Mental healthcare is in the middle of a major shake-up
Carin Baer / AMC
Much in medicine has changed since then - Hippocrates also noted that blood-letting works best in the springtime - yet our confusion over the best way to treat mental illness has remained.
"We have a lot of scientifically verified psychosocial treatments, and yet it's very difficult for consumers to access them," says Brandon A. Gaudiano, a clinical psychologist and faculty member at Warren Alpert Medical School of Brown University. "You have practitioners who use whatever they feel personally will be effective or whatever they like to use."
Many in the field are now saying it's long past time to bring evidence-based treatment to the practice of mainstream mental healthcare. A few efforts are finally moving the needle in that direction.
Delivering mental healthcare that is proven to work seems like a reasonable goal, but there are at least two key hurdles standing in the way. One, there's a lot we don't understand about what causes mental illness and how it should be treated; and two, even with the things we have studied and understand, that research only rarely seems to make it into practice.
Psychiatry and psychology have made significant strides in recent decades, but while the course of treatment for, say, strep throat is usually clear, your depression will still be treated very differently depending on whose office you show up in. Even a single practitioner will probably try one thing, then another, then maybe something else, hoping to find something that works.
Just last year, a team of scientists conducted a major review of the towering stack of research on treating depression in children and teens and concluded that "on the basis of the available evidence, we do not know whether psychological therapy, antidepressant medication, or a combination of the two is most effective to treat depressive disorders."
In short: We're really not sure what works best, or for many patients what works at all. And that doesn't even address the significant disagreement about all the different kinds of psychological therapies and medications available.
A call to action
The National Institute of Mental Health (NIMH) has had just about enough of this uncertainty, this gaping hole of knowledge when it comes to knowing how to treat the mental illnesses that afflict nearly one in five US adults. Thomas Insel, the Institute's director, has recently called out both psychotropic medications and psychotherapy for their high rates of failure, saying it's time to figure out how to develop "the next generation of interventions."
The NIMH has recently announced an Experimental Medicine Initiative, designed to bring the rigor and specificity of other fields of medicine to psychiatry, and - more specifically - psychotherapy, better-known as talk therapy. Insel argues, and few would disagree, that the currently available interventions for mental illness are woefully inadequate.
"Four decades of drug development resulting in over 20 antipsychotics and over 30 antidepressants have not demonstrably reduced the morbidity or mortality of mental disorders," Insel writes. There should be more attention given to psychotherapy, and yet, he notes in a blog post, "there are few if any 'metrics' for measuring [its] quality ... Is there any other area of health care that would tolerate this low level of quality or quality control?"
Insel points to a report released last month from the Institute of Medicine that flags "the gap between what is known to be effective and what is currently practiced" in mental healthcare, and makes the sobering point that even when we do know what works, those strategies don't consistently make it from research to practice.
Getting to the root of the problem
There are many reasons for that gap between research and practice, but part of it comes from the rift between who is studying treatments and who is delivering care.
Most people don't realize that "therapist" is a catch-all term that doesn't tell you anything about how qualified someone is to help you. People who dole out talk therapy can be psychiatrists, who have completed all the training of other medical doctors and then specialized in mental health; clinical psychologists, who have either Ph.Ds or a specialty degree called a Psy.D; or licensed clinical social workers, who have completed a master's degree and clinical training. But they can also be none of the above.
In fact, nearly anyone can call themselves a therapist and start counseling patients, and some practitioners - even some who have completed training programs of various lengths - never receive instruction on what research has shown about how and when various kinds of talk therapy are most effective.
"Compare that to something like traditional medical training," says Gaudiano. Even when doctors "are not actively engaged in research, there's this assumption that they should be basing what they're doing on evidence-based standards. We don't have that yet in mental health."
Part of that is because there simply isn't a regulatory framework for what qualifies as successful treatment, the way there is in other areas of healthcare. As Insel writes, "neither patients nor payers know how to judge what a therapist actually delivers."
Jerald Kay, a long-practicing psychiatrist and professor emeritus at Wright State University, says that while "you have to be careful about faulting clinicians," there is indeed "a quality problem."
In a 2014 paper, Kay and his co-author Michael F. Myers expressed concern that "the quality of teaching and learning psychotherapy is variable in our training programs," with a real risk that new doctors will be left to sort out for themselves what kind of psychotherapy they want to include - or not - in their practices.
The result? "There's a lot of stuff that goes on that should not go on," Kay says. "A lot of the things we do have unknown effectiveness."
Gaudiano said much of the same in a 2013 New York Times op-ed that urged the public - and, first, practitioners - to embrace evidence-based psychotherapy. "There has been a disappointing reluctance among psychotherapists to make the hard choices about which therapies are effective and which - like some old-fashioned Freudian therapies - should be abandoned," he wrote.
