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
www.pspbc.ca
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
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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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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
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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.
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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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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
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AIM: To increase Family Physicians skills and
confidence in:
A.
B.
C.
D.
E.
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
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Medical Office Assistant First Aid Course
 Feel comfortable with mental health pts
 Heightened awareness
 Know scheduling, materials required
 Have materials prepared/placed
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Method
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
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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
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Percentage of FP respondents rating the item as
"high" or "very high"
Figure 1: FPs' ratings of overall success and impact of
the Adult Mental Health module
100
94.6
57.8
94.1 (ns)
(*p<.05)
49.0
30
At end of module At 3 to 6 months
follow-up
Overall success in implementing
skills into practice
At end of module At 3 to 6 months
follow-up
.
Overall impact on FPs' patients
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99.8
100
100
98.7
100
(ns)
Depression
Other MH conditions (in general)
(*p<.05)
96.1
95.9
91.9
96.4
(ns)
(*p<.05)
88.6
(*p<.05)
84.3
81.1
(*p<.05)
77.5
Confidence in
diagnosing
.
Confidence in
treating
.
Confidence in
developing care
plans
At end
of
module
At 3 to
6
months
At end
of
module
At 3 to
6
months
At end
of
module
At 3 to
6
months
60
At end
of
module
At 3 to
6
months
Percentage of "Confident" FP respondents
Figure 2: FPs' confidence in providing mental health
care at module completion and 3 to 6 months posttraining
.
Confidence in
prescribing
medication
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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
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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………………………………………….
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Stigma
AIDs literature – AIDs patients stigmatized
1. Stigma reduced with useful interventions to treat/manage
problems/illness **
A. Information
B. Coping skills acquisition
Mental Health patients stigmatized
1. Family Physicians (FPs) self report: lack training, feel
unprepared ***
2. 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,
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Stigma results in






less prevention
more crisis
more deterioration
more relapse
more fear
vicious circle
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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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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
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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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Algorithm
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For More Information
www.pspbc.ca