OUR PATIENTS' MENTAL HEALTH: STILL FAR FROM BEGING TREATED
Mental Health - Part I
“I’m having a lot of pain and need my medication more frequently!” “I’ve been a caregiver for years. Now who is going to care for me?” “I can’t sleep…I’m so anxious and upset.” These are just some of the comments I heard from patients in recent weeks when I was on the hospital inpatient service. Patients with chronic pain misusing medications and using illicit drugs, lonely patients, anxious and depressed individuals. These issues alone create dilemmas in care for the health care system and those who work within it. Unless there are ways for patients to receive long term mental health care to help address these various issues, the problems will persist unabated.
How did we get here? Are some immune to mental health worries and not in need of assistance? Hardly. We are all in this together. Writing in The New York Times, Casey Schwartz quotes Dr. Robert Ashley, a psychiatrist in Los Angeles noting that, “everyone, every day, just wakes up with 10 percent extra pressure on them.”1 Loneliness abounds among many who lost loved ones during the height of the pandemic. And as work has shifted to an online format for many, we are more and more isolated. Many have become blasé about the pandemic, new viruses, and an uncertain fall season and beyond. Many go unmasked in crowded settings both indoors and outdoors. We’ve grown tired of the Centers for Disease Control and Prevention (CDC) announcements and advisories from state public health departments. For those that want and need help, mental health services in this country are in dire straits. The COVID-19 pandemic has only brought further into view the fact that mental health services in the U.S. are unable to meet the demand.
Mental health issues in the U.S. have been going on for decades. For example, many refer to the 1980s as the age of anxiety, while the 1990s have often become known as the age of depression.1 Throw in ADHD, bipolar disorder, and so many other mental disorders and you have a country in the 2020s whose citizens have mental health needs that are not often met at all! Along with the rise of these various mood disorders has come the development of medications to treat them.2 And good luck trying to find a psychologist or psychiatrist to see you.3-4 It is true that residency programs are graduating psychiatrists, but they cannot keep up with the demand.3 In addition to standard psychiatric residencies, combined residencies are helping, but still leave many without access to a psychiatrist (there are combined Internal Medicine/Psychiatry, Family Medicine/Psychiatry, Psychiatry/Neurology, and Pediatrics/Psychiatry/Child & Adolescent Psychiatry programs across the U.S.).3-5 With significant mental health staffing issues, many patients look to their primary care physician, APRN, or licensed clinical social worker to provide them with support.6 And more than likely, especially if you live in a rural area, telepsychiatry may be a valuable option and perhaps the only one available.7
Add the opioid crisis to the mix and associated mental health disorders, and you have a very complicated and sick society. While this group is greatly in need of assistance, they suffer from a patchwork approach and lack of organization and effectiveness on multiple levels. Substance use and mental health disorders are often linked; however, recognition and treatment is limp in our own backyards and throughout the country. Issues of funding, bias (both conscious and unconscious), legislative hurdles, and lack of infrastructure has left us with patients dying at extraordinarily high numbers. The CDC’s National Center for Health Statistics indicates that there were an estimated 100,306 drug overdose deaths in the U.S. during the 12-month period ending in April 2021, an increase of 28.5% from the same period the year prior.8 This is unfathomable and unacceptable. There must be a system in place to treat both mental health and substance use disorder effectively. Unfortunately, this is often not the case. Referred to as co-occurring disorders, it is common for those diagnosed with one to have another occurring about half of the time.9 MSD, MedNet, and the Recovery Platform are working on a pilot study together as part of a grant funded by the Delaware Division of Substance Abuse and Mental Health (DSAMH), along with the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA).10 It is a small study, but hopefully, will lead to many more patients evaluated and treated efficiently and effectively. However, we are still in desperate need of mental health services for those that want and need them apart from substance use.
We are going to need to be creative about mental health care going forward and realize one size does not fit all. For patients, an approach that hybridizes a primary care behaviorist model (also called primary care behavioral health, or PCBH) and a collaborative care model (CoCM—care management for patients with mental health conditions) seems promising.6,7 An integrated behavioral health model with a telehealth component may help many.11 While there are concerns about patient access to services along with reimbursement and technology issues16, it is likely telehealth, which includes psychiatry, will be with us for the long haul. Yet with primary care on the decline, staffing and general funding will likely be bottlenecks in seeing this being fully effective, especially since primary care providers do a lot of this work.
