issues that we have or the other things that we know about change is that if we start early or young in terms of thinking about education for people in the mental or medical workplace, that that's going to have more of an effect. And in terms of onboarding into organizations that those workplaces, when they onboard people, if they start with the anti-stigma work there, it's much more likely to be successful. And finally, if we weave change into the social fabric of a workplace, that this is going to be more effective. So I often tell this story about changing people versus changing organizations. And the story I usually talk about is an article that's listed there about Vietnam and changing hearts and minds. We often believe that the war in Vietnam ended because we changed the hearts and minds of those in Congress who were supporting the war. But in fact, the research shows that that was not the case. What happened was we voted out the hawks and voted in the doves. This relates to a clear theory in terms of change called cohort replacement theory that says a slower but more effective way to change is really to focus on young people and to change the workplace more slowly. And again, starting with educational institutions for mental and medical professionals would be a better way to go. In addition, one of the things that we know about this is that there are times in people's lives when they're more open to changing their ideas about mental health and mental illness. In fact, any kind of prejudice or discrimination. And that really has to do with these times in their lives. Again, when they're going into a new workplace, when they're going in for more education, they're more likely to do that. The other thing is that we cannot simply give people tools. We have to give them ownership of the ways to change stigma, to get them engaged in this, which our person talked about earlier, and to figure out how we can leverage things that are already good about the workplace and about the health education that we can use to sort of embed ideas about changing issues of stigma. So I think, I think that's the last slide. Yes, yes. So I think that we have a solid body of research that we can use to talk about how we change stigma in the health workplace, but it does bang up against some basic myths that people have about mental health stigma and about the way you change cultures and climates. So I hope that's useful, and I'm happy to answer any questions. Thank you. Thank you so much, Bernice. That was just wonderful. You've provided us so much food for thought and discussed some key critical areas. I think we might hold off on the questions until the end of the session, because Dr. Weissman can give his overview and discuss and portion, and then we can spend the last part of the session having some conversation with our audience virtual and in Utah. So our next presentation is going to be from Dr. David Weissman. He is going to present the NIOSH Mental Health in Health Workers Initiative, as well as comment on some future needs and directions. Dr. Weissman is the director of the Respiratory Health Division at NIOSH, a position he has held since 2005. He is a diplomat of the American Board of Internal Medicine with subspecialty certification in pulmonary diseases and critical care medicine, and a diplomat of the American Board of Allergy and Immunology. He has extensive clinical and research experience and is a national leader in the area of occupational respiratory diseases. And in addition, he has been a main leader in the current NIOSH Mental Health in Health Workers Initiative. And today we'll present an overview of both the morning session for those who may have not been able to attend, as well as our session this afternoon as the basis for discussing future needs and directions. So I invite Dr. Weissman to unmute himself and... Well, thank you, Sudha. And can you hear me okay? Yes, I can. Kent and Lee, can you hear David in the room? Yeah, we can hear you. Okay, wonderful. Perfect. Thank you. And it's an honor to be able to present and talk about such an important issue today. Next slide, please. Boy, it's taking a long time to change. Okay, so I'll be going over the various... I'll be using various talks that we heard earlier as source information to talk a little bit about where we're at in future needs and directions. Next slide. And as you heard earlier from Tom, NIOSH has really been able to increase its efforts in the area of mental health for health workers in recent times. We've been able to do that because of additional resources that we received through American Rescue Plan of 2021. Next slide. Also, as you heard earlier, the Mental Health Initiative for Health Workers focuses on these various topics that have been identified. I'm sorry, David, sorry to interrupt you, but can you share your screen? Right now, we're getting a little mini picture of the slides and a big picture of you. You're looking very jumbotron, so if you can share. Okay, Sudha... Or Sudha, do you have that? The slides, are you able to switch that, Sudha? Or do you want me to try to show the slides myself? Or just swap the view? Okay, so I can go ahead and let's see here. I'm trying to find on this. Okay. We're in business. Good, thank you. Okay, excellent. Thank you, Lee. So what I'll be doing is I'll go through each of the topics that have been identified and talk a little bit about what's been covered, maybe supplement a little bit of additional information, and then each area talk about future needs and directions. Next slide, Sudha. And we'll start with health worker burden. Next slide. So as we heard earlier from Suzanne Marsh, even before the pandemic, there was a large proportion of health workers that suffered from mental health issues. Again, to remind you, these groups of bars, the far right bar in each case, the bright blue bar is the general public. And you can see for many of these conditions, including diagnosed depression, insufficient sleep, many of the health worker occupations suffer at greater proportions than the general public. Next slide. And COVID-19 did not make things any better. And in fact, maybe even extended mental health issues even more widely among health workers. As we heard in early 2021, 53% of public health workers reported symptoms of at least one mental health condition in the past two weeks. Next slide. So there's huge burden. And so what do we need to do going forward? Well, we