Why good health includes your mental health

DR. TAFT PARSONS III (00:01):

It's something that one of my very smart supervisors used to say on a regular basis is that there is no health without mental health. If you ignore it, if you cover it up, you suffer all sorts of other health effects.

DR. DANIEL KRAFT (00:14):

Welcome to Healthy Conversations, an original podcast from CVS Health. I'm DR. Daniel Kraft. I'm sure it'll be no surprise to hear that our country is in an unprecedented mental health crisis. It's a problem faced by people of all ages, from teens experiencing record high levels of sadness and suicide risk to adults with anxiety and depression. In the latest health trends, reports from CVS Health, DR. Taft Parsons III, who's the chief psychiatric officer for CVS Health, talks about the mental health challenges facing older Americans. We clearly need to pay more attention to our mental wellbeing, so I'm glad we have Dr. Parsons here today to speak with us. How are we doing in terms of mental health right now in the United States?

DR. TAFT PARSONS III (00:53):

Before COVID, we already knew that there was more need and demand for mental health services than there were clinicians. That has only grown exponentially through COVID. So as the world shut down and people were not able to kind of rely on their usual coping mechanisms of socializing, the emotional difficulties and drains of the pandemic really took a toll. And so we have seen an increased demand across all age groups, across all demographics taking place over the last couple of years. Unfortunately, that gap between providers with appointment slots and people that need care is only going to get worse, so we found that by 2030 there's predicted to be approximately a 40% gap between providers that actually have open appointment slots and can provide care for folks and people that are in need of treatment.

DR. DANIEL KRAFT (01:49):

At the same time, COVID acted as a bit of a catalyst for bringing some care forward, certainly the virtual care. Any kind of favorite lessons learned in how to manage virtual mental health that the pandemic helped bring to the surface?

DR. TAFT PARSONS III (02:04):

In 2019, CVS provided about little under 200,000 visits for all of our members, customers, patients in all various settings. So since the pandemic started, we've done over 30 million visits in the last three years. It's just really grown exponentially, and so what we think actually happened is that as the world shut down and people were kind of forced to have that first experience, what people found is that they kind of like it. The care is very good and it's way more convenient than going in person. You don't have to get in traffic and drive over to a clinic. You don't have to sit in a waiting room, and so you can log on literally a few minutes before your appointment takes place, do the appointment and get back to your life. To this day, across all of our different lines of business on the insurance side, somewhere between about 40 and 60% of all of our outpatient visits continue to be virtual visits.

DR. DANIEL KRAFT (03:03):

And do you have a view on how those have been integrated with new digital mental health apps, whether it's platforms like Woebot out of the Stanford Medical School or ones that might even integrate wearable data to give insights maybe to your AI chatbot or to your psychologist or psychiatrist?

DR. TAFT PARSONS III (03:19):

We've seen a lot of new products coming into the space. Some are very person based and they use the technology just for the video connection, sort of like a Zoom call, the more digital AI sort of chat that's for folks that have very mild to moderate illness or they just have an issue that they're trying to work through. Others kind of leverage some sort of chat-based therapy. What we don't know is like what's going to clearly be kind of the standard bearer going forward. So right now we're letting the dust settle in that space and trying to see what works best for what type of person.

DR. DANIEL KRAFT (03:57):

Yeah, once the idea of precision digital mental health will evolve and now we can pick up some of our digital biomarkers of mental health from our voice and our movements, so it's going to be an interesting era to connect some of those dots. One striking statistic I saw from the CDC said that three and five teen girls felt persistently sad or hopeless, which is double the rate of boys and the highest rate reported over the past decade. Do you have any insights about what's sort of driving this kind of worrisome statistic?

