The two mental health disorders that I see most often in our practice are depression and anxiety and treating these disorders require lengthy office visits especially when diagnosing and treating the patient for the first time. In fact, so important is follow up treatment during the first 3 months of treating major depressive disorders that some insurance companies will penalize the provider if 3 office visits are not made within the first 3 months of starting a patient on antidepressants for the first time.

Despite the necessary time involved in treatment, mental health disorders are reimbursed at a lower rate than other medical problems. Ironically, depression and anxiety form the basis for other physical ailments and unless dealt with directly, can often lead to unnecessary and costly medical treatment as illustrated by frequent patient visits for multiple somatic complaints. Mental health and physical health/illness are intricately bound together but because of popular misconceptions, the general public (and by extension, many patients) fail to see the connection between their physical ailments and their mental health. I think back to how ignorant I once was about the mind/body connection – so I don’t blame my patients – I try to educate them. But trying to explain this link without offending and alienating patients requires building trust and confidence – difficult to establish in the 10 to 15 minutes alloted for the office visit.

The patient who comes in complaining of chest pain, shortness of breath, and palpitations – with a dash of numbness and tingling in the limbs – does not want to hear that his/her complaints, which are considerably frightening to them, are the result of anxiety. Indeed, depending on the patient’s age, family history, and co-morbidities, a detailed history needs to be done as well as a thorough exam before asking equally time consuming questions about what is going on in their lives. Can this be done adequately in 10 minutes? A provider running behind and possibly double booked may find it easier simply to order multiple tests rather than start asking about stressors in the patient’s life. For exactly the reasons mentioned, I’ve been guilty of  not asking the psychological questions myself.

Anxiety disorders affect approximately 40 million Americans 18 and older with 20.9 million suffering from some type of mood disorder. Of the top 5 most costly medical conditions treated in the U.S., mental health expenses ranks number 4 in terms of direct medical spending. In 1996, $35 billion was spent treating mental health disorders compared to $57.5 billion spent in  2006. Indirect costs are also astonishing: mental illness is associated with more lost work days than any other chronic illness. Given that 1 in 4 Americans suffer from some form of mental disorder, it makes economic sense to pay attention to these factors. But a busy provider simply may not have the time and economically, it may not make sense for him or her to do this given the reimbursement rates.

For a psychiatrist’s view of treating mental disorders, the NY TImes this week published an article “Mind Over Meds“. It’s worth taking a look at. In the meantime, there is no easy solution. We do the best we can given the constraints we have.

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