Keeping stigma out of it: Personalising the mental health conversation
Thursday 10th October was World Mental Health Day, focused this year on ‘mental health at work’. As publications and online feeds filled with the true, global extent of the situation and honest and open personal stories were shared, from comedian Romesh Ranganathan’s own struggles to learning that the latest World Health Organization (WHO) figures reveal an estimated 12 billion working days are lost every year to depression and anxiety worldwide – it’s clear that mental health, though spoken about more freely than ever before, is still a major unmet need.
Earlier this year, pharmaphorum spoke with Boehringer Ingelheim’s Nedim Pipic, corporate SVP and therapeutic area head of CNS, retinopathies, and emerging areas, and Prof Thomas Schulze, professor and director at the Institute of Psychiatric Phenomics and Genomics (IPPG) at LMU Munich (Bavaria) & SUNY Upstate Medical University, Syracuse (New York), as well as president-elect of the World Psychiatric Association (WPA). The conversation explored the findings of a recent Economist Impact report, ‘Rethinking mental health care: Harnessing new approaches’.
Personalising mental health treatment
To mark World Mental Health Day, Boehringer Ingelheim launched a campaign aimed at increasing understanding and acceptance of serious mental health issues. ‘Schizophrenia in real life: Stories of challenges, resilience, and hope’ follows real-life stories of patients and their families, exploring how they are overcoming several aspects of life with schizophrenia. It presents the personal, individualised lived experience of living with mental illness.
Prof Schulze has been involved with psychiatric genetic research since 1997, which is a major part of personalised medicine approaches in psychiatry. The hope for this area of research is that genetic variants or genetic profiles will one day help identify subgroups and make better prognoses and tailor treatments to individual needs.
“There have been advances in this field and they are being used as we speak,” said Prof Schulze. “While we can now, in cases of maybe non-response or extreme side effects, test certain variants, metabolic variants like the liver enzyme CYP450, we are still far away from a more global, all-encompassing personalised medicine approach.”
“We need imaging and more detailed phenotypes,” he continued. “Although there are companies out there that sell a lot of genetic tests and promise a lot, all these things are not based on large randomised trials.”
“There's not been a lot of innovation if you compare the 1950s […] and the first antipsychotics, then into the 1990s, where there was a second generation of those and also antidepressants,” explained Pipic. “Until today, there was not a lot, [but] there’s a lot happening at the moment, when you look at the level of innovation and the buzz in the last four or five years, especially. [But] 40, 50 years ago, there was very little innovation. There was mainly medicine with a one-size-fits-all [approach] and very little precision medicine. Now, we are better at deep understanding of the neurobiology of the brain.”
“[Treatment needs to] go beyond just the pharmacological interventions,” he continued. “If we want to recognise the needs of those living with serious mental health conditions, they are very complex and the situations of the patients are highly individualised. The future of care will lie with both more precise pharmacological approaches, but also a combination of treatment approaches. How can we address those with different modalities, which go beyond behavioural therapies, psychosocial interventions, but also with prescription digital therapeutics, for example? I think it's challenging, but at the same time, it can be very rewarding, given the high unmet need in mental health care.”
Addressing the cost burden
Indeed, globally, approximately 1 billion people live with a mental health condition; that’s one in eight at this very moment. And one in two people are predicted to experience mental illness at some point in their lifetime. Yet, 70% of the global population lacks adequate access to mental health services, and the resultant burden on the worldwide economy equates to around $1 trillion each year, predicted to increase sixfold by the 2030s.
Lisa Sharman, head of education & commercial training at the UK’s St John Ambulance service, commenting on this year's World Mental Health Day theme, said: “Mental illness costs UK businesses approximately £56 billion each year. The good news is, a little bit of corporate engagement can go a long way, with research showing that measures to improve mental health of employees will yield £5 for every £1 spent.”
