Dr. Mike Franz on the behavioral health crisis and improved care access through virtual options

“We have a pandemic on top of an epidemic” is how Regence’s Senior Medical Director for Behavioral Health Dr. Mike Franz describes the state of behavioral health today in the US.

It’s a health care topic that affects all of us, whether personally or by watching a loved one work through a health condition like anxiety, depression or addiction. A silver lining of the pandemic has been the increase in attention and resources to help people find the behavioral health care they need. Yet there continues to be stigma around mental health as well as barriers to accessing the right care.

In the latest HealthChangers podcast, we speak with Dr. Franz to learn more about today’s behavioral health crisis, ongoing stigma, and how people can access the care they need. This includes the increase in virtual care options that we can use from the comfort of home. Listen to the player or read the transcript below, which has been edited for clarity.
 

Podcast Transcript

Welcome to the HealthChangers podcast, presented by Regence, where we share real-life stories and expertise from leaders who are working to make health care simpler, personalized and more affordable. I’m your host, Ben Furr.

If you’re experiencing depression, anxiety or another condition, you’re not alone. It’s critical to access the mental and behavioral health care we need, whether that’s in-person or using virtual options. But many people experience barriers when it comes to finding that care.

Today on HealthChangers, we’re joined by Regence’s senior medical director for behavioral health, Dr. Mike Franz, to talk about how mental and physical health are equally important components of our overall health and what we can do to improve access. Dr. Franz is a board-certified child, adolescent and adult psychiatrist who still practices as a clinician on Fridays. Dr. Franz, welcome to HealthChangers.

Mike Franz (MF): Thanks, Ben. It's good to be here.

Ben Furr (BF): To start our conversation, can you give us an idea of the state of mental health today?

MF: Well, Ben, unfortunately, it's not in a good state. I like to say we have a pandemic on top of an epidemic. We really have a tremendous increase in the prevalence of behavioral health conditions in our population.

I think I’m most concerned about our kids. I am a child and adolescent psychiatrist, so I have some bias there. But some statistics that really strike me as worrisome came out last year. The CDC (Centers for Disease Control & Prevention) published a survey of high schoolers back in April 2022. They surveyed these high schoolers nationally, and the results were that:

• 44% are feeling persistently hopeless or sad
• 19% are seriously contemplating suicide
• 9% have attempted suicide

I mean, it’s just staggering. And you know, we've got a major concern there. We also have major concerns with the explosion of substance use disorders fueled by the pandemic, as well. I think a lot of the issues with the kids have been fueled by the pandemic. And opioid use deaths are beyond a hundred thousand a year now. We’re having more deaths from opiates than we are from automobile accidents. So, it's not good is the answer.

BF: What do you think some of the driving forces are behind that?

MF: I think the pandemic created some isolation and took people out of a lot of their social supports and their routine, which is especially important for kids. Isolation was, I think, a pretty big factor. So that's one. And again, focusing on kids, I think we can draw an association between the use of social media by our youth and behavioral health issues. A lot of the increased prevalence of behavioral health issues in our youth has taken place since roughly 2007, which is around the advent of the smartphone.

Then around the early 2010s, we started seeing social media become more prevalent, and along with that another increased spike in youth behavioral health issues. Although we can't prove causality, I'm very concerned about that—screen time and cyberbullying.

The substance use that I described earlier in the adult population…interestingly, kids are a little bit more inoculated with substance use these days than in previous decades. I guess that's one bright side, but it's still an issue. But among our adults and our seniors, we do see a spike in substance use disorder largely coming out of the pandemic.

And I think the other factor is, quite frankly, the political divide and the tribalism in the country. It's got people down. It's a time of unease and concern and I think that's kind of a cloud over our society right now.

BF: There's been a lot of media coverage, too, around mental health and behavioral health challenges. Can you help distinguish the difference for some of our listeners between mental versus behavioral?

MF: Sure. Formally, behavioral health is encompassing of mental health. If you imagine a Venn diagram, mental health would be inside behavioral health, and also inside would be substance use disorder. Technically and professionally speaking, behavioral health encompasses mental health like depression, anxiety, psychotic illness, developmental issues as well as substance use concerns.

