Care Redesign
Talk
What If We Treated Mental Health Like Cancer? (09:15)

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.

Of all people living with mental health disorders 12% see psychiatrist

  Click To Enlarge.

“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.

More From Care Redesign
Cleveland Clinic Time-to-Treatment Cancer Programming Overall Scorecard 2015-2017 Sample

Reducing Time-to-Treatment for Newly Diagnosed Cancer Patients

How Cleveland Clinic initiated a multidisciplinary program to reduce time-to-treatment and accomplish a 33% reduction.

Treatment Authorization Increases and Rapid Boost in New Mexico Medicaid Members Treated for Chronic HCV

A Collaborative Model to Expand Medicaid Treatment Coverage for Chronic Hepatitis C Virus

How managing the benefit coverage expansion for the treatment of HCV in New Mexico was successfully achieved after less than 2 years.

Data Analytics Improves Clinical Care

Care Redesign Survey: How Data and Analytics Improve Clinical Care

Data and analytics are a key means for clinicians, clinical leaders, and executives to transform health care delivery. Yet health care organizations have work to do in getting measures right and much to learn about effective use of data, according to our most recent Insights Council survey.

Nobody Wants a Waiting Room sketch

Nobody Wants a Waiting Room

A study in system change.

Orszag02_pullquote - In Defense of the Hospital Readmissions Reduction Program HRRP

In Defense of the Federal Hospital Readmissions Reduction Program

In the current debate about HRRP, the evidence tilts toward no effect or a beneficial one on mortality, says the former Director of the U.S. Office of Management and Budget.

odel for Complex Gynecologic Care Team at the Women's Health Institute

An Innovative Approach to Treating Complex Gynecologic Conditions

How the Women’s Health Institute at The University of Texas at Austin designed their clinic to provide comprehensive, team-based, and patient-centered care for women.

Massachusetts Community Health Centers Collaborative Teledermatology Process

A Teledermatology Initiative to Increase Access for Community Health Center Patients

A group of seven community health centers in Massachusetts collaborated to implement a teledermatology program that improved access to specialty care for patients with skin conditions and reduced overall dermatology spending.

Chang05_pullquote interpersonal medicine

Beyond Evidence-Based Medicine

Interpersonal medicine is not just about being nice — it’s about being effective.

Summary of Comprehensive Approach to Physician Behavior and Practice Change

Engaging Stakeholders to Produce Sustainable Change in Surgical Practice

How an initiative designed to improve patient outcomes and satisfaction while containing costs led to sustainable change in surgical practice and physician behavior.

Myths and Realities of Opioid Use Disorder Treatment.

Primary Care and the Opioid-Overdose Crisis — Buprenorphine Myths and Realities

There is a realistic, scalable solution for reaching the millions of Americans with opioid use disorder: mobilizing the primary care physician (PCP) workforce to offer office-based addiction treatment with buprenorphine, as other countries have done.

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

Topics

Coordinated Care

131 Articles

Reducing Time-to-Treatment for Newly Diagnosed Cancer…

How Cleveland Clinic initiated a multidisciplinary program to reduce time-to-treatment and accomplish a 33% reduction.

Care Integration

67 Articles

Integrated Care Lessons from Across the…

Just throwing things together doesn’t make for integrated care. If we spent more time looking…

Design Thinking

15 Articles

Nobody Wants a Waiting Room

A study in system change.

Insights Council

Have a voice. Join other health care leaders effecting change, shaping tomorrow.

Apply Now