Episode Transcript:
Cara McNulty
We need to have mental health at that epicenter, and not make it an afterthought, or a whispered topic.
Robert Traynham
Welcome to "Conversations in Care", a special series on the Next Big Thing in Health where we come together to have honest and heartfelt conversations about the defining issues in health care.
I'm your host, Robert Traynham, executive vice president here at AHIP. If you'd like to watch the video episode of our discussion, head to YouTube and search for AHIP Coverage, or check the show notes for links. Come on in!
I'm here with Cara McNulty, president of behavioral health and mental well-being at CVS Health, to understand what programs, conversations, and commitments we need to be focused on to raise awareness around and improve mental health, especially among adolescents.
Before we begin, I'd like to forewarn you of the serious subject matter we cover in this episode, including self-harm and suicide. If you or a loved one are seeking help, please dial 988 for immediate support.
So, I want to know two things. First and foremost, your favorite Prince song. And do you really like purple?
McNulty
Okay, easy. I love purple. Okay. Favorite Prince Song? I mean?
Traynham
I mean, Purple Rain, we’ve got…
McNulty
Cream? Okay. I mean, I'm going…
Traynham
Oh, no, no, your that'd be, that's like circa 1982, 83. Yeah.
McNulty
Yeah, I'm going...[way back]
Traynham
You know, it's funny, because I think Michael Jackson, Madonna, Prince, Tina Turner, and probably The Grateful Dead are probably like, like, just profound music. Like, to me, it just speaks to me on so many different levels. You know, I think we talked about this before, but Prince, in my mind is, you know, gone too soon, in many ways.
McNulty
Totally gone too soon. And Tina, I mean, lights out. Talk about a story.
Traynham
Let's so let's talk about that. Right. So, Tina, in many ways, grew up the American dream in many ways, you know, a success story in many ways. But she herself, really struggled with mental health. She herself has openly talked about how she didn't have anyone to talk to. How she moved to Buddhism, how she moved to singing, because at that time – and you can even fast forward to today – there wasn't anyone to talk to about mental health. There was a big stigma around that. Right? So, in many ways, she is a living, breathing example of something that I want to talk to you about. And that's mental health. Why is it, Cara, that we really don't talk about this?
McNulty
You know, it's, it's so interesting. We'll tell people how much money is on our bank account. We'll talk about our personal intimacies, we will share diagnoses of cancer, or you name it. And when it comes to mental health, there is a stigma, a myth that if we share, if we share, “Gosh, I'm struggling with anxiety, or depression, or bipolar,” or, “I've had thoughts of self-harm,” that people will equate that to being broken. And listen, it's in all of us … can't we just buck up? And in some communities, the word mental health or mental well-being is never mentioned.
Traynham
In many ways it’s a sign of weakness, not a sign of strength, right? In many ways, it is a sign of being broken, not strengthened. In many ways, yeah, I have so much money in the bank, or yes, I had this amount of incidences, you know, kissing my boyfriend or my girlfriend, but so that it's like these, like, proud achievements. But the moment you talk about being vulnerable, the moment you talk about not feeling okay, the more we start to whisper about it, and we try to, like, hide it under the rug because of the stigma. So, I want to talk about some of the great work that you're doing at CVS Health to kind of break that stigma, if you will. I want to talk for a few moments about a study, where, as I understand it, 16.3%, roughly 17%. Let's talk about that number. What does that number mean to you?
McNulty
So, when I hear 16.3%, I think, “Yes!” That number equals a few thousand mothers, fathers, sisters, brothers, children, aunts, uncles, neighbors that were prevented of dying by suicide. We put a stake in the ground. We believe suicide, in most cases, is preventable.
Traynham
Yeah, you know, if I can be vulnerable for you…I lost a really good friend of mine to suicide. And it's interesting, literally, she was staring me in the face by saying, “I'm not feeling okay.” I would say, “Eileen, cheer up,” you know, “What's going on?”
“Oh, I'm just feeling blah.” And the next moment she took her life.
So, with the benefit of hindsight… She was a mom. She's now a grandma. She was a sister, and obviously a wife and a dear, dear friend. But it's one of those things where – two things. One, I wish I would have had… I would have seen some of the signs that were staring me right in the face screaming, screaming, Cara, but I didn't hear it. And then, two, she wasn't able to say it in a way where I could hear it because of some of the stigma.
McNulty
Right. And, first, I'm so sorry, about the loss of your friend, because that that is a mother, a friend, a sister, a loved one. And often we can't see it. And so we have to, we have to help people understand what it looks like to get in there and say, “Eileen, how are you?” And I mean, for reals, not for the like, “I'm good.”
Traynham
Yeah.
