Reap benefits of integrating medical, behavioral health

(Editor's Note: This is part two of a two-part series on behavioral health issues. This month, we report on a growing trend of integrating behavioral health and medical care. In a related story, we cover the use of claims data to do outreach with workers at high risk for behavioral health problems. Last month, we reported on research linking depression and productivity.)

If one of your employees was being treated for severe back pain, would that individual be screened for depression and anxiety? Probably not, but the fact is, workers with chronic medical conditions are two to three times more likely to have a serious behavioral health condition, which often go untreated, says David Whitehouse, MD, chief medical officer for Golden Valley, MN-based OptumHealth Behavioral Solutions.

The number of hospital stays with a secondary diagnosis of depression increased 166% from 1995-2005 to 2.47 million, according to a new report from the Agency for Healthcare Research and Quality.1 In addition, depression and anxiety are linked to poor adherence to medication and treatment regiments, which exacerbates chronic health conditions, says Whitehouse.

Traditional behavioral health programs work well if employees self-identify a problem, but many don't, says Whitehouse. "There is a disjointed system that is not easy for patients to navigate. Also, there is a stigma on mental illness," he adds. Most behavioral health care is delivered by primary care physicians, which means care is not optimal and often includes short courses of medications without counseling or follow-up, he says.

Of the 20% of people who drive 80% of medical costs, half of that group has a psychiatric issue, which is often undiagnosed, untreated or only partially treated, says Whitehouse. "This significantly impacts clinical outcomes and the cost of the care," he says.

Evidence is clear

Previously, psychiatric conditions were largely ignored, primarily because employers weren't fully aware of the impact of indirect costs such as productivity and presenteeism, says Whitehouse. "Because it's hard to capture those numbers, making the case to CFOs to invest in this hasn't been easy. But the evidence is pretty clear now," says Whitehouse, pointing to a recent study showing the impact of a depression outreach program on productivity.2

A growing number of companies are integrating medical and behavioral health care, according to Whitehouse. Incorporate productivity tools into health risk assessments, by including a self-report of how medical conditions, including psychiatric conditions, are impacting the employee's productivity, advises Whitehouse. Screening for depression is not enough, he says, you also need to screen for substance abuse as well, because many individuals with psychiatric conditions abuse drugs or alcohol.

"The issues keeping people out of work are not the same as the issues impacting people at work," says Whitehouse. "Lost productivity of one hour a day turns into weeks over the course of a year. If you multiply that by the number of employees, it's like having a huge number of your workforce not turn up for the whole year."

Perform outreach

Instead of waiting for employees to reach out for help, have disease management, case management, and disability vendors do outreach with individuals identified as high risk for a behavioral health problem, says Whitehouse. "During that outreach call, which the employee has consented to, there is some attempt to get at the services and issues that are available," he says.

For example, a nurse may explain to an employee with chronic back pain that many people with this condition feel overwhelmed. If a problem is identified, the employee can be transferred to a specialist or contacted later by phone or e-mail to set up an appointment. "We tell our people there is only one goal of the first call, and that is to get to the second call," says Whitehouse. "A lot of outreach calls fail because they ask 35 questions, and the employee feels they are being interrogated."

Better identification can lead to better treatment, resulting in decreased medical costs, greater employee satisfaction, and increased workplace productivity, he says. "Just as exercise and diet can prevent a serious medical condition from occurring, stress-coping strategies can prevent a serious behavioral health condition from occurring," says Whitehouse.


1. Russo CA, Hambrick MM, Owens PL. Hospital stays related to depression, 2005. HCUP Statistical Brief No. 40. November 2007. Agency for Healthcare Research and Quality, Rockville, MD.

2. Wang PS, Simon GE, Avorn J, et al. Telephone screening, outreach and care management for depressed workers and impact on clinical and work productivity outcomes, a randomized controlled trial. JAMA 2007; 298:1,401-1,411.