“There is a gap across England in the understanding of how first aid applies to mental health – but research shows it is becoming a more frequent and urgent workplace concern,” she added. “Poor working environments pose a significant risk to mental health. These risks can range from excessive workloads to unhealthy working conditions, discrimination, burnout, and more.”
St John Ambulance provides a range of Mental Health First Aid training courses that adopt a practical approach to creating competent and confident workplace first aiders. But that’s only one part of one solution in one country: when it comes to the world at large, the issue becomes even more complex.
“We realise when we talk to governments, be it in the US, in Southeast Asia, or in the Middle East, the burden is seen by all, but it's very hard to find pragmatic and impactful solutions to really tackle what they have because the problems can be very different country by country; even within a large country, state by state, like in the US,” said Boehringer’s Nedim Pipic.
“What we are trying to do from an environment [and] policy shaping perspective is really sit down and first of all ensure that the burden of serious mental illnesses versus a lot of the other lifestyle topics is really being seen as something very concrete, and discussed at forums such as the WHO World Health Assembly [and] the UN General Assembly, and get prepared for a mental health UN SDG meeting in 2025,” he continued. “When we launch, we want to make sure that our therapies are available across the globe and not just focus on one or three larger countries.”
The ‘Rethinking mental health care: Harnessing new approaches’ report
The Economist Impact report highlights the significant barriers for those who have a serious mental illness, and the access and quality issues they have to face in mental healthcare.
“It also highlights and, hopefully, is a call to action for the policymakers to actually think a bit more of how to adequately fund the national mental healthcare services,” said Pipic. “Because we're talking about one billion people who are currently living with a mental health condition. This is not something that will go away [on its own].”
The report provides examples of some of the differences on various points discussed between each of eight countries: China, France, Germany, Italy, Japan, Spain, the UK, and the US. It suggests that: “Organisations implementing changes in practice – such as payors and clinical guideline groups – need data on the clinical and cost effectiveness of the innovation to make a convincing case for change.” That includes data to demonstrate a positive impact on mental health professionals’ practice and address systemic issues. De-siloing practice is also mentioned, as well as knowledge sharing between countries.
Importantly, the report notes the importance of a patient-centric approach: “Often, patient and caregiver voices are not at the centre of decision-making in mental health care. Representatives from these groups bring a unique and valuable perspective that can improve the quality of mental health care.”
Circumventing ‘stigma’
Among the multiple challenges yet facing this disease area, stigma and public perception are still chief hurdles to overcome.
“I think it starts with the perception of serious mental illnesses in the media, be it in newspapers, be it on TV,” Pipic posited. “Even in the professional world, when you talk to patient advocacy organisations, and a person thinks they have a mental health condition, they have a big barrier even going to a physician. The physicians themselves would say in certain countries, ‘Don't go to a psychiatrist, you will be stamped right away as someone who might be crazy. Don't even go there.’ Actually, even making sure that you get a diagnosis and you get a treatment, that's already the first stigma barrier you see, combined with the public’s wrong perception and positioning of serious mental illnesses.”
“I think it will take, not a village, [but] whole cities to address the stigma through campaigns to really educate the general public and normalise mental health treatment seeking,” he continued. “It has to be done uniformly, at a policy level, to make sure that it is a key focus across the globe.”
“Mental health conditions are a leading cause of disability and premature death,” noted Pipic. “When you look at the actions from policymaking, it's never funded well enough to really have a good national mental health strategy, how to take care of the services. It's always the same issue in all the countries, be it low, middle, or high-income. The funding is never enough or the focus is never concrete enough to go deep enough to really actually address the issues at hand […] Maybe it is a vicious circle, where it's very hard to get out of it.”
Two key points of change, Pipic suggested, include open conversation about mental health and innovative new therapies coming to market.
“It doesn't matter which continent, it doesn't matter which political system or what level of wealth this country has or so, the problems are access, the problems are not enough budget, the problems are stigma – this is, for me, the most striking aspect,” stated Prof Schulze.
