As Lt. Gov. Elizabeth Roberts said at the start of our 2011 Conference, “Healthcare today is like a deck of cards tossed up in the air. We have the opportunity to put the deck together in a new way, especially by building a better bridge between physical and mental health.”

While it may be difficult to get a handle on the overlap between physical health problems and emotional/mental health disabilities, what is known is that depression  (the most prevalent mental health disorder) is a medical problem that portends much worse outcomes for other health problems. Depression isn’t just in the head; it affects nearly every internal organ system adversely. Women are twice as likely as men to suffer from depression.

Suicide is the 10^th leading cause of death in the US and is recognized as a public health issue in RI even though the rate of suicide for women is below the national average. However, suicide rates for men are on the rise. The white population is most affected, although this population is least likely to live in poverty.

Good to Know

Depression has multiple causes. Some causes we have control over; others we do not. Preventable causes include: smoking, sedentary lifestyle, obesity, system inflammation and failure to report. But abundantly and strongly associated with depression is early childhood stress (abuse, neglect and poverty). Large-scale studies link this early life stress to many other preventable diseases.

Many risk factors for suicide are treatable but 80% of completed suicides went untreated. The number one cause of suicide is relationship separation or conflict. A program sponsored by the RI Youth Suicide Prevention Project focuses on core RI cities where more than 15% of children are living in poverty. Parents are taught how to suicide-proof their homes by such things as removing weapons and medication availability.

Recent studies show that some people are born with genes that protect them from depression and suicide no matter what their present or early-childhood stressors. Others have genes that indicate they are at greater risk.

Adverse social environments may impact physical and behavioral disease through epigenetic effects on genes that regulate physiological systems involved in stress and inflammation.

What blocks the bridge? Lack of access to universal healthcare. Access to good education. Decent housing. Stigma attached to mental health problems and suicide. Sensationalizing suicide by media.

Roadmap to Care

Both the fact and the perception of “maternal warmth” is a mitigating factor in all aspects of physical and behavioral health. We have the ability to improve preventive care by providing people with better resources to take care of themselves, their children and each other.

Because early childhood stress is implicated in both physical and behavioral health, Freud’s question, “Tell me about your childhood” turns out to be a relevant question with any disease.

Regardless of economic status, housing or education, we can improve resilience by intervening at an early age.  We may not be able to reduce poverty but we can lessen its effects on both physical and emotional health.

In Your Practice

A physical health provider writing an anti-depressant prescription and seeing the patient six months or a year later is not enough. Institute a “chain of care” for depression and other behavioral health risks. Primary care providers who screen for depression need to know where to refer patients for further evaluation and treatment. Screening is most beneficial when staff-assisted care and follow-up systems are in place. Screening tools from this website and other sources provide the first link on the chain.

Recommended:

• Initial screening
• Diagnostic interview
• Psychotherapy and/or medication and/or other integrated strategies
• Regular follow-up visits
• Treat as far as possible, including in-home psychotherapy

As Dr. Michael Fine, Director of the RI Department of Health, said at the start of our March 6, 2012 workshop: “We need to eliminate deaths from prescription drug overdoses.” RI has the third highest opioid pain-killer use in the country. And prescription drug overdose is now the leading cause of unintentional death in the state.

“Many, many people are involved with many, many prescription drugs, all prescribed by RI physicians and pharmacists.” These drugs are killing people. Dr. Fine’s goal is to work with the healthcare community to minimize misuse and still provide access to effective chronic pain management.

Good to Know

In describing the patterns of substance abuse in women, Panelist Catherine Friedman, MD, described it as an “exploding epidemic.” Opioids were available to women in tonic form 100 years ago and sold as “Mother’s Little Helper.” Women still tend to use prescription drugs as a coping mechanism. Teenagers get the drugs from their parent’s medicine cabinet. Pregnant girls have the highest rate of use, and the rate of depression is higher in opioid users. Also, the patterns are telescoping: users are more likely to progress from experiment to abuse and dependence in a shorter period of time; 3 years for women vs. 6 years for men.

RI has initiated a prescription drug monitoring task force, with the goal of creating a database to track all prescription medications prescribed and used, so that they can identify misusers earlier and intervene before they become addicted.

RI Medicaid has 175,000 members, nearly one-fifth of the population. Women with chronic pain use twice the number of services as men, at double the monthly cost. (Medicaid: Men $1200 average; women $2400).

Methadone has a much longer half-life than originally thought. It should be used with caution, especially when other opioids are prescribed.

Roadmap to Care

Allison Croke, MHA, introduced the “Communities of Care” program begun 2 years ago by RI Medicaid. This targeted intervention provides short-term case management, using an interdisciplinary team, for people who have used the ER 4 or more times in a 12-month period where chronic pain has been the significant driver.

The integrated treatment plan includes a pain management program, a team of supporters including a peer navigator, and self-responsibility combined with complementary care. Holistic nurses who are trained in outreach meet with the patient to develop their treatment plan. In addition to medication, the program supports the patient’s well-being with both physical and behavioral healthcare, chiropractic treatments, acupuncture and massage.

