Dave Vellante of wikibon.org and this is theCUBE, SiliconANGLE's continuous coverage of Dell World. 2012, we're down here in Austin, the great city of Austin, fantastic mojo here, Dell World, about 5,000 customers and partners here at Dell World and theCUBE is covering it end to end live. I'm here with my co-host. I'm Jeff Kelly also with wikibon.org. Thanks for having me on, Dave, I appreciate it. We're here with Scott Hollis, who will be our next guest, Director of Product Marketing for Performance Monitoring Business at Quest Software. Welcome. Thank you, it's good to be here. Thanks for coming on Inside theCUBE. So Quest Software, recent acquisition, about $860 million acquisition by Dell, I think back in September. That's right. So this is your first Dell World as a member of the Dell team. How are you liking the show? And tell us a little bit about kind of your role inside of Quest and now inside of Dell. Enjoying the show, making a lot of good context because we were only acquired a few months ago. Power of integration has been proceeding incredibly well. We're forming a separate software group called the Dell Software Group. And that really has three businesses within it, systems management, business intelligence and security. And that's going to be within the Dell Software Group. And we've already been talking about that here today, John Swenson in his presentation, discussed that already. And we're actually, as far as the business that I'm in is the application performance monitoring business. And so I have product marketing for all of the performance monitoring, which includes the database performance monitoring, virtualization performance monitoring, network performance monitoring and application performance monitoring. And so I think application performance monitoring is a large draw because it's all about the applications today. It's whether it's in the data center, in the cloud, private, public, it doesn't matter. What really matters is is the service that the application is intended to deliver being delivered to the end user. And so that's where we're focused. But the family of products that we have allows us to do that from the end user's perspective and to show organizations what that end user interaction, maybe it's an online revenue site, maybe it's a customer service app that the customer service team needs real time when they're on the phone. But not only do we show that front end of the user experience with the application and then the transaction tracing through the application, we allow, we provide the depth on the network, on the database, on the virtual infrastructure. So when there is that problem, our customers are able to quickly identify where in the stack, in the technology stack it's occurring. And that's really the key difference between application performance monitoring and more traditional performance monitoring that was really focused on the components themselves rather than the whole. So how does remediation occur in this model? Can you talk about that a little bit in terms of how automated it can be? Yeah, sure. There's with APM and without APM. Without APM, what happens is each of the functional silos has their own monitoring tool. When a problem occurs, there's a war room call set up and each of the experts that representing that functional team, functional teams being the network, the database, the virtual, they get on this call and they all say, it's not me. DefCon six, let's get in, right? Yeah, and it's not me, the network is great. They're pointing fingers. Exactly, and this could go on for hours, for days, for weeks. And so CIOs and VPs of IT ops have just said I've had it. I need a way that ties everything together, but there's some more traditional well-known software vendors that provide a huge monolithic platform that could take years to fully implement. What we've done is we've leveraged a very fast time to value solution that ties everything together in a modular way, and it's collaborative so that each of the distinct owners of the pillars are able to see the same thing. And then the person that owns the application that's responsible to the business is able to quickly identify where the problem is and then get right at the root cause. Because ultimately they're accountable to the business. There's service levels that have to be met for the business. So when you say it's collaborative, you have tools for them to collaborate, is that part of the? Yeah, instead of being distinct tools that they're each looking at and each of them getting a different view, there's one truth, and that one truth is in the APM solution in our fog lights. So give us a sense of how you do it. Like what's the secret sauce? I mean, you've got all this data and metadata locked within these silos. So you need to get access to that information in order to solve the problem, is that right? So how do you do that, and how do you unify that view? Well, it really has to do with each of the functional components can be installed whether it's for, like let's say, for the database administrator. The database administrator might have another tool they're using, but they will install our component there as well to gather that data. So each of the components gets installed and it feeds into a central management server. And from that, the user interface interacts with that management server. But what's really different about what fog light brings to the table is the end user's experience. We actually record what the end user's doing on the screen, and we can play that back. We also provide synthetic transactions. So from that users, not only that real user, but synthetic transactions from different points of presence so that the organization can know what the performance is of that application around the world. You're not measuring the light on the server, the server level, but you're measuring application performance as a user would see it. We're doing both. But the difference is we start from where the user sees the performance, what the user's real experience is. And then we have a synthetic ability to actually script and playback transactions. So even when there may or may not be end users, there's the synthetic is always checking availability. But when there is a problem, we also provide, which is different than most APM solutions, we provide the depth in the functional pillars, meaning the network monitoring, the database monitoring, the virtual, and these are best-of-breed solutions that we have. So we can actually drill down to find root cause. Okay, so once you find root cause, take us through what happens next. Well, there's, in order to, you want to reduce, once you find the root cause, there's a mean time to resolution. We call it MTTR, mean time to resolution, that you want to minimize. That's what the VP of IT Ops wants, that's what the CIO wants, the business exec wants. So once you can quickly identify where it's occurring, now, potentially we don't provide the depth, maybe down at the record level in the database that is needed. I know we do, but potentially, if that isn't there, then other tools would play into the picture in resolving the problem, getting at the data to resolve the problem. But we have a major auto manufacturer who had an accelerator sticking problem, and they had all the customers wanting to get at the repair, and then all of their dealerships needing to get parts as well, and they were having one problem after another. They had 37 different monitoring solutions. It was a very broad, expansive environment, a very difficult time resolving the issue. They brought in fog light, leverage fog light, and to the state forward, they've not had any of those issues. Jeff, I know you want to get into the analytics side of things, because ultimately we're trying to figure out, okay, can you use predictive analytics to solve these problems? So why don't you pick up on that next one? Right, exactly. I mean, so when we're talking about performance and monitoring of an application, I mean, it's critical not just to find, when there's a problem, but also to kind of predict and prevent that from happening ahead of time. And of course that takes a lot of analytics and under the cover. So how do you play in that space? What is your approach to that? And really, can you kind of articulate the value you think that provides to your community of customers and users? Trending data over time is something that all of our customers want. We provide that, there's extensive reporting, but what the customers really want is more, they'd love predictive, but more times than not, the predictive solutions that are out there have false positives enough. But if they can look and see utilization trends over time and then get recommendations on ways they might correct those, that especially exists in our virtualization monitoring components. There's really, really powerful capacity planning. We've got charge back capabilities. So depending on who's utilizing the infrastructure, there's ability to charge appropriately. And then of course the performance monitoring, which is key, but like you were asking, the analytics around trends, and really we look at it in three ways. There's advice, there's analysis, and there's automation. So it's one thing to monitor and provide some advice. And that's like the first step of any solution out there would do. The analysis and providing the analytics and providing some recommendations on what should be done or when capacity might be exceeded if certain changes are not made, that's pretty powerful. Even more powerful is the automation of either making those changes dynamically or allowing the self-service that we know is so popular in supporting cloud environments. And the automation is really the key. It's the nirvana that everyone is going for. Right, so does Quest provide all three distinct capabilities in a really unified manner as you were talking to Dave about? Yeah, absolutely we do. So we provide the advice, the analysis, and the automation and that's a big differentiator for us versus the other products that are out there. So we've heard a lot about conversion infrastructure and private clouds at this show. Dave and John have been talking a lot about it with many guests. So how does virtualized environments and specifically as Dell really makes this push into the private cloud business and really trying to take their customers on that journey to the private cloud, how does Quest's job become more difficult or what are the challenges associated with those kinds of environments versus a more traditional architecture that you might see that is common today but is increasingly moving to this kind of cloud-like model? Well the private cloud environments leverage virtualization heavily and the automation layer on top of that is critical and monitoring all the different components that make up a transaction because in a highly, in a private cloud environment and in a virtualized environment workloads move dynamically and when they move the different components that make up an application or a service that's being delivered to the end user you might not think that by moving application A onto host B it looks like that would be not a problem but then there's application C that's sharing resource there and you may not have realized that you're indirectly impacting application C so it gets really complicated really fast so our solutions simplify all of that and allow these organizations to adopt and thrive in a private cloud environment and here recently we announced our fog light for Windows Azure applications so if organizations are choosing to use platform as a service like Windows Azure we have support for that as well and we do that different than other vendors our customers