spending 25 years as the psychologist in an emergency psychiatric unit,
as well as treating depressed individuals with Cognitive Behavioural
Therapy, it has become clear to me that our North American health system
does a poor job of sharing knowledge regarding effective methods for
individuals to manage their own psychological difficulties. Our systems
are heavily focused upon delivering treatments, generally
pharmacological ones, and often leave patients in a passive role. If all
we expect a depressed individuals to do is be adherent to prescribed
medication, we are missing the boat in terms of the potential for
collaboration between healthcare provider and recipient.
is worth noting that antidepressant medication, the most widely applied
treatment for depression, is not particularly effective for milder
cases, although it does have the same worrisome level of side effects.
Given the high rate of sexual dysfunction associated with
antidepressant medication, one would like to be confident that the
benefit outweighs the risks of reduced quality of life, impaired
self-esteem and damaged relationships. At least within the Canadian
system, the vast majority of depressed individuals have no practical
access to evidence-based behavioural interventions. It is crucial that
healthcare providers have training and support to deliver behavioural
interventions. One such alternative is the intervention we refer to in
our research unit asSupported Self Management (SSM).
In SSM, the health care provider (typically in the primary care system) serves as a facilitator and "coach” for the patient in learning and applying mood
self-management skills. There is a significant amount of outcome
research supporting this approach. Our research unit has conceptualized
this as a form of collaborative knowledge exchange between policymakers, researchers, health care providers and care
recipients—we have focused our investigative efforts upon methods for
fostering this kind of knowledge/practice exchange among key
stakeholders. We developed a depression self management tool (Antidepressant Skills Workbook) that is available for free download from our website as well as several variants for particular contexts and populations:
depressed adolescents (Dealing With Depression), depression in the
workplace (Antidepressant Skills at Work); and depression or anxiety
difficulties associated with chronic illness (Positive Coping with
Health Conditions). The basic adult workbook is available in several
languages and as an e-book – all of these tools are free. Also available
on this website is a relaxation training audiofile and self-help guides
for dealing with suicidal thoughts.
100,000 copies of these various workbooks have been downloaded from the
website over the past six years. With support from healthcare agencies,
we have trained over 500 family physicians to deliver SSM to their
depressed patients. We carried out an implementation study to determine
the degree of update one could attain using sophisticated knowledge
exchange strategies: we studied 85 family physicians who each received a
one-hour training session and access to the workbook for enrolled
patients (an envelope the patient could return for a copy of the
workbook). These physicians distributed the request envelopes to 1300
patients over a six-month period, and 55% of these patients sent back
the envelope to request the workbook. This degree of adherence to a
prescribed therapeutic action is comparable to the adherence to
prescription of antidepressant medication. Given the minimal cost in
time and financial resources of this system intervention, we consider
this to be an impressive outcome. The
bottom line is that dissemination and support for psychological
self-management should be a core component of all mental health systems.
Collaboration in mental health care should include not only primary and
specialist care providers, but also care recipients.
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.
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.