Addressing the Mental Health Crisis: Insights from Rhode Island Experts

In this episode, we explore the multifaceted state of mental health today, driven by post-pandemic challenges, systemic barriers, and evolving care models. Join us as mental health professionals from Rhode Island discuss innovative initiatives, the promise of integrated care, and the path toward a more accessible, stigma-free mental health system.

Key Topics Covered:

• The impact of COVID-19 on mental health: isolation, uncertainty, and access issues
• The rise of awareness and its influence on diagnosis rates and help-seeking behavior
• The Open Mind Initiative: integrated behavioral health in primary care, especially for LGBTQ+ communities
• Challenges in widespread adoption of integrated health practices: funding, structural barriers, and policy hurdles
• The economic case for integrated mental health services: potential billions in savings and improved outcomes
• Shifting towards proactive, preventive mental health approaches versus reactive treatment models
• The evolving landscape of telehealth, AI, and technology in delivering behavioral health care
• How education and reducing stigma can empower individuals to seek support early

Timestamps:
00:00 - The importance of mental health month amid a pandemic-driven crisis

00:29 - Perspectives of experts on current mental health drivers and societal shifts

01:40 - How COVID-19 exacerbated mental health issues through isolation and barriers

02:10 - The societal impact of technological fracture and community support decline

02:29 - Increased awareness and its impact on diagnosis and openness about mental health

04:13 - Are we witnessing a cultural shift towards accepting mental health struggles?

06:25 - The role of social media and online communities in mental health support

07:40 - Strategies to normalize access and reduce stigma in behavioral health care

08:48 - The genesis and scope of the Open Mind Initiative at Rhode Island's Open Door Health

09:34 - Blueprint for integrating behavioral health into primary care settings

11:20 - Funding challenges and advocacy efforts for embedded mental health services

12:38 - Why integrated health models remain underutilized despite proven benefits

14:19 - The financial and health outcomes of investing in preventive, integrated care

15:36 - Systemic inertia: reactive health care vs. preventative investment

16:49 - Lifelong impact of early behavioral health intervention across generations

17:44 - Future prospects: Will integrated behavioral health become the norm?

19:21 - Barriers to systemic change: funding, politics, and systemic inertia

20:21 - What mental health professionals want the public to understand about their work

21:00 - Dispelling stereotypes around psychiatry and emphasizing whole-person wellness

Resources & Links:

• Open Door Health
• Rhode Island Public Health Institute
• SAMHSA (Substance Abuse and Mental Health Services Administration)
• Bowling Alone by Robert Putnam - Amazon

Connect with the Experts:

• Jenny Tu - LinkedIn | Twitter
• Dr. Paul Wallace - LinkedIn | Twitter

Transcript

Bill Bartholomew 0:00

May is Mental Health Month. And look, it seems no matter where we go right now, the conversation around people's state of mind is front and center. It's the world we're living in. It just is a baked-in part of it. So mental health month is really not an exclusive opportunity to have these discussions, but it's a good one. And that's what we're going to do today, coping really with the reality of what a lot of people are facing on a day-to-day basis, which is the impact of post-COVID loneliness, affordability, just a general sense of transition and uncertainty that, again, it just permeates throughout so much right now. Before we get into today's conversation, I guess uh the smart thing to do is for our guests to introduce themselves. We'll start with Jen so we can associate the voice with a person.

SPEAKER_00 0:45

Hi, my name is Jenny Tu. I am the Senior Director of Integrated Behavioral Health at Rhode Island Public Health Institute and Open Door Health and uh independently licensed clinical social worker by training.

SPEAKER_01 0:59

And Dr.

Bill Bartholomew 1:00

Wallace.

SPEAKER_01 1:01

Hey, I'm Paul Wallace. I'm a psychiatrist here at the Providence Center, as well as open door health. I'm the medical director at the Providence Center and on the uh clinical faculty with the Brown uh Department of Psychiatry and Human Behavior.

Bill Bartholomew 1:15

All right. Well, it's not uncommon here in Rhode Island, like the rest of the country, to hear that we're in something of a mental health crisis. So let's go from each year's perspectives. What's driving this right now? What's driving the current state of mental health, at least as it's perceived by so many of us, and obviously by so many of us experienced as well?

SPEAKER_00 1:37

Yeah. I think we've seen just a gradual increase in the exacerbation of people's ability to cope and manage with life since sort of COVID and since the pandemic. Um, a lot of increased isolation and uh even, you know, a mismatch of how people balance their lives pre-COVID and sort of balance their lives now, and a lot of adaptability around sort of telehealth and virtual work and things like that since then. And I think we've just continued to see this spike in lack of access, difficult barriers to care, insurance barriers, maybe uninsured barriers. And uh, you know, with a world that continues to evolve and shift in lots of tricky ways, it's exacerbated people's capacity to manage how that's impacting day-to-day functioning.

unknown 2:27

Dr.

