FEAM Statement on Mental Health Policy Issues

Statement

November 2010 The Federation of the European Academies of Medicine (FEAM)

FEAM was founded in 1993 in Brussels with the objective of promoting cooperation between the national Academies of Medicine and of extending to the political and administrative authorities of the European Union the advisory role that the Academies exercise in their own countries on matters concerning medicine and public health. As an umbrella organisation, it brings together national Academies of thirteen European member states (Austria, Belgium, Czech Republic, France, Germany, Greece, Hungary, Italy, Portugal, the Netherlands, Romania, Spain and the United Kingdom) and aims to reflect the European diversity by seeking the involvement of additional Academies and experts in its scientific activities and by collaborating with other European-wide networks on scientific matters of common interest.

Published by Psychiatrické centrum Praha - Prague Psychiatric Center 2010 ISBN: 978-80-87142-11-0 © Federation of the European Academies of Medicine FEAM Statement on Mental Health Policy Issues

A FEAM Statement November 2010

Content

Summary 4 1. Introduction 5 2. Health and socio-economic impact of mental ill-health in the EU: what is the size of the problem? 6 3. EU mental health policy at the crossroads 8 4. What should be covered in a broader mental health strategy? 9 5. Conclusions 18 6. References 19 Appendix: FEAM procedures and contributing individuals 21 This Statement was endorsed by the FEAM member Academies 22 Acknowledgements 23

3 Summary

The high burden of mental illness has been Our recommendations focus on the needs relatively neglected in EU policy. The cur- (i) to achieve better understanding of rent practice of psychiatry is undermined the psychosocial and biological factors by insufficient biological understanding of in mental disorders, together with their mental health disorders, under-recognition, interactions; (ii) to capitalise on scientific stigmatisation, a lack of effective thera- advances so as to develop more effective peutic interventions and of access to care recognition, classification, diagnosis and delivery. therapy; and (iii) to share best practice to optimise the delivery of health services. The present report draws on discussion Achieving a more productive linkage from a Prague meeting organised in 2009 of research with clinical care requires by FEAM (Federation of European Acad- improved epidemiology, increased emies of Medicine) to review some of the investment in basic, clinical, translational critical issues in contemporary psychia- and multidisciplinary research and its try and is intended to provide advice to supporting infrastructure, and new decision-makers at the EU and national approaches to networking of centres of levels in developing a more coherent policy excellence and public-private partnership for mental health. We cover policy priorities to translate scientific advances into relating to research and public health for innovation. major contributors to the disease burden, including depression, bipolar disorder, Developing this coherent strategy for men- schizophrenia, and their co-morbidities. We tal health requires increased commitment also address cross-cutting issues for mental from the European Commission and Parlia- health policy, including stigma, suicide, ad- ment. The biomedical community also has a diction, workplace stress and the challenges major responsibility to engage with policy- of adolescence and ageing. makers and the general public to com- municate about mental health disorders, their determinants, triggers, risk factors and management.

4

1 Introduction

Mental ill-health is a major public health problem for Europe, bringing challenges for patients and their families. It also creates an economic burden on society. Mental illness also brings an ethical challenge when it leads to stigmatisation and social exclusion. While the promotion of mental health has received increasing attention in the European Parliament (Brepoels, 2010) and European Commission, there is much more to be done. Both Member States and the EU must invest more in mental health services and research. FEAM convened a scientific meeting in Prague in 2009 to identify some key issues for policy makers at the EU level.

