The Canadian mental health landscape is changing fast. The rapidly accelerating pace of research and innovation over the last few decades has finally led to a comprehensive, system-wide review of the most common mental health problem: depression.

In October, a group of the country's top mental health experts, led by Canadian Mental Health Commission chair Michael Kirby, convened in Calgary to discuss depression. The result of the conference was an unprecedented consensus statement from some of Canada's most influential policymakers, psychiatrists, family physicians and patients. The statement's recommendations on ways to improve the prevention, diagnosis and treatment of depression run the gamut from amendments to the Income Tax Act that would allow caregivers to write off expenses to the adoption by family physicians of a "stepped care" approach to treating cases of depression along a scale of severity, and lots more.

The scientific chair of the consensus conference, Dr. Scott Patten, a psychiatric epidemiologist at the University of Calgary, talked to Parkhurst Exchange about the latest research on depression, new thinking on effective clinical practices, and Britney Spears' breakdown.

EXPERT OPINION

CLINICAL ISSUES

PE How is Canada doing on depression treatment?
SCOTT PATTEN A lot of the early studies were finding quite drastic undertreatment. And certainly since the late '80s there's been a very, very large increase in the provision of antidepressant medication treatment so that that's now probably in the range of about 7% of the population as opposed to, let's say 15 years ago, probably less than 2% of the population. That's quite a large increase, but the consensus is that the healthcare system hasn't been nearly as effective in delivering on non-pharmacological treatments. Cognitive behavioural therapy, for example, and other forms of evidence-based therapy. There probably hasn't been the same headway in getting that kind of treatment out to the population.

PE What advice from the consensus conference can GPs take away that's applicable to their practices?
SP One of the ideas that came out of the consensus conference is that when you look at the DSM-IV criteria for depression it sounds like a fairly circumscribed entity but there is a fairly broad range there in terms of severity and persistence - and that if the system is to respond better to these challenges it probably has to respond more flexibly. So for an individual primary care physician that might mean, for example, it might be helpful for them to learn one of the brief psychosocial interventions to deal with the episodes that occur at the milder end of the spectrum, and to initially manage it through monitoring for a few weeks to determine whether the episode might be self-limited. If you had these sorts of options at the milder end of the spectrum and then better systems for moving people on who don't respond to basic treatment, you might have a system that works much better.

PE But, realistically, how are doctors supposed to make time to provide psychotherapy to potentially hundreds of patients when they're already working above and beyond normal capacity?
SP It may be that in order to facilitate some of these goals that the current evolution that's going on in primary care may be helpful. It might mean that some of the alternate funding arrangements might be supported to integrate mental health professionals right into primary care networks. Of course at the other end of the spectrum there is also sort of an awareness that if the basic management in primary care, such as treatment with an antidepressant medication, doesn't work then the primary care physicians probably need to be able to refer those patients on to specialized mental health resources. We did have some primary care input at the consensus conference and part of the message from them was that that's not easy to do.

PE One of the most frequent complaints from Canadian family doctors is that they are finding themselves doing front-line psychiatric care because the specialists' wait times are so long.
SP I think a lot of these frictions around who should be doing what tend to be a reflection of the predominance of an acute care model and the fact that there are not systems in place for supporting primary care in any sort of stepped care strategies they might wish to employ. Whereas in the past broken bones and pneumonia, stuff like that, have been the main focus, more and more in the future it will be depression, diabetes, obesity, congestive heart failure - conditions that are better managed with chronic care models.

PE What should doctors be telling patients about self-management of depression?
SP The word we got is that for mild depression guided self-management works better than unguided self-management. But there have been these interesting efforts at unguided self-management, bibliotherapy being one. Teach-yourself-CBT books have sold huge numbers of copies, and an Australian initiative called MoodGYM did a trial showing their computerized version [of CBT] worked very well. If we are saying watchful waiting is okay at the mild end, intuition suggests that there must also be a group where just getting taught some strategies and learning about depression might actually be perfectly fine without the guidance of a health professional supporting it. But based on the scientific evidence we heard, there are still a number of unanswered questions. And even a few concerns came up about it, because the UK experience has apparently been somewhat negative. They selected a specific computerized CBT program, which they contracted [to purchase] with the software company that made this thing, and basically people haven't really picked up on it. These guys can show clinical trials showing that this does help, but patients don't really like it. And we had some presentations from non-CBT psychotherapists, saying that with these psychotherapies a big part of the impact comes through the nonspecific benefits of having someone there who can answer your questions and be supportive and can teach you a good approach, and that might be just as important as what they teach you. Those nonspecific elements are quite important. It raises the question: there may be a group who might be quite keen on [unguided self-management] but there would also be a danger of having people who need and are looking for something a little bit more and you end up telling them, "Go sit in front of this computer screen," and that's not what they want and it might not be right for them. So the idea was there's more to be learned about this, if we are going to be really seriously rolling out these kinds of strategies there's probably going to be an evaluation of their effectiveness.

