Although 21% of U.S. adults have a mental illness, access to behavioral healthcare remains out of reach for most. From 2008 to 2019, the number of adults with any mental illness increased nearly 30%. The pandemic further exacerbated mental health problems for adults and sparked an expanding youth mental health crisis. As the demand for behavioral healthcare continues to grow, Magellan Healthcare recognizes the need to increase access.

Increasing Access to Evidence-based Care

Magellan has collaborated with NeuroFlow, an award-winning behavioral health technology company, to increase access to our evidence-based digital cognitive behavioral therapy (DCBT) programs and enhance engagement. With a history of over 20 years of research and development and an endorsement from the Substance Abuse and Mental Health Services Administration (SAMHSA), Magellan’s DCBT programs are integral components of our Digital Emotional Wellbeing program, including FearFighter® for anxiety, panic and phobia and MoodCalmer for depression. Both programs, as well as RESTORE® for insomnia and other difficulties sleeping, are available online in Spanish, further increasing access to evidence-based programs.

Understanding Digital Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) is a short-term intervention that behavioral health clinicians use to help individuals overcome negative thoughts and behaviors. CBT is effective for depression, anxiety disorders, alcohol and drug use problems, marital problems, eating disorders, and severe mental illness. CBT has been demonstrated to be as effective in certain conditions as other forms of therapy or psychiatric medications. Digital CBT (DCBT) is the implementation of CBT on a digital platform with the same core principles, language and exercises used in live practice that include:

• Learning to recognize thought distortions
• Evaluating distortions against reality
• Gaining a better understanding of others’ behavior and motivations
• Using problem-solving skills
• Developing a greater confidence in one’s own abilities
• Changing behavioral patterns
• Developing coping skills

True evidence-based DCBT follows the exact CBT process, differing from evidence-informed digital programs that use some CBT practices but are not built with fidelity to the intervention model. Learn more about evidence-based vs. evidence-informed behavioral health interventions here.

Impact of FearFighter and MoodCalmer on Mental Health

Our collaboration with NeuroFlow has yielded remarkable outcomes that underscore the power of innovative partnerships. In a recent study, members participating in the Digital Emotional Wellbeing program who completed 75% or more of FearFighter and MoodCalmer reported significant reductions in anxiety and depression symptoms within 90 days.

• FearFighter users experienced a 41% average reduction in Generalized Anxiety Disorder Assessment (GAD-7) scores, compared to other DCBT users who averaged an 11% reduction in GAD-7 scores.
• MoodCalmer users experienced a 24% average reduction in Patient Health Questionnaire (PHQ-9) scores, compared to an average 13% reduction among those who completed less of the program.

Beyond these impressive results, Magellan has seen a 124% increase in registrations after launching Digital Emotional Wellbeing over previous programs. Members also report high levels of satisfaction with the Digital Emotional Wellbeing program with 85% indicating they would recommend the program to someone else.

Visit Magellanhealthcare.com/digital-bh/ to learn more about the results and how our Digital Emotional Wellbeing program, including our award-winning DCBT programs improve anxiety, depression and more.

Sources:

• Exploring Barriers to Mental Health Care in the U.S. | AAMC
• What is Cognitive Behavioral Therapy? (apa.org)
• Satiani A, Niedermier J, Satiani B, Svendsen DP. Projected Workforce of Psychiatrists in the United States: A Population Analysis. Psychiatr Serv. 2018 Jun 1;69(6):710-713. doi: 10.1176/appi.ps.201700344. Epub 2018 Mar 15. PMID: 29540118.

FearFighter® and MoodCalmer are owned by CCBT Limited Corporation, United Kingdom. CCBT has granted Magellan exclusive rights to FearFighter® and MoodCalmer in the U.S.

Evidence-based or evidence-informed treatment? Confused? You are not alone. Often used interchangeably, the terms “evidence-based” and “evidence-informed” in healthcare are two very different things. So, what do they really mean?

What is evidence-based treatment?

