This is an exclusive BHB+ article
Transitioning patients between inpatient, residential, partial hospitalization and outpatient care is often one of the hardest parts of behavioral health treatment.
Still, if providers can successfully aid patients in these transitions, it can lead to long-term recovery and well-being.
“If you look at where the biggest risk points are, where are patients most likely not to do well, and it’s at these junctures in treatment,” Dr. Andrew Gerber, Silver Hill Hospital president and medical director, told Behavioral Health Business during a recent Talks episode. “When you go from one treatment to another, it can be a level of treatment to a different level of treatment, it can be one provider to another, it can be from a different city to another, despite all the best efforts, that’s the moment patients are most vulnerable.”
Silver Hill Hospital is a behavioral health provider based in Connecticut, offering inpatient, residential, intensive outpatient, and outpatient services.
Gerber noted that investing in times of transition is crucial for providers. Still, some of the critical extra resources for those transitions are often not reimbursed, placing the onus on the provider. But investing in additional meetings and communication between providers can pay off in the long run.
Gerber sat down with BHB to discuss the continuum of care, how technology is changing care, and the importance of behavioral health parity.
The following BHB+ TALKS was hosted by Senior Editor Laura Lovett. The following transcript has been lightly edited.
Laura Lovett: Hello, and welcome to BHB’s TALK Series. I’m Laura Lovett. I’m the senior editor over at Behavioral Health Business, and it is my pleasure to introduce today Dr. Andrew Gerber, who is the president and medical director at Silver Hill Hospital. Thank you so much for coming on, Dr. Gerber.
Dr. Andrew Gerber: Thanks for having me here.
Lovett: We’re going to be talking all about the continuum of care and different treatment modalities. Let’s just start off, could you talk to me a little bit about Silver Hill Hospital?
Gerber: Silver Hill Hospital is a private nonprofit hospital that’s been around for 95 years. We were started in 1931, and we call ourselves a full-service psychiatric continuum, meaning we have three levels of care. We have an inpatient, which is the highest acuity. We have residential, which means people are living here, but in an open environment for longer periods of time, where they’re recovering from their illness. Finally, we have outpatient services, mostly intensive outpatient services for folks stepping down from residential.
We specialize in all psychiatric illnesses. We believe that folks who are suffering from psychiatric difficulties or addictions are more likely than not to have a mixture of issues. That’s more the norm. I know we like to talk about things in these discrete little boxes that our field has invented over time, but in fact, most patients don’t fit into those discrete boxes. We want to make sure that we can help people with all sorts of different things.
That goes by different names over the years. People have called it comorbidity, or they’ve called it dual diagnosis, or they’ve called it complexity or acuity sometimes. Basically, what we say to people is if you haven’t gotten help from other services out in the community or at other facilities, we can very often help. That means that we’re good at a lot of different things, particularly when they’re in combination with one another.
We also offer flexible payment options. When possible, we take insurance. Our inpatient and much of our outpatient now is fully in network with major insurance providers, as well as Medicare. Unfortunately, we can’t take Medicaid. It’s actually not allowed by federal law for independent psychiatric hospitals. In our residential services, we would love to take insurance if that was an option, but because of the nature of what we offer and the nature of what most insurance companies reimburse, that is now out of network in all but one case.
Our adolescent with one pair is in network, but other than that, we are out of network, and we help people get reimbursement. We really aim to help people all over the country. Even though we’re located in Connecticut, we serve people from all over the country, sometimes all over the world. We are big believers that what we do, especially today, is needed. We’re very proud of our mission.
Lovett: Let’s talk a little bit about how that patient population is seeking behavioral health. How has it changed over the past, say, 5 to 10 years in terms of acuity and complexity?
Gerber: I guess I’ll start by saying that probably things are more similar to how they’ve always been than anything else. That in general, most of the illnesses we treat, whether they be addictions or mental illness, are problems that humanity has struggled with for many decades, centuries, sometimes even millennia. That said, we see differences, and I’ll mention a few of those.
One is that as the supply of other inpatient beds and residential beds throughout the country has dwindled, and that’s really been true since at least, most acutely since the late 1990s, and some ways back to the 1950s, the number of beds in our country has been dwindling, and there’s some good reasons for that, and there’s some not-so-good reasons for that, but we see a gradual increase in demand.
That means the folks who come to us are folks who really, really need to be here because, given that there are not a lot of beds out there, people avoid coming to the hospital as much as possible. To some extent, that makes sense, right? If we can care for something, and people can sleep in their own beds and be with their own families, that’s always the ideal solution. I think the folks who come to us do tend to get more complex and sicker year after year.
Certainly, with COVID, we saw a dramatic rise in acuity because I think the stressors that hit our society, some of that very related to COVID itself, some of that more broadly speaking about the changes to our social systems and the way people work and the way people relate to one another, and increased loneliness. Certainly, we see increased acuity at times of national upheaval, and we’re certainly seeing that now and over the last several years.
