“I’m struggling again, doc.”
Josh, a 45-year-old man working in marketing was yet again sitting in my office dealing with a mental health crisis. This was his third depression relapse since the beginning of the COVID-19 pandemic.
Over the past two years, with the help of our in-house psychiatrist, I have prescribed Josh more than five different depression medications. However, I have only recently realized that the fluctuation in Josh’s condition has very little to do with the medications that I have prescribed. The time course of his relapses and recoveries corresponded almost perfectly with the COVID-19 lockdowns.
After a few more questions about Josh’s life, I started to understand why. With COVID measures tightened, he had stopped his gym routine as well as outings with friends and colleagues. He was home alone every day from morning to night. He felt a constant “profound lack of meaning of life.”
What Josh needs is a lifestyle where he can share his daily experience with the people he loves and cherishes. It is a lifestyle where Josh can complain to his colleague sitting right next to him when his supervisor assigns him too much work. It is a lifestyle where Josh is empowered by his social support to overcome the daily stress of life.
The pandemic has uncovered an aspect of mental health treatment that is under-valued in clinical practice – the role of social support. In my experience, most clinicians have a good understanding of the impact of a patient’s social support and life circumstances on mental health. However, despite knowing that, we still tend to look to medications and psychotherapy as the cornerstone to treatment of depression.
There are many reasons for this. Medications and psychotherapy such as cognitive behavioural therapy have strong evidence for safety and effectiveness. Most providers are quite comfortable with prescribing these as they are not only well-incorporated into our standard medical education curriculum but also frequently used in clinical practice. Also, medications and psychotherapy are treatment methods that are easily attainable without costing us too much clinic time. Writing a script and a referral to psychotherapy are much more time-efficient than a detailed exploration of a patient’s lifestyle and social ties.
To effectively help these patients, we need to work with them to understand the world around them and find the support they need.
However, treating Josh and many like him during the pandemic taught me an important lesson – individualized treatment must go beyond psychotherapy and medications. To effectively help these patients, we need to work with them to first understand the world around them and then find the support they need to help change how they perceive it.
Many qualitative studies have shown that from patients’ perspectives, successful strategies for recovery include having support from others and adopting healthy attitudes and practices. A study conducted in the United Kingdom showed that although medications are often seen as helpful, they are rated lower than support from friends and family and other therapies. So as health-care providers, how do we encourage or help our patients to attain social support?
Social prescribing is one way of accomplishing this.
Social prescribing refers to connecting traditional clinical practice with support services within the community. Recent studies and uses of social prescribing focus specifically on people who experience barriers to access medical care and whose health and well-being are affected by social determinants of health. Although an early systematic review has shown that the evidentiary value is still lacking, more recent evidence in the U.K., Australia and Canada have pointed to its promising future.
In Ontario, a 2018-2020 pilot social prescribing project across 11 community health centres had a health-care provider work collaboratively with a social prescribing navigator for people with social and medical complexities. Together, they helped patients access various supports and community assets. The final report noted that participants reported improvement in mental well-being and self-management of health, decreased loneliness and a better sense of connectedness and belonging. Although these resources were not geared toward mental health specifically but more for the community in general, the positive benefits undoubtedly helped those with mental illnesses and social isolation.
Another well-established approach is peer support groups. A peer support group is broadly defined as a “system of giving and receiving help founded on key principles of respect, shared responsibility, and an agreement of what is helpful.” It can take many forms, such as self-help groups, consumer-run organizations and services as well as peer specialists. Its effectiveness and positive outcomes in mental health have been consistently demonstrated in literature. However, based on the 2016 report from the Mental Health Commission of Canada, peer support has been underutilized in most Canadian provinces.
Moving forward, and out of this pandemic, I hope to carry forward the lessons I learned from patients like Josh. There is a need in primary care to address mental health concerns from more holistic and personal angles than medications and psychotherapies. Attributing more of the clinic visit time to discussing the role of a peer support group or providing information on community resources to our patients, and less on prescribing medications, will enhance the quality of care.
Going beyond my individual practice, advocating for a system level change to increase the accessibility of social prescribing and peer support services will help those suffering from mental health illnesses and social isolation.