Episode 69 | Feb 8, 2024

Mental Healthcare and Primary Care Collaboration, With Ravi Hariprasad

Mental health and mental health care have only gotten worse since 2020. It’s becoming harder and harder for people to make appointments to see therapists, psychiatrists, and other mental health professionals. This week Dr. Sandi discusses mental health, health coaching, and collaborative care with the founder of Intuitive Mental Health, Ravi Hariprasad.

With the state of healthcare today, many turn to their primary care physicians(PCP) for mental healthcare. Approximately 80% of all anti-depressants are prescribed by PCPs. Intuitive Mental Health is a startup that is working to help PCP deliver comprehensive and personal mental healthcare support. Ravi shares his thoughts and expertise on what the future of mental healthcare can look like when combining collaborative care, lifestyle medicine, and AI technology.

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Episode Transcript

Dr. Sandi: Welcome, everybody, to “Health Coach Talk.” It is my pleasure to welcome Ravi Hariprasad. He has an incredible background and I would like to share it with you so that you will learn about Ravi.

First of all, he is the founder of Intuitive Mental Health because this is addressing a critical gap in the mental health landscape. While over 80% of psychiatric medications are prescribed in primary care settings, for many people, this becomes just the extent of their care. Intuitive Mental Health is addressing this gap through a collaborative care model where clinicians with their unique expertise are further empowered by a robust tech stack that includes generative AI and integrates lifestyle medicine. That’s where coaches come in. Their aim is to both enhance patient care and provide increased access to care at scale. So, he was originally trained as a Cornell engineer, then turned Harvard-trained psychiatrist and public health specialist.

IMH is poised to redefine mental healthcare. Ravi’s unique journey spans from being the first clinical hire at Ginger, which is now Headspace. He’s played a significant role in its transformation into a leading telemental health company. He’s also been pioneering a large-scale mental health primary care integration using a similar care model at Kaiser, and this has benefited 200 primary care practices and half a million members.

He has been coding since age five. Incredible. Ahead of your time. And so he is going to be talking about coding today. He has been pioneering tracking technology, which inspired Find My Phone, which I know you’re all familiar with. So, Ravi, welcome to the podcast.

Ravi: Thank you.

Dr. Sandi: So, let’s begin by talking about the mental health situation. Do we have a crisis?

Ravi: Oh, my God. It’s a crisis of epic proportions, Sandi. The demand for mental health services has been climbing, and climbing, and climbing, and the mental health workforce has been shrinking. Prior to COVID, it was already at a breaking point. There were probably for every one psychiatrist out there, we needed three, and that’s in the United States. And globally, the situation is far, far worse.

And then you go through COVID and you see a tremendous surge in demand for mental health services, partially because of the destigmatization of mental health that’s occurred along with the huge stress and strain that the pandemic led to. There’s a lot of people walking around suffering. We’re just acting like nothing happened with the pandemic and everything’s normal, but not everything is okay. And you combine that with suicide rates that are continuing to climb, opiate crisis, substance abuse issues in this country. And some people have called it the second pandemic that we’re dealing with and having to figure out how to gain a handle on.

And then you think about the fact that some 50% of the psychiatric workforce is going to retire in the next five years. And that was a statistic that was cited three years ago. So, it’s an aging workforce of psychiatrists that we have, and there’s seemingly no end in sight to it. And so we’re thinking hard as a society on how we address that problem.

But these are the problems like, if we just look in our immediate family and our circles, we can see the ravages of mental health issues and what it’s causing. And it’s a problem on a global societal civilization scale. It’s nothing new. It’s always been a problem, but it’s seemingly accelerating.

Dr. Sandi: Oh, you’re so right. And it is also more and more people who are working in mental health, licensed mental health providers are not taking insurance. They have long waiting lists. They’re often cash-based. They’re unaffordable for many people. So, it is the perfect storm.

You talk a lot about the collaborative care model, which deeply resonates with me, because that’s what we teach is a collaborative care model. So, can you comment on how collaborative care can be part of the solution?

