Some colleagues of mine were sitting around the lunch table in the clinic heating up leftovers and laments. “Primary care has become so complicated lately,” one commented. She felt that there was no way she could keep up with everything. She continued, “It would take me four hours to do one whole new patient exam. It feels like every week there’s something new to be asking or checking or doing. Some new screening measure, something else to counsel them on.”
Indeed, the time for a preventive medicine visit in primary care seems to be getting shorter and shorter with a whole new regimen of “evidence-based” screenings and procedures to take care of coming out every month. Don’t forget about advanced directives or other end of life planning. Some experts recommend separate visits for that. So, in this cacophony of possibilities, how do you know where to spend your time and your efforts? How can we focus our energies on what is most important and crucial to bending the cost curve of healthcare, improving health outcomes and satisfaction with services? We should let the data be our guide…
And the data are overwhelming conclusive: Behavioral health conditions, including unipolar depression, are the single greatest category of disability in the US and worldwide.1,2 Not only are they leading the way currently, but they’re trending upwards as we develop better public health infrastructure and overcome many of the other more traditional determinants of morbidity and mortality, including injury and infection. If we are to develop a healthcare system that rewards cost savings and health, it’s impossible to ignore behavioral health conditions. Persons with chronic diseases such as diabetes and hypertension are much more expensive to care for when depression complicates their presentation,3 and their outcomes and the healthcare system’s success in controlling their conditions are much lower.4,5
The USPSTF just released updated guidelines recommending depression screening in primary care of all adults and pregnant women, and referral to treatment. Some systems have noted improved recognition and management of depressive disorders when screening was implemented. Depression is manageable and treatable, and elegant models exist for primary care providers to partner with behavioral health specialists and psychiatrists to greatly improve depression care in their own primary care practices—instead of relying on the traditional and ineffective method of referrals and waiting. These models are referred to as Collaborative Care, and have a lot of evidence behind them.6 Patients as well as primary care practitioners like these approaches better since they create a conduit to evidence-based mental healthcare services more rapidly than traditional methods with existing workforce.
Behavioral health conditions are common and costly, and if they don’t impact your bottom line and success in achieving outcomes with your patients now, they will soon. With the litany of new screens and things to talk about, there’s good reason to focus on behavioral health. In the evolving world of healthcare reform, it just makes good business sense, even if it just seems like one more thing to bring up at the lunch table.
1. Murray CJL, Abraham J, Ali MK, et al. The State of US Health, 1990-2010: Burden of Diseases, Injuries, and Risk Factors. JAMA. 2013;310:591-608.
2. Prince M, Patel V, Saxena S, et al. No health without mental health. Lancet. 2007;370:859–877.
3. Simon G, Katon W, Lin E. Diabetes complications and depression as predictors of health service costs. Gen Hosp Psychiatry. 2005;27:344-351.
4. Park M, Katon WJ, Wolf FM. Depression and risk of mortality in individuals with diabetes: a meta-analysis and systematic review. Gen Hosp Psych. 2014;35:217–225.
5. Pan A, Lucas M, Sun Q, et al. Increased mortality risk in women with depression and diabetes mellitus. Arch Gen Psychiatry. 2011;68:42–50.
6. Archer J, Bower P, Gilbody S, et al. Collaborative care for depression and anxiety problems ( Review ). Cochrane Database Syst Rev. 2012 Oct 17;10:CD006525.