In this episode of Breaking the Silence, Dr. Raman Marwaha—chair of the APA's International Medical Graduate (IMG) Caucus, is joined by Dr. Rama Rao for a thought-provoking conversation about youth suicide, cultural identity, and the immigrant experience. Dr. Rao shares his personal and professional journey, exploring the impact of intergenerational trauma, acculturation stress, and the importance of humility and humanity in clinical care. Drawing from history, psychoanalysis, and lived experience, he emphasizes the role of empathy, cultural understanding, and community in suicide prevention, particularly among immigrant youth and families.

Read more about this episode.

Transcript

Dr. Rama Rao (00:02) We need to survivors as our allies. And also we need to accept that somewhere our own powerlessness. We are just doctors, not gods. We are providers of treatment. We can't save everybody. So we need to accept our humanness.

Fatima Reynolds (00:24) Hello and welcome to the APA More Equity series, Breaking the Silence, Addressing Youth Suicide. In this episode, Dr. Raman Marwaha, a child and adolescent psychiatrist, is joined by Dr. Rama Rao Gogineni. Dr. Marwaha completed his medical degree in Delhi, India, followed by psychiatry training at Case Western and a fellowship at the Children's Hospital of Philadelphia.

He now serves as a training director and vice chair of education at Metro Health and is an associate professor. Dr. Marwaha also leads nationally as president of the American Psychiatric Association's Caucus of International Medical Graduate Psychiatrists and serves on several APA and AADPRT committees. His work focuses on community psychiatry, workforce development, and cultural mental health care.

So now let's break the silence with Dr. Marwaha and Dr. Koginani.

Dr. Raman Marwaha (01:24) It is my pleasure to introduce ⁓ Dr. Rama Rao Goganani, ⁓ who's a professor of psychiatry at Cooper Medical School of Robin University. ⁓ He's trained in psychiatry, child and adolescent psychiatry, family therapy, and psychoanalysis. He's an active contributing member of APA, ACAP, American Association for Social Psychiatry.

and World Association for Social Psychiatry. He's had a presence both at national, regional, and international levels as well. He's a contributing member of GAP since 2007 and was chair of the Global and the IMG Committee, member of the Culture Committee, and is currently chair of the Family Committee and also president of the Association of Family Psychiatrists. To his credit, he has more than 50 publications.

200 plus presentations and editor or co-editor of multiple books, including the WASP textbook on social psychiatry, besides family extending the orbit of psychic development, fatherhood scenarios development, culture, psychopathology and treatment, Eastern religion, spirituality and psychiatry, and the glow of synthesis, 12 beacons of light in social psychiatry. So Dr. Kovunani, to begin with,

Can you share what drew you to focus your career on child psychiatry ⁓ and suicide prevention, particularly among youth?

Dr. Rama Rao (03:03) Sure. kind of, my focus on many issues was influenced by what I was doing, what I'm doing, what's happening around me. I was trained at the University of Pennsylvania in adult psychiatry. I started working there as a faculty in 1979 ⁓ as the assistant director of the consultation liaison and emergency psychiatry.

I had this neurotic realization I have to learn about growing up in America to treat adults. So I was talking to Jean Hiltz, ⁓ who is doing a fellowship at CHOP. She advised me, why don't you go and talk to Jim Goldstein at Eastern Pennsylvania Psychiatric Institute and do a rotation in child psychiatry and you will learn.

about growing up in America. So I went and talked to Dr. Goldstein. He made me an offer I couldn't refuse. That is, Rao, you're so good. You can come and spend a little bit of time, six months, or half time. I'll give you half time credit. Or if you want, you can finish half time four years. Or you can come on full time after July and finish your child fellowship. So that's how I started my child fellowship.

And then of course I fell in love with child psychiatry. Then I decided to learn about family psychiatry because of my association with a Jewish South African immigrant physician named Dr. Judith Landau. So because of her influence, I learned to learn about families and psychiatry. I did end up doing fellow God Masters in Family Therapy.

I have an MFT degree. Then I became neurotic and neurotic patients developed what I call borderline ambivalent transference towards me. I could get rid of them, I could treat them. to master treating them, I finished my psychonaut training. So you got it? My growth is purely neurotic.

Dr. Raman Marwaha (05:25) Yep, Again.

And thank you for sharing that. ⁓ you have ⁓ an MFT as well. ⁓ And thank you for sharing about how you came to the US and started your training and your influences. And as someone who's trained in India and transitioned into the US medical academic system, how has your cultural background influenced your perspective on

mental health, especially within immigrant communities.

