Evidence-based or evidence-informed treatment? Confused? You are not alone. Often used interchangeably, the terms “evidence-based” and “evidence-informed” in healthcare are two very different things. So, what do they really mean?

What is evidence-based treatment?

Evidence-based care is considered the gold standard in treating behavioral health conditions. Typically, “evidence-based” refers to an individual intervention that is based on quantitative research studies conducted in controlled, blinded settings and proven to be effective across a wide range of environments and people. Medications and other treatments that receive U.S. Food and Drug Administration (FDA) approval for a certain indication are also considered evidence-based.

What is evidence-informed treatment?  

 Evidence-informed care is an approach that shows promise but lacks enough proof of success to be viewed as a gold standard. Practitioners take bits and pieces from a variety of research, including evidence-based interventions and apply them to a condition. This produces something uniquely tailored to a certain need. Unlike evidence-based treatments, evidence-informed treatments don’t have results from research in controlled settings that demonstrate their effectiveness across a wide range of settings and people. When considering medication and other drug-like treatments, evidence-informed interventions have not received FDA approval for the condition they are treating. This is called “off-label” use.

Examples of evidence-based treatments

• Cognitive behavioral therapy (CBT) is a type of talk therapy that has proved effective in the treatment of anxiety, depression, addictions, phobias and certain physical health conditions. CBT focuses on changing automatic negative thoughts that can contribute to and worsen mental health and substance use symptoms. CBT has more evidence supporting it than any other psychological therapy.
• Acceptance and commitment therapy (ACT) is a type of mindful talk therapy that helps individuals stay focused on the present moment and accept thoughts and feelings without judgment. Over 200 randomized controlled trials have proven ACT is an effective treatment for depression, psychosis, chronic pain, substance use disorder, post-traumatic stress disorder, obsessive-compulsive disorder, panic disorder and social phobia.
• Dialectical behavior therapy (DBT) is a type of talk therapy based on CBT and specially adapted for people who experience emotions very intensely. Nine published randomized controlled trials and five controlled trials of DBT have proven its effectiveness for treating borderline personality disorder, including in highly suicidal women.
• Exposure and response prevention (ERP) therapy is a form of CBT that encourages individuals to engage with their obsessive thoughts without carrying out their associated compulsions. Treatment begins with placing individuals in situations which cause a tolerable level of anxiety and gradually build up to settings they find more difficult. ERP has been proven effective for treating obsessive-compulsive disorder in numerous clinical trials.
• Eye movement desensitization and reprocessing (EMDR) therapy is a mental health treatment technique that involves moving your eyes a specific way while you process traumatic memories. The goal of EMDR is to help individuals heal from trauma or other distressing life experiences. Since the first EMDR clinical trial in 1989, dozens of other clinical trials have proven this technique is effective and faster for the treatment of post-traumatic stress disorder.
• Transcranial magnetic stimulation (TMS) is a noninvasive treatment that was first used to treat depression in individuals who were nonresponsive to other treatments. TMS involves using a magnetic coil to influence the brain’s natural electrical activity and has full FDA approval for the treatment of major depressive disorder, obsessive-compulsive disorder, migraines and smoking cessation.
• Esketamine is an FDA-approved nasal spray used to treat severe treatment-resistant depression. Esketamine was found effective in a phase 3, double-blind, active-controlled study conducted at 39 outpatient centers from August 2015 to June 2017. The study involved nearly 200 adults with moderate to severe depression and a history of not responding to at least two antidepressants.
• Fluoextine is an antidepressant medication that is approved by the FDA to treat depression, obsessive-compulsive disorder, bulimia nervosa, premenstrual dysphoric disorder and panic disorder. It belongs to a group of medicines known as selective serotonin reuptake inhibitors (SSRIs) and works by increasing the activity of serotonin in the brain. Data based on a group of 9,087 patients who were included in 87 different randomized clinical trials confirms that fluoxetine is safe and effective in the treatment of depression from the first week of therapy.

 Examples of evidence-informed treatments   

Response Disequilibrium Therapy (RDx)—Based on the response disequilibrium model, RDx puts patients in charge of implementing their own treatment procedure outside of therapy sessions in the same environments that trigger their symptoms so they can learn new behaviors to replace and control their previous responses to distressing situations.

While preliminary findings from case studies involving 19 participants with OCD suggest RDx may be a promising alternative to traditional OCD treatments, future research is needed to determine its effectiveness across a wide range of settings, people and problems to classify it as an evidence-based intervention.

• Pregabalin (an FDA-approved anticonvulsant medication and fibromyalgia treatment) has been used off-label to treat generalized anxiety disorder, social anxiety disorder, bipolar disorder, insomnia and chronic pain conditions other than fibromyalgia. For pregabalin to be used for these conditions in an evidence-based manner, the FDA would have to approve their use for each specific condition.
• Risperidone (an atypical antipsychotic medication approved by the FDA for the treatment of schizophrenia, bipolar disorder and autism-associated irritability) has been used in a variety of off-label ways, including to treat borderline personality disorder, post-traumatic stress disorder (PTSD) and bipolar disorder. To date, the FDA has not approved risperidone to treat these three conditions.

Are mental health and wellness apps evidence-based or evidence-informed?

