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How Did COVID Affect Mental Health? · CareTalk: Healthcare. Unfiltered.

• 0:00
  - Welcome to CareTalk, America's home for incisive debate about healthcare business and policy.
• 0:05
  I'm David Williams, President of Health Business Group.
• 0:08
  - And I'm John Driscoll, the CEO of CareCentrix.
• 0:11
  David, who is our honorable guest today?
• 0:14
  (david laughs)- John, whenever you say "honorable," it makes me worry you're gonna get like a sucker punch in there against them, but no.
• 0:19
  - To you, only for you David.
• 0:22
  - We have an outstanding guest today, Dr. Dena Bravata, a healthcare entrepreneur and so much more and she's gonna talk to us about mental health, John.
• 0:31
  - Well, Dena my old friend, welcome and I'm so excited to have you on for us to talk a little bit about and unpack this big issue about mental health, COVID, behavioral health, the teen mental health crisis.
• 0:47
  There's a lot to dig into since you were one of the co-founders of Lyra, and an internal medicine and a healthcare policy wonk.
• 0:56
  Welcome.
• 0:57
  - Thank you so much. It's great to be with both of you.
• 1:00
  - John, before you ask one of your big intellectual questions, can I ask a question that has been on my mind?
• 1:06
  - You could try, you could try.
• 1:07
  - Here's the question, what is behavioral health?
• 1:11
  - It's a great question and I think that people on our side, we use that term all the time and just expect everyone else to know what it is.
• 1:21
  So, behavioral health is defined as the combination of both mental health plus addiction services.
• 1:28
  And so, it is like the broadest possible category for the topic of helping people with any of those kinds of issues.
• 1:40
  - I really do hate the way healthcare people generalize things to the point where, it's really hard to understand what they're talking about but on this broad behavioral health topic, how are we doing as a country post-COVID and what's happening with mental health and addiction?
• 1:59
  - So, I think that there was just a ton of press about kind of the dual pandemic, if you will of COVID-19 plus mental health.
• 2:09
  And, I would say that one of the things that we have seen is that actually, that's kind of a fallacy.
• 2:19
  Mental health and spend for both commercially insured populations and other populations has been going up well before the pandemic.
• 2:30
  And I think some of the good things that happened during the pandemic were like a decrease in stigma, maybe we can talk a little bit more about that but so that there was like a greater recognition but actually year over year spending for behavioral health service predates the pandemic by three or four years.
• 2:55
  And the sad thing about that is that the cost just kind of seemed to be going up.
• 3:00
  - And do you think the costs mirror sort of a pre pandemic of anxiety, depression, addiction, that, that whole cluster is that really the right way to read the data?
• 3:11
  - I think it is.
• 3:13
  The conditions that you just mentioned, depression and anxiety are very, very prevalent.
• 3:20
  Now, the cost per patient for those, doesn't have to be so high because a lot of people can get outpatient care.
• 3:29
  So, you can see a psychotherapist and get talk therapy.
• 3:35
  If it's not so severe, you might be able to do well with just a digital intervention, like digital psychotherapy or you can see your primary care doctor and get some meds or see a psychiatrist.
• 3:49
  Like all of that outpatient care need not be so expensive.
• 3:53
  So, why has the slope of the curve been increasing?
• 3:57
  Well, it's both that more people are getting care but it's also that more people are getting more intensive care.
• 4:06
  And some services like addiction services in particular, can be much more costly and can sometimes require even hospitalizations or intensive outpatient programs, for example.
• 4:18
  - So how much of the growth is related just to the reduction of stigma so that untreated people are being treated and how much is let's say prevalence has gone up over time?
• 4:30
  - Yeah, well, so I think that both of these factors are playing a part but what I would say is that, pre pandemic about one in four adults reported mild to moderate symptoms.
• 4:47
  And in surveys that are coming out now, it's more than half of the population are now reporting moderate to severe symptoms.
• 4:57
  So, you have more people and because we've all just come through this, horrendous mental health, stressful period of quarantine and dealing with the pandemic, so more people have mental health conditions and we have more severe disease happening as well.