need to continue to do surveillance using available data sources. We need to address, as we've heard, the full range of health workers, not just those directly involved in caring for patients. We need to identify the populations that are the most important targets for intervention. And we need to continue to gather data longitudinally so we can track progress or lack thereof and respond. We also need to develop new sources of surveillance data, not just health surveillance, looking at the burden of mental health conditions, but hazard surveillance, understanding the frequency with which people encounter the conditions that lead to mental health issues. We also need to understand economic burden because that drives a lot of what happens in the healthcare industry. So the cost of staff turnover, of staff prematurely leaving healthcare work, the cost of bad patient outcomes. In the opposite of hazard surveillance, we need to track the uptake of best practices. And where possible, we need to improve existing surveys by adding relevant information, such as occupation and industry, to large national surveys that collect mental health information so that we can compare burden in health work compared to other occupations and industries. Finally, we need to act on these results. We need to disseminate them into the hands of people that can use the information and target efforts and follow what we do because gathering data alone isn't enough. We have to use it. Next slide. Next, I'll talk a little bit about issues related to intervention. These two topics identify and adapt tools and assimilate evidence. And next slide. And I'm going to turn here to the National Academy of Medicine, which has a collaborative on clinician burnout and resilience that's been going on for several years now. And they've established really a strong conceptual framework for the issue. And in their framework, burnout results when job demands and job resources get out of whack, get out of balance. And job demands can be determined by organizations and job resources can also be strongly influenced by organizations. Next slide. And so the National Academies has identified six essential elements as resources for health worker wellbeing. And you can see the top three circle here are all organizational issues. So advancing organizational commitment, strengthening leadership behaviors, cultivating a culture of connection and support. These are all organizational kinds of activities. Other circles that you can see here, other elements are enhancing workplace efficiency, making it easier to get your job done and gaining time. And I should say not using that time to give people more work to do, but using that time to improve their work-life balance, examining policies and practices, making it easy to get your work done, getting rid of the stupid things. And then finally, also conducting workplace assessments. So again, surveillance. Tracking burnout, tracking related conditions over time to show the impact of interventions and where more work needs to be done. Next slide. National Academies also recognizes the importance of organizational culture and organizational interventions and the importance of primary prevention over secondary and tertiary prevention. So you can see the spectrum here ranging from the base of the pyramid where you work on organizations to the top of the pyramid where you're talking about actually developing disease and treating disease. And it's best to do primary prevention. It's best to work at the organizational level and keep issues from ever happening. Next slide. And finally, from the National Academies, they emphasize what they call the quadruple aim. So of course we want health workers to have improved mental health, but we also want to do things like improve patient outcomes and improve patient care and lower costs. Those are very important motivating things for the healthcare industry. So showing that making our health workers healthier also improves these other outcomes is really important. Next slide. So how does the literature, how does our knowledge about interventions stack up against that conceptual framework that came from the National Academies? And as you've heard from Kent Anger earlier today, despite a very extensive exhaustive literature review, 54 articles were identified, which really isn't that many. And when he broke down, when he and his team broke down those articles according to their confidence ratings, only a small portion of those fell into the highest level of confidence where you were really confident of the outcomes and the conclusions of the studies. Next slide. And then in terms of the types of studies, as you can see here, only a relatively small proportion of the studies were system targeted interventions. And as Kent noted, many of those were based on individual symptoms. As opposed to organizational interventions to prevent mental health issues from occurring in the first place. Next slide. And in addition, when he broke things out by primary versus secondary and tertiary, again, it was a fraction of the studies that were just primary, although there were a number that were primary and secondary. Next slide. And then in terms of the outcomes that came from the studies, there were many outcomes that were focused on mental health outcomes for the workers themselves. But when you think back to the National Academies Framework and correlating those outcomes with things like better patient care and better outcomes, there weren't any studies reported that addressed those things. Next slide. So, and we also heard from Dr. Newman about technology for improving mental health. And I think the bottom line is the first bullet that was shown that there were many, many tech solutions, but the science was limited. And I won't read the rest of the slide. I think that's really kind of the bottom line and goes along with the swamp slide that Dr. Newman showed. Next slide. So we have a lot to do in this area of improving our understanding of interventions. Dr. Enger's team is gonna complete their evaluation of the existing evidence, which will be really important. But I think it's clear that we need to conduct new demonstration projects and intervention research for improving health worker mental health. And we really need to prioritize studies that look at primary prevention at the organizational level. We need more information about that. I think everyone has the sense that that's important