Impact of a cognitive behavioural therapy training program on family physician practices: Cross-sectional study in Norway.

OBJECTIVE: To investigate changes in FPs' self-reported clinical practices after participation in a comprehensive 1-year cognitive behavioural therapy (CBT) training course. DESIGN: Cross-sectional study. SETTING: Norway. PARTICIPANTS: Family physicians. MAIN OUTCOME MEASURES: Impact of the CBT training course on FPs' delivery of CBT to patients and their use of referral to specialized mental health care providers. RESULTS: Of the 217 FPs who had participated in the training course between 2009 and 2016, 124 completed the survey (response rate=57.1%); 99.2% of participating FPs reported using CBT tools daily in patient consultations, more than three-quarters reported changing the way they organized their workdays to accommodate CBT, and 75.0% reported using structured CBT consultations at least monthly after completing the course. The most common patient groups receiving structured CBT were those experiencing mild or moderate depression (22.8%), anxiety disorders (30.4%), or a combination of an anxiety disorder and depression (43.5%). The odds of making fewer referrals to specialized mental health care providers were 5.4 times higher among FPs who used Socratic questioning (P=.02), 4.7 times higher among those who provided consultation summaries (P=.01), and 3.3 times higher among those who had participated in a refresher course (P=.05). CONCLUSION: Comprehensive training in CBT promotes the use of CBT tools and strategies in family practice. Further longitudinal research (ideally randomized controlled studies) on patient outcomes related to CBT provided in family practices is required.

Impact of Integrated Care Pathways Within the Framework of Collaborative Care on Older Adults With Anxiety, Depression, or Mild Cognitive Impairment.

OBJECTIVES: To evaluate the impact of an Integrated Care Pathway (ICP) within a collaborative care framework for anxiety, depression and mild cognitive impairment (MCI) on clinical outcomes, quality of life, and time to treatment initiation. DESIGN: Prospective Cohort study. SETTING: Primary care practices in Toronto and Hamilton, Ontario, Canada. PARTICIPANTS: Patients of participating primary care practices born in the years 1950 to 1958. SAMPLE SIZE: Target 150 participants, 75 in ICP and 75 in Treatment-As-Usual (TAU) arm. INTERVENTION: ICP within a collaborative care framework and TAU. METHODS AND RESULTS: One hundred forty-five participants with anxiety, depression or MCI, from five primary care practices were enrolled: 69 were managed as per ICP and 76 as per TAU. All underwent outcome assessments at 6, 12, 18, and 24 months. Compared to TAU, ICP participants had a significantly higher rate of improvement in depression symptoms (ß = -0.620, F (1, 256) = 4.10, p = 0.044), anxiety symptoms (ß = -0.593, F (1, 223) = 4.00, p = 0.047), and quality of life (ß = 1.351, F(1, 358) = 6.58, p = 0.011). The ICP group had also a significantly higher "hazard" of treatment initiation (HR = 3.557; 95% CI: [2.228, 5.678]; p < 0.001) after controlling for age, gender and baseline severity of symptoms compared to TAU group. CONCLUSIONS: Use of an ICP within a collaborative care framework in primary care settings for anxiety, depression and MCI among older adults, results in faster reductions in clinical symptoms and improvement in quality of life compared to usual care, as well as faster access to recommended treatments.

Detecting young people with mental disorders: a cluster-randomised trial of multidisciplinary health teams at the GP office.

