The way mental health care is conceptualized and delivered is constantly changing. While most indicators suggest that outcomes are improving, progress has been far from linear. We sat down with Dr. James Polo, Vice President and Chief Medical Officer at Carelon Behavioral Health, to discuss how mental health care has evolved over the course of his distinguished career in psychiatry. We also explored the reasons behind current challenges in delivering effective care, how we can reduce the rate at which disorders like OCD are misidentified, and technology’s role in helping people become and remain well.
How has the field of psychiatry changed over the course of your career, and where do you see it 20 years from now?
I finished my residency training in general psychiatry in 1991 and fellowship training in child and adolescent psychiatry in 1993. The reason why that’s important is because that’s right around the time that Prozac, an antidepressant, first came to market. Prior to the release of Prozac, most of the medications that we used to treat depression had numerous side effects: weight gain, dry mouth, grogginess, fatigue, confusion, and so on.
Prozac had a huge impact on the practice of psychiatry and the treatment of mental disorders. The nineties were referred to as “the decade of the brain.” Numerous new psychotropic medications with improved side effect profiles were released to treat depression, anxiety, and psychosis. That ended up creating a shift in that more and more people began to latch on to the idea that medication was all they really needed. The culture started to shift from “I need to do something to address my problem,” to “I need to find the right medication that will make my problem go away.”
People were left with the idea that there was a medication for all emotional problems. Prior to that, the main thrust of mental healthcare focused on counseling and therapy. Although there are many different approaches to psychotherapy, the common thread is gaining insight into your thoughts, feelings, and emotions, so that through self-reflection and understanding, you can make changes in your life to achieve goals and have an improved level of emotional well-being. With medications, getting rapid relief of symptoms without side effects became possible. Maybe you were depressed, had difficulties concentrating, weren’t sleeping well, didn’t feel good about yourself, and weren’t interested in engaging in social activities. Taking medication improved all of those symptoms, leading you to believe that you were ‘ok’. In reality, though, the core reason why you were depressed in the first place was glossed over or not fully addressed, which would have been the focus in counseling.
The availability of many new medications created a different culture among people getting treatment, and the profession shifted accordingly. Many psychiatrists who had previously focused on providing comprehensive treatment with therapy started focusing on medication management as they were more or less relegated into that role through managed care, with therapy being delegated to counselors, therapists, social workers, and psychologists. As a young psychiatrist, all the patients I treated received both therapy and medication management from me in an integrated fashion. These tended to be the more complex patients, as there are many mental health disorders that can be treated by non-psychiatric counselors very effectively without the use of any medications. But in general, we moved to a system where all patients were treated by one individual for counseling, with emphasis on receiving medication from the doctor. Sadly, it is not uncommon for those two treatment providers to be disconnected from each other to the detriment of the patient in treatment.
This shift continues to have a major influence on psychiatry and mental healthcare today. We struggle with a very limited mental health workforce that cannot meet the demand for services. People experience tremendous challenges and long wait times to get in to see a mental health provider. When they finally get access to treatment, the typical patient is often thinking along the lines of “I need medication,” rather than “I need to get counseling to learn about myself.” And because it’s tough to find the right counselor, many people are treated exclusively with medication, more often than not prescribed by their family physician, or in the case of children and adolescents, their pediatrician.
Looking forward, I believe the future will focus on leveraging technology to address the needs of large segments of the population. For me, this is exciting because we’ll be able to help many more people despite the limitations of our workforce. Digital technologies are coming to market that can help people with generalized symptoms, as well as specific diagnoses, that are just as effective virtually as they are in person. Often, these are available through a smartphone and can be accessed in the convenience of your own home at the time of your choosing with a greater sense of privacy.
I think that further in the future, we’ll be using AI-driven technology, so that you can get help without necessarily having another person at the other end of the wire—because remember, one of our biggest challenges is still the workforce. We simply can’t train a sufficient workforce to keep up with the increasing demand of a growing population. So, for folks with mild or moderate conditions, applications that can continuously learn more about the individual to provide help that is specific and personalized, while interacting in a manner that provides empathy, may be the solution to our workforce shortage.
As an aside, why is there such a shortage in the workforce?