McNulty
And we have to teach people how to do that. And what to do when somebody says, “You know what, I'm not good.”
Traynham
Yeah.
McNulty
And so, we have to implore people to talk about it. Because Eileen spent years likely suffering in silence when nobody has to suffer in silence. And our mental health is just like our physical health. I mean, we talk about taking care of our physical health all the time. You can't pick up any source of media without somebody talking about how we need to eat and exercise and sleep and what's good for you and what's not. And we're only starting to hear that about mental health. I mean, every day our mental health needs care and support and nurturing and feeding. And if we would teach that and talk about it, the Eileens of the world wouldn't have to suffer alone.
Traynham
Can you talk to us about some examples that you are working on at CVS health, to help the Eileens and also to help the moms and the dads so that 16% gets higher and higher and higher? And, by the way, congratulations for that double digit number. That's a milestone in and of itself. But we always know that there's room for improvement. And we always know that there's more lives to be saved.
McNulty
There's so much room for improvement. So, we made a goal at CVS Health via the members we were serving through Aetna medical plans, that if we really believe, which we do, that suicide is preventable, then let's hold ourselves accountable. And let's put out a goal. And it might be audacious. And it's risk taking, that we would reduce suicide attempts 20% by 2025.
Well, in order to do that, you have to look at how we're talking to people, serving people, meeting their needs really differently. The whole ecosystem, right? Because it's not one effort. It's not one interaction. So, we started with the basics.
One, we really listened to people who had been struggling with self-harm, with prior attempts, to say, what would have been helpful? What did you need? They needed not to have the barrier or extra steps. They needed not to have to muster up more energy when they had none. And so, we looked at best practice, and looked at how could we do a better job of assessing people no matter what they're talking to us about? So, doing that brief check in. So, we implemented some brief screenings — a PHQ-2. If you trigger on that PHQ-2 — it’s two questions — we ask you a PHQ-9. So, we're, we're getting up front, we're not waiting for someone to be in that self-harming behavior. We started there.
Then we started looking at what needs to happen when there is the triggers of self-harming behavior. And we started looking at our data to say, what else is taking place? Is somebody in and out of the ER? Are they struggling with other physical health issues? And we started looking at patterns and then doing outreach.
And then we deployed things like, once someone had been discharged from an emergency room for self-harm, instead of sending them information about suicide, we sent them a caring contact. It's really simple. This is done all over the world. It simply says you are cared about. You are not alone. And here's some resources. The number of times people tell me, I have that postcard in my office, in my bathroom, in my bedroom. And then we continue to follow up with the resources, the care, the support, that normalizes our mental health. Having mental health issues, is part of being human. So really making it so people don't have to do this alone.
Traynham
Thank you. It sounds, like Cara, that one of the big steps here is normalizing the terminology around, “You're not alone. You're cared for. Please don't think that you have to make this journey by yourself. There is an apparatus around you, that can really help you every step of the way.”
And what I'm hearing from you is that this is a journey. And so I'm sure it would be jarring for someone to receive. Are you going to kill yourself? Call this 800 Number? Really? Can we can we back up a little bit? Can we talk about why I'm feeling this way? Can we talk about it? So thank you for making that point. Because I think that's incredibly, incredibly important.
I want to spend a few moments talking about employers and how they show up in this regard. Because my bias is, is that there could be a stigma out there by saying, “Listen, you use your PTO and use your sick day if you have a headache.” You know, if you have a major medical event, i.e., you fall down the steps, of course, you should take a sick day. What if you're not feeling great when you wake up in the morning? What if you feel like not taking a shower today? So, in other words, there's some other issues that might be going on. But it's not normalized to take a sick day for, quite frankly, you show up for work. You're not feeling great? What's wrong with you? You know, what do you do? “You need to go to the ER,” as opposed to maybe saying, “How are you feeling?” Right? Does that make sense?
McNulty
Makes total sense. It's that check in: “How are you?” Yeah, and I mean, for real, not just because we're passing, that superficial? I mean, I want to know. And I'm okay if you tell me you're not good. And you know, employers because….
Traynham
…it's not okay to be inauthentic.
McNulty
Right. And that's it. That's totally it. And if we think about the job, and that tough job employers have, you employ this diverse group of humans, which is awesome. And it's about creating a work environment, where people can feel themselves, where they can come up, they can come in like, “Take me as I am.” And in order to do that, to create that culture – and we know when you have a culture of inclusion, you likely have a culture of diversity...
Traynham
That's right.
McNulty
…And equity, and a culture that people want to be in.
Traynham
That's right.
McNulty
So creating that culture of inclusion for employers means being really open about mental health. And that it is okay not to be okay. And that calling in, or going home, because you know, what, today just isn't a good day.