BACKGROUND: Young people with mental health challenges present a major global challenge. More than half of adults with mental disorders experience their onset before age 14, but early detection and intervention may change this course. Shared care with mental health professionals in general practitioner (GP) offices has demonstrated its potential for improvement in these conditions. AIM: To investigate whether shared care with mental health professionals in GP offices increases the detection of youth's mental health disorders and is associated with a decrease in use of unspecified symptom diagnoses, as a whole and stratified by patient and physician gender and age, and type of consulting physician. DESIGN AND SETTING: This was a stratified cluster-randomised controlled trial with data extraction from electronic records. Two GP offices were recruited from each of three boroughs. Each borough had 3-8 GP offices. One GP office was randomised to the intervention group and the other to the control group. METHOD: We used generalised linear mixed models to assess whether the intervention helped GPs identify more International Classification of Primary Care 2 diagnoses of depression, anxiety and unspecified symptoms in youth. RESULTS: Over a 18-month period between between 2015 and 2017, the intervention helped GPs identify more youth with anxiety (p=0.002 for interaction), but not depression. The increase was most significant among the patients' regular GPs, less when patients met other GPs and least among external substitute physicians. The frequency of diagnoses with unspecified symptoms decreased in the intervention arm. CONCLUSION: Shared care with mental health professionals located in GP office contributed to increased detection of youth with anxiety symptoms. The increase was most prominent when the primary care physician was the patient's regular GP. GPs need to pay greater attention to detecting anxiety in youth and embrace shared care models, thereby contributing to reduced mental health disorders in this age group. TRIAL REGISTRATION NUMBER: NCT03624829; Results.

The trajectories of depressive symptoms among working adults during the COVID-19 pandemic: a longitudinal analysis of the InHamilton COVID-19 study.

BACKGROUND: Longitudinal studies examining the impact of changes in COVID-19 pandemic-related stressors and experiences, and coping styles on the mental health trajectory of employed individuals during the lockdown are limited. The study examined the mental health trajectories of a sample of employed adults in Hamilton, Ontario during the initial lockdown and after the re-opening following the first wave in Canada. Further, this study also identified the pandemic-related stressors and coping strategies associated with changes in depressive symptoms in employed adults during the COVID-19 pandemic. METHODS: The InHamilton COVID-19 longitudinal study involved 579 employees aged 22-88 years from a large public university in an urban area of Hamilton, Ontario at baseline (April 2020). Participants were followed monthly with 6 waves of data collected between April and November 2020. A growth mixture modeling approach was used to identify distinct groups of adults who followed a similar pattern of depressive symptoms over time and to describe the longitudinal change in the outcome within and among the identified sub-groups. RESULTS: Our results showed two distinct trajectories of change with 66.2% of participants displaying low-consistent patterns of depressive symptoms, and 33.8% of participants displaying high-increasing depressive symptom patterns. COVID-19 pandemic-related experiences including health concerns, caregiving burden, and lack of access to resources were associated with worsening of the depressive symptom trajectories. Frequent use of dysfunctional coping strategies and less frequent use of emotion-focused coping strategies were associated with the high and increasing depressive symptom pattern. CONCLUSIONS: The negative mental health impacts of the COVID-19 pandemic are specific to subgroups within the population and stressors may persist and worsen over time. Providing access to evidence-informed approaches that foster adaptive coping, alleviate the depressive symptoms, and promote the mental health of working adults is critical.

Psychopathology in the Offspring of Indigenous Parents with Mental Health Challenges: A Systematic Review: Psychopathologie des descendants de parents autochtones ayant des problèmes de santé mentale: Une revue systématique.

OBJECTIVE: Parental psychopathology is a significant risk factor for mental health challenges in offspring, but the nature and magnitude of this link in Indigenous Peoples is not well understood. This systematic review examined the emotional and behavioral functioning of the offspring of Indigenous parents with mental health challenges. METHOD: We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and Web of Science from their inceptions until April 2020. Studies were included if they included assessments of emotional, behavioral, or other psychological outcomes in the offspring of Indigenous parents with a mental health challenge. RESULTS: The 14 studies eligible for review were focused on parental substance misuse (n = 8), maternal internalizing (i.e., depression, anxiety) issues (n = 5), and poor overall parental mental health (n = 4). In 11 studies, parental substance misuse, depression, and/or overall mental health challenges were associated with 2 to 4 times the odds of offspring externalizing and internalizing behaviors as compared to offspring of Indigenous parents without mental health challenges. CONCLUSION: The findings suggest higher risks of mental health challenges among offspring of Indigenous parents with psychiatric difficulties than among Indigenous children of parents without similar difficulties. Knowledge of these phenomena would be improved by the use of larger, more representative samples, culturally appropriate measures, and the engagement of Indigenous communities. Future studies should be focused on both risk and resilience mechanisms so that cycles of transmission can be interrupted and resources aimed at detection, prevention, and treatment optimally allocated.