• 5:23
  And how much of it is that like, okay, well, once you get so sick, then stigma be damned if you will, I'll go in and get care, that is certainly, I think also playing a part here.
• 5:36
  - My understanding is the success rate for addiction service is actually quite low Dena, even though addiction's going up, tobacco's up among teens, alcohol's up across all categories, generalized illegal drug use seems to be up.
• 5:56
  First, is that true?
• 5:57
  And secondly, how do we fix it?
• 5:59
  - Yeah.
• 6:00
  I think it depends on the population that you look at.
• 6:04
  But taking care of addiction is a thorny problem.
• 6:11
  And there was a company called Annum which was based on the Able to Model and they took care of people with heavy drinking and the reason why the company was called Annum is because you need a year of care to really change someone's behaviors.
• 6:33
  And so it isn't to say that people who have severe depression that isn't a chronic condition that requires lifelong care but I think if you're comparing addiction issues to more kind of mild to moderate mental health symptoms, it's harder to take care of.
• 6:58
  - And what you mentioned, some people could just benefit from a digital intervention.
• 7:02
  I've read about these digital therapeutics and it's like developed like a drug, it's been approved but it seems to me, isn't it just a game?
• 7:10
  It seems like it's like a lot of just hocus-pocus involved in this.
• 7:13
  So where am I gonna be prescribed something for it like tell my kid, go play on the computer.
• 7:18
  Is it any different?
• 7:20
  - Well, so it's a great question.
• 7:23
  So, there was a study that came out in the British Medical Journal that tried to actually answer the question that you're posing David.
• 7:30
  And it's considered a negative trial.
• 7:33
  So, there were lots of studies of individual digital interventions that show that they work but this was a study that looked at trying to compare in person psychotherapy with digital psychotherapy.
• 7:47
  And it was a negative trial because the in person psychotherapy had greater benefit than the digital intervention alone.
• 7:57
  However, in an ad hoc analysis, what they looked at were those folks who stuck with the digital CBT for at least six sessions.
• 8:09
  And in that population, actually, there was therapeutic equivalents between seeing someone in person and using the digital tool.
• 8:16
  And so, my read of that is that psychotherapy is hard, you're changing how you think about things and how you behave.
• 8:27
  And if you have to show up and talk to your psychotherapist, John, about it and he's gonna harass you, have you done your homework?
• 8:35
  - I'll definitely harass him.
• 8:36
  - Yeah.
• 8:38
  - That's a motivation to do the homework and to do the hard work of psychotherapy and that with a digital tool, not all of them have that kind of accountability built in.
• 8:49
  So, a lot of experts really think of digital tools as an effective adjunct.
• 8:54
  But I think that there is also a lot of promise of using them, especially if you can use them in an engaging way so that you really can get people to like do the work because I think there's ample evidence to suggest that if you can do that, they are effective.
• 9:09
  - Dena, I think the, the other challenge in the digital therapeutic areas is that, once you start digging you realize, there's literally thousands of digital tools out there.
• 9:21
  And I think David, if you rank 'em by where it's effective and where it can be integrated but there's also some other interesting research data where a number of those subpopulations actually, where more comfortable given an alternative, being a regular client of the robot shrink, then the actual shrink for a number of reasons.
• 9:42
  One, the stigma and the personnel, they felt like they were making progress.
• 9:47
  Second, convenience, it was working if it doesn't work, they don't put people on show.
• 9:51
  Second, convenience and third, the perceived anonymity so that they could unpack it, without either success, convenience or safety.
• 10:05
  I think they don't work but if you've got those things and I think that's particularly true of harder to reach teen populations where there's some really exciting early stage stuff.
• 10:16
  And that's pretty interesting, but what I was shocked at was, but that there are literally thousands of applications out there in terms of digital mental health support or potentially behavior change.
• 10:34
  You're an expert in this area, how do you filter through for what people should be looking for versus not as an expert and a thoughtful consumer?
• 10:44
  - Oh, well, so first I would say, if someone is working with a clinician, either a primary care doc and it'd be fun to talk a little bit more about the role of primary care in treating behavioral health conditions or a psychotherapist, they likely have some tool that they have used and so, I think that, that's probably a great first step, but then I think, CBT is perfect for automation.
