Dr. Gary Proctor
Regional Chief Medical Officer
Carelon Behavioral Health
What kind of mental health and behavioral health issues are faced by patients with chronic disease?
In general, patients with chronic medical or physical diseases have the same array of behavioral health disorders as the general population. That could range from bipolar disorder and schizophrenia, to more common conditions such as major depression and anxiety disorders.
Statistically the incidence of anxiety disorders and depression are higher in patients with chronic disease. There's a lot of comorbidity between the two. Diseases such as cancer, diabetes and heart disease often have coexisting depression. Patients with asthma and respiratory disease experience anxiety due to their struggle to breathe.
So anxiety and depression are the more common behavioral health conditions. But really, it could be anything that is seen in the general public. These conditions complicate the treatment of the physical illness.
Last December was Diabetes Awareness Month. Do diabetic patients face unique mental health challenges?
Sure, depression and the psychological aspects of living with chronic illness. Individuals live with the constant awareness of coping with illness and worrying about the integrity of their their body. There are many psychological issues that accompany diabetes, COPD, kidney disease and other chronic conditions.
Medications also are a factor. For example, a diabetic on insulin may be having a reaction when their blood sugar is too high or too low. They also can have anxiety resulting from a drop in blood pressure, sometimes even a panic reaction.
COPD patients can definitely have depression. With any breathing disorder, you can have anxiety due to being short of breath and not getting enough oxygen. It's common to feel anxious because if we imagine holding our breath for a minute or longer, to the point your body starts to crave oxygen. It's like, hey I'm getting pretty anxious here and I'm fighting for oxygen. So, you know, some of the lung disorders – asthma, COPD – can have anxiety in addition to depression.
For caregivers, how do we recognize that a friend or family member might need behavioral health services?
If there's a change. If the loved one or whomever you're caring for isn't how they used to be. Maybe they're crying more or they don't get out of the house like they used to. They're not interested in things that used to interest them. You see a change in their behavior or personality. Those are signs that suggest something is different here, something's not right, and we may want to look into it.
Medication side effects also can affect mood and behavior. Patients may be dealing with multiple symptoms, feel fatigued and sick, so they slow down on their daily activities.
But when people start to decline in their functioning, there may be a coexisting behavioral health disorder. For example, somebody is struggling with cancer and the chemotherapy meds are knocking them for a loop – making them tired and sick. But on top of it, they're getting depressed and they don't want to do the things they used to do. They're not hanging out with friends or family.
So it's not about your patient still doing the fun things they used to or still being interested in hobbies. What you're looking for is a change – a change in their behavior, a change in their attitudes. Sometimes a change in their thinking. And then in particular, also a change in their daily functioning.
How can the healthcare system do a better job of recognizing patients who need behavioral services and intervening to get them the right care?
I think the treating providers – primary care physician, nurse practitioner, PA or specialist – need to get comfortable with asking sensitive questions. In the physician’s office, they should probe beyond physical symptoms. They can ask about mood, depression, anxiety, suicidal ideas or anything else.
The first step is recognizing the underlying behavioral factors. A patient may be struggling with such issues, but will not bring them up unless asked. So our first priority is recognizing that behavioral factors exist and asking the right questions.
There also are formal screening tools. In addition to routine screenings for cancer and other diseases, we should perform screening for depression and anxiety.
Behavioral health evaluations and screenings should be routinely administered, just like medical testing. If somebody has depression, it shouldn’t carry a stigma. If you have a gallbladder problem or diabetes, most folks are willing to talk about that. But if you have depression or anxiety, patients may be reluctant to talk about it with their primary care doctor.
So really it's asking those second- and third-level questions to make sure you’re doing a good job of evaluating for behavioral health disorders. And that includes alcohol, drugs and prescription medicine abuse.
In the population as a whole including those struggling with chronic medical illnesses, sometimes they'll use alcohol or other substances to self-medicate. So we want to make sure we talking about that in the primary care office.
Are new care models emerging to help primary care doctors screen for and treat behavioral health disorders?
One of the newer models is collaborative care, which is in response to the shortage of behavioral health clinicians. The traditional model is for the primary care doctor many times to refer their depressed or anxious patient to a psychiatrist. However, that doesn't work these days because of the high demand and low availability of psychiatrists.
Under the collaborative care model, the primary care doctor is responsible for physical health and whole-person care. They also address behavioral health, but in consultation with a psychiatrist. The psychiatrist guides them and educates them on the most appropriate treatment, including drug therapy, for the patient.
What do you think about the effectiveness of newer treatment modalities like telehealth, telephonic care and virtual, as alternatives to a face-to-face visit?
The good thing about telehealth is it provides access in rural and remote areas which have a shortage of behavioral health providers. You can see somebody on the other side of the state – it really doesn't matter geographically where they're at, as long they have the appropriate license and training. So telehealth really helps with geography.
Telehealth appointments also are convenient for single parents and those with transportation challenges. If you're a single mother with three kids, you can't just take off two or three hours and drive to an appointment.
Another benefit of telehealth is fewer missed appointments. The patient doesn’t have to deal with travel, paying for gas, finding child care or whatever. So there's a higher percentage of people who keep their appointments and fewer no-shows.
Telehealth has proven to be just as effective as in-person therapy. Some people still want a face-to-face appointment. It's comfortable when the patient and clinician have a relationship. But telehealth can be a good alternative.
Another emerging approach is computer-based therapies. You're not working directly with a clinician, but instead with an avatar or program. The clinician’s role is checking in and monitoring. The patient goes through modules of training, answering questions and doing activities based on their responses and evidence-based best practices.
Computer-based cognitive behavioral therapy (CBT) has been helpful in certain circumstances. Not everybody likes it or is willing to do it. But it's just another tool that can help, especially if there is limited access to a face-to-face or telehealth appointments.