When it comes to some of our younger populations– so we treat adolescents and young adults. I should have mentioned that earlier, that we see anything up from 13. We don’t have services at this point for younger than 13, but anything 13 and up, we’ll do. Our adolescents and young adults certainly have been heavily impacted by the change in their social environment, particularly around phones and social media, which we saw starting in 2008 or so.
Then last, and very, very unfortunate, we have seen a rapid rise in the rates of cannabis use, very high concentration THC in cannabis. Whenever you think about the pros and cons of legalization, there is no question that use has risen here in Connecticut after it was legalized for recreational use several years ago. That’s led to an increase in a particularly vulnerable group, I’m not saying it’s everybody, but in a particularly vulnerable group of adolescents and young adults who can suffer some very serious consequences from the use of high THC, in particular, psychotic illness, which we’re seeing more of in that population than we ever have before.
Lovett: That’s so interesting. I think we’ve been reporting more and more on that because it wasn’t on our radar maybe five years ago as much as it is today. Okay, let’s talk a little bit about residential treatment. I think today we keep hearing this really big push for outpatient services. What role does residential treatment still play, and how does that fit into that care continuum?
Gerber: Yes. It’s such an important question. I think even that word residential can mean so many different things to so many people. I’d like to give a little bit of a historical context to this. If you go back, let’s say, to the 1950s and the 1960s, there was no such thing as residential. That was not a term that was used. People talked about psychiatric hospitals. At the time, what they meant by that was much broader than we mean by that today.
For example, people who went to state hospitals, private hospitals, and so on, many of which existed really from the early part of the 20th century, what was understood by that was that there was a range of experiences they had based on what they needed and certainly based on what the institution offered.
At psychiatric hospitals where people sometimes stayed for months if not years, they might spend a piece of that in a more acute unit when they were not able to be safe or take care of themselves. In almost all of these facilities, once they were more stable, they were on open units where they had access to the grounds where they worked, where they took advantage of a full range of services. Many were almost like small towns or even cities with thousands of people, some of them, where they worked and where they had lived.
Now, obviously, we think back, and we see these old scary buildings, and we think, oh my God, that sounds terrifying, but that’s not uniformly true. Some of them were actually quite nice, and the experiences some people had were not all negative, but it was a wide range of experiences they had, including going home and coming back only when they needed to be there.
Today, we define things differently. That was all called a hospital. Really, only starting in the 1980s, 1990s, we segmented those treatments and that was largely driven by the need to control costs and the desire by various parties, whether it be the government or private payers, to say, wait a second, we can’t necessarily pay for everything for everybody. Reasonable. The new essential definition that still confuses a lot of people is that hospital-level care, or what we generally call inpatient-level care, is only one small piece of that continuum.
That’s what they used to call the acute unit. That is the period of time when you are most at risk. Those are much shorter stays, 7 to 10 days, actually. Appropriately, people shouldn’t be inhibited from their daily activities and so on, unless you absolutely have to do it for their safety. Residential is essentially what we started to call most of the rest of things, meaning anything from 7 to 10 days all the way up to months, if not years.
That’s a level of care that even within it has a range, but that’s really designed for people who are able to be safe, are able to take full advantage. They’re able to work and to learn and to do other things and be part of a community, but are not able to fully get their needs met by going home and being only what we would call an outpatient.
That residential level has always existed. It’s just what we call it now. The other term that sometimes gets used, and it’s a little confusing, is people call it an intermediate level of care. By intermediate, they mean it’s not the highest level, that is the acute inpatient setting. It’s not the lowest level, that means outpatient, the thing we’re all so familiar with, going to therapy, going to see a psychiatrist once a week or even once a month or less frequently.
That’s the lowest. The intermediate is everything in between. Even though residential levels of care, I think we talk about less as a society. I think that’s unfortunate because I think they’re essential for a segment of our population. It’s something that a relatively small number of facilities in our country do now. It’s one of the things we’re very proud to offer.
Lovett: I’ve been hearing a lot more about IOPs or intensive outpatient programs, PHPs, partial hospitalization programs. Is that something you’re looking at as part of that intermediate care? Is that a step-down service from residential? How do you see that fitting into that piece of the puzzle?
Gerber: That’s right. I mentioned you can segment residential into multiple layers. There’s even acute residential, which might mean a place that has a higher level of services. Then there’s less acute intermediate levels of care, which would include IOP and PHP. For people who might not know what that means, an IOP is generally defined these days, it stands for intensive outpatient. It generally means nine hours a week. Usually it’s divided into three days and it’s three hours per day.
Most IOPs, certainly the ones that are covered by insurance or by government payers, are group-oriented with maybe a little bit of individual, but mostly you’re in nine hours of groups per week. Partial hospital is a little higher than IOP. That stands for PHP or partial hospital, or sometimes people call it day hospital, means you go home at the end of the day, but you’re there in an institutional setting for four to five hours for five days a week.
