Improving Access to Psychosocial Treatments—Integrating Patient, Provider, and Systems Approaches

Psychotherapy works well, but our mental health care system does not. Those broad observations are underscored by 2 articles in this issue.^1,2 One can certainly cite the broad evidence base in psychotherapy for mental disorders, but these 2 articles provide another type of endorsement—both the public in Quebec and psychiatrists in British Columbia vote with their feet, so to speak—for psychotherapy. Dezetter et al¹ carefully surveyed nearly 1300 attendees at primary care clinics across Quebec on 3 occasions during a year, and found major unmet mental health needs, including major gaps in psychotherapy delivery. Hadjipavlou et al² surveyed attitudes toward psychotherapy and patterns of psychotherapy delivery among psychiatrists in British Columbia and discovered high confidence in psychotherapy efficacy and high rates of delivery of individual psychotherapy, but with few people served owing to time constraints. Nevertheless, despite the evidence and the enthusiasm, the stark reality is that most patients cannot get, and most psychiatrists cannot give, enough psychotherapy. While the obstacle is largely ascribed to insufficient funding for psychotherapy provision, pleas for more resources are unlikely to succeed.

Instead, we must improve the access to effective psychotherapeutic treatments by applying creativity and ingenuity. By using a population health approach, we can explore solutions that involve identifying interventions at multiple levels (patient, provider, and systems) and through multiple techniques and formats.^3,4 One key tenet of this approach is stepped care, where simpler and cheaper interventions are used initially, while more elaborate and expensive treatments are saved for those in greatest need.⁵ Stepped care already has wide acceptance across medicine, and frequently has been suggested in psychiatric contexts, including substance abuse, mood disorders, and anxiety.^6,7 Our (see Parikh et al⁸) own experience with recommendations for stepped care for bipolar disorder has led to research studies to compare different treatment methods with widely different costs and intensities, resulting in evidence that brief group psychoeducational interventions may be clinically equal, easier to use to treat larger numbers of clients, and far less expensive than the traditional 20-session dose of individual CBT.⁸

Scaling psychosocial interventions broadly across disorders and society requires widening the focus of interventions and delineating the appropriate provider and venue for such treatments. To begin with, the broadest theoretical principles of effective psychosocial intervention, evidence particularly favours several approaches: MI, psychoeducation, CBT, IPT, and mindfulness-based interventions.⁹ From the service delivery research literature, key lessons include the value of self-directed strategies, including traditional self-help books, websites that offer interventions, care facilitators, and peer-support group interventions.¹⁰ The burgeoning patient-centred care movement echoes larger trends in society, facilitated by the Internet, that place emphasis on what patients want, not simply what service providers wish to offer.¹¹ Affordability parallels scalability in all these musings; we must find solutions that allow us to reach many people within existing financial envelopes. Thus what kind of interventions might all these considerations evoke?

Resuming a patient, provider, and systems approach, patient-level interventions might begin with understanding how to use brief MI principles as a first step for virtually all other interventions. Overwhelming evidence across disorders documents difficulty in starting and adhering to treatment recommendations. A robust literature also shows that even 2 sessions of MI leads to improved engagement in treatment, both in medical and in psychiatric disorders.¹² Next, with the motivated patient, let us respect both patient empowerment principles and concede that most people seek (correctly!) to help themselves first before reaching for professionals. Surely, the most popular health provider now is “doctor Google,” with patients searching for explanations for symptoms and particularly for remedies for known problems.¹³ And, in 2015, that is done on the ubiquitous Smartphone, where thousands of apps exist for immediate application. Rather than leave the public to google and app alone, health providers should lead the way in providing guidance about the best websites and apps, and how to use them.¹⁴ Teaching e-health literacy should be a routine activity for all health professionals, and may be effectively and economically well delivered by colleagues in public health, nursing, and allied health. Such approaches could deliver various skill sets, including both elements of MI, specific strategies including psychoeducation, and online CBT interventions—modalities for which significant evidence exists in e-health. Such approaches would provide some help to most people, be entirely sufficient for some, and would be affordable and scalable for our society.

