The Intersection of Physical and Behavioral Health Care

People often seek medical care when their underlying problem is an unmet behavioral health issue, and sometimes medical conditions fuel depression. Identifying the primary need is the first step to better care.

The patient sitting in Cheryl Frommelt’s office was obviously struggling. He was lethargic, unmotivated, had difficulty concentrating and making decisions – all classic symptoms of depression.

Before making a recommendation, though, Frommelt, a licensed clinical professional counselor, asked a few more questions to get to the bottom of what may have triggered his issues, including physical symptoms.

“I asked him how he’s been sleeping,” she says. “He said, ‘I sleep like a rock. I want to sleep all the time.’ Fortunately, his wife was in that first session with us and mentioned he was snoring for the last year.”

Frommelt told the patient she suspected there was a possibility he had obstructive sleep apnea, a condition that impairs breathing while sleeping, and he should speak with his physician. It can cause many of the symptoms Frommelt’s patient had, including chronic fatigue, sleep deprivation and depression. The man followed up and, according to Frommelt, “his doctor said he had one of the worst cases of sleep apnea he’s ever run across.” After a month on the CPAP machine, a device the patient wears while sleeping, the man’s symptoms resolved.

“This case could have gone the typical route of talk therapy and antidepressants, and I would not have been doing this patient any favors,” says Frommelt, clinical director of the Fox Valley Institute, a counseling center in suburban Chicago. “I see a lot of people who are depressed, anxious, less motivated, but they aren’t really aware of how their physical health affects their mental health. We can’t go right to diagnosing a mental health issue without making sure the patient has had a physical exam, too.”

Coordination is key

This type of coordination is essential as providers across the health care spectrum recognize that mental health and physical health are inextricably linked. About 18.5 percent of U.S. adults per year experience mental illness, according to the National Alliance on Mental Illness. About 68 percent of those with a primary diagnosis of a mental disorder also have at least one general medical condition. Likewise, about 29 percent of adults with a primary medical condition have an accompanying mental health condition, according to a Robert Wood Johnson Foundation report.

For Frommelt’s patient, a physical issue was creating the mental health problems. In other cases, the opposite is true: The patient may consistently be seeking care for what they believe is a physical problem when it’s actually a mental health issue.

“There was a belief not long ago that mental health and physical health had nothing to do with each other,” Frommelt says. “The shift came when the health care community studied the issue and saw research that shows people who have mental health issues are more likely to have more episodes and more severe physical ailments.”

The challenge for providers and others in the health care system is to identify the underlying issues — whether they are physical, mental or both — and get the patient the proper treatment.

Finding the people who may need help

Last year, Blue Cross and Blue Shield of Oklahoma launched a program that aims to do just that. It uses advanced data analysis to review insurance claims and identify those patients who are seeking medical care for what may be a behavioral health issue. These patients are typically heavy users of emergency departments for reasons that are not urgent. They tend to have a chronic but not life-threatening physical condition, such as arthritis or diabetes, and also an untreated behavioral health issue — such as depression, anxiety, stress or substance abuse — that needs addressing.

These patients are the silent sufferers.

About 2,000 Blue Cross and Blue Shield of Oklahoma members are now eligible for the program, and the plan is to roll it out to Blue Cross and Blue Shield of Illinois members in 2018.

“These patients are the silent sufferers,” says Dr. Conway McDanald, vice president and chief medical officer for behavioral health for the Blue Cross and Blue Shield Plans in Illinois, Montana, New Mexico, Oklahoma and Texas. “But with data analytics, we are now identifying a population that previously would not be identified as a candidate for true integration with a behavioral health care program. And when that care goes up, costs go down.”

Providing the skills to manage health

Once the insurer identifies eligible patients, they’re offered an intensive 52-week coaching and care management program. Jaime Pickett, a nurse and care coach for the independent company that provides the services, says her goal is to give people the skills to manage their life, rather than try to solve their problems for them.

“Meeting the patient where they are is so important,” Pickett says. “That means being non-threatening in our communications and establishing trust with them. We can’t make stressful things go away, but we can give them the skills to manage the stressors that cause them anxiety and set them up with psychiatrists for medication support.”

She and her colleagues are accustomed to getting calls from patients at all hours of the day and night, with issues ranging from the simple to the deeply complex. Pickett’s colleague Cheryl Wood, recalls one woman who used the program to overcome alcoholism and heavy marijuana use.

“When I enrolled her in the program, within a few days she began her sobriety and completely stopped her marijuana use,” Wood says. “At the time, it had completely destroyed her life and her family’s life. She grabbed on to every life-ring that was thrown to her.”

The patient kept her phone appointments with Wood, went to a psychiatrist and participated in group recovery programs. After completing the program, she decided to become a peer mentor for a sex abuse recovery group.

“I was proud to play a role in it, but she did the hard work and she did not relapse. Every time I talked to her, she had so much insight into her behavior and the dysfunction it had caused her family,” Wood says. “I never saw anybody work so hard to do the right thing. She was one of mine I will always carry with me.”

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