This post is part of a series about how quality standards can be used to support quality improvement together with others who are working on adopting the quality standards. The introductory post can be found here.
A.K is a 27-year-old female who suffers from severe anxiety. She was experiencing panic attacks to the point where she could no longer leave her own house. The only time she went out was for her physician appointments – just a handful of those in the two years before she presented to our clinic – and those outings would be incredibly distressing for her. “I spent hours getting ready to get on a bus,” she recalled.
A.K is someone who would benefit from Cognitive Behavioral Therapy (CBT), which is one of the most effective treatments for symptoms of depression and anxiety. It has actually been found to be just as effective as medication for mild to moderate symptoms. But, not everyone in need of this type of treatment gets it, and that’s a problem. If A.K can barely make it out of her home on a good day, what are the chances that she’s going to come into an outpatient clinic on a weekly basis for CBT?
In Ontario, we have a problem with access to traditional face-to-face CBT in a timely manner. That’s one of the reasons why Healthy Quality Ontario Standards for Mental Health clearly outline the need for evidenced-based psychotherapy. At Scarborough and Rouge Hospital (SRH), we’ve been working over the past 5 years to address this concern. By offering individual CBT sessions in conjunction with group CBT within a 6 month period, we are able to provide timely services to our patients.
But, there are a good number of our referred patients who are like A.K. They can’t attend our clinic because of burden of illness, work, or family obligations. It’s not enough to just offer CBT, but we need to work on ensuring that those in need are actually receiving it. It was this line of thinking that led to the development of our iCBT program.
What is iCBT? Well, it’s an internet version of CBT where we send patients electronic modules, which go over the principles of CBT. This includes the importance of scheduling mastery and pleasurable activities, utilizing breathing and relaxation exercises, reviewing and restructuring inaccurate thoughts to more accurate thoughts, and noticing connections between our thoughts, feelings, and behaviors. Since traditional face-to-face CBT was effective, we assumed iCBT would be as well, so we rolled out the program. However, our results would indicate failure. We had a 90% dropout rate. More people were actually getting better through self-help books than our program. So what was the problem?
To determine the reasons for the high dropout rates, we talked to the patients who were part of the program and we asked basic questions like, “Why did you drop out?” The responses were eye opening and a major theme emerged - the program was too rigid. Some patients felt that the deadlines for homework completion were too anxiety provoking, so they did what made them feel better - they avoided the program altogether. And others found the pace too slow. They were higher functioning and wanted to get through the concepts faster. Then we had some who found the concepts too confusing. They wanted more examples and videos to better highlight the material. In summary, there seemed to be many concerns. But, we didn’t want to give up, because patients like A.K still needed the help. So we incorporated all the patient feedback gathered and created another version of the program, which we now refer to as iCBT 2.0.
How did iCBT 2.0 fair? Well, much better than iCBT 1.0. To date we have had 80 patients complete this program, our dropout rates are only 33%, and our results show that those who have completed iCBT 2.0 show a significant reduction in their symptoms of depression, anxiety, and stress. And don’t worry, we didn’t forget about A.K. We offered her iCBT 2.0 and she did amazingly. It took her 4 months to complete the program, but when she finished she had added a number of mastery and pleasurable activities to her calendar, was socializing, and even began working full-time.
We have now begun to offer iCBT 2.0 to most of our patients in order to meet the Quality Standards for Major Depression, which state that 16 to 20 sessions over 3 to 4 months should be offered to patients identified with severe depression within 7 days, and within 4 weeks for patients identified with mild to moderate depression. By offering a combination of individual therapy (which can be provided face-to-face or through iCBT) and using CBT groups as a way to reinforce skills learned through individual sessions, patients can be offered 16-20 sessions in a timely manner that will not affect patient flow.
We have encountered many challenges and learned many lessons
through our journey of offering CBT and wanted to use this space to expand on
some of our lessons learned:
When we first decided to focus on increasing access to CBT,
we realized what a large concern variation in clinical practice was in the
field of mental health. Although CBT is a manualized therapy, we found that many
of our clinicians gravitated more towards a supportive counselling style.
Providing training in a certain therapy does not automatically build buy-in to
want to provide that form of therapy, and a watered down version of CBT would
be a disservice to our patients. So we began chart audits, started
having more one-on-one coaching sessions with our staff, and devoted
team meetings to highlight the need to provide CBT in the correct manner.
These strategies helped us to deliver CBT more effectively, and highlighted the
importance of continuous education and training.
One of the most important lessons we have learned through
this quality improvement initiative is the need to be flexible. iCBT may
not work for everyone, just like face-to-face CBT doesn’t work for everyone.
It’s just another tool in our toolkit. We need to be flexible and meet our
patients where they are at on their journey to recovery. We know the types of
treatments that are effective, now let’s focus on ensuring they are accessible.
It is our hope that by learning about the ways a community hospital in
Scarborough was able to deliver CBT in a timely manner, other mental health
agencies and hospital departments will be inspired to do the same. Take a look
at your current state and start looking at the areas where you can better
utilize your resources. The goal of quality care in a timely manner is
attainable, we just have to start thinking outside of the box and be more
flexible with our approach.
Many thanks to co-author Dr. David Gratzer for his contributions to this post.