What the COVID-19 pandemic has taught us about Mental Health

Mental Health – The next silent Pandemic

Mental illness is the pandemic of the 21st century and will be the next major global health challenge. Despite the increased availability of antidepressants during the past few decades, limited efficacy, safety issues, and high treatment costs have resulted in an enormous unmet need for treatment of depressed mood. It is estimated that 350 million individuals experience depression annually. On average, it takes almost 10 years to obtain treatment after symptoms of depressed mood begin, and more than two-thirds of depressed individuals never receive adequate care. Enormous psychological, social, and occupational costs are associated with depressed mood, which is the leading cause of disability in the US for individuals aged 15 to 44 years with annual losses in productivity in excess of $31 billion.  In response to these alarming circumstances, in 2016 the World Health Organization declared depression to be the leading cause of disability worldwide.

Current treatments model of Behavioral Health Care do not adequately address the complex challenges of mental illness, which accounts for roughly one-third of adult disabilities globally. Before Covid-19 arrived in the U.S., the country was in the midst of a mental illness crisis. Suicide rates in the United States rose 33% between 1999 and 2017. In 2018, 1.7 million people had an opioid use disorder. Employers spend annually $100+ billion on healthcare spending related to mental illness and the indirect costs amount to $200+ billion annually. Even with this level of spending and impact, mental health cases continue to grow at a double-digit rate annually.

These circumstances call for radical change in the paradigm and practices of mental health care, including improving standards of clinician training, developing new research methods, and re-envisioning current models of mental health care delivery.

In relation to COVID-19, The American Psychiatric Association has outlined a number of steps Congress should take right away:

  • Provide health care workers with sufficient and appropriate personal protective equipment and mental health support
  • Expand telepsychiatry and require insurers to pay clinicians for providing it just like any other medical service.
  • Treat patients’ behavioral health needs the same as their physical health needs, and release emergency funding to ensure that community mental health centers, crisis centers, and essential local clinicians can meet the growing need for mental health care.

The American Psychiatric Association backs what’s called the collaborative care model, that incorporates conventional biomedical therapies and complementary and alternative medicine approaches. “Integrated care” and “collaborative care” are models of care that refer to the same kind of health care delivery system and are used interchangeably. 

Recommendations are to expand current practices to include integrative treatment strategies incorporating evidence-based biomedical and complementary and alternative medicine modalities that can be provided to patients using a collaborative care model. Recommendations also are made for a research program aimed at investigating the efficacy and cost-effectiveness of promising complementary and alternative medicine and integrative treatments addressing the complex needs of patients with severe psychiatric disorders, many of whom respond poorly to treatments available in mental health clinics.

A look into the Complementary and Alternative Treatments in Mental Health Care

In the context of the limitations of available conventional biomedical treatments, accumulating research findings are providing evidence for both safety and efficacy of select complementary and alternative (CAM) treatments of depressed mood, anxiety, and other mental health problems, including select pharmaceutical-grade natural products, lifestyle modifications (Lifestyle Medicine), mind-body approaches, and nonallopathic whole-system approaches such as traditional Chinese medicine and Ayurveda.

Examples of natural supplements being investigated as nonpharmacologic therapies include 

  • S-adenosyl methionine for depressed mood
  • Adjunctive use of nutraceuticals (i.e., botanicals and other natural product supplements) in combination with psychotropics such as 
    • Omega-3 fatty acids
    • Folic acid (especially its active form l-methyl-folinic acid)
    • 5-hydroxytryptophan
    • N-acetyl cysteine for mood disorders
  • A standardized extract of the herbal kava
  • Amino acid l-theanine

Lifestyle modifications such as regular exercise, healthy diet, sufficient sleep, and reducing alcohol and nicotine use also enhance mental and emotional well-being while reducing the relapse risk for many psychiatric disorders.

Increasingly, small community-based mental health clinics are shifting the context in which mental health care takes place to services aimed at wellness and prevention in primary care settings. Widespread use of CAM by patients who are concurrently receiving conventional treatments such as psychotropic medications and psychotherapy is driving a trend toward increasingly integrative mental health care in North America, Europe, Australia, and other world regions.

