Collaborative mental health care

In any given year, 1 in 5 Canadians experiences a mental health problem or illness.¹ This number is expected to increase considering the negative effects of COVID-19 on the mental health of Canadians.² Family practices are often the first point of access for patients seeking mental health care. Primary care is one of the most accessible health care settings, particularly in more rural and remote areas and for marginalized or underserved populations. However, many family physicians currently do not have the necessary supports or resources to optimally treat patients with mental health concerns or to meet service demands. The integration of mental health services within primary care can address this, thereby providing a holistic approach to care and ensuring patients receive high-quality, comprehensive, timely, and continuous care.

The Canadian Psychiatric Association and the College of Family Physicians of Canada (CFPC) recently published an updated position paper in the Canadian Journal of Psychiatry that highlighted the challenges, opportunities, and new directions for collaborative mental health care in Canada.³ Collaborative, team-based care can be defined as “the process whereby primary care and mental health providers share resources, expertise, knowledge and decision-making to ensure that primary care populations receive person centred, effective and cost effective care from the right provider.”⁴ Collaborative care is a core value of the CFPC’s vision of family medicine in Canada, as indicated in the CFPC’s Patient’s Medical Home.⁵

The updated position paper highlights ways to improve outcomes of primary mental health care by introducing evidence-informed, collaborative care practices such as measurement-based care, care management, and the use of patient registries, as well as regular quality improvement processes.

Primary care is an integral part of the mental health system, and collaboration between them needs to be nurtured for improved outcomes and functioning in both areas. This commentary emphasizes key elements from the position paper as they relate to family medicine and provides practical tips for family physicians to support collaborative care in their practices to respond to the rapidly evolving health care system and the changing needs of Canadians (Figure 1).

Figure 1.

Key messages

Integration of virtual care and use of technology

Successful delivery of collaborative mental health care relies on efficient and effective communication between all members of a health care team, which is enhanced when psychiatrists and mental health professionals work within primary care settings. Recently this has been expanded through the use of telemedicine and virtual care. Telephone consultations, videoconferences, mobile health care, and remote patient monitoring are increasingly being used as viable options to ensure continuity of care^6-10; this has been evident during the pandemic, as many health care teams were forced to rapidly adopt new technologies to deliver care. Embracing a shift to telemedicine and virtual care in a deliberate and thoughtful way can improve access to mental health services for many underserviced populations and individuals living in rural areas. Distanced consultations may be more convenient for some individuals and allow physicians to provide timelier care. However, it is critical that with the transition to virtual care, the quality of care—particularly continuity and coordination of care, as well as equitable access to care and privacy of care—is not compromised.

Telemedicine can also enhance ongoing communication between family doctors and mental health professionals, ensuring common goals within a single plan. Telephone or video visits can also reduce barriers to case conferences or shared care appointments with patients. The regular and open flow of information between providers ensures that patients are receiving integrated care that includes prevention, health education, wellness promotion, and support for adaptive functioning, as well as treatment and relapse prevention. Moving forward, virtual appointments and the use of technology are going to be integral to the ongoing growth of collaborative mental health care; thus, it becomes even more important that health care systems and collaborative teams address the lack of equitable access to technology and virtual care to ensure inclusivity in access and continuity of care. While telephone-based care can help overcome these challenges and is well accepted by patients, we are still learning when a face-to-face visit is necessary, most appropriate, and clinically warranted. Family physicians and mental health providers will need to determine which populations and care needs are best served by technology and how best to deploy technology to support face-to-face care.

Opportunities for earlier identification and relapse prevention

The presence of mental health care providers in primary care can support earlier detection of mental health and addiction problems, earlier interventions, and relapse prevention. It can help a practice identify and track populations with specific problems or risk factors by monitoring the progress of each individual in that group, maintaining contact with anyone who is not being seen on a regular basis, checking that specific treatments or referrals are under way, and intervening rapidly if someone is showing signs of symptom recurrence. By working together, primary care and mental health providers can divide these tasks between them, according to expertise and availability.

For example, collaborative mental health care teams in primary care are well situated to address maternal and child mental health in a proactive and integrated manner. Screening all pregnant women for depression and anxiety during prenatal and postnatal periods and treating identified problems during these stages not only has a positive effect on mothers’ health but also has substantial short- and long-term benefits for children, too, as the early years are a critical time for monitoring a child’s well-being.¹¹ The enhanced 18-month baby visit enables health care providers to identify those children with more risk factors, including adverse childhood experiences or immediate needs. It is possible to proactively monitor each child (grouped in 1-year cohorts) to check on their progress, especially those at greater risk.

Another opportunity for early identification of risks is to see every individual in a practice with a psychotic illness at least annually to monitor both their emotional and physical health. If their medical conditions are stable and well managed, it can help reduce the “mortality gap” of premature death associated with schizophrenia.¹² Also, screening individuals who are 60 or older for depression, anxiety, and mild cognitive impairment can prompt health care providers to treat these conditions and may reduce the likelihood of dementia developing.¹³

Encouraging collaborative care with other services and in other domains

Throughout the past 30 years, family doctors, psychiatrists, and mental health professionals have demonstrated how working collaboratively can provide better mental health care for patients.⁴ Family doctors provide comprehensive care to patients with an emphasis on continuity while psychiatrists and mental health professionals provide the expertise needed to manage patients with greater complexity or risk. The integration of mental health professionals within primary care settings improves access to care and positions family doctors to better engage in early detection, treatment, relapse prevention, and wellness promotion, as well as treatment for remission, a target that has important implications for recovery, functioning, and risk of illness recurrence. Collaboration with community-based organizations and initiatives, social services, legal aid, and child protection services should be encouraged so that social determinants of health are addressed in tandem to support the best possible treatment outcomes. Other domains of medical specialty services may also see potential benefits for patients and health system efficiency by integrating mental health care in these ways.

Currently, wait times to see a specialist in Canada range from approximately 2 to 6 months, depending on the specialty.¹⁴ Collaborative care can improve access while reducing wait times, avoidable emergency department visits, and hospitalizations.^15,16 By optimizing the role of all health professionals and avoiding duplication of services, it is a cost-effective model of care and one that supports population health.^17-19 Collaborating with other services and in various domains can offer continuous and better-coordinated care and can ultimately lead to better health outcomes for patients and increased capacity and work satisfaction for family doctors.

Conclusion

The concept of collaborative mental health care continues to evolve and adapt to the changing landscape of health care. The COVID-19 pandemic accelerated a shift to the provision of virtual care, allowing for collaborative care to occur without the need for co-location. This has enabled family doctors and psychiatrists to expand their clinical networks and offer expertise to a wider group of patients, and to increasingly focus on maintaining both physical and emotional wellness. Collaborative mental health care also facilitates earlier detection and relapse prevention across the lifespan, especially in the perinatal period and early years. The collaborative mental health care model has been well received by health care providers and has been shown to improve health outcomes in patients, particularly when patient-reported outcomes are measured, tracked, and proactively followed up. Moreover, this is a model that is transferrable to other domains of care and can help encourage multidisciplinary, team-based care.