The Perinatal Mental Health of Indigenous Women: A Systematic Review and Meta-Analysis.

OBJECTIVE: Although Indigenous women are exposed to high rates of risk factors for perinatal mental health problems, the magnitude of their risk is not known. This lack of data impedes the development of appropriate screening and treatment protocols, as well as the proper allocation of resources for Indigenous women. The objective of this systematic review and meta-analysis was to compare rates of perinatal mental health problems among Indigenous and non-Indigenous women. METHODS: We searched Medline, EMBASE, PsycINFO, CINAHL, and Web of Science from their inceptions until February 2019. Studies were included if they assessed mental health in Indigenous women during pregnancy and/or up to 12 months postpartum. RESULTS: Twenty-six articles met study inclusion criteria and 21 were eligible for meta-analysis. Indigenous identity was associated with higher odds of mental health problems (odds ratio [OR] 1.62; 95% confidence interval [CI], 1.25 to 2.11). Odds were higher still when analyses were restricted to problems of greater severity (OR 1.95; 95% CI, 1.21 to 3.16) and young Indigenous women (OR 1.86; 95% CI, 1.51 to 2.28). CONCLUSION: Indigenous women are at increased risk of mental health problems during the perinatal period, particularly depression, anxiety, and substance misuse. However, resiliency among Indigenous women, cultural teachings, and methodological issues may be affecting estimates. Future research should utilize more representative samples, adapt and validate diagnostic and symptom measures for Indigenous groups, and engage Indigenous actors, leaders, and related allies to help improve the accuracy of estimates, as well as the well-being of Indigenous mothers, their families, and future generations. TRIAL REGISTRATION: PROSPERO-CRD42018108638.

Strategies for engaging patients and families in collaborative care programs for depression and anxiety disorders: A systematic review.

BACKGROUND: Patients and families are often referred to as important partners in collaborative mental health care (CMHC). However, how to meaningfully engage them as partners remains unclear. We aimed to identify strategies for engaging patients and families in CMHC programs for depression and anxiety disorders. METHODS: We updated a Cochrane review of CMHC programs for depression and anxiety disorders. Searches were conducted in Cochrane CCDAN and CINAHL, complemented by additional database searches, trial registry searches, and cluster searches for 'sibling' articles. Coding and data extraction of engagement strategies was an iterative process guided by a conceptual framework. We used narrative synthesis and descriptive statistics to report on findings. FINDINGS: We found 148 unique CMCH programs, described in 578 articles. Most programs (96%) featured at least one strategy for engaging patients or families. Programs adopted 15 different strategies overall, with a median of two strategies per program (range 0-9 strategies). The most common strategies were patient education (87% of programs) and self-management supports (47% of programs). Personalized care planning, shared decision making, and family or peer supports were identified in fewer than one third of programs. LIMITATIONS: Our search strategy was designed to capture programs evaluated in clinical trials and so other innovative programs not studied in trials were likely missed. CONCLUSION: Most CMHC programs for depression and anxiety disorders adopted a limited number of strategies to engage patients and families in their care. However, this review identifies numerous strategies that can be used to strengthen the patient- and family-centeredness of collaborative care.

Integrating mental health peer support in clinical settings: Lessons from Canada and Norway.

