In our Ask a Doc series, we sit down with physicians and other clinical experts, including those at Allegheny Health Network (AHN), for a chat on an important health topic. To explore issues related to mental health and wellness, we interviewed Dr. Brad Karlin, Highmark Health’s executive medical director, Behavioral Health.
More than half of Americans will be diagnosed with a mental illness in their lifetime. Of those needing care, only about 46% receive any treatment, and a much smaller percentage complete what is considered a minimally adequate treatment.
Add the impact of the pandemic, and you can see why Dr. Brad Karlin, Highmark Health’s executive medical director, Behavior Health, says we are in a time of “unprecedented need and opportunity” in behavioral health care.
Dr. Karlin brings both micro and macro perspectives to any discussion of mental health. Experiences being helped by and later helping his grandfather inspired his career in health care transformation and deep interest in interpersonal change, and he was one of the first clinical psychologists board-certified in geriatric psychology. He has led some of the nation’s largest systemic behavioral health care transformations, including at the Department of Veterans Affairs. In this interview, he focuses on topics to help individuals be better informed and engaged in their mental health.
Don Bertschman: In communications for the Onduo for Mental Health solution our organization is piloting, there is an emphasis on “mental wellness” and day-to-day well-being and support. Why is that important?
Dr. Brad Karlin: Mental health exists on a continuum, from mental wellness to mental illness. We shift along this continuum throughout our lives, and even week to week. Both genetics and life experiences influence where we fall on this continuum. Self-care and positive health behaviors help move us toward the side of mental wellness, while accumulated periods of unmanaged stress or impaired sleep, for example, are risk factors for mental illness. It’s important to realize that this is something we can monitor and regulate with patients I refer to this as our emotional temperature.
Behavioral factors not only affect our behavioral health, but also affect and are affected by our physical health. This is because the mind and body, once thought to operate separately, are highly interconnected. Taking care of ourselves psychologically means taking care of ourselves physically, and vice versa. As one example, chronic stress leads to elevated levels of cortisol, which impacts weight, impairs the immune system, and increases risk of chronic disease. Engaging in positive health behaviors, therefore, pays dividends in terms of our mental and physical health.
Don Bertschman: Can you give a few examples of these behaviors?
Dr. Brad Karlin: First is incorporating proven techniques for managing stress and calming the mind and body. Two examples are deep breathing, which sends messages to the brain to slow down, and mindfulness, which involves focusing on the present moment. One type of mindfulness practice is gratitude, or consciously focusing on what you are grateful for.
A second critical health behavior is sleep. I talk about sleep being the center of the well-being universe, as it has been repeatedly shown to greatly impact physical and psychological well-being in many, many ways.
A third method of promoting mental wellness and resilience is social connectedness and support, whether virtual or physical. Decades of research shows the importance of social support on wellness; conversely, loneliness and social isolation have repeatedly been shown to be detrimental to both psychological and physical well-being.
Fourth, engaging in more pleasurable and meaningful activities however you define that can promote psychological well-being, and is part of certain types of treatment, like cognitive behavioral therapy and behavioral activation.
Lastly, simply stepping away from the office or home and changing your physical environment can shift your perspective and be rather helpful in the moment.
Don Bertschman: Those are good, straightforward tips, but many of us struggle to put them into practice. Is part of the challenge related to stigma like it's not OK to pay attention to one’s mental wellness or seek help?
Dr. Brad Karlin: Stigma plays a significant role in many areas of behavioral health. It’s helpful to think about both personal and societal stigma.
Personal stigma is negative attitudes one holds toward oneself, or internalized beliefs of shame, for example, that can prevent you from engaging in positive health behaviors or seeking help. This can be the result of denying or avoiding certain symptoms or characteristics that someone would rather not acknowledge or address.
Public, or societal, stigma comprises views and actions, and even discriminatory behaviors, others hold toward a stigmatized group, such as individuals with mental illness. In addition to direct effects in terms of negative policies or practices toward the stigmatized group, this stigma or social norm can become internalized and serve as a barrier to seeking help or making changes. Public stigma and personal stigma often work in tandem with one another, each reinforcing the other.
Due to the impact of the pandemic, there has been more discussion about mental health and a normalizing of certain challenges, particularly stress and anxiety. That has reduced stigma somewhat, but it is still a major issue. I would say it is still among the greatest barriers to seeking care for individuals with substance use disorders and more severe mental illness.
