September 22, 2021

[Edited for grammar and clarity]

What all physicians need to know about innovations in mental health care

[musical intro]

When he walked into my office he actually broke into tears. He explained to me that he had suffered so long and was so relieved to finally see someone in mental health that he could not cry.

Many of our patients have told us about their struggles, about getting access to care, and of course, those of us who are in this business, so to speak, are well aware that the quality of care received by many Canadians is uneven. Can we do better?

David Gratzer: Welcome to Quick Takes. My name is Dr. David Gratzer. I'm a psychiatrist here at the Center for Addiction and Mental Health. On this episode, we consider innovations in mental health care. Our guest, Dr. David Goldbloom. Dr. David Goldbloom is a senior medical advisor here at CAMH. He's also a professor of psychiatry at the University of Toronto, past guest on this podcast. And he's also the author of a new book, We Can Do Better: Urgent Innovations to Improve Mental Health Access and Care. Welcome Dr. Goldbloom.

David Goldbloom: David, it's great to be back with you. It's rare for me to be invited back anywhere, so I'm delighted to be joining the podcast again.

David Gratzer: All right. Fair enough. And on that personal note, let me ask you, how long have we known one another?

David Goldbloom: Well, this is a trivia contest because I think you and I first met when you were a junior resident training at the Clark Institute of Psychiatry. So that's probably going back. I hate to date you, but probably 20, 25 years.

David Gratzer: Around there, around there, but 21 years. That's what I meant to say. I wasn't just a junior resident – I couldn't have been more junior. It was my first day of internship. Like a lot of our residents and medical students, if you've had a role to play in terms of mentorship and supervision and it's and it's great to have had that.
Pivoting over to the book. You've just written this book. Why did you write the book?

David Goldbloom: I wrote the book because like so many people who work in our profession, so many people who are on the receiving end of care, and for the families who support those individuals, there is a shared sense that the status quo isn't good enough.

David Gratzer: Or do you think the system falls short?

David Goldbloom: I think the system falls short in a number of areas. At the most fundamental level of access, we have a deservedly terrible reputation, particularly among our primary care colleagues. But I think also at the level of diversifying the nature of what we can offer to help people.

David Gratzer: Your book, though, is not a listing of complaints or grievances. Eight chapters, eight problem sets and eight plus projects that you consider innovative and important. Tell us a little bit about that.

David Goldbloom: So, I decided to frame this book, as you indicated, around eight, very typical, I think, sets of clinical problems that can occur and think about them in terms of how things are now and how things could be. And for each of these eight clinical scenarios, I provide at least one and a half and several examples of innovations that are already with us that have already at some level proven their mettle but have not yet been scaled up and implemented in a way that would make them broadly accessible.

David Gratzer: You talk, for instance, about a person with anxiety and panic in particular, and draw, as an example, from the National Health Service in the U.K.

David Goldbloom: Right, and perhaps the biggest revolution in the provision of psychological services, probably anywhere, has been the development of the improving access to psychological therapies. In the U.K., where now a million people a year are being assessed for that service and about 600,000 a year are being treated – and that's on the public purse. And not only is it on the public purse, it's with a level of accountability to the public who's paying for it. That is really, in my view, unprecedented in health care. We have outcomes in the IAPT initiative in the U.K. on ninety-eight-point five percent of encounters. Try to imagine that for any problem anywhere in health care in Canada.

David Gratzer: And that project has grown over the years, seems to be enjoying great political support. Why don't we see more projects like that on this side of the Atlantic?

David Goldbloom: I think one of the challenges is the federation model of our health care, such that it is a provincial responsibility. It's 50 percent of each province's budget. So, there are challenges to mounting national initiatives that are different than the U.K., which is much more centralized in terms of care. But I think these are not insurmountable obstacles, because every province will be the first to say we've got a problem. And indeed, there are other initiatives that I talk about in the book that have successfully traversed provincial and territorial barriers to set up a common model of delivering care, such as integrated youth services. So, it can be done.

David Gratzer: So let's talk about something here. So, there are lessons of there are examples of innovation abroad, but you also talk about some excellence here. Talk about this one.

David Goldbloom: Sure. So this really is an innovation that's inspired by the Headspace initiative in Australia. The idea of developing community-based, youth-friendly, one stop shopping hubs where people, young people, can go without appointment and measure their access to care, not in weeks to months, but in hours to days. And they do so in a very non stigmatizing, youth friendly environment. It doesn't have the feel of a hospital or a clinic. And they can do one stop shopping with regard to mental health, physical health, educational needs and employment needs. And that's what young people are looking for. In fact, I would argue in some ways, that's what a lot of us are looking for. And this is, to me, the biggest transformation in youth mental health that's happened in several decades in Canada. And it is indeed spreading like brushfire. Every province wants in on the action.

David Gratzer: It's a true Canadian success story.

