General (physical) healthcare includes management of chronic medical conditions like diabetes, obesity, heart disease and hypertension. Behavioral health includes mental health issues (anxiety, depression, Schizophrenia) and substance abuse (use of drugs and alcohol abuse). Behavioral health issues prevent a person from getting adequate treatment for their medical conditions and causes frequent hospitalizations.
As a result, people who have both medical conditions and behavioral health issues may die lot earlier than those without behavioral health issues. Integrated healthcare is coordination of general/physical healthcare and behavioral healthcare and is the most effective approach for caring people with multiple healthcare needs and shown to have best outcomes.
Integrated healthcare is mostly done in the outpatient setting through patient’s primary care physician. For patients’ hospitalized with medical problems and who have associated behavioral health issues, integration of healthcare should start during their Emergency room visits, hospitalization and at discharge with appropriate referrals.
Dr. Madhu Sudhan Reddy Badireddy an NRI physician associated with Christus Santa Rosa Hospitals/Sound Physicians, San Antonio, Texas, United States, has been focused in his approaches of integrating behavioral health with general health. Earlier, he served as Senior House Officer in Psychiatry in the UK, as well as served as a physician in the Victoria Infirmary in Glasgow, UK. As a Hospitalist (primary care physician in the hospital), Dr. Badireddy’s efforts have been pioneer in this global health issue. Recent interview with Sreerupa Patranabish elaborates on the above perspective.
SP: Welcome Dr. Badireddy
MB: Thank you
SP: Why is behavioral and mental health integration necessary in our health care system?
MB: The mind and body interaction have been an age-old factor in living a healthy life. How we live our lives (behave), and our physical and mental health interact in complex ways. One-third of patients with a chronic medical problem have a mental disorder and about two-thirds of patients with behavioral health disorder have a medical condition. This means, a person with a chronic medical disorder is at risk of behavioral health disorder and vice versa. Bringing them together in treatment improves outcomes, decreased costs and healthier people. Integrating behavioral health care with and general healthcare is now a part of the health care system across the globe and specially in the United States.
Patients with mental illness are more likely to have chronic diseases like high blood pressure, heart disease, diabetes, and obesity. Lack of integrated care causes higher mortality and increase healthcare costs 2-3 times in these patient population. Screening and counselling of hospitalized patients for behavioral issues like anxiety, depression and substance abuse is of paramount importance. Some healthcare organizations have taken lot of initiatives to promote integrating the cares. Despite the evidence and initiatives, not all patients especially those admitted to hospitals, receive necessary screening to identify the behavioral health issues.
SP: How do you integrate behavioral health in general healthcare or primary healthcare?
MB: The first assessment that I emphasis is addressing both physical and behavioral health care. The integration can be screening, diagnosis, treatment of their chronic medical illnesses, stress-related physical symptoms, and monitor various crisis of ineffective patterns. Initially in my career, I received training in psychiatry in the UK and later completed Internal medicine training in the UK. As a result of my both trainings, my expertise in behavioral health as well as keen interest in primary care clinician merge and this helps to work together with patients and their families for making a systematic and cost-effective approach to behavioral health integration. Primary care can address this whole system, which is important aspect of this critical health issue. Many organizations have now supported this approach to integrate behavioral health.
The American Psychiatric Association, the American Society of Addiction Medicine, the American Psychological Association, and the American Academy of Family Physicians have supported policies for integration of medical care and behavioral health. For example, maternal depression can significantly affect childhood cognition. Improved cognition and avoidance of delirium significantly prevents fall of adult and elderly patients in the hospital, culminating in adherence of Joint Commission guidelines and significantly enhancing the standards of care. All of these have significantly enhanced the practice for the special care for behavioral health. The primary care setting is definitely the point of care for this integration.
SP: What are the major crisis you face in the integration of behavioral health and what are your solution methods?
MB: The integration of behavioral health can have both administrative and financial constraints. The major problem is that lack of behavioral health knowledge in primary health care physicians can cause hindrance in the care. The traditional medical and mental health treatment are different. Regulatory restriction can often cause conflict in the treatment, which is an administrative crisis in the healthcare system.
The first step is to understand the physical, mental, behavioral, and social conditions that can affect patient’s overall wellness. Behavioral services support chronic pain management offerings, managing chronic illnesses, offering specialists for counselling programs and coordinating wide array of treatment plans tailored for each individual patient as all have different crisis and problems. My initiative for behavioral health integration improvement includes assessing common mental health conditions, talk to patients who are in crisis, preventing suicide, and also discuss with patients who have substance use issues. It is a total team work of physicians and staff, which can improve the conditions in this major crisis.
SP: What are your thoughts for improving behavioral health in our health care system?
MB: My first concern is the cost of behavioral treatment which can be addressed by various policies and programs in the health care system. The coordination of the primary care physicians and behavioral health specialist can improve the quality of the care with accurate patient treatment. Patient care cost with behavioral health problems including both mental illness and substance abuse disorders can be two to three times as much higher than those without them.
By enabling motivational counselling and cognitive behavioral therapy, much improvements can be seen in patients with depression, anxiety which can help reduce their chronic problems also. For example, utilizing Cialdini’s principles of persuasion can be used to motivate patients with depression or adhere to smoking cessation. Complex or urgent cases should be addressed by a psychiatrist. The implementation of The Collaborative Care Management can improve the health conditions of these patients. While there are still barriers for integration behavioral health and primary care, there are also several positive initiatives encouraging it with new payment policies, especially in the United States, which can improve the behavioral health integration.