Mental health issues have surged at an alarming rate, affecting a vast swath of Americans.
In this episode, David Williams revisits our previous discussions on mental health, exploring topics such as the current state of mental health, its impact on various demographics, the future of care, and how new technology is innovating the mental health field.
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Episode Transcript:
David E. Williams: There's a mental health crisis in America and around the world. The pandemic made matters worse, but post-COVID we still haven't recovered. Gen Z's struggles are the most visible, but literally every generation and demographic is badly impacted. Fortunately, many healthcare providers, entrepreneurs, and activists are answering the call, bringing their expertise, technology, and organizing skills to the battle.
We've spoken with many of them on the show over the past few years, and we pulled together this compilation to help them tell the bigger story.
This episode of Cure Talk is brought to you by BetterHelp. If you've been thinking about starting therapy, there's never been a better time to give it a try. BetterHelp offers online therapy that's accessible, flexible, and tailored to your needs. Whether you're dealing with stress, anxiety, or just looking for personal growth, BetterHelp connects you with licensed therapists who can support you on your journey to becoming your best self.
BetterHelp. Never skip therapy day with BetterHelp. Visit BetterHelp.com slash CareTalk to get 10 percent off your first month and take the first step toward improving your mental well-being. That's BetterHelp, H E L P dot com slash CareTalk. Welcome to Care Talk, America's home for incisive debate about healthcare business and policy.
I'm David Williams, president of Health Business Group. We're taking a break from our regular programming this week to highlight the importance of mental health. Let's kick off this episode with a look at the current state of mental health, featuring Brad Kitteridge and Doug Nemechek from Brightside Health on opening the front door to digital mental health.
Christina Minelli, who's building a better mental health system at Quartet Health, and Rocco Coniglio, talking about long-term mental health solutions.
John Driscoll: What's changed from a health plan perspective that, you know, you and Cigna and others, United, are leaning into this as a category for care and for support?
Doug Nemecek: So I'm a psychiatrist, and so I have been paying attention to this my entire career, right? And the last 20 of that have been with the health plan. Yeah, I think the difference today is to, as Brad mentioned earlier, there's, there's a difference. Decrease in the stigma associated with this. And we've, we now have more of the data and the research that really shows not just that costs are higher and people do worse with a whole, from a holistic health perspective, if they're not getting their emotional wellness and behavioral health needs met, but that we can actually impact that by providing appropriate and timely, Mental health care and substance use care, and that those individuals are going to be more productive at work.
They're going to be more productive at home, able to take care of their families and more productive in their community as well.
Brad Kittredge: That's right. And, and, you know, I think just to add on to Doug's prior point, if we look historically at, you know, studies and the best estimates of the proportion of mental health practitioners who are practicing measurement-based care and actually collecting data on how patients are progressing through care and whether they're actually improving.
It's unfortunately been extremely low. You know, sub-20 percent for sure. And perhaps even sub-10 percent of practitioners consistently doing that. And if we're not measuring outcomes, we're flying blind. We have no idea whether care is working for a given individual or across a population or different types of interventions for the right people.
And so in many ways, the industry has sort of stagnated in this, in this sort of perception of, of more art than science, and that's held back our opportunities to lean in and collaborate together to actually develop Better, more impactful programs that are not only going to help people get access to care and fill appointment slots, but actually get benefit from that care and a measurable impact on, on both the clinical and financial side.
So by starting to as a company and as an industry, make sure that we measure outcomes consistently and thoroughly across everybody we treat. Allows us to ensure our care models effective, allows us to demonstrate to partners like Evernorth that our care is effective and to lean in to build and develop new programs that just haven't been possible before without that foundation of real data to inform them.
David E. Williams: I wanted to ask you about the pandemic, which seemed to really radically boost the incidence of mental health problems, especially for, for younger people, haven't heard an update on that. What are you seeing in terms of you know, the pandemic and it's, it's lasting impact and, you know, how that's affecting just sort of the overall amount of mental health care that's required.
