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A Look at the Gaps in Mental Health Care – An Interview with David Shern, Ph.D.

Monday, March 24, 2014


shern-bio-pic_0We recently sat down with one of the nation’s leading mental health experts, David Shern, PhD. Here’s what he told Karan Singh ( about the past, present, and future of mental health:

KARAN: We’d love your opinion on how things have changed in mental health over the past 30 years and where the biggest gaps currently sit.

DAVID: We’ve made big strides in regards to the de-stigmatization of mental illnesses. These illnesses are now regarded as legitimate health conditions and we have an armamentarium of treatments available. I think that the Mental Health Parity Act and the Affordable Care Act reflect these changes. Although we’ve come a long way and made enormous progress, there are still some big gaps in terms of unmet needs. We continue to run up against problems that relate to the structure of delivery systems as well as the accessibility of technologies that we offer. There’s a huge gap in terms of what we know to be the need for services and the rate at which people receive those services.

KARAN: And what do you think are the causes of the unmet needs?

DAVID: We’ve historically discriminated against mental illnesses and addiction conditions in insurance coverage. Mental health treatments were not mandatory benefits, had higher co-pays, and experienced more stringent utilization management — all of which continued to discourage use. We’ve made some progress with the parity legislation, which states that if there is a mental health benefit offered, it has to be offered at parity to the general health benefit. We’ve also historically under-detected these conditions in primary care. Continuing public ignorance and the shame associated with these conditions are lingering influences on decreased utilization.

KARAN: Can you talk about how primary care is stepping up to help identify those in need of services?

DAVID: The most common mental illnesses are depression, anxiety disorder, and substance use conditions. Most people with these conditions don’t get into specialty care — they’re seen in primary care. Traditionally, these conditions have not been detected in primary care settings. Years of research and physician education has started to change this and the frequency of standardized screenings for mental health conditions in primary care is increasing. We’re not where we need to be — there is still substantial under-recognition of these conditions in primary care — but we’re making progress.

KARAN: What do you think is driving the integration of mental health into primary care?

DAVID: I think a few things. First, the availability of safe and generally effective medications has given primary care physicians a new strategy for addressing depression and anxiety. Second, the pharmaceutical industry has done a good deal of direct to consumer marketing which has further ‘normalized’ discussion of treatment. The pharma industry’s work aligned with advocacy organizations’ agendas, like Mental Health America, to continue work on de-stigmatization and public education. A third influence is the increasing realization that depression, anxiety and addictions are common and are great complicators in the management of health generally and other chronic illnesses specifically. Fourth, is the research and testing of brief, reliable, screening instruments, such as a PHQ-9, which makes the ability to screen so much easier.

KARAN: Within care settings, what types of intervention are you seeing work best once an individual is diagnosed?

DAVID: We have some good, strong science based models around depression treatment in primary care. The best models have been developed in organized care settings, like the Group Health Cooperative in Puget Sound. In over 30 randomized trials, we’ve seen that collaborative care programs in which a behavioral health caregiver is present right in the primary care setting is very valuable. By responding to an individual immediately, as opposed to a delayed referral to the specialist — which is rarely followed through for a several reasons — we can start to engage the person right away and help them understand what’s going on in treatment and what their options are. These programs have been shown to significantly reduce levels of depression for as long as 5 years.

KARAN: So as we get better at diagnosing in the primary care setting, how can we fill the gap between those treated and not?

DAVID: I think it comes down to more active care management, which has been hard to do because of the structure of our healthcare system — specifically with solo practitioners and small practices that don’t have the resources to offer immediate behavioral health support. We need to link people to things that help… things that are available anytime, anywhere, at an affordable cost. For these reasons, I’m particularly intrigued by technological solutions, such as and others, to try and fill that gap. Once perceptions of technology in terms of availability and accessibility are improved, I think we’re going to see a very important difference in access to help. I also think that linking people to natural support mechanisms in their community — getting people involved in their own health and the health of others — offers great promise for addressing some of the gap. We’re excited about the emerging role for advocacy groups, such as Mental Health America, to empower people to do more in terms of recovery for themselves with appropriate, professional support.

KARAN: What do you think is standing in our way from filling the gap?

DAVID: We’re getting better at using the PHQ-9 but it still isn’t like a thermometer or a blood pressure cuff . We have the evidence that care management strategies work but we need to have financing models to support them and the capacity to deliver evidence based care in terms of technology and personnel. When it comes to finances and capacity you have to be thinking about running a practice — how will you have enough volume to make these approaches affordable? I personally think for this reason and many others, we’re going to see a shift away from solo and small group physician care into organized systems of care like the staffed HMO model.

KARAN: I’d love your thoughts on why you’re excited about the Mood Matters program.

DAVID: I just think, and others in the field agree, that we need some new breakthrough technologies. For a long time, we focused on psychotherapy and pharmaceuticals and we’ve made important progress on both fronts but things like hold tremendous potential for closing some of the gaps that we just discussed. Part of the reason we’re excited about working with is that we see it as another element of the spectrum of approaches available that can make the community as a whole healthier. As we can collect data passively, we open up a whole new dimension for health that could make a big difference for people. I just think the right idea at the right time — and I know you do too.