The American health care system has just moved closer to a goal that I and many of my physician colleagues have long desired. Recognizing that depression is a prevalent condition that’s inextricably linked to patient outcomes for physical diseases, the US Preventive Services Task Force on January 26 recommended that health care providers routinely screen patients 18 and over, including expectant and new moms, for depression. For those who are working toward the vision of a high-functioning health care system that assesses and treats the whole patient — both mind and body — this is a great moment.
Screening is a powerful tool. The Affordable Care Act (ACA) gives the task force recommendation the force of law, requiring health plans to waive copayments and deductibles for depression screenings. Millions of people with common, treatable behavioral health problems will be able to get the help they need.
This recommendation could not have come at a better time. The burden of untreated mental illness is a major public health problem that weighs heavily on our society; many people with mental illnesses do not receive the treatment they need. Several years ago, federal statistics showed that more than 60% of patients with any mental illness and 40% of those with a serious mental illness did not receive any outpatient care, inpatient care, or medication treatment to address their condition. Mental health disorders are the leading cause of disability in the US. In 2014, nearly 16 million Americans had at least one bout with serious depression, and about 30,000 Americans die each year from suicide. For the 15% to 20% of women who suffer from depression during pregnancy or in the months after giving birth, the consequences of their mental health issues are significant. A mother with untreated postpartum depression is less likely to talk to, sing to, read to, or bond with her newborn, all of which can have a negative impact on her baby’s emotional and intellectual development.
If we are going to achieve the Triple Aim — better health, better care, and lower costs — we have to recognize that mental health and physical health are indivisible. Patients can’t maintain good physical health and practice wellness and healthful behaviors if they suffer from anxiety or depression. Likewise, patients with chronic physical diseases and conditions often have underlying mental health issues that make it harder for them to comply with needed treatments and behavior changes.
By treating the whole person, we can help patients better manage chronic diseases and comply with the advice of their doctor. I have seen this repeatedly. Not long ago, a patient in my practice at the HIV clinic told me she stopped taking the anti-retroviral medications that enable her to live a relatively normal life. This patient, who had always been good about taking her medication, gave a vague reason for her decision to stop the drugs. As I probed for details, she explained that she had been deprived of sleep and depressed because her mother had been hospitalized after a stroke. Although her mother had been abusive, my patient was the only relative to visit her at the hospital. Her mother’s hospitalization had destabilized my patient. I unexpectedly found myself in a conversation with her over something that had nothing — and everything — to do with the course of her HIV. Finding out about the depression was as important to ensuring she got the care she needed as were her lipids or viral load. As a result of our conversation, I referred her for psychiatric care. She joined a peer-led grief support group, enabling her to express her complicated feelings without taking antidepressants. The situation reinforced the idea that if you are apathetic, hopeless, dark, and don’t eat or sleep, it doesn’t matter what treatments a physician offers or suggests for physical ailments — they will have limited impact. We can no longer dismiss patients as noncompliant without learning more about why. This is what patient-driven care management is all about.
Beyond identifying patients who need help and reducing the stigma of mental illness, screening will yield valuable data about the prevalence of behavioral illness, risk factors, and protective factors. It will also require that primary care physicians accelerate efforts to keep up with evidence-based treatment. If I learn from the data that 30% of my patients are clinically depressed, I’m going to want to become a lot more knowledgeable about managing depression.
There are very real concerns that the task force’s screening recommendation could identify more behavioral health patients than existing resources can handle. New Jersey, currently the only state with mandatory screening for postpartum depression, had disappointing outcomes among women on Medicaid because of lack of continuity of care across providers and the lack of integration of mental health services and support into prenatal, postpartum, and pediatric care.
I believe the task force’s national standard will help to change that dynamic and lead to concrete steps to address workforce and other access challenges that are obstacles to care of depression. The new recommendation says screening should be implemented with adequate systems in place to ensure appropriate follow-up. Faced with increased demand, quality improvement programs will figure out how to better integrate care and thereby become more responsive to patients’ needs. We need to band together and make it a priority for payers and stakeholders to use all the available tools — the technology, diverse staff resources, and payer incentives — to make this succeed.
Routine screening will strengthen the inner lives of patients and reduce the chances that any chronic health condition will progress into a life-threatening acute episode because the patient is experiencing depression.
Sandra R. Hernández, MD, is president and CEO of the California Health Care Foundation. Prior to joining CHCF, Sandra was CEO of The San Francisco Foundation, which she led for 16 years. She previously served as director of public health for the City and County of San Francisco. She also cochaired San Francisco’s Universal Healthcare Council, which designed Healthy San Francisco. It was the first time a local government in the US attempted to provide health care for all of its constituents.
In February 2018, Sandra was appointed by Governor Jerry Brown to the Covered California board of directors. She also serves on the Betty Irene Moore School of Nursing Advisory Council at UC Davis and on the UC Regents Health Services Committee. Sandra is an assistant clinical professor at the UCSF School of Medicine. She practiced at San Francisco General Hospital in the HIV/AIDS Clinic from 1984 to 2016.
Sandra is a graduate of Yale University, the Tufts School of Medicine, and the certificate program for senior executives in state and local government at Harvard University’s John F. Kennedy School of Government.