Mental health peer support is an evidence-based approach called for by Canada's mental health strategy that presents health leaders with an opportunity to transform mental health service experiences, improve health outcomes, and lower overall system costs. Originally offered in community settings, peer support has been expanding to clinical settings, but challenges to integration exist. This qualitative case study of peer support in clinical settings in Canada and Norway examines the perceived value of peer support and change management strategies that health leaders, managers, staff, and peer support providers can use to support integration of peer support in existing healthcare teams in clinical settings. Recommended strategies for health leaders include adopting a gradual approach to integration, building champions, demonstrating value, focusing on resistant groups, adopting a continuous improvement approach, setting peer support as an organizational priority, and linking peer support to patient-centred care.

Improving collaboration between primary care and mental health services.

Objective: Previous guidelines and planning documents have identified the key role primary care providers play in delivering mental health care, including the recommendation from the WHO that meeting the mental health needs of the population in many low and middle income countries will only be achieved through greater integration of mental health services within general medical settings. This position paper aims to build upon this work and present a global framework for enhancing mental health care delivered within primary care.Methods: This paper synthesizes previous guidelines, empirical data from the literature and experiences of the authors in varied clinical settings to identify core principles and the key elements of successful collaboration, and organizes these into practical guidelines that can be adapted to any setting.Results: The paper proposes a three-step approach. The first is mental health services that any primary care provider can deliver with or without the presence of a mental health professional. Second is practical ways that effective collaboration can enhance this care. The third looks at wider system changes required to support these new roles and how better collaboration can lead to new responses to respond to challenges facing all mental health systems.Conclusions: This simple framework can be applied in any jurisdiction or country to enhance the detection, treatment, and prevention of mental health problems, reinforcing the role of the primary care provider in delivering care and showing how collaborative care can lead to better outcomes for people with mental health and addiction problems.

Collaborative Care for Psychiatric Disorders in Older Adults: A Systematic Review.

OBJECTIVE: To evaluate the mode of implementation, clinical outcomes, cost-effectiveness, and the factors influencing uptake and sustainability of collaborative care for psychiatric disorders in older adults. DESIGN: Systematic review. SETTING: Primary care, home health care, seniors' residence, medical inpatient and outpatient. PARTICIPANTS: Studies with a mean sample age of 60 years and older. INTERVENTION: Collaborative care for psychiatric disorders. METHODS: PubMed, MEDLINE, Embase, and Cochrane databases were searched up until October 2016. Individual randomized controlled trials and cohort, case-control, and health service evaluation studies were selected, and relevant data were extracted for qualitative synthesis. RESULTS: Of the 552 records identified, 53 records (from 29 studies) were included. Very few studies evaluated psychiatric disorders other than depression. The mode of implementation differed based on the setting, with beneficial use of telemedicine. Clinical outcomes for depression were significantly better compared with usual care across settings. In depression, there is some evidence for cost-effectiveness. There is limited evidence for improved dementia care and outcomes using collaborative care. There is a lack of evidence for benefit in disorders other than depression or in settings such as home health care and general acute inpatients. Attitudes and skill of primary care staff, availability of resources, and organizational support are some of the factors influencing uptake and implementation. CONCLUSIONS: Collaborative care for depressive disorders is feasible and beneficial among older adults in diverse settings. There is a paucity of studies on collaborative care in conditions other than depression or in settings other than primary care, indicating the need for further evaluation.

Eliciting Provider and Patient Perspectives on New Obesity Management Services in a Team-Based Primary Care Organization.

PURPOSE: Both providers and patients may have important insights to inform the development of obesity prevention and management services in Canadian primary care settings. In this formative study, insights for new obesity management services were sought from both providers and patients in 1 progressive citywide organization (150 physicians, team services, separate offices). METHODS: Seven focus groups with interprofessional health providers (n = 56) and 4 focus groups with patients (n = 34) were conducted. Two clinical vignettes (adult, child) were used to focus discussion. Four analysts coded for descriptive content and interpretative themes on possible tools and care processes using NVivo. RESULTS: Participants identified numerous strategies for care processes, most of which could be categorized into 1 or more of 11 themes: 6 directed at clinical care of patients (raising awareness, screening, clinical care, skill building, ongoing support, and social/peer support) and 5 directed at the organization (coordination/collaboration, creating awareness among health professionals, adding new expertise to the team, marketing, and lobbying/advocacy). CONCLUSIONS: The approach was successful in generating an extensive list of diverse activities to be considered for implementation studies. Both patients and providers identified that multiple strategies and systems approaches will be needed to address obesity management in primary care.

