“Depression is one of those things that becomes this insurmountable beast at times where even the simplest tasks are very challenging. So, if you have diabetes and depression, you could see how that could then really severely impact your overall course and diabetes. And then that ends up being this vicious cycle where the more uncontrolled your diabetes is, the more could contribute to depression, then vice versa, the more you're depressed, the less likely you might adhere to diabetes treatments.”
Dr. Fernandez talks to us about behavioral health, integrated behavioral health care models, and how those are related to his other specialty, cultural psychiatry.
Pedro José Fernandez, M.D., is an Assistant Professor in the Department of Psychiatry at University of Texas (UT) Southwestern Medical Center. He serves as CO- Chief of Psychiatry at Parkland Health. Dr. Fernandez earned his medical degree at Boston University School of Medicine and holds board certification in Addiction Medicine and Consultation Liaison Psychiatry.
Shireen: Dr. Fernandez talks to us about behavioral health, the associated stigma, and the Integrated Behavioral Health Care Model.
Podcasting from Dallas, Texas, I am Shireen. And this is a Yumlish Podcast.
Yumlish is working to empower you to take charge of your health through diet and exercise and reduce the risk of chronic conditions like type two diabetes and heart disease. We hope to share a unique perspective and a culturally relevant approach to manage chronic conditions with you each week.
Dr. Pedro Jose Fernandez is an assistant professor in the department of psychiatry at University of Texas Southwestern Medical Center. He serves as co-chief of psychiatry at Parkland Health. Dr. Fernandez earned his medical degree at Boston University School of Medicine and holds board certification in addiction, medicine and consultation, liaison psychiatry.
Welcome Dr. Fernandez.
Pedro: Thank you for having me.
Shireen: An absolute pleasure. So, Dr. Fernandez, can you talk to us about why you decided to move into the field of psychiatry and how you became focused on behavior health and cultural psychiatry?
Pedro: Well, I think that's a really wonderful question. I would tell you, if you asked me 20 years ago, if I was going to be a psychiatrist, I would’ve said no.
You know, growing up, it took me a while to figure out what I wanted to do. Um, you know, options were kind of limited for me growing up. I was very fortunate to be able to get into medical school, but when I went into medical school in my concept of being a doctor, you see on television taking care of the community and that's kind of what I kind of fell in love with. But as I was experiencing, you're rotating through different fields, I realized I was naturally gravitating towards mental health and specifically the area of mental health that intersects with other areas of healthcare.
So I kind of fell in love with, you know, it used to be called like hospital psychiatry or consult psychiatry, you know, psychiatry in these nontraditional spaces because I loved being able to kind of think of a patient holistically and think about all these aspects of care, physical mental, cultural, social that kind of comes together and then how you need to use that to help heal and work with the patient. So, it was very quickly in medical school during I say very quickly, but it was actually towards the end, but it was very quickly once I realized what I wanted, that I switched gears and entered the field of psychiatry.
And then specifically the cultural aspect of that. Um, would've just come naturally because you can't necessarily work in psychiatry and take this and be in this specific deal without thinking of the cultural aspects of care.
Shireen: Can you help us understand what cultural psychiatry is?
Pedro: You know, this is a, it's a hard term to describe mostly because you know, there's so much work around it and its bans, you know, decades, but cultural psychiatry essentially thinking of psychiatry and mental health through cultural lens and understanding how individuals experienced this community culture influence both the expression of mental illness and actually a treatment of mental health. You know, I think psychiatry very early in the field just kind of focused on one population.
And a lot of our manuals of diagnosing illness and conditions were really based on this one population, but even just in the last few decades, we've really grown in understanding how culture impacts biology and not just that. How culture impacts how we express symptoms, how we seek help and how we respond to treatment.
So, I think cultural psychiatry kind of encompasses all of that and really, it's psychiatry, but it is still kind of that term where we're trying to move the field. Five years in the future you're not going to be asking me hopefully what cultural psychiatry is because all of these aspects will be incorporated in just psychiatry.
Shireen: Absolutely love that approach. What I circled back to cultural psychiatry and also some things associated with that. Um, first I want you to help us understand the correlation between diabetes or a chronic illness and depression, and really trying to understand what that connection is, which one causes, which one, um, and how they're related.
