Steps in Healing After a Loss 1. Tell the story. Telling the story of what happened, from beginning to end, is healing step in itself. Follow the guidelines in the packet, take your time, and tell it in detail. Often there will be things you've kept to yourself since the loss happened, and this is a chance to get those thoughts, feelings, and memories outside of yourself. In this setting, no one will try to "fix" it for you or tell you what to feel or not feel. Your listeners will simply sit with you and hear you. 2. Explore the meanings of loss. Each loss has multiple layers of meaning in your life, and facing those meanings is crucial to your ability to move forward. For instance, the death of a parent will have an impact on you for years into the future, even if it happened years in the past. If you can acknowledge the many things a loss means in your life, you can address them on many levels, and prepare in advance for taking care of yourself in painful situations ahead. 3. Explore what feels un-finished. Feeling that things are unfinished keeps us stuck in the pain of the loss and gets in the way of letting go of that pain (NOT of the person or the happy memories) and moving forward. When you identify what feels unfinished, you can take steps toward closure. 4. Honor what was and take steps toward closure. These are the steps you take to release the pain - letters to (or from) the other person, collages or other artwork, rituals for anniversary dates, carrying symbolic objects, times/places ways to periodically revisit the loss. Do several, including the ones you want to avoid because the sound is too painful. The relief afterwards is worth the pain of the processing. 5. Celebrate what you get to keep. After every loss, there are things you get to keep -what you learned about yourself, what you learned from the other person, happy memories, the time and experiences you had before the loss, and the strength you gained from surviving the loss. Identifying these things can help you set down the burden of your grief and heal from the pain and intensity of the loss.

In my role as director of policy and advocacy at Mental Health America, I have ongoing opportunities to lead annual policy meetings on prevention and early intervention of mental health conditions – some of which I have dealt with firsthand since middle school. Since the COVID-19 public health emergency, we have spent a great deal of time advocating for the public health response to include addressing mental health concerns – which are routinely excluded even though data shows schizophrenia was the number one co-occurring condition in people who died from COVID-19, higher than asthma, obesity, and cardio conditions. At our 2023 National Policy Institute (held right before the start of our Annual Conference in early June), we went back to youth-focused discussions. Mental health condition signs manifest by age 14 in 50% of people who end up developing them, yet, on average, 12 years go by before individuals connect to services. With Gen Z in the middle of a pandemic, ongoing violence, and digital connectivity, this year was all about Tweens, Teens, and Technology. We discussed the internet and technology's impact on youth mental health and substance use based on research by the National Institute on Drug Abuse director Dr. Nora Volkow and several psychologists who conduct annual studies on youth and media, including Dr. Yalda Tehranian-Uhls of Scholars and Storytellers and Monica Anderson of the Pew Research Center. We highlighted which technology policies currently in front of Congress will help address harms. While 1 in 3 internet users is under age 18, California is the only state to enact an Age Appropriate Design Code Law (similar to the United Kingdom law by 5Rights Foundation) to ensure youth are not exploited and targeted online. No congressional action in the U.S. has been taken to hold technology companies accountable for social media harms even though youth report spending over eight hours a day on social media. In fact, much of the over $70 billion in revenue generated by Meta in 2020 can be attributed to advertisements to youth. The Senate Commerce Committee has previously taken up the Kids Online Safety Act, the closest bill we have to a national framework alongside the Children and Teens' Online Privacy Protection Act, but has not yet done so in the 118th Congress. Recently, the Federal Trade Commission renewed and expanded its order to provide for “Blanket Prohibition Preventing Facebook from Monetizing Youth Data.” And, last year Congress funded a Center of Excellence for Adolescent Social Media Use. We greatly appreciate having its co-director Dr. Megan Moreno join the policy institute as a speaker alongside Haley Hinkle, policy counsel of Fairplay, and Alison Rice the youth initiatives campaign manager at Accountable Tech. MHA was honored to also highlight the work of Amelia Vance, chief counsel for The School Superintendents Association, Fred Dillion, head of advisory services at Hopelab, Dr. Erlanger Turner of Pepperdine University, and Mitch Prinstein, chief science officer of American Psychological Association. We applaud the decades of work by these researchers and advocates in child online safety and privacy and call on Congress to heed the U.S. Surgeon General's recommendations on Social Media and Youth Mental Health and enact a national standard to ensure online media protects youth from harm and encourages healthy exploration of topics and help-seeking behavior. Read the many reports by these leaders in the policy institute meeting agenda and watch the program here.

