www.pspbc.ca

Improving Quality of Mental Healthcare by Family Physicians in BC and

Unexpected Learnings about Stigma

Liza Kallstrom BSc, MSc, Content and implementation Coordinator for the Practice Support Program, British Columbia Medical Association

Dr. Rivian Weinerman MD BSc(Med) FRCPC PSP Physician Quality Ambassador, Practice Support Program, British Columbia Medical Association, Associate Clinical Professor UBC

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774,261 receiving services for mental health issues

703,298 by a family physician (FP)

115,905 by a psychiatrist

116,372 in a community mental health centre

21,048 in acute care

FP focus-best chance to affect most people early on

Picture in BC 2010/11

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Underlying hypothesis

Local mental health clinic group

Noticed

•SU, Bipolar, PTSD, OCD– most often missed in FP referra;s

FPs’ patients not fully engaged in care planning, treatment decisions

Mostly pills in docs’ repertoire, rarely skills

Knew

Time pressure and fee constraints

FPs self admit lack of undergraduate education in mental illness

Fear about not knowing what to do significant factor underlying physician discomfort/lack of confidence in treating mental health issues, and provider stigma- useful tools needed

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CBIS (Cognitive Behavioural Interpersonal Skills) manual an organized Assess/plan/provide skills tool - guideline based ****

To enhance MH capacity /comfort for FPs within realistic

FP time constraints and fitting MSP fee codes

To enhance client partnership and self management

Formed core of BC provincial Practice Support Program (PSP) Adult Mental Health Module

****Weinerman R et al, Improving Mental Healthcare by Primary Care physicians In British Columbia. Healthcare Quarterly, 2011. 14:1, 36-38

Local Team Developed Training Tool

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Depression used as Lens High prevalence in isolation and comorbid with other MH disorders and chronic disease

Source: Descriptive Epidemiology of Major Depression in Canada. Patten, SB; Wang, JL; Williams, JVA et al. Canadian Journal of Psychiatry; Feb 2006; 51, 2; 84.

Lifetime prevalence of Lifetime prevalence of

Major Depressive Episode: Major Depressive Episode: 12.2%12.2%

Past-year episodes: Past-year episodes: 4.8%4.8%

Past-month episodes: Past-month episodes: 1.3%1.3%

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AMH MODULE OBJECTIVES After completing the Mental Health module, FPs and health care team

will be able to effectively:

1. Screen/assess for mental health disorders

2. Use 3 Supported Self Management cognitive behavioral therapy (CBT) tools

CBIS (Cognitive Behavioral Interpersonal Skills Manual)

BounceBack program

Antidepressant Skills Workbook

3.Bill for mental health care services provided 

4.Implement with patients with mild-moderate dep/anxiety, and use with other MH disorders and chronic stable SMI /chronic disease pts where depression/anxiety is comorbid

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KEY COMPONENTS

CBIS (Cognitive Behavioral Interpersonal Skills Manual)BOUNCEBACKASW (Antidepressant Skills Workbook)

All Self Management toolsCBIS additionally had Assessment and planning tools

Screening tools PHQ 9, GAD 7

Adult Mental Health Module Content

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A. Screening Assessment and TreatmentB. Developing Care PlansC. Using Skills not only PillsD. Improving the patient experienceE. Fully engaging the patient in self management

Using a proactive approach

All within the time constraints of busy family physician practices and fitting fee codes

AIM: To increase Family Physicians skills and confidence in:

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Feel comfortable with mental health pts

Heightened awareness

Know scheduling, materials required

Have materials prepared/placed

Medical Office Assistant First Aid Course

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1. Paid learning and practicing

2. Train the Trainer

3. PDSA QI approach (Plan, Do Study Act)

4. Surveys at end of module, and at 3 to 6 month

5. MOAs simultaneously took Mental Health First Aid

Course

Psychiatrists, Mental Health clinicians from each HA

Method

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At end of module training physicians felt the training and tools:

› Improved patient care (89.1%)

› Enhanced their skills (84.0%) and confidence (85.5%)

› Enhanced skills in conducting a diagnostic interview (85.1%)

› Enabled them to decrease their reliance on medications (39.5%)

› Increased docs’ job satisfaction (67.2%)

