The Psychiatrist as Clinical Behavioural Scientist

Poor public access to evidence-based care is the biggest current challenge for psychiatrists in Canada. ^{1 –4} Despite a huge increase in prescriptions for antidepressants, there is no evidence that the impact of depression is decreasing, ⁵ suggesting an urgent need for better access to psychological treatments. ² Psychiatrists tend to practice in ways that limit access and create a misalignment so that many people who need services do not receive them and some people who do not require specialty services have access. ^3,4 Resources for mental health are finite, and reform is needed to improve access to effective treatment, particularly evidence-supported behavioural interventions. ^1,4 Although efficacious behavioural treatments do exist for anxiety, depression, and related disorders, patients seeking treatments rarely receive them because of lack of expertise and coordination in community mental health settings. ⁶ Psychiatrists can become agents of change by assuming a leadership role as clinical behavioural scientists in the development, evaluation, implementation, and dissemination of behavioural treatments in the community. ⁷

There are many barriers to implementing efficacious behavioural treatments in community mental health settings. ⁶ Efficacy studies are usually carried out in academic and research settings where treatment adherence is carefully standardized and outcome precisely monitored. These conditions are mostly not feasible in community settings, where the focus is on effectiveness: the infrastructure of most existing delivery systems is not organized in a way to implement treatments that require a rigid protocol. The resulting drop in treatment fidelity leads to a drop in effect size, ⁶ which may explain some less than favourable outcomes with behavioural treatments. ⁸ Another difficulty with implementation of new treatments is that outcomes are not routinely measured to ensure that effectiveness is sustained.

In the behavioural field, there is a trend toward transdiagnostic formulation and unified treatment protocols for a number of emotional disorders ⁹ and away from conceptualizing a number of distinct disorders: in other words, those involved in treatment development are becoming “lumpers” rather than “splitters.” This trend lends itself well to a stepped-care model of mental health care delivery in which a theory of a common psychopathological mechanism (difficulty with emotion regulation) can inform a system that addresses unique needs of individual patients. ⁹

More study is needed to confirm the prevalence and impact of mild to moderate depression, anxiety, and related disorders in the community ¹⁰ and how best to provide services to affected individuals. Even with mild cases, there is significant societal cost in terms of suffering and disability as a result of these people remaining ill. We need more research in order to predict the extent to which early intervention in mild to moderate cases of anxiety and depression prevents their progression to severe illness, prolonged disability, and mortality, particularly among youth. A stepped-care system that provides lower-intensity treatments for the large number of individuals with mild to moderate illness while allowing timely access to higher-intensity treatments for those who need them ¹¹ can improve access for everyone while ensuring that more seriously affected individuals can get the care they need in a timely manner.

Behavioural interventions are recommended as first-line treatment for mild to moderate anxiety and depression and in combination with medication when medication is indicated. ^2,12,13 The benefit of medication over placebo is minimal in mild to moderate cases, ¹⁴ and all psychopharmacologic agents have financial cost, risk of side effects, and risk of withdrawal syndrome with serotonin uptake inhibitors. Best practice advises against the use of medication as first-line intervention in mild to moderate cases; behavioural treatments tend to produce more lasting benefit than medication, and an increasing number of clients prefer talk therapy to medication. ^12,13,15

Clinical science can enhance the success of implementation of new treatments. One example of dramatic success of clinical science is in paediatric oncology, in which the prognosis in acute childhood lymphoblastic leukemia went from 80% mortality to 80% cure over a period of 30 years. This was accomplished by applying the following principles ¹⁴ :

Integrating research into standard care of patients

Combining effective treatments

Dropping ineffective treatments

Coordinating supportive and nursing care

Following patients for years after treatment.