Bill Bartholomew 2:27

Wallace, same question.

SPEAKER_01 2:29

Yeah, I would, I would um give you the imagery of the frog boiling in water where um things over a long period of time, you could say uh decades have um slowly broken down um in our in our society. And um, you know, modern technology probably bears some responsibility for that. Um, fracturing of community and and some of the community supports that provides a lot of um, you know, mental uh wellness and and support to community members uh have slowly fractured. Um take a take a book like uh Bowling Alone that was written by the Harvard sociologist uh Robert Putnam um over two decades ago that describes um some of those differences and that trend has only accelerated in recent years, um, have contributed to this um, you know, worsening mental health collectively uh in our society. And then the um to uh to to paint a somewhat rosier picture as far as uh mental health goes, I think there's an increased awareness of um people who are suffering from mental health conditions, which is um, when I say that's a rosier picture, I mean uh in the sense that um, you know, getting uh treatment, getting care starts with uh awareness that there is an issue. And whereas uh decades ago, a lot of things were probably kind of buried in the closet, nowadays more and more people are coming forward um and asking for help around uh mental health conditions, which is great. But it does uh it does lead to the end result of there being uh a much um increased demand for mental health services than in the past.

Bill Bartholomew 4:13

How much of it is an abil an increased awareness that has led to an increased diagnosis rate or an increased appetite for a person that's suffering to be able to step forward and say, hey, I want to investigate this at some level, even if it doesn't lead to a full-on diagnosis. How much of it is really just people responding in the moment because of kind of a collective sentiment that it's okay to not be okay?

SPEAKER_01 4:44

Yeah, I I think uh I think that's been a positive, and and we could, you know, we could spend um hours debating the merits of social media and the internet in terms of raising awareness for these sorts of things, um, and and all other ways in which uh social media and the internet have affected mental health. But I think to, you know, think of like the greatest generation that came out of World War II and this idea that the uh men and women who came out of that conflict um, you know, were these strong uh sort of um like Teflon individuals who had triumphed. And and you know, now we know with increased awareness, there was lots of PTSD that came from that um that war and everything that was going on in the globe around that time that just simply was not named. And it happened, um, it was kept behind closed doors. Nowadays, more and more, and not to say that um sort of penetration of mental health awareness has permeated every aspect of our society. We're far from that. But there are more people who are exhibiting different symptoms that do talk to a therapist or their primary care doctor or uh RCA psychiatrist like myself.

Bill Bartholomew 6:00

Jen, coming to that point, what do you see or what are you hearing from people that might be different than before COVID as you and and I mean people broadly, more than just patients, but what from a sentiment standpoint, as we convene here in Mental Health Month, has there been progress that has led to better opportunities for treatment? And even from again, that that piece of uh understanding oneself in the context of it's okay to not be okay, and there are different ways to navigate the world, and your way uh needs its own uh care, treatment, and direction sometimes.

unknown 6:38

Yeah.

SPEAKER_00 6:39

Yeah, I think we're probably always gonna see some juxtaposition of like an increased self-awareness and the ability to sort of ask for help and ask for support. I think some beautiful things that did come out of COVID is for people who remained very isolated even prior to the pandemic, there's a lot of online support and a lot of, like Paul said, social media influence that has impacted people to sort of say, aha, oh, I didn't realize that this thing that I've been struggling with is something other people struggle with, and maybe I should get some support around it, which I think is a beautiful thing. Um I think we've also seen a lot of people lean heavy into like that social media or online support groups being the only outlet, which then has an impact of like the in-person social interactions and sort of connection. Um, so I think there's sort of a a coin toss there of like how helpful and increased access and increased awareness, which impacts people's ability to like ask for support and help. I think part of the work that the two of us do at Open Door Health and the Rhode Island Public Health Institute is really looking at different ways to be creative to increase access and decrease barriers and hopefully also decrease stigma. Um, that has also sort of been something that in the last 20 years has gotten more and more prevalent in primary care, which is normalizing access to behavioral health supports while you're seeing your primary care provider. So I'd say like that's something that's also sort of come out of this is like, how do we normalize access and how do we streamline it in a way that's just more available with less barriers?

Bill Bartholomew 10:42

Right. The streamlining seems so, so important and something we certainly learned from COVID or through COVID in terms of brick and mortar and digital medicine. Let's talk about to this point how you and your colleagues at the Rhode Island Public Health Institute are working to address the issue. You run open door health, that's a clinic, which a few years ago launched the open mind initiative. Let's talk about the open mind initiative, what it is and how it came to be today.