5 Health and socio-economic impact of mental ill-health in the EU: what is the size 2 of the problem?

A report by DG Sanco (2004) noted the It is important to do better in understanding and historical difficulty in collecting standardised quantifying the broader impact of mental illness epidemiological statistics across all the Member on European society. There are additional public States in mental health, partly because of health burdens when mental illness presents variability in survey techniques and definition. with co-morbidities (in particular, cardiovascular Without standardised data, it is difficult to disease, diabetes and cancer). A comprehensive assess impact but, in aggregate, the cost of review of the various attributes of physical mental health problems in the EU was estimated health of patients with schizophrenia (Höschl conservatively to be 3-4% of GNP (pre-2004 2010) has provided practical recommendations data, with health care costs accounting for 2% for changes in clinical practice to manage of GDP). Depression is one of the most costly such patients. mental disorders because of the large number affected and the impact on work. European There are considerable, indirect, socio-economic estimates suggest a cost of perhaps 1% of costs of mental disorders, for example relating to GDP. Depression has also now overtaken heart lost productivity, additional social care and the disease in the EU as the major health problem impact of increased crime. There is an important in terms of disability-adjusted life years (DALY), research objective to be pursued in collecting accounting for more than 9% of all DALY in the cross-sectional and longitudinal data, to assess EU (Murray and Lopez, 1996; Spinney 2009). these impacts, evaluate causes and monitor trends in prevalence. The currently available Further information on socio-economic impact data are relatively limited and mostly obtained is available from a study by the European from outside the EU. It will also be necessary to Brain Council, which estimated the total costs give more thought as to whether mortality is a of brain disease in the EU plus EFTA countries good indicator for the burden of mental illness. in 2005 to be approximately 390 billion euros (covering health care costs, costs outside of Good longitudinal data are also particularly medical care and indirect costs, including loss of valuable in forecasting disease trends. Without work) but this comprises costs of mental health the long-term collection and analysis of data, it disorders including costs of neurodegenerative is difficult to know whether apparent increases disorders. One-third of the total burden of in prevalence are real or can be attributed to disease in Europe is caused by brain diseases better awareness and detection of disease. (Olesen and Leonardi, 2003; Olesen et al. 2008). However, whether or not the prevalence Approximately 27% of the EU population (18- of depression, for example, is increasing, 65 years) was affected by at least one mental it can be predicted that demand on health disorder in the preceding 12 months. Although services across the EU will grow because many mental disorders are widespread, the main depressed people do not currently visit their burden occurs among a smaller proportion of doctor (Alonso et al. 2004) and because of the the population suffering from severe depression, increasing prevalence of ageing populations bipolar disorder, schizophrenia or drug particularly concerned by mental health dependence. problems.

6 Investment in mental health research by the public and charitable sectors brings economic benefits. A study, supported by the UK Academy of Medical Sciences (Health Economic Research Group et al. 2008) formally compared the economic benefits (both health gains and productivity gains, direct and indirect) accruing to the UK, with the cost of research. While there are many methodological uncertainties and assumptions inherent in such a comparison, the best estimate from this initial study, allowing for time lags, of the annual rate of return on the medical research investment in mental health is 37% per year (compared with 39% for cardiovascular diseases).

7

EU mental health policy at 3 the crossroads

European mental health policy is perceived to to: (a) What is already known - the evidence be at a crossroads (Höschl, 2009) in terms of base to be used to better inform policy the need to develop a strategy to tackle the development; and (b) What is not yet known, increasing disease burden at a time when there but should be – the gaps in the evidence base. is a multiplicity of different health management practices in Member States, an underinvestment As a starting point, it is relevant to note and fragmentation of research, and the need the public health priorities in mental health to think about the promotion of mental health identified by the European Commission. (Box 1). and well-being in the general population as well as provision for those with mental Box 1: European Commission designated illness. Our report focuses on the latter and priorities for mental health while much of health care delivery remains a responsibility for the individual Member • Mental health in youth and education States, issues of public health and of support • Prevention of depression and suicide of research and innovation become core • Mental health in older people responsibilities for the EU policy-makers. • Mental health in workplace settings • Combating stigma and social exclusion At this crossroads, it is vital to identify what is desirable conceptually and what is possible Taken from the 2005 Green Paper “Promoting practically in attaining a coherent mental the mental health of the population: towards a health policy throughout the EU. Such a mental health strategy for the EU” policy should be expected to cover issues for research, professional education and innovation as well as health service delivery, From the perspective of FEAM, this “consumer disease prevention and health promotion. protection” focus on promoting mental health Developing an overarching policy will need – while necessary – is only part of the agenda also to take account of deteriorating economic for the EU. In our view, it is also necessary circumstances and other influences on the social to emphasise mental health as a medically- environment and must be alert to the potential oriented discipline that relies on achieving impact of other legislation – whether intended better understanding of the biology of mental or inadvertent – on mental health. disorders and requires significant progress in psychiatry to provide improvements in FEAM and its member academies have an diagnosis and treatment. important role to play in identifying what changes are needed in attitudes, plans and structures at the EU level and in advising on how the biomedical community can help to bring about these changes. In addressing these objectives in the present paper FEAM, by bringing together key points from material presented at a meeting in 2009, aims to highlight for policy-makers some of the critical issues in contemporary psychiatry with regard