want to know what the end users experience is with that application and yes they also want to know how the application is performing and the different components that make up the application they want both but most of the other solutions out there focus really on how the components are performing and they don't tie it together with the end user experience which is what we're known for really so the idea being certainly you want your underlying infrastructure to be operating efficiently but the most important thing is that the user the application user is enjoying a solid experience even if at times perhaps the infrastructure is not operating as efficiently as possible it's important but there are two kind of separate though tied together concepts really they are and it's interesting there's two perspectives of it one of our customers has 10,000 florists that they support and they have the infrastructure for fulfillment and the point of sale systems and everything and so real time on Mother's Day which is the big day they were actually using Foglight as in a trial capacity to see how, you know, what it could provide for them and they were noticing they were they were, the revenue was down a little bit all of a sudden and they couldn't figure out why with Foglight they could actually play back and see that in the shopping cart when you went to purchase that there was a promotion code and when they entered the promotion code it failed, that app failed and so they were getting abandoned shopping carts people going, you know, trying another so they quickly found that and they were just in awe that we can do that but then something else was interesting I went to visit them and they told me that okay, we have 26 web servers and, you know, something else I love about your product is I got a call from the boss and he says, okay, one of the web servers is at 95% CPU I need you to drop everything and go figure it out what's going on and he says, well, wait a second so he pulled up the Foglight UI and he looked at what the end users were experienced and the transaction flow and he says, but everything's I'm even better than normal all of 100% are doing great and so he called back up and he said, you know I realize there's a problem with one of the web servers but the other 25 are handling just fine and it's not a busy time of year none of our, we're not impacted revenue none of our user experience is impacted in any way he says, how about I work on that tomorrow and finish this key project that you wanted me to finish today? He said, great, wonderful so it allows you to prioritize activities and be more proactive in supporting the business instead of just being reactive and so kind of you mentioned earlier you know, Windows Azure and for instance, that kind of got me thinking about the big data space there Windows, Microsoft is working with Hortonworks on their Hadoop platform and making it available from the cloud it's very early days for big data applications that is applications built on some of these no SQL databases but how do you see that potentially impacting kind of what you do from an application performance and monitoring and management landscape? Well, the more data there is obviously there are more that application transactions are occurring and the more workloads there are it's synonymous one goes with the other in most cases and so the applications themselves rely on the databases and the file systems to be responsive and obviously if there's a hiccup in the delivery of the service to the end user you want to know where that is and if that has to do with access or processing of the data then you want to know that right away and so with APM, actually with APM in its pure state the way some of the, one analyst in particular is viewing it is that it's really just the end user's experience with the application and the application processing itself in reality, APM is making sure that that application and that service is being delivered to the end user and so you have to be able to identify and have some depth in the key components in the converged infrastructure which includes the network, the database, the processing infrastructure, the applications, the web servers, everything the virtual infrastructure was virtual or physical all of that you have to have visibility into and I mentioned earlier that we were, we provided a modular solution a lot of our customers will start with the application layer in the end user or they'll start with the database performance or they'll start with the virtual performance monitoring and then they'll expand from there because it's all integrated but it doesn't require a rip and replace you can start where your current point of pain is and over time move out some tools and consolidate so that there's one UI and one truth and we call it, the war room calls I mentioned earlier we call it blame storming you can eliminate the blame storming when you have a single view of the truth and I'm sure the internal teams will appreciate that and people get along a little bit better when you eliminate that so All right, listen guys we got to go we got to wrap the planes are backing up as they say but Scott thanks very much for coming on theCUBE we appreciate your perspective it's great to be here thank you Jeff, thanks so much right there everybody this is Dave Vellante and we're here live from Dell World in Austin, Texas 2012 this is theCUBE Silicon Angles coverage we'll be right back after this word


Right, take your straight, cut it half, measure one side, 220, get yourself a back-o-brick hammer, because it's like a bolster. Get your line over the edge of your block, check it up, mark it, push it up, push the mark on the back, too hard, done.


Good afternoon everyone. Welcome. I'm Paula Lance. I'm a professor here in the Ford School of Public Policy and also the Associate Dean for Academic Affairs, and I'm really thrilled to welcome all of you here, those who are in the audience here, and also the people who are viewing us online in real time. Thank you so much for joining us today. Our program today is made possible by generous support from the Dr. Gilbert Omen and Martha Darlene Health Policy Fund, and as many of you are aware, I assume September is National Suicide Prevention Awareness Month. So let me start with a few numbers and statistics for you. There are about 45,000 suicides a year in the United States. That is 120 per day. There are over 1400 suicides in the state of Michigan every year, and that is actually above the national average. Suicide is the 10th leading cause of death. Out of hundreds of causes of death, let me repeat, it's the 10th leading cause of death overall, and it's the second leading cause of death for young people between the age of 10 and 24. There are disparities in suicide by many different kinds of social characteristics. For example, suicide is the number one cause of death among LGBT youth, who are overall four times more likely to attempt suicide than other adolescents and young adults. Depression is the number one cause of suicide. Over 16 million people a year in the United States live with clinical depression, and it's the number one cause of disability in the United States. Depression is only one of many different kinds of mental health issues and problems that affect people and their families. As all of us know, mental health issues affect everyone. There's no family that has not been touched somehow by depression, suicide, and other mental health problems. In public policy, we admittedly tend to focus on numbers and populations, communities, institutions and systems. It's important because that's the beauty and the strength of policy. Through policy interventions, we can efficiently affect a large number of people sometimes. But also, the experiences of real people, their real lives, and their families often get lost in the numbers, in the data, in the research evidence. Today, we do want to talk about mental health policy, but in a way that acknowledges, respects, and honors the millions of individuals and their families who are affected by depression, suicide, and other mental health issues. And to do that, I'm going to start with a list. Number one, ice cream. Number two, water fights. Number three, staying up past your bedtime and being allowed to watch TV. Number four, the color yellow. Number five, things with stripes. Number six, roller coasters. Number seven, people falling over. Number eight, my favorite, chocolate. Number nine, kind old people who are weird and don't smell unusual. I'm jumping out. Number one thousand and two, when you learn something about someone that surprises you and makes perfect sense at the same time, one million, listening to a record for the first time. Those of you who have seen the play Every Brilliant Thing know that I'm reading the list from that play. The interactive play Every Brilliant Thing is playwright Duncan McMillan's poignant autobiographical story about growing up with a depressed suicidal mother whom he unsuccessfully tried to make happy by creating a list of every brilliant or wonderful thing in the world. Let's watch a very short clip from this play. Thanks. After her first attempt, a list of everything brilliant about the world, everything worth living for. Number one, ice cream. Number two, water fights. Number three, staying up past your bedtime and being allowed to watch TV. If you get through your entire life without ever once feeling crushingly depressed, then you probably haven't been paying attention. A moment in it when Ray Charles sings the word you and it sounds like it's coming out to someone else's voice. We all used to just crowd around the piano and howl it like wolves. Children with depressed parents, they have a heightened reactivity to stress because children with depressed parents, they are left to fend for themselves. But the real risk as I perceived it was that I would one day feel the same as my mum and want to take the same course of action because along with the anger and the incomprehension was an absolute crystal clear understanding of why someone would want to take their life. We were walking through the park family and we got to the middle and she stopped and bent down and I thought to do her shoelaces and I kept on going and then when I turned around she looked at me and she looked me in the eye and she took my hands and she said Will you marry me? I said yes. Let's kiss later. I hope many of you had a chance to see this wonderful play through the recent University of Michigan Musical Society offerings or also it's available on HBO. If you have on demand on HBO you can watch it anytime if you haven't seen it yet. With this personal story as a backdrop and a potential point of focus during our question and answer portion later I would now like to move on and introduce to you our panel of amazing local policy and clinical experts. So each of our panelists will be making a short presentation and then we'll move to audience questions and comments. Those of you here in the auditorium can write questions on cards that are going to be passed out and those of you who are watching us online you can tweet in your questions using the hashtag policy talks. So now it is my distinct honor to introduce to you our four panelists in the order that they'll be speaking and they're sitting in the front row now. They'll remain sitting in the front row until the Q&A period and then they'll all come up front. Our first speaker today is Dr. Michelle Reba. Dr. Reba is a practicing psychiatrist and the director of the Psycho-Oncology program here at the University of Michigan Comprehensive Cancer Center. She's a clinical professor and associate chair for integrated medical and psychiatric services