Steven M. Tovian, PhD, ABPP, is an assistant professor of psychiatry and behavioral sciences at the Feinberg School of Medicine at Northwestern University in Chicago. He is board certified in clinical health and clinical psychology and is in independent practice. He is the former chief psychologist and director of health psychology at the NorthShore University Healthcare System Medical Group. His work focuses on integrating health care " including mental health treatment in medical settings to improve overall health. To mark World Mental Health Day (Oct. 9), the American Psychological Association spoke with Dr. Tovian about the benefits of including psychologists in primary care and other medical settings and how this integration can lower costs for consumers and insurance companies.
APA. What is integrated health care?
Dr. Tovian: Integrated care combines medical and mental health care under one roof. This type of care can produce healthier patients for less or at least the same amount of expense. Further, it can offer convenience and easier access to complete health care services by removing barriers and reducing the stigma associated with seeking mental health care separately.
Integrated health care takes into account that behavior plays an important role in overall health. Under collaborative care, patients with psychological issues can get treated earlier and avoid unnecessary medical treatment. This will likely lower costs for the patient and insurance companies and give patients a better chance to improve their health.
APA. Your research has focused on psychologists working in medical settings. What are some of the benefits of this collaboration?
Dr. Tovian: Psychologists in medical settings teach health care professionals, conduct research, become involved in health care policy development, and provide direct assessment and intervention services to patients and staff. With health psychologists on site, they are able to help patients cope with illness, adhere to medical regimens, understand emotional influences on disease, improve communication with their physicians and ultimately try to prevent disease or worsening of current condition.
They serve patient populations throughout the entire life span and address health problems in every category of disease classification in all disease stages, namely, primary, secondary and tertiary medical care and prevention. Empirically validated research and clinical programs have demonstrated that psychological interventions pre- and post- surgery can lessen patient anxiety before and after surgery, reduce complications related to surgery and recovery and lessen the need for postoperative pain medications. Additionally, these interventions can speed up recovery, allowing for a faster return to health and daily function.
APA. It is estimated that approximately 60 percent of patients visit their primary care doctor for mental health issues, such as depression or anxiety. How would wider access to integrated care change this?
Dr. Tovian: Mental health problems are often medical problems in the primary care physician's office. As the above statistic indicates, there is a large incidence and prevalence of mental health disorders in primary care. There is also a high incidence of mental health diagnoses occurring with medical problems. The most frequent problems include depression, anxiety and panic, substance abuse and psychosomatic disorders. Untreated, these patients can become hard to manage by primary care physicians and specialists. Timely and early mental health interventions provided by psychologists in integrated care, for example, reduces unnecessary or unhelpful medical treatments, thereby improving clinical and cost outcomes.
APA. Can you give an estimate of how much consumers/insurance companies could save if mental health care is incorporated into primary care?
Dr. Tovian: Results from the last 35 years of medical cost offset research reveal that cost offset is greater in organized health care settings where behavioral health care and primary care are integrated and where the behavioral health care interventions are supported by research. Studies cited by Whitehouse (1997) indicate, for example, that well-designed behavioral interventions can save anywhere from 20 percent to 40 percent of previous total medical expenditures.
In another controlled study, for example, Medicaid outpatients who frequently visited their doctors and received integrated behavioral health treatment achieved a 21 percent reduction in medical costs after 18 months, while those who received no behavioral services had a 22 percent increase in their use of medical services (Pallack, Cummings, Dorken & Hanke, 1995).
APA. Your work also focuses on stress's effect on the immune system. While the government tells us the economy is improving, how long does it take for people to recover from the type of prolonged stress many have experienced?
Dr. Tovian: When something sets off the complicated series of physiological responses in the body, the resulting "stress response involves a series of more than 1,400 known physiochemical reactions in the body. Some of the most common signs and symptoms of stress include headache, backache, insomnia, tightness in the neck and shoulders, indigestion, loss of appetite or excessive eating, and increased heart rate. The physiological effects of stress can affect the brain, endocrine system, gastrointestinal system and cardiovascular system, to name a few. All physical symptoms should be thoroughly evaluated by a physician to rule out the physiological effects of stress.
Individuals differ in their response to and recovery from stress based on gender, age and past experiences with stress management. Stress can play a moderate to major role in numerous disease conditions. Stress can even lower immune system functioning. However, just because immune functioning is compromised doesn't automatically mean an individual will be ill.
Stress seems to have the greatest impact on the health of individuals who already have poor immune functioning due to age or disease, or on individuals who have been chronically stressed for reasons other than health. External problems, such as economic downturns, may indeed affect stress responses (i.e., immune functioning, behavior, emotions and cognition). Total recovery from prolonged stress secondary to the economy may take months, depending on individual differences. In fact, factors that influence the ability to cope with stress include: genetic susceptibility, insomnia, diet and nutrition, obesity and exercise management, smoking, and unrealistic goal-setting Females (including children) are more resistant to the effects of stress but researchers are not sure why. Stress can affect adults at any age and developmental stage and, again, individual gender responses depend on numerous factors.
