Mental health – from research to remission

We’re at the height of a mental health crisis, where 40 million people in the European Union (EU) alone live with depression, yet three out of four say they don’t receive adequate treatment for this. With the European Economic and Social Committee strongly recommending that the European Commission declare 2024 as the European Year of Mental Health, it’s time for policymakers, healthcare systems and society to do more and start taking action.

In 2021, just over 7% of the EU’s population reported having chronic depression – that’s one in 14 people. To put this into perspective, it means that we’re all likely to know at least one person who suffers from this disease, or may have even struggled with it ourselves.

It’s been described as the silent pandemic, and everybody from policymakers, healthcare systems and employers to wider society have a part to play in achieving the overarching goal: remission of symptoms – the key objective of treating depression – and a return to more manageable daily functioning for people living with depression.

Unfortunately, this is no easy journey.

Firstly, depression is notoriously difficult to treat, with only 40-60% of patients achieving remission after an initial antidepressant treatment. Individuals battling depression, along with their healthcare providers, have to navigate an array of barriers that have slowed the progression of treatment innovation and access to this innovation.

Barriers including stigma, a lack of vital knowledge, and the current rating scales used to measure patients’ response and remission in clinical settings have all contributed in some way to hampering progress against effective depression treatment. So, what do we do?

Just like there’s no one set route to remission, there’s no single solution to overcoming these barriers. It’s a topic that’s been on the agenda of cross-sector stakeholders for years now, but progress in the field has stalled.

It’s well known that depression severely impacts a person’s ability to fully function at work, school or to cope with the pressures of daily life. It has a way of presenting itself in different ways, through various profiles. For example, for some, depression can present itself through insomnia, heightened symptoms in the morning, or restlessness. For many of those who do seek medical support for depressive symptoms, their initial port of call is primary care physicians, rather than behavioural health providers.

‘Many primary care providers report a lack of foundational knowledge and training in the treatment of common mental illnesses like depression’

However, many primary care providers report a lack of foundational knowledge and training in the treatment of common mental illnesses like depression. Without innovation and developments in this space, there are limited opportunities for industry to invest in physician education.

This lack of knowledge means that healthcare professionals (HCPs) may mistakenly assume that all forms of depression are identical. But just take a moment to think back to the last novel you read – hundreds of pages bound together under one title, with one short blurb as a summary. It’s only once you start reading the first few pages that you’re presented with different characters, with their own motivations and backgrounds, along with different subplots, adding additional perspectives and complexity.

I use this analogy because depression is an all-encompassing term for a much wider story, of a heterogenous disease that has complex subtypes and dimensions that are not well understood. Several distinct major depression subtypes exist (melancholic, anxious, atypical, psychotic, seasonal and postpartum), each with unique features and challenges, albeit having core symptoms in common. Primary care physicians cannot be expected to be experts in every illness they encounter and if they lack fundamental knowledge of these depression subtypes, how can the right treatment pathway be identified for the person seeking support? Do all patients get tarred with the same brush? Promoting quicker referrals of people with depression to specialised HCPs would help ensure that patients get the support they need.

This gap in knowledge isn’t only present within clinical settings. The stigma challenge is something that continues to cause people living with depression to delay seeking support or achieving treatment adherence. Stigma has two major dimensions: public stigma and self-stigma. Public stigma relates to the prejudice, stereotypes and discriminatory behaviour experienced by the person living with depression. This barrier can exacerbate the self-stigma, which discourages people from seeking support and can impact their treatment. While there has been progress in changing the public perception and raising awareness of depression, there is still more to be done in order to promote acceptance of major depressive disorder as a disease like any other somatic condition.

In my opinion, this stigma also influences the notable disparity in how urgently treatment is sought for physical versus psychological conditions such as depression. If you were to fall over and hurt your leg while jogging, the next logical step would be to seek the right care you need to feel better.

If you were to feel chronic emotional pain, the steps you would take toward feeling better should be aligned to those for physical pain. I’m a passionate advocate for ensuring physical and mental health are treated with the same level of urgency, but not everybody positions somatic and psychosomatic conditions on a level playing field.

Even while this disparity between how we treat physical and psychological conditions exists, there is an inarguable link between the two. People living with depression are at increased risk of suffering from cardiovascular disease, stroke, Alzheimer’s disease and general pain. Further to this, physiological changes associated with depression, like increased inflammation, changes in heart rate, and metabolic rate and blood circulation, may also play a role in increasing the risk of physical illness. The brain is a vital organ, a complex organ, and its health is inextricably linked to our physical condition.

A final challenge is the way we diagnose, track and measure treatment progress. The complexity of this disease, in addition to some of the other barriers I’ve mentioned, all contribute to this. The current treatment landscape relies upon stringent and time-consuming diagnostic interviews to identify and monitor depressive symptoms and response to treatment, which are carried out at different time points during treatment. The issue here is that symptoms of depression may fluctuate and vary in intensity over time.  Patients who are experiencing an improvement in their symptoms may feel differently in a matter of days or even hours and there can be a lack of consensus regarding optimal recall periods for assessment tools. It raises questions about whether current intermittent scoring systems used to measure disease progression and remission are accurate means for diagnosis and assessment of long-term remission. Circling back to my book analogy, we need to measure the progression of depression across all its chapters, rather than just one.

There is no one-size-fits-all solution to overcoming these obstacles. It requires ongoing, collaborative efforts from various entities within the healthcare system and broader society to reduce stigma, foster more inclusive discussions and enhance initiatives to facilitate meaningful and sustainable change.

Having said that, progress is being made. I had the pleasure of attending a number of congresses in 2023 and it was encouraging to learn about the proactive measures being taken to surmount these challenges. For me personally, as we enter a new era of digital technology, the opportunities within digital health and biomarkers are on their way to becoming essential in helping us better understand, detect and monitor diseases, including mental health conditions.

As mentioned previously, the evaluation of disease progression and remission should take into account the dynamic nature of depressive episodes. Previous studies have proven that there are statistically significant differences in the physical activity, sleep hygiene and overall phone usage of people living with depression, and those who do not. This is where digital advances and smartphones come in – they have immense potential to allow people and HCPs to subtly measure mood and behavioural changes over an extended period of time.

As investigations into digital health continue to evolve, in addition to seeing a shift in how depression is detected and monitored in the long term, we may also have an increased understanding and awareness of how depression impacts daily functioning. Such advancements could also act as a potential solution for time-pressured HCPs and extensive diagnostic interviews.

These developments can also help to measure disease progression from a more holistic, sustained perspective and ultimately portray a more accurate synopsis of the story of depression, instead of just summarising selective chapters.

Ultimately, the story of research and remission is still being written. As digital advancements and the clinical landscape evolve, we may be presented with new challenges. We must work together to amass the tools and resilience to face depression together. We must build adaptable healthcare systems, with education at every level, to lead the efficient delivery of care. As a unified force, policymakers, HCPs, industry and wider society must pull together to co-author the next chapter in the journey to attain better treatment options and outcomes for all.