Evidence-based care is considered the gold standard in treating behavioral health conditions. Typically, “evidence-based” refers to an individual intervention that is based on quantitative research studies conducted in controlled, blinded settings and proven to be effective across a wide range of environments and people. Medications and other treatments that receive U.S. Food and Drug Administration (FDA) approval for a certain indication are also considered evidence-based.

What is evidence-informed treatment?  

 Evidence-informed care is an approach that shows promise but lacks enough proof of success to be viewed as a gold standard. Practitioners take bits and pieces from a variety of research, including evidence-based interventions and apply them to a condition. This produces something uniquely tailored to a certain need. Unlike evidence-based treatments, evidence-informed treatments don’t have results from research in controlled settings that demonstrate their effectiveness across a wide range of settings and people. When considering medication and other drug-like treatments, evidence-informed interventions have not received FDA approval for the condition they are treating. This is called “off-label” use.

Examples of evidence-based treatments

• Cognitive behavioral therapy (CBT) is a type of talk therapy that has proved effective in the treatment of anxiety, depression, addictions, phobias and certain physical health conditions. CBT focuses on changing automatic negative thoughts that can contribute to and worsen mental health and substance use symptoms. CBT has more evidence supporting it than any other psychological therapy.
• Acceptance and commitment therapy (ACT) is a type of mindful talk therapy that helps individuals stay focused on the present moment and accept thoughts and feelings without judgment. Over 200 randomized controlled trials have proven ACT is an effective treatment for depression, psychosis, chronic pain, substance use disorder, post-traumatic stress disorder, obsessive-compulsive disorder, panic disorder and social phobia.
• Dialectical behavior therapy (DBT) is a type of talk therapy based on CBT and specially adapted for people who experience emotions very intensely. Nine published randomized controlled trials and five controlled trials of DBT have proven its effectiveness for treating borderline personality disorder, including in highly suicidal women.
• Exposure and response prevention (ERP) therapy is a form of CBT that encourages individuals to engage with their obsessive thoughts without carrying out their associated compulsions. Treatment begins with placing individuals in situations which cause a tolerable level of anxiety and gradually build up to settings they find more difficult. ERP has been proven effective for treating obsessive-compulsive disorder in numerous clinical trials.
• Eye movement desensitization and reprocessing (EMDR) therapy is a mental health treatment technique that involves moving your eyes a specific way while you process traumatic memories. The goal of EMDR is to help individuals heal from trauma or other distressing life experiences. Since the first EMDR clinical trial in 1989, dozens of other clinical trials have proven this technique is effective and faster for the treatment of post-traumatic stress disorder.
• Transcranial magnetic stimulation (TMS) is a noninvasive treatment that was first used to treat depression in individuals who were nonresponsive to other treatments. TMS involves using a magnetic coil to influence the brain’s natural electrical activity and has full FDA approval for the treatment of major depressive disorder, obsessive-compulsive disorder, migraines and smoking cessation.
• Esketamine is an FDA-approved nasal spray used to treat severe treatment-resistant depression. Esketamine was found effective in a phase 3, double-blind, active-controlled study conducted at 39 outpatient centers from August 2015 to June 2017. The study involved nearly 200 adults with moderate to severe depression and a history of not responding to at least two antidepressants.
• Fluoextine is an antidepressant medication that is approved by the FDA to treat depression, obsessive-compulsive disorder, bulimia nervosa, premenstrual dysphoric disorder and panic disorder. It belongs to a group of medicines known as selective serotonin reuptake inhibitors (SSRIs) and works by increasing the activity of serotonin in the brain. Data based on a group of 9,087 patients who were included in 87 different randomized clinical trials confirms that fluoxetine is safe and effective in the treatment of depression from the first week of therapy.

 Examples of evidence-informed treatments   

Response Disequilibrium Therapy (RDx)—Based on the response disequilibrium model, RDx puts patients in charge of implementing their own treatment procedure outside of therapy sessions in the same environments that trigger their symptoms so they can learn new behaviors to replace and control their previous responses to distressing situations.

While preliminary findings from case studies involving 19 participants with OCD suggest RDx may be a promising alternative to traditional OCD treatments, future research is needed to determine its effectiveness across a wide range of settings, people and problems to classify it as an evidence-based intervention.

