To Improve Mental Health Care and Generate Cost Savings, Let’s Focus on Primary Care

By Richard L. Brown, MD, MPH

While it has been clear for years that millions of Americans with mental health disorders have suffered terribly from poor access to services, it sadly took the killing of 20 school children in Connecticut to galvanize concern about the state of mental health care in our nation.

Wisconsin Governor Scott Walker has proposed nearly $30 million in increased funding to improve mental health services in Wisconsin.  Funds would go to a new state office for children’s mental health, community-based services for seriously mentally ill adults and children, in-home counseling for children, and additional forensic units at Mendota Mental Health Institute.  Clearly, these funds are needed.

But we should make certain we do not lose sight of the concomitant need to improve services for the majority of patients with mental health disorders who do not receive specialty-based services.

In typical primary care settings:

  • Ten percent of patients have major depression, and about one-third to one-half go undiagnosed.
  • Patients diagnosed with depression often receive suboptimal care – for example, inadequate doses of antidepressants or inadequate changes in treatment when patients do not attain full remission.
  • Diagnoses of bipolar disease are often delayed for up to years while patients’ “inappropriate behaviors” wreak havoc on their lives and the lives of their family members and friends.

Research has shown we can do much better, and a large part of the answer is collaborative care.  Dozens of randomized control trials show depressed patients who receive collaborative care for depression have quicker and more complete resolution of depression than those who only receive typical care in primary care settings.  In nearby Minnesota, Project DIAMOND has found that collaborative care doubles treatment response (from 34% to 70%) and nearly doubles complete remission (from 30% to 53%) at one year.  Some studies suggest that collaborative care can be helpful for anxiety disorders and psychoses as well.

Collaborative care requires expanding the healthcare team with individuals who can spend more time with patients than typical primary care providers.  Those trained individuals (we call them “health educators”) administer standard questionnaires to gauge the severity of depressive disorders and assess for other mental health disorders.  They educate patients about depression, explain treatment options and instill optimism.  They deliver behavioral activation interventions, engaging patients in behaviors that lift depressive symptoms, such as exercising and socializing.  They contact patients regularly to maximize engagement in treatment and reassess depression severity regularly and “pull the alarm” when insufficient improvement suggests a need to reconsider treatment plans.

A rigorous study, updated for inflation, concluded that a $900 investment in collaborative care for each depressed patient yields healthcare savings of $5200 over the next four years.  That means for every dollar spent, net savings total $4.75.  If 10% of Wisconsin’s 420,000 Medicaid recipients are depressed (most likely, an underestimation), collaborative care could save the state $180 million over four years – enough to fund Governor Walker’s initiative six times over!

That’s what WIPHL is all about – delivering behavioral screening and intervention (BSI) services that improve public health while decreasing costs.  Please see www.wiphl.org for more information on how can make BSI routine in Wisconsin healthcare settings.


One Comment on “To Improve Mental Health Care and Generate Cost Savings, Let’s Focus on Primary Care”

  1. aviets says:

    As the wife of a chronically depressed person, I can see that collaborative care makes a lot of sense. My co-author and I are exploring what I think is a related idea – that of including key members of a patient’s close community in the treatment plan. Family members, close friends, teachers, and many others could have a significant impact on recovery from depression and other mental illnesses if only they were allowed to be brought into the discussion. -Amy Viets


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