QB Alex Smith's physical recovery hinged on mental health

Eighty-four days after Alex Smith suffered a compound leg fracture that jeopardized his life, he was able to talk about football again.
 

The National Football League quarterback went to the Center for the Intrepid, a state-of-the-art rehabilitation facility in the Brooke Army Medical Center near San Antonio, Texas, where he met soldiers recovering from an amputation or a mangled limb.
 

Speaking with veterans, including one who underwent more than 25 surgeries after a roadside bomb tore through his leg while the soldier served in Iraq, allowed Smith to confront his injury for the first time.

"I remember just staring at his leg and asking him, 'How do you get there?' I'm so far from where you're at mentally," Smith said. "He said, 'You're going to get a point where you're proud of your leg.' On that same trip, the words came out of my mouth, 'I am going to play football again.' I was scared to death when I said it, but that community and connection with other people who had gone through similar things helped me in so many ways."

Integrating mental health into the physical treatment of traumatic injuries, life-threatening diagnoses and obstetrics represents the next step in mental healthcare. Many hospitals have added mental health screening and referrals into primary-care visits. But those efforts are still in their infancy.

Similar to traumatic injuries, cancer diagnoses weigh heavily on patients who deal with the mental toll long after treatment ends. But most of the focus is on the physical care.

Billions of dollars are spent each year on developing new breakthrough cancer drugs. But physicians aren't adequately trained in how to broach or address patients' mental health, said Dr. Manish Agrawal, cancer center director at Aquilino Cancer Center in Rockville, Maryland.

There was no formal training about how to handle telling a patient that their cancer is progressing and how a patient copes, he said.

"Mental health is perhaps the thing that determines someone's quality of life more than everything. But so much of people's care is left unaddressed," Agrawal said. "If you don't die, a cancer diagnosis brings psychological issues associated with brushing with death."

Before the trip to the Center for the Intrepid, Smith couldn't look at his leg, which was shattered during a Nov. 18, 2018, game between his Washington team and the Houston Texans. A flesh-eating bacteria consumed his leg while he was in the hospital, almost killing him.

Although it was nearly three months after the injury, listening to peoples' stories at the Center for the Intrepid started his recovery, Smith said.

"That's the first time I did not feel alone and did not feel scared," he said. "That's where I got out of a dark place where I was consumed by my own self-doubt and pivoted to being an active participant in my recovery and confronting my injury. That physical recovery couldn't have taken place if I hadn't dealt with the mental side."

Two years of rehabilitation, therapy and dozens of surgeries culminated in an NFL comeback with Washington. His play led the team to the playoffs for the 2020 season, and Smith won that year's Comeback Player of the Year award.

Physical and mental care often have been treated separately. More healthcare providers have been incorporating mental health treatment for patients who suffer traumatic injuries or diagnoses to aid their physical recovery. The COVID-19 pandemic has accelerated that shift as more people struggle with the trauma inflicted over the past two years.

Organizations like the Maryland-based Adventist HealthCare and Sunstone Therapies, a startup launched to treat both the physiological and psychological effects of cancer, are trying to establish a new treatment model by pairing the therapeutic hallucinogen psilocybin and psychotherapy to help cancer patients cope with their disease.

Adventists' Aquilino Cancer Center screens each of its cancer patients for mental distress. It offers a psilocybin clinical trial that seeks to alleviate trauma and depression, meditation classes, one-on-one counseling, group therapy and community-based support services.

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Insurers pay for some mental health therapy, but it's typically a low amount. Agrawal said.

"There's an underappreciation for the amount of stress cancer brings and how that impacts a patient's life," he said. "Reimbursement seems to be structured around medication and procedures rather than holistic care."

People suffering from anxiety and depression are overwhelming emergency rooms. Child and adolescent mental health issues and suicide rates are surging.

Total mental health claims for children ages 13 to 18 doubled from mid-2019 to mid-2020, according to an analysis by FAIR Health.

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More than 3 million adolescents and 12 million adults had serious thoughts of suicide in 2020, according to data from the National Alliance on Mental Illness. Close to 18 million adults experienced delays or cancellation of appointments and nearly 5 million went without necessary care, NAMI found.

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"The feelings of isolation, the trauma from losing loved ones and the loss of structure and routine has created a perfect storm for mental health," said Dr. Kamilah Jackson, a medical director at AmeriHealth Caritas, a Medicaid managed care provider. "We need to provide more funding and support to bring more mental health providers into the workforce."

President Joe Biden proposed in his federal budget released last month spending $51.7 billion to improve the mental health system, including $7.5 billion for workforce development and service expansion and $35.4 billion to enhance mental health access for Medicaid enrollees. His budget would require health insurers to cover mental healthcare with adequate provider networks, which historically has been the bottleneck.

Biden budget plan prioritizes mental health, public health

"You may have an inpatient acute care hospital, but you don't have the infrastructure to support it," he said. "This is certainly among the top five issues America has to face."More than half of the counties in America don't have a psychiatrist, said Kevin Mahoney, CEO of the University of Pennsylvania Health System, citing 2017 data from the American Medical Association.

One day last week, 57% of the beds in Chester County Hospital's emergency department in West Chester, Pennsylvania, were occupied by behavioral health patients, Mahoney said.

The academic health system has tried to mitigate mental health crises by incorporating related screenings and services into primary-care visits. It has embedded social workers into larger physician practices that connect patients with resources when they are discharged, set up virtual pathways for mental healthcare and started a joint venture with area providers. But as of now, the psychiatric care network is completely disjointed, Mahoney said.

"Long-term residential care has fallen apart, inpatient (psychiatric) beds for the most part have been ceded to the for-profit side and makes placement difficult," Mahoney said.

Many people are taught to bury their feelings, especially in sports, Smith said. He hopes to set a different example as the public face of Teammates in Recovery, a mental health awareness campaign from DePuy Synthes, the orthopedics division of Johnson & Johnson.

Teammates in Recovery, which Smith is compensated to promote, seeks to create a community of support and resources for people who have experienced a traumatic injury.

"I always thought I had to portray being perfect, being strong as a sign of leadership," Smith said. "Especially after my injury and coming back, you realize it's total BS. Strength is being vulnerable."

The support from his family and his peers' shared experience brought Smith back onto the football field on Oct. 11, 2020, 693 days after his injury. On the second play, Aaron Donald, the three-time defensive player of the year for the Los Angeles Rams, jumped on Smith's back and wrestled him to the ground.

Smith popped up and looked up to the stands where his wife, Liz, and three children, Hayes, Hudson and Sloan, were watching.

"It was the most liberating feeling in my life. I got up. I wasn't fragile anymore. I broke through so many barriers in that moment," he said. "I couldn't have gotten there without addressing my mental health."