These days, you can’t browse the web or use most apps on your phone without seeing an ad for a wellbeing or therapy program or app. Used alone or to supplement traditional treatment and promote wellbeing, not all mental health, substance use and wellbeing apps use evidence-based practices, nor have they been extensively researched in treating specific conditions. Wellbeing and therapy apps are typically considered:

• Evidence-based when evidence-based interventions are fully implemented on the platform and followed by users in the same manner they would be if they were being delivered during face-to-face treatment. For example, the original evidence-based model below is used in a wellbeing app that delivers CBT digitally and all steps are followed as listed.
  1. Identify troubling situations or conditions in your life.
  2. Become aware of your thoughts, emotions and beliefs about these problems.
  3. Identify negative or inaccurate thinking.
  4. Reshape negative or inaccurate thinking.
• Evidence-informed when only certain components of evidence-based interventions are implemented on the platform, and/or the app only fully implements or uses components of evidence-informed interventions. For instance, if a wellbeing app provides CBT and only asks users to identify troubling thoughts and become aware of their thoughts, emotions and beliefs about these problems, it is evidence-informed because it does not ask users to identify and reshape negative or inaccurate thinking.

When considering using an app for yourself, your patients, your employees or your members, ask yourself these questions:

• Are the treatments used in the app based on quantitative research?
  • Were the studies conducted in controlled, blinded settings?
  • Are the treatments proven to be effective across a wide range of environments and people?
• Are all treatment steps included in the process, or has the process been watered down?
• Have the treatments used in the app received FDA approval for a certain indication, if FDA approval is possible?

Magellan’s approach to evidence-based versus evidence-informed treatments and mental health, wellbeing and substance use apps

The American Psychiatric Association and the American Psychological Association both consider evidence-based interventions preferred approaches for the treatment of psychological conditions.

At Magellan, we are leading the way in providing innovative, impactful behavioral healthcare solutions. When developing new and enhancing existing offerings , like our digital cognitive behavioral therapy (DCBT) programs, we always start with evidence-based treatments and adhere fully to all tenets. Magellan Healthcare’s DCBTs have been heavily researched in the studies below:

• FearFighter® for anxiety, panic and phobia (now available online in Spanish)
  • Computer-aided CBT self-help for anxiety and depressive disorders: Experience of a London clinic and future directions. L. Gega, I. Marks, D. Mataix-Cols. Journal of Clinical Psychology: In Session (2004), Vol. 60 (2), 147-157.
  • Computer-aided vs. tutor-delivered teaching of exposure therapy for phobia/panic: Randomized controlled trial with pre-registration nursing students. L. Gega, I.J. Norman and I.M. Marks. International Journal of Nursing Studies 44 (2007) 397-405.
  • The feasibility and effectiveness of computer-guided (CBT) (FearFighter) in a rural area. L. Hayward, A.D. MacGregor, D.F. Peck, P. Wilkes. Behavioural and Cognitive Psychotherapy (2007) 35, 409-419.
• MoodCalmer for depression (now available online in Spanish)
  • Saving clinician’s time by delegating routine aspects of therapy to a computer: A randomized controlled trial in phobia/panic. I.M. Marks, M. Kenwright, M. McDonough, M. Whitaker and D. Mataix-Cols (2004).
  • Technology-based advances in the management of depression: Focus on the COPE program. Disease Management and Health Outcomes. J.H. Greist, D.J. Osgood-Hynes, L. Baer and I.M. Marks (2000) 7, 4.
• RESTORE® for insomnia and other sleep difficulties (now available online in Spanish)
  • Implementing computer-based psychotherapy among veterans in outpatient treatment for substance use disorders. E.D.A. Hermes and R.A. Rosenheck. Psychiatric Services 67:2, February 2016, 176-183.
  • Cognitive behavioral therapy for insomnia enhances depression outcomes in patients with comorbid major depressive disorder and insomnia. R. Manber, J.D. Edinger, J.L. Gress, M.G. San Pedro-Salcedo, T.F. Kuo, T. Kalista. SLEEP, Vol. 31, No. 4, 2008, 489-495.
  • Logging on for better sleep: RCT of the effectiveness of online treatment for insomnia. N. Vincent and S. Lewycky. SLEEP, Vol. 32, No. 6, 2009, 807-815.
  • Sleep locus of control and computerized cognitive-behavioral therapy (cCBT). N. Vincent, K. Walsh, and S. Lewycky. Behaviour Research and Therapy, 48 (2010), 779-783.
• SHADE for substance use disorder
  • Randomized controlled trial of cognitive-behavioural therapy for coexisting depression and alcohol problems: Short-term outcome. A.L. Baker, D.J. Kavanagh, F.J. Kay-Lambkin, S.A. Hunt, T.J. Lewin, V.J. Carr and J. Connolly. Addiction, 105, (2009) 87-99.
  • Clinician-assisted computerised versus therapist-delivered treatment for depressive and addictive disorders: A randomised controlled trial. F.J. Kay-Lambkin, A.L. Baker, B. Kelly and T.J. Lewin. Medical Journal Australia, 195, 3, 1 August 2011.
  • Computer-based psychological treatment for comorbid depression and problematic alcohol and/or cannabis use: A randomized controlled trial of clinical efficacy. F.J. Kay-Lambkin, A.L. Baker, T.J. Lewin and V.J. Carr. Addiction, 104, 278-388 (2009).
• ComfortAble® for chronic pain
  • Cognitive-behavioral therapy for individuals with chronic pain: Efficacy, innovations, and directions for research. D.M. Ehde, T.M. Dillworth and J.A. Turner. American Psychologist (2014), Vol. 69, No. 2, 153-166.

