By Javier Fernández-Álvarez
Again this year WHO’s World Mental Health Day has arrived, and lots of efforts have been made by scientific and professional communities to spread the message about the importance of enhancing people’s mental health. However, there are numerous problems still pending to be resolved in order to increase impact in society. These are 5 burning issues that are now taking place in mental health:
1. Categorical versus dimensional classification of mental disorders
Following a classical medical taxonomy, mental disorders have traditionally been conceptualized as discrete categories. Nevertheless, throughout the years this statement has been called into question (Kendall, 1975; Widiger & Clark, 2000; Widiger & Samuel, 2005). Both the clinical practice and mountable evidence from research started to show that syndromes (bunch of symptoms) may be conceptualized as dimensions and mental disorders cannot be simply understood as distinctive diagnosis undependable one from each other. Although this topic is already an old discussion, it is still a major topic to be resolved given that the latest version of the most utilized diagnosis manuals (DSM 5 and ICD-11) still conceptualize mental disorders in categories.
Many scholars, scientists and professionals fully agree with the necessity to make advancements with regard to diagnosis classification, and in that sense alternative developments have emerged. Illustrative examples are the RDoC (Insel et al., 2010), the HiTOP initiative (Kotov et al., 2017; Krueger et al., 2018) or the p factor as a general factor in the psychopathological structure (Caspi et al., 2014). Although still not widely adopted in the routine clinical practice and they are not free of problems, all these developments constitute potential lines of advancement.
2. Gap between research and practice
This has been present from the beginning of mental health research (Parloff, 1979; Strupp, 1960). How to conciliate the close environment of research with the chaotic and unexpected nature of “the wild”? Many scholars have suggested a vast array of alternatives and procedures to combat this undoubted problem (Goldfried & Wolfe, 1996; Vivian, Hershenberg, Teachman, Drabick, Goldfried, & Wolfe, 2012; Kazdin, 2017; Shafran et al., 2009). Nevertheless, there are a vast array of epistemological and practical problems that still hinder a real articulation.
How can a strategy be developed to hurdle this stumbling block? Active collaboration between researchers and practitioners. All the research lines that have been devoted to articulating research and practice from an active collaboration between both parts has received the name of Practice Oriented Research (Castonguay & Muran, 2015).
3. To prevent or not to prevent
Prevention seems to be an ideal strategy to deal with mental health. That is, dealing with the problems from the root, even before they turn into mental disorders. Few would disagree with the fact that prevention is important, and indeed the article itself published by the World Health Organization for the 2018 Mental Health Day, contains one section about prevention. In that vein, many research lines have focused on prevention as a strategy to cope with mental disorders (Ialongo et al., 2006; WHO, 2004). Nevertheless, there are voices against, claiming that prevention entails many risks and few proven benefits. In particular, Allen Frances, a provocative scholar and author of bestsellers like “Saving Normal”, who published the following tweet:
Some days later the same provocative author, claimed:
Although the second part is undoubtedly the main aim of fair and democratic societies, is not there any space for prevention in mental health?
4. The incorporation of new technologies
Although unarguably becoming an important research area in the mental health realm, few technologies have really been integrated into the clinical practice. On the one hand this is explained in the gap between research and practice described before, but also in the specific developmental process that technology has incorporated up to now (Mohr, Weingardt, Reddy, & Schueller, 2017). Just to mention one example, tech applications are using up to now the same strategies of other kind of therapeutic interventions, but given the rapid changes and progresses that technology that has proven to be safe and effective may become obsolete in the everyday life (Fleming et al., 2016).
Moreover, people devoted to apply technology to mental health are used to describing the potential positive impact of it and the great opportunities that technologies bring due to its pervasive nature. However, what about the negative consequences? The misuse and abuse of technologies becoming for many people a well and truly dependency or the impairment of social bonds due to the replacement for non-physical interactions illustrate potential and actual results of the pervasiveness of technology, principally mobile phones (Kuss, Kanjo, Crook-Rumsey, Kibowski, Wang, & Sumich, 2018).