at the U.M. Department of Psychiatry. She's a national leader in mental health and she's the immediate past president of the American Psychiatric Association. We also have with us here today Dr. Shirveen Asari. Dr. Asari is also a psychiatrist with training in public health. He's a research investigator with the University of Michigan Department of Psychiatry. His research focuses on the intersection of community mental health and social epidemiology. As a community mental health researcher he's interested in the relationship between mood disorders and social identities and the social determinants of health and depression and mental health issues such as ethnicity, gender, social class and places where people live. Dr. Nancy Baum is also here with us today. She's a health policy researcher and the health policy team lead at the Center for Healthcare Research and Transformation otherwise known as CHART here in Ann Arbor. She leads CHART's work in the development of health policy projects focused on health reform, health status improvement and access to health care. And we're also fortunate to have with us today Trish Cortez. She's the executive director of the Washtenaw County Community Mental Health which is the safety net mental health provider serving individuals with serious mental health and developmental disabilities in our county. Trish is a registered nurse with a master's degree in community health nursing and she brings to our discussion today a wealth of experience and leadership regarding community mental health. And so delighted all four of our panelists are with us. Can you please give them a round of applause as Dr. Riba makes her way up to the podium. Thank you so much. Hi, everybody. And thanks to Paula and Emily for inviting us and for doing such a wonderful job in the arrangements. And thank you all for coming. So before we really begin this presentation, let me just ask, and I'm already standing, how many of you either in yourselves or in a family member or a close friend or colleague has had some depression suffered from some depression. Maybe you could stand up. Okay. Thank you. So this is a personal topic, right? It's obviously going to, we'll be talking about policy, but this is a very personal topic and very important. So we'll be talking in the next couple of minutes about the significance and prevalence and then we'll talk about depression and suicide across the life cycle. And if we have time, something about treatment options. Well, why is this so important? It's number one in terms of depression and number six in terms of bipolar disorder on the World Health Organization's list of global burdens of diseases for ages 15 to 45. One and six. Depression and bipolar illnesses affect one in six of us, but it touches all six of us. We don't really understand depression and suicide. Many of us don't seek treatment and even if we do, it may not be the right treatment and there are tragic consequences if this goes untreated or ignored. The past director of National Institute of Mental Health, Tom Insel, cited depression as the top cause of medical disability. And what about the burden of depression worldwide? Well, it's the largest cause of death by suicide, as Paula mentioned. It's very expensive in terms of human suffering and in financial aspects. It costs a lot and we're starting a new workplace mental health program at the Depression Center at East Ann Arbor and it impacts on absenteeism and presenteeism. Well, how do you diagnose this? In 1952, we started with a diagnostic and statistical manual right after World War II and we're up to DSM-5 and we classify all the psychiatric conditions in this manual and we update it regularly. In terms of depression and DSM-5, there are many types of depression. So it's really not easy to diagnose and there are many. Often we talk about major depressive disorder and we'll focus on that today. But I want you to understand that there are many types of depressions. And with these depressions, they're often a modifier. So here in Michigan, this is a common one, right? Seasonal changes that come with, let's say, major depression and people can also have seasonal problems in the summer as well as in the winter. In terms of bipolar disorders, there are also many types of bipolar disorders and illnesses. So it's complicated. It's not easy to make this diagnosis. And it's also, I want you to understand that it's not just a specific symptom that's pathognomonic for anyone. It has to be over a certain course of time. So sometimes somebody comes into the emergency department and we can't make the diagnosis just on seeing somebody in a snapshot. We need to see and understand somebody's life course and understand them over a period of time. But with people who have depression, often they have a depressed mood, they have a loss of interest or pleasure and sometimes in children they're irritable. So depression looks different depending on how old you are, circumstance and other medical conditions. And we'll talk about that in a moment. In terms of symptoms of depression, one can have these problems and there's a mnemonic for it. It's called sigicapse so that you can remember sleep disturbance. Sometimes people sleep more or less. They may feel guilty. They may have too much energy or a lack of energy. So it's very variable and not everybody has to have all of these problems. But often people have many of them. What about the epidemiology? Paula mentioned some. But in terms of lifetime risk for women, it's 20 percent, 10 percent for men. At any one time, about 5 to 10 percent of women may have depression, less for men. There's a gender distribution, 2 to 1 women to men in adulthood and we'll talk about children and adolescents. There's a high concordance for monozygotic twins, 50 to 75 percent. And also if you're in a family with somebody who has depression, you have a higher risk. So let's talk about, in terms of life course, in terms of children, there are children who are depressed. We're understanding more and more that depression starts in youth. And in children, it's an equal distribution for girls and boys. And it's higher for children who have co-occurring medical conditions such as type 1 diabetes, for example. There's a different acronym for depression in children. This one can be used, DUMPS. And so it looks different in children. TARD, you don't use the same sort of symptoms. But it does have a youthful beginning. And usually the peak of depression is between 15 and 24. So our thought is to get it earlier, treat it, and the quality of life improves. But often there are delays in treatment and diagnosis and there's misdiagnosis. What about adolescents? And we see many, many adolescents coming to our emergency department. Well, in early adolescence, about 8 percent. And by 18, about one in four adolescents have had an episode of depression. Up until the age of 12 or 13, it's equal distribution between girls and boys. And then around 12 or 13 girls go up higher. It's probably related to some endocrinological or other mediators. And then what about late life depression? Well, about 20 percent in community samples. And then the first onset of depression, we often see it after the age of 60. And we can see it even more with those who have co-occurring medical conditions, such as heart disease, post-myocardial infarction, diabetes, post-stroke, and neurodegenerative illnesses such as Alzheimer's or Parkinson's. What about death by suicide? This is a public health problem. Many of you have probably heard the NPR this morning or this afternoon that was about suicide in veterans. Many die by suicide each year. It's probably under-reported, and I think Paula gave some of the statistics about this. But we see it, and we've had several unfortunate suicides and youth here in Ann Arbor in the last couple of months. We're very fortunate to have prominent researchers here at the School of Public Health who organize and run the Healthy Minds study, which looks at campuses across the United States and many countries. Daniel Eisenberg and Sarah Ketchum. Lipson or Daniel is the PI for this. And they try to intervene early, and they are doing such innovative work, working with others such as Cheryl King, trying to identify and outreach students in their dorm rooms and working with RAs and trying to target certain populations that we know who are at risk in the college and graduate school years. And this is just one example I think Paula mentioned that as well, the LGBT group. In terms of late life depression and suicide, elderly white men have a lot of good things about them and for them, but not in terms of suicide rates unfortunately. They have amongst the highest rates of suicides, about five to six times greater than others. The majority of these folks have seen a primary care doctor in the last month, and so it's very important for us to think about how to intervene and to ask about this. And as Paula mentioned, most suicidal patients have a diagnosable depression. These are some of the suicide risk factors and there are, let me just read them out because it's important depression, substance abuse or dependence, physical decline, illness, terminal illness, pain, loss of independence. And I have to stop. And there are many treatments so we can talk about that. But psychotherapy, in combination with pharmacotherapy and augmentation with these other exercise, behavioral aspects are very important. So let me stop and thank you very much. Good afternoon everyone. In my five to seven minutes, I want to talk about three mechanisms how social factors influence mental health, particularly depression. So, and most of our research understanding comes from two studies, one national community survey and one ward mental health survey, both conducted by Kessler who was here in Michigan and is now at Harvard. So, of course, genetic predisposition has a role and many other factors like physical health, but my talk is focusing on economic and social and public, how social factors can influence distribution at the level of society. And please make a distinction between determinants or social determinants of depression from social determinants of use of services for depression. I am exclusively looking at or explaining social determinants of the prevalence. Starting from the outcome being depression, most of the social determinants like how we get exposed to a social risk factor like trauma, rape, fear of violence. So, the first one is the stress which its distribution is socially determined. The second one is social support. The type of job that you are performing in determines do you have social support or not and many others like education and income. And also the place that you leave like physical and social aspects of your environment. Then there is a personal asset which comes following the social determinants of health. Like do you have a high agency or sense of control over life? That comes from education. If you have higher education and you get higher pay, you have higher agency to control your life. And also do you get a good emotional regulation? Again, each year of sitting at the school having the chance to go to school increases our emotional regulation potential. Then the pattern of our time use.  