“From a substance abuse perspective, it’s a community disease. People don’t call into work or not follow through on family duties or the community aspects of their life because their hypertension is out of control. But for addiction, all of those things are at the wayside,” says Corey Waller, Senior Medical Director for Education and Policy at Camden Coalition of Healthcare Providers’ National Center for Complex Health and Social Needs.
Addiction is a community disease, and yet in often in addiction medicine, it isn’t treated that way, says Waller. People with substance use disorders are placed in recovery facilities for maybe a month, and then when they say they are better, are returned to their communities — where their next-door neighbor or significant other might be a drug dealer.
“You have to be able to get someone well in their community for it to stick,” explains Waller. Recovery failure rates are so high because of a lack of community-based solutions. “Quite honestly, without the community-based approaches, the ecosystems that envelop these patients, it’s not going to ever get better.”
Jürgen Unützer, Chair of Psychiatry and Behavioral Sciences at the University of Washington, adds that health care providers can achieve a lot when partnering with communities on mental health.
Most mental disorders surface between the ages of 14 and 24, explains Unützer, when someone is most likely in school — that’s their primary community, apart from where they live. “On a good day, kids are spending a good part of their day in school; on a bad day, they might be in juvenile justice. But those are both places where we don’t think of providing mental health services,” says Unützer. His team has worked to ensure that every middle and high school in their community has a mental health program.
As for adults, many are employed and so a big part of their community is their employer. Yet employers don’t want psychiatrists like Unützer to treat depression or panic disorder. They want him to treat absenteeism — when someone is having a bad day and doesn’t go to work because they are struggling with a mental health problem — or, “even worse,” presenteeism, when someone is having a bad day but is at work, and colleagues wish they weren’t.
“That’s not a diagnosis I learned about in medical school,” says Unützer, “so I have to really think about what does that mean and what is it that I can do as a health care provider to really help that person do better at their job.”
“But those are communities,” he says, “and if we partner with those kinds of settings, we probably can do a lot of good.”
From the NEJM Catalyst event Expanding the Bounds of Care Delivery: Integrating Mental, Social, and Physical Health, held at Vanderbilt University Medical Center, January 25, 2018.