Support for family physicians in the provision of mental health care

Mental health concerns make up a large part of FPs’ daily work,¹ but they also represent some of our biggest challenges as we try to help our patients. These challenges are numerous, including at the individual patient level (eg, diagnosis, treatment) and at the system level.

The growing burden of mental health problems our patients are experiencing—from depression to disabling anxiety to substance use disorders, or 2 of these at once, otherwise known as dual diagnoses—has been exacerbated during the COVID-19 pandemic.² Patients also face a lack of access to specialist mental health care from both psychiatrists and psychologists.³ There is a growing shortage of psychiatrists in Canada, one that is expected to worsen over the next decade and is felt most acutely in rural and remote communities.⁴

As with other populations for whom specialized care is becoming less accessible (eg, elderly patients who require geriatrician consults), for patients in need of mental health care the gatekeeper role of FPs is becoming even more important. There is also an expectation that FPs will be able to provide care that previously would have been delivered by specialist colleagues. In the field of mental health, specialist services are not always covered under public health insurance plans (eg, cognitive behavioural therapy [CBT]), and about one-third of Canadians lack access to any third-party health insurance.⁵

Even in situations where FPs feel able to diagnose and treat patients without having to consult specialists, there are equal challenges. Mental health problems may present as either physical or psychological symptoms, or as both, often the result of life stresses. Frequently, patients’ symptoms fall short of the check-box–driven diagnostic tools that we use in practice, such as the Diagnostic and Statistical Manual of Mental Disorders (DSM)⁶ or the Patient Health Questionnaire–9,⁷ making diagnosis more difficult.

Yet we know our patients are suffering and wanting our help. Many patients may find some form of talk therapy useful, but many FPs have not had such training and, accordingly, might lack the necessary confidence. Some patients could also benefit from medication therapy, even if they may not tick all the DSM boxes, but choosing the right antidepressant medication still largely involves trial and error and therefore requires time.

This month’s issue of Canadian Family Physician features several articles that can help FPs provide care to patients with mental health problems. An RxFiles article by Amy Soubolsky and colleagues (page 777)⁸ provides a practical case-based approach to help FPs provide care to patients with difficult-to-treat depression, care that in the past might have been offered by psychiatrists exclusively. The issue also features a research study by Ole R. Haavet et al involving 124 FPs in Norway who received training in providing CBT to patients (page 784).⁹ Their study shows that among the many benefits derived from CBT training, referrals to specialist care decreased and FPs felt more satisfied and less frustrated in being able to provide appropriate care for their patients.

Other content in this issue will also support family doctors in their clinical work, including a practical Clinical Review on assessing and treating patients with referred ear pain (page 757)¹⁰ as well as a new article in our Prevention in Practice series that addresses screening myths (page 767).¹¹