Hospital visits for mental health care increased among children and teens in the second year of the COVID-19 pandemic, according to a study supported by the National Institute of Mental Health. Analyses of insurance claims data for more than 4.1 million children showed an especially notable increase in acute mental health care visits—including emergency department visits—among teen girls. The study was led by Lindsay Overhage , an M.D.-Ph.D. student at Harvard Medical School, and Haiden Huskamp, Ph.D. , the Henry J. Kaiser Professor of Health Policy at Harvard Medical School. Overhage, Huskamp, and colleagues examined national, deidentified commercial health insurance claims for youth aged 5 to 17 years over the following periods: Baseline year: March 2019 to February 2020 First year of the pandemic: March 2020 to February 2021 Second year of the pandemic: March 2021 to February 2022 The researchers defined mental health-related emergency department visits as visits in which a mental health condition was recorded as the primary diagnosis for the visit. They then sorted the diagnoses into categories, which included depression; suicidal ideation, suicide attempt, or self-injury; anxiety disorder; and eating disorder. Visits with a primary diagnosis of substance use disorder were not included. From these data, the researchers identified 88,665 mental health-related emergency department visits. Relative to the pre-pandemic baseline year, the proportion of youth with at least one mental health visit decreased by 17.3% in the first year of the pandemic. In contrast, the proportion of youth with a mental health visit increased by 6.7% in the second pandemic year relative to the baseline year. The proportion of youth with multiple visits in the same year remained similar over time. Further analyses revealed notable differences according to age and sex. Relative to baseline, mental health-related emergency visits in the second year of the pandemic increased by 22.1% among teen girls (aged 13 to 17), while these visits decreased by 15.0% among boys aged 5 to 12 and 9.0% among teen boys (aged 13 to 17). The data also showed that girls’ visits increased considerably for specific diagnostic categories. For example, among girls, there was a 43.6% increase in visits for suicidal ideation, suicide attempt, or self-injury and a 120.4% increase in visits for eating disorders in the second year of the pandemic. Among boys, mental health-related visits decreased or stayed the same across diagnostic categories in both pandemic years. The researchers note that these findings are consistent with other studies indicating that the pandemic has taken a greater toll on girls’ mental health. Inpatient psychiatry admissions also increased during the pandemic. After a mental health-related emergency department visit, youth were more likely to be admitted for inpatient psychiatric care and stayed in inpatient psychiatric care longer in both pandemic years compared to the baseline year. Importantly, during both years of the pandemic, youth were more likely to spend two or more nights in a medical unit waiting to be admitted to a psychiatric unit, a practice the researchers call “prolonged boarding.” Relative to the baseline year, prolonged boarding increased by 27.1% in the first year of the pandemic and 76.4% in the second year of the pandemic. The increase in the second year of the pandemic was especially high (87.2%) among teens aged 13 to 17. According to the researchers, the increase in prolonged boarding could be due to two factors: increased demand and reduced capacity. In other words, more children needed urgent mental health care, but there were also fewer inpatient psychiatric beds and fewer qualified staff to meet those needs. The researchers note that this underscores the importance of expanding the capacity of psychiatric services for youth. Although the study focused only on youth with commercial insurance, the findings shed light on the broad need for appropriate, responsive mental health care for children and teens. The researchers suggest that educating and supporting primary care providers in delivering mental health care could help address youth mental health concerns before they require more acute, hospital-based care. At the same time, they note that supporting existing mental health care providers and increasing the pipeline of qualified staff are critical steps in addressing the provider shortage.

Is forgiveness healing? PSYCHIATRIC VIEWS ON THE DAILY NEWS We have entered the third sentencing stage of the Pittsburgh Synagogue Mass Shooter trial. It will be an opportunity of sorts for the family and loved ones of those killed or injured to present how they felt they were affected psychologically. They will continue the important psychological work of witnessing that has occurred in Holocaust survivors. Inevitably, the anguishing possibility of forgiveness of the perpetrator will emerge. A statement by a leader of 1 of the 3 synagogues located in the building attacked, the New Light Congregation, was made right after the jury decision to consider the death penalty1: “These can be no forgiveness. Forgiveness requires 2 components: that it is offered by the person who commits the wrong and it is accepted by the person who was wronged. The shooter has not asked—and the dead cannot accept.” In a psychological sense, forgiveness can be unilaterally considered by anybody who felt wronged. Historically, a somewhat similar challenge occurred in the mass shooting in the Mother Emanuel Charleston Church on June 17, 2015. The perpetrator also lived, was sentenced to death, has not asked for forgiveness, and maintains that “there is nothing wrong with me psychologically.” Many, but not all, of the family members almost immediately during the bond hearing expressed forgiveness of the shooter. Forgiveness was described by one family member as a “superpower” of “spiritual resistance.”2 Such forgiveness is culturally congruent, and there is also the possibility of empathy and compassion with the troubling backgrounds of any given perpetrator. There also seem to be similarities with other white supremacist shootings in El Paso and Christchurch New Zealand. Moreover, there was another synagogue mass shooting, that of a Poway synagogue north of San Diego on April 27, 2019. The perpetrator also believed in anti-Semitic conspiracy theories. He was caught and sentenced to life in prison. I asked a psychologist who has helped the families of that synagogue about forgiveness. It seems like there was nobody known who actually forgave the perpetrator. The day after the shooting, their Rabbi, Yisroel Goldstein, who was injured in the shooting, called to “battle darkness with light.” Can the light include forgiveness? Even if there is some tendency for religions to differ in their views on forgiveness, usually there are always some offenses that are viewed as unforgivable.3 There certainly is also individual variation in what is involved in forgiveness. It might be too sensitive to conduct long-term studies on how loved ones do after such tragedies in comparing those who forgive early on and those who do not, and I do not know any such research. One important consideration is whether such forgiveness helps prevent future posttraumatic stress disorders (PTSD) and related problems, or not. What clearly voluminous recent research results tell us is that forgiving in general is beneficial for physical health, mental health, and overall functioning. A pioneer in such research, the psychologist Everett Worthington, whose own mother was murdered in 1996 in the midst of his studies, confirmed that in a recent study across 5 countries. He offers specific tools to do so in the REACH method involving Recall, Empathy, Altruism, Commit, and Hold.4 When forgiveness is considered, it is important to separate it from justice and remembering. One can forgive a perpetrator, but still desire them to face any appropriate legal justice and to not forget the trauma. In our clinical work, my own experience is that forgiveness was often the last challenge in a patient recovering from PTSD. Sometimes that was possible at the time and sometimes not. Although it is controversial whether groups of people can forgive, there certainly are groups that are targeted. The Church and Synagogue represented racism and anti-Semitism, and the ongoing goal of the perpetrator was further escalation of violence against those groups. That is when individual psychopathology overlaps with social group psychopathologies. However, the individual is subject to legal processing, but how to address the associated offending social group is much more uncertain, but ultimately necessary. Dr Moffic is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is an advocate for mental health issues related to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of Psychiatric Times.

