How Collaborative Care Is Improving Mental Health Care
Studies show improved outcomes for complex medical and mental health problems.
Posted Sep 19, 2019
Emerging collaborative care models that include evidence-based CAM therapies will more adequately address complex challenges of mental illness
In a previous post I commented on the limitations of both conventional and CAM treatments of mental health problems and limitations of the conventional model of mental health care. I argued that collaborative care, in which patients are seen for both medical and mental health problems in the same visit, more adequately address the complex challenges of mental health care. Collaborative care is especially important given that many individuals with depressed mood, anxiety, bipolar disorder, schizophrenia, and other serious mental health problems also abuse substances or have a medical problem. In this post, I describe frequently occurring ‘comorbidities’ of mental health problems, substance abuse, and medical disorders, and briefly review emerging research findings showing the advantages of collaborative care that includes evidence-based CAM approaches improve outcomes as well as cost-effectiveness and patient satisfaction. The information in this post is based on articles published in peer-reviewed medical journals. A complete list of references is provided in the reference section below.
Patterns of comorbidity between mental health problems and substance abuse
Mental health problems are frequently comorbid with substance abuse. For example, alcohol, stimulants (e.g. cocaine and methamphetamine), hallucinogens and Cannabis can cause mental health problems or worsen problems that already exist. Panic attacks are a frequent result of stimulant use but also occur during withdrawal from stimulants or sedative-hypnotic medications. Stimulants or hallucinogens can result in psychotic symptoms that mimic schizophrenia. The use of inappropriate high doses of prescription psychotropic medications can also result in mental health problems such as panic attacks, psychosis, severe depressed mood, mania, and insomnia. It is estimated that 4 out of 10 young adults diagnosed with a severe psychiatric disorder have a co-morbid substance use disorder (Sheidow 2012). Individuals diagnosed with bipolar disorder, major depressive disorder, anxiety, and psychotic disorders or severe personality disorders frequently abuse substances. Individuals diagnosed with major depressive disorder, ADHD and borderline personality disorder are also at increased risk of abusing substances (Huang 2009; Swendsen et al 2010). In individuals who have a mental health problem and a substance abuse problem combining two or more treatments is often more effective than single treatments (Baker 2010).
Patterns of comorbidity between mental health problems and medical disorders
Severe depressed mood, anxiety disorders, schizophrenia, bipolar disorder, post-traumatic stress disorder (PTSD) and other serious mental health problems often occur together with and can contribute to medical disorders. Even as mental health problems can worsen medical disorders, medical disorders often manifest as disturbances in mood, cognitive functioning or behavior. Primary disorders of the brain such as multiple sclerosis, Parkinson’s disease, dementia, cerebrovascular accidents (i.e., ‘stroke’), and seizure disorders, can cause complex mood, cognitive and behavioral symptoms depending on the stage or severity of disease and brain regions involved. Heart disease, cancer, pulmonary disease and endocrinologic disorders indirectly affect brain function. Discrete symptoms caused by these medical problems depend on how the disease process interferes with normal brain function (David 2009).
Roughly one-third of individuals diagnosed with cancer meet diagnostic criteria for at least one psychiatric disorder, including major depressive disorder, anxiety disorders, adjustment disorders, sleep disorders, and delirium. Prevalence rates of psychiatric disorders are even higher in individuals with advanced cancer (Grassi 2014). Comorbid mental disorders reduce the quality of life, interfere with treatment adherence and (in the case of depression) may affect the rate of cancer progression (Ciaramella 2012). Mind-body therapies, meditation, yoga, Tai Chi, acupuncture, massage, energy-based polarity therapy and Reiki, and select natural products have beneficial effects on cancer-related stress (Chandwani 2012). Individuals with chronic obstructive pulmonary disease (COPD) are at increased risk of depressed mood and anxiety (Yohannes 2010). One-fifth to one-half of individuals with heart disease are also depressed and individuals who have had a heart attack are 3 times more likely to be depressed compared to the general population (Raic 2017).
