By Cori McMahon, Psy.D, NCCE, Vice President for Clinical Services
Since the start of the COVID-19 pandemic, we’ve been experiencing a time where behavioral health utilization has not just increased, the number of people seeking behavioral healthcare has quadrupled. During the pandemic, approximately 4 in 10 adults in the U.S. have reported symptoms of depression or anxiety, as compared to 1 in 10 during the prior year. The negative impact of the past year on mental health also includes difficulty sleeping, changes in eating habits, increased substance use, and exacerbated chronic medical conditions.
In a Pulse Survey, the average percentage of adults who report symptoms of an anxiety or depressive disorder has increased from 11 percent in the first half of 2019 to 41 percent in January 2021. Unfortunately, during this period of increase in behavioral health concerns and care utilization, routine medical care has been deprioritized, with fewer individuals tending to their physical wellness, often worrying about going into a doctor’s office or hospital for fear of COVID-19 exposure.
Interestingly, the experience of the pandemic has offered a significant opportunity for whole-person care. With an increase in behavioral health challenges, it’s become clear that integrated care — where a patient is understood through a comprehensive lens and is able to access treatment for both mental and physical health in the same setting — is essential for effective whole-person care.
A reciprocal relationship
Behavior is central to the development, prevention, treatment, and management of the preventable manifestations of diseases and health conditions like heart disease, cancer, stroke, chronic obstructive pulmonary diseases, unintentional injuries, pneumonia and influenza, diabetes, kidney diseases, chronic liver disease and cirrhosis, and HIV/AIDS. The connection between behavioral health and physical health is clear.
Whether considering behavioral risk factors (like smoking, poor diet, or physical inactivity) or, conversely, the emotional impact of medical conditions (depression, anxiety, and acute stress for example), it has been well-established that there is a reciprocal relationship. That is, mental health impacts physical health and vice versa. People with common physical health conditions like diabetes, cardiac problems, or obesity, have higher rates of mental health issues, with unipolar depression being the second largest contributor to disease burden in countries like the U.S. – more than heart disease, alcohol use, and traffic accidents, according to the Agency for Healthcare Research and Quality.
In fact, depression is one of the most common experiences of chronic illness, with approximately one-third of those with a serious medical condition experiencing depressive symptoms. Any chronic condition can trigger depression, and the risk increases with the severity of the illness and the impact on the patient’s life. Looking at rates of depression that occur with various chronic conditions, it is clear that it is essential to treat the whole person as the psychological and physical impact are inextricably linked.
According to an article in Personalized Medicine in Psychiatry, depression is described as a systemic disease. It is understood in this way because of the neurobiological mechanisms that explain how it impacts other medical conditions and how it increases risk for and complicates already established medical conditions. For example, increased inflammation can be observed in cancer, heart disease, and depression, while childhood trauma predisposes an individual both to depression and increased inflammation. Depression is also a risk factor for osteoporosis and fractures in older adults.
For many chronic conditions, the risk of depressive symptoms can decrease over time from initial diagnosis. However, those with heart disease and those with arthritis maintain a high risk for depressive symptoms in the long-term.
Broadly, “integrated behavioral healthcare” can be described as any situation in which behavioral health and medical providers work collaboratively. Also termed “integrated health,” “co-coordinated care,” “seamless care,” “comprehensive care,” or “integrated primary care,” this approach comes in a variety of models, varying in levels of integration and dependent upon the resources of the health care practice or system.
When behavioral health practitioners, such as health psychologists, psychiatrists, counselors, clinical social workers, or health coaches are integrated into the medical setting — whether in-person or virtually — they are able to assess the global health of the patient and work collaboratively with the medical provider, truly providing patient-centered and comprehensive healthcare.
According to C.J. Peek and the National Integration Academy Council’s Lexicon for Behavioral Health and Primary Care, “Integrated primary care is the care that results from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health and substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization.”
Ultimately, an integrated approach to assessment and treatment results in improvements in overall health, patient satisfaction, and appropriateness of healthcare utilization, and therefore better management of healthcare cost. According to Milliman, patients with behavioral health conditions cost an estimated $752 billion in healthcare expenditures annually. It is estimated that 5-10 percent of these costs can be eliminated through effective integration of care.
Further, medical costs for treating patients who have chronic medical and comorbid mental/substance use conditions are two to three times higher on average compared to the cost of those patients without these comorbidities. The projected additional healthcare costs for those with behavioral comorbidities was $406 billion in 2017 across commercially insured, and Medicare and Medicaid beneficiaries. Based on research presented in the Milliman report, it is calculated that 9-17 percent of this total additional spending could be saved though effective integration of care – with an estimated $38-$68 billion saved annually.
Technology as the connective tissue
Technology needs to support integrated care. Historically, primary care, behavioral healthcare, and dental care have been technologically separate, existing in silos. By leveraging a single platform with the ability to document in a single patient chart, there is visibility for all providers on a patient’s care team. With this increased continuity of care, providers are able to treat the whole person from their respective areas of expertise while well-informed by the perspectives of the entire team.
Technology can be used to streamline behavioral health screening, to determine level of acuity, to connect a patient with the best suited provider, and to track progress throughout behavioral healthcare treatment. Improving upon efficiency and effectiveness of care with technology allows providers to focus on valuable face-to-face interaction while benefitting from the whole picture of that patient’s well-being.
Supporting providers in delivering whole person care not only during a pandemic but in a post-pandemic world, where the value of doing so has become abundantly clear, is the next step in the evolution of healthcare. Patients, providers, health systems, and payors will benefit from addressing all of the individual’s needs by giving the right care at the right time in the right setting.