Improving Quality of Mental Healthcare by Family Physicians in BC and

1. 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

2. Picture in BC 2010/11 • 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

3. 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

4. Local Team Developed Training Tool • 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

5. Depression used as Lens High prevalence in isolation and comorbid with other MH disorders and chronic disease Lifetime prevalence of Major Depressive Episode: 12.2% Past-year episodes: 4.8% Past-month episodes: 1.3% 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.

6. After completing the Mental Health module, FPs and health care team will be able to effectively: Screen/assess for mental health disorders Use 3 Supported Self Management cognitive behavioral therapy (CBT) tools CBIS (Cognitive Behavioral Interpersonal Skills Manual) BounceBack program Antidepressant Skills Workbook Bill for mental health care services provided  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 AMH MODULE OBJECTIVES

7. Adult Mental Health Module Content KEY COMPONENTS • CBIS (Cognitive Behavioral Interpersonal Skills Manual) • BOUNCEBACK • ASW (Antidepressant Skills Workbook) • All Self Management tools • CBIS additionally had Assessment and planning tools • Screening tools PHQ 9, GAD 7

8. AIM: To increase Family Physicians skills and confidence in: • Screening Assessment and Treatment • Developing Care Plans • Using Skills not only Pills • Improving the patient experience • 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

9. Medical Office Assistant First Aid Course • Feel comfortable with mental health pts • Heightened awareness • Know scheduling, materials required • Have materials prepared/placed

10. Method • Paid learning and practicing • Train the Trainer • PDSA QI approach (Plan, Do Study Act) • Surveys at end of module, and at 3 to 6 month • MOAs simultaneously took Mental Health First Aid Course Psychiatrists, Mental Health clinicians from each HA

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

14. Outcomes Results – one Health Authority • 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

15. Conclusions 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 care • Increased their job satisfaction • Decreased their reliance on prescribing antidepressant medications • Improved 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………………………………………….

16. Stigma AIDs literature – AIDs patients stigmatized • Stigma reduced with useful interventions to treat/manage problems/illness ** • Information • Coping skills acquisition Mental Health patients stigmatized • Family Physicians (FPs) self report: lack training, feel unprepared *** • If you feel unprepared, you might fear, avoid, turn away –stigmatization **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,

17. Stigma results in • less prevention • more crisis • more deterioration • more relapse • more fear • vicious circle

18. 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

19. Other realizations Used AMH as mental health training tool for • Family Practice Residents/Preceptors • Nursing students/Teachers • Nurse practitioners • Mental Health case managers, clinicians (Pain, Aboriginal, cardiac, eating disorders, addictions) • Other chronic disease clinicians (diabetes) In urban rural or remote areas For individual or group use One language for all

21. Awards • 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

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