A certain number of people in any given population reach a point where their health status deteriorates to meeting criteria for either pre-disease or disease state for a clinical condition. People may be moving into full blown diabetes, congestive health failure, or major depression, for example. However, the path to being acutely ill is not the same for each condition. Some have alarm bells sooner than others, and some have a greater subjective sense of illness and impaired functioning along the path to fully qualifying for a diagnosis.
This discussion will focus on high level comparisons of illnesses, rather that the complexity of all the illnesses we may confront, and it primarily presents the argument that emotional health and physical health alarms often differ.
People with a confirmed diagnosis of diabetes should certainly be thinking about what they should do to contain this devastating disorder. Those in the pre-diagnostic stage might want to attend to impending doom from this illness, and yet they generally don’t feel different today than they did years ago. Consequently, many do nothing.
On the other hand, people with sub-clinical depression are miserable, and they have difficulty functioning in their everyday lives. Their alarms are blaring before they reach the status of having a major depression. People on the precipice of major depression or chronic depression (dysthymia) feel the impact of depression every day. There are two relevant points to make about this.
- Diabetes has a biological marker for distinguishing pre-diagnosis and diagnosis. Depression has no biological marker. The established thresholds for a depression diagnosis are based on the diagnostic manual which experts update by consensus every few years. Clinicians use their judgement based on these standards.
- Depression is the greatest source of disability worldwide. It would seem reasonable to expect that less advanced instances of depression are likely to be more disabling than other conditions since, in aggregate, it is a more disabling disorder.
It may be a nuance or a matter of language, but are we engaging in prevention or early treatment with people in these pre-disease states? Most doctors would seem to believe they are engaged in prevention with their pre-diabetes patients since they recommend diet and exercise solutions. People with a sub-clinical depression both need and benefit from some type of depression treatment, generally non-pharmaceutical. Sub-clinical depression care seems to clearly be a case of early treatment, and it speaks to the fact that our response to physical and emotional health alarms should be different.
It could be argued that both diabetes and depression are looming epidemics in the United States, and we certainly don’t have excess capacity within the professional care ranks to provide enhanced prevention services or early treatment for all of those potentially in need. We should move upstream in our focus from those diagnosed to those soon to be diagnosed, but how do we do that efficiently and effectively? As is often the answer in the 21st century, the answer is not care in-person, but rather virtually or remotely or digitally.
It is too often the case that telehealth or telemedicine programs focus primarily on physical health and secondarily on emotional health. This emphasis should be reversed. While this position could be supported with statistics on the prevalence and disability of emotional health conditions, this is not the preferred starting point here. I prefer to start with the doctor’s visit. This is where telehealth typically starts.
Telehealth starts with the question of how can we get that desired visit to take place on video or by telephone? This is a good substitute for many people. However, it is just modifying or accommodating our current system of care. Everything revolves around the doctor visit. Should it?
We will always need a steady supply of clinicians to treat emotion health conditions, but we will never have enough to meet the broad needs of a population. We need to help people who are worried, stressed, pre-diagnostic, fully diagnostic, chronic and suffering from multiple physical and emotional disorders. We need several modalities for intervention if we are going to make a difference.
There is another beneficial aspect to the development of digital solutions for emotional health. Clinicians have long resisted measuring their clinical results, for whatever reasons. Yet embedding short symptom rating scales into digital resources is operationally simple, clinically useful and intuitively accepted by consumers. As a result, most digital resources on the market today can provide their clinical outcomes in a way that professionals have never tried to accomplish.
Digital resources can demonstrate in both randomized controlled trials and retrospective studies that they have provided substantial symptom relief. Those comparisons to the research literature are generally in relation to clinical trials since we have little real-world data on psychotherapy.
Another important question is how well a digital platform can help people change their dysfunctional thoughts, as opposed to their unhealthy eating and exercise behaviors. We have decades of experience (from clinical studies and health plan wellness and disease management programs) telling us that people don’t readily change their health behaviors based on any intervention, be it in-person, telephonic or virtual. Changing health behaviors is extremely difficult. Changing dysfunctional thoughts may be less challenging for the simple reason that the intervention is directly focused on the problem, dysfunctional thoughts.
Feel better today