Dr Rivian Weinerman, family doctor | Medical Staff Honorary Status Island Health, VIHA & UBC Associate Clinical Professor Psychiatry
In the mid-2000’s, I was a Director of an urgent mental health clinic. Most referrals came from GPs in the community when they were stuck with a patient, or about to send the patient to emergency. They would send in patients who were very depressed or anxious. We found that many had not been asked questions [that might identify underlying issues]: substance use, sexual abuse, bipolar disorder, PTSD.
We developed a hypothesis that the reason GPs didn’t ask questions is because if they got “yes,” what were they to do? It’s very hard to refer patients into the mental health system, and GPs didn’t feel they had the skills or time to treat them.
I knew from the literature that GPs didn’t get comprehensive mental health training in medical school. They may have had a life-long relationship with a patient, but with limited tools and time constraints they hesitated to engage the patient in questions or treatment. And they treated mostly with medications which was the main tool they had.
So with another psychiatrist, Dr Helen Campbell, who had been a GP in the past, and two therapists, we developed the CBIS manual (Cognitive Behavioural Interpersonal Skills) as a tool for GPs to improve their diagnosis and treatment of mild and moderate depression and anxiety. We did not focus on psychosis disorders as we felt that they out of the scope.
If doctors could increase their confidence in better treating these patients, there would be increased patient access, and fewer referrals of these patients into the secondary system. When referrals did occur, they would be more appropriate complex care referrals.
We wanted to develop a process for GPs to ask the questions, engage patients, and use skills—not only pills—to treat them. We came up with a Cognitive Behavioural Therapy (CBT) approach—a diagnostic interview that a GP can do very briefly to get a diagnosis leading to a care plan. It guides doctors to ask the questions that are so difficult to ask—and they could do that during regular appointments.
We also utilized twenty-minute counseling sessions—a process that involves really listening and hearing, and understanding where the patient is at. It gets the patient involved, because the GP has to negotiate skills. Just ‘listening and hearing’ can be treatment—the patient is going to do better if GPs just do that.
We wanted to increase access options, so we also arranged for telephone coaching from the Canadian Mental Association Health Bounce Back Program. And if a patient was comfortable, they could also use a self-care workbook at home.
This approach—which was used to form the basis of the Practice Support Program’s Adult Mental Health module—is not just skills-based. It also fit within the time constraints of the doctor’s office and fee schedules. These were the key ingredients to its success.
We found that these skills and tools did indeed increase GPs’ confidence in diagnosis, treatment, and developing care plans, and in prescribing and relying less on the medication.1 And it increased ability for their patients to return to work. The doctors reported increased job satisfaction, because they didn’t feel they were avoiding their patients. And those results persisted three and six months after the training.
Then we thought, maybe if you gave GPs these skills and decrease their anxiety, their attitude might also change. If they had more confidence and were more comfortable asking the questions, and they felt they had the skills, they would be more welcoming to these patients, less avoidant and therefore we’d see less health care provider stigma.
In 2017, through a double-blind study, we were able to show that. By increasing comfort on the doctors’ part through training and increased skills, we saw an decrease in social distance—the distance the doctor put between them and the patient—and the doctors were more welcoming to their patients. This is a key dimension in the overall dimensions of stigma.2
We also saw that patients were feeling like they were in a whole new space. In those visits, they were feeling more heard, more understood, more listened to, more satisfied, and more at ease with talking to their family doctor.
1 Mental Health Practice and Attitudes Can Be Changed
2 Impact of Skill-Based Approaches in Reducing Stigma in Primary Care Physicians: Results from a Double-Blind, Parallel-Cluster, Randomized Controlled Trial