Pittsburgh synagogue shooter’s beliefs are shared, not delusions, says psychiatrist In this courtroom sketch, Robert Bowers, the suspect in the 2018 synagogue massacre, sits in court Tuesday, May 30, 2023, in Pittsburgh. A prosecution expert witness in the Pittsburgh synagogue shooting trial said Monday he believes convicted gunman Robert Bowers was able to form the intent to kill required for the jury to consider imposing the death penalty. Bowers was found guilty in June of killing 11 Jewish worshipers and injuring six other people at the Tree of Life synagogue in 2018. In this phase of Bowers’ trial, jurors must determine if he is eligible for a death sentence. In order to consider the death penalty, jurors must first determine that Bowers had the ability to form an intent to kill, as defined by the court. Forensic psychiatrist Dr. Park Dietz, who spent more than 14 hours in May interviewing Bowers, began testifying last Thursday. Dietz has consulted on several high-profile criminal cases; he evaluated John Hinkley Jr., interviewed serial killer Jeffrey Dahmer and testified in numerous other trials. WESA Inbox Edition Newsletter https://www.wesa.fm/courts-justice/2023-07-10/pittsburgh-synagogue-shooters-beliefs PSYCHIATRIC VIEWS ON THE DAILY NEWS Today, the third and last phase of the Pittsburgh trial begins. Last Thursday, the jury quickly decided that it can move forward to consider the death penalty. Diagnostic Expertise So far, the main witnesses have been psychiatrists and other related medical specialists. As usual, experts that were chosen by either side gave different options about the perpetrator’s mental health and how that may have influenced his crime. Much focused on whether a given psychiatric diagnosis included delusional thinking, which could have impaired his “intent.” All combined, several diagnoses were presented: -Schizophrenia -Schizoid personality disorder -Epilepsy -Adjustment disorder In addition, sub threshold symptoms and a history of other disorders became apparent: major trauma, substance abuse, and clinical depression, among them. The depth of any treatment was not apparent to me. While someone could conclude from these diverse opinions that those in clinical psychiatry are not reliable enough in our assessment ability, they would fail to understand the difference between evaluating an individual patient for treatment versus a forensic evaluation for the purpose of answering questions by the prosecution or defense. The Role of Cults and Cultish Thinking Besides the individual assessment of the accused, and any contribution of his personal history, the case also focused on his most recent preoccupation, which was online anti-Semitism conspiracy theories, specifically about one of the synagogues he attacked bringing in immigrants to replace white individuals. Discussion ensued about whether all his beliefs were just like those of others online that he viewed over and over, or that he had his own unique delusional disease. Nothing I found, however, discusses these online tropes as being parts of cults or cultish influence. Cults have never been a prominent focus for psychiatrists, but there is one diagnosis that was never brought up that could reflect cultish thinking: “Other specific Dissociative Disorder, 300.15.” Resolving a Dialectic One resolution of the differing testimonies might lie in a more complex interaction and causation of both the individual and the social. Perhaps the perpetrator had psychiatric dysfunction that made him uniquely vulnerable to undue influence, but that dysfunction did not reach the DSM diagnostic level. The undue influence would lie in the social anti-Semitic conspiracy theories which he believed—and still does—were true, and that his mass shooting would make him a hero like our country’s Founding fathers. Serendipitously, perhaps, a new book on delusions came out last Wednesday that may help our understanding.1 Right from the beginning of the book, the question of how to define delusions is conveyed. On page 3, the DSM-5-TR definition is quoted: “Delusions are deemed bizarre if they are clearly implausible and not understandable to same-culture peers and do not derive from ordinary life experiences.” The confusion from this definition in regard to the perpetrator is that his subculture affirmed his conspiracy theories, but most of the general public apparently did not. Alternatively, in the Preface, there is this current caution: “Importantly, it is established that delusional beliefs cannot be distinguished from popular unsupported beliefs on the basis of their content alone: rather, one must consider the role of social factors in acquiring and potentially spreading the belief.” Certainly, anti-Semitism conspiracy theories spread to the perpetrator. Right after the verdict of eligibility for the death penalty, a community leader, exclaimed: “It is clear that this is hatred of Jews. This is anti-Semitism. This is not a mental health issue.” I continue to wonder whether hatred is a mental health issue, however. What else is it when it is an inappropriate individual or collective psychologically-based response to a group of others? No, that does not necessarily usually fit an official DSM-5 disorder, but it would fit being a social psychopathology if only we had such a classification. As we will continue to discuss, there are treatments and interventions that can address these social psychopathologies if only we use them. Dr Moffic is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is an advocate for mental health issues related to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of Psychiatric Times. Reference 1. Hardy K, Turkington D, eds. Decoding Delusions: A Clinician's Guide to Working With Delusions and Other Extreme Beliefs. American Psychiatric Association Publishing; 2023.