That is a social patterning of a risk factor of depression. So by here I have two clusters. One social determinants like social exposures and resources and one personal assets. Both being determined by our education, income, employment and marital status and other social resources. Which themselves are under influence of these factors that I have listed here. Education quality. Do we live in New York, Detroit or Ann Arbor? Determines our education quality. That determines our emotional regulation. Employment. If you are living in Detroit, lower chance of employment if you are a black male, so that has implication for the pattern of many of those factors from time use, social support, exposure. Then does our policies which if you need money are there in place to lend or they would discriminate you against and they would not give enough lending that you need. So you cannot borrow money. Or public transportation. Do you have public transportation to go and to work so you can have lower financial distress. So you see all these policies have implication for depression through a number of constructs. And of course they are determined by public policies. So this is the first question. What are the policies that we have in New York? So this is the whole message here is not for who gets treatment for depression, but who gets depression. Determinance is mostly social and it is a social patterning. So this is mechanism one. So our exposure and our resources is different depending on who we are. Our ranking. The second one is that how much money is spent on our resources. The second one is that how much we can use our resources and use them to become tangible health outcomes depend on who we are. With almost no exception, social determinants have a strongest effect for white men in United States. So there are very few exceptions like religion and social support. But if it is an economic or social resource, that path from having access to protecting yourself depends on the intersection of race and gender and place. So it is our group membership or what part of the society are we located determines not only the access, but can we use that resource to protect ourselves. So this is mechanism two. And then the third mechanism is that because of like mistrust or discrimination. So this is continuation of that, sorry. This is, there are considerable empirical evidence suggesting that education, employment, social, environment, self-rated health do not become tangible health outcomes depending on who you are in United States. And then this is mechanism number three, which is because depression differently correlates with those factors which are important. Like depression is correlated with higher stigma if you are black male. So that means depression is more consequential if you are black male. Or also dysfunctional belief about self, others and future. From some mechanisms blacks with depression can maintain high hope maybe through social support or religiosity. So a white individual with depression would have lower level of hope compared to black counterpart. So you see this third mechanism of how society shapes our incidence, prevalence and consequence of depression is society shapes also correlates of depression. So this is the third mechanism. So I stop here. Thank you very much. Hi everybody. It's nice to see some friendly faces in the audience. I'm not going to use slides today. You can just look at this general slide while I'm talking. I think it's really important with those really dramatic statistics about prevalence and our understanding about these mechanisms that lead to depression. Some of the other things that matter though are some of these public policies that Paula referred to early on. And so I'm going to talk a little bit about insurance policies and the way we've structured things using insurance and give you a little bit of information about some things we're doing locally and that will lead into Trish's talk. So I'm going to give you a little bit of history of some relatively recent in the last few decades federal laws that have an effect on people's abilities to actually use the services that they need when they have depression and anxiety and other mental health issues. So in the late 90s and then again in about 2008 we had two federal laws that were passed that we refer to today as the parody laws. And these were laws that were put in place in order to combat a problem with the people who needed mental health services faced when they understood that these services were very expensive, needed to use insurance to pay for them. And then once they looked closely at their insurance policies, recognized that the benefits for mental health services and for substance use services were far inferior to the benefits for physical health services. So for a very long time insurance benefits that might pay all but 80 or 90% of the cost of a physical health benefit only paid something like 50% of the cost for mental health services. Insurance policies that didn't have an annual limit or didn't have a lifetime limit for a benefit for physical health services did have those kinds of limits for mental health services. And so this was really problematic and this is really a result of our misunderstanding about mental health services being really different from physical health services and people's body that includes both their brain and the rest of their body together. And so parody laws were really important. They were passed and they made giant leaps forward by saying if insurance policies offer mental health services then they have to do it at the same level that they do for physical health services. So you can't have a lifetime limit on your mental health services if you don't have it on physical health services. That didn't though require insurance policies to include mental health benefits. And so for a very long time especially skinnier policies policies that were offered by small employers, policies that people were buying as individuals had very little if any mental health and substance use services in their policies. So in 2010 the Affordable Care Act was passed and in the Affordable Care Act there was some expansion of those parody laws to cover more policies. Those policies have to abide by the rules that were put in place through the parody laws. And the Affordable Care Act said in the essential health benefits which most of you have probably heard about it includes the requirement that mental health and substance use services and treatment for the identification of those problems are included. And so most large employers were offering sort of richer packages and they already had mental health and substance use services to some extent in them. And so the essential health benefits then required those plans that were sold on the marketplace that individuals were buying and eventually many other plans to include a requirement for that. So that's sort of the history of where we are in terms of insurance policies when Medicaid was expanded in the state of Michigan which it was in 31 or two other states in the nation 600,000 plus more people were covered by Medicaid than prior to the Affordable Care Act provision to expand Medicaid, the Supreme Court saying that states had a choice, Michigan deciding to go ahead and expand over 600,000 people more are enrolled. These are people who had been uninsured for a very long time, most of them. And so you can imagine there's a lot of pent up demand for services including mental health and substance use services. So all of a sudden there's a huge demand for greater demand for mental health and substance use services. It's terrific that more people are covered but it's really important to understand that insurance coverage is not equal to access to services. Insurance coverage is really important because services are expensive but it's not enough. And in the world of mental health and substance use unfortunately we have a real shortage of providers. And so this is not a problem that's specific to Michigan. This is a problem across the nation but when you have a shortage of providers then it's complicated as to why we have such a shortage. A shortage of psychiatrists, we have a shortage of inpatient beds to treat people for mental health issues and we can go into some of the reasons for the shortages a little bit later if you're interested. So you have a shortage of providers, you have greater demand and so do we have maybe even a bigger problem than we had before. It's hard to say. Lots of ways that we think about trying to address this great demand for services. One of the things that we talk about a lot in the mental health world is something called integration, integrated services. And this is the idea that mental health some people have mild or moderate needs for mental health services and other people have more severe mental health issues or substance use issues. There's a real continuum. Some of those needs can be met in primary care.  So we talk a lot about this. There's actually decades of evidence that this kind of integrated care that sometimes we call there are other names for co-located and coordinated care that there are really good health outcomes as a result of this kind of delivery of care. What we don't do very well is pay for integrated mental health and primary care services. So for example, it would be a beautiful thing. It is a beautiful thing in some places in a primary care clinic where there will be a psychologist or a psychiatrist in an office right next to the room where somebody is talking to their primary care provider. Their primary care provider can take them by the elbow and do what's called a warm handoff and say in our primary care setting we've identified this need and instead of giving somebody a referral for mental health services and hoping that they show up weeks later when they finally get an appointment, if you just walk them right next door and hand them off to a professional, it's a nice way for people to access services. It helps with that stigma. They don't have to go and wait in a waiting room that they're not comfortable with, etc. So integrating care is a really nice idea. But when the psychiatrist and the primary care provider are having a consultation that takes 15 minutes or a half an hour to talk about this patient, we don't have any good way of paying them for that time. And so if we don't have a great way of paying them for that time where they're doing this curbside consultation one with the other about how best to treat this patient, then we have a problem. So we have evidence that this kind of integrated care works, but we have we don't have a lot of really good solutions about how to pay for it. Integration is a hot topic in Michigan. There's something referred to as the 298 problem, and 298 is the number of the section in the governor's budget, proposed budget where they use some boilerplate language to say we want to integrate mental health services with the primary care services and other physical health services by taking all the dollars that we spend in our public mental health system, which Tricia will talk about, and handing them over to one take on this, handing them over to the managed care plans who now deliver the care for most people who are covered by Medicaid. And so as you can imagine, people who are receiving these services had a very hard time understanding how it was that they wouldn't lose their very important providers. You know, you make really solid relationships with providers when you have mental health issues for a lot of people, and that was really hard to imagine, and so sort of thrown into this bucket of privatization and a bad policy idea. So in the state, right now, over the last couple years, we've had lots of stakeholder engagement conversations, lots of proposals about how we might integrate care, and there are still a lot of people who are very excited to do it, not because they don't think that conceptually clinically integrated care is good, it is, but, you know, just taking the dollars that we typically spend in the community mental health system and giving them to the managed care organizations is really controversial. So I will end there, and we can talk more about those issues in the discussion. All right. Well, thank you. Very excited to be here. I'm super excited that we are talking about these issues. These are really, really important issues, so I want to thank Paula for inviting me to come here today, and Emily for your I appreciate how much you hounded me to make sure I got my stuff in, so thank you for putting up with me. So I'm going to be talking a little bit about what's happening here in our own backyard. Does anybody know anything really about community mental health? If you do, please raise your hand. That's what I thought. So let's start with what community mental health does.  