David Goldbloom: Absolutely, and it's also a reflection of a collaboration between philanthropy and the private sector and the public sector. And philanthropy has played an important role in kick-starting this. But ultimately, this is not a fee-based program. This is a public program.

David Gratzer: What are some lessons you've learned from these innovative projects?

David Goldbloom: Well, I guess the first one I've learned, which is disturbing to me, is the long lag time. Now, we know there's a bandied about number of how many years it takes for clinical and innovation to be translated into clinical practice. And the gap is 17 years from sort of research, discovery and validation to clinical practice. I believe that one of the good things about the pandemic is it has accelerated everybody's timeline of expectation in terms of what the public expects of us. As you know, before the pandemic, seven percent of Ontario psychiatrists participated in televideo psychiatry. And as soon as the pandemic started, it crept up to 100 percent. And that is the kind of change that can happen. We saw it with vaccine development in terms of accelerated timelines. And I think really one of the collateral benefits has been to increase expectations of everybody for rapidity in transformation.

David Gratzer: You sound an optimistic note.

David Goldbloom: David, I am by nature optimistic and I'm by nature attracted to new things and new ways of seeing things or understanding things. And that doesn't mean relinquishing our past, because you'll also know I've been a staunch advocate for electroconvulsive therapy, for the use of MAO inhibitors and other treatments that some people view as being on the slag heap of psychiatric history, even though they continue to work very well. So, I'm not about abandoning things that work well, but I'm saying we need a bigger repertoire and a newer one of ways for people to access help and ways to have helped delivered to them.

David Gratzer: One of the programs you talk about is Strongest Families. Talking about something innovative, here's an intervention for youth that isn't actually specifically for youth directly, but for families and caregivers. Tell us about the program and what you thought was innovative.

David Goldbloom: So, this is a program that developed in Nova Scotia and really works on a kind of call centre model – care delivered by telephone. It's pretty low-tech in that regard. But the innovative aspects of it are treating common childhood problems by addressing the entire family rather than the child in isolation. Delivering the care in the evenings when families are most likely to be available, making it much more patient centered. And then the third thing is developing a team of coaches who are not your classical mental health professionals, but intelligent young people who are coached up in interventions to deliver common solutions to common problems and to be monitored, to be mentored, to be accountable in ways that frankly don't happen in our traditional models of practice.

David Gratzer: This is a good news story. It's a made in Canada good news story. They use these services in Nova Scotia. They use them in Alberta. Vietnam has been experimenting with this model of care. But like a lot of these innovative programs, many provinces right here at home in Canada aren't using such services or models of care. What are your thoughts about that?

David Goldbloom: Well, look, people often have trouble communicating a big message, and honestly, one of the reasons I wrote the book was trying to communicate that message to the general public, to policymakers, to patients and families, to make people aware of things, because in a vast country like ours, what's happening in Nova Scotia may be unknown in Manitoba and vice versa. So, we need to do an unrelenting job of communicating this kind of information as widely as possible.

David Gratzer: But now there are heroes in your book. Some of them are tied to these programs directly. Some of them are perhaps a little surprising to read about, including the former minister of finance, Jim Flaherty.

David Goldbloom: Right. And Jim Flaherty was, I think by most accounts, a red Tory who believed very strongly in a number of social justice issues, was, like his wife, Christine Elliot, very interested in mental health problems. And by circumstance of history and time, I had the opportunity as chair of the Mental Health Commission to present him with the interim results of the At Home/Chez Soi homelessness initiative, which is to date the largest project in the world ever conducted on trying to address homelessness. And it was done in Canada. And he was persuaded by the results to invest an additional 600 million dollars into the homelessness partnering strategy in his next federal budget. So, these are accidental moments of opportunity. I felt like Zelig sitting in his office and talking with him, but his eyes lit up when he saw the results.

David Gratzer: It is part of your work. This was when you were with them, when this when you led the Mental Health Commission of Canada, you actually went to Winnipeg and looked at one of these warehouses where they had apartments in a box, so to speak. What did that warehouse look like?

David Goldbloom: Well, it looked like what I imagined many warehouses look like stacks and stacks of fresh mattresses and microwaves and chairs and dishes and all kinds of things, and they were just ready to go and load them on pallets onto trucks and drive them to people's new homes.

David Gratzer: Housing first has been discussed for many years, but this is the big study in the area. Were you surprised by the findings?

David Goldbloom: I was indeed. And look, you know, often studies are criticized for recruiting people who are not too ill because they have to agree to come into a treatment study. They have to agree to be randomized. The people who are involved in recruiting participants for At Home/Chez Soi were seeking people out on the streets, under bridges, in parks, and having to build enough of a relationship with them to have them agree to be randomized in a scientific study. That speaks volumes to the skills of these recruiters and their commitment to helping these people.