Chronic depressed mood may result from diabetes and other diseases that affect normal insulin secretion manifesting as dysregulation of the body’s ability to metabolize carbohydrates. Depressed diabetics are at higher risk of coronary heart disease (Forrest et al 2000). Diabetes is also associated with significantly increased risk of cognitive decline, stroke and vascular dementia (Strachan et al 2003). Hypothyroidism caused by dysregulation in the thyroid or the pituitary-thyroid ‘axis’ is associated with impaired concentration, depressed mood, forgetfulness, physical and mental fatigue, and in severe cases, auditory or visual hallucinations and paranoia. It is significant that hypothyroidism occurs in up to one-fourth of individuals diagnosed with "rapid cycling" bipolar disorder. In such cases adding thyroid hormone (i.e. thyroxine) to conventional treatment can reduce the frequency of cycling (Bowden 2000). Because of the similarity in symptoms some patients with severe hypothyroidism may be misdiagnosed with schizophrenia. Panic attacks and depressed mood can also accompany abnormal elevations in thyroid levels.
The advantages of integrative mental health care over conventional treatments and CAM
As discussed in my previous post combining select conventional and CAM treatments on the basis of each patient’s unique symptoms, needs and preferences may offer more advantages compared to any particular conventional or CAM treatment. Examples of safe and effective integrative approaches used in mental health care include taking a natural supplement or a medication while engaging in positive lifestyle changes such as dietary changes, regular exercise, yoga or other mind-body practices. There is evidence that bright light therapy, transcranial direct current electrical stimulation, different kinds of biofeedback, and "energy" therapies such as Reiki, Qigong may ameliorate symptoms of depressed mood, anxiety, and other mental health problems. All of these CAM approaches may be safely used in combination with psychotropic medications in some cases improving response to conventional therapy. Depending on the unique circumstances of each patient, appropriate and effective integrative mental health care may include taking a psychotropic medication alone or in combination with a specific natural supplement, seeing a Chinese medical practitioner for acupuncture, consulting with a naturopathic doctor for advice on natural supplements, or starting a regular yoga or meditation practice. In addition to specific conventional and CAM treatment modalities, positive life style changes such as improved nutrition and regular exercise often play an important role in enhancing physical and emotional well-being. In every case, deciding on the most appropriate individualized care plan takes into account each patient’s unique history, symptoms, preferences, and financial constraints.
Collaborative care improves outcomes, increases cost-competitiveness, and improves patient and provider satisfaction
In collaborative care, a team of primary care physicians and behavioral health practitioners consult with a patient during the same appointment in order to address medical and mental health problems concurrently. Patients with depressed mood, anxiety disorders or other serious mental health problems, who have comorbid substance abuse or medical disorders often respond better and more rapidly when managed by a team of practitioners using a collaborative care model. Outcome studies have found that collaborative care models are more effective than conventional care models for treatment of depressed mood, anxiety disorders, bipolar disorder, and schizophrenia (Unutzer et al 2002; Gilbody 2006; Simon 2009; Reilly 2013; Woltmann et al 2012). Collaborative care also results in improved outcomes in individuals with medical disorders and a comorbid mental health problem including depressed mood (Katon et al 2012; Katon et al 2011), severe anxiety disorders (Katon 2002) and persistent severe mental illness (Druss 2011; Grympma 2006; Reiss-Brennan 2010).
In addition to the improved outcomes, collaborative care is more cost-effective than usual care in all categories measured, including medication costs and inpatient, outpatient, and mental health specialty care (Unutzer et al 2008). By enhancing the effectiveness of single conventional or CAM treatment modalities, targeted integrative interventions can achieve significant down-stream savings (Pelletier 2010; Herman 2012). It is significant that both providers and patients report high levels of satisfaction with the management of depressed mood in collaborative care settings (Unutzer et al 2002; Levine et al 2005). Finally, collaborative care models have been shown to reduce health care disparities in patients from different socioeconomic and ethnic backgrounds hence improve access to care (Arean et al 2005; Ell et al 2009; Ell et al 2010a, 2010b).
Collaborative care models incorporating evidence-based CAM will lead to important improvements in the quality of health care
As collaborative care models become more widely used in outpatient clinic settings, there will probably be a parallel trend toward increasing use of evidence-based CAM and integrative approaches to treating a variety of medical and mental health problems. Together these advances will result in significant improvements in the quality of health care broadly, improved outcomes in the treatment of many common medical and psychiatric disorders, more effective and more cost-effective management of complex patients who have comorbid medical and mental health problems, and improved patient and provider satisfaction.
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