“Stigma is somehow a double-edged sword because I know people in my field who say, while there is stigma, we shouldn't always talk about it […] Maybe it's better to go around and talk about the positive impact good mental health would have, instead of just saying, ‘Oh, we are in such a bad shape because there's all the stigma,’” said Prof Schulze.
“We should talk about stigma, but in a different way,” he continued. “We have to fight stigma, maybe by not mentioning stigma.”
“I had a very nice discussion with [a patient advocate],” added Prof Schulze. “I asked her, ‘What are you, are you a patient or a service user, or a person with lived experience?’ She said, ‘Well, it depends. When I'm in a hospital with an acute episode, I'm a patient. Now, that I'm here and I'm recovered and I'm giving a talk, I'm talking with you, going to the same opening ceremony with you, I'm not a patient. I'm a person with lived experience.’”
Art and mental wellbeing
Lundbeck, a specialist pharmaceutical company focused solely on diseases of the brain and central nervous system, held an exclusive exhibition back in May, during Mental Health Awareness Week – ‘Life on My Terms - Art Exhibition & Auction’ – in partnership with art and mental wellbeing charity Studio Upstairs.
Highlighting how creativity can be channelled to help people living with mental health conditions express themselves and live their lives on their own terms, at the exhibition artists with lived experience of mental health conditions exhibited their artwork and shared their own experience of how art has helped them with their mental health.
Co-hosted by Veronica Green, the aim was to bring attention to the importance of communicating both symptoms and feelings around mental health with loved ones and healthcare professionals, and to inspire people to start meaningful conversations about living with a mental health condition to help them get the support they need.
Green commented: “Being an artist with a lived experience of depression, I know firsthand how the freedom to express yourself creatively can help you to recognise, assess, manage, and overcome mental health struggles in everyday life. During that period of struggle, I learned the importance of self-care and open dialogue about mental health, and how speaking about depression openly the first time I experienced it means that, now, I’m better equipped than ever to deal with any reoccurring mental health struggles in the future.”
A global psychiatrist shortage
Nevertheless, another issue within the mental health field is the very real and global problem of a shortage of psychiatrists.
“Psychiatry does have an image problem because of it being seen as a slightly dangerous area to work in,” explained Prof Schulze. “Also, the fact that as a career choice it's seen as slightly underpaid and not as attractive as an area to go into. It's not supported as well. There are problems with both training and retaining people in this area. That's been highlighted in the report as a macro finding. There's something inherent to psychiatry or mental health care that prevents it from being at the top of the list in health policymaking.”
Often, a psychiatrist is only thought of as utilising their voice and their own brain, and not having an assistant or tech assistant. To this end, digital therapeutics can offer a combined treatment option: drug plus software.
“We need to create an innovation and enabling environment,” Pipic stated. “Pharmacotherapies and prescription digital therapeutics. Rejoin is actually a very good example of innovation, which offers these holistic solutions around the patients, beyond the pill, beyond the pharmacotherapy, and comes with a very different risk-benefit profile than what is used to. It is something that engages with the patients also when they are at home, which is a critical point for certain conditions in mental health.”
“People like technology,” commented Prof Schulze. “People still think of a psychiatrist as a guy with a couch, a sofa, and that's only psychotherapy and only traditional psychoanalysis. It's the whole perception. There are basic things that need to change, the question is why haven't they changed for 30, 40 years?”
Combining drug and digital
The drug plus digital approach is gaining momentum. For instance, last week telehealth company Talkiatry announced its partnership with Biogen to expand its support service for women who develop postpartum depression (PPD) in a move that could help drive uptake of the latter's new drug Zurzuvae. And last month DeepWell Digital Therapeutics – part of NeuFluent – received 510(k) clearance from the US FDA on its biofeedback (ABS) software development kit for use in over-the-counter treatments for the reduction of stress and as an adjunctive treatment for high blood pressure.