That’s a complex question, and I think there are a couple of reasons. The first is stigma. There are three components that have, over time, created a strong barrier to seeking help. There is self-stigma: people don’t want to feel defective or weak, so they ignore emotional problems and tend not to seek help. Then, there’s the social stigma imposed by the people around you: “My family is going to make fun of me. My friends are going to make fun of me. People will think I’m crazy.” So, you try to hold your struggles in, rather than sharing them. Additionally, there is structural stigma within the healthcare system such that for many years, healthcare professionals didn’t talk about mental health, ask questions about people’s mental health, or make it easy for people to get help for mental health problems. Overall, the bottom line is that stigma still prevents people from coming forward.
This has contributed to the supply-demand challenge affecting the workforce. If there’s no demand for services, those services won’t be developed and by default, won’t be available. While there was always this high need, there was not necessarily a high demand. Stigma essentially created an environment where we underestimated the need. Hence, we developed a workforce to meet the demand, but not the real need. And then finally, as I discussed earlier, our treatment approach in terms of integrating therapy and medication management is fractured. So, our limited workforce is not necessarily used in an efficient manner that places the patient’s mental health needs as the priority.
The bottom line is that today, we do have high demand. It is more appropriate than ever to raise your hand and say, “I think I have a problem, and I want help.” The pandemic kind of taught us that everybody is stressed—that’s the norm. Yet there just aren’t enough people to provide the array of services needed. And the services that are available are not well integrated or easily accessed.
One thing to remember is that when we say there’s a high demand, it’s not like people are dysfunctional. People can work through mental health challenges, and they frequently do. Imagine an individual who is affected by depression but still able to go to work. Aside from being unhappy, they are likely less productive and prone to both absenteeism and presentism. They may withdraw from co-workers and have relational problems. Their family is likely impacted, as well as their social life. So, the right treatment can help them feel better and be more productive at work will also improve the work relationships, family connections, and social activities. This help is not complicated to provide, but in today’s world it’s very challenging to find somebody who has the expertise to help, and then to get in the door when so many others have the same needs.
As CMO of Carelon Behavioral Health, you have the ability to touch over 90 million lives. In which areas do you believe we can make the biggest clinical impact?
As mentioned, the biggest challenge we have right now is that we don’t have a large enough workforce. Our system of care is fractured and outdated. But we also have a challenge with health literacy and, more specifically, behavioral health literacy. People have difficulty understanding that they need help, and if they do figure it out, they struggle navigating the system to get help. “Where do I go? Where do I start? Do I talk with my primary care physician? Do I talk with my health plan? Do I google ‘depression’ and figure it out from there?”
At Carelon Behavioral Health, we provide oversight for the behavioral needs of all members covered under Elevance Health in Anthem insurance products, as well as members covered under non-Blues branded state and regional plans across the country. This provides us with tremendous scale across all parts of the country.
Because we’re so large, we have the advantage that we can take risks to try new things. In healthcare, there’s a lot of talk about being innovative—trying things out when you don’t know if they’re going to work. But the entire healthcare industry operates on thin margins, so most companies tend to be risk averse. Furthermore, in healthcare, we tend to be risk-averse because we don’t want to make mistakes when people’s health is at stake. We also don’t want to waste resources. Because of our size, we can pilot things in small areas and figure out, “Will this idea work? Can this technology help? Can we make sure that it’s clinically relevant?” We still have limited resources, so at the same time we focus on cost sustainability.
As a very large corporation with values that align with doing what’s right for people, we can take risks that others won’t try. If we fail, we learn from it and use those learnings to move to the next idea so that we can determine what is going to work. With successes, we have the option to scale and implement enterprise-wide. If you’re a small, regional health plan—let’s say you operate in just a couple of counties in one state—you don’t have the resources to take those kinds of risks. We’re large, and we have more of the resources to do so. Frankly, I think it’s our responsibility to do that. We want to lead in healthcare as a trusted lifetime partner.
It’s funny because a lot of the time in business, you think about smaller organizations being more agile and more experimental, but this is the inverse of that, where your size gives you the latitude to do those experiments.
Yes—on the health payer side, we are committed to being good stewards of the premiums from all the people we care for. We must ensure we’re using those resources on treatments and approaches that make a difference, while also having enough of a margin to reinvest in other areas. So, our size gives us the ability to say, “We have a bunch of efforts going on in one area—let’s say, cardiothoracic health—that are going well. These are giving us just enough margin to invest in something in behavioral health that’s newer and less clear.” Our scale and scope allows us to learn quickly, figure out what’s going to work, and then apply it quickly so that it’s available to our consumers.
Why are many severe behavioral health populations like OCD frequently misidentified, and what can providers do to help change this?
