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As Lt. Gov. Elizabeth Roberts said at the start of our 2011 Conference, “Healthcare today is like a deck of cards tossed up in the air. We have the opportunity to put the deck together in a new way, especially by building a better bridge between physical and mental health.”

While it may be difficult to get a handle on the overlap between physical health problems and emotional/mental health disabilities, what is known is that depression  (the most prevalent mental health disorder) is a medical problem that portends much worse outcomes for other health problems. Depression isn’t just in the head; it affects nearly every internal organ system adversely. Women are twice as likely as men to suffer from depression.

Suicide is the 10th leading cause of death in the US and is recognized as a public health issue in RI even though the rate of suicide for women is below the national average. However, suicide rates for men are on the rise. The white population is most affected, although this population is least likely to live in poverty.

Good to Know

Depression has multiple causes. Some causes we have control over; others we do not. Preventable causes include: smoking, sedentary lifestyle, obesity, system inflammation and failure to report. But abundantly and strongly associated with depression is early childhood stress (abuse, neglect and poverty). Large-scale studies link this early life stress to many other preventable diseases.

Many risk factors for suicide are treatable but 80% of completed suicides went untreated. The number one cause of suicide is relationship separation or conflict. A program sponsored by the RI Youth Suicide Prevention Project focuses on core RI cities where more than 15% of children are living in poverty. Parents are taught how to suicide-proof their homes by such things as removing weapons and medication availability.

Recent studies show that some people are born with genes that protect them from depression and suicide no matter what their present or early-childhood stressors. Others have genes that indicate they are at greater risk.

Adverse social environments may impact physical and behavioral disease through epigenetic effects on genes that regulate physiological systems involved in stress and inflammation.

What blocks the bridge? Lack of access to universal healthcare. Access to good education. Decent housing. Stigma attached to mental health problems and suicide. Sensationalizing suicide by media.

Roadmap to Care

Both the fact and the perception of “maternal warmth” is a mitigating factor in all aspects of physical and behavioral health. We have the ability to improve preventive care by providing people with better resources to take care of themselves, their children and each other.

Because early childhood stress is implicated in both physical and behavioral health, Freud’s question, “Tell me about your childhood” turns out to be a relevant question with any disease.

Regardless of economic status, housing or education, we can improve resilience by intervening at an early age.  We may not be able to reduce poverty but we can lessen its effects on both physical and emotional health.

In Your Practice

A physical health provider writing an anti-depressant prescription and seeing the patient six months or a year later is not enough. Institute a “chain of care” for depression and other behavioral health risks. Primary care providers who screen for depression need to know where to refer patients for further evaluation and treatment. Screening is most beneficial when staff-assisted care and follow-up systems are in place. Screening tools from this website and other sources provide the first link on the chain.


  • Initial screening
  • Diagnostic interview
  • Psychotherapy and/or medication and/or other integrated strategies
  • Regular follow-up visits
  • Treat as far as possible, including in-home psychotherapy