Those are what I would call at the lower end of the intermediate continuum. We do IOP. We don’t have partial hospitals right now, but it’s something we’re considering for the future. I think what we find, though, is that it all matters on what the individual needs because people are just so vastly different from one another.
Once you’ve had your medication stabilized, and that often happens at the inpatient level of care or early on during a residential care, a lot of what you need is psychotherapy, and I mean psychotherapy in the broadest context, which means talking to people and helping them understand how they can function better, feel better, feel happier, be more fulfilled in their lives through changes of their behavior, adherence to medication, and so on.
Psychotherapy is a very broad construct. Some of that is group-oriented. Some of that is one-on-one. Some of that is with family. Some of that is with couples. You really need to tailor that to the individual issues that a person has. My general rule is the more you end up in a cookie-cutter system which says everybody gets treatment X, that’s usually a sign that it’s not going to work for some people because treatment X is designed for this group, and you’re trying to put this group into it.
Of course, we understand from a wider system, you think about capitalism, our goal is to be efficient and to create standardized products. Sometimes that works, and sometimes it doesn’t. My experience is for complex or acute mental illness, you’ve got to really tailor things. How to do that and still make it affordable, that’s, of course, the question for us as a society. I see IOP and PHP often as a little more cookie-cutter, and I see that there’s a need for things that are more customized.
We actually have something now that we do. We have a New York campus for outpatient, and we actually don’t call it IOP because IOP has become a very standardized term that you have to fit into that narrow box. We call it an intensive. You can tell we’re trying to use the same word, but we’re not abbreviating it IOP. Our intensive is a highly customized version of outpatient care. That can be anything from an hour or two per week up to closer to a typical IOP of nine hours a week. It’s a mixture of groups and a mixture of individual sessions. To me, that’s the highest quality care when you can really tailor it to the individual.
Lovett: That’s really interesting. To follow up on that, how do you think about supporting patients during transitions? What does that look like from an operations perspective, and making sure that the patient actually gets to the next place, and it’s right for them, and that if it’s outpatient, they’re going to sessions and have that support? What does that look like?
Gerber: It’s a great question. You may know, and some of our viewers may know that when you look– it’s not just true in psychiatry and mental health, it’s true across all healthcare. If you look at where the biggest risk points are, where are patients most likely not to do well, and it’s at these junctures in treatment. When you go from one treatment to another, it can be a level of treatment to a different level of treatment, it can be one provider to another, it can be from a different city to another, despite all the best efforts, that’s the moment patients are most vulnerable.
What I often compare it to is it’s like running a relay race. You watch the Olympics, and you watch this relay team, and they’re cruising along, and obviously, the important part of the race is how fast they can run. Then there’s that moment when one runner is coming into the zone and the next runner starts running alongside them and they put their arm behind them and they have to grab the baton and you hold your breath if you’re rooting for that team and you think, don’t drop the thing because you’ve got two people running close to as fast as they can possible run and one has to only let go when they know the other one really is holding on.
That to me is the metaphor for what happens at these junctures because you’ve got a person living their life, all the complexities of it, and they’re going to school or they’re going to work or they’ve got some residual issues or they’re taking their medicines or you’ve got providers who are running around and if they take their eye off the ball, I’m mixing my sports metaphors here, the baton can get dropped.
Of course, the consequences are terrible because that can mean someone stops taking their medicine, or stops going to treatment, or is at risk for hurting themselves or somebody else. These are such sad moments. I believe that, as your question I think was getting at, that you’ve got to surround that handoff with more resources than you’re giving in the straightaway because that’s the vulnerable moment.
Now, here’s one of the sad ironies of our system. As we strive to create systems that pay for things, we don’t do that. We don’t pay, from a payer perspective, more for those moments of transition. What we can do as a hospital, because we’re private and because we have wonderful philanthropy and we have all sorts of other resources, is we can say, we’re putting more resources into those moments of transition, and we’re owning those transitions as much as possible.
Meaning we’re having people from the outgoing team, the one running up with the baton, proactively making phone calls, having meetings, over-communicating. You have the one picking up the baton, doing the same thing, making phone calls, planning ahead, and then checking with each other multiple times. Did the patient come? Did they show up? How’s it going so far? Wait a second. He or she told me this. Is that the same thing you saw?
That level of redundancy, to me, ensures a good pass off. If you can do it within a system, all at Silver Hill, all the better because we know each other. We’re used to each other. When you’re doing it across systems, it’s harder, not impossible. It certainly requires resources, but we do it all the time with a lot of our clinical partners throughout the country.