PE Is one of the barriers to getting doctors from picking up on this guided self-management idea - which has already been adopted to varying degrees in other countries - that there is no billing code or formalized incentive to do it?
SP That general idea came up, about incentives and fee schedules in the sense that these may sometimes be a sort of a barrier. But that likely differs by province and the Mental Health Commission, being a national commission, identified that in the statement as something they probably will be wanting to look at and hopefully have some recommendations that the provincial health plans could look at in these areas. The experience that was reported to us from BC, where they have done some roll-outs with primary care systems in parts of the province was that the family physicians were actually quite well disposed to it, quite liked the guided self-management. So if anything it seemed like it was on the mental health side we weren't doing a good job of developing these materials and marketing them to make them available, which is probably true because as you say there are a lot of other countries that are well ahead of us in this regard - the UK and Australia being the two main examples there.

PE You mentioned bibliotherapy, which is an interesting self-management idea that's beginning to catch on overseas. In Wales, for instance, there's a program set up with the national library system, and a list of books are "insured" and can be borrowed for longer periods of time with a prescription.
SP There are a lot of books available and they are sort of uneven in quality, so this is one of the ideas that came up - but that particular idea didn't come up, where you could identify the ones that are really good and then give people access to them. In BC they have taken a different approach, where [psychologist Dan Bilsker] has booklets and workbooks that you can download for free, print them out and work through them. He reviewed the results of a meta-analysis that showed that guided self-managed works best, so it would be best if you had a family physician saying, "Look, here are some great materials, read through them, here's a website where you could go, and let's meet back in a few weeks," and sort of following along and helping them through it, but not needing to do the six to eight sessions of 30 minutes each of a brief psychosocial intervention. You know, full-gauge CBT takes a highly trained therapist 16 one-hour sessions or so. There are a few family physicians who are willing to set aside a lot of time in their practice to deliver that intervention to a small number of their patients, but it doesn't make sense to most doctors. This is the overarching idea, that if you had these sorts of options at the milder end of the spectrum and then better systems for moving people on who don't respond to basic treatment, you might have a system that works much better.

DEPRESSION SCREENING

PE The consensus statement recommended screening only at-risk patients, not all patients, for depression. Was that a battle to determine what the final recommendation should say? There's a huge amount of argument boiled down to one sentence there.
SP I was the chair of the expert panel and screening turned out to be a somewhat contentious issue for interesting reasons. The recommendation to restrict screening to high-risk groups is a pretty standard one in the screening literature, and it's one that is in the UK guidelines now, with the basic justification being that the existing scales have a much higher predictive values in high-risk groups and they do tend to generate a lot of false positives [in the general patient population].

PE Yes. You wrote in an article in the Canadian Journal of Psychiatry's October 2008 issue that the number of primary care patients who screen positive was half of the entire population, and almost 60% higher than the number who actually turned out to have depression as it is clinically defined. That's not very sensitive.
SP Especially if we're saying we have this huge challenge because the primary care system is under such intense time pressure. Does it really have the flexibility to be spending more time with depressed patients? Then to say that doing a screen that would result in doing a trigger referral for an assessment, and half the time would be wrong, it doesn't sound like it would be very good. So you are certainly going to get higher predictive values in high-risk groups. Our expert presenter on this was David Streiner, from McMaster and U of T. He's a biostatistician and a clinical psychologist. He was actually much more hesitant in recommending screening, even in high-risk groups. He was first of all basically saying that when you look at the cost-effectiveness, it's sort of an open question about whether that's an effective strategy, as opposed to devoting resources to other uses. And also the value of screening depends so largely on what happens next. If you are just screening and don't have much to offer the screen-positives, you are just diverting resources from people who need it more. He basically described a cautionary scenario where more research was needed. The jury panel, though, included consumer representatives, and they felt very strongly that screening was valuable. They weren't so interested in predictive values or cost-effectiveness, but their idea was this just raises the profile, that this needs to be brought into the mainstream of healthcare more, and if we are willing to say we should check someone's blood pressure every time they come in to a primary care office, maybe we should be asking them about depression too.

PE Where do you stand on that?
SP Well, I am fairly negative on the prospects for screening, myself.

PE Because you don't think it's practical?
SP Right, right. At the end of the day, I think it just sort of becomes a hassle. We actually tried a study of it here recently, and screening really works best in certain limited situations where you can do early detection and by detecting things earlier in their course make a difference in the long term. In an MS clinic we put a system in place where everyone who screened positive would get a quick assessment by a trained psychiatric nurse who would then offer them either an antidepressant or brief psychotherapy. It was all good in theory, but in the current context most of the screen-positive people already knew they had depression. Many of them were already on antidepressant medications. Some of them were already involved in treatment, and then there were a lot who had false positive results. And the group in the middle - the group who were depressed who hadn't really recognized it and could benefit from treatment but hadn't really thought about it or sought it - was a very small group. I think it's getting smaller and smaller, too, as depression becomes less stigmatized and more and more people are getting treatment. When you do that the people you tend to pick up are the people who are either dissatisfied with the treatment they've received and aren't continuing with it, or are on some sort of treatment and haven't responded well. And the amount of effort to reach that small group... There seem to be more logical ways, in my mind, to tackle that. But anyways the jury listened to the experts make their comments and listened to the comments of the more consumer-oriented people, and they came down with that recommendation which reflects what's being recommended in the UK.

