What's well known is that people with a chronic illness such as asthma, back pain, diabetes or heart disease are more likely to be depressed than the general population. What's assumed is that these people are depressed simply because of having to cope with the difficulties that come with a chronic illness. But it's not that simple, says Dr. David Whitehouse, chief medical officer for strategy and innovation with OptumHealth Behavioral Solutions.

"The trouble is that if you have one bad gene the likelihood that you have another bad gene is slightly higher," he says. "So these people have genuine full-fledged depression as a separate illness - not just because they're sick."

To make coping more effective, it's important to take a holistic approach to health care, incorporating both the mind and body into the wellness picture. As Whitehouse points out, "your ability to cope with your illness ... is significantly impacted by your state of mind."

So just what is that state of mind? OptumHealth offers MyBrainSolutions for employers to help their employees find out.

The comorbidity factor

Not only are chronic diseases and mental illness closely tied together, but so are the costs and effective rates of treatment, says Whitehouse. For example, someone who suffers from both depression and diabetes is likely to have health care costs that are 25% higher than another patient with diabetes alone. Therefore, it is paramount to help employers teach plan participants to manage both illnesses simultaneously.

The first step is to assess how well an employer's various benefits are integrated. When employers started to get serious about chronic illnesses, in came the disease management programs. The consequence, says Whitehouse, is "we split the mind and body."

An employee is referred to an expert in diabetes management, but that professional has no experience with depression. The result is the "throw-it-over-the-wall syndrome," where the depression is identified, but the patient is referred elsewhere for that treatment. Not a great solution for the approximately 75% of the U.S. population who get their mental health care from their primary care physician, says Whitehouse. "To go and make another set of appointments and take another afternoon off from work and negotiate who's going to pick up the kids and so on just creates another series of hassles in their life," he says. "What works is not just implementing a program but really finding out from the patient what they think will work for them with their schedule, their past history."

Emphasizing health psychology

Hippocrates understood the importance of going beyond the disease to identify the person who has it. Assessing the proper way to speak to individual patients is crucial, says Whitehouse: "One of the reasons disease management at times is not successful is that it really understands your disease but it doesn't understand you as a person."

Even the most compassionate and caring medical professional is going to have a hard time getting through to a patient who is scared, anxious and overwhelmed, he adds. "You think you're being wonderfully caring and they're thinking, 'Do anything to make this stop.'"

There are health psychology tools being developed to teach both patients and their caregivers a way to get a sense of a person's mental state and how they interact with their environment. OptumHealth's screening tool, MyBrainSolutions, starts with a 10-minute, Internet-based assessment known as BRISC - brain resource inventory for social cognition - that uses a normative set of demographically matched peers to create a profile of the way the participant's brain is operating. It measures three areas: negativity bias, social skills and emotional resilience.

The negativity bias takes the "temperature" of the participant's brain to assess whether or not the emotional and cognitive brain is stressed or overwhelmed, but does not reveal the underlying reasons behind the state, Whitehouse explains. The social skills assessment shows how a person views the other people in their environment: Do they see them as a help or a hindrance? The third area, emotional resilience, reflects how each of us is affected by the everyday happenings in our life and how we are capable of dealing with them. A highly emotionally resilient person can receive instructions on how to care for a chronic illness and if they encounter an obstacle they will find a way to manage or overcome it. Conversely, someone who struggles in this area will become lost the moment an obstruction arises. "There, the person needs a lot more coaching and interactive support," according to Whitehouse.

The BRISC is followed by a more comprehensive 40-minute assessment that "puts the brain through its paces" using tools such as recognizing the emotions on a series of faces and navigating mazes to help understand how the brain may be stressed.

"All our human capital every single day is held hostage by our emotional brain. If my emotional brain is off today ... I could be bright as anything but it wouldn't really matter because I'm not going to be concentrating on getting anything done," Whitehouse says. "Some employers have begun to see the importance of engaging people in brain health and things they can do to exercise , train and and understand their brains and so their emotional health is better."

Following the assessment portion, the participant can learn more brain health and how to leverage brain-body interactions to improve physical and emotional health.

A healthy option

Nationwide Insurance first introduced MyBrainSolutions to its 34,000 employees on April 1, 2009, but the company was already familiar with the concept of a brain assessment through a previous OptumHealth product designed for people already diagnosed with depression. While the original program was used in conjunction with the company's EAP, Kathleen Herath, associate vice president of health and productivity with Nationwide, was excited to introduce MyBrainSolutions to a broader audience.

"It really appealed to us because it's one of the first programs that is for people who are mentally healthy, long before they're ever in crisis," she says.

It's also been a great way to introduce employees to the EAP and Optum's counseling services that's non-threatening and destigmatizes the EAP, adds Herath.

After sending one e-mail inviting employees to try out MyBrainSolutions, Nationwide had approximately 800 people complete the first assessment, followed by 300 who did the follow-up evaluation a month later to check on their progress.

Because Nationwide already offers "a full range of coaching programs" Herath wasn't expecting large numbers of employees to respond to a single e-mail. However, she was pleasantly surprised with the numbers when they launched it again Oct. 1, 2009 and had 550 people sign up in the first few hours.

To maintain the highest privacy standards the company recommends employees don't do the program on a Nationwide computer, but no matter where they take it, there is no link between the participant and Nationwide before the results go to OptumHealth. OptumHealth does send an aggregate report that contains data such as participation rates. "From a regulation standpoint, it's not asking family history or any of those kinds of questions that are now an issue with GINA," says Herath.

Goals

Regularly strengthening the brain with positive recognition can have an effect on the way a person looks at the world. The exercises in MyBrainSolutions strengthen the contacts in the brain that increase the ability to accurately scan for a particular emotion. "If you do none of that training whatsoever, your brain decides to set its threshold based on unconscious things going on inside you," says Whitehouse. "This way, you can get people to try and set their brains to notice certain things ... and it impacts the way they react to the world, the world reacts to them, and their productivity and their happiness."

Nationwide offers a $260 incentive credit to employees' HSA or HRA accounts as well as a $260 premium discount for those who participate in a wellness program such as MyBrainSolutions. The benefit of adding MyBrainSolutions to their wellness offerings, says Herath, is that it offers people with chronic conditions a new tool to help manage their illnesses. It also provides an option for the low-risk employee population that feels they've already gotten all they can out of weight loss programs, nutrition classes and the like. "If you're operating the best you can be, even if you have a chronic disease, you're more likely to be compliant. You're more likely to do what you need to do to mitigate that disease if you've dealt with some of the other issues," she says. "So I think it's a nice adjunct for people who need a health coach for other reasons and I think it's a nice program independent of that for people who don't have any risk."

Over the long term, Herath is looking to see improved productivity levels among employees who participate in the program, as well as increased utilization of Nationwide's EAP services.

"As an industry, we haven't done a very good job about offering programs for people who are mentally healthy who just want to be mentally healthier. It's about protecting your own brain," says Herath. "We tell people to protect their immune systems, exercise, protect their cardio systems but we haven't really done anything to help people strengthen their mental outlook, and that's really the beauty of this program. It's a tool to operate your brain at its peak performance."