There are many collaborative efforts in order to hurdle the described and other obstacles in the implementation, development and use of new digital technologies. For example, Mohr and colleagues (2017) have suggest interesting alternatives in order to deal with the problems that current digital mental health research is facing, such as grasping new digital technologies primarily as technology-enabled services and not as mere products.
Besides, there are interdisciplinary groups working worldwide in order to bring forth solutions that may cope with the aforementioned problems. In the European Union, for example, there is an ongoing network (www.affectech.org) which is striving hard in order to provide ethical and cutting-edge results from the technological point of view. Apart from gathering computer scientists, engineers, human computer interaction designers and clinical psychologists, there is a strong emphasis placed in trying to go beyond the classical solutions, for example through the incorporation of sensors in wearable devices as well as incorporating alternative perspectives, such as somaesthetics design.
Researchers and colleagues of the AffecTech network, at their recent training event in Istanbul, Turkey.
This innovative approach seeks to replace the classical symbolic, language-oriented, and predominantly visual interactions of users with technologies for shape-changing interfaces or movement-tracking apps from a first-person perspective (Höök et al., 2018). These ideas are totally in line with the stance of mental health claimed by the World Health Organization many years ago (WHO, 1978), that is, trying to potentiate people’s environments to foster a richer life and not just the absence of illnesses and diseases and reaffirmed recently (WHO, 2006).
5. Controversy in scientific production
Governments pay researchers and grants using resources obtained through usual public taxes collection. Researchers need to publish articles both to wrap up the ongoing grants and to apply for new ones. These articles are published in Journals which are run by huge publishers. In turn, the usual process in these high impact Journals entails a peer review process, which is conducted by other researchers for free. Meanwhile, these publishers earn in many cases great amounts of money (1000-2000 EUR) for each publication, and sometimes even a fee for submission which is not refunded in case of rejection. More serious is that once published, these articles are frequently blocked and only if expensive subscriptions are paid by universities or libraries is possible to have access to those articles, even for authors. That is, more public resources to read a study that was reviewed with public resources and conducted by a researcher initially funded by a public institution (it is true that sometimes the institutions are private and this is the most extreme of the cases, although it is far from being an exception to the rule).
More and more voices are raising against this issue, and here there are some news that have been published in the last months about this topic. The European Union, for example, advocates for an open access to scientific articles and its mandate (http://ec.europa.eu/research/openscience/index.cfm?pg=openaccess) has helped European institutions to renegotiate some unfair contracts.
Here there are some examples
Understand the problems work towards the solutions?
Overall, there are some major problems in the mental health realm to overcome. However, while it may be true that the described issues are not minor issues, there are solid arguments to adopt a positive outlook. First and foremost, because the identification of the limitations, pitfalls and caveats represent an important advancement in any field, and particularly a scientific field. Moreover, for each of the presented burning issues there are also developments that balance the weight of negative and positive aspects. And most important, there are lots of people, scientists, academics, professionals and institutions committed to contributing to an improvement in the quality of life of our society. Hence, not everything is as bleak as it may seem when it comes to foresee the future.
AffecTech is a Marie Sklodowska-Curie Innovative Training Network funded by European Commission H2020: AffecTech – Personal Technologies for Affective Health (722022).
AffecTech supports World Mental Health Day 2018.
Javier Fernández-Alvarez (pictured top right) is an AffecTech researcher and PhD student based at the Università Cattolica del Sacro Cuore. A cognitive-integrative psychotherapist, he now works full-time on the AffecTech project, and is focused on technologies applied to clinical psychology, with a specific emphasis on developing and testing a VR based biofeedback training protocol to be implemented in mobile devices for stress management. Javier tweets at @javferalvarez https://twitter.com/javferalvarez.
Caspi, A., Houts, R. M., Belsky, D. W., Goldman-Mellor, S. J., Harrington, H., Israel, S. et al. (2014). The p factor: one general psychopathology factor in the structure of psychiatric disorders? Clinical Psychology Science, 2, 119–137. doi: 10.1177/2167702613497473.