Dr. Rama Rao (06:04) I don't know. One is, I guess maybe, I never thought about cultural background, but I can tell you, being a multi-diverse coming from India, which is not even though one country, but we have different cultures, different skin colors, different backgrounds. India has an interesting history, 3,000 years of what's happening in America, as somebody said.

India was a mixed solid, a tossed solid, and America is a transforming mixed solid. In some way, what America is today, India was, maybe a thousand years ago, maybe 800 years ago. Maybe even 1947, until 1947. If you look at Indian history, natives, Dravidians, Aryans, Persians,

⁓ Afghans, Mongols, Turks, all Europeans. India is a mixed up race. So I think most of us are somehow used to accepting, not only accepting, taking pride in diversity. And my father is ⁓ a role model. He has wonderful acceptance capacity.

And actually I have to tell you interesting, my father's nickname is Boy Jesus, even though he's a Hindu, because he was very kind to Christian poor.

Dr. Raman Marwaha (07:44) So now we know where you get your genetics from and you're talking about your role model with your father as well. And ⁓ I know we're here today to talk about the rising suicide. It's the second leading cause of death for youth in ages between 10 and 24.

And in your kind of opinion, your experience, what factors you think have kind of contributed to this over the past few decades, particularly among ⁓ immigrant youth?

Dr. Rama Rao (08:25) you don't mind, I'm going to tell a little bit about the history of ⁓ adolescent suicide in psychiatry and social sciences. The first person that highlighted suicide is Emile Durkheim. He's sociologist, a physician, mostly spent time in France, but he was born in Eastern Europe first. He has written monographs about suicide.

According to his theory, there are four different kinds of suicide. I'm not going to bore you with that today. I think people should read a little about about Emil Darkheim for people who are interested in suicide. Definitely. It's my eye-opening experience for me when I first read his stuff. So the next is the second ⁓ interesting 19th century, early 19th century, Goyath classic, The Sorrow of Young Werther.

It's a novel that was a famous book on suicide that became very popular during his days. The third is interesting. I read this monograph. In 1910, ⁓ Vienna, there was a conference about adolescent suicide. Guess who attended and gave lectures? Sigmund Freud, Frederick,

Freud, Rank, Steckel, and Tusk, and August Aijhorn. He's the one who organized the meetings. ⁓ Freud's introduction to the series is the following sentence. He doesn't understand why the life drive, which is the strongest drive in humans and animals, takes a backseat in teenagers, and they subject themselves to suicide.

I still question that though. We don't have a good answer. There are all kinds of answers. Biology, but still what Freud said in 1910, the strongest life drive, why he takes a back seat in teenagers. That's a question. That's why it rose in 1910. By the way, people who are interested, there is a chapter in a Lewis book written by

cynthia faffer she's a nationally known suicide expert it's a totally eight-page temple

Dr. Raman Marwaha (11:02) I was just going to say, wow, all the history that you're sharing. Just to know about the depth of how this is being discussed and looked into with all these icons we know in second.

Dr. Rama Rao (11:18) It

of gives a little narrative, different kind of narrative, instead of just saying it is it.

Dr. Raman Marwaha (11:25) That's, and I know you mentioned that. So there was this question that Freud had that when an adolescence ⁓ she said comes. So what do you think?

Dr. Rama Rao (11:39) Well, what they discussed in the conference is causality is what we are talking about today. Availability of the guns, changing population, age gap, changing adolescents. Everything we're talking about, that's what they wrote in 1910 monograph. So they're still right.

Dr. Raman Marwaha (12:01) Well, ⁓ yeah, all the experience. I mean, apart from these factors in your experience, do you think there are other unique kind of cultural or systemic or socioeconomic pressures that put immigrant youth at a greater risk for suicide?

Dr. Rama Rao (12:03) We are right too.

Absolutely. ⁓ Just going back to what's interesting though, in America still white youth are the highest risk. And not blacks, not Latinos. But the rate of suicidality is increasing in African Americans more than white.

⁓ Second generation immigrant youth are highest risk now. Not the first generation. First generation actually suicide risk is much less. Second generation is much higher. Then homeless LGBTQ are the highest risk for suicide. Almost half of them die, kill themselves or die. Both homicide and suicide.

They're victims. A homeless LGBTQ tribe. And boys are more than girls. I think sociology is definitely a factor. And second generation is higher than first generation. ⁓ And also Asian and Pacific Islanders are highest risk even in immigrant population. And Latinos, first, second generation.

First, Latinos in suicide route continue to grow each generation.

Second generation higher than first, third generation is higher than second generation.

