The Achilles heel of healthcare provision in many countries has long been mental health. How to diagnose it, how to treat it and how to improve care have long been, and continue to be, major weaknesses in healthcare systems worldwide.
The source of this has traditionally been thought to be financial underinvestment, de-prioritisation and thus a general underestimation of the issue’s importance. All of these are true to some extent, but even with the right funding and an adequate supply of care, mental health diagnostics and interventions have barely changed over the past fifty years.
While mental health care consistently struggles with high demand and low supply of care, it also struggles with persistent clinical ambiguity. I have experienced for myself how arbitrary diagnosis and treatment can be. And there is nothing more jarring than waiting four months for mental health assistance only for it to be exactly the same ineffective thing you did three years ago, and still miles off what private – and prohibitively expensive – therapists can offer.
Diagnosing depression relies on people recalling their own symptoms, it relies on doctors observing and probing their symptoms reliably, and it relies on doctors analysing this information to understand what people with depression experience that other people don’t. Anxiety presents differently for different patients, but will all be diagnosed as the same anxiety disorder.
By contrast, in many other areas of medicine, broad diagnoses are narrowed following symptom information as well as increasingly detailed tests. A female patient does not just have “cancer” writ large, but might have the HR+/HER2- breast cancer subtype, which requires a different course of treatment and has a different prognosis than another breast cancer subtype.
Treating such mental health issues suffers from the same ambiguities as diagnosing them. For example, the NHS offers talking therapies, but these vary in both quality and accessibility, and are generally not tailored to an individual’s specific problems. Conventional mental health pharmaceuticals, meanwhile, can require months of gruelling experimentation for each patient, who might face unpleasant side effects without an improvement.
But even with the right funding and as many therapists as the NHS needs, there would still be an underlying lack of clarity with how mental health issues are diagnosed and treated.
Historically, these diagnoses have been hard to study and even harder to understand. It is not just that a one size fits all approach to mental health provision has been the go-to because it’s all governments can afford, it’s arguably all they have been able to do.
The priority for mental health care now needs to shift from simply just getting treatment, to actually getting the right treatment. Interestingly, promising technological advances in medical research have started to unlock an entirely new frontier of mental healthcare tailored to each individual.
For example, precision psychiatry can match patients to the treatments with the greatest likelihood of success based on their unique characteristics, brain circuit biology and clinical profile pre-treatment. The declining cost of neuroimaging wearables have also enabled brain imaging and analysis at scales previously unimaginable. Within ten years, these technologies could be as ubiquitous as FitBits, according to a report from the Tony Blair Institute.
These new analytical tools could enable mental healthcare providers to develop personalised mental healthcare plans for all of their patients based on far more precise measurements.
Treatment can also become more personalised. Non-invasive brain stimulation (NIBS) – a treatment that has been in use for almost a century – can now be carefully tailored to each patient’s specific needs. One Stanford University study (albeit with a small sample size) applied a form of NIBS to patients with severe treatment-resistant depression. After four weeks of high-intensity transcranial magnetic pulses tailored to each individual’s brain, 80 per cent of participants went into remission.
These are both quite the contrast to the current clinical norm and demonstrate a potential route out of the persistent clinical ambiguity that has plagued our mental health offerings. Currently, our aim is simply to offer treatment at all – now we need to treat people correctly.