I. Introduction
Rates of anxiety and depression have risen 25% since the beginning of the coronavirus pandemic.
The trend began well before COVID. From 2015 to 2019, prescriptions for antidepressants rose 38% for teenagers and 15% for adults. Drug overdose deaths broke records in 2021, just a year after emergency room visits tied to mental health surged more than 30% among adolescents. Suicide rates are on the rise.
Mental Health America recently released the 2023 State of Mental Health in America survey. It found 50 million American adults experience at least one mental illness. A quarter of them experience severe mental illness, and roughly 30 million Americans with a mental illness have not received any treatment.
A global pandemic combined with economic uncertainty, new technologies and addictions, changing social patterns, interruptions in schooling and education, as well as other traditional worries have pushed behavioral health challenges to terrifying new heights.
It’s something physicians and clinicians have seen coming, but one needn’t have an advanced degree to recognize the patterns. A poll last November commissioned by CNN and the Kaiser Family Foundation found that 90% of adults believe the United States is experiencing a mental health crisis.
The bigger picture, though, is much more intimate. National trends are merely a collection of smaller stories, each holding an entire universe of hope and fear and struggle and possibility. Behind every statistic is a friend, a neighbor, a son or daughter, a parent—a patient.
For years the Michigan State Medical Society and its members have practiced and researched new, creative, and trailblazing ways to better integrate behavioral health into the broader tapestry of patient care. That means better identification of challenges, better connections between specialties and sub-specialties, and above all, better access for the patients who stand to gain the most.
Behavioral health integration is hard work. The work that matters most usually is.
II. BHI for Patients Unpacked and Explored
The challenges aren’t obvious from the outside. Those who don’t practice medicine or work in health care might think the path forward is simple and straight forward.
Of course, it’s not. Stigma, workforce shortages, insurer and regulatory policies that incentivize silos of care, and unaddressed social determinants of health make change difficult. Resulting in a crisis swirling around a crisis.
So how do we fix it?
“A high percentage of primary care encounters involve psychiatric issues which, in primary care, we often address,” says Robert J. Jackson, MD (Wayne County), a family physician who’s treated patients in metro Detroit for decades. “The more complex problems, though, are best cared for by a team involving mental health professionals.”
When an office doesn’t have those specialists, patients might be referred to another provider or even an “800” number for an unnamed counselor.
Through his practice and a broad variety of service organizations and initiatives, Doctor Jackson and his staff are crafting a more integrated system. They’re not alone.
Eric D. Achtyes, MD, MS, DFAPA (Kent County), is Professor and Chair of the Department of Psychiatry at Western Michigan University’s Homer Stryker M.D. School of Medicine. He lives in two worlds where integration matters—helping patients and training the next generation of frontline physicians who’ll do the work in their own practices.
“Behavioral health integration expands access to multidisciplinary care teams—the core team consisting of the primary care provider, the behavioral health specialist and the consulting psychiatrist—thus improving the quality of care by increasing access to care and decreasing stigma of seeking care,” says Doctor Achtyes. “The specialists in primary care and psychiatry come together to provide patient centered care.”
Mental health challenges, like so many physical conditions, are often chronic conditions. The first stop for patients is typically their primary care provider. When primary care physicians identify a physical challenge that requires more specialized care, those connections are commonplace and more simple.
That hasn’t always been the case with mental health.
Why doesn’t it happen more naturally? Why is it still on everyone’s to-do list?
The unfortunate reality is that many practices—especially smaller practices—still can’t afford to have a behavioral health specialist on staff, and insurers’ policies too often create unnecessary barriers to care.
Additionally, there are still too few practitioners to adequately handle the explosion in crisis Michigan’s seen these last few years. According to a study from the American Academy of Child and Adolescent Psychiatry, 49 of the Michigan’s 83 counties don’t have a single child psychiatrist in practice. Smaller counties tend to bear the brunt of the shortage, which leads to entire regions without care—including the state’s Upper Peninsula.
