Offering CBT skills by group medical visits

Authors

Fiona Petigara, MD, CCFP (biography, no disclosures)

Joanna Cheek, MD, FRCPC (biography and disclosures) Disclosures: Received funding from Shared Care: sessional funding to develop and spread CBT Skills Group Program. Mitigating potential bias: Recommendations are consistent with published guidelines (e.g. CANMAT depression and anxiety guidelines) and current practice patterns.

What I did before

Fiona (Family Practice):

Even before the pandemic, a large part of my family practice involved managing patients’ mental health concerns, with one in two people affected by a mental health condition by the age of 40. Then the pandemic caused our patients’ mental health to decline further, with those experiencing the most social inequities facing the greatest mental health decline. A survey from my Division of Family Practice in Vancouver (VDFP) showed that 30-40% of our day is spent on mental health (VDFP, 2021).

Joanna (Psychiatry):

As a psychiatrist, I would only see patients with severe, persistent, and complicated presentations, rejecting most new referrals as “not sick enough.” My community had a few small public clinics that provided psychotherapy from allied health professionals, but wait times were immense and criteria for acceptance were small. The only option left for most patients needing psychotherapy interventions was the private system. Yet psychotherapy can cost upwards of $200/hr to receive evidence-based care, leaving it out of reach for those who most need it.

As a physician faced with more patients requiring services than I could ever treat, I constantly battled the moral dilemma: is it better to provide inadequate care to many or appropriate treatment to a few? It’s no surprise that even prior to the pandemic, Canadian physicians reported a burnout rate of 50% (Lamire, 2018) with “moral distress” a major risk factor (Perni, 2017).

Fiona:

One of the factors contributing to family physician burnout is that it is impossible to meet this mental health demand in an evidence-based way. It’s well-established that psychoeducation, skills training, psychotherapy, and lifestyle measures are vital and effective aspects of mental health treatment, but there was no way I could adequately and collaboratively discuss these measures with patients, within the time constraints of each visit, and the pressure of busy clinic days.

The increasing shortage of family doctors has only exacerbated the problem as our clinics have become busier than ever. I constantly felt the dilemma of quality care versus time-efficiency for mental health, and often ended up feeling dissatisfied with what I had been able to offer to patients: long waitlists for referrals, cost-prohibitive private resources, or medications alone.

What changed my practice

The Mental Health Commission of Canada (2017) has long recommended investing in evidence-based programs that focus on early and timely intervention to have the most impact in preventing or mitigating the impact of illnesses over the life course. The challenge, however, was translating the wealth of effective treatments in our toolbox into action — specifically, how could we deliver early interventions to as many people as possible to prevent the downward spiral of untreated mental illness and its dire social consequences?

Luckily, the BC Government created “Group Medical Visit” (GMV) codes to promote physicians to deliver their services to groups of patients as “an effective way of leveraging existing resources; simultaneously improving quality of care and health outcomes, increasing patient access to care and reducing costs” (BC Gov, 2022). Physicians could also benefit by reducing the need to repeat the same intervention many times and free up time for other patients. But despite the benefits of GMVs, the code was rarely used by physicians, primarily because they haven’t had training, experience, and mentoring in facilitating groups.

Joanna:

We were fortunate to attain pilot funding from the Shared Care Committee and our Victoria Division of Family Practice to trial a “CBT Skills Group” based on mental health self-management skills (from Cognitive Behavioral Therapy, Dialectical Behavioral Therapy, Mindfulness, and Acceptance and Commitment Therapy) that could be offered in 8 weeks of 90 min sessions to 15 people at a time, covered by MSP. We trained family physicians first in Victoria (see Cheek et al, 2019), and then across BC (see Cheek, 2021), through co-facilitation with physicians with experience leading mental health groups. Physicians learned to offer group medical visits for patients within their own communities or virtually to offer treatments to patients in areas that do not have access to these services or to adapt to COVID-19.