We further validate this research with outcomes from practical application of our solutions. By doing this, we ensure our clients and members receive only high-quality products and services that work in the real world—where it really matters.

SOURCES:

• ACT is an Empirically-Supported Therapy: Background and Clinical Evidence
• Act Theory: Acceptance and Commitment Therapy Explained
• CBT Explained: An Overview & Summary of CBT
• Dialectical Behavior Therapy
• EDMR Therapy
• Exposure and Response Prevention in the Treatment of Obsessive-Compulsive Disorder: Current Perspectives – PMC
• The Evidence for Cognitive Behavioural Therapy in any Condition, Population or Context: A Meta-review of Systematic Reviews and Panoramic Meta-analysis
• Fluoxetine: a review on evidence-based medicine
• National Library of Medicine: Pregabalin
• National Library of Medicine: Risperidone
• New Therapy Shows Promise for Swift Treatment of Obsessive Compulsive Disorder – Association for Psychological Science – APS
• Psychiatry.org – Study Supports Effectiveness of New Fast-Acting Antidepressant, Esketamine Nasal Spray
• Transcranial Magnetic Stimulation
• VR therapy for OCD Can Enhance the Delivery of Exposure Response Prevention
• What is Evidence-Based Therapy: 3 EBT Interventions

Discussions about mental health in the Black community shouldn’t be limited to Black History Month in February and BIPOC Mental Health Awareness Month in July. The conversations and action steps geared toward providing education, support, and resources require a year-round effort.

A recent article published by the Kaiser Family Foundation, shares that although Black people have made great contributions and achievements in the United States, “they continue to face many health disparities that adversely impact their overall health and well-being,” which have been “exacerbated by impacts of the COVID-pandemic, ongoing racism and discrimination, and police violence against and killings of Black people.”

What impact do these factors have on the mental health of individuals in the BIPOC community? Magellan’s medical director Rakel Beall-Wilkins, M.D., MPH shares her perspectives on depression and suggestions on ways to be supportive.

What is depression and what are some signs or symptoms?

Dr. Beall-Wilkins: Depression is a clinical illness characterized by:

• Prolonged periods of low or sad mood.
• Loss of interest or pleasure in activities.
• Changes in appetite, sleep or energy levels.
• Feelings of worthlessness or hopelessness.
• Thoughts of death or suicide.

Depression can be caused by medical illness, substance abuse, and stressful social, academic, or occupational situations, but it can also develop more readily in individuals who have a family history of depression or other mental health conditions.

Other signs of depression may include:

• Withdrawing from social activities, relationships, or hobbies.
• Escalating drug or alcohol use.
• Declining self-care in the form of poor personal hygiene and grooming.
• Expressing feelings of hopelessness, worthlessness, and/or helplessness.
• Neglecting to attend to chronic medical conditions or maintain follow-up with healthcare providers.

How does depression impact individuals in the Black community?

Dr. Beall-Wilkins: As of 2020, the National Survey on Drug Use and Health found that 6% of Black American adults and 12.9% of Black American adolescents experienced a major depressive episode within the last year. Despite increasing levels of depression within the Black community, studies also show that Black Americans are less likely than their White counterparts to receive psychotherapy or medications for their depressive symptoms. This disparity is largely attributed to limited access to healthcare coverage and culturally competent behavioral health providers, as well as pervasive cultural stigma.

Is it possible for someone to experience depression that is triggered by external factors and societal issues, such as violence, police brutality, political unrest, and racism? If so, how?

Dr. Beall-Wilkins: Yes, it is possible for depression to develop as a result of exposure to sociopolitical strife. In fact, during the week following the highly publicized death of George Floyd in May 2020, rates of depression and anxiety spiked from 36 to 41% among Black American respondents to the Census Bureau’s 2020 Household Pulse Survey.

Likewise, a 2018 study published in The Lancet found that police killings of unarmed Black Americans resulted in an increase in poor mental health days among Black American respondents. Though they may not know the victims of these circumstances personally, it is very common for Black Americans to collectively internalize the trauma of these events and feel despair over the possibility that a similar fate could befall them or their close family members and friends. Moreover, the repeated nature of these events can elicit sadness, hopelessness, and fear that things will never change.

What are tips for an individual that recognizes they are showing signs of depression?

Dr. Beall-Wilkins:

• Visit your doctor and seek treatment: Regularly follow up with a primary care provider to ensure there are no untreated or undertreated medical conditions that may contribute to the development or worsening of depressive symptoms.
• Stay connected: Stay connected to close friends, family, and spiritual community for support.
• Diet and exercise play a role: Eat a balanced diet and engage in physical activity for at least 30 minutes a day, three times per week.

Resources:

• National Alliance on Mental Illness’s (NAMI) cultural dimensions website for BIPOC/AAPI communities.
• DSM-5 (American Psychiatric Publishing, Copyright 2013 (American Psychiatric Association) 
• Stanford University 
• Anxiety and Depression Association of America 

Obstructive sleep apnea (OSA) has been linked to an increased risk of physical health problems, including high blood pressure, heart disease, stroke, and diabetes. But how does OSA affect your ability to think clearly, learn and remember, and your emotional psychological, and social wellbeing?