Ravi: Yeah, totally. And in my view, it’s the only solution to the problem that’s going to work. We’re looking at… So, first of all, the insurance situation is true, right? Like, if you imagine psychiatrists and therapists in the community who are slammed with demand, phones ringing off the hook, I would say to my psychiatry practice post-COVID, the call volume has gone up about fivefold. And just contemplate what that means. And that’s just a small sample size, but that’s how extreme the rise in demand is.

And so that leads providers to wonder, are we going to deal with insurance companies and all the nonsense and the pain and claim denials and arguing, or are we just going to have a simple practice, take care of as many people as we can, and let them pay cash? So, it’s a naïve choice, an innocent choice on the provider’s side, but then it leads to this huge issue where the people who need the care the most, right, are not able to have access. And it creates a social justice issue of the highest scale in access to these services.

If you think about it, the problem is actually being borne by primary care physicians. If you can’t find a psychiatrist or a therapist and you’re struggling with severe depression, where do you go? You go to your primary care doctor and ask them for a referral. And when you try and try and you don’t succeed, that PCP has to do something. And so these guys are our heroes, but they keep getting squeezed and having to see higher and higher patient volumes and they’re down to 6-minute follow-up visits, 20-minute initial patient appointments. Where do they have the time to actually sit down, and understand someone, and be with them, and connect with them, and do the work that it requires to do a good job?

And it’s too often they do the best they can do, which is to reach for the prescription pad and prescribe an antidepressant and hope for the best and tell people to keep searching for help. And so that’s led to 80% of antidepressants, for example, being prescribed out of primary care. And these docs don’t have the level of training that would be ideal for it. They’re just doing the best that they can.

So, the collaborative care model, when used in this mental health psychiatric frame, is something different than the generic term. It’s also called COCM. It’s a model of care that has about 30 years of research and evidence that was spearheaded by the University of Washington at the Ames Center. And the first model was called IMPACT. And there have been over 90 randomized controlled trials demonstrating the efficacy of this model of care where you take psychotherapist, a psychiatrist, and you find some way of measuring outcomes and tracking people longitudinally and make sure that people are getting better.

So, you’re basically going to a PCP, and reinforcing them, and helping them do the job better, and giving them the support they need. And when you do it that way, it leads to outcomes that rival, if not superior in some cases, to specialty mental healthcare services. We have to solve the problem this way. There’s no more psychiatrists and therapists that are going to be manufactured on any short-time interval. And so the problem has to be dealt with at primary care. And let’s take the analogy of diabetes. If every diabetic felt that an endocrinologist had to take care of their insulin, there would be a lot of dead diabetics on the street. And so it has to be a primary care function.

And so the collaborative care model is the evidence-based validated method for doing this in a systematic way. And it’s vastly superior in studies to just dropping therapists into primary care and having them help out vastly. And so the Biden administration in 2022 recognized this as the only real population-based way of delivering services to meet the need. And as part of the State of the Union Address, he announced that this was his signature initiative to help with the mental health crisis. And indeed they have acted. They have gotten all payers in the country—government, private, Medicare, Medicaid programs—to now pay for collaborative care services. So, when a PCP can contract with a psychiatrist and therapist to help them out, they can get paid for it and offer these services to their patients.

So, it’s very hopeful. The scale of a psychiatrist can go from 500 patients to maybe 5,000 in a model like this. And it’s my hope with the kind of technology we’re building, we can see scale vastly higher than that. And so this is the way to address the problem in my mind.

Dr. Sandi: Well, it absolutely can be scalable and you are so correct. So, it begins with that primary care practitioner. Back in the day when I was working as a psychologist and I was a health psychologist, most of my referrals would come from primary care practitioners, and it often, in a very few number of sessions because I was focusing on mind-body medicine techniques. And long before I founded Functional Medicine Coaching Academy, we didn’t even talk about lifestyle medicine in those days. It wasn’t a thing. It wasn’t described that way.

