[Note: today’s blog is very much a group effort. It’s been written by a group of MSc students at University College London who covered this paper in their journal club today. Do let me know if you want to find out how your journal club could do something similar.]
In the near future, we are likely to see self driving cars and robots that do housework. But what is the future for mental health care?
Approaches to mental health care have already changed: from people being classified as witches to the standard of NICE guidelines. So the key question is how will this be? More specifically, how will care be formed? And, what role will professional services have?
In a personal view article, Giacco et al (2017) stirred up a debate, suggesting 4 controversial scenarios for the future of mental health care.
An open-ended online survey examining social aspects of mental health care was sent to 18 mental health professionals (psychologists, psychiatrists and researchers) from the UK, Germany, France, Italy, Denmark and Austria. The responses were then analysed for themes, including:
- ‘Instabilities’ (current issues that are likely to change) and
- ‘Drivers for change’ (external factors that could determine the future)
A workshop was held to discuss the survey’s content. This included the 18 experts from across Europe who discussed and refined the ‘instabilities’ and ‘drivers for change’.
Titles were identified and each scenario was discussed in smaller groups.
Future scenarios for mental health care
The survey resulted in the following four scenarios of future mental health care, which are not mutually exclusive:
1. Patient-controlled services
- Patients and carers will run and design mental health services and research. This means patients decide their treatment and professionals merely provide information.
- Coercion will not have a place in mental health services and the key emphasis will be on increasing patients’ capacity to make decisions.
- Crimes will be assessed exclusively by the criminal justice system, meaning that offenders with mental health problems will go to prison, not hospital.
- Lastly, professional training will be community based, to help professionals develop skills so they can fight for the rights and goals of their patients.
2. Modifying social contexts
- Services will address patients’ social environment, such as: parenting support, educational or employment needs, and relationships.
- Mental health professionals will implement options that target unhelpful determinants (e.g. social and economic conditions) that lead to mental health problems.
- Addressing social aspects of people’s lives through local authorities, care will become unified.
- The social sciences such as psychology and geography will play a big part in this.
3. Virtual mental health care
- Mental health care will be online as much as possible, with professionals as avatars with artificial intelligence, that patients can design themselves.
- Drones will be used to deliver medications.
- Those wanting human contact because they are uncomfortable with a virtual healthcare system, will be able to request a face-to-face human appointment.
- Research will concentrate on improving the software.
- While helpers can be available, there will be much less need for human staff.
4. Partners to the poor
- Mental health care will be part of a wider healthcare system targeted towards the poor. ‘Poor’ here is not just in economic terms but also metaphorically: the socially isolated, homeless, discriminated, unemployed and migrants.
- There is no differentiation between physical, psychological or social problems, and all focus on social factors that determine these difficulties.
- Communities identify risk factors for disadvantaged groups and try to minimise their negative impact.
- Society in general will be rife with advocacy for these disadvantaged groups, and policies will aim to uplift them.
Four scenarios were highlighted regarding the future of mental health care. While they differ, there are some fundamental similarities; mental health care will be shaped by social concepts and require drastic changes! What is also apparent, is the reduced need for health and social care professionals, who could be replaced by artificial intelligence or peer support workers. Other scenarios also see increases in communication between services and changes in stakeholder involvement. Not to worry though, patients, family and members of the public will still play a crucial role!
The core premise of each scenario, is who is considered an ‘expert’? Some emphasise patient knowledge, while others emphasise the role of social science and the community.
Each scenario can be judged on their likelihood or appeal! But this is likely to vary:
Depending on the underlying values, ideals, and concepts that are preferred for mental health care specifically, or even for societal life in general.
Strengths and limitations
This is what we (the journal club students) thought of the paper and the various mental health care scenarios suggested by the authors:
The paper and methodology as a whole
|Highlights current problems with mental health care.
Participants were from a wide range of European countries.
Although the experts were only in psychology and psychiatry, they varied in roles, suggesting a potential breadth of ideas.
Inter-rater reliability as the identification of themes were from two researchers.
|It may not relate to everyone.