In Your Practice

Michael Maher, MD acknowledged that managing patients with chronic non-malignant pain is very difficult, and that “we are under-educated” about the drugs we are using. Originally there were no standards for how to manage patients on pain medication. Today standards include RI Department of Health Guidelines which require a physician and patient relationship, patient history and a physical exam.

Dr. Maher added strong suggestions for improved care that include determining the functional impact of the patient’s pain, and screening for substance use disorders. Other recommendations include:

• Patient responsibility contract
• History from pharmacies of patient drug use
• On-going screen for drug misuse, abuse or diversion,
• Urine screening
• Scheduled meetings

Providers should recognize that treating pain is not just about bringing down the pain number; it is about improving the patient’s functionality. Can they go out and take care of themselves in a better way? Do they meet functional improvement goals? Rather than just handing out the next month’s prescription, ask if this medication is helping. Because these are dangerous medications, “If they are not helping the patient, get them off it.”

The World Health Organization predicts that by 2020 the leading disability in women worldwide will be depression. Women are at higher risk for both depression and suicide. At present, twice as many women as men (17%) will have a major depressive disorder in their lifetime. They have more severe symptoms, including self-criticism, guilt, worthlessness, anxiety, low energy and interpersonal sensitivity. (Carpenter)

Suicide is an escape behavior; a way to get out of seemingly unmanageable problems, including the pain of anxiety, guilt, hopelessness, loss of status, job and money, and/or relationship separation or conflict. Both disorders reflect the additional risk factors for women: intimate partner violence, eating disorders and hormonal changes. (Jordan)

Patients with multiple physical and behavioral health problems often are treated by providers, who “don’t talk to each other and make the patient way worse,” according to Jane Hayward, CEO and President of the Community Health Center Association. When chronic pain, substance abuse and chronic mental health issues are combined in one patient, the costs of treatment are 7 times higher than with just one situation. People with chronic mental illness are likely to die 25 years sooner than the average.

In many practices, including Community Health Centers, legal precedents and payor policies lag behind new integrated care solutions, and can inhibit effective patient treatment. This is a compelling issue now because of the epidemic issues around depression and prescription drug misuse, increase in illicit drug misuse and the unmet need for affordable, accessible mental health professionals.

Also of note: no one system of care is right for every setting. Effective systems of integrated care must be culturally specific. “If you’ve seen one health center, you’ve seen one health center.” (Hayward)

Good to Know

Depression is linked to multiple factors: aging, genes, hormone changes, exposure to toxins, infectious pathogens, injury and inflammation. Early childhood stress is a powerful contributor, including low socioeconomic class. Evidence of abuse and neglect is visible in brain tissue; abuse and neglect leaves a biological scar, which indicates risk of chronic inflammatory illnesses, depression and suicide.

Conditions linked to depression include diabetes, obesity, smoking, alcohol and a sedentary lifestyle. These co-existing conditions should be treated together. (Carpenter)

Bullying often precedes sexual violence and suicidal ideation. Students who are bullied at school are at higher risk of suicide. Men are exposed to more physical violence; women to more sexual abuse. (Perez)

Suicide is like having a glass already filled to the brim; just one more drop of agitation from panic, anger, helplessness—and in that moment the scale is tipped towards self-harm. It is the ultimate expression of hopelessness: “There is no answer for me and I’m giving up.” (Jordan)

Roadmap to Care

Improved care from the Community Health perspective means increasing better outcomes and decreasing costs. Many patients require a level of complex care no one person can provide. Some basic principles for integrated care include

• Patient-aligned financial incentives that allow providers to do what they do best
• Real-time patient information sharing
• Multi-discipline care teams
• Networks of care

Rapid Access RI demonstrates one approach—an urgent care center designed to divert people from expensive and excessive ER use. The Providence Center is seeing good outcomes in their intersection of primary care and behavioral health care. The challenge remains: continue to look for ways to integrate disciplines and overcome legal and policy barriers, because “We forget that we need to focus on systems of care, not systems of silos.” (Hayward)

In Your Practice

When the potential for depression or suicide appears, learn as much as possible about the patient’s history of trauma and functional impairment. Initial screening questions are listed on the Pocket Cards created for this workshop: Screening for Depression which includes the patient self-screening form (PHQ-9), and the series of suicide risk assessment questions known by the mnemonic IS PATH WARM? The SAFE-T card details Risk Factors, Protective Factors, Suicide Inquiry and recommended Interventions.

Other questions recommended at the workshop include:

• Have you ever had a period in your life when you didn’t care whether you lived or not?
• How will you behave differently when your depression is better? What is the end point? How will you know?

Consider how to move from silos of care to integrated systems of care, where the approaches of PCP’s and therapists come together to create:

o   Improved physical health, including nutrition (i.e. vitamin D for depression) and exercise to change sedentary lifestyle.

o   Behavioral health care including sessions to raise hope and self-esteem, internalize qualities of maternal warmth and assume more self-responsibility.

o   Social health including support groups for depression and suicide survivors, peer navigators and an on-going care team.

o   Complementary activities including massage, chiropractic treatments, acupuncture for pain and improved energy, and light therapy to relieve depression.