“Patients with depression, anxiety and more also often have chronic physical illnesses, and failing to integrate psychological treatment is costly,” writes Dr. Ezekiel J. Emanuel, a vice provost of the University of Pennsylvania and the chairman of its Department of Medical Ethics and Health Policy, in the Wall Street Journal. His new book is “Prescription for the Future,” just published by PublicAffairs. He has spoken at Advocate Health Care and is a venture partner at a firm that invests in Quartet.
American society has historically segregated mental-health conditions from other health concerns. Doctors and laypeople alike often dismissed such problems as existing “just in people’s heads,” as if they lacked any real biological or genetic basis.
For decades, patients with serious mental-health conditions were shunted to isolated psychiatric hospitals, far from ordinary medical care. Americans with less severe mental-health conditions found that their insurance companies “carved out” mental-health benefits from basic coverage, and the benefits were skimpy compared with coverage for physical ailments.
As for clinical practice, mental-health professionals were kept separate from physicians treating patients for other medical conditions and rarely interacted with them. The rationale for this division was to avoid the stigma of mental disorders, but it only served to reinforce the stigma. At the cancer center where I trained, we had scores of oncologists and thousands of cancer patients—but just one psychiatrist.
Thankfully, this long era of separation and indifference seems to be coming to an end. In the decades ahead, there is every reason to expect that treatment for mental health will finally become integrated into mainstream medicine.
A key reason for the shift is the mounting evidence that depression, anxiety and substance abuse—as well as more severe conditions like schizophrenia and bipolar disorder—often occur alongside other chronic illnesses. A 2011 Robert Wood Johnson Foundation study suggests that some 30% of medical outpatients and patients admitted to general hospitals suffer from a range of mental illnesses, often undiagnosed and untreated.
The failure to address these problems in a more comprehensive way is costly. According to researchers at the University of Washington, mental-health conditions account for some $200 billion a year of U.S. health-care spending. But they also add to other medical expenses. When depression, anxiety and other conditions afflict patients with chronic illnesses, the costs shoot up. Consider patients with congestive heart failure. Their average monthly health care amounts to $1,846, according to a 2008 Milliman research report, but when these patients also suffer from depression, the average cost shoots up to $2,567 a month. Even for relatively simple chronic conditions such as hypertension, depression increases costs from $550 a month to $960.
These extra costs largely arise not from mental-health care but from extra dollars spent for medical services. Picture an anxious cancer patient, fearing some new twinge or bump, rushing to an emergency room or demanding a CT scan.
Some innovators are already working to integrate mental health into general care. For years, the 16-physician group Central Medical Clinic in Honolulu routinely screened its patients for depression, anxiety and similar conditions—but, like many small practices, it couldn’t provide proper mental-health treatment. A few years ago, the clinic invited psychologists in a separate practice to share their office space. Doctors can literally walk patients over to psychologists and get them same-day care if needed.
In Illinois, Advocate Health Care also uses “co-location” this way, employing 13 mental-health providers in eight of its busiest primary care practices in the Chicago area. Advocate now systematically screens all patients 65 and older who are in the emergency room or admitted to hospital for depression and anxiety. Those who screen positive are seen by behavioral-health specialists within 24 hours.
Such consultations are increasingly done via telemedicine, since psychiatrists can be in short supply. At Kaiser Permanente’s mid-Atlantic facilities, a psychotherapist is available 24/7 by video for patient consultations. This is especially useful for those needing urgent care for depression or suicidal thoughts.
Other pioneers are using technology to link physicians, patients and mental-health specialists in what they call “virtual collaborative care.” One young company, Manhattan-based Quartet Health, uses predictive modeling to review claims and other data to identify patients who might have undiagnosed or poorly managed mental-health issues, such as those who make frequent emergency room visits for chest pain without being admitted for heart attacks. Quartet then performs a comprehensive online mental-health assessment and offers tailored solutions, including virtual or in-person therapy.
This shift in care remains a work in progress, but physicians and companies are remaking what was long an isolated, ignored area of medicine. Integrating mental health into routine care will make our health-care system more humane and affordable—and make all of us healthier.