Care for Chronic Conditions Must Include Behavioral Health Comorbidities

digital behavioral health

Managing chronic conditions requires a personalized care plan and good patient adherence to those plans. Outside of that, however, providers caring for those with chronic illnesses would be remiss if they didn’t also include screening and treatment for comorbid behavioral health conditions as a standard of care.

Why consider behavioral health in chronic care management?

According to a 2020 analysis by the Centers for Disease Control and Prevention (CDC), more than half (51.8 percent) of U.S. adults have at least one of the nation’s top 10 chronic conditions:

  • Arthritis
  • Cancer
  • Chronic obstructive pulmonary disease
  • Coronary heart disease
  • Asthma
  • Diabetes
  • Hepatitis
  • Hypertension
  • Stroke
  • Kidney disease

More than a quarter of adults (27.2 percent) have multiple chronic conditions. It’s not surprising that the overall cost of these diseases is quite high. In fact, 90 percent of the nation’s $3.8 trillion in annual healthcare expenditures are for people with chronic and mental health conditions, the CDC has found. In addition, chronic illnesses such as cancer, heart disease, or diabetes can also make an individual more likely to have or develop a mental health condition, which can lead to even greater medical costs.

A recent Milliman research report noted that medical costs for treating patients with chronic medical and comorbid behavioral health disorders are two to three times higher compared to the costs for those who do not have such comorbidities. Report authors projected that the additional costs amounted to approximately $406 billion. Patients with behavioral health conditions in addition to physical ones drove nearly 57 percent of all healthcare spending, however, very little of that money went toward treating behavioral conditions, according to the report.

Even outside of these rising healthcare costs, chronic conditions affect a patient’s quality of life. For example, people with Type 1 diabetes are up to three times more likely to have depression than those without the condition, and those with Type 2 diabetes are about twice as likely. Still, less than half of people with diabetes who have depression are diagnosed and treated for this mental health condition.

Importantly, however, integrating behavioral and medical care services can be an effective opportunity to decrease the total cost of care and improve outcomes at the same time.

ESRD and comorbid behavioral health conditions

When we examined data for a population of patients with end-stage renal disease (ESRD) for a health system client, we found about 10 percent demonstrated behavioral health concerns at intake, led by depression (75 percent), anxiety (44 percent), and suicide risk (25 percent). This is important in the context of outcomes and costs because research indicates that hospitalizations and missed dialysis treatments increase when behavioral health disorder symptoms are present.

The good news is that screening and intervention can have a demonstrable positive effect. Tridiuum data showed that this health system realized a 24 percent decrease in the ESRD patients’ PHQ9 scores after four months with 43 percent of those patients showing statistically significant improvement during that time. By connecting patients to behavioral health services, the system most likely reduced the risk for hospitalizations and missed dialysis appointments, as noted in the literature.

What chronic care providers can do

One of the best ways to ensure patients managing chronic conditions are receiving the care they need is by screening them regularly for mental and behavioral health conditions including depression, anxiety, and substance use disorders.

Based on a patient’s answers to self-assessment questions, primary and specialty care providers can then use a stepped care approach to refer patients to the appropriate level of behavioral health treatment. This approach can improve access and help patients realize better health overall.

For example, Tridiuum’s Behavioral Health Index (BHI) distills patients’ responses from ongoing assessments to surface the real-time nature and severity of behavioral health issues. The composite BHI score reflects the current state of behavioral health and provides quantified data on the patient’s progress.

Tracking the BHI score on a regular basis allows providers to monitor a patient’s treatment response over time and step up or down care as appropriate. The measurement-based process can ensure that the most effective, appropriate level of treatment is delivered to the patient. This can ultimately reduce the cost of chronic care for those with comorbidities.

Stepped Care Model Graphic


A patient scoring in the “Moderate” range, with a BHI of 51 and a PHQ of 10 may need a referral for outpatient psychotherapy, a health coaching/wellness program and monthly monitoring to help improve their health and quality of life. Whereas someone who scores in the “Severe” range, with a BHI of 91 and a PHQ of 20, for example, likely needs psychiatric care or an inpatient addiction treatment program with more intensive case management.

The Tridiuum BHI provides an efficient way for providers to screen and triage patients initially. Then, it provides the longitudinal data care teams need to track patient progress effectively.

Behavioral health must be recognized as an essential part of a patient’s whole-health continuum that contributes to quality of life. Screening patients with chronic disease for mental health and substance use disorders should be a standard tool in a provider’s toolbox when it comes to effectively managing one or more chronic conditions.