But I was talking to people about… In fact, I would have walking sessions. It was close to the lake in the Chicago area. And instead of just sitting in my windowless office, let’s get up and walk. And then after they came out, “Oh, I feel much better. I saw the lake and… Wow,” and their mood had shifted. So, we know that walking or any kind of movement is as good as an antidepressant.

But the practitioner in primary care, they don’t have the time. They don’t have the training in lifestyle medicine or to talk about the impact. So, can you share how lifestyle medicine can be integrated into this collaborative care model?

Ravi: Yeah, totally. This is one of the key innovations to the traditional collaborative care model that we’re building hard at IMH, because we need scalable methods of addressing these mental health concerns. And simple psychotherapy where a person spends an hour a week with a psychotherapist, well, then that psychotherapist who studied their whole life to gain those credentials to be a psychotherapist, they’re maxed out at 35 patients total. That’s not going to help us, and that resource needs to be used where it actually has to be used.

And so lifestyle medicine and, by extension, lifestyle psychiatry, which is a baby burgeoning field of inquiry with some good work being done, takes the question and says Okay, we know that the DSM gives us the criteria to diagnose depression, but let’s also look at the point of what constitutes remission of depression. What does it mean when someone is better? And that means you’re going to work. They’re sleeping. They’re eating. They’re exercising. They’re meditating perhaps a little bit but having a little bit of fun. And if a person does that, they actually don’t meet the depression criteria.

And so that was a question that was burning in my heart as I was going through residency training at Harvard many years ago. And I would ask all of my psychiatry teachers, these are the luminaries of the field, the best ones, the guys who wrote the books, why are we not just focusing on resolving the symptoms of the DSM criteria? And I couldn’t get a gratifying answer. And indeed, in my clinical practice over these years, practice as an integrative psychiatrist for several years now, that is the focus. That is the compass. We need to get these people functioning and living well and being well.

And when they do, what problem do we have really? And the consequence too is it’s not just a remission of symptoms. It constitutes a total rebooting of a person’s world. And it’s a miracle to witness. And I believe strongly that this doesn’t have to be done primarily by trained mental health professionals. It can be done with people who are skilled at that, who are trained at that, who have a passion for that, who want to do that work. And that’s where the health coach comes into mind.

And there’s been a lot of good work from the functional medicine school, the IFM. There’s been a lot of work that you’ve done, Sandi, to bring this and train people on how to give this gift to the world. And the American College of Lifestyle Medicine has also done a lot of great pioneering work. And we’re at a point where now this used to be called alternative medicine or complimentary care. To me, this is just plain common sense. It’s intuitive that we have to take care of people in this way.

And so a model of mental healthcare that takes the best of lifestyle psychiatry and holds it as our compass as we use the tools of mental healthcare like psychopharmacology and psychotherapy to remove the blocks, to heal the people so that they can succeed and excel at optimizing their lifestyle is how I look at this problem at this point in my career.

Dr. Sandi: Well, this is such encouraging news, and it’s exactly how I’ve always looked at this process. I was a renegade psychologist. And when I started, I was doing stress management back in the late ’70s, early ’80s, teaching people how to breathe, teaching people relaxation, how to let go of stress. And now in functional medicine, we talk about these modifiable lifestyle factors. And it’s nutrition, it is exercise and movement, it’s sleep, it is relationships, and it’s dealing with stress. And training health coaches to intervene in those areas.

And I just want to be clear for our listeners that we’re not saying that health coaches are doing psychotherapy. They are not licensed. Unless they have that training in previous training and they’re licensed, for example, in that mental health arena, but they can help people thrive. They support emotional wellness. And doing that through positive psychology, which is often looking at what’s strong with you, not what’s wrong with you, how can people thrive. And it is often in a short period of time.

Our research shows that even five sessions with a health coach and this can be done in groups, which would be even more scalable because you put people in groups, and now they feel not alone, and they are connecting with one another, and feeling hopeful.

So, I’m really, really encouraged by this by this model. And so can you say more about the role the health coaches can play? Because we had a conversation before this recording, and you have talked about wanting to engage health coaches in this exciting, new venture of yours, this intuitive mental health.

