We Know Mental Health Affects Physical Health. Why Don’t We Act Like It?
By Helen Ouyang
“Dr. Ouyang is an emergency physician and an associate professor at Columbia University.
“Do you think my symptoms could be from stress?” This is a question more and more of my patients have been asking me when seeking care for problems such as a stubborn cold or an aching back.
For other patients who don’t first raise the idea, when I propose that their mental health could be worsening their physical symptoms, they no longer bristle at that suggestion. An idea that was once dismissed as New Age fluff is now being embraced.
Our health care system, however, has yet to catch up to this connection. While it promotes preventive care, the emphasis has largely been on physical health, overlooking the significant influence of mental well-being on our overall health and vulnerability to illness. For people to truly be healthy, modern medicine must prioritize the prevention of mental ailments alongside physical ones.
It wasn’t long ago that even hinting at the notion that a relationship exists between our mental and our physical health would inevitably seem to frustrate, even infuriate, patients, as though their suffering wasn’t real. And for good reason. Women have endured the dismissal of their symptoms for centuries, resulting in missed and delayed diagnoses, even death. Pain in Black patients is often undertreated. Doctors in the past would offhandedly call certain symptoms “supratentorial” — meaning “it’s in their head.”
But our understanding is evolving, as a growing stream of research challenges old assumptions. Psychological disorders such as stress, depression and loneliness are now known to be associated with impaired immune defenses, leading to increased infections and weakened responses to vaccines. Chronic stress can disrupt our gut function, slow our wound healing and age our cells.
Our minds’ potential to unravel our bodies goes even further: People with symptoms of depression have a greater risk of developing coronary artery disease. Among patients who already have heart failure, those struggling with loneliness are around four times as likely to die. Job stress has been linked to strokes.
Fortunately, while poor mental health can worsen our physical states, the inverse seems true as well. Research suggests that interventions that boost mental health can enhance immune function, reduce inflammation and improve blood pressure and cholesterol. Stress management may shorten the duration of respiratory illnesses and lead to better glucose control in people with diabetes. In fact, overall psychological resilience has been found to be protective against cardiometabolic diseases such as heart problems, stroke and diabetes, as well as death from any illness — even after adjusting for differences in demographics.
Mental resilience could enhance our psychological well-being, which could in turn improve some of our physical ailments. Even having more optimism could help ward off disease — not just by improving our biology, but also by encouraging us to have healthier habits.
Can one simply build resilience? Experts now believe so — that resilience is a skill set that people may be able to learn over time. This is much easier said than done, but research shows it’s possible: Massachusetts General Hospital’s Resilience and Prevention Program delivered workshop-based resilience training to young adults at risk for mental illness, and it decreased their psychiatric symptoms, even reducing loneliness.
Yet much of our health care system remains obstinately siloed, with mental health relegated to the sidelines of preventive medicine.
Preventive medicine has given Americans vaccinations, colonoscopies and mammograms, and screened us for hypertension, high cholesterol and diabetes. The Affordable Care Act made “prevention is better than cure” a tenet of our health care system, mandating that insurers fully cover these services. Prevention in psychiatry has not kept up.
Many people don’t bring up their mental health at their checkups. And many doctors don’t ask. Patients who do discuss their psychological state during their insurance-covered preventive exams may be served with an unexpected bill. That these visits are often called an “annual physical” — emphasizing physical over mental ailments — is itself revealing.
Even when primary care providers screen for early signs of depression and anxiety, they often lack the training, resources and time to address what they might uncover. I feel the same in the E.R., where, again and again, I am at a loss about where to send people for mental health care. Who is accepting new patients — without requiring them to pay substantial money out of pocket?
Reimbursements around mental health are particularly low and come with significant administrative burdens, which discourages providers from taking insurance. This leaves patients with few options for their behavioral health care. While the federal mental health parity law prohibits insurers from charging higher co-pays for behavioral health visits than they do for other conditions, insurers can put up other barriers such as excluding certain diagnoses or managing the number of therapy sessions. The result is a system that too often fails to handle brewing mental health problems until they’ve already taken a physical toll.
What’s promising is that there are already some innovative approaches to build on. A collaborative care model that includes mental health care managers results in better outcomes for depression, anxiety and substance use. A new Medicaid rule change allows reimbursement for professional consultations, which could help primary care doctors meet their patients’ needs by seeking the advice of their psychiatry colleagues. Mental health services are also being integrated intosome school-based health centers. We need more such efforts that aim to dissolve the barriers between physical and mental health.
Routinely providing preventive mental health care could also reap significant economic benefits. Patients with concurrent mental illness generate some of the highest total medical costs in the United States, most of which is not spent on behavioral health. But mental well-being has been shown to reduce overall health care usage and costs, as well as improve education and employment. For adults who already have a chronic medical condition, receiving mental health services was found in one analysis to reduce their overall health care expenditure by nearly 22 percent. An ounce of psychological prevention may well be worth a pound of medical cure.
We need a care system and a medical culture that support the health of the whole person. My patients seem to already grasp this truth. Many of them are eager for integrated care that prevents both mental and physical illness. Now the health care system needs to catch up to their wisdom so that we can actually help them do so.
Helen Ouyang (@drhelenouyang) is a physician, an associate professor at Columbia University and a contributing writer for The New York Times Magazine. She is also a fellow at the Type Media Center.
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