At the provider level, in addition to facilitating e-health, we should recognize some basic contradictions: many people are not able or willing to complete a full standard regimen of 16 to 20 sessions of 1-on-1 psychotherapy. Further, we tend of offer these treatments in ways that meet provider needs—such as offering them only during the normal working day, which is a challenge for many people. Providers will also need to explore the notion of comparing cost and benefit; is there a package of skills and support that may be delivered effectively in a brief intervention, rather than insisting on traditional approaches? For instance, Simon et al¹⁵ demonstrated that just 8 sessions of telephone-delivered CBT with antidepressants worked substantially better than pharmacotherapy alone, and provided substantial clinical benefit. In a Canadian context, Lam et al¹⁶ demonstrated that the same 8-session telephone CBT intervention reduced workplace disability in depressed patients, with obvious clinical and financial benefits. Additionally, the phone therapy was designed to be flexible, with CBT sessions scheduled in the evening—thus patients could avoid both missing work and the other impediments to help seeking, such as expensive parking and transportation difficulties. IPT, too, has phone studies across multiple clinical contexts and uses a relationship-focused intervention relevant for complex patients with disrupted attachments.¹⁷ Additionally, IPT has been adapted to groups run by lay providers.¹⁸ Group interventions of evidence-based treatment should become far more common—something that is unlikely, based on current training and practice habits as noted in this issue’s study of British Columbian psychiatrists.² Finally, as Hadjipavlou et al² demonstrated that, while many psychiatrists practice psychotherapy, the number of patients treated is low owing to the intensity of one-on-one care. Psychiatry has a rich tradition of examining how to teach psychotherapy, and many residency programs have remarkable cohorts of psychotherapy supervisors dedicated to improving psychotherapy training and supervision.¹⁹ This resource suggests another way for more effective use of psychiatrists—while they must continue to provide some direct therapy, imagine the multiplier effect if every psychiatrist also had a cohort of other health professionals providing psychotherapy, who could be supervised in a group format.²⁰ The reach of psychiatric expertise would be profoundly and appropriately extended.

These patient- and provider-level approaches have implications for health systems, and so, combined, may also be considered a systems intervention. More specific system modifications are vital. First, the health system must be able to fund alternative providers to provide brief interventions. The United Kingdom has been the pioneer in this approach through its IAPT initiative, with features such as 2-year, college-educated therapists providing brief CBT in primary care clinics. The evaluation data of the IAPT program are encouraging, and numerous other countries are implementing versions of it, particularly Australia, also with success.^21,22 An immediate practical opportunity involves Telehealth Ontario, a Ministry of Health and Long-Term Care service, fully funded by the Government of Ontario, that provides free phone access to a registered nurse, 24 hours a day, 7 days a week, for anyone who has any health questions. Imagine if a fraction of these nurses could be trained and designated as telephone CBT or IPT therapists, with access to these therapists given by prescription from a primary care provider. Family doctors routinely evaluate physical injuries and refer to physiotherapy; why not have a similar process for mood and anxiety disorders, with the family physician evaluation potentially resulting in a referral to a Telehealth nurse for CBT or IPT (with or without medications, as per the physician and patient collaborative decision)? Another key system intervention would be the expansion of psychiatric sessional funding to allow for supervision of other health providers delivering psychosocial interventions, improving the access of many more people to psychiatrists. Funding should be flexible regarding using technology for treatment delivery, where a rich evidence base already exists.²³ We should encourage phone, video-conference, or secure Skypelike interviews (which has already been approved in British Columbia through the innovative Medeo system). The health system must provide direct funding for outcome evaluation and comparative effectiveness research to learn which approaches work best. Such evaluation should definitely not be left to traditional research agencies, whose mandate is much more aligned with creating better research rather than urgently improving health service capacity or reducing disability.

The final systems perspective involves weaving these all together with a stepped care vision. People in distress will have been educated, perhaps in high school, about e-health literacy, combined with an anti-stigma campaign to encourage help seeking; they will go to recommended sites, ideally created by governments, that allow for quick self-identification of problems, triage of more urgent issues directly to health care providers, and encouragement of use of various websites, apps, and self-help strategies for people with the most mild illnesses. The principle of periodic re-evaluation would be explained; people taking a self-help treatment for, say, depression would monitor their progress by self-administered rating scales, such as the Patient Health Questionnaire (commonly referred to as PHQ-9), with a clear notion of when to change treatments or seek professional help. Patients entering the health system would have several formats of psychosocial intervention open to them: face-to-face or via telephone and (or) video. Multiple effective treatments would be available in a group format, with groups run in the evening or on weekends to facilitate access. Initial evaluation and ongoing monitoring would also allow for streaming of the more ill patients more quickly to more intensive treatments with mental health specialists. Post-acute care, ongoing wellness programs—incorporating both physical and mental aspects of health, perhaps mindfulness-based—would be provided by various health providers. And interdigitating with the system at various junctures, psychiatrists would provide direct care, supervision, triage, and lead efforts to evaluate outcomes—a personally satisfying use of many skills for the individual psychiatrist, and an effective and economic use of those skills for the maximal benefit of society.

Abbreviations

CBT

cognitive-behavioural therapy

IAPT

Improving Access to Psychological Therapies

IPT

interpersonal therapy

MI

motivational interviewing