Doug Nemecek: Yeah, I think the pandemic gave us a couple of lessons. One is that absolutely every one of us was impacted enough by stress and it allowed us all to, to help. Decrease that stigma we talked about before I'd start talking a little bit more. We saw huge increases in demand for outpatient behavioral healthcare and resources.
And I think a lot of people thought that would go away when the pandemic ended. But we have that has not happened. We've continued to see you know, even this year another 10 to 15 percent increase in the in the number of visits that people are getting. And that's More people accessing behavioral health care as well as those that are accessing care using it more than people did on average prior to the pandemic.
The other lesson from the pandemic that I think was really important is that it forced us to start to look at different ways to deliver behavioral health care because we couldn't go to the doctor's office anymore and couldn't couldn't make those trips. And so that the development of digital care and virtual care that makes it more.
Convenient for individuals. They don't have to take a half a day off of work and drive all the way across town to go see a therapist. They can do it from home or from their car or wherever they're at. And the privacy piece of that and especially in in smaller areas where, you know, people still because of the stigma might not want their car seen in the parking lot at that, where they, where that therapist office is that all of that goes away with, with these these new digital and, and virtual care platforms and, and that's helped a lot.
So we continue to see demand continue to increase and new innovative ways to deliver care. Doug, is
John Driscoll: that, is that, is that demand across every age category or is it primarily in certain subsets? I mean, obviously being, since the invention of the like button, you know, self harm in teens has got, has rocketed.
There's obviously a lot of, a lot of you know, undiagnosed anxiety and depression among surviving seniors. I mean, there's a, are there particular categories or do you see it across the board?
Doug Nemecek: Well, we've seen increase in demand across the board at all age groups, but some stand out. So, so when we think about adolescence, adolescence we've seen some of the biggest increases in demand for mental health care, young adults, those 20 to 26, right?
Large increases in the number suffering from anxiety, depression, substance use issues and seeking care. We've seen adolescent suicide rates really continue to increase across the board. And and so really that demand and we started looking at how do we get more care and more services to them? And again, the using digital, using other means and innovative programs to engage them the way that they want to be engaged and are willing to be engaged to access care really important.
But we're seeing that across, you know, across all age groups.
David E. Williams: So how do we think about how big of an issue this is? I mean, we talked about how, you know, everybody knows something or maybe you know somebody or maybe you know yourself is that's affected. But Is there a way to get a handle on how big of an issue maybe mental health is overall and then SMI within, you know, within the U.S.?
Christina Mainelli: Yeah, absolutely. So, it's estimated, and these are recent stats, that more than one in five U. S. adults live with a mental illness. And if you add an addiction, you can imagine how that how much larger that is. It is alarming to know that over half of adults with mental illness go untreated, completely untreated.
And the impact of mental illness on our kids is staggering. So almost half of adolescents have had a mental health issue. And adolescent suicide is the second leading cause of death in that age group. The first leading cause of death for kids age 14 and 15. It's really, you know, a huge issue. And why does this matter?
It really affects everyone. It impacts productivity at work. It impacts employment rates. Individuals with SMI oftentimes are out of work. It impacts lifespan. Individuals with SMI can live an average of 15 to 17 years less than average adults. There's an impact on education. Kids with mental health issues are two times more likely to drop out of high school.
So there's so many impacts. There's economic, there's impacts on vitality, lost earnings, and, and on our communities and our families.
David E. Williams: So, one of the striking things you mentioned is the impact on lifespan, and of course when you hear about things like, you know, heart disease, diabetes, certainly that affects people at different ages, but a lot of times it's a matter of somebody who's older by the time they really have that.
You talk about a 14 or 15 year old you know, with a suicide. And, you know, you're taking 80 years off of somebody's lifespan when you do that. So the impact of each one of these things, not just devastating within the community, but measured just in terms of, and to the family, but measured just in terms of lost years of life is just very, very striking and makes it all the more important to, to do something about it.