› Increased pts’ return to work (78.8%) ability to stay at work (88.8%) with CBIS

Patient experience:

› Increased feeling of partnership and increase in comfort talking to their doctor (82%)

Newly learned practices were sustained or improved at 3 to 6 months followup over time with various cohorts

Results Over 1400/3300 docs in province have been or are being trained (525 surveys)

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Figure 1: FPs' ratings of overall success and impact of the Adult Mental Health module

49.0

57.8

94.6 94.1

30

100

At end of module At 3 to 6 monthsfollow-up

At end of module At 3 to 6 monthsfollow-up

Overall success in implementingskills into practice

. Overall impact on FPs' patients

Per

cent

age

of F

P r

espo

nde

nts

ratin

g th

e ite

m a

s "h

igh"

or

"ver

y hi

gh"

(*p<.05)

(ns)

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Figure 2: FPs' confidence in providing mental health care at module completion and 3 to 6 months post-

training

99.8 100 98.7 100

91.995.9

84.388.6

77.581.1

96.1 96.4

60

100

At

end

ofm

odul

e

At

3 to

6m

onth

s

At

end

ofm

odul

e

At

3 to

6m

onth

s

At

end

ofm

odul

e

At

3 to

6m

onth

s

At

end

ofm

odul

e

At

3 to

6m

onth

s

Confidence indiagnosing

. Confidence intreating

. Confidence indeveloping care

plans

. Confidence inprescribingmedication

Per

cent

age

of "

Co

nfid

ent

" F

P r

espo

nden

ts

Depression Other MH conditions (in general)

(ns)

(ns)(*p<.05)

(*p<.05)

(*p<.05)

(*p<.05)

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730 - # patients with initial PHQ-9 score > 10

17 – average initial PHQ-9 score

10 – average follow up PHQ-9 score

-7 – average change in PHQ-9 score

73 – average days from initial to follow up PHQ-9

Outcomes Results – one Health Authority

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Family Physicians are willing recipients of training when they are reimbursed to attend and the tools are extremely practical and fit within their time constraints

This module was extremely successful in changing Family Physicians practice and feeling they had:

Improved patient careIncreased their job satisfactionDecreased their reliance on prescribing antidepressant medicationsImproved their patients’ ability to work

This change in practice was sustained or improved at 3-6 month followup over time with various cohorts

Patients felt more comfortable and engaged

AND………………………………………….

Conclusions

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AIDs literature – AIDs patients stigmatized1.Stigma reduced with useful interventions to treat/manage problems/illness **

A. Information

B. Coping skills acquisition

Mental Health patients stigmatized1.Family Physicians (FPs) self report: lack training, feel unprepared *** 2.If you feel unprepared, you might fear, avoid, turn away –stigmatization

Stigma

**Brown, L. Trujillo, L., Macintyre, K.; (2001)Interventions to Reducde HIV/AID Stigma: What have we learned?, Horizons Program/Tulane School of Public Health and Tropical Medicine,

New Orleans, Louisiana,

***Clatney, L., MacDonald, H., & Shah, S.M. (2008). Mental health care in the primary care setting: Family physicians’ perspectives. Canadian Family Physician, 54,

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less preventionmore crisismore deteriorationmore relapsemore fear vicious circle

Stigma results in

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Major insight evolved as physicians became more knowledgeable and comfortable/confident with the AMH training…..

And linking with the AIDs literature……

Realized -AMH training could lead to less avoidance and stigmatization of patients struggling with mental health problems.

Recent Mental Health Commission data on Module has shown that CBIS/ASW significantly decreased stigmatizing attitudes of physicians, residents after one day training by 10%- largest finding to date.

www.gpscbc.ca/psp-learning/mental-health/tools-resources

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Used AMH as mental health training tool forFamily Practice Residents/PreceptorsNursing students/TeachersNurse practitionersMental Health case managers, clinicians (Pain, Aboriginal, cardiac, eating disorders, addictions)Other chronic disease clinicians (diabetes)

In urban rural or remote areasFor individual or group use One language for all

Other realizations

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CMHA Leadership award

HEABC 2010 award for Innovation

UBC 2011 CME/CPD award for Innovation

Permanent Journal 2012 Special Quality Award and

invitation to submit manuscript to journal

Awards

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Algorithm

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