Four years ago, David Floody retired to Tofino, still called the tough city as an echo of its wild days as a busy fishing port.
After a lifetime of teaching English in high school, he wanted to write novels. But the tough city – made tougher by its grey, windy winters – upset those plans, thrusting Mr. Floody into depression and anxiety.
“It was interfering with my retirement that I had planned for 32 years,” he said. It was his first brush with mental illness, and, like most Canadians, when he decided he needed help, he turned to his family doctor.
Often, that would mean a quick prescription. But Mr. Floody’s doctor did something different, connecting him to a new program called Bounce Back that allowed him to gain control over his mood disorders without medication.
The program is just part of a transformation of the way patients with mood disorders are treated in B.C., and its backers hope it will lead to a revolution across the country.
The shift toward treating mild to moderate mood disorders in a family doctor’s office emerged from the convergence of three interests. The B.C. government wants to contain health-care costs; General practitioners want more training and better pay for dealing with mental-health patients; and psychiatrists want more intervention before patients’ symptoms become acute. The result: treatment without the stigma of entering the mental-health-care system. It costs less, and it reduces the chances that symptoms will escalate.
Mr. Floody, who was diagnosed with Type 2 diabetes 12 years ago, was a prime candidate for the program, as mental-health issues often accompany chronic disease. He changed his lifestyle, but his diabetes was wearing him down in ways he hadn’t expected. “I didn’t anticipate there would by a psychological side effect. I felt blindsided,” he said.
With the assistance of a video, self-help workbooks and a telephone coach, Mr. Floody has made it through the past few months feeling in control of his health.
“It came down to one huge insight the program provided. When I had it, it seemed so obvious,” he said. “It showed me it’s not the negative thoughts and feelings you have, it’s how you choose to react to them. Before, I was reeling from some of them and I didn’t have strategies to deal with them.”
He is one of 31,000 British Columbians who have accessed Bounce Back, developed with $6-million in provincial seed money to the B.C. division of the Canadian Mental Health Association. More than 4,000 people have used the telephone coaches.
These services are part of a provincial program that also includes training for doctors.
A detailed analysis of the program is still under way, but some regional health authorities report it has reduced waits for mental-health services.
And together, the components have helped family physicians diagnose mental-health issues and taught them to access the tools in their practice, where an average patient visit lasts no more than 15 minutes.
This year, well over 600,000 British Columbians will see a family doctor about a mental-health concern, making GPs the front line in screening and treatment. Most have little basic training for this, and few resources.
“There are not enough specialists to see all the patients,” Dr. Rivian Weinerman said, gesturing toward the door of her office at Victoria’s mental-health hospital. As site chief of psychiatry for the Vancouver Island Health Authority, her world revolves around acute mental-health-care needs, but she was disturbed by missed opportunities to detect and treat cases early.
She and a handful of colleagues were working to develop better diagnostic tools for GPs and to show how alternate therapies can augment or replace antidepressants. The linchpin is cognitive behavioural therapy – teaching patients to recognize distorted or negative thoughts and actions and change the patterns. The trick was showing doctors how to offer it in a busy family practice.
“We wanted GPs to change gears with their patients, to be able to say, ‘Instead of handing you some benzos [benzodiazepines, a type of antidepressant], I will show you how you can control your anxiety,’” Dr. Weinerman said.
She assembled a manual that doctors can use to apply CBT in an office setting.
The program is not designed to replace treatment for severe mental-health disorders. But it is one more option for less acute cases in which drugs don’t always work. In fact, up to half of patients do not do well on medication. Even those who respond to antidepressant or anti-anxiety drugs can still benefit from dealing with the underlying mental processes and behaviours that contribute to their disorders.
Last year, Dr. Weinerman learned of an opportunity to spread the word. A committee of bureaucrats and doctors was seeking ways to address the shortage of family doctors and proposed boosting their fees for treating mental-health issues. Dr. Weinerman offered her work as the way forward. The committee jumped at it, and she designed a provincial curriculum in which doctors are trained to spread the word to their colleagues.
Her training program aims to give family practitioners better skills to diagnose hidden mental health problems, to provide basic CBT therapy and to connect patients to community services like Bounce Back. So far, 500 family doctors in B.C. have taken the training. Another 140 are waiting.
Like other provinces, the B.C. government is under pressure to rein in health-care spending.
This has meant that, increasingly, only patients with acute mental-health needs are offered services. “I felt better knowing GPs were trained with skills and tools to fill in the gaps for those patients we are going to say no to, so we are not closing the door on them,” Dr. Weinerman said.
Some express caution about the limits of the program. Duncan Shields, president of the B.C. Association of Clinical Counsellors, warned that patients with significant anxiety disorders or depression can’t expect a few short sessions with their GP to help them. “Most physicians don’t have time to open up an issue where someone is going to become emotional – they are going to have the pressure of a waiting room behind them.”
Kim Koopman was referred to the program as a supplement to antidepressant medication, but found even talking her telephone coach a trial. Her depression had taken deep root. “I had no tolerance, I wasn’t patient,” she said. “I completed it to the best I could, but I think I allowed my depression to go too far.”
This week, one of the founders of the Scottish version of Bounce Back arrived in B.C. to launch training for the next phase.
Ann McCreath will teach coaches to lead free, 12-hour “Living Life to the Full” programs for the public. These workshops are billed as life skills. Who doesn’t, as the promotional material says, want to “feel better, happier and more in control of your life?”
Today, with the initial $6-million government project almost complete, it is not clear whether B.C. will supply more cash to train additional doctors.
That likely depends on the detailed analysis of the program to be presented at a national mental health conference in May in Winnipeg. The preliminary findings are positive, and B.C.’s Health Minister, Kevin Falcon, expects the results to cause a national stir.
“This is exactly kind of program that I believe is critical to how we refurbish health-care services,” he said in an interview.
“What we tend to do now is deal with people when they are at an acute stage. We need to get to them when someone is presenting with early indications of mental-health issues – this is kind of early intervention is exactly the appropriate response.”
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Justine Hunter
The Globe and Mail
