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The Psychiatrist as Clinical Behavioural Scientist

Poor public access to evidence-based care is the biggest current challenge for psychiatrists in Canada. Despite a huge increase in prescriptions for antidepressants, there is no evidence that the impact of depression is decreasing, suggesting an urgent need for better access to psychological treatments. 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. Resources for mental health are finite, and reform is needed to improve access to effective treatment, particularly evidencesupported behavioural interventions. 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. 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. There are many barriers to implementing efficacious behavioural treatments in community mental health settings. 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, which may explain some less than favourable outcomes with behavioural treatments. 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 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. More study is needed to confirm the prevalence and impact of mild to moderate depression, anxiety, and related disorders in the community 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 steppedcare 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 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. The benefit of medication over placebo is minimal in mild to moderate cases, 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