APA. What is integrated health care?
Dr. Tovian: Integrated care combines medical and mental health care under one roof. This type of care can produce healthier patients for less or at least the same amount of expense. Further, it can offer convenience and easier access to complete health care services by removing barriers and reducing the stigma associated with seeking mental health care separately.
Integrated health care takes into account that behavior plays an important role in overall health. Under collaborative care, patients with psychological issues can get treated earlier and avoid unnecessary medical treatment. This will likely lower costs for the patient and insurance companies and give patients a better chance to improve their health.
APA. Your research has focused on psychologists working in medical settings. What are some of the benefits of this collaboration?
Dr. Tovian: Psychologists in medical settings teach health care professionals, conduct research, become involved in health care policy development, and provide direct assessment and intervention services to patients and staff. With health psychologists on site, they are able to help patients cope with illness, adhere to medical regimens, understand emotional influences on disease, improve communication with their physicians and ultimately try to prevent disease or worsening of current condition.
They serve patient populations throughout the entire life span and address health problems in every category of disease classification in all disease stages, namely, primary, secondary and tertiary medical care and prevention. Empirically validated research and clinical programs have demonstrated that psychological interventions pre- and post- surgery can lessen patient anxiety before and after surgery, reduce complications related to surgery and recovery and lessen the need for postoperative pain medications. Additionally, these interventions can speed up recovery, allowing for a faster return to health and daily function.
APA. It is estimated that approximately 60 percent of patients visit their primary care doctor for mental health issues, such as depression or anxiety. How would wider access to integrated care change this?
Dr. Tovian: Mental health problems are often medical problems in the primary care physician's office. As the above statistic indicates, there is a large incidence and prevalence of mental health disorders in primary care. There is also a high incidence of mental health diagnoses occurring with medical problems. The most frequent problems include depression, anxiety and panic, substance abuse and psychosomatic disorders. Untreated, these patients can become hard to manage by primary care physicians and specialists. Timely and early mental health interventions provided by psychologists in integrated care, for example, reduces unnecessary or unhelpful medical treatments, thereby improving clinical and cost outcomes.
APA. Can you give an estimate of how much consumers/insurance companies could save if mental health care is incorporated into primary care?
Dr. Tovian: Results from the last 35 years of medical cost offset research reveal that cost offset is greater in organized health care settings where behavioral health care and primary care are integrated and where the behavioral health care interventions are supported by research. Studies cited by Whitehouse (1997) indicate, for example, that well-designed behavioral interventions can save anywhere from 20 percent to 40 percent of previous total medical expenditures.
In another controlled study, for example, Medicaid outpatients who frequently visited their doctors and received integrated behavioral health treatment achieved a 21 percent reduction in medical costs after 18 months, while those who received no behavioral services had a 22 percent increase in their use of medical services (Pallack, Cummings, Dorken & Hanke, 1995).
APA. Your work also focuses on stress's effect on the immune system. While the government tells us the economy is improving, how long does it take for people to recover from the type of prolonged stress many have experienced?
Dr. Tovian: When something sets off the complicated series of physiological responses in the body, the resulting "stress response involves a series of more than 1,400 known physiochemical reactions in the body. Some of the most common signs and symptoms of stress include headache, backache, insomnia, tightness in the neck and shoulders, indigestion, loss of appetite or excessive eating, and increased heart rate. The physiological effects of stress can affect the brain, endocrine system, gastrointestinal system and cardiovascular system, to name a few. All physical symptoms should be thoroughly evaluated by a physician to rule out the physiological effects of stress.
Individuals differ in their response to and recovery from stress based on gender, age and past experiences with stress management. Stress can play a moderate to major role in numerous disease conditions. Stress can even lower immune system functioning. However, just because immune functioning is compromised doesn't automatically mean an individual will be ill.
Stress seems to have the greatest impact on the health of individuals who already have poor immune functioning due to age or disease, or on individuals who have been chronically stressed for reasons other than health. External problems, such as economic downturns, may indeed affect stress responses (i.e., immune functioning, behavior, emotions and cognition). Total recovery from prolonged stress secondary to the economy may take months, depending on individual differences. In fact, factors that influence the ability to cope with stress include: genetic susceptibility, insomnia, diet and nutrition, obesity and exercise management, smoking, and unrealistic goal-setting Females (including children) are more resistant to the effects of stress but researchers are not sure why. Stress can affect adults at any age and developmental stage and, again, individual gender responses depend on numerous factors.
