Embedding Mental Health Care Where It's Needed Most
Many people with chronic gastrointestinal (GI) diseases suffer in silence.
“GI conditions are often stigmatized” in a way that other conditions may not be, says clinical psychologist and researcher Jessiy Salwen-Deremer, PhD, director of behavioral medicine at the Walter and Carole Young Center for Digestive Health at Dartmouth Health’s Dartmouth Hitchcock Medical Center (DHMC). “It’s socially appropriate for someone with insomnia to say, ‘I’m exhausted because I didn’t sleep well,’ but with GI, it’s not the same. People don’t say, ‘I’m exhausted because I got up six times with diarrhea last night.’”
But in Salwen-Deremer’s gut-directed group hypnotherapy sessions, it is not only appropriate but encouraged to share those details because the patients understand one another’s struggles. “For some folks, they have never talked about their symptoms before, but in this group, everyone gets it,” she says.
Salwen-Deremer and her team developed these and other disease- and symptom-specific treatment sessions as part of a complete redesign of the Gastrointestinal Behavioral Health Program she leads at Dartmouth Health, supported by a one-year, $300,000 award from the Susan and Richard Levy Health Care Delivery Incubator in 2022 and a philanthropic gift from a grateful patient.
The redesigned GI behavioral health program is just one of many initiatives across Dartmouth Health to increase access to high-quality mental health care for adult and pediatric patients. There are now psychiatrists, psychologists, behavioral health clinicians, advanced practice registered nurses, trainees, and other mental
health providers embedded within 13 different services across Dartmouth Health, including primary care, pediatric sleep medicine, the cancer center, and women’s health, among others.
“When you refer a patient to general psychiatry, they don’t know who they’re going to see, and some patients never come,” says Christine Finn, MD, medical director and vice chair for clinical services in the Department of Psychiatry at Dartmouth Health and an associate professor of psychiatry at the Geisel School of Medicine at Dartmouth. “But when we’re part of the primary care team [for example], it gives us a different relationship with the patient. Their primary care doctor can say, ‘I want you to see Dr. Finn; her office is just down the hall.’ That’s reassuring to the patient.”
From primary care to specialty care
Psychiatric clinicians were first embedded into primary care settings when Finn helped establish a collaborative care model in 2009. Its success in primary care led Finn and others to use the model to embed psychiatric care into subspecialty settings, too. Not only does embedded care within host departments increase access to psychiatric care, but it also increases patients’ willingness to engage with their medical care. For example, if anxiety or pain is interfering with a patient’s medication adherence, a disease-specific behavioral health clinician can help manage those issues.
“We do targeted work, helping to treat the primary medical condition by treating the behavioral health factors influencing the patient’s ability to participate in their care,” says Sivan Rotenberg, PhD, assistant professor of psychiatry at Geisel, clinical health psychologist at Dartmouth Cancer Center, and director of the specialty side of embedded care in the Department of Psychiatry. “Taking your medications, improving your diet, whatever the component is—that’s all health behavior change. Our team addresses those factors so the patient can be part of their own care.”
Embedded care also creates more touchpoints between patients and providers so that no one falls through the cracks. If a medical specialist or primary care physician prescribes an antidepressant, for example, the doctor might not see the patient again for three months. But if the patient has a bad side effect and quits taking the medication, “it’s better to know they stopped taking it after two weeks rather than three months later,” Finn says. A mental health care clinician embedded within a specific department can check up on the patient in the meantime and “can give redirection if we know what’s going on. With more information, we can incorporate that into the patient’s treatment plan.”
Specialized care to treat the whole person
Ultra-specialized clinical providers like Salwen-Deremer, who focuses specifically on behavioral health care for
people with inflammatory bowel disease, are still rare. But programs like hers have made it easier to serve more patients using streamlined processes, group therapy approaches, and new patient-provider communication tools.
For example, the redesigned GI behavioral health program offers a host of virtual small-group classes where
patients meet with Salwen-Deremer or another clinician for behavioral health therapy to address a variety of GI-specific problems. These sessions offer patients a range of treatments for the disease symptoms themselves and the additional challenges that stem from them. Patients can access therapy to manage chronic pain associated with GI symptoms, develop a personal plan to manage food avoidance, and learn cognitive-behavioral techniques to manage stress and anxiety, among other offerings.
“Think about GI disease as an octopus: The disease is the head with the main symptoms, but the tentacles reach into and get stuck on so many other areas of your life,” says Salwen-Deremer, who is also an assistant professor of psychiatry and of medicine at Geisel. “The relationship between the GI disease and mental health then goes both ways. For example, depression and stress are pro-inflammatory, so we look at those as both outcomes of the disease, and also contributors to the symptoms and disease experience.”
And because the redesign of the GI behavioral health program allows Salwen-Deremer and her team to provide therapy to approximately five to 10 people at a time, the group treatment sessions have dramatically reduced delays for GI patients seeking mental and behavioral health care, shortening a months-long wait to just a few weeks. The group sessions have resulted in an uptick of more than 90% in the number of appointments per year and a more than 70% increase in individual patients treated per year.
“It’s not that we could see more patients because people were getting less treatment, but instead people are actually getting more treatment with this new model,” Salwen-Deremer says. “We’re increasingly learning that people with chronic conditions have a better quality of life when they get complex, multidisciplinary care. It makes sense to care for patients this way.”