What I do now

Fiona:

This reduced the need to repeat the same interventions many times while also increasing patient engagement and motivation from group membership. In this way, physicians can more efficiently see large numbers of patients we already see in our offices and can be more effective as educators of a group, compared to what can be offered during a busy clinic day.

This project also capitalizes on economies of scale, wherein a family physician trained in the curriculum may focus part of their practice on group delivery and receive referrals from other physicians who are then more available for other demands of their practices.

I trained to become a facilitator and now offer two groups a week. In a similar fashion, a handful of physicians have been able to create a service that is broadly accessible: there are currently 28 CBT Skills Groups facilitators offering more than 30 groups a month and managing more than 500 monthly referrals through a centralized BC referral centre that was established to streamline the process. To date, more than 1,500 family physicians across BC have taken advantage of the opportunity to refer patients to the skills training.

My training as a facilitator and the mentorship I now have with my psychiatry colleagues have improved my capacity to manage mental health conditions in my clinic. As a family physician teaching mental health skills, I value the implicit message to patients that mental health is an integral part of overall health and a vital part of primary care. As a facilitator, I deeply value the rich teachings and the opportunity to have time and space, outside of my busy clinic setting, to educate and coach effective mental health strategies. My time facilitating groups does not take away from my practice, it enriches it, giving more meaning to my work.

Joanna:

We as physicians are demonstrating that mental health is an essential part of our patients’ health and we will spend our limited time filling the holes in the public system in accessing psychotherapy services if other mental health providers are not funded to do so. We continue to advocate for more allied health professionals to be funded to offer more access to counselling. At the same time, by having physicians offering these group medical visits, we demonstrate that learning self-management skills like CBT is an effective medical treatment just like medications. This reduces the unhelpful “splitting” between biological and psychological tracks of services. Having trusted family physicians deliver mental health services can also reduce stigma by showing that mental health affects general health and is valued as a vital part of primary care.

Offering these groups also gives physicians practice and tools to manage our own mental health and prevent burnout. Because these skills and groups have helped us so much with our own wellbeing, we’re hoping to share the experience with our colleagues by offering the 8-week CBT Skills groups to BC physicians through UBC CPD, where physicians can participate in the full program with peers, while receiving CME credits. This program offers CBT skills to physician-only groups and enables a space to learn powerful skills for our wellbeing.

While GMVs may sound daunting at first, our program is well supported both administratively and educationally. Physicians are welcome to use pre-made resources and slides or make their own. Workshops are offered to physicians on topics such as facilitation skills, trauma-informed care, and equity, diversity, and inclusion.

For physicians unable to offer or train in this practice, they are able to simply refer their patients to our program, noting this service is only provided in BC. The referral form is available at cbtskills.ca or through PathwaysBC — download PDF.

References

1. BC Government. Health: Specialist Group Medical Visits. (View) Accessed Mar 16, 2022.
2. 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(8): 316-323. (View)
3. Cheek, J. CBT Skills Spread Initiative: Building a program to support doctor and patient mental health. BCMJ. 2021, 63(9): 290-1. (View)
4. Lemire F. Combatting physician burnout. Canadian Family Physician.  2018; 64(6): 480. (View)
5. Mental Health Commission of Canada. Strengthening the Case for Investing in Canada’s Mental Health System: Economic Considerations. 2017. (View)
6. Perni S.  Moral Distress: A Call to Action. AMA Journal of Ethics. 2017. (View)
7. Vancouver Division of Family Practice: White Paper – Mental Health and Addictions Care in the Community Intersecting with Patient Medical Homes and Primary Care Networks. Internal Document. July 9, 2021. (Request with CPSBC)
8. Von Rueden U, Gosch A, et al. Socioeconomic determinants of health-related quality of life in childhood and adolescence: results from a European study. Journal of Epidemiology and Community Health. 2016, 60:130-135. (View)

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