Dr. Dan Bilsker (biography and disclosures)
What I did before
As a psychologist specializing in cognitive behavioural therapy (CBT), I treat depressed individuals, usually referred to me by family physicians or psychiatrists. I find CBT to be a wonderfully effective and flexible form of intervention. I have seen many individuals acquire crucial skills – behavioral activation, identification and replacement of distorted thinking, etc. – with substantial antidepressant effect. I felt very good about doing this clinical work and seeing individuals cope more effectively and recover from depressive episodes.
What changed my practice
But I also see the reality that the vast majority of depressed individuals will never have access to this form of intervention. CBT is minimally available in the public health system, and even in the private system there are a limited number of psychologists with adequate training in this therapy. And there is a financial barrier, although CBT works more quickly and is therefore less expensive than other forms of psychotherapy. About 10 years ago, I began to work with a mental health services research group dedicated to improving the way mental health care is delivered. I had the opportunity to develop an alternative approach to delivering CBT-based intervention for depression.
What I do now
Working with other researchers and clinicians, I produced a series of self-management workbooks designed to teach depressed individuals evidence-based skills for mood management, available for free download from our website (http://www.comh.ca/selfcare/). Rather than focusing my practice only on individual patients, I was able to deliver a low intensity CBT intervention to a very large number of people, many times more than I could ever treat individually. This involved a trade-off: the large clinical effect I get working with an individual vs. the smaller clinical effect from self-management teaching delivered to a vast number of people. Just to give a sense of the numbers reached by this intervention, about 80,000 of the self-management workbooks have been downloaded in the last six years and about 50,000 have been distributed by provincial ministries, health agencies or other organizations. To make this intervention more effective, we developed training modules for family physicians: about 700 BC family physicians have been trained to help their patients access the workbook and use antidepressant skills.
The message is that innovative forms of service delivery have the potential to greatly expand the scope of depression intervention. But where a powerful nonpharmacological intervention is sought, treatment by a well-trained CBT psychologist remains the gold standard.
References: (Note: Article requests might require a login ID with the BC College of Physicians website or UBC)
Bilsker, D., Anderson, J., Samra, J., Goldner, E.M., & Streiner, D. (2008). Behavioural interventions in primary care. Canadian Journal of Community Mental Health, 27, 179-189. (View article with CPSBC or UBC)
Gellatly, J., Bower, P., Hennessy, S., Richards, D., Gilbody, S & Lovell, K. (2007). What makes self-help interventions effective in the management of depressive symptoms? Meta-analysis and meta-regression. Psychological Medicine, 37, 1217-1228. (View article with CPSBC or UBC)