November 5, 2009

Beyond Medicine: Addressing Broader Roots of Illness in Health Care Reform

Op-Ed from APA CEO Norman B. Anderson about integrating psychology into health care reform.

Research has clearly demonstrated that health and illness are determined by a complex interaction of biological, behavioral, psychological, socio-cultural and environmental factors, as well as a person’s coping resources and access to health care. Each of these factors must be addressed if true health care reform is to be achieved.

The interaction among these factors is especially significant for chronic diseases, such as diabetes, heart disease, stroke, lung disease and many forms of cancer, which are the main drivers of health care utilization and costs. Unhealthy behaviors, such as smoking, physical inactivity, poor nutrition and excessive alcohol use, are the four leading factors that contribute to the high prevalence of chronic disease and premature death in the U.S. These behavior-linked illnesses affect more than 40 percent of our population and account for 75 percent of personal health care spending.

Another key problematic behavior is non-adherence to medication regimens -- wherein about one-third to one-half of patients do not take prescribed medication as directed. Such non-adherence not only reduces the effectiveness of medication but can also have deadly consequences.

The prevalence of unhealthy behaviors is striking. The good news is that these behaviors represent modifiable risk factors—we can change them to reduce our risk of chronic illness.

Mental disorders must also be given heightened attention in health care reform. According to the National Institute of Mental Health, nearly a quarter of our nation, or 58 million people, suffer from a diagnosable mental disorder in a given year. The World Health Organization estimates that mental disorders account for 15 percent of the disease burden worldwide, taking into account years of life with disability and years of life lost. This disease burden is higher than all cancers combined. Shockingly, adults with serious mental illness served in public mental health systems die of physical ailments an average of 25 years earlier than those without severe mental illness.

Depression in particular is highly prevalent and is the cause of a huge disease burden due to its disabling nature and the toll that it exacts on other illnesses. Depression increases rates of suicide and death from heart disease. It prolongs recovery from illness and surgery, and it increases the levels of chronic pain. Fortunately, there are excellent cognitive behavioral therapy approaches and medications that are very helpful for treating depression, but they can only work if patients have access to such treatments.

Over the last two decades, there has been a wealth of research demonstrating once and for all that there is no separation between the mind and the body: They are an integrated whole. What we call the mind can have profound effects on biology and vice versa.

For example, worry and stress can lead to measurable and profound effects on nearly every system of the body, including the immune, cardiovascular and central nervous systems. Negative emotions, such as excessive anger and anxiety, can have similar effects. On the positive side, practices such as meditation and relaxation training can be health-enhancing for many people.

So how should health care reform take into account the wider determinants of chronic illness, particularly those associated with behavior, mental disorder and the mind-body connection?

First, we need to fully integrate mental and behavioral health components into primary health care, where there is collaboration among various health professionals, including psychologists and other mental and behavioral health experts, who can address different components of a patient’s health care needs. There is evidence that such coordinated, mind/body-focused care produces better outcomes for patients and lowers health care costs.

To accomplish this goal, we need to ensure that we have a diverse health care work force composed of physicians and other health professionals that is trained to offer such vital integrated, interdisciplinary care. And this work force must address the growing disparities in health and health care related to the changing demographics of our society, which include both a rapidly aging and increasingly racially and ethnically diverse population. For instance, it is essential to provide services that are culturally and linguistically competent to meet the unique health care needs of our racial and ethnic minority populations.

Finally, in addition to providing universal access to quality physical, mental and behavioral health care, we need to ensure that everyone has access to quality health promotion, wellness and disease prevention services. Our lives depend on it.

Norman B. Anderson is Chief Executive Officer of the American Psychological Association and former Associate Director of the National Institutes of Health.

The American Psychological Association, in Washington, D.C., is the largest scientific and professional organization representing psychology in the United States and is the world’s largest association of psychologists. APA’s membership includes more than 150,000 researchers, educators, clinicians, consultants and students. Through its divisions in 54 subfields of psychology and affiliations with 60 state, territorial and Canadian provincial associations, APA works to advance psychology as a science, as a profession and as a means of promoting health, education and human welfare.