What is your sense of the impact that we had from the pandemic? You know, there's a lot of discussion about what the impact was, especially on adolescents.
Christina Mainelli: Yeah, I would say, so the stats I gave are kind of during or post-pandemic, you know, pre-pandemic, we'd say. 1 and 10 adults had a mental health issue post-pandemic.
1 and 5, I mean, it really the numbers have doubled tripled. So it really is an issue. And while lots of sort of new entrance in the space. Are available now, and there has been relaxing of policy. And procedures, which has helped to provide access to care and solve a little bit on the supply side. I'd say that the demand side is going up faster than the supply side, and that's one of the big issues.
David E. Williams: Got it. So let's talk about, you know, opportunities for innovation. Because we can sit here and lament the problems and say, yeah, this isn't, isn't this a problem? Yeah, it sure is. But what, what to do about it? Where can we innovate?
Christina Mainelli: Sure. So you know, there are a lot of opportunities to innovate in mental health.
And as I said, you know, with the onset of the pandemic, we did get a lot of new entrants in the mental health space. You know, some may say too many because there's a lot of point solutions out there. But when you look at really, Sort of systemic change in particular, I would say in dealing with the seriously mentally ill, because this is where I'd say we have the biggest challenge and the biggest opportunity.
So, a couple of areas to innovate, and by the way, I will share, I think some of these innovations. The behavioral health industry can borrow from the physical health industry. So we talked about kind of my journey from physical health, behavioral health, social care. I really see an opportunity to leverage things that have worked on the physical side of healthcare in behavioral healthcare, in particular with the seriously mentally ill population.
So first of all, One of the big issues in behavioral health care, and in particular, very acute with the seriously mentally ill, is our fragmented delivery system. So, physical health doesn't talk to behavioral health. It is hard to get access to an appointment. It is hard to get, to ensure that the patient even made it to the appointment.
It's hard to get the follow-up notes on the physical health side. In behavioral health, and in particular in patients with serious mental illness, It is important to treat the whole person. So in order to do that, we've really got to bridge physical health, behavioral health, And also have hybrid delivery models that include bricks and mortar and virtual care.
So the opportunity to innovate here is really to leverage multidisciplinary care teams, virtual and on-the-ground care delivery, and also tapping into other services that aren't traditionally paid for by the behavioral health care system. That's one area to innovate for sure. Second, it's really hard to engage patients with moderate to severe mental health issues.
Very hard to engage. It requires new models of care. It's not going to be one size fits all. And by the way, people with moderate to severe mental illness, this is not just a Medicaid issue. It's not just a Medicare issue. It crosses all lines of business. All walks of life so that we need new models of care, not one size fits all.
Digital tools may work for some, peers on the ground in their home may work for others. And in most cases, it's a combination. So second area to innovate is really around patient or member engagement and using all the tools that we have available to us. The third place to innovate and this is a big one.
is really around getting aligned incentives and payment models. So this is gonna require models that reimburse for services outside of just behavioral health care. You yourself said, David, that many folks with physical health issues often have a behavioral health issue. That is very true. Therefore, when we think about behavioral health, in particular those with moderate to severe mental illness, we need models of care that reimburse for physical health, behavioral health.
And for some of these additional services, like peers, that are typically not reimbursed. And we also need to measure success against total cost of care. Because once you treat a behavioral health need, you will also see, likely, a benefit on the physical health side of this, of the house, with reduced hospital admissions, with better adherence to medication.
use of lower-cost patient settings. So really it's important to look at total cost of care when you're looking at, in particular, the moderate to seriously mentally ill.
Rocco Coniglio: I think we're behind the curve on telehealth as, as generally speaking for healthcare. And you know, I think the pandemic forced some of that upon us, which, which I guess could be part of a silver lining to it.