If you have ever worked a 24-hour shift or experienced back-to-back days of poor sleep, it probably comes as no surprise to hear that OSA has been linked to cognitive and mental health issues. OSA causes frequent breathing interruptions, or apneas, while you sleep—as many as 30 per hour. OSA is associated with:

1. Trouble concentrating—OSA can lead to significant changes in two important brain chemicals, gamma-aminobutyric acid (known as GABA) and glutamate. Together, these two chemicals help maintain balance. People with OSA may have decreased levels of GABA and elevated levels of glutamate. GABA is a chemical messenger that acts as an inhibitor in the brain. It slows things down and helps you remain calm. Glutamate, on the other hand, speeds things up. When your glutamate levels are high, your brain is working in a state of stress and does not function as effectively.[1] Glutamate in high amounts has also been shown to contribute to brain damage.
2. Memory problems—Throughout the night your body fluctuates through different sleep stages, allowing your brain to process and sort out all the information it has gathered throughout the day. OSA stops the flow of oxygen to your brain or completely cuts it off multiple times during the night, robbing your ability to reach deep and restorative sleep These frequent disruptions can contribute to memory loss and have a negative impact on overall brain performance.[2]
3. Poor decision-making—Sleep is essential in maintaining brain health and contributes to your ability to learn and recall information. A lack of sleep caused by OSA can cause frequent problems with attention and concentration. If you suffer from OSA, you may have trouble focusing at work or school, being creative, solving problems, and making decisions.[3]
4. Depression and stress—OSA can cause hundreds of interruptions in your breathing during the night, which can set off a constant fight-or-flight response. You may wake up suddenly with your heart racing, sweating, and a feeling of doom. This can carry over into the daytime, causing you to feel run-down and sleepy and your body to be without the energy it needs to protect you against depression and stress.[4]

The good news about obstructive sleep apnea’s impacts on cognitive and mental health

While OSA can negatively impact your day-to-day life, there is hope. The harmful cognitive and mental health effects of OSA can be reversed with treatment. For some, this may mean lifestyle changes. For others, it may mean continuous positive airway pressure, or CPAP—a machine that helps you sleep easier.

Want to learn more about obstructive sleep apnea?

Find the recording of our webinar, “Obstructive sleep apnea: Impacts, diagnosis and treatment,” to hear board-certified somnologist and neurologist, Dr. Karen Jablonski, physician clinical reviewer, Magellan Healthcare, and I discuss the mental and physical health impacts of OSA, and OSA diagnosis and treatment here.

[1] https://newsroom.ucla.edu/releases/sleep-apnea-takes-a-toll-on-brain-function#:~:text=They%20found%20that%20people%20with,calm%20%E2%80%94%20like%20a%20brake%20pedal.

[2] https://goodsomnia.com/blog/snoring-sleep-apnea/can-sleep-apnea-cause-memory-problems/

[3] https://www.sleephealthsolutionsohio.com/blog/sleep-apnea-and-brain-health/

[4] https://www.everydayhealth.com/sleep/sleep-apnea-link-depression-anxiety/

Men, women, and children. Black and white. Rich and poor. Depression affects Americans from all walks of life, regardless of age, gender, race, ethnicity, and socioeconomic status. In fact, the Centers for Disease Control and Prevention estimate that one in thirteen of us is living with depression.[1]

• In 2019, nearly 13 million U.S. adults and 2.7 million U.S. adolescents had at least one major depressive episode with severe impairment in the past year[2], including:
  • Almost 10% of females and 6.0% of males[3]
  • Approximately 15% ages 18-25, 9% ages 26-49, 5% ages 50+[4]
  • About 7% Hispanic or Latino, 9% White, 6% Black or African American, 5% Asian, 4%[5] Native Hawaiian/Other Pacific Islander, 9% American Indian/Alaskan Native[6]
• About 31% of Americans in poverty and almost 16% of those not in poverty report having been diagnosed with depression [7]

Recognizing signs of depression

Depression is often referred to as a silent illness. Many people who suffer from depression secretly struggle and never seek help. Signs and symptoms of depression include:

• Low mood or increased irritability
• Feeling empty or numb
• Loss of energy or motivation
• Loss of interest in regular or recreational activities
• Feelings of guilt, restlessness, hopelessness, worthlessness or fear
• Sleeping too much or too little
• Changes in appetite or eating behavior
• Poor concentration
• Suicidal thoughts

If you or someone you love is experiencing any of the common risk factors and warning signs associated with depression, online or in-person depression screening is the first step toward improved mental health and wellbeing.

Benefits of depression screening

Screening is a valuable tool in the identification and treatment of depression. One of the most common screening tests for depression is the Patient Health Questionnaire (PHQ). Early identification and treatment of depression can:

• Slow its progress
• Improve your physical health
• Prevent years of suffering
• Decrease the risk of death by suicide
• Place you on the path to a happier, healthier life

Visit here to complete the PHQ-8. Once you complete the assessment, be sure to review your results and any recommendations with your doctor.

Who should take a depression screening test?

