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The Podium

The case for integrated mental health care

“Julia’’ is a 38-year-old patient of the Family Medicine clinic at Boston Medical Center. Originally from Puerto Rico, she married young and was in an abusive spousal relationship for years. Both of her children were born without an important but not essential part of their brain. Now ages 4 and 6, they have spent their lives going from one specialist to the next. Having finally left her abusive marriage, Julia takes care of them without the support of family or friends. Julia is morbidly obese and suffers from diabetes, high blood pressure, high cholesterol, and chronic pain. She also suffers from debilitating depression, anxiety, and panic attacks. Despite our intensive outreach, she rarely makes her scheduled appointments and when she does, her depression and anxiety are overwhelming and it is hard to address her health issues and needed lifestyle modifications. She has been referred multiple times to psychiatry and counseling, been admitted for her depression, and cycled though multiple medications and behavioral health providers. But she, like her children, is trapped in a fragmented system where her care is being held up by many hands. Hands that do not touch. And though we have tried everything, our system is failing her.

This month marks the 50th anniversary of President Kennedy’s signing of the Community Mental Health Act — a bill that aimed to bring greater awareness and acceptance for mental health disorders. Though perhaps the scope and depth of mental disorders is better understood today, our medical system’s approach to caring for those who suffer remains fractured. With the political rancor over the Affordable Care Act and the recent government shut down, many have lost sight of the fact that the ACA offers a real solution to the mental health care crisis: the integration of mental health and primary care.

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The National Institutes for Mental Health estimates that every year, about one in four adults suffer from a diagnosable mental disorder. When applied to a recent population census, this calculates out to roughly 60 million adults who are affected with a known mental disorder — and does not account for the scores of individuals who are not diagnosed. Given these numbers, it is no surprise that mental disorders are the leading cause of disability in the United States. In fact, as cited in several recent studies, as many as 70 percent of today’s primary care visits stem from psychosocial issues. Though patients typically present with physical complaints such as fatigue and pain, there is data to suggest that there are often underlying mental health conditions . In fact, studies show that as the number of physical symptoms of a patient goes up, the number of psychological symptoms also increases and vice versa. And for those living with chronic medical illnesses, the worst medical outcomes (e.g. high disability, and early death) occur in those who also struggle with a mental health disorder such as depression or anxiety. A recent report documented that individuals who suffer from the most serious mental illnesses will die twenty-five years earlier than the average American.

Knowing this, it would make sense to approach patients as a whole entity: able to take care of all of their needs, physical and psychological in one place. Unfortunately our system is fractured and set up so mental health specialists and health care providers work in silos: sharing neither physical space nor charts to communicate about the diagnosis and progress of their patients. For instance, as primary care physicians, we are often not able to read notes about our patient’s treatment plan with their mental health specialist and often patients are unable to communicate or remember what happened. In turn, few health care providers properly screen patients for mental illness — in part from a lack of training or in some cases, from a sheer lack of time.

This gap in care not only creates frustration for providers involved in patient care but can result in poor medical outcomes. Multiple studies have shown that treating a chronic condition such as heart disease, pain, or diabetes without treating concurrent mental health conditions is generally ineffective. This kind of fractured care can ultimately lead to much higher health care costs. For instance, depressed primary care patients use almost twice the healthcare costs as non-depressed patients.

My colleagues and I have made real progress in treating the whole patient by using team based approaches and information technology, however true mental health integration and whole care can not happen without a shift in policy and funding. When enacted, the ACA will provide this desperately needed support and have an immediate impact on addressing how we integrate primary care and mental health services. This will lead to improved patient outcomes and lower medical care costs, something everyone should support.

Dr. Katherine Gergen Barnett is a family medicine physician at Boston Medical Center.
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