Clinical Integration and Stigma: On Treating Mental Health and Substance Use Disorders as Medical Illnesses

We have heard a lot in recent years about population health and clinical integration, but what does that really mean? Obviously, there are the textbook definitions, but what would it mean to truly care for every aspect of the patient’s health? What might we be missing when we develop systems to address population health? One answer might be those medical issues about which we are never told and that we never see. Patients with mental health and substance use disorders frequently fall through the cracks in our healthcare system, not because we are unaware of those illnesses, but because of a societal stigma which prevents the patient from ever presenting.

Because of how these illnesses present, the general public does not think of them as true medical illnesses as they think of cardiovascular disease, stroke, infections, or cancer to name a few. A patient with severe depression could present with a lack of energy and not wanting to leave their bed or their house, potentially leading people to berate the patient for being “weak” or “lazy”. Substance use disorders have been treated for centuries as a moral failing on the part of the patient. And yet, a second-year medical student can describe for you the biochemical changes in neurotransmitter mu receptors that occur in the brains of patients with substance use disorders. Entire categories of medications to treat depression are based on the altered serotonin reuptake in the brains of those patients. These are true biological, organic, and medical changes on a cellular level in a patient’s physiology just as we see biological, organic, and medical changes on a cellular level in patients with heart disease or cancer. By any definition, these are physiologic and medical illnesses, not moral failings or things that are “just in someone’s head”. 

Yet society does not see these illnesses the same way. When a patient unfortunately commits suicide, people become angry with the patient, but nobody becomes angry with a patient for dying of kidney disease even though kidney failure costs roughly as many lives as suicide does in the United States every year. Patients with mental health and substance use disorders do not die solely of suicide and overdose, they have much higher risks of mortality from other illnesses. Patients with these disorders die anywhere from 2 to 4 times the rate of patients without mental health and substance use disorders from diagnoses such as heart disease and diabetes, even when adjusted for socioeconomic factors. The reason is that their underlying illness prevents them from seeking medical attention or, when they do seek medical attention, they present in atypical ways. This leads to a gap in our ability to truly care for patients on a true population health level.

“Patients with mental health and substance use disorders frequently fall through the cracks in our healthcare system, not because we are unaware of those illnesses, but because of a societal stigma which prevents the patient from ever presenting”

So how can we address this and improve this? One way could be through technology. Data mining supplemented by AI could possibly pick up subtle and early signs. Prompts from an EHR could move clinicians to ask more probing questions. But the EHR prompts already exist and data mining’s utility here would be limited as long as patients underreport their symptoms due to societal stigma and being limited by their illnesses. Ultimately, we need to be addressing the stigma around these illnesses in both direct and indirect ways. Both clinical and nonclinical people need to be taught that these are true medical illnesses that need medication and other interventions to treat them. While it is understood that somebody could take medications to treat their high blood pressure or high cholesterol or diabetes, things like medication-assisted treatment for substance use disorders is still frowned upon in some parts of the 12-step and addiction treatment community. That needs to change, and it can only change with educating people in healthcare as to what the actual medicine, science, and evidence show. By changing the way we speak about it to patients, we can emphasize that these are just other medications. While it might sound trite to think that changing some medical terms could make a difference, over time we will convey a different way to think about them to nonmedical people. If we think about these illnesses differently, then we treat them differently. If depression, anxiety, schizophrenia, opiate addiction, and any of a multitude of other illnesses are thought about the same way that cancer or heart disease is, it can relieve stigma and make it easier for patients to seek the help that they truly need.

The goals of population health are to treat a patient across multiple times and locations to prevent illnesses from worsening earlier. This keeps the public healthier while reducing the burgeoning costs of healthcare. But if we are undertreating illnesses that multiply the morbidity and mortality of our patients by several times, we can never truly achieve our goals. Ultimately it is up to us to help change how society views mental health and substance use disorders. Our patients are depending on us.