Women’s Health is Mental Health. Mental Health is Women’s Health.

Crazy. Manic. Hysterical. Emotional. Overwhelmed. Lady problems.

These are just a handful of words that I have heard used to describe a woman’s mental or emotional state over my 30 years as a frontline OB/GYN — a testament to both our culture and healthcare system’s radical misunderstanding of female mental health and the intricate ways in which the female brain, hormones, and environment interact to influence health and wellbeing in a distinctly female way.

With a longstanding belief that mental health is women’s health and women’s health is mental health, I am thrilled to announce that Tia now offers mental health as a “core” element of Tia’s comprehensive women’s care model — available today to Tia patients virtually, and soon, offline at the Tia Clinic.

The Disproportionate Female Effect

It is well known amongst both researchers and healthcare providers that women are disproportionately affected by mental health disorders due to a myriad of sex-specific differences in brain chemistry, adverse sociocultural factors, and of course, hormones. In the U.S., women from puberty to menopause are diagnosed with depression and anxiety at 2X the rate of men and take antidepressants at 2X the rate of men.

As Tia’s Chief Medical Officer and first practicing gynecologist at the Tia Clinic in NYC, I’ve seen firsthand this population health data mirrored in our patient population.

And over 13% of Tia patients currently take an SSRI (a selective serotonin re-uptake inhibitor such as Lexapro, Prozac or Zoloft).

In light of Covid-19, the need for mental health integrated into our core offering has become even more evident — we’ve seen a 400% increase in mental health-related messages on our Virtual Care platform and a 200% increase in messages associated with mental health-related medications.

It is in response to this evidence and escalating patient need that we’ve accelerated the launch of our mental health program.

Mental Health the “Tia Way”

As the modern medical home for women, it has always been Tia’s intention to incorporate a multifaceted mental health program into the nexus of our women’s care model, alongside other evidence-based wellness modalities such as nutrition, acupuncture, and physical therapy. We believe these offerings should be “core” and not delivered in a silo.

Mental health encompasses biological contributions to mental wellbeing but also considers other integral factors such as the mind <> body connection, substances, and their abuse, lifestyle habits and behaviors such as sleep and nutrition, and external, environmental and situational forces.

Accordingly, providing comprehensive mental healthcare for women the “Tia Way” includes:

#1: Robust mental health screening for anxiety, depression, trauma, domestic violence, and safety in your environment as part of every Well-Woman Exam and other complex health visits (e.g. sleep disorders, mood changes, sexual function, weight gain, fertility). We believe this is essential for both accurate diagnosis, triage, and treatment of mental health disorders that are all-too-often “missed” in a gynecology or primary care context, and also for disease prevention and care management of other common issues with high comorbidity rates.

#2: Training for all Tia GYN and PCPs on mental health screening & appropriate medication management, including the interactions between SSRIs, other medications and hormone modulators including birth control.

#3: The inclusion of a licensed clinical therapist — available virtually today and soon, on-site at the Tia Clinic — who will practice in a “Collaborative Care” model to enable both counseling and medication management prescribed by an accompanied physician.

#4: Free, group-based community programs such as “Support Circles” (virtual and in-person) for women struggling with anxiety, trauma, and grief or loss. These community programs connect women with other women and a licensed clinical therapist in a safe, trusted context to enable ongoing education, healing, and support to compliment 1:1 care.

#5: Care teams that can facilitate seamless referrals into other mental health providers for issues that escalate and are out of Tia’s scope (e.g. complex medication management, addiction support, schizophrenia, bipolar disorder, suicide). We recognize the broad spectrum and complex nature of mental health and the need for highly specialized care. Like any primary care provider, Tia serves to be the “front door” and the initial point of triage existing to both provide care and route patients’ care to others as appropriate.

Tia’s Mental Health Care Model

In designing Tia’s mental health care model, we looked to proven playbooks from leaders in the field, and layered in our unique understanding of how female health is distinct from male health, asking ourselves: what type of mental health support would the majority of Tia’s patients benefit from? Where is Tia uniquely suited to play and where should we partner? And how can we deliver high-quality care, most affordably to maximize access?

These are our core tenets:

Collaborative Care

Significant, high-quality research spanning three decades from the American Psychiatric Association has shown that the Collaborative Care Model — the integration of mental health into a primary care setting — is both highly effective and efficient at delivering improved outcomes for patients mental and physical health, while also controlling costs, and improving access as well as satisfaction with care.

Given the high comorbidity rates of mental health and chronic disease (amongst women and men), the inclusion of mental health into a patient’s “front door” care setting — primary care, or in the case of many women, their OB/GYN — is increasingly important.

The four core tenets of Collaborative Care are emblematic not only of Tia’s mental health program but of our Care Model more broadly. Across all aspects of women’s health at Tia, we practice Collaborative Care that is team-driven, measurement-guided, population-focused and evidence-based.

Multiple Tools in the Toolkit

At Tia, we adhere to a “multiple-tools-in-the-toolkit” approach to female health, both mental and physical. This means when a patient reports mood changes or anxiety (for example), we consider medication (if appropriate) in addition to other “tools” — inclusive of therapy, hormone modulation, diet, sleep, acupuncture, meditation, and other non-pharmacological interventions.

As an integrative Care Team, we do not prescribe to an “either-or” approach, but instead, strive to provide our patients with options, education, and counseling on the best choices for their individual needs and realities.

Our care model is manifested in the technology we build — designed not only to enhance patient choice but also to encourage informed and shared-decision making for patients and providers alike.

The Distinctly Female “Hormonal Grid”

At Tia, we approach a female patient’s physical, mental, and emotional health through the hormonal grid — considering many aspects of diagnosis, treatment and prevention of a female’s health through the hormonal state in which she is currently existing — natural cycle, synthetic hormones for contraception, pregnancy, or a period of hormonal deprivation such as postpartum or menopause. We know that these hormonal states influence metabolism, brain signaling, immune function, DNA repair, and mood.

With this nuanced understanding of the hormonal grid, we educate our Tia Care Providers to consider if and how SSRIs and hormone modulators interact in a patient. For example, what is the interaction for someone who is taking estrogenic birth control, Prozac, and Klonopin to manage anxiety and depression? We always consider whether an SSRI or hormone modulator is appropriate, or should be considered in addition to, or in lieu of, the other.

Accessibility

Extensive research tells us that access to mental health — due both to a shortage of licensed mental health providers as well as the cost of care — remains the biggest issue facing both women and men nationwide. More than a quarter of adults who experienced serious psychological distress in the previous year in the U.S. reported an unmet need for mental health care. Almost half of the people with unmet needs reported that they did not receive treatment because they could not afford it. And while access issues are particularly extreme for low-income populations and people of color, the problem permeates across the socioeconomic spectrum; with 40% of privately insured patients with serious distress lacking mental healthcare due to cost.

In NYC — one of the top healthcare capitals in the world — there are only 291 mental health providers for every 100K people in 2019, ranking New York State the 17th in terms of patient and provider availability. With the majority of mental health providers operating outside of the insurance system, and cash prices that can exceed $400 per hour, mental health remains inaccessible to the majority of New Yorkers, and women nationwide.

While the reasons for these access barriers are deeply rooted and complex, Tia is committed to making mental health more accessible through affordable cash pricing as well as working with commercial payers Tia is contracted with to be able to accept insurance coverage in the near future. Despite the inherent challenge and complexity of the insurance system, we believe that working with insurance providers to push for expanded coverage is the most critical thing we can do as an innovation in the space to enable access for women at scale across the socioeconomic spectrum.