What do we do about mental health?

We talk a lot here at Occupy Healthcare about the importance of redesigning the healthcare system. We have discussed in great detail the importance of primary care and the need to have robust primary care services to truly help impact the health of the community. We have also discussed mental health before and the need for better whole person treatment. But when reports in the media continue to emerge highlighting the problems associated with treating mental health, we must tackle the issue.

First, let’s talk about what we know about mental health.

For decades we have known that more mental health is seen in primary care than in any other healthcare setting. The prevalence of mental health problems in primary care are substantial. Consider the following statistics (all of these data can be found here):

•84% of the time, the 14 most common physical complaints have no identifiable organic etiology
•80% with a mental health disorder will visit primary care at least time in a calendar year
•50% of all mental health disorders are treated in primary care
•48% of the appointments for all psychotropic agents are with a non-psychiatric primary care provider
•67% with a mental health disorder do not get behavioral health treatment
•30-50% of referrals from primary care to an outpatient mental health clinic don’t make first appointment


Second, we know that when mental health needs are not met, it costs healthcare a lot more:

•Mental health disorders account for half as many disability days as “all” physical conditions
•Annual medical expenses–chronic medical & mental health conditions combined cost 46% more than those with only a chronic medical condition
•Of the top five conditions driving overall health cost, mental health can be found twice.

Employers, one of the primary purchasers of healthcare, often are the ones being impacted by mental health more often than not. Consider the following numbers:

Of note, these data represent the top 10 health conditions driving costs for employers (Medical + Prescription + Absenteeism + Presenteeism; Costs/1000 Full Time Equivalents). As one can easily see, depression trumps everyone in terms of cost and presenteeism (showing up for work but not really being there or at 100%) significantly surpasses absenteeism and medical utilization. These data show how individuals who show up for work with untreated (or poorly treated) mental health are a primary driver of employer cost.


Further, when we look at the cost of mental health conditions “comorbid” with chronic disease, the numbers do not get any rosier. Consider data the Robert Graham Center found in the Medical Expenditure Panel Survey:

Annual Cost – those without MH condition Annual Cost – those with MH condition
Heart Condition $4,697 $6,919
High Blood Pressure $3,481 $5,492
Asthma $2,908 $4,028
Diabetes $4,172 $5,559

It’s quite clear that when mental health conditions are seen along side chronic disease, there is a higher likelihood that there will be a greater expense associated with that patient. The authors of this paper see the significance of these data and conclude their paper with the following:

“Carve-outs of mental health benefits (i.e., only paying for mental health care delivered by mental health professionals), high copayments for mental health treatment, and inadequate reimbursement are barriers to effective collaboration and disincentives for primary care physicians to screen for and adequately treat mental health. Fixing disparities, removing mental health carve-outs, and creating blended payment systems could improve mental health treatment in primary care. This would support integrated, patient-centered mental health care that is consistent with the principles of the medical home.”

Finally, because more mental health is seen in primary care than in any other healthcare setting, it appears that one solution to tackle mental health is to better integrate mental health providers into primary care. And while there is robust data to support this notion, healthcare policy still has a tough time wrapping its head around bringing together two historically disparate systems.

It is quite clear that we need to do more in healthcare around mental health; however, rarely, if ever, are patients just presenting with a mental health condition.

As seen in the graph above, the higher the number of physical symptoms (the x axis or numbers on the bottom), the higher the likelihood one has a mental health diagnosis (the y axis or the percentages on the left). If one looks at these data, what stands out is the substantial overlap between mental and physical. Some may say inseparable overlap. After all, is there really any difference between your mind and your body?

While we have separate systems (a mental health system and a physical health system) to treat the whole person maybe it is time we start to reconsider how and where we treat mental health. Maybe we stop calling it mental health in the first place as that appears to be a misnomer and maybe we start focusing on comprehensive whole person health?

It’s really just about health, isn’t it? Health is health is health? Or is it?

To better address mental health, where we need to go and what we need to do, here are a few suggestions:

We must start to develop a system that can take care of the whole person and not just pieces of the person;

We must start to invest and educate our providers on how to deliver team-based care;

We must start to better consider the patient preference in their care, and how best to provide that care where they want that care;

We must create a financial payment system in healthcare that can support better healthcare integration and team-based care delivery;

We must have a healthy and robust primary care system that is well prepared to help both the mental health AND physical health needs of our patients, families and communities; and,

We must start to modify our thinking about mental health as not just one isolated aspect of health. Maybe when we do, we can start to better understand what must be done to meet all a person’s healthcare needs.

Dr. Miller has his doctorate in clinical psychology and is an Assistant Professor in the Department of Family Medicine at the University of Colorado Denver School of Medicine where he is the Director of the Office of Integrated Healthcare Research and Policy. His core task is to integrate mental health across all three of the department’s core mission areas: clinical, education, and research. Opinions expressed here are his own and not those of his employer.

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  • http://www.spherit.com Spherical Phil


    Great information about what is going on.

    Agree we need a system to treat the whole system, but how can such a system come about when we don’t know, or at least don’t have a shared definition, of what a whole person is or what the whole of health is?

    And I will suggest that the issue is a bit broader than simply trying to integrate mental and physical health.

    What I really like was your comment that patient preferences in their care must be considered.

    But how can patient preferences be captured in a timely cost effective manner?

    But even more of an issue, how can patients come to know and understand the full range of care options available to them in a manner that the average, non-medically trained person can understand so they can make informed decisions?

    Great sentiments in your posts, but the challenge may be a bit more complex yet.

    Spherically speaking of course.