PHYSICIANS' MENTAL HEALTH

PE Depression among doctors is a major problem. You recently co-authored a study on medical residents' mental health, called "The happy docs study," which appeared in BMC Research Notes in October 2008. The results were quite unsettling, with 18% of physician reporting fair or poor mental health. There have been several major initiatives set up in recent years to help doctors with mental health issues, to prevent and treat depression and suicidality, which is more common in the medical profession than almost any other group. Have those projects, like the Ontario Medical Association's Physician Health Program or the Alberta Medical Association's Physician and Family Support Program, been on the right track?
SP They haven't really been fully fleshed out. One thing about depression is it is very common in all of the sort of professional and white-collar occupational groups. We had this discussion at the conference on the issue of stigma, and there was a consensus - and a lot of the docs spoke up about this - that we love to talk about reducing stigma in the population so people will come to us more readily seeking help, but within the profession there were a lot of comments made in the hallways and at the coffee breaks that when it's a colleague that stigma really sticks around.

PE Have you seen that in your career?
SP Yeah. We don't walk the walk we talk sometimes about stigma. If we have a colleague who seems to be struggling with a mental health issue, we don't always react in as positive and helpful ways as we might. I have seen a few times in career where people have developed an illness, a mood disorder usually, and the colleagues don't approach it in a concerned way. It's not friendly advice, like "We have this support system in place, why don't you give them a call?" It's more like "You're doing stuff too slowly. What's the matter with you? You're not performing. You're indecisive." More sort of criticizing people on the surface level without really thinking, when sometimes it seems quite obvious when that might reflect a mental health issue. It seems to be an unwillingness to accept that that would happen in a professional person, which is ridiculous. I can't see why it's the case except for reasons of stigma. People are hesitant to broach the topic because with the stigma in their mind they feel they're being critical or condemning that colleague by suggesting that it might be a mental health issue, when really that would be a constructive way to deal with it. That would be a supportive as opposed to hassling them about what might be some of the symptomatic manifestations of it. I've seen that happen a few times. People get dragged up on the carpet of their department head or whatever and get criticized for not performing at the level they're expected to perform. But if that was a patient who was doing very well at their career and was a highly effective person and all of a sudden isn't performing, mental health is the first thing you'd think about. And somehow if it's a doctor, there's a blind spot there. But I think we are making headway now compared to what it was before. We have these systems in place, and I think there has also been a general enlightenment about these conditions. A lot of the younger physicians are just so much more enlightened than previous generations - they talk about depression or anxiety in the same way they would talk about other medical conditions. They don't experience any shame about it, and when they need treatment or support they seek it out. So I think there is sort of a generational issue going on there too.

PE What that seems to indicate is the central role that education plays in reducing stigma, because education is one of the things that's probably changed most in that regard.
SP Education probably has a lot to do with stigma. Interestingly, at the conference, people who talked about stigma said that education is just one piece of the puzzles. The thing that really combats stigma is exposure. When you have people who are competent, effective people that are respected, standing up saying "I have had depression, I had panic attacks, this is what I did about it," that is hard for people to ignore, whereas information they might receive at a seminar is easier to ignore.

PE At the Canadian Medical Association conference in Montreal in August, Austin Mardon, a respected Canadian geographer and NASA scientist who has schizophrenia, gave a speech that there was very well received.
SP That's apparently the most effective way to combat stigma. In the general public, celebrities have helped in that manner.

PE Excepting Tom Cruise, of course.
SP [Laughs] Well, you have people like Margaret Trudeau or Jane Pauley who have been speaking out or writing books, and that goes a long way towards reducing stigma, but we are not there yet because you see other examples of what appears to be perhaps a mental illness affecting a celebrity and they end up being ridiculed and made fun of.

PE Are you referring to someone like Britney Spears?
SP Something like that scenario, yeah. People seem to jump on that as a way to attack a person, which shows the different response. If Britney Spears developed cancer, they probably wouldn't - well, maybe they would be interested in sordid ways. But if it's stigma among health professionals, there's an example of the [Canadian Medical Association] doing something pretty notable inviting someone like that to do a talk. Epidemiologic data would suggest that 25% of the audience would know exactly what he was talking about, and probably 100%, if they are thinking about their colleagues, would have brushed up with that as well. That's fantastic. Another anecdote: a teenager I know developed a panic disorder, he started having panic attacks. But among him and friends, there was no shame, no blaming, no ridicule. Just absolute understanding, and they were willing to treat that as the same thing as if he had broken his leg or something and he wasn't able to play on the hockey team. It was just wonderful to see, that they have the capacity to get around this without any of the old baggage that the previous generations have carried. They talk about depression and anxiety and those things are completely real to them, not just something that happens to other people or is tied in with weakness or a lack of morality. I think we're going to see progress as that cohort ages.