The U.S. Preventive Services Task Force recommends screening for depression in the general adult population, including pregnant and postpartum women. Although anyone can develop depression, regardless of their age, ethnicity, or background, depression is more common among people who:

• Have a family history of mental illness
• Have another mental health condition, like anxiety
• Struggle with a substance use disorder, like drug addiction or alcoholism
• Recently experienced a stressful life change or traumatic event

However, anyone who has any signs of depression should take a depression screening test.

Screening and treatment

While screenings are not a professional diagnosis, they do point out the presence or absence of depressive symptoms and can indicate if a referral for further evaluation is needed. You should see your doctor or a qualified mental health professional if you experience five or more depression symptoms for longer than two weeks or if the symptoms are severe enough to interfere with your daily routine.

Proper treatment of depression has been proven to effectively reduce depressive symptoms, decrease the risk of relapse and recurrence, and decrease emergency department visits and hospitalization rates.

Learn More

Visit Magellan’s Behavioral Health Resources page to learn more about depression and other mental health conditions.

If you’re in crisis or have suicidal thoughts, seek help immediately. Please call 1-800-273-8255 (National Suicide Prevention Lifeline) or call 911 and ask for help, or go to your nearest emergency room.

[1] https://www.cdc.gov/tobacco/campaign/tips/diseases/depression-anxiety.html

[2] https://www.nimh.nih.gov/health/statistics/major-depression

[3] https://www.nimh.nih.gov/health/statistics/major-depression

[4] https://www.nimh.nih.gov/health/statistics/major-depression

[5] https://www.nimh.nih.gov/health/statistics/major-depression

[6] https://www.nimh.nih.gov/health/statistics/major-depression

[7] https://news.gallup.com/poll/158417/poverty-comes-depression-illness.aspx

Among those who experience a mental health illness, more than half do not receive treatment.[1] The 2019 National Survey on Drug Use and Health reveals no treatment was received by:

• 90% of the 20.4 million individuals aged 12+ who have a substance use disorder (SUD)
• 55% of the 51.5 million individuals aged 18+ who have any mental illness (AMI)
• 35% of the 13.1 million individuals aged 18+ who have a serious mental illness
• 90% of the 9.5 million individuals aged 18+ who have a co-occurring SUD and AMI
• 57% of the 3.8 million individuals aged 12-17 who have had a major depressive episode

In fact, what we’ve seen in our data is that 60% of patients who are admitted to inpatient care were first seen in a primary care setting within 6-12 months of the admission and the mental health condition was either missed or not addressed.

Through effective screening for mental health conditions on your own or through a physician or mental health professional, it is possible to identify problem areas and get help, so you can live a happier and healthier life.

Mental health self-screening tools

Magellan Healthcare provides links to reputable, free self-assessments of behavioral/mental health, substance use and more.* Once you complete an assessment, be sure to review your results and any recommendations with your doctor.

• Addiction(CAGE-AID)
• Alcohol consumption (AUDIT-10)
• Anxiety (GAD-7)
• Bipolar disorder
• Child depression (CES-DC)
• Child trauma (CTS)
• Depression (PHQ-8)
• Drug abuse (DAST-10)
• Eating disorder (SWED)
• Insomnia (ISI-7)
• Obsessive compulsive disorder (OCD) (Y-BOCS)
• Pain (PEG-3)
• Parent mental health
• Postpartum depression
• Post traumatic stress disorder (PTSD) (PC-PTSD)
• Psychosis (PQ-B)
• Youth mental health

*Note these are links to outside websites that are not monitored by or affiliated with Magellan Healthcare. If your screening results indicate you are at high risk, call 911 or go to the emergency room immediately.

We encourage you to watch a recording of our webinar, “Depression is more than just a rough patch,” and find additional resources addressing depression at MagellanHealthcare.com/Mental-Health.

[1] https://www.samhsa.gov/data/sites/default/files/reports/rpt29392/Assistant-Secretary-nsduh2019_presentation/Assistant-Secretary-nsduh2019_presentation.pdf

Even before the COVID-19 pandemic entered our world, the prevalence of mental illness and suicidal ideation in the US was increasing. In 2019, 61.2 million American adults (24%) had a mental illness and/or substance use disorder, an increase of 5.9% over 2018.[1] Depression – a sad mood that lasts for a long time and interferes with normal, everyday functioning – for those under age 50 increased steadily from 2016 to 2019:[1]

• 6% increase among those aged 12-17
• 1% increase among those aged 18-25
• 6% increase among those aged 26-49

From 2009 to 2019, suicidal thoughts, plans and attempts increased among:[1]

• Young adults aged 18-25, 95%, 98.8% and 62.4%, respectively
• Adults aged 26-49, 23.3%, 50% and 24.5%, respectively

Increased stressors brought about by the pandemic – grief and loss, social isolation, financial instability, fear, etc. – have exacerbated the state of mental health in the US. More people from January – September 2020, compared to all of 2019, sought help for anxiety (93% increase) and depression (62% increase).[2] Since COVID-19 began, suicidal ideation in the US has more than doubled, with younger adults, racial/ethnic minorities, essential workers, and unpaid adult caregivers experiencing disproportionately worse effects.[3]

Recognizing the symptoms of depression

Depression can have different symptoms depending on the person, but in most people, a depressive disorder changes how they function day-to-day, and usually for more than two weeks.

