In the U.S., one in five adults experiences a mental illness but 60% of people with a mental illness don’t receive professional help. Such statistics are a proxy for people’s suffering proof of unmet needs.
The alleviation of that suffering isn’t simply a question of the effectiveness of individual mental health professionals or treatments. As that 60% statistic shows, it is also necessary to look at the larger systems and cultural forces that prevent more people from seeking and getting help.
That was one reason that Allegheny Health Network (AHN) converted its Psychiatry Department to an institute model to improve access through better organization and integration of mental health services. We sat down with Doug Henry, PhD, vice president of AHN’s Psychiatry and Behavioral Health Institute (PBHI), to discuss both the challenges of mental health care in the U.S., and how the integrated behavioral health approach, telemedicine, and other efforts can help meet those challenges.
Nikki Buccina (NB): From a patient's perspective, what did the transition from a department to an institute model look like?
Dr. Doug Henry (DH): It looked like standardization. Now, a patient can walk into practices in different places and have them feel very similar no matter where they occur in AHN’s system. From the architecture to practical things like the greeting and the check-in process, the institute model helps ensure that the experience will be consistent. Most importantly, the high quality of service is the same throughout the institute, which is currently comprised of six inpatient units and five outpatient locations, including the Women’s Behavioral Health Clinic.
NB: The institute also emphasizes an integrated approach to behavioral health. Can you talk about what that means?
DH: We’re adding integrated access points within different medical subspecialties, most commonly primary care, but others as well, such as autoimmunity. That means that we place a behavioral health consultant (BHC) either a psychologist, licensed clinical social worker or licensed professional counselor and a psychiatrist within that practice to provide direct support. The BHC is typically onsite to provide in-person service, while the psychiatrist would more commonly provide curbside consultation to the medical subspecialist, guiding prescription and treatment planning.
The Primary Care Institute at AHN has become a national leader in integration, working in collaboration with the PBHI. AHN integrated behavioral health currently offers patient access in roughly 60 different locations in this way.
There are numerous advantages to the integrated approach it simplifies the experience for clinicians as well as patients. Another advantage is that it reduces stigma, something that’s been worked on for many years with limited success. So, when you go to your primary care doctor, if everyone receives a screening for depression and anxiety, then that makes the experience of regular mental health hygiene just like any other aspect of your care.
NB: At an individual level, this also makes me think about integrating mental health and physical health how important is that connection?
DH: We have more and more consistent research that finds physical and behavioral health are aligned. Even with something like Alzheimer’s disease, two things that have successfully slowed its course are regular exercise and reading, and exercise really seems to be the cornerstone. As time passes, I believe we’re going to find more and more proof that exercise, even just a regular walk or a brief pedal, is effective not just with Alzheimer’s but also depression, schizophrenia, and other conditions.
ND: What are your thoughts on how social determinants impact behavioral health issues?
DH: We have to look closely at social determinants, including providing social determinant screening. AHN’s Center for Inclusion Health designed a comprehensive social determinant screening tool that is standard at the center, and it’s being introduced into primary care and other access points now as well. We want it to become a universal screening so we can always get a good sense of the level of stress someone has from their environment, the forces impacting their health, independent of a behavioral health disorder.
As science advances, we have learned that social determinants are very meaningful, especially for the lowest 30% on the socioeconomic scale. Something like the frequency of lead paints used in the neighborhood you grew up in has been directly correlated with IQ.
So we have to know these things, and address them as much as possible. Transportation is another one. It makes sense that if people don’t have access to transportation and can’t get to doctor’s appointments, then that would impact their health outcomes. And that’s where you see partnerships with companies like Uber or Lyft that can help people who don’t have access to transportation.
NB: How would you describe the demand for mental and behavioral health care in the U.S.?
DH: The demand is enormous. Our institute is growing rapidly to meet that demand. There is tremendous momentum and support, including at the enterprise level, for growing behavioral health at AHN because our leadership is aware of the huge demand, and the industry-wide challenges in meeting that demand.
NB: Is something driving an increased demand for mental health care is it that people are more willing to talk about mental health? Or is it a result of the climate and culture we live in?