Ravi: Yeah, no absolutely. A hundred percent resonate with your perspective, Sandi. And at the end of the day, the point is to get the outcome, right? The patient doesn’t care about what modality or what was done to them. They just care about… They came with a problem, they’re suffering, and they’re begging for help, and they’re at their lowest point. Is someone going to reach out and give them a hand and help them and get the job done? And so I guess that’s the engineer in me being, kind of, agnostic to how it’s done, just that it gets done and it gets done in a way that’s consistent with values and what a person would want for themselves.

Let’s talk about the role of health coach. I think you’re right. The health coach is not doing psychotherapy. This is specialized: dealing with trauma, dealing with acute psychiatric conditions, dealing with hardcore personality disorders. This takes a lot of skill and training and supervision to create a therapist who can handle that. And that should be done by them.

But there’s this all other aspect. I think one point that’s really worth making here, Sandi, is in my training as a psychiatrist, when I was studying psychotherapy, I remember a professor teacher pointing out to me and all of us that years and years of research in the realm of psychotherapy has failed to show a difference between modalities and outcome. pause for three seconds.

Years and years of research in the psychotherapy realm has failed to show a difference between the different modalities, psychoanalysis, CBT, psychodynamic therapy. So, the implication of the research was that it’s the bond, it’s the connection, it’s the very human relationship between coach and patient or psychiatrist in-patient, therapist in-patient. The feeling that someone has my back, that someone’s going to be here with me on this journey and going to follow me and my give me pointers and keep me motivated, and I’ll try. And I’ll try again with and from them. That actually makes the difference.

And it turns out that there’s research on peer-to-peer counseling, just getting friends, or even anonymous friends. And does that the difference.

So, what we’re trying to do is create high-quality relationships with enough contact, with enough density of interaction, and that is really hard to do with licensed psychotherapists because they’re at such a premium and they’re so expensive and unaffordable. But with health coaches, we have a chance to actually give people the depth of connection that’s going to move the needle and make them feel connected. And being able to do this in an insurance model turns us into a gift to the population. And then at the same time, the coach has the skill of optimizing their lifestyle, which is half the game, right?

So, this is my conception of how a health coach plays into this game and working seamlessly, interdigitating with the care team. And we’ll talk a little bit about the technology, perhaps later on this conversation that can enable this to be done in a safe way and in a way that we’ve not been able to think about in the past. And I’m hoping that that empowers a platform like IMH that brings everyone together for their healing journeys.

Dr. Sandi: I love it. It reminds me of an experience that I had when I was working as a psychologist. I was a partner with a group of psychiatrists. And one in particular, he specialized in working with adolescents, and these were kids who… In those days, hospitalization or short-term hospitalization was often common standard of care for somebody who needed a residential or short-term hospitalization placement. So, this psychiatrist had weekly groups of kids in his office. Often it was post-hospitalization, getting them back into the community.

And he didn’t lead those groups. He had somebody who worked for him. I don’t think he even had a bachelor’s degree. He had worked in one of those residential units, and it was like magic. The connection that he had with those kids, I mean, the psychiatrist was just doing the supervision and oversight and if those kids needed to be on meds, for example. But the work, the transformative work was really being done by this residential aid, and he connected with those kids, and they changed, and they loved him, and they looked forward to coming to group and they participated and we all saw it.

And so anyone listening who thinks, “Well, I don’t have the training in healthcare. I don’t think I could do this,” you can. It is the ability to listen, the ability to build rapport to connect with people. And that is that human element that you spoke about. So, thank you for that.

Ravi: It’s the connection, the compassion, the universal love that we have for the people that we serve that… I don’t know. Somehow when people feel that connection, it’s healing, right? It’s what it does, the healing.

Dr. Sandi: Exactly.

Ravi: In fact, silence is healing. If you can just be quiet in that connection, that does half the game. And no class of human, no educational degree, no boundary has a monopoly on the ability to serve that up.