Findings of a survey published by the Bravewell Collaborative, support that integrative treatment strategies incorporating pharmaceuticals and evidence-based CAM therapies are often beneficial for common medical and psychiatric disorders, and this survey highlights depressed mood and anxiety as among the top 5 health concerns for which CAM and integrative approaches are most beneficial.

Challenges with CAM

Although it is estimated that more than 50% of all individuals with a diagnosis of mood or anxiety disorder use CAM therapies to manage their symptoms, few disclose CAM use to their psychiatrist, family physician, or other conventional health care practitioner. To complicate matters, many widely used CAM therapies are supported by limited research evidence. Relatively few CAM therapies have been substantiated by consistent positive findings from large, well-designed, placebo-controlled studies. Furthermore, most CAM therapies are limited by incomplete knowledge of mechanisms of action, small study sizes, inconsistent research findings, and—in some cases—safety concerns. Patients who use nutraceuticals or other CAM therapies not supported by strong research place themselves at risk of disappointing outcomes or potentially serious safety problems when such therapies are used in combination with pharmacologic agents.

Emerging Paradigms of Integrative Mental Health Care

Increasing acceptance of CAM therapies in the US and other economically developed world regions is the result of scientific advances, social trends, and the availability of safe, affordable nonpharmacologic treatments. Biomedicine is evolving in response to increasing openness to nonallopathic systems of medicine among conventionally trained physicians in the context of growing patient demands for a variety of treatment choices that are not presently included in the dominant model of mental health care, as well as more individualized health care. The result has been the emergence of integrative medicine in response both to patients’ needs, practitioners’ changing perspectives, and the limitations of the current model of care. 

Integrative medicine affirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by research evidence, and goes beyond the limitations of biomedicine or CAM by incorporating diverse treatment approaches with the goals of achieving optimal wellness, preventing relapse, and improving outcomes. Integrative mental health care emphasizes wellness and healthy lifestyle choices while addressing the range of complex biological, psychological, cultural, economic, and spiritual or religious factors that affect general well-being and mental health. As such, integrative mental health care is an evidence-based, research-driven paradigm that acknowledges the legitimacy of conventional and CAM treatments and recommends specific treatment combinations supported by research findings.

Cost-effectiveness Considerations; How the Integrated / Collaborative Care Model could reduce the escalating direct / indirect behavioral health cost

Findings from economic modeling research support that although treatment strategies that incorporate CAM and conventional biomedical treatment modalities may initially be costly, downstream savings can be achieved when such integrative strategies yield positive long-term outcomes. Systematic reviews of economic modeling studies on comparative cost-effectiveness of conventional vs CAM or integrative treatments of many medical and psychiatric disorders support that CAM or integrative treatment is cost-effective and may result in cost savings in some cases. It has been argued that higher upfront costs of CAM or integrative health care may be offset by improved work productivity and increased future quality adjusted life years. In the same vein, a study done in Australia estimated that switching depressed individuals from a conventional antidepressant to St John’s wort (Hypericum perforatum) could result in a potential savings of AU$50 million per annum. 

Conclusion

Currently available conventional biomedical treatments, CAM treatments, and the dominant model of care used in the US and other world regions fail to adequately address the complex biological, social, cultural, and spiritual dimensions of mental illness. These circumstances define an urgent agenda for broadening the current paradigm of mental health care to include evidence-based integrative treatments incorporating conventional and CAM modalities and implementing a collaborative care model on a large scale in primary care settings aimed at wellness, prevention, and treatment of specific psychiatric disorders.

Accumulating research evidence supports that lifestyle modifications including changes in diet and exercise, mindfulness meditation and mind-body practices, and select natural products are beneficial, safe, and affordable interventions for many common mental health problems that can be safely combined with pharmacologic and psychotherapeutic interventions and can easily be incorporated into mainstream mental health models of care. Based on research, current work etc., it seems like that Integrative Mental Health model could truly help us drive better outcomes and charter the next frontiers for Mental Health care.

References

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