• Pregabalin (an FDA-approved anticonvulsant medication and fibromyalgia treatment) has been used off-label to treat generalized anxiety disorder, social anxiety disorder, bipolar disorder, insomnia and chronic pain conditions other than fibromyalgia. For pregabalin to be used for these conditions in an evidence-based manner, the FDA would have to approve their use for each specific condition.
• Risperidone (an atypical antipsychotic medication approved by the FDA for the treatment of schizophrenia, bipolar disorder and autism-associated irritability) has been used in a variety of off-label ways, including to treat borderline personality disorder, post-traumatic stress disorder (PTSD) and bipolar disorder. To date, the FDA has not approved risperidone to treat these three conditions.

Are mental health and wellness apps evidence-based or evidence-informed?

These days, you can’t browse the web or use most apps on your phone without seeing an ad for a wellbeing or therapy program or app. Used alone or to supplement traditional treatment and promote wellbeing, not all mental health, substance use and wellbeing apps use evidence-based practices, nor have they been extensively researched in treating specific conditions. Wellbeing and therapy apps are typically considered:

• Evidence-based when evidence-based interventions are fully implemented on the platform and followed by users in the same manner they would be if they were being delivered during face-to-face treatment. For example, the original evidence-based model below is used in a wellbeing app that delivers CBT digitally and all steps are followed as listed.
  1. Identify troubling situations or conditions in your life.
  2. Become aware of your thoughts, emotions and beliefs about these problems.
  3. Identify negative or inaccurate thinking.
  4. Reshape negative or inaccurate thinking.
• Evidence-informed when only certain components of evidence-based interventions are implemented on the platform, and/or the app only fully implements or uses components of evidence-informed interventions. For instance, if a wellbeing app provides CBT and only asks users to identify troubling thoughts and become aware of their thoughts, emotions and beliefs about these problems, it is evidence-informed because it does not ask users to identify and reshape negative or inaccurate thinking.

When considering using an app for yourself, your patients, your employees or your members, ask yourself these questions:

• Are the treatments used in the app based on quantitative research?
  • Were the studies conducted in controlled, blinded settings?
  • Are the treatments proven to be effective across a wide range of environments and people?
• Are all treatment steps included in the process, or has the process been watered down?
• Have the treatments used in the app received FDA approval for a certain indication, if FDA approval is possible?

Magellan’s approach to evidence-based versus evidence-informed treatments and mental health, wellbeing and substance use apps

The American Psychiatric Association and the American Psychological Association both consider evidence-based interventions preferred approaches for the treatment of psychological conditions.

At Magellan, we are leading the way in providing innovative, impactful behavioral healthcare solutions. When developing new and enhancing existing offerings , like our digital cognitive behavioral therapy (DCBT) programs, we always start with evidence-based treatments and adhere fully to all tenets. Magellan Healthcare’s DCBTs have been heavily researched in the studies below:

• FearFighter® for anxiety, panic and phobia (now available online in Spanish)
  • Computer-aided CBT self-help for anxiety and depressive disorders: Experience of a London clinic and future directions. L. Gega, I. Marks, D. Mataix-Cols. Journal of Clinical Psychology: In Session (2004), Vol. 60 (2), 147-157.
  • Computer-aided vs. tutor-delivered teaching of exposure therapy for phobia/panic: Randomized controlled trial with pre-registration nursing students. L. Gega, I.J. Norman and I.M. Marks. International Journal of Nursing Studies 44 (2007) 397-405.
  • The feasibility and effectiveness of computer-guided (CBT) (FearFighter) in a rural area. L. Hayward, A.D. MacGregor, D.F. Peck, P. Wilkes. Behavioural and Cognitive Psychotherapy (2007) 35, 409-419.
• MoodCalmer for depression (now available online in Spanish)
  • Saving clinician’s time by delegating routine aspects of therapy to a computer: A randomized controlled trial in phobia/panic. I.M. Marks, M. Kenwright, M. McDonough, M. Whitaker and D. Mataix-Cols (2004).
  • Technology-based advances in the management of depression: Focus on the COPE program. Disease Management and Health Outcomes. J.H. Greist, D.J. Osgood-Hynes, L. Baer and I.M. Marks (2000) 7, 4.
• RESTORE® for insomnia and other sleep difficulties (now available online in Spanish)
  • Implementing computer-based psychotherapy among veterans in outpatient treatment for substance use disorders. E.D.A. Hermes and R.A. Rosenheck. Psychiatric Services 67:2, February 2016, 176-183.
  • Cognitive behavioral therapy for insomnia enhances depression outcomes in patients with comorbid major depressive disorder and insomnia. R. Manber, J.D. Edinger, J.L. Gress, M.G. San Pedro-Salcedo, T.F. Kuo, T. Kalista. SLEEP, Vol. 31, No. 4, 2008, 489-495.
  • Logging on for better sleep: RCT of the effectiveness of online treatment for insomnia. N. Vincent and S. Lewycky. SLEEP, Vol. 32, No. 6, 2009, 807-815.
  • Sleep locus of control and computerized cognitive-behavioral therapy (cCBT). N. Vincent, K. Walsh, and S. Lewycky. Behaviour Research and Therapy, 48 (2010), 779-783.
• SHADE for substance use disorder
  • Randomized controlled trial of cognitive-behavioural therapy for coexisting depression and alcohol problems: Short-term outcome. A.L. Baker, D.J. Kavanagh, F.J. Kay-Lambkin, S.A. Hunt, T.J. Lewin, V.J. Carr and J. Connolly. Addiction, 105, (2009) 87-99.
  • Clinician-assisted computerised versus therapist-delivered treatment for depressive and addictive disorders: A randomised controlled trial. F.J. Kay-Lambkin, A.L. Baker, B. Kelly and T.J. Lewin. Medical Journal Australia, 195, 3, 1 August 2011.
  • Computer-based psychological treatment for comorbid depression and problematic alcohol and/or cannabis use: A randomized controlled trial of clinical efficacy. F.J. Kay-Lambkin, A.L. Baker, T.J. Lewin and V.J. Carr. Addiction, 104, 278-388 (2009).
• ComfortAble® for chronic pain
  • Cognitive-behavioral therapy for individuals with chronic pain: Efficacy, innovations, and directions for research. D.M. Ehde, T.M. Dillworth and J.A. Turner. American Psychologist (2014), Vol. 69, No. 2, 153-166.

We further validate this research with outcomes from practical application of our solutions. By doing this, we ensure our clients and members receive only high-quality products and services that work in the real world—where it really matters.

SOURCES:

• ACT is an Empirically-Supported Therapy: Background and Clinical Evidence
• Act Theory: Acceptance and Commitment Therapy Explained
• CBT Explained: An Overview & Summary of CBT
• Dialectical Behavior Therapy
• EDMR Therapy
• Exposure and Response Prevention in the Treatment of Obsessive-Compulsive Disorder: Current Perspectives – PMC
• The Evidence for Cognitive Behavioural Therapy in any Condition, Population or Context: A Meta-review of Systematic Reviews and Panoramic Meta-analysis
• Fluoxetine: a review on evidence-based medicine
• National Library of Medicine: Pregabalin
• National Library of Medicine: Risperidone
• New Therapy Shows Promise for Swift Treatment of Obsessive Compulsive Disorder – Association for Psychological Science – APS
• Psychiatry.org – Study Supports Effectiveness of New Fast-Acting Antidepressant, Esketamine Nasal Spray
• Transcranial Magnetic Stimulation
• VR therapy for OCD Can Enhance the Delivery of Exposure Response Prevention
• What is Evidence-Based Therapy: 3 EBT Interventions

Post Traumatic Stress Disorder, commonly known as PTSD, comes in many forms and affects children and adults alike. Early descriptions of PTSD are found throughout literature. The hallmarks of war-related PTSD were described in Homer’s The Iliad. Shakespeare wrote of the symptoms in Henry IV and A Midsummer Night’s Dream. In recent times, books such as The Things They Carried (Tim O’Brien) describe the effects of war and the risk for PTSD-related suicide. Movies such as Ordinary People and Mystic River portray the effects that loss and abuse have on families and individuals. The daily ease of access to images on the internet and television puts the fodder for PTSD in front of all exposed to electronic media. We have only to listen to the news to learn of all the possible inputs that can cause PTSD—the tornado that sweeps through a Midwest town, atrocities happening to people in places such as Syria, beheadings, and stories of abused children. PTSD can affect one individual at a time, or a lone event can bring PTSD into the lives of many with a single swath.