Often with depression, for example, some of the most beautiful days I experience are in the fall in Minnesota. People who have clinical depression, often find the fall in Minnesota to be the hardest. It's a transition. So not assuming that what I experience is what someone else experiences. And when employers can welcome and be inclusive and drive that inclusivity around your mental health and well-being as well as your total health, they win. I mean, when people want to stay, people want to give the best they can, then people are jazzed about the company they work for.
Traynham
I want to spend a few moments chatting about some other solutions. Technology, we understand that there should be some guardrails there. In many ways, technology is open. It meets people where they are, there could be a sense of inclusion and connectivity. And in many incidences, it could drive even more loneliness or whatever the case may be. How are you tackling this in your role at CVS health?
McNulty
So, we know, technology is such a powerful tool. And with that power comes great responsibility and some really hard reality.
Traynham
Yeah, yeah.
McNulty
So, I think about the work we do with adolescents. And if you think about the impact right now on adolescent mental health, and what we have seen, during a pandemic, post-pandemic, social unrest, all the changes in the world, our adolescents and young adults have struggled. And, and social media, which has been a big form of their interaction and engagement and how they connect became a primary tool for connecting because they weren't engaging with their friends, they likely didn't go to school in person, maybe they didn't get to go to that, you know, internship. We were isolated.
What we've seen is adolescents, young adults, Gen Z is a population, that is spending three or more hours on a device a day and has an increase in depression and anxiety. And it doesn't mean it needs to be consecutive, it means throughout the day. The average person picks up their phone 120 times a day. We are connected to these devices.
But what we see is for adolescents, what they notice, and young adults, what they notice on social media is the best of the best, because it's what we put out there, you know? It's the best vacation. It’s the best pictures. It's the best filters. It’s all of it. And you start to feel, these adolescents and young adults start to feel that, “Oh, look at everybody has it put together and I am so alone.” And then you overlay, LGBTQ. And we even have a greater disparity.
And so we are addressing this by, one, talking about it. Two, we work with schools, communities, employers, you name it, to not only look at what is best practice, but how can we empower that ecosystem change?
So, with adolescents, we developed a whole initiative where we talked with adolescents, we learned what adolescents needed, we looked at how to help them engage in this conversation. We wrote a toolkit for adolescents, for parents, for schools, and teachers and superintendents, all different toolkits on, “Hey, how do you address mental health? How do you really make it an inclusive discussion? And, “How can we get these young adolescents and adults in need the support that they deserve? Before they're in crisis? It's why we talk about mental well-being. Mental well-being is really addressing that holistic, upfront. Make your mental health part of your total health.
Traynham
We've seen recently a United States Senator and also some other influencers out there, particularly in Hollywood, openly talk about their mental health journey. Do you believe that's a good thing, that more and more people of stature are talking about this in a way that perhaps individuals could say, “Finally, I'm not alone. Finally, when I open up my device or turn on the television set, I see someone that either looks like me, and or someone that I admire and respect?” Have you seen a correlation there?
McNulty
Absolutely. And we not only need those famous or influencers or celebrities to talk about it. We need you and I talking about it. We need the local pastor to talk about it. We need the sales clerk to talk about it. Because you might relate to somebody very different than who I relate to. And we have to cast the net wide.
You know, one of the things I share is I'm in this field, my husband and I have two kids. They're 22 months apart. And when our second daughter was born — I’m in this field and before I know it, this little baby is sick, and she has RSV which is a respiratory issue. And you worry about them not being able to breathe. And so, I thought, well, sleep deprived, I have a two-year-old and this baby, I'm just going to hold this baby. I'm just going to hold this baby because then I'll know she's breathing. And I really don't need to get out of my pajamas because like, then I'd have to put her down. So, I don't really need to shower. And I don't, I don't need to eat. And in a very short amount of time, I'm not eating, showering. I'm not sleeping. I'm sitting on the floor in my kitchen, bawling, holding a baby who I know is breathing. And I'm like — she's breathing. And I have a toddler next to me rocking back and forth. “Mama's crying, mama’s crying.”
I had every resource possible. Every resource: insurance, a partner that is in it with me. I'm in this field.
And I couldn't get myself off that kitchen floor.
What I needed was exactly what my husband said, which was, “You know what, Cara, this isn't how this is supposed to go. I don't know exactly what to do. But we're going to do it together.” And, and then we got help.
I had no idea what postpartum anxiety was. So, the more we share… that young baby is about to turn 18. I can't tell you the number of times I share that story. And someone makes a comment to me like, “I have just gone through that.” Or, “I'm going through it.” Or, “Oh, you look like you have it all together.” Like oh, I still have anxiety, still treat my anxiety. Like, talk about for reals. But the more we do it, the more we normalize it.