So I think, but I don't think that that necessarily replaces in-person visits and some of the value that you can get from some of those in-person visits, even in mental health. I think mental health is an obvious place where you can use telehealth a little bit more than you might be able to in other specialties.
You know, many other specialties need to be more hands-on but we always viewed telehealth as a tool in the tool belt, not a not like a binary, are you telehealth or are you in person?
David E. Williams: Next up, we'll hear about the impact of the pandemic on mental health care from entrepreneur Dina Bravada.
And we also have a couple of celebrities opening up about their own experiences and sharing the stories of people who inspire them. That means Courtney B. Vance talking about Black mental health and former Congressman Patrick J. Kennedy with his profiles of mental health courage. How are the kids doing?
How about mental health for kids? How's that going? I've heard a lot of concerns and, you know, maybe split it out by age group because it's not just, you know, kids versus seniors.
Dena Bravata: Yeah so I think that and I, I hope that that this will not be news to people. I think that there is now a light that is being shown on really this mental health you know, like epidemic you hate to use that word these days for depression.
Kids and teens. So the rate of growth of mental health spending among adult populations was about 13 percent between 2021 and 2022 for kids. So for pediatric population. So that's 12 and under the rate of growth. Last year was 23 percent and for teenagers, it was 18%. So, so like, so, so, and the actual spend on those kids is higher.
So it's, it's not quite double, but almost. And so, so why is that right? Like why are, I mean, they're little people, why aren't there bills smaller than for adults? And experts in this area, you know, really you know, corroborate this finding, which is that like kids are presenting later in their course of disease.
Therefore, they're requiring more intensive therapies, right? Often they're actually requiring hospitalization. So a lot of those factors that we talked about earlier that are driving costs, we see that in particular in pediatric and teen populations.
David E. Williams: You've talked about also kind of revolutionizing mental health in the black community.
What, what would that actually take? So we're not just talking about incremental improvements.
Courtney B. Vance: Well, I, you know, I, I don't know, you know, technically what that would take because the, the medical industry is shifting. Doctors are having more and more on them. They come in with the same amount of, of debt.
And in order to take care of that debt, they had to service the numbers and in order, you know, and so maybe they don't have time to actually do so. Tell me about what's going on. How are you doing? They don't have time to do that. And so the pressure is on them. I, I, I would have to say that, you know, it's, it's a, it's a huge issue.
You know, that, that really has to do with taking care of people. And, and in order to do that, doctors need to be taking care of themselves so that they can afford to have the, they can afford to take care of, you know, the one-on-one and to have a relationship with, with their patients. And they can, and they, and also probably they need to be schooled.
In the medical profession about their bedside manner, how you actually talk to people and engage with people that are different from yourself. And you know, they may approach when a black person comes in, they don't know how to talk to them. And so they are, maybe they're a little afraid they'll put off in case, in which case the person, Of color.
Who's who's a patient just like I don't want to go back to that person. They don't like me. And it's that it's that ephemeral. It's it's a it's a relationship. It's a marriage of sorts. The doctor-patient relationship as opposed to a number, you know, and it's it's it's looking at things a different way.
And that the doctor's students, when they come out of medical school, they're probably being taught the same way, you know, and the whole idea of the doctor-patient relationship, it's a relationship.
John Driscoll: Do you think we've really, that the public's understanding has really changed about The mental health being integrated into, into physical health, or do we still have a lot of work to do there?
Patrick J. Kennedy: Well, we have a ton of work to do there because frankly, most people don't avail themselves of mental health and addiction services till they're stage four illnesses. And that's principally because one, stigma is still alive and well, and two, none of us want to walk that, kind of those eggshells to tell the person we love that they're in trouble until it becomes really obvious when in fact what we need to do is get in there early as if it were cancer or cardiovascular disease and say, listen, this is going to be a lot easier for you to deal with if you start dealing with it now.
