Dr Joanna Cheek: Mental health care isn’t within reach to those who need it the most

By Dr Joanna Cheek
As originally published in The Vancouver Sun.

As our world clashes and collapses around us, it’s no surprise that one in two of us will be diagnosed with a mental health condition by the age of 40, with one in five people experiencing an active episode each year, reports the Mental Health Commission of Canada.

I’m one of the people who struggle. You likely are, too.

Our discomfort and despair, our anxiety and anger, these are the appropriate alarms to a world on fire. Because we need to feel deep distress when our world is endangered. Because right now, it is. If mental health symptoms are the canary, then our coal mine is toxic.

We are living in a time of unremitting crisis. Of climate collapse and pandemics, runaway inequities and conflicts. Our alarms keep sounding because we are exposed, relentlessly, to the intensifying problems of our world that constantly assault us with toxic stress.

This week I felt appropriate distress as a queer mom answering my children’s questions about why people across Canada are protesting the “harmful indoctrination” of children with schools’ 2SLGTBQIA+ inclusive curriculum. Protesters held signs that schools were “grooming” children to be queer — what many shouted to be a sin, evil, and in need of eradication. Exposures to this kind of toxic stress are the source of the soaring rates of mental health symptoms reported in 2SLGTBQIA+ youth and other groups facing discrimination.

But then people who experience the most toxic stress feel the one-two punch of mental health inequity: Adversity and inequities create mental health symptoms, and they also limit one’s access to mental health supports, as the current system isn’t within reach to those who need it the most. This is why our mental health system, like schools, must have equity, diversity, and inclusivity at the centre of every step of its delivery.

Steve Cole, a genomics professor at the University of California, Los Angeles, studies how social stress causes inflammation by affecting our gene expression. When we anticipate a threat, our distress pushes us to react in life-saving ways, with our bodies built to ramp up inflammation, preparing us to repair the potential wound from a scary creature with big teeth and sharp claws.

This stress system works well if what we are fighting is a one-off encounter with a sabre-toothed tiger, says Cole, but not if the threat is the constant social stresses that we face in modern society. Our stress response isn’t that specific; it’s still stuck in the Stone Age by assuming the most helpful response to all threats is preparing the body to heal from a wounding injury.

But when our stress response is constantly going off, our body gets stuck in a state of chronic inflammation. Cole and many others’ research shows that chronic stress increases our risk of inflammatory-mediated diseases such as mental health conditions, cardiovascular disease, diabetes, Alzheimer’s, cancer, and many other illnesses.

The pandemic uncovered hard evidence of the harmful inequities that we’d been observing for decades.

“Black, Indigenous, and people of colour were overrepresented, their bodies subject to inflammation of all kinds, long before the SARS-CoV-3 virus ever settled into their lungs,” writes Rupa Marya, a physician and associate professor at the University of California, San Francisco, and Raj Patel, a public health researcher at the University of Texas, in Inflamed: Deep Medicine and the Anatomy of Injustice.

“To wonder why some things settle in some bodies and not others is to begin to ask questions about power, injustice, and inequity,” they continue.

Then COVID created what the Canadian Mental Health Association called an “echo pandemic” of mental health, with the people most heavily impacted being those who’d already experienced the most inequities, such as women, LGBTQIA2S+ people, individuals with inadequate financial resources or job or housing insecurity, newcomers to Canada, racialized communities, Indigenous people, and people with disabilities.

And yet these people needing mental health services the most couldn’t access it. Even before the pandemic, a Stats Canada survey showed that Canadians reported mental health counselling to be their most unmet need, and those in highest distress were the least likely to have access to it.

With the costs of mental health services a major barrier outside of the public health system, 80 per cent of people were left trying to manage their mental health care needs within the publicly funded primary care system, the Mental Health Association reported. And yet we also have a primary care crisis, with more than half of British Columbians finding it difficult to access a family doctor or having no access at all, a 2022 Angus Reid poll reported.

Fuelled by the moral distress of not being able to serve those most in need in our current system, our team of doctors created the CBT (cognitive behavioural therapy) skills group program in Victoria in 2015 to fill the gap in public services by offering equitable, accessible, and timely evidence-based mental health treatments for early intervention on a large scale.

With startup funding from the Shared Care Committee (a partnership of the Doctors of B.C. and the Ministry of Health) and the Victoria Division of Family Practice, we developed an eight-week program to improve access to mental health services by seeing patients more efficiently and effectively in groups of 15 people, all while benefiting from the destigmatization and support of belonging to a group.

Because of its local success, the Shared Care Committee funded the provincial spread of the project in 2020 to train over 100 doctors across the province to offer these groups both in person and virtually. These groups empower patients with the best evidence-based strategies, drawing from cognitive behavioural therapy, dialectical behavioural therapy, acceptance-based therapy and mindfulness.

Yet we soon realized that even the evidence-based practices we were drawing from required updates to ensure our program centres on equity, diversity, and inclusivity.

With funding from the Shared Care Committee and Vancouver Division of Family Practice, we consulted diverse voices, including people who identify as Indigenous, 2SLGTBQIA+, neurodiverse, disabled, and a variety of cultural identities to improve the safety and accessibility of our program. We also trained our facilitators with workshops on anti-oppression and anti-racism, gender inclusivity, and trauma-informed care.

We sought out new facilitators who represented the diverse lived experiences of our participants, offering affinity groups for participants who feel more comfortable in groups with shared experiences, such as those specific to age or gender, 2SLGBTQIA+, people of colour, and Indigenous identities.

The program offers a range of groups, all accessible to participants through one referral by a primary care provider as it is funded by B.C.’s medical services plan.

In addition to our foundations program, there are groups for mindfulness, insomnia, raising resilient kids to support parents and caregivers, and an ADHD skills for success program. With 397 different groups offered by physicians across the province this year, new participants can start attending with few barriers and little or no wait time.

Every door of our system needs to be inclusive and accessible if we are to create a healthy society. And only when our world feels safe and fair, can our distress alarms finally rest into wellness.

Dr. Joanna Cheek is a psychiatrist, cofounder and physician co-lead of the CBT Skills Group (cbtskills.ca), and clinical associate professor of medicine at the University of British Columbia.