For providers, I think we all intrinsically know that that’s a key moment. I think for families or for patients, they may not realize in advance how important those moments are. I’ve had patients or families say, wait a second, I just got to the hospital, and you’re already talking to me about what’s going to happen when I leave. Isn’t that a little fast? What I generally say to them is, it’s not too fast because we need to be ready, and we need to make sure that that transition is handled super carefully.
Lovett: You’ve mentioned before that residential often does not get reimbursed by payers. Can that be a tricky transition because of that? Are patients concerned about that? Does that have to get skipped because a patient says, “I need this to be covered?” What does that look like?
Gerber: You’re exactly right because ultimately, in the real world, the highest quality clinical care is not the only thing that decides what patients get. Finances decide it too. If you’re a patient or a family, and you have to make that decision, and you’re at an inpatient level of care, and someone recommends residential, and you look at all the options, and they’re not financially feasible, and it’s a little more complicated than I said, often there are some residentials that are. They tend to be not as robust as the residentials that are not.
Again, there’s nobody I know who went to medical school or psych grad school or social work school who wanted to give different levels of care based on how much money people had. We took oaths to treat every patient the same, but then we come into the real world, and the real world, at least in the system we have in this country, it does affect people. You have to work with the real world.
If someone’s leaving one of our inpatient units, and for whatever reason can’t afford the residential that we think would be best for them, of course, we work with them to make that transition to wherever they’re going to go. Whether that’s an IOP or a PHP, or sometimes not even that, because IOPs and PHPs, depending on where you live and depending on the problems you have, may or may not be feasible or available.
I think that one of the things I hear very frequently from patients and families I talk to is that they just assumed that our healthcare system was more robust and that, as a country, you would get good care. I will say that in other areas of medicine, I went to medical school, and I worked in surgery, and worked in internal medicine and pediatrics, and I’m not saying any of those are perfect, but those systems are generally better set up for people getting high-quality care that is reimbursed. Mental health, for a host of reasons, is not.
People say, but that’s so unfair. That’s so wrong. It’s an illness like anything else. Why should it be different? That’s what’s led many of us to get involved in an advocacy movement that’s generally referred to as mental health parity. For those who haven’t heard that term, mental health parity means that we as a society have an obligation, which by the way is a federal law since 2008, that we reimburse, that insurance companies, payers, government reimburses mental health care at the same general level as we reimburse physical health.
That’s not to say every illness is exactly the same. Of course, there’s differences, but the principles have to be in parallel. I don’t know anybody who thinks we are following parity right now. Whether it’s the payers, the providers, the families, we all agree that we are failing at parity despite it being a federal law since 2008. I think there’s a lot of practical challenges to that. Sometimes it’s been the federal government being involved. More recently, it’s been at the state level.
I’m proud that here in Connecticut, we just passed a stronger parity regulation than we’ve had in the past. Just last year, there are other states like Illinois and Massachusetts and California, New York that have led the way in this. I think really nationwide, we need better legislation to make sure that patients and families have access to high-quality care regardless of whether it’s physical health or mental health.
Lovett: That makes so much sense. Parity is something we’ve been covering for a long time and slowly seeing some progress. Definitely interesting to keep top of mind. Let’s talk a little bit about treating co-occurring conditions. How does treating co-occurring conditions differ from treating that single primary diagnosis in terms of a treatment plan, outcomes, who needs to be on the team? What does that look like?
Gerber: That’s a great question. Let me start by saying that in some ways, one’s framework matters. I would start by, in my mind, I actually reframe it. I say, wait a second, it can sound like the norm is one diagnosis and co-occurring is something different and unusual, but in fact, it’s the other way. The norm is multiple diagnoses. Patients will frequently say to me or their families will say to me, “Wait a second, what does it mean that my son or daughter has ADHD, depression, and cannabis use disorder?”
They have three separate problems. I say that tells you about our words, not about your kid. Meaning they sound like three separate things because we built a system that tried to put people in these neat little boxes, but that’s not what the real world looks like. Most people, 70%, 80% of the patients we see here at Silver Hill Hospital, now, yes, we have a more acute level, but the vast majority of them have not just two or even three, but meet criteria for four or five different diagnoses.
That’s the failure of our nomenclature, not saying that there’s something so unusual about this individual that we had to give them four or five words. I don’t think we’ve done a good job as a field with our naming because I think we confuse a lot of people, and it leads them to think, wait a second, but there’s a treatment for ADHD, and there’s a treatment for anxiety, and there’s a treatment for cannabis. Does that mean I need three separate treatments?
The answer is usually, no, that’s not what it means. What it means is you need a well-trained team of providers who are comfortable with all the complexity that goes into the individual. You might even call it the normal complexity. Now, yes, people are coming here with illnesses, but it would be as if– imagine if you went in for a surgery and the doctor says, well, I only operate on people who are exactly 5 foot 6 inches tall and their appendix is exactly in this place and it’s exactly this size. That would be ludicrous.