Castonguay, L. G., & Muran, J. C. (2015). Fostering collaboration between researchers and clinicians through building practice-oriented research: an introduction. Psychotherapy Research, 25(1), 1-5. doi:10.1080/10503307.2014.966348
Fleming, T. M., de Beurs, D., Khazaal, Y., Gaggioli, A., Riva, G., Botella, C., et al. (2016) Maximizing the impact of e-therapy and serious gaming: time for a paradigm shift. Frontiers in Psychiatry, 7(65).
Goldfried, M. & Wolfe, B. E. (1996). Psychotherapy Practice and Research. American Psychologist.
Höök, K.; Caramiaux, B.; Erkut, C.; Forlizzi, J.; Hajinejad, N.; Haller, M.; Hummels, C.C.M.; Isbister, K.; Jonsson, M.; Khut, G.; et al. (2018). Embracing First-Person Perspectives in Soma-Based Design. Informatics, 5, 8.
Ialongo, N. S., Rogosch, F. A., Cicchetti, D., Toth, S. L., Buckley, J., Petras, H., & Neiderhiser, J. (2006). A developmental psychopathology approach to the prevention of mental health disorders. In D. Cicchetti & D. J. Cohen (Eds.), Developmental psychopathology: Theory and method (pp. 968-1018). Hoboken, NJ, US: John Wiley & Sons Inc.
Insel, T., Cuthbert, B., Garvey, M., Heinssen, R., Pine, D.S., Quinn, K., Sanislow, C., & Wang, P. (2010). Research domain criteria (RDoC): toward a new classification framework for research on mental disorders. American Journal of Psychiatry, 167, 748-751
Kazdin, A. E. (2017). Addressing the treatment gap: A key challenge for extending evidence-based psychosocial interventions. Behaviour research and therapy, 88, 7-18
Kendell, R. C. (1975). The role of diagnosis in psychiatry. Oxford, England: Blackwell Scientific Publications.
Kotov, R., Krueger, R. F., Watson, D., Achenbach, T. M., Althoff, R. R., Bagby, R. M., . . . Zimmerman, M. (2017). The Hierarchical Taxonomy of Psychopathology (HiTOP): A dimensional alternative to traditional nosologies. J Abnorm Psychol, 126(4), 454-477. doi:10.1037/abn0000258
Kuss, D.J., Kanjo, E., Crook-Rumsey, M. et al. (2018). Journal of Technology in Behavioral Science, 3, 141-149. https://doi.org/10.1007/s41347-017-0041-3
Mohr, D. C., Weingardt, K. R., Reddy, M., et al. (2017). Three problems with current digital mental health research and three things we can do about them. Psychiatry Services, 68, 427-9. 10.1176/appi.ps.201600541
Parloff, M. B. (1979). Can psychotherapy research guide the policymaker? A little knowledge may be a dangerous thing. American Psychologist, 34, 296-306.
Shafran, R., Clark, D. M., Fairburn, C. G., Arntz, A., Barlow, D. H., Ehlers, A., … & Salkovskis, P. M. (2009). Mind the gap: Improving the dissemination of CBT. Behaviour research and therapy, 47(11), 902-909.
Vivian, D., Hershenberg, R., et al., (2012). A broadly defined Intervention-Focused Translational (IFT) model as a framework for a discussion on the integration of science and practice. Psychotherapy, 49, 143–151.
Widiger, T. A., & Clark, L. A. (2000). Toward DSM–V and the classifi- cation of psychopathology. Psychological Bulletin, 126, 946–963.
Widiger, T. A., & Samuel, D. B. (2005). Evidence-based assessment of personality disorders. Psychological Assessment, 17(3), 278-287. http://dx.doi.org/10.1037/1040-35188.8.131.528
World Health Organization. (2004). Prevention of mental disorders: effective interventions and policy options – a summary report. [cited 13 Oct 18]. http:// www.who.int/mental_health/evidence/en/prevention_ of_mental_disorders_sr.pdf
World Health Organization. (1978). Declaration of Alma-Ata [cited 13 Oct 18]. http://www.who.int/publications/almaata_declaration_en.pdf
World Health Organization. (2006). Constitution of the Wolrd Health Organization [cited 13 Oct 18]. http://www.who.int/governance/eb/who_constitution_en.pdf