In my work as a therapist and clinical leader, I’ve seen how rarely depression exists in isolation. A person seeking therapy may also be managing anxiety, heart disease or chronic pain. They may lack support at home or have struggled to find treatment that works. Each factor affects how they experience depression and what they need from care.
Imagine a patient living with depression, anxiety and heart disease. Depression makes it harder to take medication, exercise, sleep well or attend medical appointments. Anxiety symptoms can sometimes feel like signs of a cardiac event. The patient sees several providers, but no one has a complete view of all they are experiencing.
Our healthcare system often describes this person as a “complex patient.” But complexity is not a diagnosis or a fixed label. It reflects the combined effect of a person’s symptoms, physical health, treatment history, social support and life circumstances. Understanding that complete picture is necessary to determine what effective care should look like.
People managing chronic medical and mental health conditions are among the costliest health plan members. One analysis found that high-risk patients with both generated 64% higher claims costs than matched patients without a mental health diagnosis. Other research has linked these comorbidities to greater use of ambulatory care, emergency departments, hospitals and prescription medications.
We've built our clinical model at Two Chairs to handle a broad range of clinical complexity. In recent peer-reviewed research, we demonstrated that Two Chairs delivered meaningful depression improvement for patients living with heart disease, respiratory problems, diabetes and cancer, with outcomes comparable to the broader study population. The results demonstrate that the Two Chairs model can work for patients whose combined physical and mental health needs often contribute to greater healthcare spending.
What does the research tell us about patient complexity and depression treatment outcomes?
The study, published in Frontiers in Psychology, analyzed 7,161 adults receiving psychotherapy for moderate to severe depression at Two Chairs. Researchers examined how patient characteristics affected the likelihood and timing of clinical response, defined as at least a 50% reduction in depression symptoms, and remission.
Across the study population:
- The median time to clinical response, defined as at least a 50% reduction in PHQ-9 scores, was six sessions.
- Patients who achieved remission reached it in a median of eight sessions.
- Nearly 82% of responses occurred within the first 12 sessions.
The outcomes extended to groups commonly associated with more clinical needs or higher healthcare spending.
Patients with chronic medical conditions, including heart disease, respiratory conditions, diabetes and cancer, achieved depression outcomes comparable to the broader population. After researchers accounted for other factors, chronic medical conditions did not independently predict a slower response.
These findings are particularly relevant because behavioral and physical health are closely connected. Depression can make chronic conditions harder to manage, while pain, functional limitations and medical uncertainty can worsen depression. This shows that people with overlapping behavioral and physical health needs can improve in outpatient care.
Higher acuity did not necessarily mean slower improvement
Our new research found that patients with some of the most complex and costly conditions can make meaningful progress in outpatient therapy, often within the early stages of care. The findings also offer insight into what clinicians and health plans should expect from care designed for this population.
While symptom severity and suicidal ideation are typically associated with higher healthcare costs, Two Chairs patients entering care with greater depression severity or suicidal ideation improved faster than average. Patients reporting suicidal ideation at intake responded in a median of five sessions, compared with six sessions across the full study population.
The clinical implication is that acuity alone cannot predict a patient’s trajectory. Clinicians need to pair the initial assessment with consistent measurement once treatment begins.Two Chairs delivered particularly timely outcomes for members who may require the most support and generate some of the highest costs.
Timely outcomes across insurance and demographic groups
Medicare and Medicaid members who achieved a response did so in a median of five sessions, compared with six sessions overall. Age and gender did not independently affect the response rate after other factors were considered. Patients identifying as Black or Hispanic also had a faster adjusted rate of response.
These results are meaningful because older adults, publicly insured members and people from historically underserved racial and ethnic groups often face barriers to effective behavioral healthcare. They demonstrate that timely outcomes are possible across a broad patient population.
Why complexity is cumulative
No single patient characteristic determined who would improve. The accumulation of factors across a patient’s clinical profile provided more useful information.
Comorbid anxiety, chronic pain and greater diagnostic complexity were associated with a slower response. When these factors overlapped, patients often needed more time or support. Still, complexity did not prevent meaningful progress.
Researchers illustrated this difference using modeled patient profiles. A lower-complexity profile had an estimated 81% probability of response by session 12, compared with 47% for a higher-complexity profile.
That gap can inform treatment planning. It should not become a reason to restrict care. Nearly half of the modeled high-complexity patients were still projected to respond within 12 sessions.
Assessing complexity at intake can help clinicians anticipate the level and type of support a patient may need. A person with depression, anxiety, chronic pain and limited social support may benefit from closer monitoring, increased care coordination, and psychiatric and psychotherapy treatment plan from the start.
Once treatment begins, the patient’s actual progress becomes increasingly informative.
What should health plans expect from behavioral healthcare?
Research has linked effective mental health treatment with lower total healthcare spending. A national study of adults with common chronic physical conditions found that receiving mental health services was associated with $1,146 less in total healthcare spending per person during the following year. The largest reduction was associated with psychotherapy and medication together.
Health plans should evaluate behavioral healthcare as part of managing total health, particularly for members whose mental and physical conditions contribute to higher utilization.
That requires looking beyond access and average session counts. Plans should ask providers who is improving, how quickly improvement occurs across different patient populations, how clinicians identify stalled progress and how the care model responds when a patient needs a different approach.
The Two Chairs research offers evidence that patients with complex clinical and medical needs can achieve meaningful improvement, often within the first several sessions of outpatient therapy. Delivering those outcomes requires an accurate view of the patient at intake, consistent measurement throughout care and clinical support to adjust treatment as new information emerges.
That combination gives clinicians a stronger basis for selecting the right level of care, responding when progress stalls and helping each patient achieve the best possible outcome.
