New Objectives for Improved Patient Care in Mental Health

by Lisa Brauer, PhD

Research in the field of psychiatry has been ongoing at an ever-growing pace. The body of medical literature relative to psychiatry is vast⎯with over two million articles published annually in over 20,000 health-related journals(1)⎯and expanding rapidly, doubling every 10 to 15 years.(2) The expansion of the medical literature, coupled with advances in biomedical technology that aid in the development of novel methods of investigation, should allow for an improved evidence base on which to rely for delivering optimal care to patients.

Yet, according to Thomas Insel, Director of the National Institute of Mental Health, there remains a significant gap between our knowledge and the delivery of care in our mental health system. In his 2009 article in the Archives of General Psychiatry, Dr. Insel comments, "While we have seen profound progress in research (with molecular, cellular, and systems neuroscience revealing new, unexpected insights about the brain), the gap between the surge in basic biological knowledge and the state of mental health care in this country has not narrowed and may be getting wider."(3)

In the article, Dr. Insel reviews data indicating that psychiatry has lagged behind other medical specialties in terms of the public health impact of research. He points out that mortality rates related to psychiatric disorders have not decreased, whereas those related to cardiovascular disease, stroke, and cancer have steadily declined. Dr. Insel reports data from 8 states collected and reported by Colton and Manderscheid(4) showing that patients with serious mental illness continue to have shortened life spans relative to those without, by as many as 32 years. Furthermore, he describes the results of a report by Kung and colleagues showing that suicide rates remain high in patients with mental illness, at more than 30,000 deaths per year in the United States.(5)

According to Dr. Insel, mental illness-associated morbidity also has not declined. Mental illness remains the leading cause of disability in the United States among individuals 15 to 44 years of age.(6) And, in spite of the fact that more patients with mental illness received treatment over a 10-year period, this did not result in reduced disability. He attributes this in part to the fact that most patients do not receive evidence-based care. Dr. Insel reports data from the National Comorbidity Survey-Replication study showing that only half of patients with major depression are treated and only 20% of those patients receive "minimally adequate care."(7)

Limitations of currently available pharmacologic treatments and inadequate training in and use of psychosocial approaches also contribute to the delay in improving mental illness-associated morbidity and mortality. With respect to pharmacotherapy, Dr. Insel points out that even in large-scale controlled clinical trials that use evidence-based treatments under optimal conditions, many people still do not achieve remission or recovery. He summarizes the issue this way: "Typically, clinical trials for antidepressant medications that seek some improvement in symptoms rather than remission and that consider improvement after 12 weeks of treatment a success are setting a very low bar for people with a life-threatening disorder defined by acute suffering.” Both researchers and clinicians need to bear in mind the significant variability in treatment response across patients, to strive for therapies that can be tailored to individual needs, and to aim for remission and recovery as treatment goals.

In terms of psychosocial interventions, Dr. Insel says the data may be more promising (for example, assertive community treatment for patients with schizophrenia). Nevertheless, the benefits of these types of programs are less well-known to some in the mental health community, and many clinicians do not receive training or support in how to use them. Consequently, evidence-based psychosocial treatments are underutilized.

Dr. Insel identifies four strategies for closing the gap between knowledge and practice based on the "notable successes" observed in other areas of medicine. First, he says, we need to conceptualize mental illnesses as disorders of specific brain circuits and to focus on this underlying pathology rather than basing treatment choices on the pharmacology of available medications. The focus on drug mechanism of action, instead of the pathophysiology of the disease, he says, is a bit misguided, "as if the cause of schizophrenia were the absence of neuroleptics." As part of the effort to elucidate pathophysiology, identification of key pathways and studies of genomics, "risk architecture," and epigenetics will be needed.

Next, Dr. Insel emphasizes the need to remember the developmental basis of mental disorders and to develop biomarkers for early detection and diagnosis. Basing a diagnosis of schizophrenia on the appearance of psychotic symptoms, he says, is "analogous to diagnosing coronary artery disease by myocardial infarction." Early detection and intervention may allow us to prevent some of the disability associated with disease progression.

Third, we need to emphasize the need for individualized treatments. According to Dr. Insel, clinical trials help to understand the effects of medications but they cannot target treatment to individual patient needs. He cites research suggesting that "the heterogeneity of mental disorders [has been demonstrated] at the level of genes and brain circuits."(8) He urges researchers and clinicians to remember that the lack of statistical significance of a treatment in a large clinical trial does not exclude the possibility of profound benefit for a smaller number of patients. To address this, he says future studies need to consider moderators of treatment response that could ultimately be used to individualize care.

Finally, Dr. Insel emphasizes the need to leverage the "untapped power of select psychosocial treatments." There are a number of evidence-based options for providing psychosocial support to patients, yet clinicians often are not sufficiently trained in their use and third-party payers may not cover those services. Where feasible, however, these approaches should be integrated into patient care.

Dr. Insel summarizes the problem this way: "None of the progress we are seeing in clinical research will have the necessary impact on public health unless we can close the gap between what we know and what we apply in practice. This translational gap exists throughout medicine, but the problem is more acute in psychiatry because so much of mental health care takes place outside the health care system. Individuals with serious mental illness appear in the criminal justice system, homeless shelters, emergency departments, and college counseling centers—almost everywhere except in specialized clinics and hospitals with the resources for optimized treatment of serious brain disorders." He emphasizes the importance of translating knowledge not only from "bench to bedside" but also from "bedside to practice.” “Unfortunately, the problems of dissemination or implementation are no less complex than understanding the intracellular signaling pathways or the language of genetic transcription. Progress will only be made with a realistic assessment of the current state of affairs, an acceptance of just how serious the challenge will be, and recognition that the task can be mastered. The challenge for those who seek to prevent and cure mental illness is awesome." Clearly, there is a need for enhancement of the available evidence base upon which mental health providers can rely when making treatment decisions. In the meantime, clinicians may benefit from considering the challenges posed by Dr. Insel with regard to early identification of patients with mental illness, individualized treatment consisting of both pharmacologic and psychosocial approaches, and the need to continue to transfer newly acquired knowledge into practice improvements.

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References

1. Jainer AK, Javed MA, Simpson I. Evidence based practice and its relevance to psychiatry. Pak J Med Sci 2005;21.
2. Nagurney JT. Evaluating the literature. June 23, 2006. http://www.emedicine.com/emerg/topic748.htm. Accessed 9/11/2006.
3. Insel TR. Translating scientific opportunity into public health impact. A strategic plan for research on mental illness. Arch Gen Psychiatry 2009;66:128-133.
4. Colton CW, Manderscheid RW. Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Prev Chronic Dis 2006;3:A42.
5. Kung HC, Hoyert DL, Xu J, Murphy SL. Deaths: final data for 2005. Natl Vital Stat Rep 2008;56.
6. World Health Organization. The world health report 2002: reducing risks, promoting healthy life. Geneva, Switzerland: World Health Organization; 2002: http://www.who.int/whr/2002/en/. Accessed June 18, 2008.
7. Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, Rush AJ, Walters EE, Wang PS; National Comorbidity Survey Replication. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA 2003;289:3095-3105.
8. Walsh T, McClellan JM, McCarthy SE, et al. Rare structural variants disrupt multiple genes in neurodevelopmental pathways in schizophrenia [published online ahead of print March 27, 2008]. Science 2008;320:539-543.