A sample of 18 experts is not representative.
Experts only came from European countries
Didn’t include experts of other disciplines such as politicians, historians etc, that may consider other factors of change (Becker, 2017).
Measurement bias: some of questions in the survey specified numerous examples, which could have forced participants to produce information they did not really believe.
Scenario 1. Patient-controlled services
|Self-management and control over treatment decisions, may increase adherence to it.
It seems logical that patients who use the service get a say in how it is run, as only they truly know what it is like.
|While lack of coercion can increase adherence to treatment, coercion is sometimes necessary if people lack the capacity or are high risk (i.e. Mental Health Act).
If there is a reduced need for experts, funding may be reduced.
Scenario 2. Modifying social contexts
|Modification of a person’s bad social factors were addressed. However, identifying strengths of an individual can aid recovery and empowerment (Pattoni, 2012). It may be better to modify social contexts by building on supportive aspects.
A main focus is on the collaboration between services. It is unclear why this would be special to the future since studies have reported this already exists (Atwal & Caldwell, 2005)
Scenario 3. Virtual mental health care
|Reduces human error.
Drones may guarantee patients get essential medication.
There’s emerging evidence that avatars can be beneficial in mental health, e.g. for psychosis (Leff et al, 2013, 2014).
By tailoring the avatar to their preferences, patients may feel more comfortable.
|Harder to build rapport and to perceive nonverbal cues, which can be more indicative than language.
Service users may be less inclined to trust the software and technology.
Relies on patients having access to modern technology, which may not be the case (see the Inverse Care Law).
Scenario 4. Partners to the poor
|Health care that doesn’t distinguish physical and psychological problems would be beneficial as it treats patients’ holistically. Mental health problems are often also associated with physical problems.||What about mental health care for members of society who do not meet the disadvantage criteria?
Biological and psychological contributions will be undervalued.
What do you think?
Mental health is a constantly evolving field, and clearly we are a long way from knowing everything. Reducing the number of experts involved in the mental health care system may slow this progress and hinder the development of mental health knowledge.
Allowing more focus on possible environmental causes or factors, instead of the over-emphasised biological ones, may allow a greater awareness of how to prevent the onset of disorders in the first place and reduce the prevalence of mental health problems generally. It may also reduce individuals thinking that ‘they are the problem’, as an emphasis would be placed on their environment and upbringing, rather than just on them.
However, this is a Personal View (or the diverse views of 18 leading experts brought together into a personal view article), with the aim of encouraging discussions, not influencing policy. Whilst we find each of the four scenarios to be quite extreme, we do believe that aspects from each could be crucial for the sustained development of our future mental health care service.
Giacco D, Amering M, Bird V, Craig T, Ducci G, Gallinat J, Gillard SG, Greacen T, Hadridge P, Johnson S, Jovanovic N, Laugharne R, Morgan C, Muijen M, Schomerus G, Zinkler M, Wessely S, Priebe S. (2016) Scenarios for the future of mental health care: a social perspective. The Lancet Psychiatry, Volume 4, Issue 3, 257-260 http://dx.doi.org/10.1016/S2215-0366(16)30219-X
Becker T (2017) “The future’s in the past” (commentary). The Lancet Psychiatry, 4,178-179. [Abstract]
Pattoni L. (2012) Strengths-based approaches for working with individuals. IRISS.
Atwal A, Caldwell K. (2005). Do all health and social care professionals interact equally: a study of interactions in multidisciplinary teams in the United Kingdom. Scandinavian Journal of Caring Sciences, 19(3), 268-273. [PubMed abstract]
Leff J, Williams G, Huckvale M, Arbuthnot M, Leff A. (2013). Computer-assisted therapy for medication-resistant auditory hallucinations: proof-of-concept study. The British Journal of Psychiatry, 202(6), 428-433.
Leff J, Williams G, Huckvale M, Arbuthnot M, Leff A. ( 2014) Avatar therapy for persecutory auditory hallucinations: What is it and how does it work? Psychosis, 6(2), 166-176.