We haven't had those conversations with our loved ones and in this book profiles and mental health courage. I not only tell the stories of these twelve courageous people who tell everything, but they had me talk to their parents, their brothers and sisters, their kids. They're therapists, they're friends and colleagues at work.
They really had me talk to people, frankly, that they don't talk to anymore because their illness has so isolated them. This book is different in that it includes all the people around the person, including, as you know, John, my cousin, Mark McMurray, his son, Harry died of suicide at 23. The first time Mark really talked about his son's suicide was when I interviewed him seven years after Harry had died.
And Mark was, you know, very full of trepidation. Should I do it? Once he got in, he was, it was cathartic for him, which only proves the point that we need to open up and talk about these things. Then he had me talk to Harry's brother, his other son. Belton and Belton said things that Mark had never heard that Mark had me talk to Harry's roommate at college.
Harry's roommate in college told both Belton and Mark things that they had never heard of before. So my point is, if we had had a better chance for everyone to share, there may have been a better chance for them to have intervened earlier And more aggressively with Harry than was the case because they felt like they couldn't talk about that personal business that, you know, I don't want to violate his privacy.
John Driscoll: But, well, and we've got a quiet epidemic that's becoming louder and louder every day of suicide, not just in the military, but across society, particularly of when you start throwing in self-harm and just deep challenges, self-image for young people. I mean, it's I, that's a, that's a, that's a, it shakes me to hear that Patrick, but I think it's a critical conversation to your point about the only way we're going to intervene early is to understand early,
Patrick J. Kennedy: you know, it is remarkable. These illnesses that we wait until they become. Yeah, real, really sick people. And, you know, the African proverb, if you want to save someone from drowning, try making sure they don't fall in in the first place. We just don't go upstream. And we have to going back to my original point, John, come up with a new financial model.
You know, all these European countries that have national health systems do so much in terms of social supports for these illnesses. Early intervention for the services. Why? Because it saves the macro costs, which, by the way, they bear because they come from these big, you know, centralized health systems.
We have to figure out a way to incentivize those long-term. And we need partners to be able to do that. Ultimately, this will only work if the financial incentives align with screening earlier. But today, payers like, Oh, geez, do I really want to know that they need help? You know, because they might not be with me in a year from now.
That's a kind of defeatist system. We have to fix the system if we're gonna help people.
David E. Williams: The digital health revolution is tackling challenges throughout healthcare and mental health is no exception. In this final section, we'll hear from three entrepreneurs who are making a big difference. David Coe shares how the CALM app is improving wellness.
Sarah Adler of Wave discusses Gen Z-specific approaches. And Tamir Aldad of Mindful Care shares his approach to psychiatric urgent care. So you mentioned that you know, the B2C users, the directed consumers have asked that their employers pay the bill. But is there a good rationale for an employer to be managing stress and reducing stress?
Burnout. Is that something that should be on their high on their agenda?
David Ko: Absolutely. I mean, thank you for asking that, David. I mean, there's two things. One today when employees you know, have a sea of things to choose from, whether it's around your employee assistance choice of menus of benefits from employers today, it's really hard to discern one thing from the other.
You know, the way it's presented to you, right. With the app icon and things like that. And so, you know, a lot of times these benefit managers come to us. And we start to talk to them about our product and they're all users of our products. So one that definitely helps in the process when we talk to them.
The second is they just want their employees to use the services that they offer So that they find not only is the engagement and the activation really high with us So they know actually we're, if they offer us as a service, people actually use it as a benefit. So often these benefit managers talk to us and say, we have all these benefits, but nobody will use them in the company.
So we could tell them, but unless we like have the CEO message them or others. they won't use these products. And so many of these benefit managers say mental health is important for us, but we don't know what types of services we should be offering. And so we try to check all these different boxes for them today.
And you know, that's one of the reasons why we also renew at such a high rate with so many of our employers today.
David E. Williams: How is the mental health?
