Improving Access to Psychosocial Treatments—Integrating Patient, Provider, and Systems Approaches

Psychotherapy works well, but our mental health care system does not. Those broad observations are underscored by 2 articles in this issue.1,2 One can certainly cite the broad evidence base in psychotherapy for mental disorders, but these 2 articles provide another type of endorsement-both the public in Quebec and psychiatrists in British Columbia vote with their feet, so to speak-for psychotherapy. Dezetter et al1 carefully surveyed nearly 1300 attendees at primary care clinics across Quebec on 3 occasions during a year, and found major unmet mental health needs, including major gaps in psychotherapy delivery. Hadjipavlou et al2 surveyed attitudes toward psychotherapy and patterns of psychotherapy delivery among psychiatrists in British Columbia and discovered high confidence in psychotherapy efficacy and high rates of delivery of individual psychotherapy, but with few people served owing to time constraints. Nevertheless, despite the evidence and the enthusiasm, the stark reality is that most patients cannot get, and most psychiatrists cannot give, enough psychotherapy. While the obstacle is largely ascribed to insufficient funding for psychotherapy provision, pleas for more resources are unlikely to succeed.Instead, we must improve the access to effective psychotherapeutic treatments by applying creativity and ingenuity. By using a population health approach, we can explore solutions that involve identifying interventions at multiple levels (patient, provider, and systems) and through multiple techniques and formats.3,4 One key tenet of this approach is stepped care, where simpler and cheaper interventions are used initially, while more elaborate and expensive treatments are saved for those in greatest need.5 Stepped care already has wide acceptance across medicine, and frequently has been suggested in psychiatric contexts, including substance abuse, mood disorders, and anxiety.6,7 Our (see Parikh et al8) own experience with recommendations for stepped care for bipolar disorder has led to research studies to compare different treatment methods with widely different costs and intensities, resulting in evidence that brief group psychoeducational interventions may be clinically equal, easier to use to treat larger numbers of clients, and far less expensive than the traditional 20-session dose of individual CBT.8Scaling psychosocial interventions broadly across disorders and society requires widening the focus of interventions and delineating the appropriate provider and venue for such treatments. To begin with, the broadest theoretical principles of effective psychosocial intervention, evidence particularly favours several approaches: MI, psychoeducation, CBT, IPT, and mindfulness-based interventions.9 From the service delivery research literature, key lessons include the value of self-directed strategies, including traditional self-help books, websites that offer interventions, care facilitators, and peer-support group interventions.10 The burgeoning patient-centred care movement echoes larger trends in society, facilitated by the Internet, that place emphasis on what patients want, not simply what service providers wish to offer.11 Affordability parallels scalability in all these musings; we must find solutions that allow us to reach many people within existing financial envelopes. Thus what kind of interventions might all these considerations evoke?Resuming a patient, provider, and systems approach, patient-level interventions might begin with understanding how to use brief MI principles as a first step for virtually all other interventions. Overwhelming evidence across disorders documents difficulty in starting and adhering to treatment recommendations. A robust literature also shows that even 2 sessions of MI leads to improved engagement in treatment, both in medical and in psychiatric disorders.12 Next, with the motivated patient, let us respect both patient empowerment principles and concede that most people seek (correctly! …