Let’s talk about OCD specifically. If you’re a practicing clinician, you’ll see fewer people with OCD than people with depression or generalized anxiety disorder, and you’re less likely to recognize something if you see it less often. This is no different in any other specialty. Breast cancer has a high prevalence and is well-studied, so it’s easier to diagnose. Other cancers that have a low prevalence might be more subtle and therefore harder to diagnose. It’s no different in mental health. When you have a less prevalent diagnosis, you don’t get as much practice seeing it, and these conditions can be hard to detect. In mental health, it can be even more complicated, because the symptoms involved in a diagnosis are more varied and cross over multiple diagnoses.
I can take just about any diagnosis in the DSM, and it will say, “To have this diagnosis, you have to have the following four criteria—A, B, C, and D—and out of the next ten, you must have two or three.” That’s significant because I can take ten people with the same exact diagnosis, and each one has slightly different symptoms. So, one of the challenges in mental health, particularly when somebody is doing the evaluation who doesn’t have a lot of experience, is that there’s a temptation to make two or three different diagnoses, rather than landing on a singular diagnosis, because so many of the symptoms overlap.
I’ve seen patients with OCD who will tell me they’ve been evaluated before, and they’ve never gotten any real help. I’ll ask, “What have previous providers told you you’re struggling with?” They might reply: “Well, one said I have an anxiety disorder. Another one said I have depression and tend to have some obsessive-compulsive personality traits.”
So, they have three diagnoses. Do they have elements of anxiety? Yes. Do they have aspects of depression? Yes. Do they have obsessive-compulsive symptoms? Yes—but treating each of those three disorders separately requires a different approach from the singular, correct diagnosis of OCD.
Another tricky thing is that very often, patients who are seen for some of these complex disorders—OCD, trichotillomania, schizophrenia—see multiple different providers and get numerous diagnoses. Often, people will come in to see a new provider and simply say, “I’m here because I have X condition,” and the assumption is that they’ve been evaluated well. The provider will start from that point, rather than thinking to themselves, “They’ve been diagnosed with X, but should I reevaluate for Y instead?”
One of the ways that I think we can do a better job is by promoting greater awareness and helping consumers better understand disorders like OCD. That way, they can recognize their own symptoms and be empowered to potentially ask the question, “Is it possible that I have this condition? I’ve heard about it; I’ve read about it; I’ve seen it on the internet.”
We can also do better on the diagnostic side by ensuring that we perform comprehensive evaluations in a standardized manner. This is nothing new—but there are some providers who don’t do it. They work more off the cuff: “What are you here for today? Tell me a little bit about your family history. Do you have the following symptoms? By the way, I’m going to do a mental status exam.” As a result, they decide that you have a diagnosis based on that evaluation, but it could be different every time—they haven’t taken a comprehensive, standardized approach to formulating a diagnosis.
This only leads to more issues down the road. People become labeled with an incorrect diagnosis, and they go through years of treatment that are never quite right. Perhaps one day, somebody decides that it’s time to do a complete reevaluation and see what’s really going on: “I wonder if you don’t have bipolar type two. I wonder if what you have is major depression.” All of a sudden, it completely changes the course of treatment. It’s an ongoing challenge—if you’re not careful, you tend to treat people for what they’ve been diagnosed with before, and you don’t necessarily know whether that diagnosis was accurate to begin with.
Let’s go back a bit. You got your bachelor’s at West Point, your MD at Uniformed Services University, and served in the US Army for several years—including a posting in Iraq. What kind of influence did your experience in the military have on your career after leaving the army in 2010?
I spent almost 29 years in the military, and I spent my time in the military as a physician psychiatrist the entire time. I had lots of experience because I was a practicing psychiatrist earlier in my career. Then I became more of an executive leader in the latter part of my career, and deployed multiple times to different parts of the world.
I learned three main things in the army that I’ve carried with me into the civilian sector. The first is that healthcare is a team sport. From very early on, physicians are trained to be very individualistic. They’re trained to sit down with a patient, do an evaluation, think critically about what they have, and decide how to treat them. What I learned in the military is that while those are vital skills, you can do so much more when you’re part of a broader team. I say it that way because, very often, I was deployed in an environment with limited resources and limited people. So, though I could do some things alone, I always had to rely on everybody else. Healthcare needs are incredibly complex—no one specialty operates all by itself, separate from the rest of the system. Different clinicians and groups have to share information and collaborate continuously. If you’re going to take care of somebody well, you have to help them and help the other people who are helping them.
