“I haven’t seen her in months,” said the collateral on the other side of the phone. “Suicidal Ideation” was the chief complaint on the emergency department board when the initial consult call came in. As the substances metabolized out of her system and my patient became more alert, she revealed the true reason for her presentation; “I needed food.” The fragmented pieces of her life slowly came together to reveal the tumultuous history of how she came to be. She was a daughter with severed family ties, a friend struggling with substance use, and a neighbor experiencing homelessness. At that moment, she used her knowledge of the system for survival; a place to rest her head and find food to eat.

I wondered how I could assist with her mental health if her basic needs were not being met. As providers, most of us can drive home in our respective vehicles to a warm bed and meal of the day. We can wash off the weight of the day with a hot shower and a towel to bundle us up. For those among us who might develop addictions or other health challenges, we are offered resources for our addictions and time to recuperate through time off. Even with the availability of resources for us as practitioners, we can still experience difficulty navigating our mental health; what more for the patients we treat?

As a pediatrician receiving psychiatric training, I have had the opportunity to see how mental health evolves through the lifespan. As my patient’s collateral recounted her unstable childhood, I reflected on how children enter their respective family units with no indication of how their environments will shape their emotional well-being, safety, and adulthood. In an ideal world, children would be provided the opportunity to live in an environment that nurtures their well-being. However, the unpredictable nature of the human experience reveals the principle of inequity. As the resources dwindled and the societal safety net weakened, my patient reached for a branch that offered an illusion of safety—drugs.

Drugs were introduced in her adolescence and contributed to several inpatient hospitalizations during her formative years. I often wonder whether she was the student in class asked to leave due to angry outbursts or the student sleeping during class, but never asked why? Similarly to my patient, transportation, finances, and accessibility are among several factors hindering children’s access to pediatricians, psychiatrists, and therapists. For most children, school is a place they are expected to be daily. Buses are available for transport and free lunch services ensure they are fed. From the preventative lens of my pediatric training, schools offer an opportunity for early intervention. The expansion of school-based mental health services can be a powerful tool to strengthen the societal safety net before patients fall through the cracks.

As often as students are taught “the mitochondria is the powerhouse of the cell” and other foundational concepts, integrating discussions about mental health into general health curriculums could empower children to manage their mental health with coping skills, stress management, and recognition of warning signs. My patient was one of many children introduced to substances during the vulnerable age of adolescence. Discussions regarding substance use and its effect on mental health can be an interceding factor during a time when maladaptive coping skills can intertwine into the growing brains of children. Partnerships between community child psychiatrists and training programs could facilitate evaluations, recommendations, learning opportunities, and continuity of care to ensure children are addressing their mental health at a critical age.

The experiences offered to me in my psychiatric training continuously remind me of our duty as physicians to recognize the surrounding determinants hindering our marginalized populations. As trainees, we are in a unique position for constant exposure; a strength we can harness. Medical schools introduce most students to the social determinants of health; training presents the opportunity to intervene as rising practitioners. Like my patient, many other patients typically discharge to shelters or return to the streets where their stressors and exposures readily welcome them back. If transportation serves to be a problem, consistent mobile clinics could be shuttled to surrounding shelters and offer evaluations, medication management, harm reduction solutions, and continuity for our patients. Such services can be integrated into the training curriculum to take what we learn in the classroom and institute tangible interventions for the social inequities trainees are actively seeing and patients are experiencing.

With the understanding that efforts can be limited by finances, time, and staffing, immediate interventions are being offered in the emergency room setting, where many of our marginalized patients present. In an effort to meet patients where they are, I have found that this setting offers trainees the opportunity to provide community resources and preventative measures. Addressing all the needs of our patients can feel overwhelming when resources appear sparse; however, we are able to connect our patients with community resources offering shelter, food, and treatment. We can also provide harm reduction techniques to minimize adverse effects as our patients navigate their sobriety, mental health, and overall stability. My patient’s main concern was ensuring her basic needs were met. When she inevitably returns, she will be able to keep adding tools to her toolbox to remain safe while navigating her addiction and mental health.

As psychiatrists in training, we have the privilege of studying the very organ that influences human behavior and response. We are offered insight into some of the deepest secrets, desperate moments, and challenging trials of the human experience. Our prescriptions can only carry our patients so far without the bare necessities to offer them the safety to heal. As a collective, I hope we continue to remain motivated to advocate and cut through the forest of disparities obstructing our patients’ pathways forward. This way they can reach through and grasp the hand extended to them when they are ready.