Prevalence of PTSD in the U.S.

PTSD is common. The lifetime prevalence of PTSD among adult Americans is 6.8 percent (National Comorbidity Survey Replication). For adolescents, the six month prevalence was estimated to be at 3.7 percent for boys and 6.3 percent for girls (Kirkpatrick, 2003). The prevalence is much higher among Veterans. Men and women who had served in the Vietnam War have a lifetime prevalence of 30.9 percent and 26.9 percent, respectively. Studies of Gulf War Veterans reported a current prevalence of 12.1 percent, and 13.8 percent for Veterans of Operation Enduring Freedom/Operation Iraqi Freedom (Kang, et al 2003; RAND Corporation 2008). Unfortunately, PTSD is often underdiagnosed in the medical setting—with symptoms being attributed to a “normal” response to a trauma, misdiagnosed as depression, or altogether missed because of the physical presentation of the condition.

PTSD Symptoms and Impacts

PTSD symptoms are not limited to only the emotional, but also bring physical impairment in many forms. The condition affects those people supporting the individual with PTSD, often causing distress to family, friends, and colleagues. It is important not to approach PTSD with a single point of view — the victim of a natural disaster may have different experiences and risk factors than a combat veteran, for example. What is the same, however, is a set of symptoms based in some form of exposure to a traumatic event, resulting in significant distress and impairment in an individual’s ability to perform in her or his roles, whether within family, employment, or other social units.

No matter the cause, the response to a traumatic event is similar, whether described in the 8^th Century BC, or in 2016. In 2013, the American Psychological Association updated the criteria used to diagnose PTSD. According to current diagnostic criteria, the diagnosis of and symptoms attributable to PTSD must include at least one month of:

• Direct exposure to a stressor; witnessing the stressor in person; indirectly learning of a loved one exposed to a violent or accidental circumstance; and/or repeated or extreme indirect exposure to aversive details of the event, typically by a professional exposed to the stressor (e.g. first responders)
• Persistent and intrusive re-experience of the event through memories, nightmares, flashbacks (e.g. dissociative reactions), distress after exposure to a reminder of the stressor, and physiological reactivity after exposure to a trauma-related stimuli (e.g. jumping up after hearing a door bang unexpectedly)
• Avoidance of distressing trauma-related stimuli, including thoughts or feelings, and/or trauma-related external reminders such as situations or people
• A negative effect on thoughts and mood, including an inability to recall features of the trauma; persistent negative beliefs; persistent and distorted self-blame and/or blaming others; persistent negative emotions such as fear or anger; diminished interest or pleasure in activities; feeling detached or estranged from others; and having a persistent inability to experience positive emotions
• Alterations in physiological arousal or reactivity including irritable or aggressive behavior; self-destructive or reckless behavior; hypervigilence; exaggerated startle response, problems in concentration, and/or sleep disturbance
• Distress or functional impairment in relationships, social, and occupational roles

What PTSD Feels Like

PTSD doesn’t always occur immediately after the traumatic event. In fact, in some cases, the diagnosis may not be made for up to six months with the gradual onset of the full symptoms. Some individuals with PTSD develop dissociative symptoms as the primary feature of the condition. Those affected describe a sense of being an outside observer or detached from oneself (depersonalization), and/or the sense that things are not real or are distorted (derealization). See the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition for a detailed description of the diagnostic criteria for PTSD.