• 11:13
  - Cognitive behavioral therapy, the traditional talk therapy.
• 11:17
  - Yes. Thank you.
• 11:18
  And so, but like the instance, like what is the issue that this psychotherapy is trying to take care of?
• 11:27
  And to what extent is the digital tool very specific for that?
• 11:31
  So I'll give you a great example, so Sleepio was based on the principal investigators, had done all this work and really demonstrated what was necessary for cognitive behavioral therapy for people with insomnia.
• 11:49
  And then they built a digital tool based off that extensive knowledge.
• 11:54
  And, oh, by the way, it really works.
• 11:57
  Sleepio is a great digital therapeutic for people with primary insomnia and so there are other applications.
• 12:06
  So the other folks have built specific things for women with postpartum depression, for example.
• 12:13
  And I think that kind of specificity of what are the exercises, that are like specific for that particular population.
• 12:20
  That would be another thing that I would look for.
• 12:23
  - That's probably good because-- David are you smiling because you're thinking about what my psychiatrist is working on with me because it's a broad range.
• 12:30
  If that's what your question is.
• 12:31
  (david chuckles)- No, John, here's what I'm thinking about.
• 12:33
  So, you think about, we use these terms like adherence, so you want someone who's adherent to their digital therapeutic.
• 12:38
  Well, it's not that different from thinking about somebody who's building an app and they try to make it to be addictive.
• 12:43
  Now, as Dena said that, the whole point about behavioral health is it encompasses addiction as well as mental health.
• 12:50
  So, some of the same things that we look for adherence is actually is kind of causing addiction or it's gonna play on the same kind of forces there.
• 12:57
  So, I like the idea-.
• 12:59
  - No, it'd be the same neural pathways, you're right.
• 13:02
  - So and then if I liked it, the digital health is convenient.
• 13:06
  On the other hand, maybe if I have anxiety, it also enables me just to stay on the sofa instead of going in and even if I don't get anything out of the therapy session itself, the fact that I got on the train or went outside, had to get dressed, maybe that's therapeutic too.
• 13:19
  So, I just wanna caution us to be careful about what we're enabling and getting excited about.
• 13:25
  - Yeah, David, you're kind of touching a little bit, with this convenience factor, on the role of telehealth in behavioral health.
• 13:35
  Maybe we could talk about that for a second?
• 13:36
  - Sure, let's do that.
• 13:38
  - And Dena you're doing a very nice job.
• 13:39
  You don't realize that John is such a difficult guy that when you say, maybe we should talk about this, he's supposed to say, you're being guided, John, let's talk about this.
• 13:48
  Okay, let's talk about telehealth and let's talk about primary care too.
• 13:53
  (all chuckling)(john mumbles)- Dena, let's take into telehealth because telehealth is the hot new thing or was the hot new thing in healthcare.
• 14:05
  Now, at the end of the public emergency regulations, it's really under a new level of scrutiny as to whether the flexibility that the FEDS allowed, David, you gotta follow the regulatory stuff.
• 14:18
  - Gotta do it, John.
• 14:18
  - Mostly.
• 14:20
  - That there may be some restrictions and barriers put into something that it felt like during COVID we kind proved that it worked.
• 14:27
  Any thoughts on that and specifically with regard to mental health access?
• 14:32
  - Yeah, for sure.
• 14:32
  So, prior to the pandemic, there was about 4% of outpatient visits for commercially insured populations, were managed through a telehealth visit and that went to in excess of 90% by April of 2020.
• 14:50
  So, a month into the pandemic and there's a lot that is hidden in that enormous shift from not just who got telehealth services but very importantly, who provided them?
• 15:07
  So, prior there were a lot of companies like, tell Doctor On Demand, Amwell that were specific companies that provided telehealth services.
• 15:18
  But what we see today in this enormous shift is that actually like every doctor in America or many doctors had to be able to offer telehealth.
• 15:30
  And so, I think for me as a primary care doc historically, that's a great thing because it means that the patient's care is not being dis-coordinated, they aren't getting like a telehealth service from one entity that's not necessarily able to see their full medical record and isn't sort of the team taking care of them.
