Update, 2014: The finished (and still growing) Integration Academy website is here.
I’m en route today to New Orleans for a meeting about adding something back in to primary care that used to be there, a long time ago: care for behavioral and mental health issues. The project is to unite mental health with primary care.
It’s worth explaining why this is being fixed, and why I’m involved. First, please watch this presentation by Ben Miller of the University of Colorado, an expert voice in the field. It describes the NIAC (National Integration Academy Council), a new project of AHRQ, the Agency for Healthcare Research and Quality. This New Orleans trip is for a meeting of NIAC, of which Ben is a leader and I’m a member.
NIAC is the steering committee for AHRQ’s Academy for Integrating Mental Health & Primary Care:
The AHRQ Academy for Integrating Mental Health and Primary Care on Prezi
Why was this in the reform bill?
Some primary care practices – for instance, my doctor’s – already have counseling and psych services within the same “shop,” but that’s rare. There are several consequences, for instance:
- Getting such services requires an outside referral, which some people feel has a stigma attached to it
- Some insurance plans don’t count those separate practices as “in network”
- Doctors in non-integrated practices are less familiar with the basics, and may miss signs they might otherwise catch.
Aren’t mental and behavioral issues separate from physical health?
No; an immense body of research shows that they’re tightly connected. I wrote about this at some length in my book, and it’s such an important issue that it was given a full half day “town hall” session at this fall’s AHRQ’s annual meeting.
In a hallway meet-up the night before, my colleague Gary Oftedahl of ICSI described it as “rediscovering the neck.”
My role in the NIAC
I’m serving as a voice of the patient, the “customer,” to balance the perspectives of the 20+ academics, practitioners and advocates who are also serving. I applaud AHRQ and the NIAC leadership for this – I’m told that it’s pretty unusual for an ordinary citizen to be involved.
A personal note:
I started in the NIAC project without much sense that this was directly relevant to me. I mean, I’ve had counseling at times, and a couple of times I’ve had a shrink of one sort or another; but I too thought of it as “divorced” from my physical health.
But as I started to work on the project, and heard stories, I recalled my annual physical five years ago, in which one of my dozen agenda items was that for the first time in my life I’d been feeling down. In my note to Dr. Sands I phrased it that “For the first time in my life, I feel like my options are closing down, not expanding.” We discussed whether I might consider medication, and I said I didn’t know whether I really needed it because I had numerous life circumstances that would justify feeling down.
But he told me – correctly – that we used to distinguish between “situational depression” (based on life circumstances) and “endogenous depression” (something inside you physically), but “Now we know the biology is the same and the treatment is the same.” Isn’t that interesting? Whether the state of being depressed somehow arises in your cells or from your feelings, it’s the same thing and you treat it the same.
So he prescribed a mild antidepressant and I gladly took it.
I recently asked him, based on my NIAC work, how he (a part-time primary doctor) knew that. He replied, “We have mental health integrated here.”
As a final note of mystery, consider that a week after that physical, we discovered that I was dying of Stage IV cancer. How odd that my mood had been “For the first time in my life, I feel like my options are closing down.”
Of course, when my cancer cleared up, my mood was much better. We’ll never know how the depression arose, nor how it cleared up – but we do know it doesn’t matter.
And when the re-integration is complete in a few years, every patient in a primary practice will have access to the same care that I got.
Scott Strange says
I’m glad this is taking place, finally. While I didn’t have cancer, the life-long condition of diabetes has certainly played into my clinical depression.
The stresses associated with a long-term chronic condition, no matter which one, are finally starting to be acknowledged and addressed. Long-term, the mental and emotional issues can pile up leading to a decline managing your physical condition.
I hope no one else has to struggle to get all the care they need, not just the medical care. IMO, counseling should be a standard part of any diagnosis that is substantially life changing for an individual and their loved ones
e-Patient Dave says
Great item, Scott – I already passed it along to some of the NIAC team. Well said.
I have to say, I’m always puzzled when people dismiss their own conditions as “Well, it’s not like I have cancer.” Amazingly, I went from diagnosis to “all better – go out and play” in 7 months. You don’t have that luxury.
And besides, I’m an “anti-should” guy when it comes to facing ANYthing. In my view, if I (or anyone) face a rough situation – as I define it – then I need help! Hello, is there a mystery here?
To me it all comes down to well-being … as in, being well, or not. If I’m not well, and my own efforts aren’t working, I want help.
And yeah, a life-altering diagnosis ought to come with counseling, to help deal with it. That’s what they do with HIV testing.
Hm, thinking about that … it was the patient community that demanded that, wasn’t it??
Scott Strange says
Thanks Dave… I wasn’t really dismissing my condition as much as I was trying to acknowledge that we both are patients and our own conditions, or those of loved ones, are the most important ones to us.
I don’t understand what it’s like to have cancer and you don’t understand what it’s like with Type 1 diabetes. As long as we both understand that we don’t understand, that gives us a starting point… sounds kind of convoluted, but I find it works for me.
And I think you are right, help dealing with it all is what the patients demanded…
I would like to see more “treatment” for mental health problems solved with thorough medical examinations – find the physical causes – say of depression – treating the physical problem which may eliminated the mental “illness”, and using alternative treatments in place of the the prescribed medications. The medications can also cause additonal mental health problems. Medications can become addictive. They do not cure.
e-Patient Dave says
Hi Jill – I hear you; I’d just caution against an absolute statement that medications don’t cure. I don’t imagine you meant it as an absolute against all medications… and in any case, I imagine you do support the more whole-person approached implied by the re-integration of primary care with mind issues, yes?
For a long time, people thought that “hardware” (i.e., the brain) and “software” (i.e., thoughts) were separate. There is growing evidence that they are strongly connected, and thus the more one lives with a mental illness the more the hardware changes to support that illness. (Think of it as the mental analog of physical training.) Recent connections between nicotinic receptors and nicotine addition, traumatic brain injury and PTSD, and other disorders, not to mention positive software-hardware connections (e.g., motor learning and habit formation) show that there is a biochemical basis for things that we may internalize as “software” issues. Early intervention for problems like depression can prevent the formation of depression as a “habit”, and the better that we arm our front-line providers with the tools to address these, the happier we will be. For many mental health problems, there is a simple medicinal way to address the problem that can be applied quickly and based on the kind of assessment that a primary care doc could do. This would help reserve the experts for the more difficult cases and to help evolve the care strategy. I developed software for a project like this in depression and bipolar disorder for several years at Kaiser, and in a randomized trial we made a real difference.
Sue Woods says
Wonderful that you are involved, although you are no “ordinary citizen”. If the 20+ Academics want to have a participatory design, they need to bring additional patient voices in — in particular those who receive or received a good degree of care in our current version of mental health systems/providers.
e-Patient Dave says
I’ll pass that along, Sue.
Is there a website for the Academy yet?
e-Patient Dave says
Hi, JG – good to hear from you.
There’s not a website yet. Rumor says it’ll be up in a few weeks, which makes it January. If you subscribe here, or come back and check, you’ll hear about it when it’s live.