Unfortunately, PTSD predisposes affected individuals to other behaviors that can be emotionally and physically harmful. Persons with PTSD are more likely than persons without PTSD to develop alcohol use disorder (AUD) and substance use disorder, including tobacco, pain medications, and illicit drugs. Nearly half of people with PTSD can suffer co-occurring depression. Physical symptoms and conditions associated with PTSD include cardiovascular conditions such as hypertension, pain, gastrointestinal symptoms, and musculoskeletal symptoms.

While it is very difficult to predict who will develop PTSD, some factors may increase the risk of developing the symptoms, including:

• Getting physically hurt during the trauma
• Seeing another person get hurt or killed
• Having childhood trauma
• Having a sense of horror or helplessness during the trauma
• Having little or no social support after the event
• Dealing with additional stressors after the event, such as losing a loved one, ongoing pain or injury, or loss of one’s job or home.

Taking Care of Oneself after Trauma

While trauma impacts everyone differently, there are some ways to reduce the risk of developing PTSD. Examples include:

• Seeking out support from other people, including friends and family
• Talking about the trauma soon after it occurs
• Attending a support group with others who may have had similar experiences
• Learning how to acknowledge and accept your actions in the face of the trauma
• Having a positive coping strategy; being able to act and respond effectively despite feeling fear

PTSD does not have a cure, but symptoms can be managed to help an individual function better in day to day life. The recommended treatment of PTSD largely is based on the use of medication and psychotherapy. The earlier treatment is started, the more likely the treatment will have positive effects. Combinations of medication, psychotherapy and support are typically the most effective way to ameliorate symptoms.

Therapy for PTSD

Several therapy types have been shown to reduce the physiologic responses to stimuli, or alleviate intrusive thoughts by teaching a person the skills to identify triggers in order to better manage their symptoms.

• Cognitive behavioral therapy has been shown to be effective in treating PTSD. In addition to educating people of their symptoms, cognitive behavioral therapy can also include prolonged exposure (PE) therapy to address the traumatic event. During PE one gradually approaches trauma-related memories, feelings, and situations that have been avoided since the trauma. By confronting these challenges, PTSD symptoms decrease.
• Novel treatments for PTSD include Eye Movement Desensitization and Reprocessing (EMDR). This is a form of psychotherapy that involves the patient paying attention to a back-and-forth movement or sound while thinking about the upsetting memory long enough for it to become less distressing. During EMDR, one learns about their physical and emotional reactions to trauma, targeting the upsetting memory, discussing the memory, and ultimately focusing on a positive belief or feeling while the memory is in one’s mind.
• Cognitive restructuring or processing therapy helps the affected person work through faulty memories of the trauma, and challenges their interpretations of the event, experience of the event, and beliefs that life is full of ongoing danger. Cognitive processing therapy teaches new ways to handle upsetting thoughts and to develop a new perspective on both past and future.

Other therapies include training in relaxation and anger-control skills, group therapy, couples therapy, family therapy, implementing an exercise program, and sleep hygiene. While often tempting in the short-term, it is essential to avoid self-medication with alcohol or other substances such as pain killers that often are habit forming, and may exacerbate symptoms.

When approaching our programs, we at Magellan recognize the importance of identifying PTSD symptoms early on. We hope to spread the understanding that one’s response to trauma does not reflect failure, or weakness in character. Rather, we believe that raising awareness and understanding of PTSD is essential to tackling this condition, which affects so many Americans. As we move forward in developing and integrating new programs, we are keenly interested in supporting individuals, families and healthcare providers to increase access to resources for PTSD education, treatment and support.

Looking for more information on PTSD support? Click here for a list of resources and tips, or call 1-800-273-TALK if you are in crisis.

There are many healthcare-oriented apps in the marketplace, but there are few out there that offer cognitive behavioral therapy (CBT) and that have also been built on a multi-decade foundation of program efficacy data. Magellan’s CBT apps engage participants in psychoeducational content and activities through interactive sessions designed to maximize self-management of behavioral health symptoms such as sleep, depression, and anxiety. We recently released three apps to the Apple App Store including RESTORE (for insomnia and sleep problems), FearFighter (for anxiety, panic, and phobia), and MoodCalmer (for mild to moderate depression) and have plans to release two to three more in the near future.

But what does it take to build and release these kind of apps?

