The committee co-directors, from left to right: Dolores Malaspina, MD, MS, MSPH, Vice Chair of DEI for Psychiatry, and Shilpa Taufique, PhD, Director of the Psychology Division.
Separate apologies by the American Psychiatric Association and the American Psychological Association in 2021 hopefully marked a turning point for mental health care. For the first time, each association officially acknowledged how the disciplines have enabled and even promoted systemic racism and inequity over the years, with detrimental effects on patients, families, and providers. (The psychology association included a chronology of historical harms inflicted.) The associations pledged to take action.
The Department of Psychiatry has begun initial steps to address similar shortcomings and opportunities, working within Mount Sinai Health System but also looking to influence decisions made beyond our walls. The Psychiatry Diversity, Equity, and Inclusion Steering Committee is a psychiatry-specific committee that meets at least every other week, spans the Health System, and includes 40-plus members. Crucially, those members come from a range of personal perspectives and professional backgrounds, ranging from trainees to department chairs.
The group has also formed subcommittees to focus on specific tasks and projects. Areas of concern include drawing greater diversity into our clinical teams and leadership roles and supporting existing faculty identifying as Black, Indigenous, and/or a person of color (BIPOC). The committee also wants to expand access to marginalized populations and revise the way clinicians approach their care. We are acknowledging the problem, voicing our support, and looking to act as soon as possible.
Maintaining and Developing Diversity Among Mental Health Providers
The American Psychological Association found that in 2015, 86 percent of U.S. psychologists were white, while just 14 percent came from other racial and ethnic groups—a less diverse representation than the population as a whole.
We need to change who can access our disciplines. For historical reasons, candidates from certain populations often cannot afford to take on residencies and other training programs. We are working to increase salaries and funding to ensure we can recruit a diverse group of trainees to enter the field.
We also want to retain our existing BIPOC faculty by providing the mentoring they seek and ensuring they have support to grow and thrive. Those efforts will likely include pathways to professional advancement and promotion that may not have existed before.
A specific, pending step focuses on how we elicit feedback and handle concerns within our department. While existing reporting mechanisms have a role at our institution, we acknowledge that people may not want to participate because of the punitive nature often involved when expressing concerns. People may wish to help or change rather than to seek punishment of individuals.
In response, we are establishing an anonymous system for raising concerns or seeking advice. We believe this step will reduce hesitations to reach out, open a true dialogue, and give us a timely, ongoing sense of the changes needed across our units, meetings, and department.
Addressing Disparities in Mental Health Care
Historically, the country has featured separate and unequal tracks of mental health services—one for patients with insurance and one for those without. The disparity in access for the latter group has clear implications for both mental and physical health. People with untreated and undertreated mental illness often die several decades before other patients when it comes to conditions such as heart failure and metabolic disease. In addition to the personal burden, these costs weigh heavily on health care expenditures.
We acknowledge equitable solutions to access will take time, and we do not yet have specific projects to announce. But we do have immediate efforts to revamp the care we provide in our clinics. Too often, diagnoses and treatments across psychiatry and psychology have been biased (unconsciously or not) by race and socioeconomic status. For example, BIPOC patients continue to get over-diagnosed with schizophrenia and psychosis.
As a field, we need to assess and account for factors such as exposure to racism, disadvantage, and other trauma—as well as the intergenerational transfer of that trauma. To that end, our committee:
- Seeks to integrate areas where psychiatry and psychology trainees can learn together, right from the start, so providers in both disciplines will think about patients in a more diverse and inclusive manner
- Aims to improve training across Mount Sinai, so clinicians can better assess trauma and help a diverse range of patients
- Works with ongoing clinical meetings to update longstanding protocols and procedures
- Plans to launch a public seminar series on diversity, equity, and inclusion, based on lectures provided to various Mount Sinai departments
Accounting for Social Determinants of Mental Health
We need to challenge existing conventions and assumptions in psychology and psychiatry. For too long, we have overemphasized the small role played by inherited genetic variants and also allowed a racialized biology to linger. While the DSM-5 Steering Committee recently removed language tying biological factors to differences in outcomes by race, we must still place the true drivers of psychological distress and psychiatric disorders front and center.
Those factors come in the form of social determinants of mental health—based on the similar line of research showing one can predict residents’ physical health by zip code. These determinants start very early in life and can include:
- Amount of food you can access, as well as the type and quality
- Experience with racism, stress, and other trauma
- Exposure to toxins because of community environment and infrastructure
- Lack of access to outdoor space and greenery
- Living with inadequate heating and cooling
At Mount Sinai, we are working to incorporate a comprehensive cultural assessment of every patient in our department. It is a significant undertaking—clinicians must take a nuanced approach for each patient and determine how and when to make inquiries—but a necessary one. Doing so can provide the care each patient needs and deserves.
Promoting Diversity Through Research and Looking to the Future
Research represents a final area of focus for our committee—both supporting BIPOC researchers applying for grants and also promoting projects that may lead to more equitable and inclusive mental health care. While the National Institute of Mental Health has shown a greater openness toward funding such work, we will advocate for further movement in this direction.
We know work by our committee and like-minded supporters in our field may ultimately take generations. But we need to start somewhere. We hope to make substantive change in the near term, then continue to build off those improvements—to support our team members, our patients, and their families. By working together, we can make a positive and valuable impact.
Shilpa R. Taufique, PhD, is an Assistant Professor of Psychiatry at Icahn School of Medicine at Mount Sinai and Director of the Division of Psychology. Dolores Malaspina, MD, is a Professor of Psychiatry, Neuroscience, and Genetics and Genomics at Icahn Mount Sinai and Vice Chair of DEI for Psychiatry. Together, they co-chair the Diversity, Equity, and Inclusion Steering Committee within the Department of Psychiatry.