The cry of a “mental-health crisis” is heard all across the land—but who shouts the loudest, patients, payers or providers?
Treatment of mental health means different things to different people. Providers want to evaluate properly, but an in-depth diagnosis during an office visit takes time in an already crowded day. Payers see their largest expense of mental-health dwarf other medical categories and they bare the burden of both treated and untreated mental health disorders. It is the largest health care expenditure at over $200 billion per year with second place being cardiovascular at a cost of $147 billion.(1) Patients see increasing “costs” in both the hard dollars they spend and in the very real consequences of not treating their mental illness.
The history of medical treatment is based on a patient-driven, provider-response system: The patient recognizes a symptom (rash, fever, pain, cough, etc.), and they exhaust their own resources (personal experience, family history, WebMD, etc.) to assess severity before they determine whether the condition does or does not require professional medical attention. If severe enough, they make an appointment, and a doctor determines whether the complaint needs reassurance, further evaluation, referral, or treatment. That’s been the natural flow for longer than any of us has been alive.
Yet, ultimately, the programs that require the doctor to do the screening and identifying have built-in shortcomings, whether it be the patient’s motivation to seek treatment or his/her thoroughness in reporting issues, or the doctor’s availability or expertise in a particular area.
However, in the case of mental-health issues, we must acknowledge that, thanks to modern technology, the patient could initiate their evaluation process instantly, in the privacy of their own space, and “perform” the screening, on demand, at any time of the day or night, on weekends and during holidays, etc. By employing existing instant, on-demand technology, we’ve identified an innovative way to address mental-health concerns effectively and at substantially lower cost.
It is estimated that 25% of all Americans will have some type of mental-health disorder in their lifetimes—and too many go untreated. Failure to treat means ongoing suffering and hopelessness, decreased motivation, loss of social function, and affected relationships, with increases in substance abuse and risk-taking behavior that can lead to prison, self-harm and suicide. (One late but growing concern is the cry for better mental-health assessment and treatment for the mentally ill in our prisons and jails. Alarmingly, our prisons deal with more seriously ill people than do our hospitals.)
A variety of possible solutions have been and regularly are suggested; however, providers and payers alike agree on one thing: Early detection and intervention improves outcomes.
It’s imperative that a new model for treatment of mental health promote early recognition, and it must allow the patient the ability to initiate mental-health treatment with fewer obstacles like access and cost. The most effective mental-health model will provide tangible gains for patients, providers, payers and policymakers alike.
We’re aware of patients (and their loved ones) who spend weeks, months and even years “self-analyzing” strange, new emotions, frustrated at trying to determine if what they feel is cause for real concern. During that phase—before treatment failure is even an issue—patients would benefit dramatically from access to an assessment to determine whether their symptoms are significant and need to be evaluated, or they’re just a part of normal life.
Because every interaction these days feels immediate, the new model requires innovation and technology. We can “like” or “favorite” something we approve of (or “frowny-face” or “thumbs-down” something we don’t), and in that very instant the social-media poster knows what effect his/her contribution is having. We’re no longer content to “please allow 6-8 weeks for delivery”; we want everything overnight—and that better be first thing in the morning! This includes mental health evaluation.
To be sure, words like “innovation” “technology” can be daunting to physicians and to patients, so the solution has to be simple, straightforward and approachable, in order to facilitate optimal adoption rates. Technology needs to come from an atmosphere or interface relatable for both patients and providers.
From a patient’s perspective, the ideal first step toward proper, effective treatment is a comprehensive online self-assessment tool, accessed from the privacy of the patient’s own space and employing their own personal device (smartphone, laptop, tablet, etc.).
MoodDoctor is such an online self assessment tool. It asks the questions normally posed at a professional intake by someone using screeners, in addition to their own questions about depression, anxiety, mood disorders and ADHD. The assessment tool then generates a report for that licensed professional, identifying whether or not the responses meet criteria for a DSM-5 disorder, as well as other key screening questions about behavior, substance abuse and suicide.
MoodDoctor does not make a diagnosis. A written assessment can never replace the clinician, but it can supply answers to the questions that would be asked. Doing this serves two purposes: First, it promotes early recognition of symptoms by the patient or family, representing the first step of diagnosis and treatment. And second, it transforms the initial evaluation from a frenzied, sometimes uncomfortable information-gathering session to an interaction where the patient—comfortably and without pressure—can share information, after which the medical professional can review the data, make the proper diagnosis, and explain treatment options.
The follow-up visits are defined and have purpose: A quick 3-week telemedicine call or is made to check tolerability and compliance. A 6-week visit is for symptom review and to determine whether treatment has reached expected remission. The patient should then follow up, either by visit or telemedicine, every 3 weeks following good clinical practice guidelines until remission is achieved..Once into remission, the follow-up for refills should occur every 3 months, alternating office and telemedicine visits. After a year of remission, a determination needs to be made to see if it is appropriate to taper off meds or educate the patient on the need for chronic or lifetime use. Too many patients remain on medication for years needlessly because, at refill visits, no one bothers to determine if chronic treatment is appropriate. The following is a summary of a model using early intervention and treating to remission aided by technology.
|Patient has first recognition of symptoms||Online assessment / private device / MoodDoctor||Gather information / Assess symptoms for significance|
|Intake – Initial office visit||Office visit||Use the MoodDoctor report Diagnose, Educate, Rx plan|
|Week 3||Telemedicine/phone||Compliance and Tolerability|
|Week 6||Office visit or Telemedicine||Review improvement|
(every 3 weeks until remission)
|Office visit or Telemedicine||Treat to Remission|
|Remission date||Office visit||Treat to Remission|
|3 months post remission date||Telemedicine/phone||Assure still in Remission|
|6 months||Office visit||Assure still in Remission|
|9 months||Telemedicine/phone||Assure still in Remission|
|12 months||Office visit||Taper acute / Educate chronic|
New Technology of Mental health treatment Model “Early intervention and treat to remission”
Advantages of this new model
- Promotes early intervention with patient-initiated self-assessment
- Transforms the initial visit from time-consuming information-gathering into a productive experience for both provider and patient, allowing education and instruction
- Identifies co-morbid disorders for treatment, promotes appropriate referrals including therapy
- Designated visits for comprehensive treatment with purpose and treatment goals
- Clinical guidelines can be followed to treat to remission and appropriate long-term management
- Telemedicine allows for simple access, which is beneficial for compliance and provides tremendous cost savings by decreasing utilization of care, decreasing incidence of ER and inpatient psych
- Effective assessments lead to discovery of related symptoms that need treatment, ie psychotic features, behavior disorders, risk-taking behavior, suicide or substance abuse
- Identify patient more appropriate for referrals to psychiatry or therapy and counseling
Results: Improved quality of care with reduced cost and higher patient and provider satisfaction
- Patient awareness about the availability to self-initiate care
- Provider adoption – utilizing the self assessment in initial visit and adopting telemedicine
- Providers need adequate financial incentive to make Telemedicine visits. Payers must recognize the huge savings in this model, and insurance needs to deliver adequate reimbursement for the telemedicine visit (rather than the current system of a patient-paid $50/visit)
The patient-driven, provider-response model is outdated, ineffective and, ultimately, too dangerous and costly. By employing an instant, on-demand technology with a comprehensive online self-assessment tool, the patient initiates diagnosis and treatment from the privacy of his/her home or office on his/her own personal device (smartphone, laptop, tablet, etc.). With the full support and attention of a trained, licensed medical professional for every step of evaluation and treatment, the patient enjoys an optimal experience in an innovative way to address mental-health concerns effectively and at substantially lower cost.