In the age of holistic health, digital tools and medication can work together to help treat patients

A panel featuring Doctor On Demand, NeuroFlow, Hims & Hers, and Amwell discussed at Invent Health

One of the most notable changes to the treatment of mental health since the 1980s has been a major increase in the use of psychotropic medications; in fact, a 2011 report from the National Center for Health Statistics (NCHS), found that the rate of antidepressant use in this country among teens and adults, meaning those 12 and older, increased by around 400% between the years 1988 and 1994, as well as between 2005 to 2008.

Now, mostly thanks to the pandemic, the number of people on prescription mental health medication is up, with over 65 million Americans now taking these drugs. In all, 18 states have seen between 10% to 20% increases in the number of people taking prescription mental health medication over the last year, with Colorado, West Virginia and Montana seeing the largest increases.

This is all happening at the same time as a larger shift in healthcare that would potentially signal a decrease in the use of drugs, as it becomes more value-based and more holistic, and it becomes a system in which a person's entire life is seen as being part of their health. 

During the The Future of Mental and Behavioral Health, from Vator and UCSF Health Hub, the idea of getting away from a mental health system that relies on medication came up on a panel moderated by Bambi Francisco Roizen, founder and CEO at Vator, and Dr. Archana Dubey, Global Medical Director at HP.

"Archana and I have been talking from the start of this program how we're moving away from sick care to self care, and we're moving away from this whole pharma science. This sort of one input or reductionist approach of just taking a psychrotrophic for a mental illness toward behavioral science," Francisco said.

"Do you agree that we're moving away from this old pharma science to a new behavioral science? And if you agree, has that been difficult for you to articulate that to your customers?" 

The first to respond was Dr. Peter Antall, Chief Medical Officer at Amwell, who said it was "an oversimplification to say that we're moving from one model to a new model," even as there has been "an acceleration of the use of digital technologies and tools."

"We are seeing more self-help, more mindfulness, and mindfulness is trending these days for the right reasons, because it can be a very effective tool. So, we are seeing an acceleration of many tools that are not pharmacologic, but I don't see that happening in lieu of the proper use of pharmacologic tools when appropriate," he said, noting cases where there's major depression that's debilitating, or diseases like bipolar disorder or schizophrenia, and medication is often useful and necessary.

While we're getting better at the non-pharmacological tools, as well as providing new and different ways for patients to access care, that doesn't mean that the other types of care have to be sacrificed, he said.

"We're also helping overcome stigma. I hear again and again from different patients or different populations, usually anecdotally, that, 'I would have never gone and received care at an office called psychiatry, but since I can do it from the comfort of my home, and I don't have to worry about seeing my neighbor in the waiting room, I'm willing to engage.' There's a lot of good evolution happening but it doesn't have to be at the expense of the proper use of medications when necessary or appropriate."

Dr. Ian Tong, Chief Medical Officer at Doctor on Demand, agreed, noting that "we all just went through the hardest year we've ever been through in our lives."

"Because so many people have had just such a hard year, it actually has removed a tremendous amount of stigma across the board, to where you might say we all have the biggest excuse ever to acknowledge whatever behavioral health or mental health concerns and issues we may feel," he said

Stiil, Tong said, the different types of treatment are not in competition with one another and, "We need the whole spectrum or the gamut of an arsenal."

"If you ask a doctor that question, it’s very natural for us to go to, ‘Look, we know for the more severely ill, and the ICD-10 diagnostic clinical elevations, we can do some things with them and the medications work very well.' But I know there’s also a concern on the payers’ side, 'But aren’t we overmedicating people right now because everybody's on something now and are we reaching for that too easily?' And so, I like that we're having that debate, but it's not one or the other," he said.

Ultimately, it's all about getting smarter and learning as much as we can about all the tools, including coaching and the social determinants of health, which can also have a major impact on mental and physical health.

"There are bigger things that are not necessarily clinically issues, but maybe are defined by your zip code, that have a huge impact on your mental health and your well being and your ability to find physical outlets. We talked about going for a run: there are some places where people aren’t going for a run because it’s not a safe thing to do in their neighborhood. We need to figure out the tools that those individuals need, and sometimes those are not clinical," Tong said.

Chris Molaro, CEO at NeuroFlow, also agreed, saying, "it's not a zero sum game, it's about the right care at the right time and using measurement-based care."

"That's where technology can help play a part in helping the care delivery organizations identify who actually needs to be on those therapeutics and medications, and then therapeutics plus coaching could make a world of difference as opposed to a pill, which is not going to be the silver bullet. If you can enhance that and you can measure outcomes and say, 'Wait a second, this is trending in the wrong direction, maybe we should think about keeping them off this or changing their medication, changing their dosage,' data can help inform that care delivery."

Dubey asked Dr. Patrick Carroll, Chief Medical Officer at Hims & Hers, about how his company is helping its constituents, who are primarily Millennials, so they're often on the younger side.

"As a practicing clinician, I see that there's a little bit of an easier adoption of medication to treat mental illness in my younger demographics than older demographics, because of course there's stigma around mental illness but also around medications for mental illness," Dubey said.

"There's much more adoption in the younger demographic around, ‘Yeah, I needed help. I needed medications, too.’ And so how you are developing clinical protocols around that?"

Carroll responded that, during the 30 years he spent as a primary care physician, he saw very few Millennials, and noted that they're uncomfortable talking about the issues that Hims & Hers addresses, including hair loss and sexual health, which is why it made sense to add behavioral health.

"I know, as a primary care physician, that talk therapy would only go so far for some patients, and that medications did have a very valuable role. So, we've decided we're going to offer a holistic approach to behavioral health care," he said.

That's why the company offers free group sessions around topics that include dealing with stress during the pandemic, as well as individual psychotherapy, which Hims & Hers is building out for every state.

"You have to have a holistic approach to this, because behavioral health issues, even if you just focus on anxiety and depression, they can be very complex and one size doesn’t fit all. For most patients, it is a combination of psychotherapy and medications. Particularly for our demographic, it seems like that is the most effective, although not every patient will end up on medication, which is great, but a lot do need that, along with psychotherapy."

Antall closed out the discussion by tempering some of the enthusiasm for the new tools and new ways of thinking about treating mental health a bit, acknowledging that "trends kind of come and go."

"There was certainly a period where the SSRIs were the big new thing and everyone went on Prozac for minor blips in their life. I’m obviously exaggerating, but what's important to do is to recognize that when something's trending, there's there may be some value there, but sometimes the pendulum swings a little far during these periods," he said.

"Part of the reason I bring that up is, let's not forget that the tried and true methods of CBT and other other forms of talk therapy are still very valuable and often the treatment most associated with long-term remission or resolving of the condition. We have a lot of shiny new toys these days in health IT, and many of them are wonderful and have a role, but we're also trying to remember what is evidence-based and well established and often very effective."

(Image source: aarp.net)