Dr. Robert TwillmanRobert (Bob) Twillman, PhD, FACLP, is a pain management psychologist with St. Luke’s Behavioral Health Specialists, in Kansas City, Missouri. He also serves as the newly-minted manager for psychology services for Saint Luke’s Health System.

He previously served as executive director of the Academy of Integrative Pain Management and as chair of the Prescription Monitoring Program Advisory Committee for the Kansas Board of Pharmacy. He maintains a volunteer faculty appointment a clinical associate professor of psychiatry and behavioral sciences at the University of Kanas School of Medicine.

About 80% of Dr. Twillman’s patients have chronic pain and he works as part of an integrated team consisting of physical medicine and rehabilitation (PM&R) clinicians, neurosurgeons, neurologists, anesthesiologists, pain specialists, and physical therapists. Here, he talks with Psycom Pro about treating mental health disorders in the context of intractable pain.

Psycom Pro: Mental health disorders such as depression and chronic pain conditions commonly overlap. What has been your clinical experience?

Dr. Twillman: The vast majority of my patients have co-existing mental health and chronic somatic conditions – but then, that is my area of specialty, so it’s hard for me to say how often that combination occurs in other settings. One thing I have puzzled over is the extent to which one condition commonly precedes the other, and I think I see it as about equal.

Some people with pre-existing mental health conditions who then experience a somatic illness just don’t have the wherewithal to cope with that somatic illness as well, and they end up more debilitated as a result. On the other hand, I see people who develop a chronic somatic illness and, as a result of its impact, develop a mental health disorder. After all, if you wake up with chronic pain, for instance, and go to bed at night with that same pain, and know that it’s still going to be there tomorrow morning, that can get depressing. So, by the time I see these patients, both their mental health and somatic condition are in full force, and my goal is to help them dig out of two inter-related problems.

Psycom Pro: What challenges are you facing in daily practice?

Dr. Twillman: There is no shortage of referrals of patients with chronic pain seeking behavioral or mental health care. It is currently taking about 3 months for new patients to see me. The behavioral health service line at my institution is relatively new, and thus still developing, so right now, the demand far outstrips the supply. Almost every patient referred to me carries a diagnosis of a mood disorder (depression, bipolar mood disorder) or an anxiety disorder (generalized anxiety disorder, PTSD, or panic disorder).

We are only scratching the surface with respect to providing the number of treatment slots needed across our system, so I am hoping to be able to develop the psychology service to the point where we are closer to meeting that need.

Psycom Pro: Do you ever refer patients for medical care if you think their mental health condition is a sign of a physical illness?

Dr. Twillman: Absolutely. Sometimes, I get referrals from other mental health providers, and while they are good at recognizing the mental health conditions that patients have, they don’t always recognize the physical illnesses, so I will facilitate referrals where needed. Sometimes, because of my experience, I am suspicious that there is something physical going on that needs to be checked out, so I’ll again make referrals as needed.

Sometimes, I also will be able to go back to the referring provider and suggest that they check out some medical factor – such as the person with metastatic prostate cancer, several years ago, who turned out to be depressed because his pain prevented him from doing things he enjoyed. We were able to resolve both his depression and pain because I recognized a vitamin D deficiency that we were able to correct.

Psycom Pro: What kinds of assessments would you perform in either of those scenarios?

Dr. Twillman: For me, the most important assessment is always hearing the patient describe what is going on, what has been done for it, and what they want to accomplish by working with me. I always review the chart to see what the medical professionals think is going on, but it is common for patients to have different opinions about the causes of their problems. Sometimes, those patients are right, and the professionals are not; other times, it’s the other way around. But it is vital that I understand the patient’s experience so I can help educate, intervene psychotherapeutically, and refer for other helpful treatments. It is common for patients to tell me that no one has ever really listened to their full story, and my ability to do so really helps cement a therapeutic relationship.

Psycom Pro: Do you notice whether patients’ physical health improves along with improvements in their mental health?

Dr. Twillman: I think improvement is bidirectional. Often, improving someone’s depression or anxiety will help improve their pain and functional impairment, and improving their pain and functional impairment improves their depression and anxiety. We can make a big error if we fall too far into Cartesian dualism, however – these things are all part of one indivisible system, and we, the patients, and their other providers all need to recognize that these issues affect each other.

When I ask patients if they notice that their depression or anxiety worsens when their pain worsens, they are quick to endorse that notion. They are usually a little slower, but many also endorse the notion that their pain worsens when their anxiety or depression flares up. That, alone, is a key early insight for many patients.

Psycom Pro: Given the common overlap between chronic illness and mental health, do you feel current screens, such as those conducted in primary care for depression (PHQs), are doing enough to identify mental health concerns in individuals presenting with somatic issues or even visiting a clinician for a regular checkup? In other words, what if mental health were considered on an equal playing field to physical health, starting at the stage of initial assessment?

Dr. Twillman: I think standard screening instruments for depression, anxiety, and PTSD, in particular, have considerable value if they are really used as intended, and used universally. Too often, elevated scores on these instruments do not prompt the next level of inquiry (ie, asking the patient to say more about their mental health concerns). These instruments are so face-valid that most patients know what they are being screened for, and if they mark enough symptoms to hit the threshold, to some extent, that can be considered an invitation to further assessment.

(More on current gaps in mental health screenings in our special report)

In our pain clinic, patients complete the PHQ depression screen at every appointment but they don’t complete the other screens; other types of practices are more hit-or-miss with respect to screening. Unfortunately, there is still enough stigma around mental health conditions that many patients won’t talk about their challenges unless directly asked.

Psycom Pro: With that point in mind, what advice do you have for medical clinicians when they are assessing a patient for a chronic, often painful, condition? On the other hand, what advice do you have for mental health clinicians when they are working with someone who clearly has issues with chronic pain, obesity, diabetes, or cardiovascular disease?

Dr. Twillman: It is incumbent upon all of us to recognize that pretty much every chronic condition I can think of really is best conceptualized within a biopsychosocial-spiritual model. That is, the patient’s total experience often involves some degree of disequilibrium in most, if not all, of those functional domains. If we fail to adequately understand the roles played by biological, psychological, social, and spiritual factors in determining the patient’s current condition, then we are unable to provide the best treatment because we inevitably omit one or more domains.

Our goal in caring for a patient is not the absence of pain, the absence of functional impairment, the absence of depression or anxiety. The goal is restoring the patient to wellness, which is truly a synergistic concept in which the whole is greater than the sum of the parts.


What’s Next: Should there be an annual mental health assessment?

Read more on overlapping psychiatric disorders and physical conditions, the policies coming out of the Biden Administration to improve access to mental health services and behavioral health treatments, and a special report on depression screening gaps in the United States – and where the field of psychiatry goes from here.

Last Updated: May 12, 2021