DR. TAFT PARSONS III (04:24):

They haven't had their kind of usual coping mechanisms. If you think about teenagers, they tend to be very social people. When they haven't really been able to lean on that in the way that they're used to doing it, it really creates a lot of emotional stress for them. It does seem to be somewhat proportionally more for adolescent girls as opposed to boys. Kids have had to go through different rounds of virtual school versus in-person school, being able to socialize, not being able to socialize and feeling isolated from their friend groups. All of these things have kind of worn on them over the last couple of years. The more time kids spend on social media in particular, the more passive time kids spend on social media, the more of a detrimental effect it does seem to have on their emotional state. Probably the one good thing is that young folks in particular are really much more able to speak up about the emotional distress that they're going through and reach out for help in various ways,

DR. DANIEL KRAFT (05:24):

And I can almost imagine no one teen et cetera is built the same way. Some might want badges or points or virtual or real hugs. Do you see sort of a shift in the bigger field of psychiatry to learn how to really tune it to the individual rather than the standard DSM?

DR. TAFT PARSONS III (05:40):

You see it kind of going both ways. We're trying to make behavioral health and psychiatry as personalized as possible. What medications might you metabolize more quickly? What conditions might you have a higher risk of developing? But also at the same time, there's a push within behavioral health and psychiatry to also standardize and measure and make sure that people are getting what we would call evidence-based care backed up by the best of science.

DR. DANIEL KRAFT (06:08):

Yeah, 100%. So moving from teens to older Americans, they certainly have their own set of issues. Your new CVS Health trends report on the future of health, aging showed a real dichotomy of statistics around the mental health of older Americans. Those over 65 say they're at the most freeing stage of their life with eight in 10 saying they're able now to focus on what makes them happy. This is despite all the challenges that come with sort of growing older, are there any insights that younger generations can learn from older adults about resilience, optimizing not just health span but mental health span.

DR. TAFT PARSONS III (06:39):

So at the same time that like 95% of older Americans are saying that they feel very good about their mental health and they're happy, a good 40% of their primary care physicians are very concerned about their older patients' mental health. There seems to be this split between kind of how they perceive their mental health versus how others are perceiving their mental health. I do know that as we look into the data within CVS, we do see very high prevalences of mental health disorders and needs. One of the encouraging things is that across all age groups, we are seeing an increased likelihood of folks kind of reaching out and actually getting into treatment. Even with our older Americans, they are kind of coming forward more and getting the treatment that they need at a higher rate.

DR. DANIEL KRAFT (07:27):

We know that about 75% of those under 65 have gotten some form of mental health while older folks, 43% of those over 65 have done so. And as you mentioned, the stigma is a bit lesser than in past generations.

DR. TAFT PARSONS III (07:41):

Probably the one good thing that happened through the pandemic is that there was kind of this acceptance of people talking about their emotional needs. Traditionally, there are populations that see psychological struggles, psychiatric illness as some sort of emotional or spiritual weakness, and so there was very much a change in the perception of that. Really kind of as folks would talk more about how they were struggling, what they were finding is number one, they weren't alone. My friends and family members are struggling with it. And so there was much more acceptance of kind of saying, "We understand. Let's see how we can get you into the treatment that you need." COVID for some reason or other gave it a kickstart, but it's going to continue to take quite a bit of time to get everybody thinking about mental illness in the same way that they think about high blood pressure, diabetes, that they would chat with their neighbor about.

DR. DANIEL KRAFT (08:38):

In general, men are a little more reluctant to seek care. Any kind of lessons in how to encourage the male gender to think more about mental fitness?

DR. TAFT PARSONS III (08:46):

Having emotional distress and emotional needs in our culture has been traditionally seen as a weakness. You suck it up and it's really not conducive to people living a fully healthy life. We continue to see women presenting for treatment at a higher rate than men. Rather than shrink away and withdraw guys are much more likely to act out when they are in emotional distress. It might come across as irritability or anger as opposed to sadness. Really kind of being open and making it okay for them to talk about what has them in that emotional state can be quite helpful.

DR. DANIEL KRAFT (09:26):

I'm part of a virtual men's group and they have sort of these deep dive sessions where people just having a friendly ear to share their emotional struggles. It can go a long way and remind folks that they aren't alone in their struggles. And speaking of alone, we just saw the announcement by the surgeon general about social isolation and it's tremendous impact on health, more dangerous than a two pack a day of smoking. Is that something that CVS Health can tap into?