SPEAKER_00 11:10

Yeah, so the open mind subset of the services that we have at Open Door Health is essentially sort of the behavioral health arm of primary care. What I mean by that is our clinic is the first clinic in the state that specializes in LGBTQ AI plus health care. Um, we serve everybody in the community. We are a sexual health clinic that focuses on primary care, gender care, hep C, HIV, and AIDS care, and a lot of other public health initiatives such as food insecurity and access to healthy food options, um, and a wide variety of other initiatives. And a couple of years ago, um, you know, I think in recognition of some of these gaps and barriers, we were seeing organizationally, um, you know, primary care providers sort of feeling really overwhelmed by sort of how do we help our patients who have this co-occurring piece of medical need and behavioral health need. Um, and RIPHI and Open Door Health did a really good job of subcontracting with some psychologists and some additional folks through Brown Health to sort of start some behavioral health services. And then sort of predating me and sort of when Dr. Wallace came into the picture, um, the organization applied for a large grant to implement behavioral health integration in primary care. Um, and that was sort of um a stepping stone for us to look at how do we do integrated behavioral health in primary care. Um, I don't know, Paul, if you want to add a little bit more and then we can kind of cover more details.

SPEAKER_01 12:46

Yeah, to um to get a little bit more in the weeds. So this uh program that was kicked off at um open door health and and continues to this day um came from a SAMHSA grant, which SAMHSA is the large federal agency that funds a lot of these innovative programs around um behavioral health and substance use. And um, you know, regular readers of the news will be aware that um in January, SAMHSA was very much in the crosshairs of the current federal administration. And, you know, we're grateful to our federal delegation, which is involved uh in um advocating for continued um funding through SAMHSA for programs like this and programs around the country. Um, but essentially, you know, the the uh genesis of this is just like what Jen was saying this idea that um a huge percentage of primary care visits are actually primarily about behavioral health. Uh primary care is the front door in which a lot of people first access behavioral health. And so um the idea is uh with something like this, with an integrated behavioral health program like what we have with open mind is providing the support that primary care doctors um need and deserve to be able to address their uh patients' issues as it relates to behavioral health.

unknown 14:06

Yeah.

SPEAKER_00 14:07

I kind of like to say that primary care is a whole health perspective. And when we do integrated behavioral health, we're pulling all those things together and we're understanding that people's behavioral health impacts their medical care and their health, and that their health care might impact their behavioral health care. And when we align together as providers, we'll be able able to better take care of all of the patient need.

Bill Bartholomew 14:28

Well, it it it also seems that there's an industrial agreement, by and large, that integrated health is the correct model, or at least the most likely to be successful in terms of general outcomes model. Yet even with what we're describing right here, or what you're describing right here, is b is integrated health practices in practice. But why hasn't this been adopted writ large throughout public health and medicine in the United States? What's the barrier?

SPEAKER_01 15:00

So um I I I think Jen will probably have uh much to say about this, but I'll just say this is the um this is the the billion dollar question. This could be the the trillion dollar question. Um and uh and you know truly not being facetious, a lot of this has to do with funding streams and how um our uh healthcare is is funded in this country. Um and uh and that is uh a um a topic that I'm I'm unable to sort of put in a nice little uh package for you here. But um again, a lot of this has to do with uh funding, you know, which makes the world go round, including healthcare. And then the second piece is um structurally uh figuring out how to do it uh correctly in a way that um works for the uh, you know, both the patients and the staff of an organization like Open Door Health. So um, you know, again, uh we're grateful for SAMHSA for funding this program and allowing us to develop those best practices, which uh then in turn we really do hope uh get mirrored um, you know, not only throughout Rhode Island, but but even beyond our uh our borders. And there have been some initiatives um, you know, led by a few individuals at the Department of Health to really bring together primary care practices and replicate the um the best practices that we're uh developing at open door health. So um people are thinking certainly about how to scale this and make this a more widespread uh initiative. Um, but you know, as you can imagine, there are uh there are many, many barriers to make that happen.

Bill Bartholomew 16:40

Yeah, and there, but there's also on the flip side, there's studies that show that this could save the United States somewhere between 40 and 70 billion dollars a year if it's implemented. So a lot of times there's there's two sides to that equation. I think it probably has a little bit to do with the nature of our healthcare system on the whole, but we are seeing a movement towards this in a lot of spaces that are shifting also towards kind of balancing telehealth and new AI technology, whether that's scribes or whatever it is. So, how much of this is part of a broad ecosystemic shift towards, hey, there's a new model, it's integrated, and we're really heavily relying on technology and the funding that goes into that technology to deliver better patient care and then hopefully save billions of dollars for taxpayers. Is that kind of the trend right now? As as is that a fair read of what is sort of happening on the ground at the Redown Public Health Institute right now.