Traynham
100%.
The reason why I brought up my friend Eileen, is because and you just shared it with your daughter is because oversharing in this way. Overly communicate, but also just being vulnerable. Yeah. And the reason why I think this is so important Cara, is because, guess what? Breaking news: I am human. And so are you. Yeah. And so, no matter what title we have, no matter how much money we have in the bank, it, kind of, doesn't matter.
What matters is walking this journey called the human race and saying, “Listen, I've kind of walked in your shoes a little bit, would you mind me sharing my story? Because maybe, maybe you can learn from that? Or maybe we can walk together on this journey.”
McNulty
Right.
Traynham
And it's a journey called life.
McNulty
It's totally is. And if we do that, and do it well, my guess is me sharing that story, you don't think anything different? No. Except yes! That's what we need to do. People inherently want to support each other.
Traynham
100%
McNulty
They want to support each other? And the worst case scenario? Is when we don't know, because we want to help people. I know, you want to help your friend. I know that. And so the more we talk about it, the more we make it easier for people to get care and support. The more we normalize, the more we make providers available in communities – that represent that community – the better off we are, because all of us will have some kind of mental health disruption.
Traynham
100%
McNulty
That doesn't mean it will be an illness. But we will have disruption.
Traynham
100%. So we talked a lot about the problem. We actually also talked a lot about some solutions. Real talk. How comfortable are you in that progress of 20% by 2025? Realistically, how comfortable are you with it?
McNulty
I'm really comfortable. And that's also scary, because I'm really comfortable when it comes to the adult population. And that's what we set that goal at.
But what we saw is that we weren't making progress on adolescents and young adults. And so we are now saying, “Okay, what we do for, the average 30, 40, 50 year old, 60, is really different than what we do for adolescents and younger adults.” And so that is where we have to, we have to dig deep, because it is different, how we deploy initiatives and provide support. And so we're making improvements in that adolescent population. But that is the population that is experiencing the greatest impact in increasing suicide rates right now.
Traynham
Yeah. In many ways — I don’t have the numbers to back this up – but it feels like that is the population that is under the most duress. It feels like just given so much in innovation, which is a good thing we already talked about. There's a lot there with respect to their own mental health. And with innovation that could go the opposite way. We have We'd even talked about AR, VR — artificial reality and virtual reality. We haven't talked about the shrinking attention span that is currently at 9.5 seconds, but it's getting shorter and shorter and shorter. We haven't talked about how so many people, adolescents think that their phone is their friend. And so confides everything in this device, and barely looks up and gives their friends eye contact. And so there's a lot — much more work to be done there. I'm editorializing. But from your perspective, currently the next big thing in health is:
McNulty
It will be where we don’t treat mental health and physical health separately, and we all talk about it. But that it is, no matter what is happening. You’re having a baby, we’re talking to you about the changes in mental health. You have a new diagnosis, we’re talking to you about that mental health. And again, we talk about that, but we’re really making it happen.
I would say the next big thing, also, is how we use technology and data to get ahead, to be looking ahead and to be planning that everybody's going to have disruption. But we're talking about it differently. We're acting differently. We're deploying initiatives differently. I mean, maybe we'll even use, you know, new technology to deploy how we deliver therapy, and counseling, maybe we'll use virtual reality to meet the needs of people in populations or in communities where there is a lack of providers.
Traynham
Yeah, it's interesting, because let's say hypothetically, you live in a rural area, you depend on public transportation. And as we all know, with public transportation during the weekday, it's pretty robust. But on the weekend, it's pretty sparse for the most part. And so I want to talk to a therapist on a Sunday afternoon. That's just how I choose to show up. But perhaps the therapist — a physical therapist — is not available on a Sunday. Can I fire up my phone or my other smart device and maybe do something via the metaverse or AR, VR in the future? And perhaps maybe on the other side of that screen. There isn't any bias. There isn't any anything there but just a loving, reaffirming, listening ear. You know, I guess my last question for you, Cara, is, do you think that's during our lifetime? Or do you think this is like George Jetson 50, 60,100 years from now?
McNulty
Oh, I think it's during our lifetime. Yeah. If we don't invest in the mental health and well-being of our communities, of our families, of each other. What do we have? We often say without health, we have nothing. I would say without mental health, at the core, our health is impacted. Our economy has impacted our relationships, our ability to strive and function, to find peace, joy, to grieve. We need to have mental health at that epicenter, and not make it an afterthought, or a whispered topic.
We need to talk about mental health and well-being really differently. And I believe that will happen. I believe it is.
Traynham
Very well said Cara McNulty. Thank you very much for joining us. Thank you.