According to Doctor Achtyes, a lack of residency slots contributes to the problem as well. In 2018, there were 1,180 active psychiatrists in the state, notably below the national average. Nationally, we’re already experiencing an estimated 6.4% shortage.
By 2025, the U.S. Department of Health and Human Services estimates that shortage will rise to 12%.
Angela L. Pinheiro, MD, JD (Clinton County), testified in 2019 at a special hearing on Behavioral Health convened by the Michigan House Appropriations Subcommittee on Health and Human Services.
Michigan’s current public mental health system is focused mainly on those with serious symptoms and diagnoses who also have had a significant functional decline, she told lawmakers.
“Relying solely on that approach is akin to treating individuals only after the first heart attack or treating those with opioid use disorder only after an overdose. Research tells us that prevention, early identification, and aggressive evidenced-based early intervention is essential if we hope to positively influence the course of the disease and impact the rate of disability.”
To Doctor Pinheiro’s point, research shows the rate of recovery and full-time employment for those developing schizophrenia spectrum disorders can be doubled if appropriate treatment is offered within a few weeks of onset of psychosis.
The World Health Organization recommends treatment begin within 12 weeks. In Michigan, treatment typically takes more than 52 weeks—a full year—to begin.
Similar studies show similar outcomes with other mental health challenges, as well. A lack of screening, early identification, and the unavailability of treatment has a real world impact on real people.
“Without developing an integrated system to ensure early and seamless access to appropriate treatment and level of care, physicians and advocacy organizations like the Michigan State Medical Society will be left asking for help year after year to stem the consequences of a fragmented mental health system,” Doctor Pinheiro warned the committee.
III. BHI for Providers Unpacked and Explored
Integration has a compounding effect, too. Patients who need help receive it more quickly and effectively, and that means primary care providers can treat patients more efficiently, as well.
Doctor Achtyes points to research showing many primary care providers feel less comfortable caring for patients with psychiatric conditions due in part to gaps in their training. Many of those providers felt much more comfortable with the support of a mental health professional, especially a psychiatrist.
“Unmet mental health needs only increase the visits to the primary care providers,” said Doctor Achtyes. “Integration of care, or collaborative care, decreases the primary care provider burden by referring the patient to the collaborative care model which provides timely access to mental health services. This also makes the patient visit to the primary care provider more productive by focusing more on the physical issues in the time allotted and by being able to refer the patient to collaborative care for quicker access to mental health care.”
Even before the pandemic, MSMS was on-the-ground in Lansing educating lawmakers and their policy staff about the intricacies of integration, and advocating on behalf of our local communities.
“Such access requires a seamless, integrated system responsive to the needs of patients across the entire spectrum of symptom severity,” Doctor Pinheiro, a board-certified psychiatrist and Medical Director for Community Mental Health for Central Michigan told lawmakers. “A system grounded in collaborative care and evidence-based approaches provides the expertise necessary to treat patients who are experiencing mild to moderate symptoms where they are most likely to seek care combined with the ability to rapidly access subspecialty care to effectively intervene when symptoms become more severe and returning care oversight back to the patient’s medical home when symptoms have stabilized.”
Doctor Pinheiro’s work to educate policymakers hasn’t slowed down in the years since she first testified.
“Unfortunately, politics have taken center stage,” she says. “Solutions require innovation, with the focus on the patient from all parties—insurers, physical and mental health providers, health systems, organizations that help with social determinants of health, advocates, the state, the Legislature and others.”
Easy, right?
Maybe it’s not as hard as it sounds.
“I am personally involved in working with other states where stakeholders have humbly come to the table,” said Doctor Pinheiro. “They’ve agreed on the issues and are ready to do what it takes to innovate and integrate care. It has been so very exciting!
“I have seen the strides the field and the local health systems have made, however most, if not all, have been internal to their practices or physical health community. I have also seen many, many terrible outcomes resulting from lack of innovation and integration between the physical and mental health systems.”
IV. The Path to Progress
What might that look like in Michigan?
The Michigan State Medical Society and its members have spent years exploring, researching, and crafting the framework.