SPEAKER_00 17:39

Yeah, I can uh jump in a little bit on that. So I think healthcare is very much so a reactive system. We wait until people are really sick and then we figure out how to treat them, and it's sort of a problem fix it dynamic. And if we think about what I'm just gonna say as being trauma-informed care or preventative care, which we know costs more in the beginning, but the payoff is sort of exponentially more helpful and costs savings in the end. What we're talking about is investing more money that potentially will have less fiscal impact in the beginning. But quite literally, an integrated behavioral health is something having worked in integrated behavioral health for almost 12 years now in multiple locations, is sort of like early intervention for generations of population, in particular if you're working at a healthcare organization that goes from pediatrics to adult medicine. I have been fortunate enough to meet with parents and children and grandparents and have there be this impact about decreasing decreasing stigma and increasing access and targeting things sometimes before they even start when we talk about some chronic kind of conditions around social determinants of health and behavioral health and the intersection of health care that will have lifelong impacts on family systems. And so I really do look at it as like there might be this front-end cost that is like, how do we figure out how to cover this in diverse funding streams and take care of people better, take care of a medical system better, change that system, help medical providers to do their job better, while knowing that the cost savings is indeed what you said, Bill, which is this huge amount of cost savings at the tail end. Less ER visits, less acute visits, less critical care things, less inundation of the rest of the behavioral health system, and truly would be transformative, but there have to be some decisions and some more public health kind of dynamics to tackle where the gaps end up being that makes it feel hard to do.

unknown 19:50

Yeah.

Bill Bartholomew 19:50

Dr. Wallace, what are you seeing from your standpoint in terms of a movement towards integrated care as a as a practice that is kind of the the norm? Uh, do you think that's something that we're going to get to in the next decade, or is this a long, long haul?

SPEAKER_01 20:06

Yeah, I mean, it it it requires visionary leadership because um of what Jen was saying, that uh you make a you make a front-end investment that um saves you, you know, many billions of dollars down the road. But um when you're you know, when you're um uh to explain a bit, the traditional payment model in healthcare is something called fee for service, where you get paid based on the service you provide, uh, no more, no less. And um the way, for instance, Medicaid, Medicare, most uh insurers pay for, say, like a therapy appointment or a psychiatry appointment, it's it's quite paltry compared to something like um, you know, a uh uh cardiology intervention or a knee replacement or something along those lines. So essentially um behavioral health ends up being a money loser for a lot of healthcare systems. Um, if you're again just taking this narrow view of healthcare finances within a healthcare organization or within um, if you're you know an elected official, you might say, um, you know, this is this is not a good investment. Now, if you're taking a more big picture view and saying, well, by treating this um, you know, this young person who is uh, you know, having the his first episode of psychosis now, you're gonna allow him to stay out of the hospital. He's gonna be able to complete school, he's gonna be able to get a job, live independently. Um, again, the the finances clearly, in the long view, clearly point towards uh investing in that care up front. Um, but it, you know, once again, it really requires someone to um take this whole person view and this long-term view of how we fund healthcare, which is something that there are um, you know, there have been movements to do this for uh, you know, several decades now, and they kind of ebb and flow with um sort of the uh the winds of our sort of political system. Um, but there definitely are people who are advocating for this uh within Rhode Island in the present day. Um, and there has been some progress made. Um but unfortunately, like like all of these um programs that uh you know uh are vulnerable to the shifting winds of politics. Um, you know, we take one step forward and and two steps backwards at times.

Bill Bartholomew 22:29

Last question here for sort of last 30 seconds each. Uh what do you what do you want people to understand about the work that you do that they may not understand?

SPEAKER_00 22:42

It's always tricky to explain sort of behavioral health interventions because I think there's a lot of uh assumption if you haven't been a receiver of services. So I think that, you know, from a care perspective, my job is to assist people in being as healthy and safe as they can be. Um I think systemically for us at RIPHI and open door health, we want to increase access and decrease stigma and really help people just be as healthy as they can and move forward in the world in a way that they feel like they can manage things as safely as possible.

SPEAKER_01 23:19

Paul. Yeah, I think the um the the sort of uh stereotype of a psychiatrist is someone who's wants to push meds on people is something I'd love to dispel. Um, I think, you know, most psychiatrists are thoughtful individuals who really want to look at whole person uh wellness. And um, that can include medications, but certainly includes um, you know, talk therapy. And honestly, a lot of most of behavioral health uh happens outside of, you know, like the four walls of a of an office or a computer screen if you're doing telehealth. Um and I know that's something, you know, RIPHI and open door have been really um forward thinking about um whole person health. And um, so I'd encourage people who are curious about meeting with a psychiatrist to do so. Um, you know, it's a chance to have a conversation and, you know, again, think about sort of whole person wellness um beyond just uh medications or uh interventions that are more medical.

Bill Bartholomew 24:22

Paul, Jen, thanks so much for your time today. Thanks for the great work that you do. And uh hey, this is Bartholomew Time.