DR. TAFT PARSONS III (09:50):

In our Medicare population, we have specific programs to identify folks that are at risk for social isolation, and we have offerings that are additional benefits and pilot programs to get folks connected to others. We're trying different approaches as we are doing a much better job at recognizing things that have not traditionally been connected to healthcare that really have a large effect on our overall health and wellness.

DR. DANIEL KRAFT (10:17):

It's not all about drugs and being on the couch. At the same time, we know that about half the US population lives in federally designated mental health professional shortage areas, and this shortage is expected to worsen, especially as many older providers are retiring. Any insights on how we can address the crisis of providers themselves?

DR. TAFT PARSONS III (10:36):

It used to be part of our diagnostic formulation to talk about the social factors that are kind of affecting the psychiatric presentation. How does the ability to access transportation to get to and from appointments, how does the stress of maybe not having stable housing or being able to keep the lights or the heat on, how does that affect your mental health? And so finding ways to use non-clinician to address a lot of those things that increase your level of stress and distress have been quite effective. So we think that that's a good way to kind of extend more care to more people.

DR. DANIEL KRAFT (11:13):

So we spend a lot of time thinking about the sick care side of the equation, but what about the opportunities to be more proactive and preventative, whether it's teaching kids mindfulness techniques, social connection, is that something that can be emphasized? Getting folks to be mentally not just resilient but have sort of better mental hygiene through simple things like joining certain community efforts, any sort of data or insights on how we can move the needle back from what's been exacerbated by the pandemic?

DR. TAFT PARSONS III (11:39):

There has been a push and a move to address mental health and wellness on more of a continuum rather than looking just at the sixth side of the equation. We do a lot of that through our Resources for Living program, which is our EAP offering that really focuses on constructive problem solving before somebody has kind of a formally diagnosed disorder. We are experimenting and doing pilots with digital solutions that really focus on self-guided mindfulness, relaxation techniques and providing a lot of training and education on how people can actually just take better care of themselves. Doing things like sleep hygiene, taking better care of their diet, getting more active. Those things we think do have an effect on the development of formal disorders. It's a little harder to kind of demonstrate that from a data standpoint, but it certainly does decrease stressors that we know lead to exacerbations of illness that people have.

DR. DANIEL KRAFT (12:36):

Now we can sort of digitally measure behaviors, sleep, voice related to anxiety, cardiac stress levels through heart rate variability, lots of new ways to maybe find that proactive signal and intervene early and have folks be part of self-care rather than the sick care side.

DR. TAFT PARSONS III (12:52):

Yes.

DR. DANIEL KRAFT (12:53):

On prior Healthy Conversations, we've covered the elements of disparity and certainly black and brown communities are often disproportionately undertreated for mental health, even though their burden of mental health often is on the top end of the scale, what can be done to address those disparities, social and otherwise?

DR. TAFT PARSONS III (13:10):

Not unlike other areas of healthcare, disparities exist within behavioral health as well. We have a goal to increase the screening for depression and connecting folks to care within underserved populations over the next couple of years, like our mobile clinics as an example, where we are adding depression screenings to the other cadre of services that we have. We are doing pilots where we're putting out depression screening tools within some of our CVS retail locations, focusing on how do we turn that into the work that we do on a day-to-day basis as opposed to we don't talk about that. There's a difference between detection of depression in black and other minority populations as opposed to white populations. Really part of it is having the data so that we have a better idea of where those disparities exist so that we can come up with targeted programs to correct that and make sure that we're doing as good a job with all populations

DR. DANIEL KRAFT (14:08):

Right. And kind of maybe reach individuals where they are. I think one of the potential opportunities of this new world of Chat GPT and generative AI is you can translate complicated health instructions or mental health elements into the right language based on age, culture, language, personality type and socioeconomic conditions. Is that part of precision mental health going forward?

DR. TAFT PARSONS III (14:28):

AI and the potential with Chat GPT has started to come up quite a bit in the last few months. It's not there yet. Does it have the capability to do those things? I think the answer is yes. I think that it's going to get much better at kind of targeting folks that have historically been disadvantaged. I think that it's going to do a better job of coming up with how do you intervene in a culturally competent and appropriate way really to engage more people in accessing care.