What can MSD do going forward? Working to support group sessions with or without a therapist can help.12 Building a system similar to “Battle Buddies,” a peer support strategy developed by the US Army, could be effective.13,14 We need to reach out to legislators for them to recognize and support the mental health needs of their constituents. We need to identify grants that may be available to fund innovative services to provide help and support. Health care systems must be part of the process and be fully supportive. The federal government needs to approve funding for the mental health industry. Insurance plans are falling woefully short in providing parity for those with mental health and substance use disorders.15 This must be a top priority at the state and national levels for those making critical decisions about payments for those providing these vital services. We must be vigilant in the effort to continue to bring this issue to the forefront!
Matthew J. Burday, DO
1. The New York Times (subscription). The Age of Distracti-pression. Available at: https://www.nytimes.com/2022/07/09/style/medication-depression-anxiety-adhd.html. Accessed August, 22, 2022.
2. Cuijpers P, Stringaris A, Wolpert M. Treatment outcomes for depression: challenges and opportunities. The Lancet Psychiatry Nov 2020; vol 7(11); 925-927. https://doi.org/10.1016/S2215-0366(20)30036-5.
3. GoodTherapy®. Is There a Shortage of Mental Health Professionals in America? Available at: https://www.goodtherapy.org/for-professionals/personal-development/become-a-therapist/is-there-shortage-of-mental-health-professionals-in-america. Accessed August 22, 2022.
4. Harrar, S. Psycom. Inside America’s Psychiatrist Shortage. Available at: https://www.psycom.net/inside-americas-psychiatrist-shortage. Accessed August 22, 2022.
5. The Association of Medicine and Psychiatry. Residency Programs. Available at: https://assocmedpsych.org/studentstrainees/residency-programs. Accessed August 22, 2022.
6. American Psychological Association Center for Psychology and Health. Behavioral Health Services on Primary Care. Available at: https://www.apa.org/health/behavioral-health-services-primary-care.pdf. Accessed August 22, 2022.
7. Henry, Tanya. American Medical Association. Offering integrated behavioral health care via telehealth a win-win. Available at: https://www.ama-assn.org/practice-management/digital/offering-integrated-behavioral-health-care-telehealth-win-win. Accessed August 22, 2022.
8. Centers for Disease Control and Prevention National Center for Health Statistics. Drug Overdose Deaths in the U.S. top 100,000 Annually. Available at: https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2021/20211117.htm. Accessed August 22, 2022.
9. The New York Times (subscription). Experts Say We Have the Tools to Fight Addiction. So Why are More Americans Overdosing than Ever? Available at: https://www.nytimes.com/2022/06/24/opinion/addiction-overdose-mental-health.html. Accessed August 22, 2022.
10. Delaware Department of Health and Social Services. Delaware State Opioid Response (SOR) Initiative Information for Providers. Available at: https://dhss.delaware.gov/dsamh/startexp.html. Accessed August 22, 2022.
11. Agency for Healthcare Research and Quality. Telehealth and Behavioral Health Integration. Available at: https://integrationacademy.ahrq.gov/about/integrated-behavioral-health/telehealth#:~:text=Telehealth%20technologies%20can%20support%20the,is%20easily%20adapted%20to%20telehealth. Accessed August 22, 2022.
12. Fraga, Juli. The Washington Post. With therapists in short supply, group counseling offers alternative. Available at: https://www.washingtonpost.com/health/2022/07/02/group-therapy-alternatives-mental-health/. Accessed August 22, 2022.
13. Albott C, Wozniak J, McGlinch B, Wall M, Gold B, Vinogradov S. Battle Buddies: Rapid Deployment of a Psychological Resilience Intervention for Health Care Workers During the COVID-19 Pandemic. Anesth Analg July 2020; Vol 131(1); 43-54. doi: 10.1213/ANE.0000000000004912
14. The Battle Buddy Foundation. About Us. Available at: https://www.tbbf.org/about/. Accessed August 22, 2022.
15. U.S. Department of Health and Human Services. U.S. Departments of Labor, Health and Human Services, Treasury Issue 2022 Mental Health Parity and Addiction Equity Act Report to Congress. Available at: https://www.hhs.gov/about/news/2022/01/25/us-dol-hhs-treasury-issue-2022-mental-health-parity-addiction-equity-act-report-to-congress.html. Access August 22, 2022.
16. Handzel, S. MDLinx. The rise of telepsychiatry: Improving access to mental healthcare. Available at: https://www.mdlinx.com/article/the-rise-of-telepsychiatry-improving-access-to-mental-healthcare/5NSooG8BG9LNhJN2nPraTU. Accessed August 26, 2022.