The second thing I learned is how to be efficient. I’ll give an example from the year I spent in Iraq: We deployed at the very beginning of the year, knowing that we would be in a remote location in a danger zone. I was responsible for ensuring that we were always ready to provide battlefield medicine–this included personal readiness, adequate supplies, blood flow, air evac support, etc. We had limited resources, and needed to make sure that we used those limited resources most effectively. Is there another approach that would be quicker? Are our processes all aligned with what we’re trying to achieve? How can we ensure that we aren’t wasting any resources?
Now, years later, I’ve come to realize that our civilian healthcare environment is facing a lot of shortages: a shortage of nurses, shortage of physicians, shortage of beds. So, one of the biggest challenges we must grapple with is making sure we implement efficient systems. How can we get the work done in the fewest steps, maintain safety, and remain good stewards of our limited resources so we can bring costs down?
The third crucial thing I learned in the army is that you must have a system of accountability. You must check things to ensure they’re actually getting done. If you’re not checking, things begin to fall by the wayside—they’ll go unnoticed or become neglected. The system needs to include accountability and metrics for quality, safety, and experience. In other words, if we want folks to receive high quality healthcare while having a pleasant experience that results in improved health outcomes, then we have to have to build in measures that allow us to track our progress and make adjustments or corrections when we need to.
One last thing I’ll highlight about the military is that it was never about making money; it was always about accomplishing the mission. The military medical force exists to ensure that we have a standing military force for all the things the country needs regarding safety and security.
You are also a child psychiatrist. What should providers consider when treating children?
I think this is a really important question because as we move farther out of the pandemic, we are learning how much the pandemic impacted the lives of children—in some cases, much more than it impacted the lives of adults. If you listen to current media, you’ll hear about kids experiencing emotional struggles at higher rates than ever before. Suicide rates are increasing; kids feel like their mental health needs can’t be met.
Getting help for a child is very challenging, and there’s a huge shortage of child psychiatrists and specialists in child behavioral health. I spent many years in clinical practice seeing kids from the age of five through adolescence, and I often saw young adults in college who still lived in the context of a parent taking care of them, though they were over the age of 18. I would say that when working with children, you have to remember that even though the child is the patient, you also have to work through the parents.
Let me give you an example of why this is so important. Imagine a nine-year-old starts treatment, and their parent says, “My kid won’t pay attention, and they get low grades. I think my child has ADHD, and I want you to put them on Ritalin.” Now, some providers will evaluate the child and come to the same conclusion. “The kid does have ADHD. I’m going to put them on this medication, and they’re good to go.”
However, if you stop and talk to the child, you find out that they’re not worried about not paying attention. The child’s not even concerned about their grades. What they’re worried about is, “I have no friends, and other kids make fun of me.”
As a provider, you might make an assumption: “If I help the child calm this behavior, maybe they’ll have friends, and maybe people won’t make fun of them.” In reality, that’s just not the way kids work. Somehow, you have to make sure that you’re still addressing the child’s concerns at the same time that you’re managing the parent’s concerns.
My experience working with children has shown that they tend to focus on things related to their sense of self-esteem and their relationships with friends, while parents focus more on their behavior. So as a provider, you need to make sure that you’re looking at both. This becomes more challenging with age. Say the typical adolescent comes in and his parents say that he is aggressive, getting into fights, not following the rules, and has declining grades. However, adolescents frequently engage in all kinds of activities that they don’t share with their parents. The adolescent reveals that he didn’t make varsity football, feels rejected by the “cool crowd” and has started to drink and try drugs to “feel” better. So there are two different sets of concerns, both valid and needing attention.
This is critically important, because we have an even greater shortage of specialists to treat children and adolescents, so providers who don’t have the proper expertise or experience treating children become tempted to focus more on what the parents want, and less on what the child needs. When that happens, the child’s experience sticks with them and creates a belief that mental healthcare sucks, that it can’t help them: “My parents dragged me in. They told me I was a problem and needed help, but no one actually helped me. I’m still struggling with things that they never even asked me about.” It’s supposed to help them with what they’re going through, but it only makes them less likely to reach out for help in the future.
I have learned that I have to be very careful to make sure that I’m respectful to the parents, listen to what they have to say, and then spend time with the child and figure out what they want. Of course, there are all kinds of nuances about what you should and shouldn’t share with the parents based on the age of the child, but it’s so important for a child in treatment to be engaged, feel optimistic, and realize that somebody truly cares about what they think.