A series of Guiding Principles (see sidebar) have informed their work: 17 ingredients for a brighter future. Michigan physicians agree that efforts to improve behavioral health services must address stigma, cultural competency and disparities. They agree that patients should receive the care they need at the place and time that’s right for them. They agree that the core components of effective clinical models include patient engagement, patient education and support, medication management and psychotherapy as clinically indicated. They’re united around much more.
Getting the physician community on board with principles and a path forward is one thing, but getting payers and policymakers along for the ride is an entirely different process.
To that end, physicians have settled on four key pillars they agree are necessary to support the kind of integrated service delivery structure that would make a practical difference during a time of spiraling mental health crisis.
They’re asking insurers to support primary care providers in the delivery of mental health services by turning on the codes for the Collaborative Care Model.
Over 50% of all mental health care is already delivered by a PCP, and 70% of all primary care visits have mental health drivers. Giving those physicians access to psychiatric consultation is essential since most don’t have extensive clinical training in behavioral health or are not effectively familiar with short-term therapeutic interventions.
The collaborative care model—or CoCM—is an evidenced-based model that has shown superior efficacy to treatment in over 80 randomized trials. It’s based on systemic screening, treatment to target concepts and uses a team approach with a PCP overseeing care. Behavioral health care specialists provide care management and short-term interventions and a psychiatrist acts as a consultant, reviewing diagnoses and medication regiments.
It’s a system that allows a single mental health care provider to care for many times the patients he or she may otherwise be able to treat.
The truth is, referring patients out for mental health care is not always effective. Over 50% of patients referred do not follow-up and only approximately one-third engage in ongoing treatment.
Getting them the help they need immediately, through the providers they know, trust, and have already approached, can make all the difference—if the policy and payer framework would only let them.
Second, physicians are encouraging reformers to enable the primary care provider to be central in the referral process for subspecialty mental health care through Community Mental Health (CMH) while providing standing to appeal an adverse determination.
Doctors need the ability to better advocate for their patients when critical care is denied.
Third, evidence-based mental health and substance use screenings and early intervention should be encouraged and routinely available to persons of all ages including children and adolescents prior to any functional decline.
Expanding access to care earlier in the process—or before the challenging process even begins—can save lives.
Finally, physicians agree that billing and coding policies are needed to enable doctors, psychiatrists regardless of setting, and other providers to be reimbursed for providing more cost-effective team-based and integrated care that includes screening, case management, consultation, and other related care.
Primary care physicians know they can make a difference. They know they can improve the health and wellbeing of their patients and their communities. They know how to do it. Unfortunately, the current system makes it difficult to integrate care in a meaningful way.
Previous attempts at reform have fallen short over disagreements around the financial model for integration. Physicians want what’s best for their patients.
The Michigan State Medical Society has advocated that Lansing first determine the clinical model and recognize the role of primary care. The Society successfully advocated for the collaborative care model to be included in last session’s Senate BHI package. Unfortunately, the Legislature adjourned without finalizing its work on this issue.
Progress is possible.
A patient is experiencing a mental health challenge. They visit their primary care physician. Primary care practices have the support and the information they need through the availability of consults and easy referral paths. Practitioner shortages have been addressed. Residency slots filled. Care integrated. Social determinants of health addressed. Care and treatment covered by insurers.
One visit starts the process moving, and roadblocks have been cleared away. Services. Treatment. Saved lives.
Imagine the relief. Now let’s achieve it.
Resources
1. COVID-19 pandemic triggers 25% increase in prevalence of anxiety and depression worldwide (who.int)
2. 90% of US adults say mental health is a crisis in the United States, CNN/KFF poll finds | CNN
3. The Implications of COVID-19 for Mental Health and Substance Use | KFF
4. The State of Mental Health in America 2023: Adult Prevalence and Access to Care – NextStep Solutions (nssbehavioralhealth.com) 5. 90% of US adults say mental health is a crisis in the United States, CNN/KFF poll finds | CNN
