Every 14 minutes, someone dies from suicide in the United States; every 8 minutes, some dies from a drug overdose. A quarter of all health-related disability is due to mental health and substance use conditions, according to the World Health Organization — 8 times more than disability caused by heart disease and 40 times more than cancer.
“As a psychiatrist, I’m here to tell you that mental health problems are not a rare thing,” says Jürgen Unützer, Professor and Chair of the Department of Psychiatry and Behavioral Sciences at the University of Washington. “I have not met a family that hasn’t been touched by a mental health or substance abuse problem at some point in their lives.”
In the next 12 months, only 1 out of 10 people in the U.S. living with a diagnosable mental health or substance abuse problem will seek out a psychiatrist, while 2 out of 10 will see any kind of mental health specialist, and 4 out of 10 will see a primary care provider. But most will receive no formal treatment whatsoever.
“How would we feel about this if this was cancer?” asks Unützer. “What if we said, of all the people living with cancer in the United States, in the next 12 months, 1 out of 10 will get to see a doctor who is trained to see patients with cancer? We would probably find that totally unacceptable. But that’s where we are in mental health.” And not only is lack of care within a year an issue, but it takes 10 years for many people living with a mental health or substance abuse condition to receive a proper diagnosis and treatment.
Continuing the cancer comparison, Unützer notes that the U.S. spends a lot of money on making sure people are comfortable talking about cancer, thinking about prevention, and screening for it. Cancer screening often happens during primary care visits, and if it’s caught at stage 1, it can more easily be cured. “That is exactly where we need to be in mental health care, but we’re not anywhere near that,” says Unützer.
How can we make this better? Unützer proposes doing exactly what we’ve accomplished with cancer: instead of siloing it outside of medicine, we should make behavioral and mental health, and addiction medicine, an integral part of all of health care. The way to achieve this is through collaborative care.
Primary care teams in the University of Washington collaborative care model, for example, consist of patient, PCP, behavioral/mental health care manager, and psychiatric consultant. The mental health care manager could be a nurse, social worker, or psychologist who works alongside the PCP to treat common mental health conditions and common addiction problems. Each time a patient comes in or is on the phone, they use a brief, validated rating scale to check for mental health or substance abuse conditions and to determine how bad that condition might be. “Just like with blood pressure and with diabetes, we need to have a target, we need to know what are we treating,” says Unützer.
The mental health care manager is trained in a variety of brief, evidence-based interventions or counseling strategies for use in the PCP’s office to help patients, and patients are tracked in a population-based registry tool to make sure they don’t fall through the cracks. The team psychiatrist’s role is to advise on what to do for patients who aren’t showing signs of improvement, and to occasionally see a patient in person or via telemedicine.
The collaborative care model is now part of every UW Medicine primary care clinic and has expanded to more than 100 primary care clinics throughout Washington state. It’s a standard part of prenatal care, for example, having treated some 3,000 pregnant women struggling with a mental health or substance abuse condition over the last 5 to 10 years. “When you do that, when you provide that kind of care to a young mother, not only are you helping that mother, but you’re helping a young family,” Unützer says. “This is as close as we’re ever going to get to immunizing an unborn child or a young child against having mental health and substance abuse problems in the future.”
“More than 80 studies show us that if you do this right, you more than double the likelihood that somebody with a mental health or addiction problem will get well,” explains Unützer. “There’s also good research that shows that patients like this kind of care, doctors like this kind of care, and this is good business.” For every $1 spent on collaborative care, health organizations gain back $7 in cost savings over the next 4 years. “That’s the Triple Aim of health care reform right there,” says Unützer. “That’s better access, better quality, better outcomes for fewer health care dollars. That’s dynamite.”
The data existed 10 years ago, but we didn’t have a way to pay for integration of mental health services into primary care then. Today, we do, thanks in part to CPT billing codes, which Medicare honors nationally, Medicaid honors in many states, and commercial payers are starting to cover. Thousands of primary care practices can now bill standard insurers for the kind of collaborative care Unützer describes. “That gives us the opportunity to reach thousands and thousands of patients in their primary care offices with brief, evidence-based effective treatments for common behavioral health or substance abuse conditions,” says Unützer. Unützer’s team is also involved in training 3,000 psychiatrists across the U.S. in this kind of teamwork.
“Mental health problems are common. They can be treated. But most of us are not getting good care,” says Unützer. “When we put our heads together, our systems together, when we make mental health care part of all health care, we can have a tremendous impact on our patients’ lives, and we’ll probably end up with healthier communities.”
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.