Steps for Ensuring Care at the Right Time: Initiating and Continuing Care as Needed

Many of us have lost loved ones to cancers diagnosed too late. Others have grieved losses due to interrupted care for chronic conditions like heart disease. The behavioral healthcare field has grappled with the reality that we mistakenly care for common problems like depression and addiction as if they were acute rather than chronic problems. Many of those problems go undetected for years.

We need to rectify this history of failure to initiate or continue treatment as needed. An examination of the clinical conditions themselves reveals some clues, but solutions for our field mostly lie elsewhere. As a clinical specialty that can be accessed directly or upon referral, our field looks like any other. However, is it appropriate to designate behavioral healthcare as specialty care?

Behavioral healthcare needs are primary care needs. Our field was new when primary care was developing in the 1960s. We were a minor focus then, but high prevalence rates and effective solutions now support making our field part of primary care. We can prevent many failures to initiate or continue care for behavioral health conditions by moving services to the primary care setting.

Initiating care when needed

It is common for people to start treatment too late or end it too soon. This is true to some extent for every healthcare specialty. All types of healthcare will be improved when we address some general impediments to accessing care. These solutions relate largely to how we organize and finance healthcare delivery in this country. Yet our field requires a unique solution as well.

Every behavioral healthcare clinician has interviewed a new patient who has seemed depressed and reported no previous treatment for depression. Patients have often lived for years with these symptoms being overlooked by loved ones and by PCPs who lacked adequate training. This has led to efforts to buttress the work of PCPs with training, consultation and various forms of collaboration.

Efforts to support the current system only make sense if it is fundamentally sound. PCPs have demanding jobs and they miss critical signs and symptoms at times. Yet the misses for behavioral health are different in kind and quantity. An entire class of issues, health behaviors, are fueling chronic diseases and being marginally addressed. Psychological distress silently motivates countless PCP visits.

The scope, depth and consequence of the behavioral issues being missed in primary care today exceed the ability of the best PCPs to meet the challenge. The problems have been known for decades. We now have PCPs dispensing 80% of the medication for depression. Unfortunately, many people get prescriptions they do not need, while others suffering from depression are still being missed.

Medications are a small part of the problem. People with pre-clinical levels of depression, anxiety and substance use are cycling through medical treatments as their conditions advance without interruption. This would require not just detection, but also a clinical conversation. Psychotherapy, or some brief variant of it, is well beyond the ability of the PCP, and most have no interest in such training.

We will detect many problems earlier and intervene more effectively for others by inserting behavioral health clinicians in the primary care setting. This is a major change that will require collaboration at an operational level, and the initial funding for such a transformation can only occur within healthcare systems with value-based financing. These changes do not fit the fee-for-service model.

Continuing care when needed

Long-term psychotherapy was once the norm for our field. Psychoanalysis launched this with its insistence on several years of treatment for the least neurotic among us. Brief therapy models in the 1980s broke that mold. They appealed to managed care companies but few therapists. Yet one idea was compelling: having brief, intermittent episodes of therapy across the lifespan.

No institutional structure was found to support such an intermittent therapy model, and so it is a relic of history. Yet the idea seemed familiar. It was reminiscent of primary care’s periodic check-ups. The clinical focus on coping with life’s developmental challenges was good. Yet brief therapy’s response to people in need of extended care was absurd: stop now, but you can return later.

Institutional support for this intermittent model now seems like a natural fit within the primary care setting. Chronic problems like depression need more than an acute treatment episode, but the extended meanderings of psychoanalysis or supportive psychotherapy are unnecessary for most people. Primary care is a sound, multifaceted model for long-term healthcare.

The other modification to continuous therapy is adjustment of the length and type of sessions. People do not always require 50-minute sessions, and digital exercises can be interactive and educational, much like personal therapy sessions. While some clinical models have prioritized the needs of clinicians or payers, the primary care model has aspired to be more patient-centered.

Two key strengths of the primary care model are that people return periodically, regardless of their perception of need, and concerns get identified for monitoring over time. These two built-in factors address our limitations. We are unable to predict when new problems might emerge, and we cannot predict which concerns dissipate and which deepen with time.

Ensuring better mental health and a healthier lifestyle

Academic or lengthy arguments rarely capture the public’s imagination. Straightforward and compelling statements are needed. A few key points stand out. PCPs are failing patients needing our specialty both in terms of detection and treatment. They miss signs and symptoms of illness due to a lack of biological markers to test. They lack a therapist’s interpersonal skills to resolve a multitude of issues.

Since they lack psychotherapy skills, PCPs cannot resolve the distress and maladaptive patterns people exhibit on a path to more severe clinical disorders. They cannot address the root causes driving chronic medical conditions since this would require behavior change skills. They can prescribe medications, but this fails to help people with a wide range of both non-clinical and diagnosable behavioral disorders.

Patients need a primary care system that promotes better mental health and a healthier lifestyle. The current system does not address total health. Physical health alone gets prioritized. Mind and behavior are critical sources of overall health, and we have clinicians who can help. Behavioral healthcare should be easy to access and stigma-free. We will reach that goal as it becomes a routine part of primary care.

Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.