Dr. Sandi: Yes, exactly. And I don’t want to be critical of the mental health providers. So, there are many psychiatrists, psychologists who have that connection with people, and then there are some who do not as well.

Ravi: Oh, I mean to include them, too. When the therapist is able to heal, it’s that quality.

Dr. Sandi: Yeah, exactly. So, let’s turn to AI. This is a subject that is often feared. What is happening? I’ve seen stories that we’re working on… Your watch will have your health coach attached to it, your virtual coach, but it won’t be a real human. So, can you share this whole world of AI and how coaches can actually benefit from integrating AI?

Ravi: Yeah. No, it’s a huge topic and it fascinates me to no end. I’ve been a lifelong student, and I’ve worked on learning a great many disciplines and to realize that the price of intelligence is coming to zero is both as exciting as it is scary. And this was all ignited, of course, with ChatGPT making its debut in November, October of 2022. And the world is forever different.

In my mind, we’re looking at a singularity of the history of humanity where our machines now have intelligence. To quote Google CEO Sundar Pichai, the transformation we’re about to see with AI is graded at the level of fire or electricity as opposed to internet or smartphone for the amount of transformation that’s coming. And the world looks about the same to us, but in reality, the rate of change around us is going to escalate in coming years. And it’s going to be amazing, and it’s also going to be scary. Both sides are going to be there.

And my focus is around finding ways to harness this technology, to heal, to uplift people and to serve society. And I have a strong belief that that potential is very much there. And so IMH is the application of these tools to make us more human, to give us more connection and to allow us to connect with people even better and to take care of more people. So, I don’t think we have to grossly fear it. We have to just be aware of the fact that these things are happening and learn how to use them to our advantage.

Dr. Sandi: So well said. And it is that magic of having the human connection, which can be a coach, a clinician, or a connection with even peer-to-peer in a group, for example. But it is that magical human connection where you know that you’re being listened to, you feel heard, combined with the best of AI, with technology. And certainly we are looking at the benefits of… We’re tracking data. We have CGMs. We have our smartwatches. And so as coaches become more comfortable integrating this technology and there’s many different applications, remote patient monitoring being one where even the insurance companies are now paying for that. So, it is exciting to think about the future and how this technology can be leveraged in a very positive way.

Ravi: Yeah, let me give a little bit of example there, too. And it’s a little abstract because I think it might be helpful, right? In my mind, it isn’t that the AI replaces the human. It’s that the AI becomes our superpower. And so imagine if you’re with one of your clients and all of a sudden you have, at your fingertips, all the knowledge you need about what this person has been doing, what their concerns are. And when you say I would like you to eat a Mediterranean diet, that that automatically gets sent to the person, questions that they have about it, or being answered and presented to you at your next session, so you can discuss them with them. And when there are things that are concerning to you like you’re getting into some deep trauma. The AIs are able to guide you at how to handle it and refer it to, in our system, your supervising therapist who can continue to carry the torch. So, it allows us to be a little more fearless, a little more engaged and connected with the person and to know that you have this backup that’s with you and doing the work is, kind of, the way to look at it. So, it’s exciting times.

Dr. Sandi: Definitely exciting. Ravi, where can our listeners find you?

Ravi: Well, if anyone’s interested in what we’re doing at IMH and wants to join us on our quest in supporting the mission, find me on LinkedIn. That’s a good way to reach out to me directly. And also you can check out website at intuitivementalhealth.com and find more information about what we’re doing and reach out to us there.

Dr. Sandi: So, you heard that, and we will also include in the show notes. Ravi, this has been a fascinating conversation, and I would like to continue it, to have you back with updates on you and your mission, your work with what you have started, and I think this is so needed at this time. It’s a critical need and to look at your vision for how you are addressing this that still aligns with our vision at FMCA and how we train health coaches to be that mental health, not the provider, not the licensed provider necessarily but that key person because you’re helping people to change.

Ravi: Fantastic. Thank you, Sandi.

Dr. Sandi: Thank you.