Stigma can also be a significant issue with postpartum depression. There are often feelings of guilt and shame stemming from negative thinking that this is not the way a mother “should” feel or act. In addition to these thoughts and feelings are the physical symptoms of depression, including difficulty sleeping and reduced energy. These thoughts, feelings, and behaviors, in turn, affect one’s ability to function and carry out parental responsibilities, which can create a vicious and reinforcing cycle.
Don Bertschman: We are doing a separate article on the enterprise behavioral health strategy you helped develop, and how it fits into the Living Health strategy. For now, could you zoom in on the value of making care more proactive?
Dr. Brad Karlin: By leveraging data and advanced analytics, including claims data, EHR data, and other data an individual chooses to provide, we can move up the timetable of detection in some cases identifying a potential behavioral health problem even before an individual or primary care provider is aware of it. Earlier detection gives us an opportunity to right-size or “bite-size” interventions, including what we call lower-intensity interventions, which might be a digital solution, helpful information in the moment, and/or support from a behavioral health coach. Many individuals who are less inclined to seek formal behavioral health treatment are more open to lower-intensity, personalized interventions or to speaking with a behavioral health coach. Right-sizing treatment and moving upstream in this way also provides an opportunity to personalize behavioral health treatment, which has been an elusive concept in the behavioral health field.
An exciting opportunity for moving even more upstream is digital phenotyping, which involves using passive data acquisition through cell phones or wearables to detect changes and signals in behavior that can predict a behavioral health problem before a provider or even the patient would. Potential signals include rate, rhythm, or content of speech, sedentary behavior, social communication, and sleep changes.
Don Bertschman: Screenings are also becoming more common how useful are they?
Dr. Brad Karlin: A number of well-validated screening measures, or questionnaires, exist for detecting depression, anxiety, and other behavioral health conditions. They are generally simple and take only a few minutes to complete. Recommended screening measures, such as the PHQ-9 and GAD-7 have been subject to scientific scrutiny and shown to be very accurate. They are highly recommended for use in primary care and other settings, not only to help detect a condition, but also to indicate the level minimal, mild, moderate, severe which helps determine the appropriate intervention.
These symptom measures also help in monitoring improvement or exacerbation of an individual’s condition over time. This is important for providers to inform clinical decision-making as part of what is known as measurement-based care.
There is meaningful qualitative information in screening instruments that can guide a conversation and development of, or change to, a plan of care.
Don Bertschman: Another kind of proactive care involves follow-up when someone has been in the emergency department due to a mental health condition. There are clinical quality measures involving 30-day follow-up, for example. Why is this important?
Dr. Brad Karlin: Whether it’s the emergency department or in-patient facility or even a nursing home, clinical experience and research clearly demonstrate the importance and opportunity for proactive follow-up and continuous care for improving and sustaining clinical outcomes. When an individual presents to an emergency department, they receive immediate care that addresses the acute issue, but they're not receiving the full treatment that we know yields better long-term outcomes and addresses the underlying issue. Follow-up helps ensure that people receive appropriate evidence-based care beyond that initial emergency as well as knowing how and where to get care, and feeling ongoing motivation and commitment to do so.
The type of follow-up varies. It may, for example, include a case manager following up within a period of time, as happens with an increasing number of health care systems. The standard is to begin that follow-up process before a person leaves the facility to instill the expectation of continuation and follow-up contact and engagement, to allow opportunities for questions and discussion, and to detect likelihood of follow-up or potential ambivalence. This may even involve a conversation with the person who will help them after they’re out of the facility.
Don Bertschman: Two common mental health struggles, depression and anxiety, range from minimal to very severe. Stigma, relational dynamics, and societal expectations can create uncertainty about when to seek help. What advice would you give on that?
Dr. Brad Karlin: A couple factors are important in recognizing a need and then taking action. First, the symptoms one is experiencing represent a change from the past that has noticeable interference in functioning, such as social, occupational, or school functioning. Second, the symptoms and impairment are for an extended period. We all have bad days, obviously, but if there’s impact on functioning for a couple weeks, generally speaking, that is usually a signal that a person could benefit from reaching out for help. Reaching out earlier often means the issue will be easier to address.
Specific symptoms include emotional symptoms, such as sadness, irritability/moodiness, fear or worry, and loss of interest in previously enjoyable activities; social symptoms, such as changes in social behavior like isolating or distancing from others; physical symptoms, such as changes in appetite or sleep; and cognitive symptoms like difficulty concentrating, racing thoughts, or thoughts of harm to self or others. In the presence of thoughts of harm to self or others, it is advisable to reach out for help right away.