Obesity services planning framework for interprofessional primary care organizations.

Aim We report on a formative project to develop an organization-level planning framework for obesity prevention and management services. BACKGROUND: It is common when developing new services to first develop a logic model outlining expected outcomes and key processes. This can be onerous for single primary care organizations, especially for complex conditions like obesity. METHODS: The initial draft was developed by the research team, based on results from provider and patient focus groups in one large Family Health Team (FHT) in Ontario. This draft was reviewed and activities prioritized by 20 FHTs using a moderated electronic consensus process. A national panel then reviewed the draft. Findings Providers identified five main target groups: pregnancy to 2, 3-12, 13-18, 18+ years at health risk, and 18+ with complex care needs. Desired outcomes were identified and activities were prioritized under categories: raising awareness (eg, providing information and resources on weight-health), identification and initial management (eg, wellness care), follow-up management (eg, group programs), expanded services (eg, availability of team services), and practice initiatives (eg, interprofessional education). Overall, there was strong support for raising awareness by providing information on the weight-health connection and on community services. There was also strong support for growth assessment in pediatric care. In adults, there was strong support for wellness care/health check visits and episodic care to identify people for interventions, for group programs, and for additional provider education. CONCLUSIONS: Joint development by different teams proved useful for consensus on outcomes and for ensuring relevancy across practices. While priorities will vary depending on local context, the basic descriptions of care processes were endorsed by reviewers. Key next steps are to trial the use of the framework and for further implementation studies to find optimally effective approaches for obesity prevention and management across the lifespan.

Strategies and impacts of patient and family engagement in collaborative mental healthcare: protocol for a systematic and realist review.

INTRODUCTION: Collaborative mental healthcare (CMHC) has garnered worldwide interest as an effective, team-based approach to managing common mental disorders in primary care. However, questions remain about how CMHC works and why it works in some circumstances but not others. In this study, we will review the evidence on one understudied but potentially critical component of CMHC, namely the engagement of patients and families in care. Our aims are to describe the strategies used to engage people with depression or anxiety disorders and their families in CMHC and understand how these strategies work, for whom and in what circumstances. METHODS AND ANALYSIS: We are conducting a review with systematic and realist review components. Review part 1 seeks to identify and describe the patient and family engagement strategies featured in CMHC interventions based on systematic searches and descriptive analysis of these interventions. We will use a 2012 Cochrane review of CMHC as a starting point and perform new searches in multiple databases and trial registers to retrieve more recent CMHC intervention studies. In review part 2, we will build and refine programme theories for each of these engagement strategies. Initial theory building will proceed iteratively through content expert consultations, electronic searches for theoretical literature and review team brainstorming sessions. Cluster searches will then retrieve additional data on contexts, mechanisms and outcomes associated with engagement strategies, and pairs of review authors will analyse and synthesise the evidence and adjust initial programme theories. ETHICS AND DISSEMINATION: Our review follows a participatory approach with multiple knowledge users and persons with lived experience of mental illness. These partners will help us develop and tailor project outputs, including publications, policy briefs, training materials and guidance on how to make CMHC more patient-centred and family-centred. PROSPERO REGISTRATION NUMBER: CRD42015025522.

Presence with purpose: attitudes of people with developmental disability towards health care students.

