By Cori McMahon, Psy.D, NCCE, Vice President for Clinical Services
The connection between behavioral health and physical health is clear and has been well-established in the literature.
“Behavior is central to the development, prevention, treatment, and management of the preventable manifestations of diseases and health conditions (heart disease, cancer, stroke, chronic obstructive pulmonary diseases, unintentional injuries, pneumonia and influenza, diabetes, suicide, kidney diseases, chronic liver disease and cirrhosis, HIV/AIDS) on which the U.S. spends about $1.5 trillion, 75% of our annual healthcare costs.” (Behavior Matters)
When considering this connection, we think about the interplay and cumulative impact among things like behavioral risk factors, genetic predisposition, and environmental factors. Behavioral risk factors might include smoking or alcohol use, poor diet, or sedentary lifestyle. An individual might have a genetic predisposition for a medical condition like family history of diabetes or cancer. And environmental factors might include social determinants of health like food or housing insecurity, which lends to exposure to chronic stress.
Experiencing one or more of these factors can impact health in all other areas, resulting in comorbidities. In this case, we are considering the reciprocal relationship between behavioral health and medical conditions, and each has significant impact on the other.
Behavioral health’s inextricable connection
People with common physical health conditions (diabetes, cardiac, cancer, obesity, etc.) have higher rates of mental health issues, with unipolar depression being the second largest contributor to disease burden – more than heart disease, alcohol use, and traffic accidents. Let’s focus on a few prominent medical conditions in the U.S. and consider the reciprocal relationship between mental health factors and physiological functioning.
According to an article in the Journal of the American Medical Association, individuals living with type 1 or 2 diabetes are at increased risk for depression, anxiety, and eating disorder diagnoses. Prevalence rates of depression could be up to three times higher in those with type 1 diabetes and twice as high in people with type 2 diabetes compared to the general population globally. Those with diabetes are 20 percent more likely to have anxiety than those without it and anxiety appears in 40 percent of diabetes patients.
Unfortunately, less than half of those with diabetes who have depression ever get diagnosed and treated for it. The presence of depression and anxiety in diabetic patients results in:
- Worse prognosis for diabetes
- Poor glycemic control
- Decreased adherence to care plans
- More long-term complications
- Decreased quality of life
- Increased unemployment and work disability
- Increased mortality
According to the American Cancer Society, there will be approximately 1.9 million new cancer diagnoses in 2021 and patients experience a range of psychological distress marked by sadness, anxiety, anger, pain, concerns with body image, and identity disturbance (Sage) (Routledge) (Annals of Oncology) (Biological Psychiatry) (Cancer). The typical prevalence of significant psychological distress among those diagnosed with cancer ranges from 29-43 percent and up to one-fourth of patients meet criteria for depression, which is more than double that of the general population.
Experiencing anxiety upon a cancer diagnosis is not unusual and often begins as a temporary worry or fear after treatment or a medical exam. In severe cases, one’s ability to function on a day-to-day basis may be severely impacted. Some patients experience “scanxiety” which can occur days or weeks before follow-up scans (x-ray, CT, MRI).
Those with lung cancer have the highest levels of psychological distress, experience stigma, and suffer from overall general health problems and lung cancer stigma has been shown to be a significant predictor of increased depression and decreased quality of life. Overall, across cancer diagnoses, a depression diagnosis and higher levels of depressive symptoms predict elevated mortality.
Depression is the most common psychological comorbidity related to kidney disease or renal failure. The prevalence rate of depression in the dialysis population ranges from 23-40 percent. Approximately 17 percent of the end-stage renal disease (ESRD) population had major depression and when these patients experience comorbid depression, there is an increase in:
- Ambulatory visits
- Emergency department visits
- Days of lost productivity
- Functional disability
Further, extreme anxiety and somatic symptoms of anxiety like shortness of breath, heart racing, chest pain, sweating, and fear of dying, may occur for ESRD patients. Although these symptoms can occur seemingly without triggers, there are many valid reasons for them. For patients facing this very serious medical issue, the process of dialysis and potential for medical complications pose very real reasons for worry. Unfortunately, repeated observation studies have demonstrated that dialysis patients have suicide rates at six times the general population and major depression is predictive of mortality.
The cost of untreated behavioral health
As indicated in the Milliman report, Economic Impact of Integrated Medical-Behavioral Healthcare, only 14 percent of people with insurance are receiving treatment for mental health or substance use disorders, but they account for more than 30 percent of total healthcare spending. The total spending for those with behavioral health issues is estimated to be $525 billion annually and total healthcare spending is estimated to be $1.7 trillion annually. Because of fragmented care, however, the total cost of care for those experiencing comorbidities is much higher.
Effective integration of medical and behavioral care could save $26-$48 billion in annual healthcare costs. According to a report in Behavioral Health Business, patients with behavioral health conditions in addition to physical ones drive nearly 57 percent of all healthcare spending. However, very little of that money goes toward actually treating behavioral conditions.
Besides the obvious detrimental impact on the individual themselves, there is a negative impact on the entire healthcare system when behavioral health concerns are not adequately screened for and addressed. Knowing the impact that behavioral health has on physical functioning and medical illness, regular screening will allow for early intervention, decreasing the impact that behavioral health has on overall wellness and ability to improve medically.
As an example, it is estimated that there will be 18 million cancer survivors living in the U.S. by 2022. The growing number of survivors poses a challenge to healthcare and behavioral health systems seeking to meet these patients’ long-term health needs. Simply put, when behavioral health is addressed early and often, overall cost of care is more effectively managed.
Multipronged approach to intervention
Primary care settings provide about half of all mental healthcare for common psychological disorders. Unfortunately, medical providers often lack the time or training to help patients manage behavioral health problems in evidence-based ways — other than offering medication treatment. Because overall health is impacted by various factors, behavioral, physiological, and environmental, it is essential that interventions to address health issues include a multipronged approach. There are behavioral interventions like stress management, behavioral sleep management, behavioral pain management, and psychological interventions addressing quality of life.
Many behavioral health interventions are as effective as medical ones, and oftentimes comorbidities are most effectively addressed with a combination of medical and behavioral intervention. While integrated care is increasingly popular, there is a qualitative difference between having access to a behavioral health provider who is located down the hall or is available via contracted referral and working collaboratively with a behavioral health provider who is co-located in the medical clinic and able to truly engage in cooperative patient care.
Historically, the medical model has focused solely on addressing issues once they have occurred (putting out fires once they are already ablaze, if you will). Unfortunately, those fires are much more costly to the patient and to the system once they’re well-established and burning.
In response to this challenge, medical practice is slowly making a shift toward a wellness model where routine screening is valued, maybe even rewarded, and is recognized as essential for making an impact on overall health outcomes and quality of life. Screening for behavioral health should be as routine as having blood pressure taken prior to a medical exam and the opportunity to intervene on any areas of concern will have an equal or greater impact.