and that's reflected in the National Academies framework, but we need more data about it. We need to demonstrate feasibility of interventions and we need to document impact on multiple endpoints. Of course, meant worker mental health outcomes, but also quality of care and patient outcomes and return on investment, cost benefits from reduced health worker turnover, reduced malpractice claims, and so on. And again, we need to disseminate results and promote the uptake of current and best future practices. Next slide. Next, I'm gonna touch briefly on generating awareness. Next slide. And as we heard from Dr. Pesco-Salido, we really have a ways to go, not just in raising awareness, but in changing people's hearts and minds. And as she said, I think this is really impressive that 57% of emergency physicians said that they would be concerned for their job if they were to seek mental health treatment and 27% had avoided it and 6% wouldn't even answer the question. We have a lot to do to change the hearts of not only the people who are suffering with mental health issues, but also change the cultural framework that they're working in so that they can get help. Next slide. And we have to take the principles that we heard about, about focusing on what matters most and changing organizations and starting young and educational program and changing cultures. We have to weave that into our efforts. Next slide. So what are the future needs and directions? So awareness of issues and solutions and changes in heart really are needed by many. Leadership and management of healthcare organizations, health workers and unions, providers caring for health workers with mental health issues, and others, third party payers, professional groups, families, the general public. There are many targets that need to be addressed to change hearts and minds. And there are many pathways. Again, as we heard, just doing public health awareness campaigns isn't enough, but it's part of the solution. Doing research, publications, presentations to appropriate groups is important. And forming partnerships, actually forming partnerships and getting out there and doing demonstration projects and changing the way that healthcare is delivered and the work settings that health workers are in are really important. And that'll segue to the next slide, Suda, to the final topic, which is partnering for impact. Next slide. And we can't move the needle. We can't improve mental health for health workers without bringing in a wide number of partners and a lot of resources. Within NIOSH, we've brought together a number of programs that are concerned about this issue and are passionate about this issue to work together. So our Total Worker Health Program, our Work Organization and Stress Research Program, our Healthy Work Design and Wellbeing Cross-Sector and our Healthcare and Social Assistance Sector, all of these programs across NIOSH have come together to collaborate on this important issue. Next slide. And NIOSH recognizes that we can't do it alone. And in fact, no single organization can do it alone. So this requires partnership between government and industry and labor and academic and advocacy organizations to make things change. This is really going to take a lot of effort by everyone who's listening to this presentation and all of their organizations. We all have to buy in and be involved to make things better. So with that, I'm going to stop and thank you for attending and thank all the presenters. That was just really a wonderful set of sessions. And Sudha, I'll turn it back over to you. Thank you so much for that overview and for your comments on various aspects of the information that's been presented in both sessions. We're going to open up for a question answer portion here in a moment, but I just want to, because I didn't get a chance in the first session, I would like to just briefly acknowledge a few groups of individuals. First of all, all our speakers, thank you so much. The audience should know that the speakers have been working together to build cohesion and coherence across presentations, sharing slides and ideas for several months now. So Tom Cunningham and I really, really appreciate all the effort that the speakers have put in. We also would like to thank Dr. Howard, John Howard, the director of NIOSH, as well as several key individuals, Dr. Paul Schulte, Dr. Casey Chosewood, Dr. Naomi Swanson, for their tremendous support and guidance through this entire process of now a couple of years in leveraging this opportunity and putting it in action and the entire NIOSH scientific working group for the Mental Health and Health Workers Initiative. And we would like to thank the organizers of the meeting for giving us this tremendous opportunity and honor to present all of the ideas we've been working on to you. And finally, I'd like to present all the, thank all the attendees. This has been a difficult time for everyone in the past few years out in the field, and we've all gone through the ringer. And so thank you so much for all your efforts on the front lines and for giving us your attention today. So with that, I think we can try to have some Q and A. There were a couple of questions on the virtual line. More comments, I think, from Anamika DeWilde. Based on the National Stigma Studies, there is evidence that you should not share your mental health diagnosis and only refer to your issues as struggling. But then she commented that she thought the news on depression was good, that I think Bernice had been talking about. So Dr. DeWilde, if you have any other comments regarding that and want to share on the line, please do. But I think we'll move to the room for any questions there. Yeah, thank you for all the presenters, good one. A question, this is more, I'd like to get the thoughts of Dr. Pesco-Salido. Was wondering, I mean, if we were to apply the theory of reasoned action or the theory of planned behavior, and for issues such as mental stigma, there are two components that you can put heavy weightage on for the behavioral outcome. One would be the perceived norms or the individual norms, and the second one would be the behavioral controls, right, the behavioral control, which could be individual controls from family, friends, community, or the workplace, for that matter. Now, it's tough to judge which one would be. Obviously, both would be equally important out there, but is there something that you would prioritize? Would