Dr. Raman Marwaha (13:54) So that's an interesting kind of ⁓ fact that you mentioned that, you know, with generations, second generation has a higher risk in immigrants, ⁓ even third higher. do you, I can you talk about like how maybe intergenerational or immigration-related trauma might play a role in kind of some vulnerabilities among immigrant families?

Dr. Rama Rao (14:19) Sure. The Purnima Mehta was a child psychiatrist from Ann Arbor. She has written, I think in 1970 or something, she hypothesized it is the second generation acculturation aspects that might have contributed to her suicide. And that still holds true. That is second generation, third generation.

Whenever they have a lot more conflicts with their cultural identity, racial identity, particularly if they felt a discrimination, stigma, or a grunt to school problems, other psychosocial determinants, if they contribute, the combination of those two. I think that's one reason why they have highest risk.

Dr. Raman Marwaha (15:17) Okay, that's interesting. So thank you for sharing that. ⁓ Do you also think, I mean, there's often a stigma around mental health. I mean, overall there's a stigma and then especially in immigrant households, there's more of a stigma. Does that also impact kind of detection, treatment of mental health issues?

Dr. Rama Rao (15:40) Well, I don't know, though, but stigma definitely prevents getting help. Whether there is more stigma about suicide in Indian Hindus, probably not. Christians also have high stigma. Some groups more than others. And still the Caucasian whites are the highest suicide risk. So we think it is a race I don't know, though. Maybe it is.

you

Dr. Raman Marwaha (16:11) Okay, yeah. And what about ⁓ like barriers, like language barriers or lack of insurance or ⁓ immigration status? ⁓ Does that also maybe play a role in kind of ⁓ immigrants getting access to mental health care?

Dr. Rama Rao (16:33) But again, the suicide rate is not high in the first generation though. So you would think it would be highest in the, if they are the factors. That's why combining with the acculturation conflicts, plus those, what you see, you need both. Bicultural identity.

Dr. Raman Marwaha (16:59) And also looks like acculturation and those conflicts ⁓ are playing kind of a role in the second generation or even the follow through generation, especially with kind of youth suicide as well. What do you wish more mental health professionals understood about kind of approaching care for immigrant youth and their families?

Dr. Rama Rao (17:26) I don't know there, I'll tell you what I do though. There is so much so-called evidence-based medicine sometimes instead of expanding our knowledge, put us in boxes. They're necessary though. I think we need to create our own box with what's already in the literature. If we have anxiety about talking about suicide, we need to acknowledge it.

And by the way, one of the things we don't talk about, even with suicidal patients, how do they feel about dying, not suicide? We really talk about death, death wish. When did they start talking about dying, not suicide? So I think it's an extension of wish to die, wish to...

Rejoin universe, God? We don't know. When you just pathologize it, the patrons feel judged.

It's almost like treating offenders. If you just talk to offenders as if it's a bad behavior, they're not going to talk to you. If you see it as a psychopathology-based, psychodynamic, cognitive aspects, culturally-based phenomena, they'll open up to you.

You see, I'm not saying that, but if you give them the message, you'll claim of it. And if you talk to traumatized women from Sub-Saharan Africa, they don't see themselves as trauma victims. They see themselves as survivors.

Dr. Raman Marwaha (19:14) ⁓ And I think that's a great point that you kind of ⁓ see, you bringing that psychodynamic perspective as well. And I love that thing you said, create your own box ⁓ and the importance of kind of acknowledging, ⁓ which is kind of like crucial. And do you think there's a role for kind of like community organizations or faith or culturally specific resources to kind of help with

kind of the connection for immigrant youth or their resilience, fostering their resilience.

Dr. Rama Rao (19:51) I'm going to come back to you a little bit one more minute. I want to tell Baiba what's in my box. My closest friend at the age of seven or six drowned, died.

that created a set of feelings about losing friends' death. I wondered afterwards, did he kill himself? I don't think so. But I took hurt him. I don't know where I got that in my head, did he kill himself? I know he didn't, he drowned. But the question is, on the second is, I have family suicide. said, a couple of, one suicide.

So how much these play a role in my treating, empathizing, or running away from it?

So our box is us also, our family, our culture.

If you come from a culture where suicide is a sin, can you take tackle? Or what are you going do about that in the box where it's suicide is a sin?

Dr. Raman Marwaha (21:05) Yeah, and that must have had a big impact on you, as you ⁓ mentioned, and how you created your own box as well.

Dr. Rama Rao (21:17) created but also accepted. It helps me. ⁓ God, things happen. My job is not to judge. Be helpful.