There's 46 CMHs in the state of Michigan, and essentially we serve people who are low income Medicaid and who have kind of deep-end needs. So adults with serious mental illness, youths with serious emotional disturbances, and youths and adults with intellectual developmental disabilities, and certainly also individuals that have a co-occurring condition. And what's different about CMH, and it's a little bit talking kind of both Dr. Asari and Nancy, is that mental health provides a much broader array of service because of the exact issues that Dr. Asari talked about with social determinants of health. So a typical coverage for mental health is you see a doc, you can see a nurse, get an injection, you have some therapy, and that's pretty much the basic package. Community mental health, one of the bread and butter services that we provide is case management, because one of the things that we talk about in the community mental health world is that the medical model is necessary, but it's not sufficient. In community mental health we have to get people housed. That is a form of treatment. We need to get people secure with their food needs. We need to do a whole array of issues to address the, what Dr. Asari had on his slide, before we can get to treatment. So that is one of the fundamental differences in what we do versus what traditional insurance plans cover. In addition to lots of other services like people who need residential support, people who need support with getting employed, people who have a whole host of issues that need to be addressed. Community mental health also, we are 24-7-365 mobile crisis. We respond to any crisis in the community. We also are, because of the reasons I just discussed, also are very integrated in a lot of other social service systems. We are the mental health provider in the jail. We staff the mental health court. We are in the primary care safety clinics helping with the integrated care efforts that Nancy just talked about and the list kind of goes on and on from there. So one of the big impacts that happened to us in the last couple of years is that concurrent with the implementation of Medicaid expansion, which here in state of Michigan is called Healthy Michigan HMP, Healthy Michigan Plan, the state made a decision around financing and what the state did at that time is concurrent to the implementation of HMP, they took about $200 million out of the CMH system statewide, which for us was about a 60% reduction in our funding. And it was not the Medicaid but it was what we call our state general funds and those were precious at the time because those are not as regulated as Medicaid is and those were the dollars that we had to do flexible, creative things like have a psychiatrist in a safety clinic like doing paying for jail services and most importantly for us is that we kind of anybody who kind of met the diagnostics and functional limitations we served everyone blind to pay and they got case management and they got assertive community treatment services and the list goes on and on. So when this funding went away it was an extremely challenging time because at that time what we had to do is that we had to actually discharge people who maybe just had Medicare. Medicare does not cover all those services and so we needed to go through and start looking to see who can we hand these individuals off with not really super great resources and issues like as Nancy talked about. So what happened is that we ended up no longer being able to be the safety net provider for all. This kind of shows you in 2014 we served roughly just about 650ish or more individuals who did not have a form of Medicaid that we paid for their services out of our general funds. Now we're down to about 115 who are now currently in our system and we're holding on to them because they're so ill that really it would be like an emergent or urgent situation if we did not serve them. So we've held on to the deepest end people because out of sheer necessity. We've had to close our front door and so that unless people meet an urgent emergent need we cannot bring them in and we have to try to refer them to the best resource we can find in the community. So this gives you an idea of kind of the impact that this has had. What we're seeing locally in our trends we're seeing that you know I also want to say that Healthy Michigan we are now serving roughly about 700 individuals on Healthy Michigan in the CMH system. So it has been a wonderful resource because on Healthy Michigan they do get the full array of services covered under other traditional forms of Medicaid. What we're seeing is the blue line is people who are actually Medicaid and with us we serve them we know them we hang on to them that our inpatient is going up a little bit but what we're seeing kind of exploding is that there is another population mostly Healthy Michigan who are showing up in ERs and our inpatient rates we're seeing as just kind of skyrocketing year over year. Our corrections data this is from our Washington County Jail. Again the blue line you can see over over the years we've kind of kept it steady of what individuals who are ours are also in our county jail but again we're seeing this other trend of another population that has now exceeded the number of people who are actually enrolled in community mental health. So we're seeing that people are landing in other places. This is a slide from the Washington County Public Health Department there's a lot of information on there but I'm just going to point out that the startling increase of suicides that we're seeing in our young and our youth between the ages of 15 and 24 we are seeing in the last six years or so a 433% increase in the number of completed suicides in our county. So as we have been experiencing all this and when we received our funding cuts back in 1415 some of the things that we did in our community and was that we needed to really do a thorough analysis of what are we going to do how are we going to handle this so I reached out to our good friends and colleagues over at chart and Nancy actually was one of the staff at chart that helped us do this to do kind of a deep analysis of gaps around substance abuse and mental health services in our community. Washington County Sheriff Jerry Clayton and I also because of the intersect between our two worlds is not insignificant. Also hosted a sequential intercept mapping workshop two day workshop where we had everyone from kind of the public safety justice mental health substance abuse housing and others world all come together to really look at you know in every single kind of intercept where an individual is having some interaction with law enforcement etc what are our resources what are our gaps and what do we need to do and so we conducted that in addition our two major health systems in our community did a joint needs assessment was called Unite and they also did their assessment the overwhelming conclusion of all of it is mental health substance abuse is the top priority in this community and what we are also experiencing is that the community capacity to serve individuals with be with behavioral health issues is very limited and this is something that we are seeing as Nancy said it's not just a Washington County issue it's a state and national issue that we are facing. One of the consequences of these limited resources what the chart report also found is that what it's leading to is there's a delay in people getting to services whether it's outpatient inpatient substance abuse etc we are seeing their extended wait times in our psychiatric emergency our psych departments are literally University of Michigan or Michigan Medicine now is now they're actually having to look at the physical plant because they can't have, they have so many bodies that are coming in right now we are also seeing a discharge of getting people off in patient units because we don't have that the most appropriate or can't access the most appropriate kind of step down for that individual and we are asking our community providers who historically CMH is taking care of these kind of deeper end people we are asking primary care physicians and other providers that haven't really typically worked with individuals who experienced schizophrenia for example and so we are really pushing our community partners to really kind of expand their scope of practice so the major conclusion is that we are really at a point where we need to strategically expand our community based care across the full continuum of services for mental health and substance abuse and one of the things that has been popped up in the chart analysis is that we really need to do a better job of having a comprehensive community based crisis care program that can take people who just need to walk in, short stays, final what they need and get them to the right place that has been one of the number one priorities that have come out of all of these analysis with our sequential intercept workshop that we did again the same themes coming up we need to expand our crisis response strategies as a community we need to expand our substance abuse treatment another piece that came out of that because of the nature of that workshop is that we also need to make sure that first responders such as law enforcement such as paramedics also need to know how to address or at least identify that there is a mental health crisis before them and not necessarily whatever else it may be and so we've done a lot of training particularly with the sheriff's office of training all 150 sheriff deputies on how to manage a mental health crisis and then also expanding kind of the use of peer supports which has really been a very effective way of kind of addressing some of these needs through peers with lived experience so our kind of local reality is that there's kind of a perfect storm that's happened here in washington county we've got an opioid epidemic I think just about everybody knows about that we are seeing increases in suicide we are seeing increases in inpatient crisis services we have a capacity issue in the community we've got funding restraints like we've had we haven't seen before but we've also had you know that our community has really analyzed situation and I do believe that we are really at a point right now where we care are going to be transitioning out of mode and really going into more like proactive strategic planning together as a community some of the advantages that I think is is unique to washington county is that we are really a community rich with partnerships so we are now working with leveraging those partnerships working with our community providers our housing network etc because this is really kind of a it's going to take a village to really start addressing some of this we are all trying to expand we also need to make sure that we are lining our efforts that right now whether you're in the substance abuse world or mental health or you're part of a health system everybody's trying to try to address the same issues so there's a lot of moving parts but we need to make sure that we are doing those in concert