Sarah Adler: Yeah, it's a, it's a, it's a good and debatable question. For my vantage point in my expertise, I think it is not great to be quite honest. I think that Gen Z is really struggling.
There are tons of reasons why their generation is just fundamentally different than ones that have come before. Part of that, of course, is social media and being a digital native. Part of that is just kind of the. The state of the world these days. And part of that is the fact that Gen Z also for the first time has a language to describe what's happening for them.
So I think it's all of these things together that are, are really creating the very true feeling that Gen Z is, is what I lovingly call the misery generation.
David E. Williams: Well, I guess misery loves company. So that's why you started one.
Sarah Adler: That's exactly right.
David E. Williams: So this is just a huge demand for behavioral health services in this generation.
And supply, as far as I can tell, is insufficient. It's not growing, certainly not growing fast enough. How do we possibly bridge that gap between supply and demand?
Sarah Adler: Yeah, I fundamentally believe that the way to do it is is really threefold. It is through better data infrastructure that we're investing in to really understand who needs what care pathway at what time.
It's the acceptance and the the proving out of the efficacy of new care delivery models that really leverage. Lay health care workers like peer, peer counselors and coaches combined with that data infrastructure and that technology so that we can really kind of pull people who do not need the highest level of care out from the most intensive and expensive resources.
And then thirdly, it is I think really a, an alignment of the financial incentives between the stakeholders, between the patients, the clients, the users, whatever they're calling them, and the people who are actually paying for health care in this country.
David E. Williams: What is the biggest problem in mental health today?
Tamir Aldad: The biggest issue is access to care. We have patients waiting six to eight weeks to see a provider if they have insurance. In that time, patients, Their symptoms could worsen. They could be a risk to themselves, a risk to others. If they have substance use disorder, it could worsen. So we need to be very cautious and mindful of the fact that if we don't improve access to care mental health we'll only get worse.
David E. Williams: I know a lot about urgent care and I see it, but I never really thought about it for behavioral health, but it's something you offer. What is urgent care for behavioral health?
Tamir Aldad: So our philosophy is that patients right now waiting to see a psychiatrist or a mental health provider sometimes go to the emergency room to access care.
Going to the emergency room more often than not is inappropriate, and our goal is to create an urgent care model where we offer and triage patients to assess their symptoms, and the severity of those symptoms, and advise them on what the next best step is. So our version of Urgent Care is similar to the medical version of Urgent Care, where we offer acute same-day, next-day treatment for patients that otherwise would be inappropriate for hospital admission.
David E. Williams: Why is it so difficult to find a behavioral health provider, and why don't they take my insurance?
Tamir Aldad: So it's two things. One, the demand is extraordinary, so providers can pick who they want as patients. They don't have to take my insurance. Everyone, and they can be quite selective. And unfortunately, reimbursement is very low.
So if you do have insurance, clinicians are properly incentivized. So if they accept insurance, they usually pick those that are higher paying, or if they don't want to deal with that, then they just accept cash.
David E. Williams: I want to talk about social media for a minute, not podcasts, of course, but how is social media impacting mental health?
Tamir Aldad: I think it's doing two things. One, people are very informed, very aware, a lot more educated. It's becoming a lot less taboo. So that there is. something positive about the increased exposure to knowledge that comes with social media. The risk, though, is that it creates a very artificial environment where people are comparing lives that can create a sense of jealousy.
It could also be very triggering because a lot of information is at your fingerprint. So we really have to be careful with the consumption, particularly if people are sensitive to triggers and also constantly reframe situations to realize that. What looks like reality sometimes isn't on social media.
David E. Williams: Well, that's it for our special episode of CareTalk, focusing in on the massive challenges and emerging solutions in mental health care. Thanks so much for joining us today. Please make sure to come back next week when co-host John Driscoll and I resume our normal schedule. And remember, if you like what you heard, or you didn't, please subscribe on your favorite service.
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