you go towards the perceived norms or the behavioral controls? Well, actually, I'm a sociologist, so I'd have to go somewhere else entirely. And where I would go to, I would go to social network theory and suggest that if you want to change people, you need to change the people around them as well as target them. And so you need to give ownership to the people that, whose behavior you wanna change in terms of developing and reducing stigma. So I think those things then interact with the kinds of factors that you're talking about, because we know, for example, in the theory of reasoned action, that norms come from the climate around people and the information, advice, et cetera, they get from people around them. So I would say that really the key is figuring out who your targets are and giving them ownership with the information from those theories about how to change things. So it would be a social network approach as opposed to a pure psychological approach. I don't know if that helps. Thank you. Great talks and great presentations, thank you. I have a comment more than a question. We talk about employee wellness all the time, but I'm particularly concerned about workers' compensation settings where we have individual providers and physicians that see these employees on a daily basis. What I've seen, both as a medical director and a physician in the clinic, is that the elephant in the room is that the employee who often seeks treatment with us doesn't trust us, the so-called workers' compensation physicians. And then when you're trying to pitch an app and say, here, why don't you try it, they either say, okay, but when they come back for a follow-up, they don't try those things. And the other thing is the lack of time, as well, to address the stigma and pursue issues. And I don't know if you have any recommendations for the physicians and providers in the trenches, but just a comment there. Maybe I could take, could I take the first pass at that? Sure, go ahead. So what you're describing in terms of the issue of trust is one that goes well beyond this topic. I mean, let's recognize that if you can't establish a bond with your patient, and they're coming to the room thinking that you're not on their side, first and foremost, as actually the AECOM ethical code of ethics would say you should be, if they don't see that and appreciate that, I don't care if you're ordering three sessions of physical therapy, or you're recommending that they use a particular digital app for mental health, that bond's not there, that adoption is not gonna be there. So I think that's a broader issue for all of us in the field. Now, remind me what the second part of your question was. It was just about, you know, lack of time and barriers, corporate pressures to address that stigma. Do you wanna, do you want to do that? Right, so, and maybe we'll pitch that to one of the other speakers, is how in a busy clinical setting do we as occupational medicine providers address stigma? Could I sum it up that way and see if we have a comment about that? Well, that's a tough one. I think that, you know, you address, I think you address stigma by not putting the burden entirely on the physician. I think you have to sort of, like I talked about, you have to weave it into the entire clinic and in the, you know, the workplace setting so that it doesn't fall just on a provider making a recommendation. But if somebody suggests, if a physician suggests an app and other people are using it or everybody's talking about it, the uptake is gonna be greater. I wonder if some of this is also perhaps looking at this as a hazcom issue. This is a hazard in the workplace. Individuals who have significant mental health concerns or problems going on are at, are vulnerable for a whole host of adverse outcomes. And we've seen some of that data. And maybe this is an opportunity to talk about organizational level hazard communication efforts, get some health communicators involved. I mean, I'm somebody who's sitting inside NIOSH, not out in the field. So my comment might be of limited use, but on the other hand, if we maybe think about it in sort of the classic occupational safety and health paradigm, if this were a chemical or some other physical hazard, we would be thinking about a hazcom program or a risk communication approach. And maybe that's an avenue, because as Bernie said, having the onus on the occupational health physician, when you see one of the staff in the clinic and that's where you're starting to raise the question, it's perhaps not as effective or there's a lot of burden on the occupational health practitioner at that point. So maybe there's an opportunity in that way. One of the things that we see in stigma research is the change that is happening is happening among the millennials and the earlier generations. And if they maintain that, then I think workplaces are gonna have to change because according to Project Healthy Minds, 30% of millennials say that they will decide whether or not they're gonna work somewhere taking into account the mental health climate in that workplace. And I think we see a lot of people not going into medicine and particularly not going into psychiatry because of the concerns that they have about what's happening in medical school and what's happening in the workplace. So I think we're gonna have to change that if we want to have a suitable workforce or enough of a workforce. I think that's good news, by the way. Thank you for that. And I do agree with the need for structural change. And we do have the luxury because we treat our own employees as well. And your point is well taken because we do get together with management and so on and so forth. The leaders, if you will, to create that culture of change as well. So thank you. We have no one else staying up here in the room. Do you have some other questions or comments that have shown up online? No, I do not. And we are just a few minutes shy of the end of the session. So if we have no other questions, we can probably wrap up. Again, thank you to everyone. And I hope you enjoy the rest of the meeting. Thank you all. Thank you all. Thank you, everybody. Thank you, everyone. I'll be sending an email out to everyone to follow up. So thanks. Thank you.

mental health stigma

workplace

prejudice

discrimination

mental health

productivity

access to treatment

healthcare workers

barrier to seeking treatment

primary prevention

COVID-19 pandemic

research