Pedro: You know, in both diabetes and depression are both chronic medical conditions and there are actually chronic medical conditions that have high overlaps. You know, if you look at the literature, there's some statistics that show up to one third or half of the patients with diabetes also struggle with clinically relevant depression and how these two conditions intersect is really interesting.
Both diabetes itself as an illness can help contribute to an individual's vulnerability for depression, both biologically, but also how diabetes impacts and social function. I mean, having diabetes, especially if you're thinking of type one diabetes, you're tied to doctors’ appointments, you're tied to checking your sugars.
You're tied to insulin, especially if you develop that earlier on, you're more predisposed to having stress that could contribute to depression. And then depression can impact diabetes care. You know, when someone's depressed, they often don't eat the healthiest food. They often are not exercising. They're not on top of their health or wellness.
Depression is one of those things that becomes this insurmountable beast at times where even simplest tasks are very challenging. So, if you have diabetes and depression, you could see how that could then really severely impact your overall course and diabetes. And then that ends up being this vicious cycle where the more uncontrolled your diabetes is, the more could contribute to depression, then vice versa, the more you're depressed, the less likely you might adhere to diabetes treatments.
Shireen: Now I want to go back to the cultural psychiatry piece and understand the stigma around mental illness. Can you speak to the stigma associated with mental health and what is really being done to overcome it today?
Pedro: You know, stigma is a huge issue for mental health. I think it's prevalent in all the communities, especially it's much more prevalent in communities of color.
I, myself, am Hispanic immigrant to this country and I could speak firsthand how I've seen family members, loved ones, friends kind of…The stigma and the misconception of mental illnesses seeking mental illness treatment can mean. And it really impacts folks, the ability to kind of seek care except care.
And it's really challenging because it ends up becoming an epidemic for folks who are struggling and suffering, but just not talking about me and then the community doesn't talk about it. So, it's a huge public health challenge. You know, there's a lot of ways to try to overcome it. And I think kind of one of the biggest ways of approaching it is first of all, just understanding the communities, you know, an approach in one community is not going to be necessarily relevant in their communities.
So, you need to kind of get to know the patient population or the population you're working with, get to know them and also hopefully get their investment. You know, one of the most popular ways to try to kind of overcome stigma is working with the culture itself. Essentially having community members, engaging key members of community, whether it's church figures, whether it's, um, kind of whatever important figure with us in the community to be more open.
I think when individuals see others, especially other people that they have in high regard within their own community, talking about it. That's a really good way of de-stigmatizing. You know, other ways of approaching that is eating, just changing the way that we're providing and allowing folks to access care.
For some ways, you know, some individuals identify that they have mental illness and then seek mental illness. It's challenging because they don't want other members in their community to know. You know, I think sometimes it's important to create a safe space where they could seek treatment anonymously.
Obviously, that's not a quick fix to the solution because ultimately, we want to de-stigmatize it by making it more publicly accepted. But I think in the early stages, you need a kind of avenue for folks to kind of seek care of that.
Shireen: I love that approach. And, um, I was also going to ask you, what, what are you seeing or what can health systems broadly do to address mental health?
I know Parkland Health is doing some interesting work there. Can you speak to some of that?
Pedro: Yes. Yes. So, you know, we're using a lot of those same principles. So, Parkland Health in association with Dallas County, City of Dallas, we implemented a community, helped me to assess. Which I think is a really wonderful initiative.
They've done this a few times before the latest one was in 2019, and essentially what the Dallas County CHMA has done is attended by populations at risk due to prevalent health disparities, as well as medically underserved areas within the county. So, you know, we have many residents in Dallas County, especially in geographical vulnerable areas that don't receive adequate medical care, and that could be the result of multiple factors, either their uninsured, financial transportation, um, socioeconomic barriers. It really makes it difficult for them to maintain their health. So, they did this very extensive assessment. One of the most important keys to that assessment was bringing in community members to speak on their own behalf of what they see in their community and what are the needs they have, I think if you ever do these initiatives and don't include the community you're working with at the table to kind of advocate for what they need, you're going to be less successful and you're really not going to do a good job and, you know, Parkland city of Dallas. And I think their voices really impacted the information we obtained and then ultimately, it’s using that information to do a comprehensive plan and implementation plan. So that's something that we did.
If you remember back, I said, this happened in 2019, while we're all still living this, this was right before the COVID pandemic. So, when it came to the implementation plan, that was at the very beginning of the pandemic. And if you could imagine the hospital system, the community, the nation had a lot of things to tackle at that time, which was very overwhelming, but you could see Parkland's commitment to this implementation plan because nothing's slowed down.
