Prior to the pandemic, mental health conditions were the leading cause of disability in Canada, with one in two people affected by 40 years of age.[1] Now, COVID-19 has turned this crisis into a catastrophe, with half of all Canadians reporting worsening mental health,[2] and those experiencing the most societal inequities facing the greatest mental health decline during the pandemic.[3]

Before the pandemic, 85% of Canadians felt that mental health was among the most underfunded services in health care.[4] Canadians reported counseling to be their highest mental health care need,[5] yet it was also the least likely to be met, largely because most counseling services remain outside the public health care system.

Consequently, most people end up managing their mental health in primary care,[4] with publicly funded physicians often the only affordable option for patients. With so few services available in this model, patients often can’t access care until they are severely symptomatic. By then it’s too late: symptoms are entrenched, with poor prognoses and spiraling psychosocial costs.

Instead, supporting patients when their symptoms require only minimal intervention not only reduces downstream costs, but also empowers patients to self-manage their symptoms.

Starting small with local solutions

In 2015, a small group of physicians in Victoria came together to develop a cognitive-behavioral therapy (CBT) group program to offer equitable, accessible, and timely evidence-based mental health treatments for early intervention on a large scale.

The Shared Care Committee and the Victoria Division of Family Practice supported this team to collaboratively build a curriculum targeting primary care patients that could be delivered through 90-minute group medical visits over 8 consecutive weeks. The curriculum drew from the most evidence-based self-management skills, such as CBT, dialectical behavioral therapy, and mindfulness.

How it worked

The group created a sustainable delivery model that capitalized on physician facilitators, using existing MSP fee codes, and accommodated training of new family physicians through co-facilitation in ongoing patient groups. Administration was streamlined through a centralized referral centre, offering both patients and physicians maximum flexibility. The outcomes of this initiative have previously been reported in the BCMJ,[6] indicating effective results with economic benefits.

Building on success for provincial spread

As communities around BC became interested in launching similar initiatives, the Shared Care Committee selected the program for provincial spread. The program had already been expanded to nearby locations—Vancouver, Nanaimo, and Salt Spring Island—but geographic barriers became a major obstacle to it spreading more widely.

Virtual care provides greater access

When COVID-19 hit, the team pivoted to telehealth, with virtual groups offered within a week. A comparable-sized group program resumed within 3 months of the start of the pandemic.

Evaluations of patient satisfaction, helpfulness, and safety, and symptom-rating improvements showed virtual groups were comparable to the in-person experience, with more people preferring the virtual groups.

The virtual format also solved the problem of geographic barriers for training for more remote physicians—physicians anywhere could join an experienced facilitator in a group, complete the training, and become equipped to offer their own groups.

Supporting the mental health of physicians

The pandemic also stressed the ongoing need for mental health supports for physicians, so the founding physicians collaborated with the Physician Health Program (PHP) and several Divisions of Family Practice to offer physician-based groups. These groups provided doctors with the opportunity to begin learning and practising skills for mental health within a collegial environment. The groups had lengthy wait lists almost immediately.

Opportunities and next steps

The Shared Care Committee has brought together the CBT Skills Groups Society of Victoria, UBC CPD, and the PHP to expand the virtual groups to both patients and physicians across BC, well beyond the considerable number of patients who have participated so far—14 000 patients have been referred by 1500 family physicians across the province.

Starting this winter, physician wellness will be the focus of a UBC CPD series of CBT groups and workshops, where specialists and family physicians can meet virtually to support their personal well-being and gain grounding in group facilitation (including trauma-informed care and inclusivity training). Practical aspects of CBT will also be taught for physicians to share with patients.

Selected physicians can choose to continue training with the CBT Skills Groups Society to offer their own CBT skills groups to patients across the province.

Visit https://ubccpd.ca/collaborate/portfolios/cbt-skills for details on how physicians can participate in this program.
—Joanna Cheek, MD
Psychiatrist Lead, UBC CPD Physician Wellness

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This article is the opinion of the Shared Care Committee and has not been peer reviewed by the BCMJ Editorial Board.

References

1.     Canadian Mental Health Association, National. Fast facts about mental health and mental illness. 19 July 2021. https://cmha.ca/brochure/fast-facts-about-mental-illness/.

2.     Angus Reid Institute. Worry, gratitude & boredom: As COVID-19 affects mental, financial health, who fares better; who is worse? Accessed 17 September 2021. https://angusreid.org/covid19-mental-health/.

3.     Jenkins EK, McAuliffe C, Hirani S, et al. A portrait of the early and differential mental health impacts of the COVID-19 pandemic in Canada: Findings from the first wave of a nationally representative cross-sectional survey. Prev Med 2021;145:10633.

4.     Canadian Mental Health Association, National. Mental health in the balance: Ending the health care disparity in Canada. 17 September 2018. https://cmha.ca/brochure/mental-health-in-the-balance-ending-the-health-care-disparity-in-canada/.

5.     Statistics Canada. Data. Accessed 17 September 2021. https://www150.statcan.gc.ca/n1/en/type/data?MM=1.

6.     Cheek J, Burrell E, Tomori C. Self-management training in cognitive-behavioral therapy skills: A project to address unmet mental health needs in Victoria, BC. BCMJ 2019;61:316-323.