Another clinical science success story is the treatment of first-episode psychosis. ¹⁴

Application of clinical science methods in behavioural health care in Britain has led to success in the implementation of the Improving Access to Psychological Therapies (IAPT), ^4,11 a long-term, large-scale initiative that took on the slogan, “no health without mental health.” As of November 2012, more than 1 million people entered treatment, and 680,000 completed treatment with recovery rates between 45% and 65%. Forty-five thousand people moved off sick benefits, and 4000 new practitioners were trained. IAPT has led to a major transformation of mental health services in Britain and has particularly improved child and adolescent services as part of a secondary prevention initiative. ¹⁶ Reports from 2016 suggest that 2012 levels of referral and effectiveness have been sustained and that older individuals and those with chronic medical conditions such as diabetes benefit from IAPT interventions. ²

Success of the IAPT project was the result of a commitment to best practice based on NICE guidelines with a focus on providing evidence-based care, particularly cognitive therapy for anxiety and depression. ¹¹ IAPT is a stepped-care model with a centralized intake process that matches treatment intensity with severity of illness. Mild cases of anxiety and depression are managed at the primary care level with exercise, mindfulness, and Internet- and computer-assisted cognitive-behavioural therapy (CBT). ² Less severe cases receive less intensive and less costly interventions with flexibility for escalation to higher-intensity treatment when things get worse or do not improve.

IAPT has created a newly defined workforce of psychological well-being practitioners who work closely with family doctors, assist patients to navigate the system, provide support for electronically guided CBT, ² provide materials for self-help, and conduct psycho-educational groups and exercise groups. Shared care with family doctors between psychiatrists and family doctors and use of less intensively trained providers in the primary care setting help to make more effective use of psychiatrists. Teamwork is essential in these mental health teams that provide supervision and support of workers, with an emphasis on consistency and cohesion through agreement on treatment principles. Regular case reviews allow for timely decisions about stepping up of stepping down treatment intensity. ¹¹

National Institutes of Health Clinical Science Model for Improving Care

In America, the National Institutes of Health (NIH) has offered a number of strategies for implementation of scientifically supported interventions. ⁶

Changing the System

Most mental health care delivery systems lack the infrastructure to ensure that patients are matched in a timely manner with an intensity of intervention that matches the severity of illness. Centralized intake and stepped care are recommended, which require flexibility and timely access to expert assessment to allow intensity to increase during a crisis and then decrease as the crisis resolves. Psychiatrists have the expertise to assess patients and be part of treatment planning by multidisciplinary teams.

More research is needed to support the hypothesis that brief, intermittent treatment is equal to or more effective than extended treatment, ¹⁷ and more data are needed to explore how group treatment compares in effectiveness with individual treatment. If group treatment outcome is found to be superior to individual treatment outcome, that has major implications for how resources should be allocated. ⁶

Stepped care lends itself to providing more extensive evaluation and more intensive treatment for individuals who do not respond well to lower-intensity treatments. Psychologists and psychiatrists need to collaborate and work in teams to find interventions for nonresponders.

Changing the Interventions

Proven efficacy of a treatment in a research setting does not guarantee that it will be effective in a community setting. ⁶ Psychiatrists need to work with other clinical scientists, psychologists in particular, to create and adapt interventions that meet the needs of the local community. As interventions with proven efficacy are adapted to unique community settings, outcomes must be consistently measured order to ensure that effectiveness is maintained. As an example, dialectical behaviour therapy (DBT) ¹⁸ has proven efficacy for borderline personality disorder and other emotion regulation disorders, yet there are challenges to dissemination of the tested form of DBT because of the rigor of training and the ability of the care delivery system to support extended-hours availability of therapists. ¹⁷ We need to know if DBT is effective in a system in which extended-hours availability of therapists is not feasible. In addition, shorter, group-only versions of DBT ^19,20 are showing promise and can become integral components of a stepped-care system that focuses on brief, intermittent group treatment.

Refining the Interventions

Intervention development and implementation needs to balance maintenance of potency with feasibility of implementation for the unique population that clinical scientists are trying to serve. This means balancing simplicity with fidelity, providing adequate therapist training and supervision, and making treatment and training materials available. ¹¹

Identifying Mechanisms of Change

Treatment development and implementation needs a robust theory of mechanisms of psychopathology and remediation. ^7,21 Without a solid foundation in basic science, a treatment is likely to lose its effectiveness as changes are made to address the needs of the clinic as opposed to adherence to the theories of psychopathology and change that drive the treatment. ^6,7 Treatments that are principle driven have greater validity and acceptance by providers and patients when theories are openly shared. ²² Agreed-upon principles of treatment lead to better consistency within the treatment team, and psychiatrists, with their knowledge of neuroscience, can provide supervision and training based on these principles.

