Primary Care Is Key to Reversing Covid-Related Suicide, Overdose Trends

Even as we were in the process of projecting them, the numbers were sobering.

Last spring, as the nation was in the midst of the first stages of the Covid-19 pandemic, the Meadows Mental Health Policy Institute modeled the effects that the likely economic impacts of the pandemic would have on mental health, and specifically on rates of death from suicide and drug overdose.

Using data from many countries and comparable recessions, our model projected that for every five-percentage-point increase in the unemployment rate, we could see 4,000 additional deaths from suicide a year nationwide, along with nearly 5,000 more deaths from drug overdose. As the unemployment rate in the United States skyrocketed from 3.8% in February 2020 to 14.7% by April 2020, we could see the massive scale of the tragedy we were facing. And while economic recovery has occurred since, its results have been uneven across geographic regions and sectors of the economy and inequitable across racial and cultural groups.

Additionally, the broader effects of the pandemic beyond economic woes were harder to quantify, but it is clear that stress from working and schooling at home, close confinement, exposure to and the grief of losing friends and other loved ones adds to the emotional toll.

How to Respond

We then turned to the obvious question that our data raised: What can we, as a nation, do to respond to these needs, as well as the underlying epidemic of rising suicide and overdose rates that dates back over a decade?

As with many medical advances over the last few decades, a big part of the solution resides in primary care. The evidence-base for addressing suicide and overdose effectively in primary care centers on the Collaborative Care Model (CoCM), a proven model with more than 80 rigorous studies behind it that integrates mental health care provision within the primary care office. So, we analyzed what difference universal access to CoCM would make on dealing with this surge of despair-driven death and morbidity.

We found that universal access to CoCM would not only erase the potential spike in deaths from suicide brought on by the pandemic recession, it held the promise of significantly reducing rates of suicide below pre-pandemic levels. Our model indicated universal access to CoCM would save between 9,000 and 14,500 deaths from suicide every year. Expanded to include universal access to best practice opioid treatment (medication assisted treatment, or MAT), primary care-based interventions could annually prevent 24,000 additional deaths from overdose.

Why the Collaborative Care Model Works

So what exactly is the Collaborative Care Model, and why is it so effective at treating mental health issues?

CoCM is an evidenced-based practice that treats mental health issues no differently than physical ailments. Whether suffering from depression or a sprained wrist, people simply need to visit their primary care provider (PCP) to get the care they need. PCPs providing CoCM have a team of professionals on hand to help treat mental health needs, including a mental health specialist (either in person or remotely) who carefully tracks each patient’s case and ensures no step in their treatment is missed.

The magic of CoCM is found in its ability to identify and effectively treat mental illnesses early, long before they escalate to a level where they require major intervention.

CoCM is adept at detecting these issues whether or not they are the reason a patient goes to the PCP in the first place because it incorporates another proven approach: measurement-based care (MBC). In every routine check-up, MBC screens for common physical markers like blood sugar and cholesterol level, and this can be expanded to include screening for emotional ailments like depression, anxiety, and substance use. When such a need is detected, the PCP can immediately consult with the mental health specialist, and they can quickly decide on a treatment the patient can begin that day.

That treatment plan is also measurement-based, meaning progress is tracked, and providers can make refinements that might be needed to more effectively achieve a positive outcome.

By expanding MBC and effective care available during routine PCP visits to mental health needs, patients can begin treatment at the earliest detectable onset of symptoms. As we’ve learned from treating health conditions like heart disease and cancer, the earlier you begin care, the easier — and less expensive — it is to effectively treat.

This is a course correction of 180 degrees from the unfortunate way most systems currently work, a confusing and fractured maze that treats only part of a patient’s overall health, too often leaving them on their own to find the care they need for a mental health need, and indirectly contributing to the ongoing stigma surrounding mental illness.

This has, unfortunately, led to a national average wait time of eight to ten years before a patient begins getting effective care for a mental illness. By that time, the disease has often reached critical levels, law enforcement is frequently involved, and the first treatment occurs at an emergency room or jail cell.

With CoCM, treatment is not only more effective, it’s less expensive in the long run.

A recent national study found that, if only 20% of Medicaid recipients with depression had access to CoCM, the Medicaid system alone could save an estimated $15 billion a year. Proven savings in Medicare and Medicaid settings total 6 to 1 in total medical costs, given that people with untreated depression often suffer from other health conditions that compound both their suffering and costs of care.

Currently, CoCM is only available to a small fraction of Americans, but there are signs that this is already changing. Fifteen states to date are making CoCM part of its Medicaid programs, and more are considering it, with the promise to save significant taxpayer dollars.

Employers are increasingly embracing CoCM in their health plans, recognizing it is better for both their employees’ well-being and their company’s bottom line. In fact, more than 90% of commercial insurance plans now pay for it.

Released late last year, the Action Alliance’s Mental Health & Suicide Prevention National Response to COVID-19 calls for expanded use of CoCM to combat pandemic-driven increases in deaths of despair, observing that CoCM “has been shown across more than 79 randomized controlled trials to be effective in improving outcomes related to depression and anxiety, medication use, mental health quality of life, and patient satisfaction, when compared to usual care.”

Notably, some of the more influential health care systems in the nation are taking steps toward its widespread adoption. In Texas, for example, Baylor Scott & White Health is in the midst of a system-wide implementation of CoCM, launching the program in two large practices in Central Texas and Fort Worth, with the goal of making it available across all of their primary care practices over time.

Given the added strains Covid-19 is imposing on our nation’s mental health care systems, the need for a change to CoCM has never been more profound. We need to continue promoting this evidence-based model to help people everywhere get the quality, integrated health care they need, where and when they need it.

Andy Keller is President and Chief Executive Officer, Linda Perryman Evans Presidential Chair, of the Meadows Mental Health Policy Institute.