First and foremost, teamwork.

The best apps, healthcare or other, are not built by one person. They require a team of individuals coming together to work towards common goals. Our primary team includes two product owners, and two project managers who collectively work to get the vision from senior leadership (e.g. sketching ideas, wireframing, developing a curriculum), and then oversee the development teams building the apps (e.g. writing user stories, participating in daily scrum meetings, recording and producing videos, providing feedback), and then ensure smooth and timely deployment of various iterations that get delivered to our customers (e.g. delivering training, scheduling releases, communicating upgrades). Without teamwork these critical processes could not be completed and the App Store would have three fewer apps.

Second, and also very important, user feedback.

We have tens of thousands of active users on our platform, and we know that the majority of individuals who do two or more sessions report improvements in their sleep and mood. Therefore, it is very important for us know how to keep our users engaged. To drive engagement we seek out users and give them the opportunity to give us feedback on what would make our apps more helpful and more useful. Importantly, our users do not just include patients, members, and consumers, but also clinicians, care managers, and providers. We investigate how they use our apps and what features they would like to have included.  We incorporate this user feedback into our development sprints using what are called “user stories.” User stories help keep us focused on the core needs of our users, and they give us clear actionable tasks that can gauge what makes our apps successful and can also determine development steps for future iterations. For example, when we started asking our users what they would like added to our apps’ user experience, we learned about different features they would like to see. To help frame those features from the user perspective, we listed them out in user stories, such as, “As a RESTORE user I would like my sleep diary data to sync with my sleep data in the HealthKit app on my iPhone, so that I can see how data from my wearable device aligns with the sleep goals I set in RESTORE.”  When we roll out features developed from user stories, we see our engagement grow from previous years, and we validate our overall approach.

Lastly, we need to measure, test, learn, and keep building.

Our apps include a lot of content, in both English and Spanish speaking versions. The primary psychoeducational components include video recordings of narrators and clinical vignettes. The videos vary in length, and for each video embedded in the apps (there are dozens) we need to measure the length, test how long we can keep users watching, and learn from their experience. We have found that some videos are more watched than others, and we have found greater acceptance with shorter video length. Aside from just the videos, we have run a battery of tests on the features embedded in our apps and platform. These tests help us work out the bugs and improve the overall user experience. Once we are satisfied with our testing, we determine our readiness for release. Apple is pretty thorough with its acceptance and release of apps to the App Store, and we were very pleased with the turnaround time. We are now preparing to release our apps to Google Play, and will also be releasing later iterations with enhanced graphics, text-based reminders, and other features recommended by our users. Ironically, our apps are both complete and never finished, but I look forward to seeing how our apps will evolve, and continue to lead individuals to more healthy, vibrant lives.

It’s 11:30 on a Tuesday night in the emergency department of a local county hospital. The doctor pulls back the curtain on his next patient and frowns. He has seen this man before. He looks down at the chart and recognizes the name. He’d been in about eight weeks before with trouble breathing and chest pains. Gears click in doctor’s memory, as he recalls this patient. His medical work-up had shown nothing acutely wrong. He’d been encouraged to take his usual medications, and sent home with instructions to see his regular doctor as soon as possible to make sure his chronic diabetes and congestive heart failure were under good control.

The doctor pulls a stool across the floor and sits down bedside.

“Hi Brian, what seems to be the trouble?”

“My chest. I couldn’t breathe. And I can’t seem to concentrate. I just don’t want to do anything.” Brian’s voice is listless and low, and he looks fatigued.

“I see you were in a couple of months ago. Did you go and see your regular physician?”

Brian shrugs but doesn’t say anything. His eyes are fixed firmly on the floor.

The doctor pauses. He looks at Brian for a while. The man looks like he hasn’t taken care of himself. His clothes are wrinkled, and he’s lost some weight since his last visit to the emergency department. The doctor looks over Brian’s vitals and labs. He finds nothing concerning on physical exam. He asks, “Brian, has anyone ever talked to you about depression?”