David Gratzer: The book talks about, as we've discussed today programs for: youth to access mental health care; for those with mood and anxiety to have access to evidence based psychotherapy free at the point of use; for people who are homeless to have access to a home that they can call their own. But your book doesn't talk about certain things that might have been in a book that had been written 10 or 20 or 30 years before. There's no mention really of biomarkers or new drugs or imaging. FMRI's are absent from your book. How come?

David Goldbloom: I think there are absent because there has been a sober recognition that the imaging to date, while it's important and has made some contributions to refining how we use medications for instance, has not been the “aha” moment that people hoped for. And it echoes when electroencephalograms were first developed. They were once described as the royal road to the unconscious. And that, of course, turned out to be a bit of a bust. And my concern in writing this book was not about the very exciting ongoing research around the most fundamental levels of human inquiry, including brain imaging, including certain aspects of genetics and big data as an important field. I was preoccupied with what are things that could make a difference in the next three to five years. So that was a first criterion. The second criterion was that I couldn't be encyclopedic, I couldn't be exhaustive, and I didn't want to be exhausting. So, I narrowed the field further to include just a sampling. And it's an idiosyncratic sampling. Sometimes it was based on the fact that I knew some of the innovators and therefore it was easier to get them to talk with me and describe their innovation.

David Gratzer: You've alluded to being later in your career. What's something that's changed about psychiatry over these years of practice and advocacy?

David Goldbloom: Well, I think a number of things have changed, I've seen, particularly among young psychiatrists, a renewed commitment to working with severely mentally ill individuals. And that's a that's a welcome shift. I think that I've seen in our own institution increased enthusiasm for being in the trenches of emergency room work and inpatient care. I've seen a shift in kind of accountability to patients and to families, and that's a welcome thing. And obviously, the stigma around mental illness, while not gone, has diminished compared to when I started out. So, it's part of the public conversation as well as the private conversation.

David Gratzer: COVID has obviously changed things. Any thoughts on how the pandemic might change the delivery of care, or do you suspect once Delta fades, and Delta will eventually fade, we'll go back to business as usual?

David Goldbloom: I don't believe we'll go back to business as usual. And I don't believe the public, our patients and their families will allow us to do so. Obviously, the elephant in the room has been the transformation of our ability to deliver care via televideo. And it is, I believe, more patient-centered. It's also and I've written about this, the reinvention of the house call, so that we are now seeing people where they live, how they live, where meeting their pets, we're seeing their homes, we're meeting their families more easily. And it is a huge convenience factor for patients to be able to connect via televideo rather than take a half day off work or arrange for child care. So, I don't think it's going to be the only way we connect with patients. And we must never lose sight of those people who don't have broadband, don't have hardware, don't have software, don't have housing, don't have privacy in ways that would prohibit them from being engaged this way. So I think we're always going to have the need for face-to-face care, office care, clinic care and hospital care. But I think we can broaden our repertoire.

[Rapid fire minute]

David Gratzer: Dr. Goldbloom, it is a tradition here. To end the podcast by doing a rapid-fire minute. Are you ready?

David Goldbloom: With a certain degree of dread, yes.

David Gratzer: We can't disappoint the Quick Takes listeners.
All right. We'll put a minute on the clock. Several questions. Here we go.
Dr. Goldbloom, what was the biggest surprise in writing this book?

David Goldbloom: Finishing it. I thought I was never going to finish it because innovation is always continuing, I had to draw an arbitrary line in the sand and say, stop writing.

David Gratzer: Hoped for reaction when people read this book.

David Goldbloom: Surprise and hope.

David Gratzer: Favourite innovation.

David Goldbloom: That's like asking about a favourite child.

David Gratzer: What's your next book about?

David Goldbloom: I'm not sure that I have another book in me, but I'm getting old enough that I could look back and maybe write about earlier parts of my life

David Gratzer: To our clinician colleagues, the psychiatrists who are listening right now. What's something that you'd like them to think about having written this book?

David Goldbloom: I'd like them to think about what are the things that are of proven value or coming attractions that juiced me that I'd like to know more about. How can I change what I'm doing currently?

David Gratzer: And one last question at the buzzer. Are these Simpson clouds on the cover of your book, sir?

David Goldbloom: I am so upset about this. It was my wife, who has never watched The Simpsons, who saw the design for the jacket and said that looks like the opening montage of The Simpsons. And that had completely eluded the publisher as well. But we decided there's a bit of a ray of sunshine and hope to it, so we stuck with it.

David Gratzer: Well, that's the end of the minute, and we're approaching the end of the podcast, I'd really like to thank you for taking the time and I'd really like to thank you for writing this book. It's an enormous service. It's a great book. It's highly readable. It's also an important book. Congratulations.

David Goldbloom: Thank you so much. This was fun.

David Gratzer: Thank you.

Outro: Quick Takes is a production of the Center for Addiction and Mental Health. You can find links to the relevant content mentioned in the show and accessible transcripts of all the episodes we produce online at porticonetwork.ca/web/podcasts. If you like what we're doing here, please subscribe.
Until next time.