and so that's what we are also discussing education that's part of what this whole event is about right so we need to get a lot of education and advocacy around these issues we have started talking about a community based crisis program again we're the right service at the right time that's not necessarily to be in the jail or the emergency room that work is underway as well as trying to kind of stabilize the system by doing more integrated care efforts for example and really trying to make sure that we are kind of doing a better job of helping we have the historic knowledge and expertise around some of these issues from our perspective but then how do we help our partners kind of expand what they're doing so these are the things that we're doing we are doing a lot of law enforcement training we are doubling down our efforts in terms of our partnerships with our schools we have in Ann Arbor public schools alone we lost 9 youths last year to either overdose or suicide that is a startling high statistic and I think one of the most important things we need to do is just a full blown everybody needs to get on board with kind of busting the stigma around mental illness and really taking it is that the brain is an organ just like your heart just like your lungs just like anything else and we need to stop treating it like it's something different thank you I'd like to invite our panelists to come up front they were all under extreme time constraints and packed a lot into their short presentation so please join me again in thanking them for working under challenging circumstances we've covered a lot of ground and I see that there's been a lot of audience questions coming in so as our students sort through them I would like to just give them another moment I'm going to start off our Q&A session by just asking any of the panelists you don't all have to respond to this but I don't know if any of the panelists had an opportunity to see the play Every Brilliant Thing and just want to share any reactions to any aspect of this performance that resonated with you and the work that you do in the area of mental health I will start as a son I don't think it's on hit it I can talk loud I did have the opportunity to see the show at the Arthur Miller Theatre on North Campus and so as most of you probably know this is a theater in the round and it's very inviting and the other thing that's very inviting about it is that the show engaged the audience I'm not sure you can get this from the clip but the show engaged the audience constantly throughout the entire show almost there was somebody from the audience on the stage and some of them were there for a really long time I started thinking about this is a really interesting metaphor for the way we need to address mental illness it really requires our community it requires our family and our friends and professionals and everybody you know addressing mental illness is not a one man show even though this was a one man show so that was sort of my thoughts about it Thank you Dr. Reba It's one of the hardest things for a child to have a parent with any illness right including mental illness I was thinking I work in the cancer center and we have camps summer camps for children whose parents have cancer and they can go for years to these camps we don't have that for children whose parents have psychiatric problems think about it Yeah that's great well I'm now going to turn to our students who will be asking the questions that people in the audience have sent in again I want to remind our viewers who are watching online that you can tweet your questions into hashtag policy talks we have two students here with us today they're going to introduce themselves and they're being assisted by Professor Natasha Pilkowskas as well and sorting through and organizing your questions so thank you Good evening now I'm here my name is Nadine I'm a senior in the BA program studying public policy with concentration of women's health policy the first question from the audience is it seems that there's a tension between wanting to diagnose people with official DSM defined conditions so that their conditions and challenges can be seen as legitimate but simultaneously wanting to avoid further stigmatizing these individuals by labeling them how do you personally reconcile with this and how can policymakers help you That's a great question Just to make it clear that I'm not a psychiatrist Paula was kind enough to say I'm a psychiatrist but I'm a primary healthcare physician so I was not practiced on just those research so if I didn't respond anything related to diagnosis because I'm not a practitioner He's dodging a question that I know he could answer Why are we talking about stigma and trying to have a correct diagnosis for somebody I guess that's an important question you wouldn't want to have an oncologist treat you without having the right diagnosis based on pathology and radiographs and testing and so even very fundamentally talking about diagnosis it's an interesting issue we don't we use DSM is used by all mental health practitioners not just psychiatrists and the idea is for us to have a common language so that if you come to see me in one building but you go to see somebody in another building and we look at the records we can understand what the course of treatment is or how do we treat to remission of that problem and so we're trying to you know we use this to try to help people but I I guess others think of this as stigmatizing so that's a really important question I think as a policy issue and it would be really interesting to have a conversation about this with others in the room if you're interested Thanks Hi I'm Katie Allen and I'm a dual master's in the School of Public Health and the Ford School and I'm also interested in other health issues so this is a slightly different not quite related question but Dr. Baum talked about how mental health issues often require a different kind of care than physical health issues for moderate to severe cases of things like depression is treatment seen as something that can be done effectively in a certain number of months or is depression more across the lifetime issue probably best answered by clinicians The idea is that we need to get it early into prevent recurrences we're not doing a very good job with this prevention especially as we're talking about services and funding that's really the issue because you know we're seeing more and more people coming into the emergency department not just for psychiatric problems but for all conditions because they don't have the money to go to primary care to get testing for problems and by the time they have a problem it's very severe so we're trying to prevent recurrences but in fact there are many illnesses in psychiatry just like in other conditions where we think of it as a chronic condition but we want to try to prevent severe episodes of that condition that's really the goal to try to improve quality of life for everybody knowing some of the literature there is a literature saying that after three hits of depression the biology changes significantly much more than the hit number one and hit number two so if someone has experienced three episodes the risk of recurrences just is proportionately higher in future compared to two episodes you know just to say we see young people not getting the right diagnosis and you know they turn to drugs or alcohol to treat their fidgetiness or hyperactivity or mood to try to make themselves feel better or put on you know drugs because they're misdiagnosed where psychotherapy or other treatments like exercise sleep you know might change in diet and poverty you know we were talking about homelessness poverty what impact that is on children who have to you know not be able to see regular teachers or get educated so you know these all these determinants really impact on you know people having three episodes what we're trying to prevent is having people having three episodes trying to trying to help them earlier on in their life is there is something called telescoping effect which means if you are a vulnerable member of a vulnerable population like a minority or not that much access the same disorder would result in worse conditions so like a telescope you would transition faster to the worse outcome so that is why social determinants are also important after the development of depression so that was a good segue into the next question so there's a little bit of context to it right now there's a national push to recognize Middle Eastern North African check box is a point of census data it's more specific to the state of Michigan because Southeastern Michigan has a large population of Middle Eastern and North African persons I guess the question would be then if we are classifying a large population in this community as white how do we look at their trends especially with many of them coming from war torn situations how do we look at their trends over a long span of time and how do we make sure we're servicing those people as a marginalized identity and not as a homogenized identity if I can answer that first my personal opinion is that that's a wrong decision to count Arab Americans or Middle Easterns as white because particularly for example the first generation of immigrants it's a group of immigrants which means high risk even if the ethnic backgrounds of centuries ago have some similarities to whites still the risk profile is totally different so my answer is that that's the wrong start to call them white so yeah sorry I think guys may have said that wrong so they're pushing to have a Middle Eastern North African check box because currently that would be great yeah that's a step forward because I myself am a Middle Eastern and I take white which makes me very angry and okay I don't even myself benefit from my ethnic identity I am an ethnic researcher I do these type of stuff and then I check the wrong answer so that is table situation but okay so the first issue is that profile of exposure and experiences are very different and specific and being an immigrant especially first generation immigrant is comes with a lot of adversities social adversities and being a Muslim who many of those people are also increases religion related discrimination and all the exposures especially the current climate so yes unfortunately even this is the thing we know what exposure is happening and we know what is the solution but still exposure is happening and solution is not being provided that's the same situation with blacks that we know there is discrimination we know that it is poverty which has very particular type of solution we know they do not get the same care or treatment but we continue despite knowing the situation it's happening and continuing so I think that is the same case for another ethnic minority to be added to this census data collection is this on? yes so in our world we have to collect lots and lots of demographics so we are now having to add more check boxes in all the things that we are required to track the state did also implement a policy around that everyone within the CMH system all of our providers need to are required to go through cultural competency training so I think that those are kind of the beginnings which then those trainings will become more robust as we continue to track who is it that's hitting our systems and what do we need to do to add to those trainings I'll add one more thing Trish may be too modest to add this herself but our community mental health organization here in Washtenaw County is a leader in finding ways to share data appropriate ways to share data information but that are sufficient for providers to know enough about their patients and to know enough