Literature Collection

Objective In 2015, the Australian Government introduced several mental health reforms, including the requirement that Primary Health Networks (PHNs) provide stepped care services for Australians with mental health needs such as anxiety and depression. This paper reports on the development and feasibility study of StepCare, an online stepped mental healthcare service in general practice that screens patients, provides immediate feedback to patients and general practitioners (GPs), transmits stepped treatment recommendations to GPs and monitors patients' progress, including notification of deterioration. Methods The present codesign and feasibility study in one PHN examined: (1) the acceptability and feasibility of StepCare to GPs, practice staff and patients; (2) the impact of StepCare on clinical practice; and (3) the barriers to and facilitators of implementation. Results Thirty-two GPs, 22 practice staff and 418 patients participated in the study. Overall, patients, practice staff and GPs found StepCare acceptable and feasible, commending its privacy, the mental health screening, monitoring and feedback. They also made suggestions for service improvements. GPs reported that StepCare helped with their identification and management of patients with common mental health issues. Conclusions Preliminary data suggest that StepCare may be acceptable and feasible in Australian general practice, helping GPs identify and manage common mental health problems in their patients. The study provides implications for policy and practice, and points the way to future translational research into stepped mental health care. What is known about the topic? Depression and anxiety are common illnesses in primary care and GPs are ideally placed to implement stepped care approaches enabling early detection and accessible, effective care. What does this paper add? Developed in and for general practice, StepCare is the first fully integrated stepped approach to primary mental health care in Australia. As a first step in a translational research program evaluating the effectiveness of StepCare, this paper reports data regarding the feasibility and acceptability of the service. What are the implications for practitioners? Integrated into the workflow of general practice, StepCare is an online service that helps GPs detect new cases of depression and anxiety, provide evidence-based stepped care treatments and monitor patients' progress.

PURPOSE: Community Health Centres (CHCs) are an essential component of primary health care (PHC) in Canada. This article examines health providers' understandings and experiences regarding stigma towards mental health and substance use (MHSU) issues, as well as their ideas for an effective intervention to address stigma and discrimination, in three CHCs in Toronto, Ontario. METHODS: Using a phenomenological approach, we conducted twenty-three interviews with senior staff members and peer workers, and three focus groups with front-line health providers. Ahybrid approach to thematic analysis was employed, entailing a combination of emergent and a priori coding. RESULTS: The findings indicate that PHC settings are sites where multiple forms of stigma create health service barriers. Stigma and discrimination associated with MHSU also cohere around intersecting experiences of gender, race, class, age and other issues including the degree and visibility of distress. Clients may find social norms to be alienating, including behavioural expectations in Canadian PHC settings. CONCLUSIONS: Given the turmoil in clients' lives, systematic efforts to mitigate stigma were inhibited by myriad proximate factors that demanded urgent response. Health providers were enthusiastic about implementing anti-stigma/recovery-based approaches that could be integrated into current CHC services. Their recommendations for interventions centred around communication and education, such as training, CHC-wide meetings, and anti-stigma campaigns in surrounding communities.

BACKGROUND: Opioid-related overdose deaths have risen sharply among young adults. Despite this increase, access to evidence-based medication for opioid agonist treatment (OAT) for youth remains low. Among older adults, barriers to OAT include the paucity of buprenorphine-waivered prescribers and low rates of prescribing among waivered physicians. We have increasingly found in our clinical practice significant stigma related to using OAT to treat addiction for young adults. In this series, we describe three cases of young adults who faced significant stigma related to their treatment. CASE PRESENTATIONS: The first case is a young male with a history of significant trauma and a severe opioid use disorder. He started buprenorphine and has found a job, stayed abstinent, and began a healthy relationship. At each step in his recovery, he has faced resistance to taking medication from other treatment providers, directors of sober houses, and his parents. The second case is a young woman who presented to a substance use treatment program after a relapse. She was unable to restart buprenorphine despite our calling to ask that it be restarted. Ultimately, she left against medical advice and was stabilized as an outpatient on buprenorphine. The final case is a young woman who stopped buprenorphine after being told she was "not sober" while attending 12-step group but restarted after conversations with her clinical team. In each case, the patient has continued their medication treatment and are stable. CONCLUSIONS: Opioid-related deaths continue to rise among all age groups, including young adults. Stigma related to medication treatment can be a substantial barrier for many young adult patients but there are concrete steps that providers and communities can take to address this stigma.