The DeepWell software provides biostimulation in interactive media that activates the user’s vagus nerve while increasing patient engagement, reducing sympathetic nervous system activation, and releasing dopamine for coping, thereby improving resilience and stress and hypertension reduction.
The clearance follows the July 2024 proposal from the Centers for Medicaid and Medicare Services (CMS) for codes to enable Digital Mental Health Treatment (DMHT) devices to become reimbursable as a physician service beginning in 2025. DeepWell’s co-founder and chairman, Ryan Douglas, stated: “With the work the Digital Therapeutics Alliance (DTA) has done to secure reimbursement pathways, the last mile was to build technology that allows engaging media to be efficiently evaluated and marketed as a medical device.”
“The DeepWell clearance, along with DTA’s work with Congress to secure reimbursement pathways, will bring mental and physical health support to millions of struggling American families,” said Andy Molnar, CEO at Digital Therapeutics Alliance and member of the FDA Digital Health Advisory Committee.
In the UK, despite government committing to spending 8.9% of all NHS funding on mental health treatment last year, it is thought that the pipeline to build new facilities and train new staff will take years and yet be insufficient to meet demand. Nonetheless, in August, Oxford University Innovation announced new online therapies provided by Koa Health that could enable NHS therapists to help two to three times more patients recover from things like PTSD and anxiety.
NICE Early Value Assessment (EVA) recommended these digitally enabled programmes as therapist-assisted treatment for adults, adolescents, and children. The four internet-based therapies have been developed by researchers at the Department of Experimental Psychology and Department of Psychiatry and were rolled out last month. Created with funding from Wellcome and the National Institute for Health Research, the courses will be made widely available across NHS Trusts, mental health facilities, schools, and colleges.
Professor Cathy Creswell, a psychologist at the University of Oxford, noted: “Recent surveys suggest ongoing increases in the number of children and young people that are experiencing anxiety problems. Our online platforms, which were developed with support from the National Institute for Health and Care Research (NIHR) Oxford Health Biomedical Research Centre (OH BRC), provide practical tools with guidance and support to help tackle issues from home.”
Professor David Clark, also at the University of Oxford, added: “Social anxiety disorder starts in childhood and is remarkably persistent in the absence of treatment. Internet programmes that deliver optimal treatment for both adolescents and adults have the potential to transform lives and enable people to realise their true potential at school, in the workplace, and in society”.
It’s estimated that every week in England, one in four people will experience a mental health problem of some kind. And one in six people report experiencing a common mental health problem – like anxiety or depression – in any given week in England. Everyone deserves support when they need it, in whatever form is most effective for them, so they can live their life on their own terms.
About the interviewees
Nedim Pipic has overseen the therapeutic area Central Nervous System (CNS), retinopathies and emerging areas at Boehringer Ingelheim since August 2022. In his role, he leads the strategic direction of the portfolio with a focus on addressing high, unmet needs in chronic and complex mental health conditions. It is Boehringer Ingelheim’s ambition to bring mental health care to the next level through precision psychiatry, a targeted approach which investigates the brain biology associated with symptoms experienced by people living with mental health conditions. Previously, Nedim has held a variety of roles in oncology, cardio-renal-metabolic as well as respiratory diseases with increasing commercial and general management responsibility. He is a medical doctor by training and holds a degree from the Medical University of Vienna.
Professor Thomas Schulze is Professor and Director, Institute of Psychiatric Phenomics and Genomics (IPPG) at LMU Munich (Bavaria) & SUNY Upstate Medical University, Syracuse (New York), and President-Elect, World Psychiatric Association (WPA). His research focuses on genotype-phenotype relationships in psychiatric disorders. He coordinates a German-wide center grant on longitudinal psychosis research and spearheads an international study on the genetic basis of response to lithium treatment in bipolar disorder, comprising several research groups from Europe, the Americas, Africa, Asia, and Australia.