about what their patient's challenges are to actually address them well and my parting interest shop is a leader and somebody who we hold up all the time as really forward thinking and trying to be creative because of course there's that tension between privacy and having enough information for providers to really start dealing with. So I have a two part question that's coming from two different people they tied in together so why has there been an increase in suicide rates among youth over the past six years and what are some early interventions that could occur as to potentially later intervention? I can start it off and I'm sure others can add to it but you know it's probably multi factorial we don't really know the answer but some things that we think are occurring as well. The question has been shown to be a real strong determinant. Facebook and other electronic media out there you know it's a lot of children and youth are going on and seeing what others are doing and feeling envious or feeling left out they're using that as a way to communicate without really friendships you know talking about you and I think I'm a lot older than many of you but in my day I was on telephone too much and using the telephone and nowadays I don't know about you but the telephone in my home doesn't ring and many of us don't even have it landline anymore so kids are just thinking that they're having friends but they really don't they're doing video games and that friendship those bonding being in somebody's home where there's a parent perhaps they don't have a parent in their own home supervising so kids are being unsupervised coming a lot of activities after school so they're tired and maybe they're not sitting around the dinner table talking about issues and problems you know there were a range of issues and then also the lack of perhaps preventive care that many children may not be able to see a pediatrician or other physician who may be able to screen for depression and other issues in themselves or in their parents so these are some of the issues but probably not all of them I think in this poverty all those issues are as well major issues what I can add is we don't know what exactly is causing the increase in youth suicides what I can tell you of the deaths that we've seen here in Washtenaw County for CMH our suicide rates for the people that we serve are extremely low extremely extremely low and the suicides that we're seeing are not actually necessarily low income that we're seeing so one of the things that we did for after one of the more recent one the summer suicides that had a tremendous impact they all have a tremendous impact on our community but one that happened in our local schools a lot of families come out to ask what am I supposed to how do I talk to my kid who was in his class or you know my younger siblings go with their younger siblings say elementary school or what have you and what we also talked about we had a psychologist come and also talked to these parents and Paula said I'm a nurse but it's been so long since I've been a nurse so nobody can have a medical emergency right now I've been an administrator for way too long so but what I also kind of learned even in that session is that you know that the frontal lobe correct me if I screw anything up is kind of the part of your brain that makes you kind of like think before you do and that doesn't get fully developed until you are in your in your 20s and so combine that with social media and the kind of the culture instant gratification I mean you gotta send that text back right away you have to I mean and so you're almost it's almost like we're pouring fuel on you know an underdeveloped think before you do part of the brain and so I think between the bullying and the social media and the culture of instant gratification like must respond must respond that that is all playing into what we're seeing but interestingly enough our low income folks the other the other piece I think is that culturally I mean I think you know I don't know they're still talking about it but every it's a culture of everybody wins everybody gets a trophy you know one of the things that we also kind of talk about is that the folks that we serve because they're they've been living in poverty or that they're pretty resilient and so is there also are we building kind of a culture where our youths are not even are losing some of that resilience because maybe the worst thing that could happen to someone is when they get you know they get their heart broken for the first time and you know what are all the previous experience that happened to that so I think that there's also a piece of the culture around resilience that also you know could potentially play a factor in all this but we're trying to figure this out and if I can add just briefly if you look at the trend of psychiatric disorders over the past 5 decades or 4 decades there is an increasing trend so that those type of increases are not new and are not specific to suicide overall they are increasing and then the second one is that the structure of the family and also function of the family so the more families are single headed and now the conversations are less or the type of social support so the trend in a structure and function of family over the past decades which result in of course that increase in mental health problems including suicide I mean the other aspect is the substance problems substance use and dependence and the opioid crisis so often that's in adults right so often they have children so so we're seeing that as a widespread national problem which has a lot of tentacles into society okay so this is a long one okay is it fair to say that conservative legislators and policy makers believe that mental health problems are more of a family and personal issue and that is what we addressed by support systems gained through individuals families and churches or private community organizations rather than society of larger government infrastructure so I guess the question is yeah that was the question if I can start the whole ideology of right and especially extreme right is responsible and nothing is more than individual responsibility so if there is a problem then we should be able to see the cause like a parent is absent or something is wrong with the person so it's blame the person so this is ideology at the same thing with poverty so the right is has the belief that the poor is doing something wrong or something immoral is with the poor so that is a part of the ideological view of a big part of this country that's a really complicated question I think it's very hard to look into the minds and the hearts of any politician I will say that the more conservative policies that have really been challenging the Medicaid expansion and are really important for us to think about the reason I say this is that Medicaid is the major payer for mental health services and people with mental health and substance use needs are very expensive there's about 20% of the people in who are covered by Medicaid have a mental health or substance use issue and we spend about half of our Medicaid dollars on those individuals and so you can see with this problem this disproportionate problem that anytime we make really significant changes to the Medicaid program like ending the Medicaid expansion in the 30 plus states who have expanded or adjusting from the way we currently pay for this entitlement program to something that is limited to a per capita cap or to a block grant type of funding we really start to threaten our ability for those particular low income individuals to get the mental health and substance use services that they need so I think without looking into hearts and minds we can say that certain policies are more challenging for the very people who need these services you know what anybody suggest that cancer should be treated by the family yet for some reason we know it's hard for some people some maybe legislators to think that depression and bipolar illnesses are medical conditions just as Trish said brain these are brain illnesses so you know this is why public education and for like this are so important because this is not about just toughening up and doing better this is this is about treatment and this is why you have to get a proper diagnosis legitimate diagnosis and get evidence based treatment I'm so sorry to say we're out of time and I know we haven't gotten to many of your questions we've talked about so many different things today we've talked about prevention and social aspects of that we've talked about diagnosis and treatment we've talked about community mental health issues public policy again I apologize we didn't get to all of your questions we are having a reception right outside of this room and the panelists will be staying around so we can have some more informal discussions for those of you who are here and also I do want to mention that right outside the door here there is a table and a staff member from the department here at the University of Michigan with some resources if anyone wants to talk about what's available here at the University of Michigan depression center we do have some information there thank you so much for joining us and please join me in thanking our wonderful panelists for the day


This one it's a day one basically another one of these like system guys who are like oh we're going to go short at 930 we're going to you know basically the idea of this trade is basically you know because of your your system you expect it just to keep fading all the way down all day and never get any volume you know all I would say is that if you're going to trade like this keep in mind the range we're opening up at the very bottom of the range you know seems like a chase on the short side yeah I mean this this this guy has submitted a couple where he's just kind of talking about his like system or whatever there's a couple of those guys I've seen you know I mean that's that's mine I just think number one if you're going to trade like this shorting support yeah it's the opposite of what we kind of teach here but I will say this if you are looking to go short and this is what you want to do go short at 930 you've got to have a component of the range right you're shorting at the very bottom of the range very very bottom low a day you know you need to you need to basically you know incorporate something like that if this is the way you want to trade you got to incorporate something that's range bound like if I was going to short like this I'm going to completely tell you right now I would not short if this is opening up here I would short at least if we get to 50% or more of the range that I'd look to go short in this area you know I'd want some type of range component because like again if you're just going short low a day 930 every time like that's not going to work right um another thing is I'd definitely be tighter on the risk so I would not be risking he went short basically at three bucks he covered at 350 I would never uh what kind of system is this pristine basically what you do is you form an excel sheet and uh yeah you uh you come up with some type of data and uh this is what you do you just go short at 930 and you hope it fades um it's the short and pray system I'm not trying to chirp anyone like you can trade your own way I'm like you know I'm kind of like done with that all I'm saying is just if you want to trade like this again um you know I would I would definitely add some type of range component I would have tighter risk and um also um another thing is that for me anyway I would want some type of resistance component like this is what I see here like if I was a short seller right now um this is the