The Disconnect Between Health and Mental Health

May 20, 2013

Editor’s Note: This column previously appeared in Bridge Magazine.

Recent reports about a Medicaid experiment in Oregon reveal a major disconnect we have in the health care world: we make a historic —and unwarranted— distinction between “physical health” and “mental health.” Worse, that distinction actually interferes with both our investment in mental health treatment and patients’ willingness to seek treatment.

The Oregon Medicaid study is about the impact that Medicaid coverage has had on a group of low-income individuals who obtained health insurance coverage for the first time several years ago. Researchers have been studying Oregon because of a unique set of circumstances that resulted in some uninsured adults being randomly selected to receive access to Medicaid, while others were not. That circumstance enabled a randomized controlled trial to be done in the “real world” —a rarity in health services research.

The experiment’s initial set of results, which relied on self-reports by the participants, were released last year. In the first year of the study, those with Medicaid coverage reported better health than those who were in the control group. In the most recent report, which includes second-year findings, researchers used actual health measures for cholesterol, high blood pressure, diabetes, and depression. This second set of data resulted in a more nuanced and complicated conclusion than the first-year report. Specifically, the researchers found no impact in the two years with regard to cholesterol and high blood pressure; an increase in diagnosis and treatment of diabetes but no impact on blood sugar levels; a significant reduction in depression; and a significant improvement in financial stability for those with Medicaid coverage compared to the control group.

Because these findings were released while many states are still considering whether or not to expand Medicaid, the Oregon story was reported across multiple media outlets. Headlines ranged from the fairly neutral (The New York Times: “Medicaid Access Increases Use of Care, Study Finds”) to the more judgmental (Forbes Magazine: “Oregon Study: Medicaid ‘Had No Significant Effect’ On Health Outcomes vs. Being Uninsured”).

Some commentators have said that the study and resulting headlines were almost like a Rorschach test about what one believes about the Affordable Care Act and the Medicaid expansion. But, even articles and publications that are generally favorable to the Medicaid expansion often reported that the study showed that the Oregon experiment had no impact on health.

These headlines are stunning in several ways. First of all, they generalize a few measures over a relatively short period of time to a sweeping conclusion about health insurance. But, beyond that, they seem to entirely discount the improvements in mental health as a “health outcome.”

In the Oregon Medicaid experiment, the rate of depression dropped by more than 9 percentage points and the relative improvement compared to the control group was 30 percent. Why is it that we don’t identify the significantly lower rates of depression as a significant health outcome?

For years, we have had research on the causes of depression and other mental health conditions. While the causes are likely multifactorial, including a combination of genetics, environment, biology and psychology, the National Institute of Mental Health describes “depressive illness” as a “disorder of the brain” —not a personal weakness.

More than 10 years ago, visionaries at the University of Michigan, under the leadership of Dr. John Greden, established the country’s first Depression Center. Dr. Greden reasoned that until we treat depression like we do cancer— as a disease that requires focused, team-based research and collaboration —we will not make the kind of progress in understanding this disease that we need to. Today there is a National Network of Depression Centers that includes 21 of the nation’s top academic institutions.

It is disappointing to realize that 10 years of this kind of work has not erased the distinction between “physical” and “mental” health. If we had, the headlines about the Oregon experiment would have been something like this, “Medicaid Coverage Shown to Have Significantly Improve Health relative to being Uninsured.” We should only be so lucky to find a health impact as large as this in other areas of the Oregon health experiment.