Learn the FACTS:

• Feelings: Being extremely sad and hopeless, losing interest or enjoyment from most daily activities
• Actions: Exhibiting restlessness or feeling that moving takes great effort, having difficulty focusing, concentrating on things, or making decisions
• Changes: Gaining or losing weight due to changes in appetite, changing sleep patterns, experiencing body aches, pain, or stomach problems
• Threats: Talking about death or suicide, attempting suicide or self-harm
• Situations: Experiencing traumatic events or major life changes, having a medical problem or family history of depression

A serious symptom of depression is thinking about death or suicide. If you are in crisis or considering suicide, or if someone you know is currently in danger, please dial 911 immediately.

We encourage you to watch a recording of our webinar, “Depression is more than just a rough patch,” and find additional resources addressing depression at MagellanHealthcare.com/Mental-Health.

Jamie Hanna, MD, serves as the medical director for the Magellan of Louisiana Coordinated System of Care (CSoC) program. She is board certified in Psychiatry and Child and Adolescent Psychiatry. Prior to joining Magellan in 2020, Dr. Hanna served as an assistant professor and assistant training director with Louisiana State University School of Medicine, working with the acute behavioral health unit, and leading the psychiatric consultation-liaison service and emergency psychiatric services at Children’s Hospital of New Orleans. Dr. Hanna completed medical school at the University of Alabama School of Medicine and a subsequent internship in Pediatrics, residency in General Psychiatry, fellowship in Child and Adolescent psychiatry, and fellowship in Infant Mental Health with Louisiana State University in New Orleans.

[1] https://www.samhsa.gov/data/sites/default/files/reports/rpt29392/Assistant-Secretary-nsduh2019_presentation/Assistant-Secretary-nsduh2019_presentation.pdf

[2] https://mhanational.org/issues/state-mental-health-america

[3] https://www.cdc.gov/mmwr/volumes/69/wr/mm6932a1.htm

By Dr. Beall-Wilkins and Dr. Jamie Hanna

Magellan Health hosted a free webinar for September Suicide Prevention Awareness Month. If your question wasn’t answered during the webinar, or if you would just like to learn more about suicide prevention, read on for information shared by our webinar presenters, Dr. Rakel Beall-Wilkins, MD, MPH, and Dr. Jamie Hanna, MD. For more information and resources addressing suicide prevention, and to watch the recording of this webinar, visit MagellanHealthcare.com/Suicide-Prevention.

Question: Please say more about the interplay between chronic pain and suicide risk.

Dr. Beall-Wilkins: It is estimated that the prevalence of suicidal ideation is roughly three times greater in people living with chronic pain compared to those who do not have chronic pain, and chronic pain is linked to higher rates of not only suicidal ideation but also suicide attempts and completed suicides.[1] When coupled with impaired functionality and disability, chronic pain can result in socioeconomic hardships and limitations in access to care that further exacerbate both physical and mental health symptoms. Chronic pain and depression often go hand-in-hand, and clinical studies have shown that upwards of 85% of people with chronic pain have experienced severe depression.[2] It is essential that patients with chronic pain be routinely screened for psychiatric symptoms and acute safety concerns, and that they be referred to treatment if issues arise.

Question: Is a person really considered suicidal if they have considered it a lot but have never acted on their thoughts? What measures can we put in place for individuals with a baseline of passive suicidal ideation who are in outpatient therapy?

Dr. Hanna: Understanding the risk factors that can lead to suicidal behavior provides an opportunity to identify and support people at risk for suicide. Risk factors include a previous suicide attempt, diagnosis of mental illness/substance use, isolation, social/legal problems, trauma in childhood, a family history of suicide, recent stressors and access to lethal means. Learn more about suicide risk and protective factors from the American Foundation for Suicide Prevention and the Centers for Disease Control and Prevention. Suicidal ideation – or thoughts about suicide – is also an important risk factor and can be a warning sign of imminent suicidal behavior. There is greater risk when suicidal thoughts occur more often, over greater time periods or are more challenging to control; there are fewer barriers to acting on the thoughts; and the reason for the suicidal thoughts is to stop the pain. Identifying suicidal ideation and implementing treatment strategies are critical in preventing suicide.

It is always the goal to treat suicidality in the least restrictive setting and subsequently, treatment of suicidal ideation often occurs in the outpatient setting. There are a variety of measures that can be put in place to assess and treat suicidal thoughts in the outpatient setting. Some of these include screening, crisis intervention, and evidence-based and research-informed interventions.

One example of a screening tool is the Columbia-Suicide Severity Rating Scale (C-SSRS). This scale focuses on evidence-based metrics to assess the severity of suicidal ideation and behavior. Items on the scale also serve to differentiate between suicidal and non-suicidal self-injurious behavior.

Crisis intervention assistance is typically provided by connecting a person in crisis to trained staff for support and referral to additional services. The goal is to impact key risk factors for suicide, including depression and hopelessness, increase future mental healthcare access, and put space and time in between suicidal thoughts and action. Examples of crisis intervention services include the National Suicide Prevention Lifeline (1-800-273-8255) and Crisis Text Line (text HOME to 741741).