But I think more broadly speaking, I use the term “behavioral health” to describe our thoughts, feelings, behaviors, our emotions, our psychological state, a sense of mental wellness or not. That's how I conceptualize it.

BF: We all, I mean, each of us experiences day-to-day fluctuations in our emotions and feelings. How can someone tell the difference between day-to-day versus a legitimate behavioral health issue?

MF: Yeah, you're right. I mean, we all have good days and bad days, right? And it's very normal. We don't need to pathologize sadness, anxiety or worry. These are normal human emotions. Life isn't always pleasant. Life isn't always wonderful. That's okay. That doesn't mean you have a behavioral health condition.

I would say, for example, that it's normal and it can even be helpful to have some anxiety before taking a test. It can motivate one to study and focus and perform well. Or at work, if we're getting ready for a presentation that we know is coming up, we'll pay close attention to getting it ready and then focus when we perform it. So, these emotions can be adaptive. However, they can become overwhelming and cause significant emotional distress, and most importantly, begin to impact functioning in multiple domains like our social relationships with family or friends, or occupational functioning. If we can't get up and go to work, or when we do, we just can't perform (or for kids academically), then we need to think about this rising to the level of a mental health disorder, if you will, or a behavioral health disorder.

Likewise, for substance use, some substances can be used recreationally with minimal adverse effect and it's a part of adult society. But when it gets to the point of causing problems and there are feelings of needing to cut back or experiencing truly adverse effects of it like the inability to perform as you once said, then that use of substance may be getting to a point where it's more pathological. Whether it's mental health or substance use concerns, that's probably the time then to think about reaching out and getting some help.

BF: In terms of barriers to care, what's preventing…because the statistics you mentioned earlier are astounding around child mental health and behavioral health. What are some of the barriers to getting the care that many of us need?

MF: I would, in the past, probably always start that conversation with stigma. I don't have a lot of evidence for this, but I think there's a general sense that one of the silver linings in the pandemic, I would say, is that there seems to be so much more acknowledgment of behavioral health conditions being a problem and being real and prevalent in society. For example, now it seems like any family I talk to is touched by a behavioral health issue, if not the person themselves. It's just becoming so ubiquitous (present) that it can no longer be kept in the closet. I think in the past, stigma played a big role in people not wanting to seek help because they didn't want people to know about it. I'm sure that’s still the case to a significant extent, but it's getting better.

Beyond that, I would say that barriers include a lack of an adequate supply of behavioral health professionals in our country—regionally and locally as well. There is this mismatch with this increased demand and need for behavioral health treatment. We have, quite frankly, a supply that diminished somewhat over the pandemic as the health care sector experienced burnout, and behavioral health providers were affected by this as well.

There has been some transition from behavioral health providers from brick-and-mortar offices to wanting to work at home remotely/virtually as the pandemic did allow a lot of us to do in various businesses. That's been a barrier, but at the same time, it's opened up some opportunities by allowing folks to get help more through virtual resources.

BF: What can be done to increase access to behavioral health care?

MF: The fact that the workforce has moved out of traditional brick-and-mortar locations or are at least delivering more of their services through telehealth modalities, even if they continue to have an office setting, as well as the advent of virtual-only regional and national providers. There is a ton of venture capital moving into this space. It's a major disruptor, and in my opinion, a welcome disruptor in the behavioral health world. Because we really haven't improved access or improved outcomes in the past 30 years or so of behavioral health treatment. I think there are new opportunities now for providers to render services differently so that they can reach you just in your home. You don't actually have to go to an office. These services can be rendered with synchronized video. In some cases where it's clinically appropriate, just telephonic communication may be okay, although there can be some quality concerns there.

