Bridging Medical and Mental Health: From the Doctor’s Office to the Therapist’s Couch

The doctor re-entered the office, looked at Alex, and said, “Well, your cholesterol is up and your blood pressure is running a little high. Other than that, things look fine.” Alex felt a mix of relief and confusion. “So I don’t understand—why am I exhausted all the time? Everything feels heavy and my migraines seem worse.” The doctor smiled reassuringly and said, “Sounds like you’ve been under a lot of stress. Try slowing down and exercising. Take the medication, and I want to see you for a follow-up.” Alex walked out with a familiar sense of dread and despair.

Studies indicate between 30% and 50% of patient visits to primary physicians result in medically unexplained symptom diagnoses. Also known as functional somatic syndrome (FSS), included are such ailments as gastrointestinal (GI) symptoms; back/arm/leg/chest/joint pain; headaches; fibromyalgia; chronic fatigue syndrome (CFS); and asthma. Research also continues to find a high correlation between stress/mental health and physical health. Because people may be more likely to visit a physician than a mental health specialist, physicians are in a unique position to advocate for increased mental health literacy and care.

The following are highlights of some of the associations found in different studies on psychosocial stress and mental and physical health.

S/A/D = ⇗ Illness: Presence of Stress and/or Anxiety and/or Depression is associated with increased prevalence of physical illness:

1. A: Associated with chest pain and increased visits to cardiologist.
2. A/D: Associated with dental disease such as advanced decay and tooth loss.
3. S: Divorcees 1.48 times more likely to be diagnosed with an infectious disease. Risk continues 15 years on.
4. S/A/D: Associated with dental disease such as increased decay, tooth loss, and temporomandibular joint pain (TMD/TMJ). Also associated with triggering, exacerbating, and/or prolonging asthma episodes. As many as 33% of dermatological disorders correlate with mental health concerns such as anxiety, obsessions and compulsions (OCD), depression, and psychosis. Postpartum depression risks include psychiatric conditions, volatile intimate relationship, life stressors, undesired pregnancy, fertility challenges, pregnancy complication/loss, family stressors, financial stressors, and trauma-related stressors.

Illness = ⇗ A/D: Presence of illness is associated with increased prevalence or risk of developing anxiety or depression:

1. Pediatric chronic illness: Increased risk of anxiety, depression, and other emotional difficulties.
2. Cystic fibrosis (CF): 13% to 33% of adults with CF had depression, 30% to 33% had anxiety. Among minors, 8% to 29% had depression. Increased suicidality is a concern.
3. Dermatological disorders: As examples, eczema, acne, psoriasis, and alopecia are associated with social anxiety and major depression.
4. Diabetes: Depression present in about 33% of people with diabetes type 1 and 37% of people with diabetes type 2.
5. Fibromyalgia: Anxiety issues present in more than 30% of patients. About 35% had a mood condition. Internalized/suppressed anger and poor/maladaptive coping strategies are common.

S/A/D = ⇗ Illness = ⇗ S/A/D: Bidirectional association; presence of either S/A/D or illness correlated with increased risk of developing the other:

1. Gastrointestinal disease: Inflammatory bowel syndrome (IBS) associated with anxiety and depression. About 40% of patients with inflammatory bowel disease (IBD: Crohn’s disease and ulcerative colitis) have anxiety. Stress and mood conditions are risk factors for IBD relapses. Poor coping skills associated with triggering Crohn’s.
2. Headaches/migraines: Stress and depression linked with chronic migraine. Comorbidity with anxiety is 2 to 5 times the rate for the rest of the population. Other associations: history of abuse, abandonment, isolation, dependence, shame, and emotional inhibition.
3. Heart conditions and cardiovascular surgery: Anxiety correlated with increased rate of coronary heart disease and vice versa. Depression affected 30% to 40% of patients before and after coronary artery bypass graft surgery (CABG). Nearly 11% of CABG patients developed generalized anxiety or panic. PTSD symptoms found in 18% post-op.
4. Hypertension: Association between anxiety/depression and hypertension.
5. Pneumonia: Risk of depression increased following hospitalization for pneumonia. Risk of hospitalization due to pneumonia increased by depression.

The implication of the correlation between psychosocial stress/mental health and physical health can no longer be dismissed. Comorbidity of medical ailments with stress and mental health issues correlated with poorer health outcomes such as decreased lung function, higher diastolic blood pressure, impaired wound healing, poorer physical recovery, increased risk of inflammation, wound complication, infection, low birth weight, preterm birth, preeclampsia and miscarriage, increased admission to ICU, need for mechanical ventilation, and in-hospital death.

Furthermore, studies also found that patient health outcomes were impacted by the presence of psychosocial stress and mental health concerns among parents and caregivers of the patients. A study found moderate to severe depression and anxiety among 25% and 33% of caregivers, respectively. It seems such distress increased risk of neglectful treatment, medicinal mismanagement, abuse, and worsening relationship with the patient, which in turn correlated with compromised immune system, reduced physical health, and increased mortality among patients.

A health care model bridging medical and mental health is in the best interest of the people we serve—and fundamental for improved treatment outcomes.

Given such findings, it comes as no surprise such entities as the Global Initiative for Asthma, the American Heart Association, and the International Committee on Mental Health in Cystic Fibrosis support addressing psychosocial and mental health concerns as a standard of care.

Significantly, studies found brief behavioral psychotherapy interventions to positively impact health. For instance, relaxation and imagery techniques reduced stress, improved wound healing, and eased the severity of GI symptoms and conditions such as IBS, ulcerative colitis, and Crohn’s. Other brief interventions including improved coping skills were associated with reduced risk of inflammation, decreased blood pressure, and reduced anxiety and depression symptoms. Notably, studies also found the combination of brief psychotherapy interventions and psychopharmaceuticals associated with greater reduction in depressive symptoms than pharmaceuticals alone.

Despite findings and associations that seem to call for a collaborative medical and mental health model, screening for mental health concerns and making interventions is still not common practice among physicians. With the mounting understanding of the body-mind connection, it is paramount that all stakeholders become advocates toward an integrative health care approach.

Following are a few suggestions for mental health specialists, medical health specialists, and consumers of medical/mental health care on how to become proactive in this endeavor:

Mental Health Specialists

• Meet and greet: Introduce yourself to general practitioners, OB-GYN doctors, nurses, and/or other professionals/specialties of interest in your community.
• Survey and review: Explore doctors’ concerns for their patients and viable referral processes. Stay informed with the latest journals.
• Workshops: Develop psychoeducation and skills-building workshops to offer doctors’ patients.
• Tools: Become familiar with the screening tools you can introduce to doctors such as PhQ-9, GAD-7, suicidality assessments, etc.
• Collaborate: Refer to different specialists to rule out and treat medical aspects that may be impacting the people who come to you for help.

Medical Health Specialists

• Expand network: Include psychologists/psychotherapists in your network as well as psychiatrists.
• Screening process: Adopt a screening process for your patient visits (as well as part of pre- and post-op care) such as the PhQ-9 and GAD-7.
• Monitor caregiver’s health: Include caregivers’ mental health screening and support as a main intervention for chronic and terminally ill patients.

Medical/Mental Health Care Consumers

• Self-advocacy: Review literature related to your health concern and common mental health associations. Discuss these ideas with your doctor or therapist.
• Stress-reduction training: Ask your doctor or therapist about stress-reduction and coping skills workshops/exercises.

A health care model bridging medical and mental health is in the best interest of the people we serve—and fundamental for improved treatment outcomes.

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