For a decade I struggled against pain. Chronic, often debilitating pain. I cried the day I bought seat adapters to help me sit; I felt I was crossing from healthy to disabled. The pain upended my life: I was at the top graduate school in my field and couldn’t make it through a work day without sneaking off to a corner to lie on a bench. I couldn’t cook dinner and also clean. I couldn’t drive so had to take jobs near my home, or homes near my job. I’d lived in Europe and had plans to live in Asia and Africa but cars and planes were hell, and I needed my doctors.
I drained my meager salary into primary care doctors and specialists, surgeons and strange monks who channeled energy flow. No one could find a cause for the pain, so I lived with unending fatigue, loss, and deep fear — no, terror — that I’d continue getting worse. The moment I stepped into a car I’d start thinking constantly about how much pain I’d be in by the end of the ride. Pain interrupted my sleep. I wondered, if I ever recovered, if my boyfriend would still like the other me, the original me.
In ten years of severe chronic pain the closest any doctor ever came to addressing my mental health was to suggest I try to do less, and instead watch more TV.
I believe that mental health is a critical part of human life. I believe that most people miss the triggers and needs for mental health and bury them to focus — at best — on physical well-being. I believe that mental healthcare should be incorporated into patients’ care at the moments they need it most, even if they do not yet know they will need it.
We are just beginning to understand the full benefits of quality mental healthcare. As in most cases, with mental health the money speaks louder than the philosophy. Employers are at the frontlines of healthcare cost and innovation, and recent financial data indicates that depression costs employers $17 per employee per year. The COVID-19 pandemic is estimated to cause a 50% increase in prevalence of behavioral health issues in America, leading to expected cost increases for employers of $100 billion to $140 billion in 2021 alone. Lost productivity for those with depression costs employers an additional estimated $109 per employee, more than 10x the cost per employee with diabetes (which receives far more attention).
Adding to the impact, these costs compound: the costs for an employee with diabetes increases $2,000 to $5,000 per year if that employee also has depression. As major health insurers bring together claims data from medical and mental care for the first time in decades, they are discovering that any member with a chronic medical condition plus a mental health condition costs thousands of dollars more per year than those with only the medical condition — nearly twice as much. With multiple chronic medical conditions, or when the mental health condition is substance abuse or a severe illness, the cost increase is far higher.
According to the CDC, 6 in 10 people in the US suffer from one chronic condition and 4 in 10 from multiple chronic conditions (not including mental health conditions). With 1 in 5 adults experiencing a mental health condition prior to the COVID-19 pandemic (before the 50% increase), and prevalence higher in those with a chronic medical condition, the cost impact will be stunning.
Mental health challenges decrease patients’ ability to adhere to medication and other therapeutic regimes, and to live healthy lifestyles. But medical and mental health conditions exacerbate each other through both behavioral and chemical effects, so no matter how diligent a patient or provider works to live a healthy life, it may be futile while the mental health condition is left unaddressed. I believe that quality of life will increase and cost of care will decrease when we begin educating and offering mental wellness support to every patient at key trigger moments like a new diagnosis or an event that changes their identity.
I know a young woman named Molly who was a contemporary dancer until she injured her knee. She was the star, the soloist under the spotlight during the grand finale. She was to be a professional, famous, until her dreams crashed to a halt.
When the pain and tightness in her leg didn’t go away, her doctor pressed on her muscles and swiveled her leg. Molly grimaced. There was surgery and then physical therapy, and the surgeon said she’d be back to normal in six months. Dancing? Well, normal for normal people: make dinner, walk to the bus stop. Dancing, probably not for years, if ever, and certainly not as a profession. Why, did she want to be a dancer?
Molly didn’t do dance; she was a dancer. Her friends were dancers. Her magazines were about dance. She struggled to do the physical therapy — what was the point if she couldn’t dance? She hated seeing her body in the mirror, the body that had failed to be a dancer, that looked less and less like a dancer’s. She couldn’t watch dance performances or read magazines or talk about her former dance idols with her former dance friends; they made her heart ache. Molly had the best surgeon in the city. She had the best physical therapist for the most complicated cases. She did not have a therapist; after all, her injury was physical.
I believe Molly would be happier, healthier — and have lower healthcare costs long term — with mental health support. She does not know she needs it. Neither, apparently, do her primary care doctor or her surgeon.
Every time someone is diagnosed with a life-changing health event, their mental burden spikes. The greatest struggles come when identity must shift. Diabetes. Cancer. Chronic pain. Death of a loved one. Becoming a parent. Aging. An injury that prevents work. Disability.
I believe that at these trigger moments, each individual should be offered mental health support. We should explain the value: people like you who experience this are much happier and healthier if they take advantage of this care. We should make it easy: here’s a simple service to get connected to quality, covered care. We should make it normal.
When I worked in East Africa, volunteers were trained to counsel all patients who were diagnosed with HIV, a disease whose burdens they would have to manage every day for the rest of their lives. Medication adherence. Behavioral adaptations. Social stigma. Checkups. No patient was given a diagnosis or treatment without a counseling session. Counseling was embedded in the patient journey, even at the most rural clinics that lacked reliable electricity and specialized staff. No matter how long I work in the United States, I am still surprised at how many challenges facing developing countries are still so prevalent in our healthcare. If they can master this, we can start doing it too.
While I was living in Switzerland, one doctor I visited told me to give up on finding a cause or cure and take more pain medication because he couldn’t help me. The next doctor also said he couldn’t help me, but he recommended a book on chronic pain. It cost $90, but I bought it. In that book I began to learn how anxiety increases tension which increases pain. I learned about fatigue and loss and depression exacerbating pain. Slowly, over the following years, I became more aware of this in my own body. I was also better equipped to find people who helped — physical therapists and trainers who talked to me about my hopes and fears and feelings. When I began to work in mental health, I thought it would be like working in diabetes or hip replacements — an interesting field that impacted my friends — but instead found myself in the most personal domain of medicine I’d ever encountered. I had names now for the challenges I’d faced and the tools I’d found, so painfully slowly, to overcome them. I had been lucky to find my way at all.
Our patient journeys need to change; let’s start now. Start with primary care, with collaborative care. Start with triggers in the EHR. Start with basic education and tools for primary care providers and nurses (and physical therapists!) so they can identify, educate and refer their patients. Start with covering therapy and encouraging its use, including in collaborative care: an easy-to-access provider network, in-network, well-paid, with quality digital tools. It’s time to live and heal better, and cheaper.