There are only a small number of evidence-based treatment interventions directly targeting suicide risk. These include cognitive behavioral therapy for suicide prevention (CBT-SP), dialectical behavior therapy (DBT) and Collaborative Assessment and Management of Suicidality (CAMS). Additional research-informed interventions include collaborative safety planning and reducing access to lethal means. These interventions are emphasized in both the CDC suicide prevention strategy and the Zero Suicide approach to suicide prevention.

Question: What do you say to someone who says they want to die and that life is torture, and asks why they were born? What types of things can you tell the person going through this, and how do you do it without sounding judgmental?

Dr. Beall-Wilkins: Feelings of despair, hopelessness, worthlessness and helplessness are commonly experienced by people who are in the midst of a mental health crisis. During episodes of emotional distress, it can be very difficult for some people to think positively or constructively, and this can manifest itself in the form of self-deprecating statements and thoughts of self-harm. When someone is feeling this way, it can be helpful to reassure them that things can get better, and that comprehensive treatment can improve how they feel. It’s also very important to assess their safety, inquire about any thoughts they may be having of hurting themselves or someone else, and encourage them to seek immediate professional help if they’re feeling unsafe.

Question: I had a family member take her life on 9/7. She went about her day as normal, and then chose to take her life that evening after placing her kids down for the night. As a family member, we are still trying to figure out why. Is this a normal feeling? Similarly, for people attempting to support those with suicidal thoughts, or who have tried to support someone who died by suicide, what suggestions do you have to help them find the balance between supporting the suicidal individual and feeling overly responsible for the suicidal individual’s choices, behaviors, etc.?

Dr. Hanna: When a loved one dies by suicide, intense emotions – such as disbelief, anger, guilt, isolation and despair – can become overwhelming, and there is no right or wrong way to feel. Many people will feel confused as they try to understand why their loved one chose suicide. And it is likely there will always be unanswered questions. The events which lead to suicide are often complex and most commonly there are many factors that contribute to a person ending their life.

The feeling of guilt can lead suicide survivors to blame themselves for the death of their loved one. It is critical that survivors do not blame themselves, and that they seek support and engage in self-care. Support and self-care can include reaching out to community members, such as friends, family, co-workers and mental health providers. Both in-person and online support groups are available specifically for suicide survivors. The American Foundation for Suicide Prevention provides resources to find a support group. It can also be beneficial to seek professional help with a licensed therapist or psychiatrist, especially for symptoms of depression and thoughts of suicide.

Question: The hardest part about helping someone who is suicidal is the concern that the police will be called, and the person will end up in handcuffs. How can we change this?

Dr. Beall-Wilkins: It is often the case that family and friends of those who are experiencing acute mental health crises face the prospect of summoning law enforcement to assist in maintaining safety and facilitating transportation to care. This can be a very daunting prospect and a growing movement of advocates, policymakers and mental health providers are now pushing for reforms that would reduce the likelihood of adverse outcomes in these circumstances.[3] One such reform involves greater collaboration between police departments and mental health clinicians, including training, education and joint response to crisis calls. Preliminary data indicate this approach can be a very effective means of reducing adverse outcomes, increasing public safety and strengthening trust within communities.[4]

Question: Is being suicidal hereditary? Are the mental/emotional issues that caused a previous suicide in a family hereditary?

Dr. Hanna: There is clear evidence that suicide can run in families, and family history of suicide has been identified as a significant risk factor for suicide. Studies show that individuals who have a parent or sibling die by suicide are two and a half times more likely to die by suicide than those without a family history of suicide. Research has identified a number of genes that appear to be associated with suicide risk. Psychiatric illness has also been shown to run in families and is a risk factor for suicide. Depression plays a role in over half of all suicide attempts. Children of parents with depression are three times as likely to develop major depression, anxiety disorders and substance use – all of which increase the risk of suicide.

While family history of suicide and psychiatric illness are important risk factors of suicide, other risk factors include previous suicide attempts, depression, substance use, stressful life events, physical illness and access to lethal means, among others. Suicide occurs as a result of many interacting genetic and environmental factors. Family members share genes, and they often share experiences – they eat together, live together and face economic stressors and loss together. These shared experiences may combine with genetics to increase an individual’s vulnerability to suicide. This does not mean that everyone with a family history and increased risk of suicide will have suicidal behavior, but that they could be more vulnerable and should take steps to reduce their risk. These may include early evaluation and treatment of mental illness and building protective factors to buffer against suicidal behavior.

Question: Could you speak to the legalities of those who need help but are past the age of responsibility, and family members and friends are told there is nothing they can do if the person refuses the help or that we can’t keep them somewhere against their will?

Dr. Beall-Wilkins: In most jurisdictions, the ability to commit an individual to treatment against their will is typically conferred by the courts based upon three guiding principles: harm to self, harm to others and evidence of significant mental deterioration that renders an individual unable to practice self-care in their own best interest. If an adult person is explicitly stating an intention to hurt themselves or others, or exhibiting grave mental disability, they can be involuntarily committed for observation, evaluation and acute stabilization.