• 15:51
  Okay, so to your point, telehealth peaked and is starting to come down a little bit, but the public really figured out that even seniors whom we might have thought to be less tech savvy, other populations that I think we were all surprised, used a lot of telehealth.
• 16:18
  Now, on the commercial side today, interestingly about 80% of telehealth services are for a behavioral health condition.
• 16:30
  And that makes a lot of sense because you can do psychotherapy, you don't really need to do a physical exam.
• 16:37
  Like you guys figure out which of you is having a bad day or not via this modality.
• 16:45
  And so tele-psychiatry, tele-psychotherapy now representing just this huge proportion of all telehealth services.
• 16:55
  We published a paper a few months ago and I think it's notable to say, who is not getting telehealth and who is not having access to tele-psychiatry and tele-mental health and it's people in rural areas, it's younger people, it won't surprise you that it's lower income and other populations, other vulnerable populations.
• 17:21
  And so, I think the SDH disparities that we have elsewhere in healthcare are evident here as well.
• 17:31
  - So, you talked about, people surprised that maybe older populations are willing to use telehealth, now they tend to be well insured with medicare and they use Zoom so that they can talk to their grandkids and all that, how are the kids doing?
• 17:44
  How about mental health for kids?
• 17:47
  How's that going?
• 17:47
  I've heard a lot of concerns and maybe split it out by age group'cause it's not just kids versus seniors.
• 17:54
  - Yeah.
• 17:55
  And I hope that this will not be news to people.
• 18:01
  I think that there is now a light that is being shown on really this mental health, like epidemic, you hate to use that word these days for kids and teens.
• 18:14
  So, the rate of growth of mental health spending among adult populations was about 13% between 2021 and 2022 for kids, so, for pediatric populations.
• 18:30
  So, that's 12 and under, the rate of growth last year was 23%.
• 18:36
  And for teenagers it was 18%.
• 18:41
  And the actual spend on those kids is higher, so, it's not quite double, but almost.
• 18:50
  And, so why is that?
• 18:53
  They're little people, why aren't their bills smaller than for adults and experts in this area really corroborate this finding, which is that kids are presenting later in their course of disease, therefore they're requiring more intensive therapies.
• 19:12
  Often, they're actually requiring hospitalization.
• 19:15
  So a lot of those factors that we talked about earlier that are driving costs, we see that in particular in pediatric and teen populations.
• 19:27
  - One more, I got another drug question, John, before, it'll slip my mind.
• 19:30
  How is the legalization of cannabis playing into mental health for teens and for adults for that matter?
• 19:40
  - I'm not an expert in the area.
• 19:42
  I think that, certainly there are acute illnesses associated with acute psychosis from use of marijuana that are driving hospitalizations at, that's an expensive thing to take care of.
• 19:59
  Also, there are folks who are suffering from addiction, even though they're classically not considered highly addictive substances, some people are finding behaviorally that they're unable to sort of enjoy a day without them.
• 20:16
  So, I think that still today, what's driving the big numbers for commercially insured populations, it's much more alcohol and the other sort of standard substances.
• 20:35
  - So Dena, I wanted to dig into, the stigma meter here, if you say you are the most stigmatized form of health conditions, like sexually transmitted diseases, sexually transmitted stuff and the least is like going to the pediatrician when your child spikes a temperature of over a 100.
• 20:57
  Where are we in terms of progress to get mental health and addiction services closer to just like a visit to a clinician versus something that's hidden, which I think is a compound challenge for mental health in general.
• 21:15
  - Yeah.
• 21:16
  A friend of mine who's a smart benefit leader said to me, pre pandemic, that let's see, I wanna be able to quote him exactly, that the specter of shame around mental health extends deeply into my office.
• 21:37
  And by that he meant that the notion that you would walk into the head of HR of your department and say, my heroin addiction is really getting the better of me, I'd like some help please.
• 21:49
  That's not something that happens very often.
• 21:54
  And so, I think that certainly for addiction in particular, the stigma is still very hard.