We continue to dedicate our resources in rolling out and addressing these healthcare disparities and health needs despite our own struggle, search plans and all of those other things. So, I think not only is it doing the assessment, having a good implementation plan and both of them should also have a voice for the community, but ultimately is maintaining that commitment despite all these other factors.
Shireen: I appreciate you sharing that and really setting the stage for what other health systems can do to really address and first understand the needs of the population that they're serving, and then start to address them. You mentioned earlier, as we were talking about the stigma associated with mental health in particular, in an earlier conversation, you had talked about.
How just taking their approach to the diabetes clinic that also provides mental health services has been very unique in terms of the way people are open. And again, going back to the stigma of it, but be open to getting the help they need. Can you first tell us about the problems that you saw and then how you went about overcoming them?
Pedro: Let's see, like I already mentioned, there's this huge overlap of diabetes and depression and not just depression, other mental illness, you know, there's anxiety. And there's also other folks with chronic mental illness that actually develop diabetes because even the treatment for chronic mental illness makes them vulnerable to developing metabolic syndrome, weight gain, and diabetes.
So that's the big problem. And how do you best address this? Because both could be very challenging, dressing and treating diabetes is challenging, addressing and treating mental illness is challenging. So, we tried various approaches, you know, I think at one point. We brought in diabetes care into our behavioral health spaces.
And I think that was a really good first step. I think that it was an acknowledgement of these two conditions that we need to be able to work together, diabetes and mental health, to be able to address it because working in silos is not going to be effective. The problem with that is I think it fell back to stigma.
A lot of folks don't have a stigma in accepting and accessing mental health. So even just coming into a behavioral health clinic, a psychiatric clinic could be challenging. So, we changed the approach and we flipped it. So, we actually partnered with our diabetes team, which by the way, we have a strong relationship between our diabetes teams and behavioral health team.
They really get it, which is one of the hardest challenges of implementing any integrated system. Having invested and, um, kind of advocates on both sides, but they really got it. So, what we did is we started to introduce mental health services in the diabetes clinic. So, when someone went in to see their diabetes doctor to have routine diabetes care, their doctors, providers would identify, this is someone that also is struggling with mental health, and they would just put in a referral or walk the person over to our provider.
So, we started by having a psychiatrist there and then we quickly identified that we needed more services. So since then, we've also added a therapist and I think it's really been really wonderful because then those behavioral health members actually not only are able to kind of address these needs, but they also are able to help de-stigmatize it.
Because not only is it really easily accessible, but they’re also receiving it in their diabetes treatment. So, it just really normalizes it, addressing their behavioral health becomes just like addressing their blood pressure or addressing other chronic medical conditions. So, moving in together just can de-stigmatize it, makes it accessible and improves coordination.
Uh, one thing I want to mention about that really, I think is really wonderful is the fact that how providers can even help support, you have the diabetes doc helping to encourage the individual in seeking mental health treatment and actually sticking to the mental health treatment and vice versa.
Mental health providers are then able to reinforce the need for appropriate diabetes care. And sticking to the treatment. So, they work really wonderfully synergistically.
Shireen: Thank you for sharing that. I do want to turn a little bit to your recent publication. Your research, your most recent publication is about integrated behavioral health care, IBHC models, and benefits of implementing them in the existing healthcare system.
Can you tell us what IBHC models are and how implementing them can meet needs in today's health care systems?
Pedro: Okay. So integrated behavioral health care is a catch all term that encompasses all models of care that involves bringing in mental health services in medical clinical spaces. So traditionally it's primary care, but you could also think of integrated behavioral health, and like I just mentioned in diabetes or in HIV or in other medical clinics, there's a lot of different models out there, but what's been really consistent is that these models are really successful in general. And I'm going to focus right now on primary care. The majority of folks that received mental health treatment in the country right now receive the treatment through primary care.
And oftentimes primary care physicians aren't really equipped or supportive in providing effective mental health care. Not only that, but the majority of folks who could benefit from mental health services don't ever seek mental health services. But they do pass through primary care. So that really creates a really wonderful opportunity to have a better impact on individuals, mental wellness, by bringing in the surfaces there.