You pay your surgeon or the insurance pays your surgeon because they have principles in mind and they understand all eventualities. They’ll say to you, I don’t know exactly what your appendix is going to look like until you’re on the operating table and I open up and I say, “Oh, you know what, this one goes a little bit this way, so I have to cut it off here and I have to put the sutures there and I have to tie up these blood vessels.”
We take that for granted in physical medicine. Somehow in psychiatry, we act like everybody’s supposed to be the same. What I believe is you need really well-trained mental health professionals who’ve had a breadth of experiences, who’ve treated substance abuse, who’ve treated anxiety, who’ve treated depression, who’ve seen it in all sorts of different combinations depending on age, gender, family, makeup, life experience, trauma, all of the things that go into this and see the person as one person so that when the patient or their family comes and says, “What’s going on,” they don’t say, “Well, you’ve got five different things.” They say, let me explain to you what’s going on.
You don’t expect your surgeon to say five different things. They say, “Okay, this is what I found.” This is what language is good at. We tell the narrative of what happened to this person, how they ran into these different difficulties, why, for example, and what’s a common situation, that somebody had an underlying vulnerability to being more anxious. That’s something we’re often born with. Often folks who have those vulnerabilities often have trouble in settings like typical school where you’ve got to sit in your chair and not move.
We’ve led over time for them struggling with what we call attention, which is a consequence of the way we set up classrooms and expect them to sit still all day, and they got more and more anxious until one day they started using cannabis, and they realized, “You know what, cannabis makes me less anxious, I feel better. I worry less about my grades even though my grades are going down because I’m not paying much attention.” Now we say they have three different things. That’s one person.
What do we do? We want to get to the origin of the problem. We say, “Okay, well, listen, before you can respond well to treatment, first we have to cut down on the cannabis because you’re not going to do well in therapy or respond well to any medicines we use because you’re high most of the time.” We say, “Okay, first let’s stop the cannabis,” but we’re not going to stop there. We’re not going to claim that’s the whole problem.
We’re going to say, “Now that we have you off cannabis, before we send you back out and there’s a risk of you starting again, we’re going to give you skills to treat your underlying anxiety. We’re going to use some combination of psychotherapies.” There’s many psychotherapy interventions for anxiety. Maybe we’ll use a little bit of medicine as well. Maybe not. We’ll help treat the underlying anxiety.
By the way, along the way, we’re going to help you figure out strategies so that you can succeed in school or work. There’s different ways to do that. Some of that is working with the school and the teachers. We have lots of different interventions that help people do it. Yes, we have medicines for that too, but we may or may not use the medicines.
All three things, I’m just using this as one example, there’s almost an infinite number of them, have to be addressed together by experienced people who are used to doing that. If you do that, lo and behold, it’s much more likely that when it’s time to now move to a lower level of care, maybe you were at residential and now you’re at IOP, or maybe you’re an outpatient, and you know what, those folks stay better.
I’m not saying that there aren’t still vulnerabilities, but it is much more likely that they don’t hit that horrible revolving door that we all know so well, where the problems all seem to come back, and then they end up back at a higher level of care or not doing well or using too much cannabis, or something like that. That’s the best prognosis for the future is treating all of those, which you’re calling comorbidities, as a single illness that needs attention.
Lovett: Yes, that’s really interesting. It makes a lot of sense. One other big topic that has been circulating around behavioral health today is measurement-based care. How do you think about measuring those outcomes? What metrics are you looking at? Maybe it’s different for each patient population.
Gerber: No, it’s a term that we use a lot. today. Like a lot of things, it came out of a great idea. It came out of something that I am a big believer in and also can get misused. Let me sketch it out. At its best, the concept of measurement-based care is that even though it’s complicated to talk about people’s mental states, and which of us hasn’t heard somebody say, “Well, if you have a blood pressure, that’s very nice. I have these two numbers; I can just use those.” If I have your red blood cell count. If I have some pathology report on an oncology report, that’s so concrete.
Mental health is so much harder to measure, but we don’t and we shouldn’t give up on it because you can measure hard things. We have the whole history of science measuring things that seemed unmeasurable. Imagine going back before there were microscopes and trying to measure all sorts of things that now we take for granted. Imagine before we had the home testing kits and the fancy labs and the automatic blood pressure cups, all the things we do.
The same is true in mental health. We have better measures today than we ever had before. There are literally thousands of different ways to capture these things. By the way, it’s only getting better. AI, one of the amazing applications of AI, and there’s bad applications and there’s dangers, but there’s also incredible positive things, if you can take whole conversations and find ways to translate those into measurements.
It’s something we’re doing a lot. It’s overheld both here in Connecticut and down on our New York campus. Maybe I’ll have a chance to chat about that later. The first thing you have to recognize with measurement-based care is it is possible to measure. You need to know what you’re doing. There’s a big literature. Earlier part of my career, this was something I did my PhD in measurements of psychotherapy outcome because I was fascinated by how to measure things.
