Vital Signs That Suicide Care Is Alive

Is the grace period for mental healthcare over?   After 10 years or reimbursement rate increases, no more pre authorization requirements and a laissez faire approach to managing total spend, the commercial and government sponsored plans are set to turn up the attention on cost and pivot to supporting models that make a difference, get people to goal, save the system and save a life.

Issue #1: Too What End? That’s Really The Question

Too many psychiatrists and outpatient mental health practitioners are coming into the network and expect a prolonged, unchecked set of services – but that’s not good for the patient, Ish Bhalla, MD, former behavioral health value medical director for Blue NC, told me in 2023. “Access has become a quality measure, but it’s not a really good one…I’d like to see us incentive the practitioners to work toward an end goal.” Expect this to be targeted to therapists and LCSWs as much as psychiatrists, and to make its way into contracts, utilization management and network contracting. “95% of outpatient mental health therapy is not good quality,” according to consensus from our panel of psychiatrists who advise health insurers.

Issue #2: Default Diagnostics

One of the issues is poor diagnosis, relying solely on the patient to dictate the diagnosis, and therapy that devolves into a chat among friends – not a means to a goal. “A lot of is really poor supervision – it’s either not happening or not helpful – and some of it is defaulting to labeling everyone with anxiety, PTSD and depression, when that’s not usually the case.” It’s a default set of diagnoses - when it’s often something much more specific, a trauma, event, an avoided moment like the passing of parent, a way of being raised. In our survey of 77 sr. medical directors charged with overseeing behavioral health spend for U.S. health insurers, 84% said the problem with outpatient therapy is not the intent of the therapists but the training and the lack of specialization. Said one psychiatrist for an insurer: “I think part of the reason for the rise in suicides is of course societal, but we talk about in the media the wrong way - we need to think of it as a condition, a situation, almost a chronic condition that needs the level of attention as heart disease, diabetes - suicide care should not be at the point when the 25 year old says they are thinking of killing themselves, it should have started well before that, and we need to train our mental health practitioners in how to do it.”

Issue #3: The Right Rx

Part of the issue, according to parents who’ve lost kids to suicide, is that the therapists and doctors have missed the fixable signs. Several moms said their daughters suffered for years from undiagnosed celiac disease which led to fatigue, depression and suicide thoughts. “It took a really good psychiatrist to the idea that the depression and fatigue was quite possibly Lyme or Celiac - and it was,” Paula Castilla said, thanking her kid’s doctor for being willing to raise it and help address it. “The pill wasn’t the answer.”

This sort of going the extra mile is rarely incented or encouraged in our health care system and it’s rare. The default for many practitioners is actually to label the situation and prescribe a drug.

Ever wonder why physicians prescribe antidepressants in teens at such a high level? Prescriptions for these medicines rose 63% amongst adolescents during the pandemic for example.

Doctors often make the decision “in the midst of a suicide situation,” as psychiatrists and even pediatricians are often alerted to a teen who acknowledges thinking about it, even if no plan has been made. The decision to prescribe an anti-depressant is, according to many of these professionals, essential in that situation to stabilize.

There are alternative treatment approaches however that have sprung up recently as a way to head of suicide and treat it before an event happens, and create a system of support that empowers the patient. Vita Health, the nation’s only known organization offering telehealth focused suicide care, has done well to change the narrative around suicide and the results. The company trains its clinicians to help individuals during this period. It’s not about “preventing” suicide as much as tackling the condition head on, in a way that helps the teen or adult directly learn from and manage through their thoughts about suicide and, in some cases, their attempt. This model is virtual as a way to be more accessible and because the impact on outcomes is better. The clinician and patient come together when they need to, unconstrained by insurance barriers.

“You create trust and assurance and make it okay,” one teen, Mark, 18, said of his experience with virtual suicide care. “Before I had to wait a week to see my psychiatrist in his office…it was harder that way….I saw those appointments as something as I was being told to do, as opposed to something that I wanted to do to get better.”

At Vita, psychiatrists and therapists go through a training around suicide care and how to talk to and with patients. They offer the person the chance to talk to a clinician “where they are at” and in a very specialized program that head of psychiatry Neil Leibowitz, MD, says doesn’t lump them with others who may be suffering from depression or anxiety, but not suicidality.