My father was such an inspirational man that showed me the values that were the core of his existence. In my wildest dreams, I could not imagine how my dad overcome such hardest obstacles in life to achieve what he achieved on a personal and professional level. He touched many hearts, as he genuinely did mine. Each day I hope to mirror and refine those values that I have been taught. I am sad that my father is not around in flesh, but I do feel his presence in spirit and memories. I know that I am thinker, by the ways in which he helped me to see a better world, one that he wanted me to help out in. I am only a mere product of such an amazing, inspiring human being, who is forever by missed by his family. My Father and I Back when I was young and 17. My dad taught me a lot about how to treat his patient as I have some amazing memories of his patients saying such kind words about how much my dad helped him/her. He was my role model and I wanted to help people just like him. Half the time I have a frank and candid conversation with parents about how to alter their parenting style to be more authoritative. Discipline is important, so is love and nurturing as it is paramount in building self-esteem and confidence. So many adults had rough childhoods because their parents didn't tools necessary to shape, inspire and model them. My parents weren't perfect they were a product of poverty and limiting nurturing in their lives. But they tried their best and im grateful through the ups and downs. Here is a interesting piece that may help enlightenment the teamwork that is necessary for both parents in the eyes of a child! One who loves till her eyes close, is a *Mother*. One who loves without an expression in the eyes, is a *Father*. ____________________________ *Mother* - Introduces you to the world. *Father* - Introduces the world to you. ___________________________ *Mother* : Gives you life *Father* : Gives you living __________________________ *Mother* : Makes sure you are not starving. *Father* : Makes sure you know the value of starving __________________________ *Mother* : Personifies Care *Father*: Personifies Responsibility __________________________ *Mother* : Protects you from a fall *Father* : Teaches you to get up from a fall. __________________________ *Mother* : Teaches you walking. *Father* : Teaches you walk of life __________________________ *Mother* : Teaches from her own experiences. *Father* : Teaches you to learn from your own experiences. __________________________ *Mother* : Reflects Ideology *Father* : Reflects Reality ___________________________ *Mother's* love is known to you since birth. *Father's* love is known when you become a Father. ___________________________ Enjoy what your father says. Keep loving your mother. ___________________________ Just feeling blessed and grateful for what I have, as many people don't have love or guidance in life. Despite my battles, I have always had such kindness and caring people in my life.

The Art of Happiness is a book that I would highly recommend to read. It was co-written by the Dalai Lama and a psychiatrist Howard Cutler. Dr. Cutler poses questions to the Dalai Lama about various elements of happiness, through his knowledge and wisdom about life. It helps to put into perspective what are the most important aspects that can lead to a happy life. It is based on the foundation and tenets of Buddhism, however described through real-life examples. The book explores how training the human outlook on life can alter one's perception. It illustrates that one's state of mind is much more heavily influenced by internal peace than external factors, conditions, circumstances, or events. One of the factors that is consistent discussed through the book is the importance of human contact and connection. This is one factor that I believe is on a decline as we live within isolated bubbles "pseudo-connected" through technology. However, reduction in face-to-face contact seems to be a rare occurrence at time. One of the aspects of life that I observe is how disconnected we can be from one another. I think that any type of technology has its pros and cons, however it is humans that can alter how such technology would influence one's life. I find myself often enjoying a random conversation with a stranger, which I believe is very important. I had an interesting conversation with an older gentleman that other day that had various questions about my race, ethnicity, and culture. It was nice to share aspects of myself with a complete stranger who appeared to desire contacting with another human being. It was interesting to learn about his life and various chapters that existed within his sense of happiness. Source: Vilash Reddy, MD

One movie that I think was very fascinating is a movie called Happy, which is available on Netflix. It is documentary film directed, written, and co-produced by Academy Award nominated film-make Roko Belic. It discusses principles of happiness, particularly through the perspective of positive psychology, through a series of interviews of people from 14 different countries, with varying cultural, socioeconomic differences. This was created based on Belic's interest in trying to understand the fundamental aspects of happiness, which stem from a article he read "A New Measure of Well Being From Happy Little Kingdom", which indicated that the US was the 23rd happiest country in the world. I am not sure how this ranking was measured. Belic spent several years, meeting hundreds of people, to explore his own curiosity of what factors lead to someone being happy. The film helps deconstruct happiness from an abstract concept to a possible formula based on the principles of human psychology. It was interesting because many of the aspects of happiness that were discussed coincide with concepts that were discussed by Abraham Maslow's hierarchy of needs illustrated below. Maslow's theory suggests that the most basic level of needs must be met before the individual will strongly desire (or focus motivation upon) the secondary or higher level needs. Maslow also coined the term "metamotivation" to describe the motivation of people who go beyond the scope of the basic needs and strive for constant betterment. The movie reflects, that regardless of socioeconomic factors and wealth, a individual was capable of feeling happy if he/she were capable advancing their life according the hierarchy that had been stated by Maslow. I thought this was an interest parallel which was not discussed in the movie, however coincided. I think in many ways I believe that Maslow's hierarchy applies to my life, where I try to focus on my health first and foremost. Source: Vilash Reddy, MD