An example of applied neuroscience is the current trend in behavioural health care that recognizes that many mental disorders share a common causal mechanism, that is, difficulty regulating emotion because of faulty neural network development as a result of early life adversity. ^7,8,21 This is a paradigm shift that allows for a transdiagnostic approach that supports a unified treatment protocol for a number of disorders in which the treatment focus is remediation of emotion regulation deficits through skills training, particularly in the group setting. ^8,19,22

Efficacy Testing in Real-World Settings

When a therapy with proven efficacy is introduced to a community setting, there is a need for ongoing evaluation of fidelity assurance, adaptability, and effectiveness. This means integrating research into the standard care of patients. ^6,11,14

Next Steps

Research as Part of Standard Care of Patients

Meaningful change will require a disciplined clinical science approach to the implementation of behavioural treatments by following a model such as the NIH stage model ⁶ or the IAPT ¹¹ approach, in which every step from basic science to treatment development, to efficacy and effectiveness studies, and to widespread dissemination is guided by research and evaluation. Full implementation of a treatment is not complete until that intervention is optimally efficacious and implementable with fidelity by practitioners in the community. ⁶ Leadership by psychiatrists and collaboration with local health authorities, academic departments, and national regulatory bodies is needed to support and enhance practitioners’ clinical research skills along with higher expectations on residents to participate in clinical research as part of their training. Residents should also demonstrate clinical research experience with measuring and analyzing outcomes, measuring fidelity to treatment, and knowledge of literature on efficacy research.

Combining Effective Treatments

System change may require some upgrading of psychiatrists’ knowledge of behavioural neuroscience, clinical research skills, and expertise in evidence-supported treatments such as CBT and interpersonal therapy (IPT) to provide supervision of medical and nonmedical providers in the stepped-care environment. Residency training needs an increased focus on behavioural theory and practice, working with teams in a stepped-care environment, and supervising nonmedical staff providing CBT and IPT.

More research is needed to establish the effectiveness and acceptability of medication follow-up in a group setting, ²³ and more needs to be done with regard to sharing mental health care with family doctors so that psychiatrists provide consultation and advice, enabling family doctors to provide a more holistic package of care to mentally ill patients.

The expanded role of psychiatrists in a reformed community mental health care system would include:

Providing one-time assessments of patients

Working closely with primary providers in shared care settings to conduct conjoint interviews, supervise therapy, and give advice on medication management

Taking a leadership role in designing treatments and evaluation of outcomes

Teaching of and team work with nonmedical providers in evaluating patient progress and treatment planning

Acting as co-therapists in skills training groups and medication follow-up groups

Providing time-limited individual psychotherapy as part of a program such as DBT but generally avoiding repeated visits with individual patients

Dropping Ineffective Treatments

To make more effective use of their expertise, psychiatrists in the publicly funded system need to stop operating on a private practice model that provides long-term individual follow-up for a panel of patients so large that these practitioners are unable to see new patients. ⁴ Medication follow-up can be done by family doctors in consultation with psychiatrists ⁴ or through group medication follow-up. ²³

The publicly funded mental health care system cannot afford to continue to support psychiatrists doing long-term individual therapy, particularly psychoanalytic or psychodynamic therapy. ^4,11 Whether long-term individual psychotherapy should be an uninsured service like cosmetic surgery is open to question. ⁴ Preferential reimbursement through changes to fee schedules for psychiatrists with proven competence in CBT or IPT is an option, along with limiting the number of individual sessions that are reimbursed. Evaluation of the effect of each system change is necessary along with measures to ensure adherence to evidence-based treatment.

Residency training programs will need to adjust to new realities with less emphasis on molecular biology and more emphasis on higher levels of neural organization, particularly the neuroscience of cognition, emotion, and emotion regulation. Reducing resident involvement in individual psychoanalytic and psychodynamic therapy training will free up time for an increased focus on CBT and IPT skills, group therapy skills, program evaluation skills, and competence with a unified treatment protocol with emphasis on emotion regulation training. Transference interpretation as a treatment strategy is not supported by evidence and is discouraged in an empirically supported treatment for borderline personality disorder. ²⁴

Conclusion

Clinical science that focuses on behavioural treatments in a stepped-care and shared-care system can go a long way to improving access to effective treatment for all Canadians. Letting go of treatments that are costly and less effective will be a significant challenge and will allow psychiatrists to take on a more meaningful leadership role in mental health care reform.