CONTEXT: Early clinical encounters help medical and nursing students build professional competencies. However, there is a necessary emphasis on patient autonomy and appropriate consent. Although most individuals do not object to student involvement in clinical encounters, there are occasions when personal preference and health care education conflict. Many studies have evaluated patient attitudes towards students across a variety of specialties. OBJECTIVES: The purpose of this study was to identify the attitudes, comfort level and preferences of individuals with developmental disability (DD) towards the presence and involvement of medical and nursing students during clinical encounters. METHODS: Adults with DD across the Hamilton-Niagara region were invited to participate. Focus groups were moderated by two students with a health care facilitator and physician-educator. Participants were provided with focus group questions in advance and encouraged to bring communication aids or care providers. Data were analysed for emerging themes by two independent reviewers, who then compared results. RESULTS: Twenty-two individuals participated. A wide range of opinions were expressed. Some participants were positively disposed towards students and perceived better care and improved communication with the health care team. Others were indifferent to students in a clinical setting. The final group was opposed to the presence of health care students, expressing confusion over their role and purpose, uneasiness with deviation from the norm, and concerns about confidentiality. Informative introductions with confidentiality statements and the presence of a supervising clinician were seen as helpful. CONCLUSIONS: People with DD are affected by above-average health care needs. Their input into health care planning has been limited. Their opinions on health care learners varied considerably. Themes relating to attitudes, comfort and preferences about student involvement provide impetus for health care training practices that promote person-centred approaches and improvements to the quality of care received by people with DD.

Developing an evaluation framework for consumer-centred collaborative care of depression using input from stakeholders.

OBJECTIVE: To develop a framework for research and evaluation of collaborative mental health care for depression, which includes attributes or domains of care that are important to consumers. METHODS: A literature review on collaborative mental health care for depression was completed and used to guide discussion at an interactive workshop with pan-Canadian participants comprising people treated for depression with collaborative mental health care, as well as their family members; primary care and mental health practitioners; decision makers; and researchers. Thematic analysis of qualitative data from the workshop identified key attributes of collaborative care that are important to consumers and family members, as well as factors that may contribute to improved consumer experiences. RESULTS: The workshop identified an overarching theme of partnership between consumers and practitioners involved in collaborative care. Eight attributes of collaborative care were considered to be essential or very important to consumers and family members: respectfulness; involvement of consumers in treatment decisions; accessibility; provision of information; coordination; whole-person care; responsiveness to changing needs; and comprehensiveness. Three inter-related groups of factors may affect the consumer experience of collaborative care, namely, organizational aspects of care; consumer characteristics and personal resources; and community resources. CONCLUSION: A preliminary evaluation framework was developed and is presented here to guide further evaluation and research on consumer-centred collaborative mental health care for depression.

Framework for advancing improvement in primary care.

A consistent feature of effective healthcare delivery systems is a strong and well-integrated primary care sector. This paper presents a framework that describes the key elements of high-performing primary care and the supports required to attain it. The framework was developed by the Quality Improvement and Innovation Partnership in Ontario (now part of Health Quality Ontario) to guide the process of primary care transformation. The first section of this paper presents and describes the framework, the second proposes implementation strategies and the third identifies system-level structures and policies needed to support primary care transformation. The framework has three components: (1) the major constituencies that primary care serves ­ patients, families and their local communities; (2) the desired outcomes of primary care (better health, better care, better value); and (3) the attributes that will enable primary care organizations to attain these outcomes. These attributes are a population focus, patient engagement, partnerships with health and community services, innovation, performance measurement and quality improvement and team-based care.Proposed transformation strategies include building system capacity and capability, ensuring access to resources, providing support from coaches and employing effective spread and sustainability strategies. Broader system-level structures and policies necessary to support and sustain a high-performing and continually improving primary care sector include clear goals; a comprehensive approach to performance measurement; systematic evaluation of innovation; funding incentives aligned with quality outcomes; a system of local primary care organizations; support for inter-professional teams; funding for research to inform primary care policy, management and practice; patient enrolment with primary care providers; and mechanisms to support coordination and integration.