So, kind of what I described with bringing mental health services into diabetes. It's the same approach of bringing mental health services within primary care, where you oftentimes, and there's different models and different approaches of how they go about some models that rely on social workers, nurse practitioners, psychiatrists, psychologists, but at the very heart, it's the guiding principles of having structured unified screening for mental health.
Making it an accountable care system. So having ways of cracking patients and also tracking outcomes and also implementing evidence-based care.
Shireen: I do want to tie this back to cultural psychiatry? So how could IBHC models potentially help patients from a cultural psychiatry perspective?
Pedro: So, there's a lot of benefits to it. Um, but I think one of the biggest benefits to it is that one, it makes seeking mental health treatment much easier for underserved communities or communities of color.
I mentioned stigma. Stigma is always so challenging, but stigma is easier to surmount when one, you normalize the experience and two, you just make it a little bit easier to access. One, you know, bringing in mental health within the primary care setting just automatically normalizes it. You know, when I worked as an integrated psychiatrist I would be seeing patients in the same room as their primary care doctor.
So, the image people have of the psychiatrist with the couch and the nice lighting I was right there with the exam table. I had my nurse and people, rooming patients in and out primary care doctor walking in, they walked out and I'm coming in and coming out. So, it just makes it just more normal and easier to accept for folks.
It is very challenging to engage folks in accepting mental health treatment, but people trust their primary care doctor. Especially if you have that good relationship. I mentioned I wanted to go into medicine because I wanted to be. Right. I want it to be that community primary care provider. So, we naturally have this trust towards them.
So, it makes it much easier to then have that person talk to you by saying, you know, I noticed you're struggling. I know you might not feel comfortable. Meeting with someone or trying out this medication or trying out therapy, but you know what? I have this one person and he's just down the hall and I could just bring any right now.
And you don't, you just need to meet him once and just say hi, if you don't feel comfortable, you don't have to go back, and you be surprised and that's called a warm handoff where you have one provider bringing in another provider in the same room with the patient and introducing themselves. And it's funny, just that human contact.
Just makes it much easier for that patient to, to say, you know what, I'll see you I'll give you a shot, especially again, in this environment.
Shireen: Absolutely love that. Do you see any other challenges outside of stigma? Um, any other challenges in the implementation of the IBHC model and how could those be addressed effectively?
Pedro: You know, the biggest implementation barrier is funding. Um, at the end of the day IBHC models, you know, I'm going to put on my administrative IBHC models unfortunately aren't direct revenue generators for large hospital systems. And I think that by and large has been a challenge. In general, mental health providers don't really generate a lot of revenue.
So, a lot of systems, even though it is really important. A lot of systems might not invest sufficiently in mental health services. Luckily there's a lot of things coming out. So, Medicare has approved collaborative care codes, which allow primary care providers to bill for some of these services, which help offset the cost.
And there's a lot of other analysis out there that shows that if you implement IBH models, specifically collaborative care, collaborative care is a specific model within that big domain of IBH. But if you implement club or care, for example, you have a significant impact on decreasing costs, uh, improving overall health.
So, you know, if you are appropriately treating someone's mental health. They're more likely to adhere to their diabetes treatment. They're most likely to adhere to their hypertension treatment. They're less likely to require higher levels of medical care, emergency room, medically hospitalized, and that actually saves systems money.
So, there's all this literature to support it, but at the same time, it's still a struggle and in a lot of institutions to implement these models, because again, the financial barrier.
Shireen: Interesting. And it's really about having the foresight to see the investment dollars today, and having the huge ROI downstream.
So, with that, Dr. Fernandez, we are through the end of the episode at this point, how can our listeners connect with you and just learn more about your work?
Pedro: So, you know, I would point your listeners to two major sources. One is Parkland Health, and the other one is UT Southwestern. Both institutions are doing really amazing work, innovative work regarding healthcare and especially mental health care.
So, I think that'd be a really wonderful resource for your listeners.
Shireen: Lovely. And for our listeners after this episode, head over to our social media and answer one very simple question. What is the one thing you could do or are doing to improve your own mental health? There are things that you are doing, share with us on Facebook, on Instagram, head over, find the podcast post and let us know.
What is the one thing that you could do or are doing to improve your mental?
We’ll see you there after the episode. With that, Dr. Fernandez, it has been an absolute pleasure. Thank you so very much for your time.
Pedro: Thank you. And I really feel appreciative to be able to speak to you and your listeners.
Shireen: Thank you for listening to the Yumlish Podcast.
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