Now, we add those two more words, based care. What that means is it’s not enough for us to just write journal articles. If you’re an academic, you get promoted because you wrote articles about these new measures. You’ve got to apply it to the real world. Increasingly, what you’re seeing in hospitals, and we do it every day here, is gathering the appropriate measures on all of our patients.
You can’t come into Silver Hill Hospital and not have a series of measures that are some filled out by the patient him or herself. We engage families, we fill them out as clinicians, and then we have to use those measures to feed back to the treatment team to say, “Hey, this is improving. This doesn’t seem to be improving. This is getting worse.” True measurement-based care integrates those measurements into the daily decision-making.
Nobody would want to go to a medical hospital and find out that their doctor never looked at their labs. That would be malpractice. Because of the challenges in mental health, it’s taken much longer. I believe we are now at a place where it is an expectation and really a requirement for all high-quality treatment to use measures to track treatment all along.
I do want to say one more thing, though, which is that I did mention at the beginning that that’s the positive aspect of measurement-based care. I’m very proud of where we are at Silver Hill in terms of doing that. There is a danger. The danger is that you use the measures to reduce the complexity to the point that it’s not good care. I’ll give you an anecdote from medical school. One of the things that I imagine every medical student heard, and I certainly remember it being repeated to me, is treat the patient, not the numbers.
You never want a situation– Some of you may be watching The Pitt. I just watched an episode last night. It’s a great show on an update of ER, and they have lots of great medical– it’s very well done, by the way. You could imagine this being a lesson that Dr. Robby teaches his medical students, which is you could imagine coming in and head down. They’re barely making eye contact with the patient, and all they’re doing is saying, “Oh, you have a white blood cell count of such and such, and you have this. I better do such and such,” and not even paying attention to the person in front of you.
That’s not good care. You need to incorporate both. We do that here. I think the danger, if we only incentivize the measurement, you can accidentally de-incentivize all human interactions. What I’d like to see in our field is that we don’t lose sight of all the other pieces, so it’s not only the numbers. It’s numbers as a supplement to what we do as human beings.
Lovett: That makes sense. I think that’s a really interesting point because I don’t think we talk a lot about the downsides of what measurement-based care can be, because there’s always going to be ups and downs, but I think we always just think of that as that’s the future. That’s really interesting. I wanted to touch a little bit on treating adolescent populations. How is that fundamentally different from treating adults with a similar diagnosis? How do you approach that? Also, are there other stakeholders that need to be at the table?
Gerber: I love adolescents. It’s actually my preferred group that I work with. I trained as a child and adolescent psychiatrist. What I often say to people is, it’s a funny thing, an artifact of history, that treating children and adolescents is a specialty because to some extent, every adult was once a child or an adolescent. I believe that thinking about adolescents is actually a framework by which all patients should be treated.
Let me say what I mean by that. Adolescents, there’s a few things very interesting with them. One is, they’re in a period of change. Most psychiatric illness has its origins in the years between, let’s say, puberty and young adulthood. The reason for that is that’s when the brain is growing and maturing into its adult state. Because these are brain diseases and they’re all affected in that way, that’s when the things consolidate.
It’s also when you’re being called upon to do all the new challenges, whether it’s academic or it’s work-related or it’s relationship-related. All of those things happen in those years. We shouldn’t be surprised to think that adolescence is this period where there’s both great opportunity but also great challenges. I think where adolescents fit into our society is also rather complicated.
We do a funny thing to adolescents, I would argue, which is on the one hand, we tell them, “This is your moment of self-invention. You’ve got to go out there and find out what you’re passionate about. Do you want to be a professional basketball player or do you want to be a scientist or do you want to work in the store?” It sounds very nice to tell people this.
Then when they go and do things differently than we might have wanted them to do as parents, as teachers, as society, we get very upset and say, “Oh, you’re rebellious and you’re a risk-taker.” Sometimes we even get insulting and say, well, your frontal cortex isn’t fully developed. As someone who did neuroscience research, I always felt that was a little unfair because evolution designed adolescents to be more experimental.
Why? Because it’s good for our population. It’s good for the human condition. If you look back at history and you ask who made the biggest discoveries, who changed the world in the most positive ways, it’s not people my age. It’s people between the ages of 15 and 30. There’s an old thing in science, certainly in physics and in math, where if you look at where people made their big discoveries, they don’t even do it past 30 because their minds were so flexible. Their minds were so able to see things in new ways. We need them to do that.
Rather than pathologize adolescents, maybe I’m slightly romanticizing it, I think adolescence is this incredible gift. It’s this opportunity. If you as a therapist or psychiatrist can foster that and unlock the potential of an adolescent who may be ridden with anxiety, or using substances, or afraid to do all these things, and you can help free them up, the amount of potential that’s there in almost all is really quite amazing.