Dr. Raman Marwaha (21:29) Okay, I love that. ⁓ Job is not to judge, but to be helpful. Now, I know that again, just kind of going back to that, do you think there's like with community, with culturally specific resources, how can that help with our faith, with resilience or connection for our immigrant youth?

Dr. Rama Rao (21:54) I think this is where the NAMI, ⁓ American Association of Suicide Prevention, our organizations, APA, child psychiatry, there's so many ⁓ support groups out there. I think we need to use them. We need to use survivors as our allies. And also we need to accept that somewhere.

our own powerlessness. We are just doctors, not gods.

We are providers of treatment. If cancer patient doesn't get better, it's not our fault.

We can't save everybody, so we need to accept our humanness. We are doctors. That's all we are.

Dr. Raman Marwaha (22:47) And ⁓ talking ⁓ about survivors as our allies and experiences, without reaching any confidentiality, do you have a story or a case that illustrates or talks about challenges or maybe successes in working that you've had with at-risk immigrant youth?

Dr. Rama Rao (23:18) I'll say a famous quote by one of my teachers, Bob Sadoff. He was a forensic psychiatrist, one of the best in America. He said years ago, the following, this is quote, I'd rather meet somebody in the court than meet them in the graveyard. Don't worry about getting sued. Worry about saving lives.

I'm not saying we should not, we should be careful. But our goal is don't avoid, don't do anything, just avoid court. Our job is to save lives. If you think about it, I think you do the right thing. You don't go to court. Our mission is not to protect ourselves from getting sued. Our mission is save lives, protect.

enhance functionality of our patients.

By the way, if this is your mission, nobody's going to sue you.

Dr. Raman Marwaha (24:28) you

Yeah, which is, which is, think, again, again, so important ⁓ to self-reflect and kind of think about that, that, you know, this is the mission again. How do we kind of like help our patients ⁓ and kind of do what we're kind of, you know, best kind of trained to do ⁓ as well. And I know you've had so much experience. If you wanted to share kind of any case or any experience that you had,

⁓ feel feel like again, share.

Dr. Rama Rao (25:05) Well, I think I already said my friend, I thought that's an interesting, my closest friend. And ⁓

Actually, just came to my mind. One of my professors in medical school, he was on black pressure medicine, the serpilin. He suicided. And there's a side effect of the medication.

I still, I can't forget that. He's a wonderful man, but he's a side effect of medication. He kill himself. What else? The other thing, this is a slightly different. I treated a wonderful young lady in a hospital setting years ago. I had a very good relationship, but she didn't get better from depression or suicide.

We send her to a long-term facility.

But six months afterwards, she wrote me a letter, Doctor, you are the best doctor I ever had.

And then I appreciated, felt good. And then I found out a month later she successfully killed herself. I can't forget her. I could see her face. Beautiful, innocent.

⁓ But that's the only

Dr. Raman Marwaha (26:41) Mm-hmm.

Dr. Rama Rao (26:42) patient that I experienced in my life, in my time.

Dr. Raman Marwaha (26:48) So thank you for sharing these cases. And I'm sure they were kind of, they've all kind of, know, cases that have kind of happened, like you've already formed your box and you keep on kind of ⁓ evolving your box as well. ⁓ So ⁓ I know that, ⁓ you know, you've mentored, ⁓

international medical graduates, so many of us and so many young psychiatrists for over, again, decades. ⁓ I mean, I am amongst one of them. ⁓ What guidance do you offer them when it comes to kind of working with diverse, at-risk youth population?

Dr. Rama Rao (27:34) Well, first thing is we need to evaluate ourselves. But we're all prejudiced, judgmental. That's part of human behavior, loving yourself, loving what you got, skin color, your looks. We have to self-evaluate. Second is ⁓ just evaluate what your thoughts are, feelings are about suicide, death.

The other world we go to after that are now no no other world. And think about that death talks about death, not just suicide. And the family is the survivors of suicide. Yeah, the American Association of their wonderful both NAMI and if we can get involved, help them. That would be wonderful. Can you hear me?

Dr. Raman Marwaha (28:27) Yes.

Dr. Rama Rao (28:31) And ⁓ if it happens, meet the family, console them, help them if they're But again, luckily, I never had suicide in my practice, thank God. But it happens to all of us. We are not gods.

Dr. Raman Marwaha (28:55) Yeah. And thank you for sharing that. Now, you know, looking back at your journey, I mean, from India to Cooper, national leadership, what have been some of like the most meaningful kind of moments or lessons in your career so far?