DH: Yes to both. If you were to look at it very scientifically, I think the most salient factor is increased awareness. I also think there’s been a reduction in stigma in recent years, so you have people who are more willing to bring it up.
Environmental factors are important too. We’ve had a breakdown of traditional structures, some of which have helped people solve problems of identity in the past. I’m talking about religious affiliations, family structures, and other things that were in place for long periods of time. In a way, because people have more freedom, there’s a certain level of stress or anxiety that comes with that, particularly for young people.
Technology is another element. We know that social media is correlated with rates of depression in young people. They’re suffering from the comparison that social media invites. They’re also suffering because and again, I’m talking mostly about young people the amount of time spent with technology has interfered with their ability to form interpersonal relationships. Life lived alone is impossible. If you take away the basic development of skills needed to form lasting relationships, it contributes to higher rates of depression.
The positive is that where people didn’t want to talk about mental health issues in the past, we’re making progress. That’s not only important at the individual level, it also means we have much better data gathering, which leads to better research, therapies, and eventually, relief.
NB: Is the demand for mental health services higher than the supply of mental health professionals?
DH: Yes, I’ve seen estimates that the U.S. only has 55% of the psychiatrists that it needs to meet current demand, and there is a documented shortage across most areas of mental health. In almost any region of the country, as a patient, it’s difficult to be seen for psychotherapeutic services in a timely manner, and it’s even harder to get into psychiatric medication management services. The reason for that is actually quite simple reimbursements for outpatient behavioral health services are insufficient to cover the cost of providing them. So, it’s no mystery why we have narrow access in the U.S. to ambulatory behavioral health care.
We transitioned to an institute model in part because it’s the best way to leverage every psychiatrist, psychologist, and mental health professional we have. A licensed professional counselor working in a traditional, free-standing, community behavioral health clinic may be able to maintain a caseload of 25-35 patients. In an integrated setting like the model AHN Primary Care created, they’re able to manage 75-120 cases.
NB: Why are there insufficient reimbursements? Does it go back to stigma, or am I oversimplifying?
DH: It does go back to stigma, but there have been different answers at different points in time. Part of the reason is that society has a limited amount of money to spend on health care, and with that limited pool, people with certain acute medical needs have been prioritized. Unintentionally, that meant there wasn’t much left to go to behavioral health.
Now, these days that is starting to change, and I am encouraged to see that there is more funding support for behavioral health programs. At AHN specifically, we have the ability to design new models and systems of delivering care because of that enterprise-level commitment.
Let me give you an example of why that investment in behavioral health makes sense. A panic attack feels like you’re dying it feels like you’re having a heart attack and has many of the same symptoms. Without behavioral health support, someone experiencing a panic attack may go to the ER. There is a good chance that a doctor might send the patient for an MRI to look for, say, a pulmonary embolism. We end up spending thousands of dollars to diagnose something that isn’t there. Panic sufferers can easily be taught how to breathe in a way that remediates the attack, and actually prevents them from occurring in the first place. Without this, the same person may present in the emergency department 10 or 12 times a year with attacks. When you look at the bigger picture, that’s just one example where investing in behavioral health can help decrease total cost for the whole health care system, which is one of the challenges that the enterprise has dedicated itself to addressing.
NB: Is the use of telemedicine another way to ensure that people have access to mental health are more people using telemedicine?
DH: It’s not necessarily the case in every subspecialty of health care, but, yes, there’s definitely been an increase in telemedicine for behavioral health services. There aren’t a lot of providers offering this, but we have seen the utility, demand, and benefit, so it will continue to grow.
As it stands, the AHN Psychiatry and Behavioral Health Institute already provides more telemedicine services than any other institute at AHN. As it evolves, patients will be able to receive psychotherapy or medication management services on their smartphones. No waiting. No fighting traffic. No paying for childcare. None of those barriers will contribute to high no-show rates at mental health clinics. None of those barriers will impede someone’s ability to get the service they need.
We’re also being more proactive, facilitating wellness before people come to the emergency department or require hospitalization. For example, nurses have been placed in certain primary care practices to coordinate care and perform check-in calls for the highest-needs patients.
We can eliminate many emergency department visits, and a whole lot of human suffering I think our integrated system allows us to do some amazing things.