bare 2005 system yeah exactly it's like bare version one well it's like windows like vista right um but anyway I would look to go short into 350 area this type of resistance line right in here that's where I would personally look to go short obviously you know kind of hindsight but there isn't really a line till 350 lines up with the whole number lines up with the resistance um you know that's just what I would do but again we do have a ton of these like system guys it's not MIC process but and I'm not going to sit here and chirp them I'm just saying you know you gotta have some type of range component you can't just go short at low day I've never seen a bear chart go short at low day that's all I'm gonna say Dominic yeah I mean we can clearly tell it's just chasing right I mean there's like technically there's no mean like you know just like little here and uh I couldn't see view app here but you know if I assume it would be somewhere around like this area that's where you start about maybe like you know at view app and this is like yeah you know props to him for sending you know this chart you know it's like like I think we can learn a lot from this um there's like really no point chasing guys I mean you can clearly tell you know there's no meat left if you want to chase okay let's say if you want to chase let's say you want like you know like confirmation or whatever you want to chase you know look at this support slam it right down here and we stop here you still have a lot of meat left right I mean that's like okay with I mean slamming chasing whatever you want to call it and I you know I mean it would be best if you could wait for the top to set and and then you know scaling back to the bounce like this or this year I mean it's you know in hindsight right I mean easy set and now when when we see complete chart and you know it's oh yeah it's super easy you should short here and call for you short here and cover here right easy set and done but always look at the support okay key support and this is like the key you want to you know chase here slam right down here or like wait for this line or like you know simply wait for view app I would say view app is somewhere around this area yeah exactly and you know short near there and you may maybe stop over here that means you can still have a lot of meat you know laugh on the bone it's like this like literally no meat and also he he shorted right at the open okay chances are you know like at the open we've been talking about this a lot if you long by straighter right you don't want to long into the pops right and for a short trader you don't want to short into the watch right at the open this is like the the most kind of dangerous thing that you can do like you know right at the open right like you know I'm a short by straighter you know at the open I want to stop to pop for me to get in all those people who are anticipating you know and also shorts are covering I want to short into the pops at open so you know when it's like people are panicking so you can watch and so I can cover and that's all okay I hope you guys can learn from this uh yeah what's up guys sorry a little late what's up bro what's up dude I uh I looked at the clock and I was like oh man it's already 10 minutes in um so guys really quick just a very quick you know when you've been doing this for a while you get to the point where you can eyeball something immediately and know what's wrong or what's right with it and the first thing I want you to ask yourself always every time you take a trade is let me see if I can annotate this is yeah guys where are the outer lines right like where are the resistance points if you're hitting down here that's real can you guys see this annotation can you guys see yeah okay this is chasing this is a problem even this is a problem honestly like I don't even want you hit guys outer lines where are the resistance points so when we say line a line at m i c you know this is a major level this is a major level is for pre-market the point is is because there's a quote-unquote reason a ceiling rather for these for for the stock to fail for it to come down for people to be stuck and want out it's like jumping on a bed in an apartment you're gonna hit your head on the ceiling and these are those points


Hey guys, welcome back to Six Sisters Stuff. Today I am in Disneyland and I'm gonna share with you 10 of the best foods that you can buy at Disneyland. So I am with my sweet friends from Dallas, Texas and we are on a... Yeah! Only go for the rides. We love going for the food. Now if you have been to Disneyland before, you know that their food is amazing. Let me show you some of my favorite foods. Starting off with number 10 are the delicious bread bowls. My favorite place to get them is California Adventure. This is called Cafe Bakery. It's right as you're coming off Pixar Pier on your right. So they have their amazing broccoli and cheese soup, but if you're looking for something delicious, their clam chowder is to die for. Now I have a few tips. It is possible to order two things of soup and one bread bowl and if you go before 11 o'clock, you will beat this lunch rush. Now they have a bakery tour in the back if you're looking for some free samples and it's fun for the kids. Number nine, the pretzels. Now these are one of my favorites because they're not very messy. They're perfect for kids and adults and they come in the cutest shapes. Now there are different flavors and different dips for different locations. This one is by Guardians of the Galaxy and this is the Parmesan Cream Cheese jalapeno pretzel. Oh my word, it's amazing. Then they also just have plain and simple ones. These are perfect for kids. I personally love to dip these into the cheese dip. Now this one was new for me. A friend introduced me to their caramel popcorn. You can buy these from stands all over the place. This one was also by Guardians of the Galaxy. I love it because it's so easy to take on rides while you're waiting in lines, while you just need a little snack. Now we just packed this into our bag and took it onto the ride. Now you can also get different kinds of popcorn at different locations. This one's called Disney's Trolley Candy Treats and they're all different kinds of flavors. They're all amazing. As we're out and about, we ran into the Disneyland Insiders. Now if you've never checked out their channel, you need to. They have so many tips and tricks when you go to Disneyland. They're in the park many times a week. So they are going to share with you some of their favorite food tips. So my favorite thing for food at Disneyland is the mobile ordering because it's so much easier than waiting in line and you can get so many more rides done. And my favorite place to mobile order is the Dole Whip because it tastes so good and there's usually such a long line that having a mobile order is great. Now I'm going to have to agree with him. The Dole Whip is one of my favorite things. So number seven on our list. Now if you've never had the Dole Whip, there's two different kinds. There's one with pineapple juice and one just of the ice cream. Now I did what he said. I tried the mobile order. I told him what my order was and picked it up right there. Now if you didn't see the line, it's about an hour long to wait for the Dole Whip. The mobile ordering is amazing. So my favorite thing is the Cake Pops. They're so good. My favorite place to get them is the food corner because when you go down underneath the Hungry Bear restaurant you can see a beautiful view of the Rooms of America. It's so awesome. Now she knows me really well because whenever I go to Disney, Cake Pops is one of the things I either bring home or eat right there on the spot. So to continue on the mobile order trend, my favorite place is the Bangle Barbecue because they're like really healthy snacks.  Then they have like chicken skewers and beef skewers and vegetable skewers and it's just so delicious. So these three from the Disneyland Insiders had yet to steer me wrong. So I decided to give Bangle Barbecue a try. I had never tried it before and I'll tell you what. Number five is this Bacon Wrapped Asparagus. It was the perfect snack. They also have these hummus bowls so you get three different kinds of hummus, some vegetables. Now I love eating snacks but I also really like to eat healthy. They also have these beef skewers and chicken skewers served with rice. It's delicious. Now staying a little on the healthy trend, they have fruit stands all over the place at Disney. You can get little baggies of grapes. You can get little baggies of fresh cut pineapple. My girls, when I take my little girls, they love to each pick out a fresh pickle and don't worry, they're thinking of adults too. They also have spicy pickles here. I just love how Disney can offer you different things from healthy to sugary, kind of whatever you really want. Now this one that was just across from the Jungle Cruise, they have all kinds of healthy snacks. So right when you get off Splash Mountain, there's a little shop called Poo Corner and it has the best desserts. I love that they have a little window that you can actually watch them make it. So number three on my list is chocolate covered pineapple.  It's fresh pineapple and it's so good. All right, on to number two, the Tigger Tail. I found this at Poo's Bakery, but you can find it in multiple locations around the park. So let me tell you what's in it. You have marshmallow dipped in caramel, dipped in chocolate, dipped in sprinkles with more chocolate on top. It's pretty much heaven. All right, now we're going to jump to the Jolly Holiday Cafe. It's one of my most favorite places, especially to get their raspberry macaroons. Now I smushed this one before I filmed it, but you can get the gist of it. Macaroons with the cream filling with fresh raspberries in the middle. Now it is tied for my number one thing to get at Disneyland. I get it a few times every Disney trip. Okay, I have to admit I have two number ones. My second one is called Disney Chocolate Grams. Now they stopped selling these for a little while and it was devastating, so I actually taught myself how to make them. But inside is an amazing peanut butter filling that literally melts in your mouth. So I'm going to actually teach you how I make these Disney Grams. So you're first going to take two cups of chocolate chips, a little bit of shortening, and you're going to microwave it until it's completely melted. Next you're going to take a graham cracker and completely submerge it into the chocolate. Now you want every corner covered. Then put them on a lined baking sheet until they cool. Now for the middle part, you're going to add some peanut butter, powdered sugar, vanilla, milk, and mix it all together. Now I'm going to put a link in the description for you so you can find the exact measurements there.  Then put it flat so you can actually put things on top. Mix your chocolate chips and shortening all over again. But this time you're just going to drop the chocolate on very gently and cover all of your peanut butter. Now once those are hardened, I take the extra chocolate and just do a little drizzle decoration on top. Now after you have these Disney Grams at Disneyland, you're going to want these all year round, and now you can. Now you may have noticed Jen from a little bit of Calm & Crazy in my video, and of course the Disneyland Insiders. Go head over to their channel to see all their Disney tips. Tell them that Kristen sent you over. I'll put a link to them in the description. I hope you enjoyed all of these Disneyland foods. I would love to hear what your favorite thing to get in the park is. Alright you guys, thanks for stopping by. I'll see you later.