What’s the Best New Year’s Resolution?

Health and Wellness, David W. Covington, Integrated Care, Behavioral Health Version 3.0, RecoveryNearly half of Americans made a New Year’s resolution over the past week. I did. I pledged to return to the Six Gap Century road race in north Georgia, which means I’ll need to spend a lot more time on my road bike in 2014. In fact, many people’s resolutions revolve around health and wellness, and the top ten year over year include losing weight, getting fit, eating better, and quitting smoking.

Resolutions for improving health aren’t limited to individuals. A recent Forbes article highlighted Obamacare’s focus on prevention and wellness, and if you’ve been in a Walgreens in the past year, you’ve probably heard, “Be well,” at the register. It’s the spirit of our time.

It turns out that these are all great goals to have. A meta-analysis by Holt-Lunstad et. al. surveyed 148 studies of mortality risk in 2010 and quitting or decreasing smoking was #2 in the list of effective means to reduce mortality. Increasing physical activity (#5) and losing weight (#6) were also positively correlated. Abstaining from excessive drinking and getting an annual flu shot, while not your typical New Year’s resolution, were also helpful (#3 and #4, respectively).

But the #1 most significant action one can take to improve mortality odds and health outcomes? The one neglected by many of us in our New Year’s resolution? Have more friends. Research shows that a stronger social network of family, friends, and relationships is really good for your health.

Make no mistake: lifestyle changes and improvements in health and wellness are important, particularly for individuals with Serious Mental Illness (SMI). A 2006 research study of six states by the National Association of State Mental Health Program Directors (NASMHPD) found a decreased average life span of 25-30 years compared with the general population.  And it’s not that healthcare leaders and policy makers aren’t doing a lot to tackle the problem. There has been tremendous focus since USA Today brought the disparity to the public’s attention, explaining that those with diagnoses like Schizophrenia, Bipolar Disorder, and Major Depressive Disorder are dying at the average age of 50, while most Americans are living into their late 70s. You’d have to look to countries like Afghanistan for a comparably low life span, where professional primary care and preventive services are unavailable at levels in Western countries.

Typically, our analysis of mortality rates for individuals with SMI has been based on medical conditions, rather than the root causes. While suicide was an issue cited in the USA Today report, the larger challenge was preventable diseases. Individuals were 3 to 5 times more likely to have heart disease, diabetes, and respiratory problems like COPD, and obesity was a very significant issue. A very large percentage of these individuals also smoke. Quickly, many policy makers called for systems change.

Historically, a Grand Canyon-sized chasm existed between “silos” delivering these services; care was fragmented. That is all changing, and we are seeing the most fundamental administrative and organizational changes in the public behavioral healthcare system since deinstitutionalization. The 2010 Milbank Memorial Fund report “Evolving Models of Behavioral Health Integration in Primary Care” provided a basic road map.

The Chronic Care Model (also, called the Planned Care approach) has been shown to yield the strongest outcomes and dramatically improves care coordination, active follow-up, and training so individuals can self-manage their own illnesses. Care is closely and fully integrated, care teams are prepared and proactive and engage in productive interactions with individuals receiving services who are informed and activated. In this fully integrated model, behavioral health is a routine part of medical care. Mental health staff members are not coming from a specialty niche, but are members of the core care team.

Consensus believes, and nearly 80 randomized clinical trials suggest, that the planned care model is a really good “resolution” for our healthcare system.  There are also many health plans focused on important elements (using the out-of-vogue term “disease management”) like healthy eating, increased physical activity, and smoking cessation.

The integrated care movement continues to transform the way behavioral health, primary care, and specialty medical services are delivered and managed. But how much effort are we spending on the problem that can give the greatest outcome?

There are a few prophets out there we should listen to. Rick Brush is a former Cigna executive who launched Collective Health. He contends that perfect healthcare service delivery might solve 30% of the life-span disparity, but the stronger challenges are the social determinants of health. Similarly, Emory researcher Benjamin Druss points to the importance of non-medical factors, such as a history of abuse and/or neglect, past trauma, environmental stressors, poverty and, again, social supports and connectedness (Robert Wood Johnson Foundation, “Mental Disorders and Medical Comorbidity,” 2011).

Social supports and friends seems to be a greater challenge for men. It’s not uncommon for a woman to report having coffee with a close friend they have known since second grade, and they seem more apt to expand their network over the course of their lifetime. Thomas Joiner has written about the opposite proclivity in the male gender (Lonely at the Top). His Interpersonal Theory of Suicide proposes that one of the two required elements for suicide risk is feeling, “I am alone;” what he calls thwarted belongingness.

For those with Serious Mental Illness, improving social networks is a stark challenge. When I was at Magellan Health Services, our team reviewed nearly 20,000 Health Risk Assessments for those being served in the most intensive behavioral healthcare services. We developed a social supports algorithm that considered the answers to three questions:

1) Do you have someone to talk with about your problems (besides a professional)?

2) Do you have someone to go out with for a movie or meal?

3) Do you live alone?

Forty-one percent reported rarely or never for the first two questions and also shared that they lived alone (see Slide Deck Presentation). These are the same individuals struggling with multiple chronic health conditions, and we have rarely focused on the link between improving health and improving social supports. While coaching on diet, exercise, and smoking cessation, as well as better care coordination, will make a difference, we must concentrate our efforts attending to those for whom “friends just can’t be found” (from the old Simon & Garfunkel song).

One Health is a company working to tackle this challenge by bringing social networking and other online self-management supports to individuals with SMI, but it’s time for direct service healthcare leaders to innovate in this area as well. Former SAMHSA administrator Charlie Curie is fond of saying that people with mental illness want the same things the rest of us do: a job, a safe place to live, and a date on Friday night…the friends who will provide the supports that actually promote health, wellness, and longer life.

Of course, there are many positive things happening regarding integration, and the related challenges are sufficiently great, that it’s easy to say we should wait. I recently had lunch with my friend and national peer leader Eduardo Vega. His reply was germane. “It’s not so much that we don’t see the glass as half-full; it’s just that we’re really thirsty.”

Perhaps it’s time for a new New Year’s resolution, one that may make the most difference of all.

*Note: David would like to acknowledge the Magellan Health Services Regional Behavioral Health Authority where he was responsible for the integrated care program from 2010 to 2013. Eduardo Vega is the Mental Health America of San Francisco executive director and a member of several national leadership groups, including the National Action Alliance for Suicide Prevention. 

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