Editor’s Note: This content has been excerpted from the book Caring for Our Communities: A Blueprint for Better Outcomes in Population Health. The content has been edited for length.
In the United States, so many aspects of behavioral and emotional health are simply not addressed as doctors steer focus toward the pathophysiology of disease. It certainly is a lot cleaner to focus our efforts on the mechanical aspects of the body than to dive into emotional aspects such as depression, anxiety, loneliness or isolation. Physical and emotional conditions coexist most of the time. Not only does chronic illness often precipitate depression, anxiety and other forms of emotional instability, but the converse is also true.
The effects of chronic illness are as deep as they are broad. As we manage our populations, we must be mindful that mental health disorders are likely present along with chronic physical health conditions as either effects or contributory causes. Given the constraints of the system in American medicine, we often fail to focus on the behavioral aspects of care in chronic illness management. A clear-cut connection exists between people’s chronic illnesses and their mental health, and we don’t do an especially good job of identifying this and then helping patients through it.
While mental health issues were prevalent before the COVID-19 pandemic, alarmingly, the pandemic made matters even worse. It demonstrated how the need for behavioral health services is affected by social and environmental factors. Pandemic living brought about a massive outbreak of psychological illness due to factors such as social isolation, limits on businesses, stay-at-home orders, financial pressures, grief, fear of illness and death, unemployment, and food and housing insecurity. A Centers for Disease Control and Prevention study reported that from August 2020 through February 2021, the percentage of adults reporting symptoms of anxiety or depressive disorder increased from 36.4% to 41.5%. Those reporting that they needed but did not receive mental health counseling or therapy during the preceding four weeks also increased significantly to 11.7%.
Barriers to Behavioral Health
Social stigma around seeking professional mental health services has always been a major barrier to care. One of the areas with the greatest social stigma in behavioral health is suicidal ideation. In a survey of 2,200 U.S. adults conducted by three national organizations dedicated to suicide prevention, respondents were asked, “What do you think are some of the barriers that prevent people who are thinking about suicide from seeking help?” The top three responses, in order, were feeling like nothing will help, embarrassment and not knowing how to get help.
In addition to social stigma, a significant percentage of respondents cited barriers to seeking behavioral healthcare, including inability to afford treatment, lack of access to treatment, lack of social support, fear of disappointing others and fear of losing a job. These perceived barriers are common throughout the spectrum of behavioral health management.
Breaking Down the Barriers
Many of these barriers are more than just perception—they are realities. We suffer a lack of capacity to manage behavioral health, and that perception is amplified by the lack of access to care and inability of so many to afford it. If providers are interested in advancing population health and community wellness, we must increase our involvement in the behavioral aspects of dealing with chronic illness and disability.
One encouraging step in this direction was made in early 2022, when the American Psychological Association developed a policy titled “Psychology’s Role in Advancing Population Health.” The APA laid out four guiding principles for the use of members, committees, divisions and boards in their population health endeavors:
- Work within and across diverse systems to advance population health. This includes partnering with community leaders, local institutions, faith-based organizations, schools, employers and others to develop solutions that address the unique challenges of their communities.
- Work “upstream” by promoting prevention and early intervention strategies. Psychologists contribute to developing, disseminating and implementing evidence-based models for prevention and early intervention and would create tools to screen and monitor for unmet needs.
- Educate psychologists and community partners on population health. This involves educating psychologists and others in the behavioral health workforce in concepts of population health and community wellness.
- Enlist a diverse array of community partners, including a broad range of national, state and local stakeholders within and outside of healthcare.
Atrius Health, based in eastern Massachusetts, has been developing and refining its behavioral health program since 2015. A substantial problem before the start of the program was that full-time therapists had average caseloads of more than 100 active patients, which meant they could not see patients more than once per month, well below the once-a-week recommendation in the literature for effective treatment. In addition, new patients had average wait times of 60 days for an initial therapy session and 45 days for follow-up appointments.
The solution had two major elements:
- A triage and referral process was designed so that behavioral health clinicians saw the most clinically complex patients while high-functioning patients were referred to an external network of community health providers.
- Evidence-based guidelines were developed, implemented and trained so patients in the program received consistent, measurable treatment focused on solutions.
This program has resulted in reduced caseloads for clinicians and significantly decreased wait times for new patients who need services the most. It has also helped ensure that patients are quickly routed to the lowest cost setting appropriate to their care needs. While triaging new referrals is an appropriate and timely way to serve patients with the highest needs early, suspending care for patients of any level of need is still unfavorable, especially if you or your loved one is the one in need.
Mark Angelo, MD, is CEO, Delaware Valley ACO.