DR. DANIEL KRAFT (14:58):

Yeah, I think it's certainly imperfect today, but things are moving quickly and I even saw a couple years ago, the Veterans Administration had a health virtual bot, right? Where it would look at the individual, their eye gaze, their voice, their tonality, and respond with pretty good interactions, whether it was around depression, anxiety, and I imagine that can be tremendously upleveled with eventually the avatar of your clinician or your mother or your favorite character, particularly useful with folks who might have autism.

DR. TAFT PARSONS III (15:24):

It's a little bit different as see folks that look like you, that seem to have the same cultural background as you discussing the same issue, and it helps you to connect a bit better. A company called Psych Hub, they're creating their patient educational videos in a culturally competent way from an equity standpoint that needs to be accounted for and companies are really stepping up.

DR. DANIEL KRAFT (15:46):

And the cutting edge and future of medical education. I can go into my Oculus headset and there's a platform traveling America while black or while disabled. Are you seeing ways for those of us who aren't psychiatrists or psychologists, but are medical or healthcare practitioners better ways to engage patients with their mental health?

DR. TAFT PARSONS III (16:03):

Some of the standardized screening tools are getting more widely used to kind of start a discussion about people's needs. One of the areas where we see a lot of movement is in the primary care arena. When I trained, the family practice residents would come through for one month of psychiatric training on an inpatient service where they would essentially be doing evaluations for dementia versus delirium. It looked nothing like what they would eventually see in their own primary care practice. Up to about half of the people that come in on a day-to-day basis are actually coming in with some behavioral health need as part of that chief complaint. But over the last few years, we've seen a lot of push to screen for depression, for anxiety, that first and second line medication management, having a place to refer them for therapy. We're not there, but we are getting to the point in other specialties of medicine where they feel comfortable at least assessing for people's behavioral health needs. That is significant progress from, I'd like to say not that long ago when I trained, but it's getting longer and longer every year.

DR. DANIEL KRAFT (17:14):

Speaking of supporting PCPs and other healthcare professionals, there's that old quote "physician heal thyself," and we've certainly seen burnout and mental health issues across healthcare workers from physicians, pharmacists, physical therapists, and beyond. Any insights or work by CVS or others that you're aware of that is going to help better address the mental health of healthcare providers.

DR. TAFT PARSONS III (17:34):

We've recognized clinician burnout as a very specific problem and within CVS we do provide a fair amount of actual care in a very specific way because I'll say unfortunately, doctors, nurses, other clinicians are horrible patients. We are very much do as we say, not as we do, and we don't take good care of ourselves. And I think we used to be able to kind of white knuckle it through.

(18:02):

What happened during COVID is it really kind of pushed us over a little bit of a tipping point. And so we've seen a lot of very highly qualified, very good clinicians throwing in the towel as everybody else around the country was losing friends, family members, people were very sick and in the hospital, clinicians were having the same experience, but also having to go to work and take care of folks that look like the people that they were concerned about. We are having some targeted programs really structured around how do you step back, how do you find ways to take care of yourself? How do you acknowledge the needs that you actually have? We need to be able to take care of the behavioral needs and mental wellness needs of that population to keep us ready and able to care for the rest of the country.

DR. DANIEL KRAFT (18:52):

Both need to heal and support our healers.

DR. TAFT PARSONS III (18:55):

It's something that one of my very smart supervisors used to say on a regular basis is that there is no health without mental health. Hopefully the guy who said it, maybe he'll hear it. If you ignore it, if you cover it up, you suffer all sorts of other health effects. And so really making sure that you're taking care of your whole person is super important.

DR. DANIEL KRAFT (19:17):

Absolutely. That's key. So with that, I really want to thank you DR. TAFT PARSONS III, the Chief Psychiatric Officer for CVS Health, for joining us on Healthy Conversations today. For more information on mental wellbeing in older adults, you can find the latest health trends report on the future of healthy aging at CVShealth.com. I'm DR. DANIEL KRAFT. You've been listening to Healthy Conversations: the podcast, subscribe to stay up to date with our latest episodes.