ROBERT HUFFSTUTTER / Flickr
Kay and other experts we spoke to argued that while there is certainly room for improvement in terms of bringing a more evidence-based approach to treating mental illness, it's important to acknowledge that, at the same time, psychotherapy is not always intended to treat the kind of simple, clear problems most research studies are designed to measure.
Glenn Shean, a psychologist at the College of William and Mary, acknowledged that "many practitioners of psychotherapy ... are not well-informed" about the latest research. But it's also true, he explained in an email, that "many individuals in therapy seek empathic support and understanding, not symptom change or emotionally challenging therapy."
Furthermore, people who show up in a psychotherapist's office often have multiple diagnoses: anxiety and depression, for example. Such patients are often excluded from research studies, which are usually trying to gauge the effect of one intervention on one particular problem. Complicated patients may be a liability in research, but they are a daily reality in practice.
Even without multiple overlapping problems, the idea that we have well-defined, consistently diagnosible mental illnesses is in many cases something of an illusion. Trying to define a standard treatment for what we call "major depressive disorder is analogous to giving a new antibiotic to everyone with fever," Insel writes. The variable matrix of symptoms is easily identified, but what's causing them is a mystery. (That treat-first, understand-later approach is pervasive in medicine, but it's especially emblematic of psychiatry.)
Efforts to rectify this patchwork approach - by looking for biological signs of mental illness, leaning on empirically validated treatments, and more - have been embraced by many, but are still too often often met by resistance. "Even commonsense and basic attempts to move toward the process of basing practice as much as is reasonable on scientific evidence has been stymied at every turn by some factions," Gaudiano noted, in a special issue of the Clinical Psychology Review devoted to "The Future of Evidence-Based Practice in Psychotherapy."
In the end, the National Institute of Mental Health's call for a more rigorous and evidence-driven approach to mental healthcare, while welcome and necessary, may require a wholesale rethinking of not just how we treat mental illness, but of mental illness itself. Psychiatric illnesses - which routinely overlap and co-exist - are usually diagnosed using a checklist of vague symptoms. Is it any wonder that treating them is often more art than science?
'The next generation of interventions'
Despite massive investments in research from the pharmaceutical industry, medications to treat mental illnesses - while helpful to many - have failed to deliver on their initial promise. "Either alone or in combination with other treatments, they have not proven sufficient," Insel writes. Yet while the NIMH has made talk therapy-based treatments a priority, there is simply not comparable funding available to study them.
"Whereas industry invests nearly $2 billion for each drug brought to market, the NIMH's full annual budget is less than $1.5 billion, with less than 10% invested in clinical trials," Insel wrote last year in JAMA Psychiatry, in an essay announcing a plan to double down on such trials.
This year, the NIMH is demanding more trials that help researchers understand exactly how diseases work rather than simply whether or not a treatment is effective. Such an approach should help mental healthcare start to move away from that treat-first, understand-later approach. If we can figure out the underlying causes of different diseases, developing effective treatments will be much more straightforward.
Beginning a year ago, all researchers receiving funding from the NIMH - the main source of funds for studies of psychotherapy - must register detailed data from their clinical trials in a national database as part of an effort to "accelerate research progress." The data will help toward one of Insel's major professed goals: "precision medicine for mental disorders."
That goal is reflected in the NIMH's controversial recent project to classify mental disorders by pointing to specific symptoms as well as data from brain imaging, genetics, and more rather than prescribing treatments based only on vague umbrella terms like "depression." More effective individualized care is also an end goal of a new initiative that aims to finally develop better ways for assessing how psychotherapy is actually working in practice.
Pilot programs in the UK and in the Veterans Affairs Healthcare System in the US are already showing that delivering evidence-based psychotherapy at a larger scale is possible - a health system just has to make that a priority. That's exactly what the National Institute of Mental Health is now trying to do.
That doesn't mean it will be easy. While the Affordable Care Act has finally begun to make access to mental healthcare - which remains a huge problem - easier for everyone, our healthcare system is still fragmented, not unified, as in the UK. The NIMH can nudge the system in a particular direction - and the Institute of Medicine is now calling on the Department of Health and Human Services to review the evidence on psychotherapy and develop guidelines for treatment - but neither agency can make a binding decree. Still, these are important steps.
We have to finally acknowledge, Insel says, that research must reflect the complexity of real-world patients so the practice of mental healthcare can lean on research more without squashing the agency of practitioners, whose clinical judgment remains a crucial piece of the puzzle. "Surely the time has come to recognize that there is not a magic bullet for most people with mental disorders," Insel writes. "The best treatment will involve access to multiple interventions tailored to the needs of an individual patient."
That may not be a magic bullet, but it's a start.
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