I came across a post earlier today that stood out today. It made me think about a human spirit, drive, and adversity. I was really surprised when I read about the life of a very well-known actor Keanu Reeves. I was amazed at the course of his life and it makes you realize how much we often don't know what someone has been through or experience in life. Early Life Keanu was only three years old when his father left their family. He did keep in contact with his father, till 6 years of age. However, due to financial issues stemming from his parents' divorce, he moved from city to city during his childhood, later attending 4 various high school. He struggled academically due to diagnosed dyslexia, which made his school years challenging, until leading him to drop out of high school. Death of Loved Ones In 1993, early in his career as an actor, he lost his best friend River Phoenix, from a drug overdose at the age of 23. This was a very devastating point in his life, made him realize the fragility of life. In 1998, Keanu met Jennifer Syme. She ended up becoming pregnant 1 year following. At 8 months pregnant their child was born stillborn. It was suspected that the death of their daughter was a driving force to the end of his relationship. 18 months following the separation, Syme died in a car accident. Triumph While dealing with the aftermath of tragedies and loss, he channeled his energy toward his craft. In 1999, he released the blockbuster movie hit The Matrix, which has historically been one of high grossing movies, which later lead to subsequent sequels. Unlike like scenes in the Matrix, where he dodged bullets, personally he learned to deal with the pain and suffering of being "hit" at various points in life. River Phoenix was one of his best friends that died from a drug overdose tragically at a young point in his career Generosity/Philanthropy Keanu is a charitable human being. It is estimated that he has given 2/3rd of his income to the Matrix and subsequent sequels to his staff who was involved in specials effects and building of the sets. In addition, he became the caretaker for his sister Kim, who was diagnosed with leukemia. His sister battled leukemia for approximately a decade, later her cancer was found to be in remission. He donated a substantial portion of his money to cancer charities, research center, and treating hospitals. Some of charities that he has supported include Stand Up to Cancer and the SickKids Foundation. Humility Humility. Even though Keanu is worth well over $100 million, he does not walk around with bodyguards. He is not chauffeured, as he rides the subway. Possibly hoping to reduce or decrease his carbon footprint or increase his ability to connect with other people. He has been photographed truly desiring to get understand life through other people's perspective. He is a very mindful and intentional human being. He chose to make his suffering his leverage to overcome hurdles. I really admire that money never went to his dead and he tries each day to be a good human being and treat people kindly with his action and not his words. Source: Vilash Reddy, MD

The CEO of the AFSP discusses the big 1-year anniversary of the 988 Sunday July 16 marks the official 1-year anniversary of the National Suicide Prevention Lifeline's new number, 988. Bob Gebbia, CEO of the AFSP, sat down to discuss this important stepping stone in crisis mental health. Bob Gebbia is CEO of the American Foundation for Suicide Prevention, which has become the leading suicide prevention nonprofit organization in the United States. He is also a founding member of the National Council for Suicide Prevention, serves on the National Lifeline Advisory Committee, the Executive Committee of the National Action Alliance for Suicide Prevention, and is the past Chair of the Board of Directors of the National Health Council. What is 988? Crisis and Suicide Hotline? The 988 Suicide & Crisis Lifeline (formerly known as the National Suicide Prevention Lifeline) provides free and confidential emotional support to people in suicidal crisis or emotional distress 24 hours a day, 7 days a week, across the United States. The Lifeline is comprised of a national network of over 200 local crisis centers, combining custom local care and resources with national standards and best practices. The 988 Suicide & Crisis Lifeline is a leader in suicide prevention and mental health crisis care. Since its inception, the Lifeline has engaged in a variety of initiatives to improve crisis services and advance suicide prevention for all, including innovative public messaging, best practices in mental health, and groundbreaking partnerships. The U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) and Vibrant Emotional Health launched the Lifeline on January 1, 2005. Vibrant Emotional Health, the administrator of the grant, works with its partners, the National Association of State Mental Health Program Directors (NASMHPD), National Council for Behavioral Health, and others, to manage the project, along with Living Works, Inc., an internationally respected organization specializing in suicide intervention skills training. The 988 Suicide & Crisis Lifeline has been independently evaluated since its inception by an investigation team from Columbia University’s Research Foundation for Mental Hygiene. The Lifeline receives ongoing consultation and guidance from national and international researchers and experts focused on suicide prevention and crisis response. Here are facts about the benefits of 988. Source: Psychiatric Times