I think in my field, a lot of what my job is these days because I lead a hospital, is to try to help people feel excited about the work they do. I know that when people see their patients not as, “Oh my God, there’s one more problem I have to fix.” That’s never a good sign. If you see your patient as, “Wow, here’s this human being with amazing potential. I can do relatively small things.”
It’s relatively small to meet with somebody for an hour a day and do therapy with them or prescribe medication. I can, with that relatively small invention, unlock all this potential. What a privilege. What a gift we can give them and their families and really the whole world. You can see why I think adolescence is a particularly special time.
Lovett: I love that. I remember so many times in college, you’d be talking about the prefrontal cortex is not developed. It feels so patronizing at the time, but that’s just such a really lovely way to put it, that there’s so much potential. I think probably a lot of adolescents and young people would really appreciate it. I did want to go back to technology a little bit. I wanted to loop back around to that. How do you see technology impacting care in the future?
Gerber: Listen, like everything else, technology is an enormously powerful tool that can be used for good and it can be used for bad. I’ll start with the good, which is that I think we talked a little bit about measurement so far. I think we have the ability to study and analyze our patients in a way that then it helps improve treatment and we’re just scratching the surface. How do we use that?
To give you an example, at Silver Hill New York now, we have a program, we call it Mental Health Intensive, where when everybody comes, they get an Apple Watch or an Oura Ring. Oura Ring is one of those digital rings. With obviously their permission and they come because they want to do this, we are now tracking their activity data in a very secure way, their location data private to them.
We’re pushing questionnaires to their phones and with their permission, we’re video and audio taping their sessions, both individual and groups. What we then do is we actually use AI because this massive amount of data that this generates would be unwieldy otherwise, to now create feedback which we share with them. It’s their data, it’s not our data, it’s theirs. We use all those new tools to empower them.
The model, as you might get the sense of, is much more like what people do with their exercise watch or with their treadmill or with– there are a whole bunch of different things you can buy, where it’s not about a professional telling them what to do, it’s about how do we give them the data as individuals to better inform their own wellness, health, and self-care. That to me is an unalloyed good.
I think you’re going to see a lot more of that essentially become the norm in treatments. We do some of it up here in New Canaan. I’d like to do more of it here, but I think you’re going to see that everywhere very soon. I think that another good, although you’re already going to start to hear some of my caution, is that of course human interactions are going to be limited by our availability and by the financial feasibility.
If you want to see your therapist and you have a question for them, you probably need to wait a week until you have your next session with them. Maybe you can email them. It depends on your therapist and whether you’ve worked that out and so on. Therapists can’t be available 24-7. We do have the ability, we’re starting to see now, for us to use AI and other aids to provide coaching and structure for people much more frequently.
Who hasn’t tried going to ChatGPT or to Claude or Gemini and ask a question? It’s private, it’s immediately available, and to be honest, it’s surprisingly good. Now, what’s the danger? The danger, of course, would be A, that those tools are not like talking to a human. We’ve all read the stories about the AI that spoke to somebody and encouraged a delusion or led to some terrible behavior maybe.
It could also lead to dependency. Instead of figuring it out for myself, what if every time I wasn’t sure what to say to somebody or what to do, I just went and consulted and did exactly what the AI. That wouldn’t be developmentally wise either. We’ve got to figure out what’s appropriate. What I believe is that it’s actually our responsibility as healthcare professionals to make recommendations. Not that we’re trying to control people. At the end of the day, a lot of these tools are going to be available, particularly to adults.
Maybe they shouldn’t be to younger people. I’m certainly a believer we should do more regulation, certainly for people prior to high school. I think we can help people just the way we coach people on exercise and diet. I think we need to coach people on the appropriate use of AI in positive ways and where it’s not so positive. I think there’s great opportunities with that.
The last thing I’ll mention, and this feels a little more science fictiony, but I think it’s worth keeping in mind is remember most of physical medicine was transformed by diagnostic testing that would have sounded science fiction 10 years before it existed. The X-ray has been around for a while, but when the CAT scans and MRIs first came out and we could visualize the functioning of organ systems in real time in living people, that fundamentally changed medicine.
The brain is much more complicated than any other organ in the body by orders of magnitude. It’s taken us longer, but we now have the ability, particularly through brain MRI, to see functioning brains and to understand the activity patterns in those functioning brains that I still think have great promise for the future. It is one of those technologies that I think was overhyped.
If you go back even to the late ’90s, early 2000s, people were sometimes predicting we were going to be able to diagnose all mental illness within the next 10 years through MRIs. That has not come to pass. None of us would ever want to predict that’s coming around the corner, but I do think we are going to be able to use brain MRI in much more effective ways. Caveat, I did spend a part of my career at Columbia doing brain MRI research, so I do believe that that’s still untapped.