• 22:06
  During the pandemic people talked about sort of mommy's little helper and many employers put out many new benefits around mental health.
• 22:21
  - We did a bunch, which we added all kinds of stuff because we work from home and you can't even help your friends if you're aren't run around them, if you're work from home.
• 22:31
  At a number of different levels, we at the CareCentrix and a number of others tried.
• 22:36
  I still feel though that you're reinforcing the truth, which is, let's look at opioid use.
• 22:41
  Opioid use epidemic is still going up.
• 22:43
  It is a common problem.
• 22:45
  It's often triggered not by choice but if you don't go for help, it's gonna end poorly.
• 22:58
  I fear we're not making enough progress fast enough.
• 23:02
  David, what say you, you're sitting up, you're sitting up there with a stern look on your face, am I running over my time?
• 23:10
  - Well, John, I thought I was just trying to correct for the smile,'cause you didn't seem to like that one before so.
• 23:16
  No, I don't know.
• 23:18
  I think it's limited, what an employer can really do.
• 23:23
  They're gonna go and solve all the problems and you talk about the opioid epidemic was upon us and it seemed to have gotten worse during the pandemic.
• 23:36
  It's harder to do anything about it'cause people aren't even working, you've got things like fentanyl that are out there, so imagine trying to stop that.
• 23:44
  So, we just have just this huge problem.
• 23:46
  And I guess the question is, whether we have an opportunity to be optimistic here or not?
• 23:52
  I understand yeah, that the spending's gone up, there's a lot of problems been noted, maybe some digital therapeutics can help, there's things that can be done in the primary care and telehealth and so on.
• 23:59
  But are we gonna be here in five years just talking about how it got so much worse and we saw it coming or we had some possibility to do something to slow the this bad progress.
• 24:10
  Maybe we should talk to the expert about that.
• 24:12
  Dena, that's probably a great question to end on.
• 24:16
  What your read five years from now, where will we be?
• 24:19
  And how might we get there faster?
• 24:22
  - Yeah, am enormously hopeful.
• 24:26
  So, one of the great things is that, there are effective therapies for the most common behavioral health concerns.
• 24:33
  We have effective psychotherapy medications.
• 24:37
  So, I also think that there's like this emerging field of interventional psychiatry that's very interesting.
• 24:45
  So, in the olden days, we maybe thought about ECT as like the only intervention and it was shrouded in this kind of like-.
• 24:54
  - Electroconvulsive therapy.
• 24:56
  - Yes. Yes.
• 24:57
  But today we have novel interventions, including transcranial magnetic stimulation.
• 25:04
  I think there's a lot of enthusiasm and study now around the use of psychedelics, especially for people with treatment resistant, depression and anxiety.
• 25:15
  So, I'm very hopeful about this increasing expansion of effective therapies.
• 25:22
  And back to the point about the role of employers, I think that employers have a huge role to play because if your employer is saying, look, this is so prevalent and we all have to take care of our stress and our mental health.
• 25:38
  And today 78% of employers offer a mental health program and many of them offer more than one.
• 25:47
  So, not just like an EAP but like a range of programs for folks with more mild, moderate disease and then for more significant disease.
• 25:57
  And so, I am very hopeful about this.
• 26:04
  We talked about teens and there are companies like Brightline that are really just dedicated to kids and their families and you so we're having more and more innovation around the care of specific populations as well.
• 26:20
  So, I think lots to be very great.
• 26:22
  - Great.
• 26:23
  Well, John, now I'm smiling John because I love ending on an optimistic note and I wanna say that's it for yet another addition of CareTalk.
• 26:32
  We've been speaking today with Dr. Dena Bravada about behavioral health.
• 26:36
  I'm David Williams, president of Health Business Group.
• 26:39
  - And I'm John Driscoll, the CEO of CareCentrix.
• 26:42
  And David, again, I need to remind you that the future will be owned by the bold and the optimistic and the practical.
• 26:49
  And we've got one of those bold, optimistic and practical agents of change in Dr. Dena Bravada.
• 26:55
  Dena, thanks for joining today.
• 26:56
  - Thank you so much, it was really fun.
• 26:58
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• 27:03
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