This Pride Month we decided to take a look at two different but intersected perspectives on what this month means in our current environment. The first is from Mental Health America’s President and CEO Schroeder Stribling, and the second is from Mental Health America Director of Public Awareness and Education Em Skehill. Gen X: Schroeder Stribling The joy in Pride Month is indisputable. Millions of LGBTQ+ individuals and communities and supporters come together in waves of colorful celebration, and after all these years it’s still thrilling to call out “Happy Pride!” to a friend across the way. My own lifetime has spanned the years from Stonewall to legalized same-sex marriage. Along the way, the mental health field removed “homosexuality” from the DSM (the diagnostic manual) and the “pathologizing” of sexual orientation and gender expression diminished, alongside widespread condemnation of “conversion therapies” which aimed to “cure” us. LGBTQ+ Remembering our proud history of struggle and progress will power our resolve and sharpen our wisdom. From Harvey Milk and Marsha P. Johnson, to the extravagant balls in “Paris is Burning” and the black-and-pink T-shirts of Act Up proclaiming Silence=Death, to Don’t Ask Don’t Tell to Obergefell – we should remember it all this Pride Month. But now in my 50s, I fear that our progress is eroding. We have seen the introduction of numerous anti-LGBTQ+ legislation at the state level, specifically anti-trans legislation, and threats to drag events this year have been rampant. In my mind this Pride Month, the black-and-white image of drag queens being shoved into a paddy wagon is juxtaposed with the colorful Barbie lawn display I saw in Washington, D.C.: sparkly, decked-out dolls with a sign that read “Drag Is Not a Crime.” It seems the clock is ticking backwards. I am concerned for the queer youth of today. I worry about the mental and emotional toll on LBGTQ+ students in schools where pronoun recognition or queer-positive library books are being debated. I worry for trans adults in states where their access to ongoing medical treatment is threatened. I worry especially for Black, Indigenous, and people of color (BIPOC) youth and young people of all intersectional identities who are at risk of exclusion and discrimination on several fronts. This Pride Month, we commit ourselves to understanding the lived experience of LGBTQ+ youth, being responsive to their needs, and following their leadership. Millennial: Em Skehill The joy in Pride Month is indisputable. While we love our queerness all year, June is a time when we get to see, experience, and celebrate ourselves even more loudly. The sense of community and love among LGBTQ+ folks often feels stronger and deeper, and it’s a time I feel more connected than ever to our queer ancestors across the globe. Those positive feelings aren’t gone this year, but they are certainly complicated by current events. In 2023, it feels like we have gone backwards after coming so far – trans rights are being stripped away, and in many areas it isn’t safe to celebrate, or even visibly identify as queer. Within the queer community there’s an unspoken understanding that this year, Pride is scary. With the increase in mass violence – especially toward identity groups, and even more so toward the trans community – Pride celebrations feel like an obvious target. Multiple far-right extremist groups are planning to escalate attacks on our community this month. While we hope these plans are thwarted, many feel like there’s no way to guarantee both our safety and our pride. On a less threatening, but still hurtful, level, we see our month watered down by rainbow capitalism – corporations using Pride Month as a performative business strategy without actually supporting the LGBTQ+ community. It turns the focus of Pride away from LGBTQ+ protests, rights, and freedom and toward mainstream companies – many of which, sadly, drop their support come July 1. This year, we’ve felt that ally ship taken away from us before June even began with a number of businesses deciding to cancel planned events or merchandise releases related to Pride. You may have seen this tweet circulating recently: “For pride month this year, can straight people focus less on ‘love is love’ and more on ‘queer and trans people are in danger.’” Many people consider themselves an ally in that they support LGBTQ+ rights and join in Pride celebrations, but it hurts when they don’t show up in the ways that we need them. We’re challenged this month with holding our love for Pride and everything it means, while enduring an onslaught of identity-based discrimination, hate, and trauma. We’re experiencing multiple feelings at once that really run the gamut – from joy to sadness to fear. Pride Month grew out of the 1969 Stonewall Riots. This month isn’t rooted in celebration, but in resistance, human rights, and reclaiming our narratives from people who hate or deny our existence. Part of that does include celebrating us. Joy is a form of resistance. Whether you identify as LGBTQ+, are questioning your identity, an ally, or simply curious to learn more, we hope everyone takes some time this month to consider how the current environment is affecting your mind or those around you. Learn more with our resources. Mental Health America will continue standing with the LGBTQ+ community and working to make our country safe for all, no matter how they identify. Source: Mental Health of America