I would say the same for genetic analysis. Genetics transformed many physical illnesses when we understood exactly the genetic makeup. In fact, in some cases, it’s even leading to gene therapies that may be cures. We’re not quite there yet, but for diseases that have played humanity for millennia, maybe ultimately cured through understanding the genetic bases. There was a hope.
I remember earlier part of my career hearing people say, we are going to understand the genetics of every major mental illness, and we’re going to be able to address all these things. That’s again, not come to pass, except for in very rare circumstances, but you can’t give up because even though it’s more complicated, I do think there’s a lot of important information in the genome that is going to help us understand.
Think of it this way: what we now call depression is not one thing. It’s presumably dozens, maybe hundreds, or even thousands of different things that can lead to depression. What we call schizophrenia is not one thing, but we don’t have the tools to break that down. I believe through imaging, particularly brain MRI, through genetics, we increasingly will be able to do that. We’re already starting to.
It’s very much in the research literature. It’s not yet made it into clinical practice because it’s not quite robust enough yet, but I would expect within the next 20 years for you to see more of those technological advances coming into the clinical assessment. For example, making it a standard practice in hospitals to do an MRI or to do a genome scan where 10, 20 years ago, that would have been unthinkable. Stay tuned because I think things are ahead.
Lovett: I think biomarkers and being able to use that in behavioral health is just such an interesting concept. Also, I’m curious about how this will be eventually reimbursed and what that will look like. The next step is operational after it gets all the clinical validation. We’ll be watching.
Gerber: Absolutely.
Lovett: All right. As we’re coming to the end of our time together, I always like to ask, if you had a magic wand and could change one thing about our behavioral health system, what would it be?
Gerber: I’ve thought a lot about this. I’ll tell you, what I want to try to do is get at the origin of the problem. It’s not that there aren’t many, many things I want to fix, but I would start by changing something that I believe is so fundamental that if you could meaningfully change it, that it would have lots of long-term impact. That would be stigma. As long as we are afraid to talk about mental illness in ourselves, in our children, in our society, as long as it’s hushed tones and embarrassment, then it makes all sorts of progress harder.
When I think about what is another fundamental problem in our system, I think ultimately that we’re not reimbursing adequately for high-quality treatment. I believe the origin of that is stigma. Remember, in a capitalist society, consumers make the decisions. I know it’s not perfect, but by and large, insurance is purchased. Most healthcare in this country is reimbursed by employers who have insurance policies for their employees.
Those policies are purchased by the employer. I’m an employer. I’m a CEO of a company, a nonprofit company, but I made the decision with my team about which insurance we had. I would argue that if we have more options and there’s more transparency to all those decisions, which would come, by the way, from reductions of stigma, there’ll be more competition among the different resources. Now, there are payment issues, right?
One company or one employee may choose to spend more or to get paid less in salary because they wanted more of the benefit or something. Of course, it also leads to political change because politicians, then, if there’s less stigma, are talking more about this, are caring more about it. Their constituents are coming to them. People are voting for these reasons. All the things that would come to light if we had less stigma would lead, I believe, to a more transparent and ultimately higher functioning system that would raise the priority of the treatment of mental illness. Ultimately, that leads to good things.
These are hard problems. Certainly, it’s tempting to say, “Oh, I would eradicate depression, I’d eradicate psychosis.” I ultimately believe that it doesn’t work that way. That actually the human brain needs to have variety. This is another really interesting topic, which is when we think about all the variety of human experience and the variety of human abilities, I would argue that we sometimes conflate the vulnerability to an illness with just a problem.
We don’t see that those same traits have enormous adaptive advantages in other people. I’ll tell you one favorite example I have is people think ADHD is a terrible thing. If you’re a hyperactive boy trying to sit through class and you’re in fourth grade and your teacher’s getting mad at you because you keep fidgeting or you keep getting out of your chair, it just seems like a bad thing.
If you’re in medical school and you go to the emergency room and you watch emergency room doctors, you could watch The Pitt; every one of them would meet criteria for ADHD by that standard. They are running from one room to another with an ability to think quickly and go back and forth that I’m sure didn’t work well for them when they were in fourth grade, but it works in that setting. In fact, we all benefit from it. Those same traits.
I don’t mean to be Pollyanna about it. I’m not suggesting that there aren’t very severe versions of all these things that are just problems, but I do believe these traits have positive sides to them as well. I think that makes us, if you think about it, embrace the range of human experience and to really celebrate that. Then ultimately, you don’t want to reduce that. We don’t want to all be the same. We want to be different. How do you keep that variety, but also make it possible for people to succeed and be happy and fulfilled no matter what set of characteristics they have?
Lovett: I think this is a great note to end it on. Thank you so much. This was a great conversation. I feel like I learned a lot. Thank you to everyone who joined today.
Gerber: Thanks, everybody. Thank you.