In the case above, Brian is a fictional character, but the situation is not. The co-occurrence of mental health disorders with physical ailments is common. A Substance Abuse and Mental Health Services Administration (SAMHSA) report found that 68 percent of adults with mental disorders have medical conditions, and 29 percent of adults with medical conditions have mental disorders. The most common of these is depression. Many research studies have found high rates of comorbid depression with chronic and terminal medical conditions. In many cases, the medical conditions or treatments for the conditions can cause depression. In others, the depression itself can lead to health behaviors that cause or worsen medical illness, and even higher risk of death. For instance, persons with depression have higher rates of smoking cigarettes than the general public. This can lead to heart disease. But, depression itself can also cause changes in brain chemistry and platelets, which can worsen existing heart disease.

Common Conditions with Comorbid Depression

Comorbid depression in some medical conditions is common. According to the National Institute of Health, there is a close relationship between depression and other physical ailments:

• Alzheimer’s disease and other dementias
• Cancer
• Coronary artery disease
• Congestive heart failure
• Diabetes
• Epilepsy
• HIV/AIDS
• Multiple sclerosis
• Parkinson’s disease
• Rheumatoid arthritis
• Stroke
• Systemic lupus erythematosus

Depression also has a negative effect on treatment and outcomes for these diseases. A 2015 published research study showed those with comorbid depression had more negative outcomes for their primary ailment than those who only had the primary ailment. Research also shows a lower quality of life, lower compliance with medical treatments, and lower rates of exercise and healthy eating habits for patients with comorbid depression compared to those with the same physical ailment(s) who did not suffer from depression.

This comorbidity has consequences beyond the health of the patient. People with multiple medical conditions are a rapidly growing and extremely costly segment of the US population. Patients with behavioral health disorders spend more on treatment for general medical conditions. When compared to those without depression, overall health care spending for medical conditions is higher than those without, in addition to treatment for the depression itself.

Improving Care for Comorbid Behavioral Health Conditions

The first step is identifying patients with comorbid behavioral health conditions before they reach the dangerous and costly levels discussed above. The primary care setting may be the best place to first find depression. But how?

Magellan’s Screen and Engage program is an innovative, user-friendly application that primary care physicians (PCPs) can use to identify patients at risk for a mental illness. Using a Magellan-provided iPad, the patient answers questions about his or her health and well-being while waiting for an appointment. The screening tools are also available in Magellan’s Virtual Care Solutions. Magellan’s proprietary algorithms assess the results, identify potential behavioral health issues and suggest recommendations for treatment, and flag clinicians to engage the patients.

The benefits of the tool are clear. Given the limited amount of time that a PCP has for each appointment, he or she must focus the conversation on the primary reason for the visit. As such, there is little opportunity to probe for behavioral health concerns. By conducting the screening before the short appointment, the PCP has a chance to be notified of the screening results, and discuss them during the visit.

Screening for behavioral health conditions is just the first step. Step two is treating them. In general, depression is treated with either medications and/or cognitive behavioral (CBT) psychotherapy. CBT is a specific type of therapy that relies on identifying and changing ones thoughts that can lead to depression. Research shows that the combination of the two is better than either done separately. While it may be easy to receive anti-depressants from medical doctors, it is often difficult to find CBT.

Cobalt, Magellan’s computerized Cognitive Behavioral Therapy (CCBT) program, is a cost-effective solution to address common behavioral health conditions. Cobalt provides CCBT online or through a smartphone/tablet app. This makes face-to-face CBT—proven to work but often difficult to find providers, especially in rural areas and for working people—available anywhere, any time. It is also a more private approach to CBT. Patients can access treatment from their homes versus an office.

Computerized CBT has proven to be just as effective as in-person CBT. Magellan offers Cobalt modules for insomnia, depression, anxiety, substance use disorder and obsessive-compulsive disorder, treating more than 90 percent of behavioral health conditions seen in primary care and behavioral settings.

Tackling Comorbid Conditions for a Healthy Future

At Magellan, we have made it our mission to help individuals like Brian, whose case is all too common. Tackling comorbid behavioral health issues alongside common medical conditions is one way we do it. Investing in and using new technology, we can identify more people who need help and expand their access to effective, proven treatments.