Whether is due to lack of treatment and follow-up or poor compliance with medication. studies show postpartum black women experience three times higher maternal mortality rates than than their white and hispanic counterparts. Learn more about this topic from the Psychiatric Times article below: There are significantly larger rates of maternal mortality in the peri- and postpartum period in the United States compared with other countries across the world. The US is considered a first-world country, with a systemic prioritization placed on access and utilization of health care. However, mortality rates are 10 times that of similar first world countries. Out of every 100,000 live births, approximately 33 lead to maternal death in the US. This is in comparison to other first-world countries such as Japan or Australia, where deaths are 2 to 3 per 100,000 live births.1 Figure. Peri/postpartum Maternal Mortality Rates by Year and Race When separating out maternal mortality rates by race in the year 2021, Black women in the US experienced a far worse outcome. Maternal mortality rates were 70 in 100,000 live births. Comparatively, in white women, approximately 27 out of 100,000 live births resulted in maternal mortality.1 Preliminary data from 2022 indicate an across-the-board drop to pre-COVID-19-pandemic levels, underlying the role the pandemic played in access to adequate health care.2 See the Figure for peri/postpartum mortality rates for Black compared to white women through years 2018-2021. At present, there are no dismantling studies examining the specific variables that contribute to the high rates of mortality in peri-and postpartum Black women. Several variables have been examined (eg, socioeconomic status, level of education/career status, access to health care, social support system, advocacy efforts, pre- or concurrent levels of medical and mental health comorbidities) and none of these alone were found to be the contributory variable.3 A Black woman with a high-level career, level of notoriety, and a higher socioeconomic status, is still at the same risk of mortality as a Black woman who does not fall within these categories. The abovementioned variables appear to be under a larger umbrella of “pervasive systemic racism” that most researchers and clinicians hypothesize to be the causal factor of high levels of mortality in peri- and postpartum Black women in the US. Mental health comorbidities and treatment participation in Black peri- and postpartum women are some of the most important variables when considering mortality. The presence of undiagnosed and untreated anxiety and depression can influence access to and proper health care (eg, efficiently address biological comorbidities such as high blood pressure), impact infant care and wellness, and access to building effective social support systems. In the US, studies have found that the rates of peri-and postpartum depression and anxiety do not differ between Black and white women. During the peri- and postpartum period, the diagnostic rates of anxiety and depression are between 10 and 33%.4-6 Although studies show anxiety and depression rates do not differ in white vs Black peri- and postpartum women, Black women are 3 times less likely to report their symptoms and seek out evidence-based care.4,5 Thus, the rates for Black peri- and postpartum women are likely higher than studies have indicated due to low levels of reporting. While mental health may be one piece in a larger puzzle, it remains a very important one. It is comingled with the several variables listed above and is a contributing factor when considering mortality rates. The American College for Obstetrics and Gynecologists recommends, across race, screening for anxiety and depression at least once during the peri-natal period, “closer monitoring” for those with a history of anxiety and depression, and at the one-time 6- to 8-week postpartum check-up appointment.7 Juxtapose this with evidence-based mental health clinicians, who more routinely use screening measures (weekly, if not biweekly) and have access to their patients frequently enough to follow through on early detection. The Edinburg Postnatal Depression Scale8 or Beck Anxiety/Depression Inventories9,10are the most common measures used to detect clinical anxiety and depression in peri- and postpartum women. However, while even they have good psychometric properties, they are not sensitive to cultural and race differences in women specific to the peri- and postpartum period. After the 6- to 8-week postpartum appointment, care of the patient typically transfers back to the primary care physician. During this interval of time, the paucity of continuous care, especially when patients may experience active depression and/or anxiety, is cause for concern for self-advocacy and commitment to care. Some researchers have found there are disproportionate levels of access to and active engagement in treatment across Black postpartum women with depression.11 White postpartum women were 2 times as likely, even if actively symptomatic, to successfully initiate mental health care.11 Interestingly, Black women have been found to prefer psychotherapy over psychotropic medications,12-14 emphasizing the importance of access to mental health care prior to and after birth. Medical and mental health comorbidities in Black women during the peri- and postpartum stage can influence the experience and outcome of the birthing and postpartum recovery process. The intertwined nature of pre-existing and/or concurrent anxiety and/or depression and medical comorbidities during the pregnancy, birth, and recovery process is individual and complicated by systemic racism underlying decades-old medical systems. Case Example “Tara” (identifying information and situation changed to protect patient confidentiality), a 35-year-old Black woman resided in Upper East Side of New York City. She had been married to her husband, Benny, for 10 years. They had gone through several rounds of IVF to successfully conceive and carry a baby to term. She had been diagnosed with major depressive disorder and generalized anxiety during her IVF process and remained symptomatic (seeing a psychologist), but choosing to remain unmedicated during her pregnancy. She was a pediatrician and well-versed in medical language and how to advocate for herself. At her 38-week appointment, her OB/GYN, with permission, broke her water, as Tara was dilated and complaining of severe back pain, suspected to be labor pains. Her blood pressure was borderline high (130 systolic/88 diastolic), but her OBGYN reported that was to be expected undergoing labor pains at now almost 4 cm dilated. Tara had a very smooth natural vaginal delivery and reported to her husband