We see this now in our utilization data here at Regence that even though the rest of health care has been going back to in-person appointments to a large degree in the behavioral health world, 50% of all of our behavioral health services are still rendered virtually via telehealth, which is remarkable. I'm not sure we're ever going to go back to that. I think that does improve access. There’s no need for transportation. I think it allows for additional efficiencies. I think it provides, to a certain extent, a more satisfied, happier and sustainable workforce when they can work out of their home or in a place that's more conducive to their needs. Certainly, our members enjoy this. There has been research done, even though it’s just been since the pandemic, that patients are really appreciating these services and have a satisfaction level that's equal or more so than having in-person appointments.

BF: So that's kind of a silver lining, I would say, just increased access with telehealth. What about stigma? I mean, you touched on this a little bit earlier, but there's been a lot of media attention, as you noted, around mental and behavioral health. Do you think that helps reduce the stigma associated with seeking treatment and care?

MF: I do. I think—you talked about silver linings—I think the pandemic had a silver lining in regard to stigma. Just that it was in the media so much. And our families and our friends have experienced so much behavioral health concern that now it's just out in the open. It seems as though the shame and the stigma associated with that has been dwindling.

I’d like to note that it's the one thing that seems to cross political divides. Our political leaders can agree on so little these days, yet behavioral health is the one thing that is pretty much indiscriminate in how it affects the population. We just saw some major legislation passed by the federal government back in December that continues to fund behavioral health at an increased level, which is really needed given the burden of behavioral health that we have among the population.

So, I see stigma diminishing. I see it becoming less of a barrier, but it's still present and something we have to address. I think there are some additional things we can do about it. One of them is what we're doing right now, it's talking about it. But I also think you know, appropriate self-disclosure just as we talk about our own or our family members' health issues, whether there's a heart problem or a lung problem, the more we bring out into the open that we may be struggling with behavioral health issues. For example, at various times in my life, I've been in therapy and I've found it very helpful for treatment of depression or anxiety. At times, I've taken medication, which I've also found helpful. I think when we can share that and talk about it, we further destigmatize it. So that's one thing we can do.

BF: That's great. I mean, I don't think many of us would be ashamed of a sprained ankle or a broken arm necessarily. So, the same level of disclosure and comfort should probably apply to our mental health. All right, well, this conversation is really helpful. As we wrap up our podcast episode, any final thoughts for our listeners on the importance of behavioral health and how to access it?

MF: You know, one thing we haven't touched on yet that I am very passionate about is the connection between behavioral health and physical health—the connection between mind and body. After all, the head is connected to the body. We have opportunities now to really integrate our health delivery systems in a way that understands that. So that whether you go to your primary care provider or your cardiologist, or if you're in the unfortunate situation of having to go to the emergency department and even end up in the med-surg unit of the hospital, we can integrate behavioral health into all those settings, all those service lines, all those workflows. We're beginning to do that.

Specifically, with primary care, there are some well-researched integrated models that have moved behavioral health into that setting using consultation with psychiatrists and embedding therapists who work shoulder-to-shoulder with primary care providers and their teams to render behavioral health care part and parcel of the overall health care that's being delivered in those settings.

This is really important for the obvious reason that we talked about, which is there's such a prevalence of behavioral health. And one way to increase access is actually to deliver it in various medical settings instead of having to refer out to a special behavioral health clinic on the other side of town, or even virtually having to enroll in a specialty behavioral health virtual provider, which you can do. But it is also important to just improve overall health outcomes. Behavioral health really drives underlying chronic medical conditions. And there's good research here that depression, anxiety, especially substance use disorder can really drive poor outcomes and increase cost for chronic medical conditions like coronary artery disease, diabetes, COPD and asthma. And so, we need to identify any underlying behavioral health condition, what we call a comorbidity, and effectively treat that, and then we can get better control of those chronic medical conditions, the patient's overall health, and decrease the total cost of care by two to four times in the process. So, there is a tremendous opportunity with the integration of behavioral health, and I think that is going to continue to be our future.

BF: Well, Dr. Franz, thanks so much for joining us on this episode of HealthChangers. We appreciate your time.

MF: Thanks, Ben, for the opportunity. Good talking with you.

And that wraps this episode of HealthChangers. Episodes are available on your favorite podcast platforms like Apple Podcasts, Stitcher and Spotify. Just search for HealthChangers. Thanks for listening.