Meeting the needs of the mental health care crisis: Proposing a community stepped care model
Introduction
A significant discrepancy exists between the demand for mental health services and those available to patients and their primary care providers in Canada. Canadian family physicians rate psychiatry as the most challenging speciality to access1-3 and report feeling underprepared to deal with severity and scope of mental health patients they face in practice4-5. With the advent of the COVID-19 pandemic, it was predicted the burden of mental illness wouldincrease, and this has, in fact, already been observed6-7. Solutions to the mental health care crisis in Canada are essential and urgent.
Here, we suggest the most effective, patient-centred and provider acceptable model for delivery of mental health care is centred around stepped care by family physicians with specialized training in mental health. This model requires adaptations to current training. Certainly, more research is required to provide necessary and appropriate attention to curriculum development, acceptability, accessibility, implementation and, subsequently, to evaluate success. Our aim here is to introduce the broad strokes of this model as a potential solution to the urgent need for revision in theprovision of primary mental health care.
What would stepped care look like?
Collaborative care models and their effectiveness for treating complex mental health issues in the primary care setting have been well described in the literature8-10. The core principles of a collaborative care model inherently recognize the centrality of primary care in the treatment of mental illness, appreciate the limitations of the physician in meeting the entirety of the complex needs of the patient, and champion the value of an interdisciplinary team to address complex and interrelated physical and mental health concerns. While collaborative care remains an important tenet of care, alone, it is not inherently resource efficient. To make the best use of our mental health resources it is important we appropriately match patients (and their family physicians) with the mental health services they require.
In their 2016 article, “Choosing Wisely? Let’s Start with Working Wisely”, Kurdyak, Wiesenfeld and Sockalingam astutely articulate the absence of alignment between psychiatric service need and access. They discuss the notion of a centralized intake system involving community care, primary care, community psychiatrists as well as ‘stepped care’ at the hospital level, similar to models in other areas of medicine such as cancer and cardiac care11. In a community based stepped care model, triage would begin beforepatients reach the hospital; patients would be triaged to alternate levels of care within the primary care setting,thereby mitigating referrals to psychiatry or hospital-based psychiatric programs. This process would be facilitated by family medicine physicians with specialized training in mental health care who provide an additional tier of community-based support. The process is outlined in Figure 1. The stepped care model can serve to complement and support a robust collaborative care model where it is already in place or function independently in less well-resourced practices. Virtual care, which has become commonplace during the COVID-19 pandemic, would make this model accessible to family physicians across a variety of practice locations and models.
Figure 1
The stepped care model would ameliorate wait times to psychiatry by reducing psychiatry case load as well as providing intermediary support for patients awaiting psychiatry. Further, it provides family physicians with support for complex cases. Community based stepped care can be adapted to many areas of mental health in which familyphysicians receive limited training but are often faced with in their clinical practices including but not limited to Child and Adolescent Mental Health, Severe Mental Illness, Co-morbid Physical and Mental Illness, Addiction Medicine, and Psycho-Oncology.
Developing a model of care grounded in the centrality of primary care is essential. Family physicians are ideally positioned to diagnose and treat mental health concerns because they are often the first health care providers to whom patients present. Family doctors are, in fact, already delivering a tremendous amount of the mental health care inCanada. Additionally, mental illness and physical illness are inherently linked and family physicians are distinctly suited to provide the comprehensive care required to treat patients presenting with ailments resulting from the complexinteraction between the two.
Curriculum: What and When?
The development of a full curriculum for the training of family physicians with enhanced skills in mental health care is beyond the scope of this paper. However, it warrants mention that the Assessment Objectives for Certification in Family Medicine from May 2020, does contain an addendum listing eight additional topics with competencies for mental health12. We would suggest these competencies to be an excellent ‘jumping off’ point for the development of asupplementary primary care mental health curriculum.
The question of when to train family physicians for this role is complex. There has been much controversy about the impact of enhanced training programs on the practice of comprehensive primary care13. Nonetheless, resident demand for third year enhanced training programs remains high14. There has also been discussion about lengthening family medicine residency training, thereby keeping Canada in line with three-year training programs in the UK and France15.
Regardless of the direction in which residency programs choose to go, it is clear there is a role for enhanced training in some capacity- during residency or after- to develop the skill set and leadership necessary to implement a community stepped care model for mental health. Further study is required to determine the optimal timing for this training, taking into account the multiple stakeholders involved.
The Time is Now
While the gap between the provision of care and the need for mental health services has long been challenging, the urgency of the situation has rapidly increased due to the COVID-19 pandemic. Predictions made during the spring and summer of 2020 regarding the increasing mental health burden of the pandemic have, unfortunately, borne out6-7.
Data from the Canadian Mental Health Association (CMHA) released in December 2020 indicate 40% of Canadians report a deterioration in their mental health since March; this is more pronounced in young people, for whom mental health was already a grave concern prior to the pandemic. There has been a significant increase in suicidality in the population, worsening pre- existing mental health conditions as well as rising substance use. As before the pandemic, most Canadians are unable to access mental health services. Margaret Eaton, president of the CMHA advised: “Lengthy wait times are a problem, in part, because there has been a chronic underfunding of community-based mental health services and a reliance on intensive, high-cost services like hospitals and acute care. If we fund community-levelinterventions, this will alleviate pressure on an acute-care system already hit hard by COVID-19—and get people the help they need sooner.7”
Conclusion:
It is evident the mental health crisis in Canada and Ontario is worsening and likely to continue to do so during and in the aftermath of the pandemic. It is time to provide family physicians with the support and training they require tocontinue to provide community mental health care, but in a more effective model that meets the needs of patients, physicians and our healthcare system. A community based stepped care model meets these needs. It will require thespecialized training of family physicians, an intervention for future study.
Dr. Rachel Shour is a community family physician with a focused practice in psychotherapy and mental health. Her clinical area of interest is in the intersection between mental and physical health with a focus on psych oncology and reproductive medicine. She recently completed her fellowship in the Medical Psychiatry Alliance at the University of Toronto, Department of Psychiatry. She is a Lecturer in the Department of Community and Family Medicine, Temerity Faculty of Medicine.
Dr. Adrienne Tan is a clinician-educator and Director, General Psychiatry Residency Program in the Department of Psychiatry, Temerity Faculty of Medicine, University of Toronto. Clinically her expertise is in C-L (Consultation-Liaison) Psychiatry, providing psychiatric care to complex medically ill patients for a variety of specialized medical and surgical services at the University Health Network. She has also led a national steering committee to have C-L Psychiatry approved as an Area of Focused Competence (AFC) by the Royal College of Physicians and Surgeons of Canada (RCPSC).
References
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