Dr. Rama Rao (29:19) ⁓ Well, I think there's so many. The first thing is I ⁓

I felt so loved, accepted by my training director and my colleagues. Two examples come to the, Jeff Greenbaum was my colleague in a past year residency. I was sleeping on the floor and then he came to my floor of my room, my bed, and they said, why are you sleeping there without no bed? So he drove me.

to a used furniture store, bought a bed, brought it to my house. I didn't bother sleeping on the floor, that I'm used to it. And then he invited me to the Passover meal at his home in Long Island, Hewlett, Long Island. I still have memories of enjoying that Jewish meal, not a great taste though.

family and just I still have so much great feelings that that continued. Alberto Rich was my ⁓ chief resident. was a Mexican Jewish guy. took care of me. Somehow like you guys, all of you take care of me as an old man.

Dr. Raman Marwaha (30:51) and how you take care of all of us. So I think that that power of acceptance is ⁓ and kind of helping is so, ⁓ again, I mean, those things are so powerful. And, you when we're talking about kind of just the, again, the kind of gravity of kind of youth suicide crisis, like what gives you hope?

Dr. Rama Rao (31:15) Well, I'm going to give a philosophical answer though. What gives me hope is pretty simple, but not just about suicide, about anything. That is, what Darwin said, propagation of species and survival of the species are the driving force of all animals in our life.

Fatima Reynolds (31:34) Doctor, sorry, could you repeat that? There's like a phone ringing.

Dr. Raman Marwaha (31:41) I know there's something, some alarm going off in my hospital. I have that. But I am on headphones.

Dr. Rama Rao (31:53) I don't know what that is.

Fatima Reynolds (31:56) Yeah, maybe give it a minute just because it's gonna come.

Dr. Raman Marwaha (31:59) ⁓ I'll mute out if it's coming from me.

Fatima Reynolds (32:05) That's it stopped. Okay, sorry. So you were saying what gives you hope if you could just repeat your answer.

Dr. Rama Rao (32:11) The scientific answer though, is a propagation of species, what Darwin said and what Freud repeated in his drive theory, that is propagation of species and survival of species are the characteristics of life, not just humans. Since the evolution of life on the earth, some millennia years ago, that's what's happening.

So it's going to continue to happen. Same thing about what Freud said, the same thing. The aggression drive is survival of species and sex drive is propagation of species. People mistake those two things as if he's talking about sex, he's not. He's really talking about propagation of species. That's what gives me hope. The second is what last year, our lecture, IMG lecture,

Gratitude. We are all born with gratitude, not because we are any better. It is a trait we all need to transmit goodness, life, good to our future generations. It's biological, we're all biologically programmed to pass on goodness, life, greatness to our future generations. Yeah, some...

There are change his cons. There is a bad people come and go. But overall, for the last 40,000 years, since Cro-Magnum came into the universe, we continue to grow and grow and grow, becoming better, less aggressive. We're not killing each other as we used to. That's what gives me hope. There's a scientific answer, though. You always can find something wrong.

That's my dot really an answer to your question.

Dr. Raman Marwaha (34:13) You know, thank you for kind of talking about that. you know, lastly, for our listeners, whether they're clinicians, community workers, or ⁓ parents, what's one thing you want them to walk away with from today's conversation?

Dr. Rama Rao (34:33) ⁓ You know, I'll repeat what I said though. I feel fortunate. Life is good to me. Life is good to most of us. Yeah, there are some similar, some back, some psychosocial determinants, some pathology.

Positive psychiatry, positive psychology, positive behaviors have been the source of our goodness, of our past and our future. ⁓ I don't know. That's my view and that's what I see. ⁓ That's what helped me. Whether it's my friends that helped me to come to America.

my family that gave me life and wonderfulness, and my training programs that gave me good education and love and affection and opportunities to grow. That's what I see mostly.

Dr. Raman Marwaha (35:41) Thank you, Dr. Goganani. I a lot of gratitude to you to having this conversation today. I appreciate all your time.

Dr. Rama Rao (35:51) Thank you.

Fatima Reynolds (35:54) Thank you for joining us on Breaking the Silence, Addressing Youth Suicide. Please visit the Medical Minds podcast homepage at psychiatry.org for more information and a resource document related to this episode. We also invite you to visit psychiatry.org slash more equity, M-O-O-R-E-E-Q-U-I-T-Y for more information on the APA More Equity in Mental Health Initiative. Take care.

Dr. Raman Marwaha (36:23) The views and opinions expressed in this podcast are those of the individual speakers only and do not necessarily represent the views of the American Psychiatric Association. The content of this podcast is provided for general information purposes only and does not offer medical or any other type of professional advice. If you are having a medical emergency, please contact your local emergency response number.