Additionally, everyone can benefit from the self-care and positive health behaviors we talked about earlier which can help recalibrate your emotional temperature, or where you are on the continuum from minimal to severe. If we invest in our psychological health, we can increase our emotional resilience.
Don Bertschman: Another condition that gets mentioned a lot but maybe isn’t well understood is post-traumatic stress disorder (PTSD). Can you give us an overview?
Dr. Brad Karlin: PTSD is a severe and persistent reaction to a traumatic event. By “persistent” we usually mean symptoms persist for a month or more. The traumatic event could be military combat, violence or sexual trauma, a serious accident, a natural disaster and it can be experienced directly or as something one witnessed.
Symptoms that often follow the traumatic event include intrusion symptoms, such as nightmares, flashbacks, or disturbing memories that serve as reminders of the traumatic event. Another prominent characteristic of PTSD is avoidance of triggers that are reminders of the trauma. With combat-related trauma, that might mean avoiding loud noises, crowds, or public places. An individual often goes to great efforts to engage in avoidance behaviors, which is understandable, but actually has the effect of reinforcing anxiety and PTSD symptoms and makes it difficult to discern or trust non-threatening environments. Other common symptoms include changes in mood, hyperarousal, and hypervigilance.
It’s important to emphasize that there are effective treatments for PTSD. These include specialized evidence-based psychological treatments for PTSD, such as Cognitive Processing Therapy and Prolonged Exposure Therapy. These treatments are recommended at the highest level for PTSD. During my time in VA, my team led the world’s largest implementation of these treatments, which led to robust improvements for many veterans.
Don Bertschman: In a previous article, you talked about the “quality problem” in behavioral health care. What are the key points about quality…even for people who are frustrated with long waits and might see the “access problem” as a priority?
Dr. Brad Karlin: Access is clearly important necessary, but not sufficient. The good news with quality is that we have very effective, recommended, Grade A treatments for many behavioral health conditions. The problem is that the most readily available treatments are not always the ones with the highest levels of evidence for effectiveness.
The comparison I used previously was supportive talk therapies and cognitive behavioral therapies (CBT) in treating a condition like depression. While supportive talk therapies, which are unstructured and often involve talking about one’s week or whatever comes to mind, may be helpful in the moment, they do not typically lead to significant and lasting gains. Evidence-based psychological treatments, on the other hand, include active ingredients of cognitive, behavior, and/or social change. CBT, for example, helps people develop more flexible ways of thinking about themselves, others, and the future, as well as behavioral strategies, that lead to improvements in depression and other mental health conditions, as well as overall functioning. It is the most studied psychological treatment in existence, demonstrated to be effective in decades of clinical trials. CBT and other evidence-based psychotherapies are also usually time limited; while treatment length is tailored to the individual and based on the achievement of personal and measurable goals, treatment usually lasts 12 to 16 sessions, with follow-up booster sessions sometimes provided to help sustain gains.
For individuals with lower levels of need, elements of CBT or other evidence-based psychological treatments can be incorporated into the lower-intensity interventions we discussed, such as a digital intervention or communication with a behavioral health coach.
Don Bertschman: There has been media coverage about a study questioning the effectiveness of certain antidepressants. What high-level advice can you give people about the use or potential overuse of prescription drugs for mental health?
Dr. Brad Karlin: For certain conditions like severe depression, medication is an important part of treatment, ideally combined with evidence-based psychotherapy. The research is clear that for more severe depression combining medication and psychotherapy yields more favorable outcomes than either treatment alone. With other conditions, such as psychotic disorders like schizophrenia and bipolar disorder, medication is primary. However, even in these instances, increasing research has shown CBT and other evidence-based psychological treatments to often play an important role in helping with coping and recovering from cognitive, behavioral, and social characteristics of the illness.
In other instances, medication is common but not necessarily the most effective or recommended approach. For example, the Grade A recommended treatment for insomnia is cognitive behavioral therapy for insomnia (CBT-I) and it’s highly effective. However, most people who have insomnia receive a hypnotic or other sleep medication. In the very short term, it might make them sleepy, but it could have adverse effects, and longer term, medication is clearly inferior to CBT-I. Anxiety disorders are another example where I would say there is an overprescribing of benzodiazepines, often through primary care. Even if intended for a very short period of use, they're prone to creating dependence, and longer term they do not perform well and may have adverse effects. At the same time, specialized forms of CBT and other evidence-based psychotherapies for anxiety disorders are most effective and recommended at the highest level and as first-line treatments.
Don Bertschman: Digital therapeutics, behavioral health apps, and whole online behavioral health platforms are popping up at a rapid pace. What is your assessment of what’s on the market and what should we think about before using an app or signing on to a platform?