that she did not expect her first birth go so well. Twenty-four hours after delivery, Tara woke up in a sweat and reported that she did not “feel well.” Her nurse came in and took her temperature, noticing it was barely above normal at 99.9 oF. Tara reported her pain was at a level of a “6” on a scale from 0-10. The nurse asked Tara and her husband about any pre-existing conditions and they reported that she was medically healthy, and had been diagnosed with depression and anxiety. The nurse ordered acetaminophen for Tara and told her she would be back in 2 hours to check on her and to get some rest. Benny reported that Tara looked better after 30 minutes. Tara awoke 1 hour later in pain. The nurse came in and noticed Tara had passed a large blood clot (can be part of the normal process of expelling birthing remains after a vaginal birth). She said that Tara would be fine and that she would order a narcotic pain killer. Tara’s pain subsided after being given the pain killer and while she was asleep the nurse reported to her husband that “some women just cannot handle the pain of childbirth, especially when they have a low tolerance for discomfort being diagnosed with anxiety and depression.” After being discharged from the hospital, Tara continued to experience high levels of generalized pain. She called her OB/GYN and was encouraged to take more narcotics. Two to 3 days after taking narcotics, Tara’s pain continued. Her husband called an ambulance. Tara coded and passed away en route to the emergency room. Autopsy results revealed Tara had been suffering from eclampsia that had gone undiagnosed, as her blood pressure clinically elevated into dangerous levels within days after her discharge from the hospital. Her physical complaints were misinterpreted as an anxious reaction to her birthing process and were not diagnosed and treated properly. Improved Avenues for Care and Future Research Upon reflection and examination of Tara’s care, it is noticeable there were several issues consisting of lack of patient advocacy, miscommunication among medical professionals and with the patient, disregard and/or the misinterpretation of symptoms experienced by the patient, minimally adequate medical and mental health care, and concerns of micro-aggressions and overt racism. If these issues had been sufficiently addressed, it may had resulted in Tara’s survival, rather than her unnecessary death. Currently, several community-based programs have been developed to increase positive birthing outcomes and decrease medical and mental health comorbidities in Black peri-and postpartum women. Prevention programs, such as the Milwaukee Birthing Project, employed a “life course perspective” including building support systems and skills aimed to reduce a cumulative life stressor response (systemic racism) thought to contribute to both infant and maternal mortality rates.15 Each mother was paired with a “big sister” to communicate with on a biweekly basis with goals such as improving prenatal care, birth outcomes, increasing social network access, and more. These were part of a larger 12-point plan to reduce the disparity in the Black-white birthing outcome. Results were promising, indicating improved birth outcomes compared with a control group, but the data was limited due to poor follow-up with participants.15 Table. 5 Areas of Well-Being for Health Care Providers to Address16 The UNC Collaborative Center for Maternal and Infant Health has sought to recommend a more comprehensive approach. Depression in the peri- and postpartum period has been found to have an intergenerational aspect, where adults who have been neglected tend to pass on the neglect to the care of their infant.16 Therefore, in addition to the recommendation of evidence-based mental health treatment (eg, cognitive-behavioral treatment for anxiety and depression), the 4th trimester project recommends health care providers address 5 other areas of well-being (Table).16 This research has found that postpartum care (termed 4th trimester), should be designed for a Black woman’s individual needs and constraints, should be implemented prior to birth; improve upon patient-provider communication; focus on retention and activation of information received from the provider to the patient; and should be empathic, culturally-sensitive, and aware of systemic racism underlying the US health care system.17,18 These programs have called for a more holistic approach to peri- and postpartum health care in Black women. Assessing and treating mental health concerns, such as anxiety and depression, is vital in peri- and postpartum Black women, but it is also not the entire clinical package that is needed. One of the major obstacles to following through with a more holistic approach is continuity of care. While health care providers have been found to provide helpful recommendations, the onus of responsibility for follow through on the recommendations relies solely on the patient, who may not have the financial, social, mental, physical, or logistic support to successfully implement adequate care. Providers may fall victim themselves to perpetuating an ineffective health care system, not knowing the limitations of the patients themselves.17 Larger changes in US government policy and grant allocation, as well as peri- and postpartum education of providers (eg, effective and empathic communication systems with marginalized groups and recognizing the role of systemic racism, etc) and patients (eg, education in mental and physical health of the mother and infant at different stages in peri- and postpartum care, etc), are needed to drastically improve peri- and postpartum mortality (and morbidity) of marginalized groups, especially that of Black women. Dr Kaplan is a clinical psychologist and director of the Washington Anxiety Center of Capitol Hill. Dr Dumessa is a clinical psychologist at the Washington Anxiety Center of Capitol Hill.Ms Ruiz is research assistant and graduate student at the Washington Anxiety Center of Capitol Hill and the Catholic University of America. 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