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To Prevent Chronic Illness, Start With Mental Health

It should come as little surprise that the pandemic triggered a surge in mental health issues. Millions lost their jobs, life-threatening illness lurked at every corner, and socializing in person became dangerous. Indeed, the CDC recently reported that since the pandemic started, 41% of Americans reported symptoms of anxiety or depression — up from about 11% in 2019. The trends were even more alarming for children. Compared to 2019, mental health-related visits to the emergency room for children ages 5 to 11 and 12 to 17 increased a relative 24% and 31%, respectively.

Perhaps even more troubling is the fact that behavioral healthcare professionals are struggling to meet the demand for their services. To be sure, mental health resources were stretched thin before the pandemic. But a February survey by the National Council for Mental Wellbeing found that over two-thirds of member organizations have seen increased demand for their services, and a similar proportion have had to turn patients away.

These trends are concerning in their own right, but they have grave consequences for America’s physical health as well.

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Depression: Complication or Cause of Chronic Illness?

We often talk about depression as a complication of chronic illness. Indeed, by some estimates one-third of all patients with chronic disease also suffer from depression. As the thinking goes, once a patient is diagnosed with diabetes, for example, the weight of their diagnosis fills them with despair and sadness, leading to depression.

But what we don’t talk about enough is how depression can lead to chronic disease, rather than the other way around.

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Many of the hallmark symptoms of depression result in unhealthy behaviors that can lead to or worsen chronic disease. For example, patients with depression may not have the motivation to exercise regularly or cook healthy meals. Many also have trouble getting adequate sleep. To cope with their feelings, some may overeat or turn to drugs and alcohol, wreaking havoc on their organs over time.

Depression can also impact medication adherence in patients that already have chronic illness. Forgetfulness is a common symptom of depression, and naturally, depressed patients may forget to take their medication. In other cases, they may simply lack the motivation to do so, seeing their life as worthless. In a grim sense, failing to take one’s medication can be thought of as an act of self-harm.

As a result, patients can become chronically ill while being too depressed to properly manage their condition. Many become high utilizers, cycling in and out of the hospital and racking up bills that only compound their stress.

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But there is hope: By treating patients’ depression, we can improve or even prevent chronic disease.

Moving Toward a More Holistic Healthcare System

Too often, we treat mental health and physical health separately. But the two are inextricably linked. Left unaddressed, the current surge in depression and anxiety will contribute to a surge in chronic disease.

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This isn’t a problem for the behavioral healthcare system to face on its own. Primary care physicians and specialists from oncology to endocrinology to cardiology need to take steps to address the way their patients’ mental health affects their overall health, and approach care from a truly integrated perspective.

Yes, our behavioral healthcare system is already stretching the limits of its capacity. But if we do not meet the mental health crisis with the response it demands, we could see our medical healthcare system strained in the same way. It won’t be easy, but with creative, novel solutions, we can get the mental health crisis under control.

One focus should be telehealth, which helps expand access to behavioral health treatment. The behavioral healthcare system has long been plagued by wide disparities in resources depending on where people live, with rural communities having the greatest shortages (not coincidentally, rural communities also have the highest rates of chronic illness). With telehealth, patients can see mental health specialists across state and county lines without leaving their homes. Congress and the insurance industry must extend telehealth coverage beyond the pandemic to maintain this vital avenue of care.

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Any progress on tackling the mental health crisis will also depend on addressing the socioeconomic and cultural factors that both drive mental health problems and pose obstacles to care. The pandemic has emphasized the impact of economic security and social support on mental wellbeing. Yet, behavioral healthcare remains too costly for many and woefully underfunded.

Stigma poses another barrier. While mental health concerns have become more normalized, many still feel shame about seeking help. In particular, racial and ethnic minorities are much less likely to seek treatment for mental health issues than white people. Healthcare providers and payers should pay close attention to patients in these communities when it comes to mental health — even if the patients decline to report symptoms.

A Data-Driven Approach to Behavioral Health

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Data can be a useful tool in predicting which communities will be more vulnerable to behavioral health problems due to cultural and socioeconomic factors. For example, consider Harrison County, Mississippi. The county is home to Keesler Air Force Base, housing 7,000 active duty personnel. Active duty suicides are at a 6-year high. In addition, thousands of Vietnamese refugees flocked to the region’s oyster industry in the 1960s and 1970s. Vietnamese Americans have high rates of depression (30.2%) and are less likely to seek help from mental health professionals.

Sure enough, the Harrison County suicide rate is 50% higher than the rest of the state.

By training machine learning algorithms on this data, it’s possible to create risk-prediction models that enable care teams to understand which patients may be at greater risk and what their risk factors may be. These insights enable care teams to take more targeted and proactive action to address behavioral health problems before they manifest physically.

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This approach has proven successful. For example, one community oncology practice increased their depression screenings by 171% and depression diagnoses by 22% within 2 years of implementing this approach to mental health.

As the shift to value-based care accelerates, it will become increasingly important — from a patient experience, outcome, and cost perspective — for healthcare organizations to address the mental health issues driving their patients’ physical health problems. Patients, providers, and payers would all be better off with a more holistic, integrated approach to care that treats the whole patient, not just their physical ailments.

John Frownfelter, MD, is an internist and physician executive in health information technology and is currently leading Jvion’s clinical strategy as their chief medical officer.

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