Dr. Brad Karlin: There is great promise with respect to digital behavioral health applications and related technological innovations, but also a lot of noise. It’s very difficult for consumers, but also providers, health care systems, and employers, to make sense of the current maze of solutions.
There are approximately 20,000 behavioral health applications in market today. Most have had little or no empirical scrutiny, so it’s important to be cautious. Research shows significant challenges with engagement for most solutions, with average engagement as low as 5% or less after two weeks.
The best of the digital solutions have real promise some have been shown in randomized control trials to be on par in effectiveness with certain clinical interventions. There are two necessary qualities for superior digital behavioral health applications that drive better outcomes and engagement. First, the solution must incorporate evidence-based content, which most typically is adapted from cognitive behavioral therapy or other forms of evidence-based psychotherapy. Second, a solution must have quality design, functionality, and interactivity so that it is easy, appealing, and engaging to use. Otherwise, even if you have quality content, you end up with low engagement. Neither is sufficient, both are necessary.
Don Bertschman: What about large online platforms? Getting back to frustrations with access, any platform that guarantees a virtual appointment within days can be tempting.
Dr. Brad Karlin: Let’s first step back and talk about the expansion of telebehavioral health care, which has been a tremendous development. We have known from over a decade’s research that behavioral health care delivered through a telehealth modality is about as effective as in-person care for many people and situations, and has the advantages of expanding access, making it easier for people to fit appointments into busy lives, and also avoiding the stigma some people feel about going to a mental health appointment at a public facility. Despite all that, levels of telebehavioral health care use were quite low prior to the pandemic. Now, that’s changed within our organization, for example, telebehavioral health care use increased almost 7000% in 2020, and we are still seeing about 50% of outpatient behavioral health delivery through telehealth, so it’s clear that individuals are willing, and often prefer, to receive behavioral health care this way.
With increasing clinical need due to COVID-19 and recognition of a field ripe for much-needed clinical and technological innovation, we now have a proliferation of telebehavioral health platforms fueled by private investment. These platforms help to increase access, often making it possible for individuals to see someone within days or even the same day. However, these platforms are highly variable with respect to quality and delivery of evidence-based treatment. Some can be a reasonable option for individuals with more garden-variety depression or anxiety something uncomplicated in nature. For individuals with more severe levels of need or complicated presentations, it is especially important to be discerning and factor in considerations beyond access.
Moving into the future, the differentiators in this space will be those who not only solve for access through telebehavioral health, but also overlay the quality emphasis, including the delivery of evidence-based treatment and ongoing measurement of outcomes.
Don Bertschman: In a video, Dr. Margaret Larkins-Pettigrew, our chief clinical diversity, equity and inclusion officer, talks about both access and understanding as part of addressing mental health disparities. Is this another example of access being necessary but not sufficient?
Dr. Brad Karlin: I often talk about mental health treatment including both physical and psychological access. Clearly there are disparities in physical access to behavioral health treatment across groups based on race, ethnicity, age, sexual orientation, geographic location, and so on. That must be addressed, but we also need to think about disparities in psychological access which involves understanding of and attitudes toward seeking behavioral health treatment. Stigma, attitudinal barriers, lack of information, and behavioral health literacy all impede likelihood of engaging in behavioral health care, and more so for certain groups, consequently contributing to disparities. We must work diligently to solve these issues it is not enough to simply build it and expect they will come. We need to meet individuals where they are and address informational, attitudinal, motivational, and other needs for engaging in behavioral health care. This also includes ensuring access to providers who are representative of the populations they serve and who instill trust and credibility.
Within geriatric psychology, my clinical specialization and an area in which I’ve conducted extensive research examining factors related to utilization and engagement in behavioral health care, older adults have repeatedly been shown to be among the least likely to seek treatment. That’s due in large part to psychological access challenges, including lack of awareness, negative attitudes toward treatment shaped by earlier characterizations of mental illness and treatment, and lower digital literacy. Another key finding in our research is the important role of perceived need. Older adults often do not perceive a need for behavioral health treatment. However, we have found that when they do and engage in care, they typically benefit significantly.
There is a lot to talk about and plan for from a health equity standpoint. In both physical access and psychological access, we see significant barriers for multiple groups, and opportunities to do much more to address those barriers and reduce disparities. This is a time of considerable need, as well as considerable opportunity, for behavioral health care and we don’t want the opportunity limited to just some. To truly realize this promise, we must change old models of care and create a re-imagined approach that is personalized, proactive, engaging, and quality-focused.