Rakel Beall-Wilkins, MD, MPH, served as a medical director for Magellan Healthcare. Prior to joining Magellan in 2018, Dr. Beall-Wilkins assisted in the launch of an addiction psychiatry clinic embedded within Harris Health System’s Healthcare for the Homeless Program, to combat local impacts of the nationwide opioid and synthetic cannabinoid (“K2”) epidemics. Dr. Beall-Wilkins also served as a member of the Baylor College of Medicine faculty with clinical duties at both the Ben Taub General Hospital Psychiatric Emergency Center and the Thomas Street Health Center. There she helped to expand behavioral health services by launching a neurocognitive clinic collaborative to better screen, diagnose and treat individuals with HIV/AIDS-associated neurocognitive disorder and psychiatric comorbidities. She is a graduate of the University of Texas at Austin and the Johns Hopkins School of Public Health, where she obtained a Master of Public Health degree. She obtained her medical degree from Baylor College of Medicine. 

Jamie Hanna, MD, serves as the medical director for the Magellan of Louisiana Coordinated System of Care (CSoC) program. She is board certified in Psychiatry and Child and Adolescent Psychiatry. Prior to joining Magellan in 2020, Dr. Hanna served as an assistant professor and assistant training director with Louisiana State University School of Medicine, working with the acute behavioral health unit, and leading the psychiatric consultation liaison service and emergency psychiatric services at Children’s Hospital of New Orleans. Dr. Hanna completed medical school at the University of Alabama School of Medicine and a subsequent internship in Pediatrics, residency in General Psychiatry, fellowship in Child and Adolescent psychiatry, and fellowship in Infant Mental Health with Louisiana State University in New Orleans.

For more information and resources addressing suicide prevention, and to watch the recording of this webinar, visit MagellanHealthcare.com/Suicide-Prevention.

[1] Pergolizzi JV (2018) The risk of suicide in chronic pain patients. Nurs Palliat Care 3: doi: 10.15761/NPC.1000189.

[2] Sheng, J., Liu, S., Wang, Y., Cui, R., & Zhang, X. (2017). The Link between Depression and Chronic Pain: Neural Mechanisms in the Brain. Neural plasticity, 2017, 9724371. https://doi.org/10.1155/2017/9724371

[3] https://www.npr.org/2020/09/18/913229469/mental-health-and-police-violence-how-crisis-intervention-teams-are-failing

[4] https://www.apa.org/monitor/2021/07/emergency-responses

Behavioral health is an important indicator of a society’s overall wellbeing, as it interacts closely with physical health. Unfortunately, most individuals do not receive the behavioral health treatment they need. Fear of treatment, shame, and embarrassment keep many from seeking care. More than one-third of Americans live in areas lacking mental health professionals.[1] Fifty percent of individuals who receive a behavioral health referral do not follow through or have only one visit.[2] Collaborative care addresses these problems by providing physical and behavioral health care in the primary care setting.

What is collaborative care?

Collaborative care is a specific type of integrated care developed at the University of Washington’s AIM Center that treats common mental health conditions, such as depression and anxiety, that require systematic follow-up due to their persistence. Based on principles of effective treatment of chronic illness, collaborative care focuses on defined patient populations tracked in a registry, measurement-based practices, and treatment to target. Trained primary care providers and embedded behavioral health professionals provide evidence-based medication or psychosocial treatments, supported by regular psychiatric case consultation and treatment adjustment for patients who do not improve as expected.[3]

Principles of collaborative care

Developed in consultation with a group of national experts in integrated behavioral health care in 2011 with the support of the John A. Hartford Foundation, The Robert Wood Johnson Foundation, Agency for Healthcare Research and Quality, and California Healthcare Foundation, five core principles define collaborative care and should inform every aspect of implementation to ensure effective collaborative care is practiced.[4]

• Patient-centered team care—Primary care and behavioral health providers effectively work together using shared care plans that include patient goals. Being able to receive both physical and mental health care in a familiar location provides patients with comfort and reduces duplication of assessments. Increased patient engagement often leads to a better health care experience and improved patient outcomes.
• Population-based care—Care teams share a specific group of patients that are included in a registry. The registry is used to track patients and ensure that no one falls through the cracks. Patients who do not show improvement are outreached, and behavioral health specialists offer caseload-focused consultation.
• Measurement-based treatment to target—Each patient’s treatment plan includes personal goals and clinical outcomes that are measured using evidence-based tools, such as the Generalized Anxiety Disorder scale on a routine basis. If patients do not improve as expected, treatments are adjusted until clinical goals are met.
• Evidence-based care—Patients receive treatments with sound research evidence to support their efficacy in the treatment of the target condition, including various evidence-based psychotherapies that have proven effective in primary care, such as problem-solving treatment, behavioral activation, and cognitive behavioral therapy, and medicines.
• Accountable care—Providers are responsible for and receive reimbursement for the quality of care and clinical outcomes, not just the volume of care provided.

Collaborative care has been proven to double the effectiveness of depression care, improve physical function, and reduce health care costs. Magellan Healthcare’s evidence-based Collaborative Care Management product, enabled by NeuroFlow, provides care management and psychiatric consults for primary care patients and augments physical health providers’ staff with Magellan staff to facilitate integrated physical and behavioral healthcare. Learn more here.

[1] https://usafacts.org/articles/over-one-third-of-americans-live-in-areas-lacking-mental-health-professionals/

[2] https://aims.uw.edu/collaborative-care

[3] https://aims.uw.edu/collaborative-care

[4] https://aims.uw.edu/collaborative-care