Health Care Must Open More Doors to Mental Health Patients

Benjamin F. Miller, PsyD
Arpan Waghray, MD


If someone we love has a physical ailment, we can list a variety of places for them to seek care: a clinician’s office, a pharmacy, an urgent care clinic, a school health clinic, an emergency department — the list goes on.

And, in every case, we would feel confident the clinicians in those places would know how to handle the case — or at least know where to send the patient if they need more intensive or specialized care.

But, sadly, the same isn’t true for a loved one with a mental health or substance misuse need, even thought mental health problems are more prevalent than many physical conditions.

As deaths of despair from drug or alcohol misuse or suicide continue to rise, we need a comprehensive, coordinated “no wrong door” approach that fully integrates mental health into the health care system and beyond. We need to transform our clinical practice, creating more options for care and putting mental health and substance use patients’ best interests first. Policy and payment reform must happen to make this new vision of care possible.

Consider that there are an estimated 44 million U.S. adults with mental illness, and more than half  — 24 million — did not get treatment in the past year. Among the 1 in 5 adults who did seek treatment, many did not receive the optimal, evidence-based care they needed. Even worse, 6 in 10 young people with severe depression received no treatment, a risk factor for depression in adulthood. Imagine if half the people with broken arms just had to figure out a way to manage it on their own.

There are many reasons people don’t get adequate mental health care or any at all, from stigma to lack of health insurance coverage. But another major barrier, which gets less attention, is the actual design of our health care system — it doesn’t make things easy.

In terms of how we provide them and how we pay for them, we’ve segregated mental health and substance misuse services from other medical services. Yet, we know that mental and physical health are inextricably linked. For example, having diabetes boosts the likelihood someone will have depression, and vice versa. Having both conditions increases the risk of a host of physical complications.

We can — and must — change the system to better reflect this knowledge. We can catch mental illnesses and substance use disorders before they become full-blown crises. Just as we monitor blood pressure every time someone goes to their primary care office, we can ensure that wherever people go for help — whether in an emergency or for a regular check-up — they are connected to mental health support on the spot.

It’s a tall order, but it has to be done for the good of our nation. Some first steps include:

  • Integrating mental health and substance use services into primary care. This includes embedding mental health clinicians into primary practices and creating standardized care pathways that enable physicians to better address common conditions, like depression, anxiety, ADHD and insomnia.
  • Employing digital solutions. Health care systems are piloting ways to provide psychiatric care via apps and other digital means.
  • Acknowledging emergency departments as the first point of entry for many people with mental health care needs. Across the nation, some leading health systems are integrating behavioral health in emergency departments and the community.
  • Looking for upstream solutions. Health systems and community partners can work together to redistribute mental health throughout all entry points, including schools, places of worship and workplaces.

Everybody, everywhere should have their mental health needs identified and treated. We can achieve this goal if we stop shuttling mental health patients through a separate door and instead redesign our systems to ensure better coordination.

Dr. Arpan Waghray is chief medical officer for Well Being Trust and system medical director for behavioral health at Swedish Health Services in Seattle.

Dr. Benjamin F. Miller is chief strategy officer for Well Being Trust, a foundation established by Providence St. Joseph Health to advance the mental, social and spiritual health of the nation. 

2 replies »

  1. Nothing is more important. Thank you.

    Recall that mental health is a little different from physical health: it can have improper chemistry—from genes, from diabetes, from hypothyroidism, Cushings, endocrine problems of all sorts, electrolyte problems, epigenetics engraftment from experience, trauma, toxins, drugs, etc., in other words synoptic abnormalities screwing up the entire machinery of the brain—and, moreover, it can also have acquired bad wiring of synapses in certain portions of the brain from things like PTSD, toxic parenting, humiliating psychosocial experiences, assaults, bad luck from poverty, racial or sexual mistreatment…a long list, involving some of the acquired synaptic connections. So, mental health is like fixing a junction box in a telephone exchange. There could be the wrong capacitors and resistors and copper AND/OR there could be some bad connections.

    Thus, the big problem is to figure out how to get the large resources to do all this.

    This means we have to get the chemistry correct and, secondly, we have to reconnect some synapses in new and healthy ways. This means psychotherapy, counseling, behaviorism approaches, and much time and cost. But, again, nothing is more important.

  2. What is it that maintained each person’s HEALTH during the some 200,000 years of human existence before our world-wide healthcare institutions began to evolve 200 years ago? To begin a search for upstream solutions, this is the essential question. It is unlikely that the current paradigm of our nation’s healthcare industry has the capability to equitably explore these upstream solutions. Paradigm paralysis has set-in from the institutional co-dependency that exists between the institutions that offer regional Complex Healthcare and the institutional sources of payment for this Complex Healthcare. The co-dependency has made it impossible for the the service institutions and the economic institutions to honor socially responsible collaboration. Socially responsible means locally mediated, community by community.

    The scientific career of Professor Elinor Ostrom applies. See this citation:

    To apply the Design Principles established by Professor Ostrom, I offer one possibility with a Congressionally defined cost of $1.00 per citizen per year. See this citation:


    Remember again, the stethoscope was first described in 1819.

    We should all remember the hallmarks of our nation’s worsening HEALTH: maternal mortality, child neglect, childhood obesity, adolescent suicide/homicide, substance over-dose mortality, homelessness, midlife addiction/disability, mass shootings and decreasing longevity at birth (4 years in a row).

    I end with two inexorable facts. There are nearly 700 women who die with a pregnancy annually in the USA simply because they lived in the wrong OECD nation before their pregnancy began. Mass shootings as well as maternal mortality have worsened between 1984-1999 and 2000-2015 by 234 and 239%, respectively.