Unite and Conquer: Time to stop talking about integrating behavioral and physical health, and just do it

Baby, meet bathwater. A recent STAT piece takes down the Patient Health Questionnaire(PHQ)-9, the form used to screen for depression, because it was created by Pfizer. The company pushed the form to primary care providers (PCPs) as a screening tool in the early 1990s, hoping PCPs would be more liberal in their use of the screener than behavioral health practitioners, and so, bigger boosters of the company’s new drug Zoloft. 

It’s news to no-one that drug companies want to sell drugs. The real lesson to be learned here is subtler. We urgently need to focus on making connections, not divisions, between primary care and behavioral health.

A big part of why I chose psychiatry as a specialty is that I recognized my patients’ family, background, work environment, relationships, and physical health issues all contribute to the presentation I see. When I look at a patient comprehensively, in all their complicated context, I’m better and more efficient at my job. This matters when one in 10 Americans suffers from depression and over a third will have anxiety in their lifetime, while  ⅔ of US counties don’t even have one psychiatrist, and there are major medical professional shortages across the board (117,000 physicians left the workforce, just between 2019 and 2021).

Notably, the number of primary care visits for a mental health concern recently has gone up by 50%. Patients are telling us what we need to know and do. Treating mental and physical health as inextricable, because they are, is the best path to measurable wellbeing. Whatever form you use.

In the STAT article, the marketer who came up with the idea for the PHQ-9 screening said that when the form was introduced, PCPs “were scared of mental health, they felt they didn’t have the expertise for it, but their patients were depressed”. So they blithely asked the nine questions and moved straight to prescribing drugs with little follow up. Apart from giving PCPs way too little credit, this minimizes the fact that we have the cure for such a siloed scenario: education and integration.

Stressing about a single tool in isolation misses the forest for the trees. At my company,  Included Health, we’ve used the PHQ-9 (and the General Anxiety Disorder Questionnaire, the GAD-7) prior to behavioral health visits for years because it’s a concrete, validated source of screening information that provides a starting point for conversations with patients and a baseline for ongoing monitoring. It’s also a time-saver for clinicians and in overburdened systems and provider shortages. We need more, not fewer, ways to gather clinical information efficiently. 

Of course we need to go further than forms and preliminary assessments. With a nationwide network of providers cross-trained in behavioral health, Included Health has fully integrated primary care and behavioral health. We’ve also integrated operations (call notes, intake details, visit charts) for smooth handoffs between physical and mental care. This kind of integration is essential if you want to both destigmatize behavioral health treatment and simultaneously address physical well-being.

And we do, or we should. Those who suffer serious behavioral health issues tend to die earlier than the general population and, crucially, the majority of those deaths are due to chronic physical conditions such as cardiovascular, respiratory and infectious diseases, diabetes, and hypertension. Integration is vital. It helps by increasing trust and engagement with sufferers over time. All those artificial barriers between different types of caregivers come down. The member’s story comes into sharp focus. Misdiagnoses, so often related to rushed visit encounters or an incomplete clinical picture, are avoided. Members feel comfortable coming back. 

If the logical arguments about quality of care and outcomes don’t sway you, maybe the return on investment will. Senate Bill 178 in Arkansas intends to mandate a more integrated approach, requiring all payers to reimburse for “Collaborative Care Model” care, which provides team treatment for behavioral health patients and has shown to increase access to behavioral health care, save money, and improve outcomes. Research shows that for every $1 spent on this model of care there is a $6 savings in overall healthcare costs.

No one screening form can do it all. Let’s acknowledge that and agree it’s time for sponges not siloes: we need continually to be gathering and sharing information on behavioral health in a clinically meaningful way to better serve patients. There’s enough proof that integrating primary and behavioral health care works. Now it’s time to walk the talk, PHQ-9 in hand.