8 What should be covered in a broader mental health 4 strategy?

4.1 Improving analysis and use of the is important (see also section 4.2.5) with the evidence base on disease burden inference that early intervention is highly relevant. During the FEAM meeting in Prague in 2009, Jordi Alonso noted that mental disorders have Epidemiology continues to be important only relatively recently attracted attention as in several respects: for setting the a major contributor to disease burden. Data research agenda and for policy and service from the WHO World Mental Health Survey development. Efforts to improve EU are now available for several EU countries, information about disease burden need to be providing comparable data on prevalence, accompanied by comprehensive assessment of socio-economic impact and co-morbidities the quality of psychiatric services, identifying (Alonso et al. 2007). This survey should serve the regional and cultural differences in Europe as the basis for more systematic data collection (Höschl, 2009). That is, mapping of the disease in the future. As DG Sanco (2004) have burden must be augmented by mapping described, in the European context there is still of mental health care services (and their much more to be done: quality) in order to provide the information resource to agree evidence-based standards • To collect comparable data in longitudinal of care – to inform policy for consistent surveys, to focus on population groups service provision and for the training of (especially children and older people) and on future medical professionals. But who should high risk groups (e.g. migrants); help to organise (and audit) this sharing of • To analyse the available epidemiological data information and its implications for best in order to evaluate the determinants of practice on “what works”? FEAM recommends mental health, to improve the identification that the academies consider, together with the of other high risk groups and to assess the professional societies and with advice from impact of public health policies and specific patient groups, what more they might do. interventions; • To develop a mechanism to share the 4.2 Addressing key societal challenges: conclusions in order to stimulate joint public cross-cutting issues for mental health effort across the Member States. health policy

Good examples of what can be achieved in There are challenges for policy-makers that detailed epidemiological studies within a pervade consideration of most if not all of Member State were reviewed by the mental disorders. The policy decisions Peter B. Jones. For example, a cross-sectional will, themselves, be influenced by the broader analysis of first episode schizophrenia and societal environment: concern has been other psychoses (the Aesop study), helped to expressed that the economic downturn will clarify social determinants, identify high-risk exacerbate problems in mental health if groups (such as migrants) and, by employing health budgets are cut. The decision-maker the techniques of biological psychiatry, in health departments has a broad agenda allowed a clearer understanding of the to cover in improving care of the individual, mechanisms by which stress affects mental strengthening population-level promotion and health. Longitudinal data from the British support, and tackling co-morbidity. But public 1946 Birth Cohort Study (Colman et al. 2007) policy must also address many other societal demonstrated that adolescent mental disorder issues usually assumed to be outside the 9

4 What should be covered in a broader mental health strategy?

responsibility of health departments – issues Suicide and attempted suicide can be seen associated with the economy, social inequity, as a marker of effectiveness of the care of school education, employment, urban and psychiatric patients. According to Eurostat rural development, management of migrant data, there are now approximately 63,000 and other minority groups. The particular suicides annually in the 27 EU countries. policy challenges listed below are drawn from National suicide rates tend to be lower in the presentations in Prague. Southern European countries although some other countries, particularly with high 4.2.1 Stigma baseline suicide mortality (e.g. Denmark, Norman Sartorius introduced the crucial topic Hungary, Austria and Germany) have seen of stigmatisation, with its pervasive effects significant declines in recent decades (OECD, and multiple consequences (Thornicroft et al. 2008). Zoltán Rihmer summarised data to 2009). Stigmatisation is a major obstacle to show that although suicide is a very complex, the provision of mental health care and often multi-causal, behaviour, studies from several leads to inadequate care of those suffering EU countries find that inadequately-treated from co-morbid physical and mental health depression is a leading cause, particularly in disorders. It has a significant negative effect the presence of substance abuse disorders and on quality of life of those who have mental other psycho-social risk factors. As more than disorders and those who care for them. It two-thirds of suicide victims die by their first contributes to the lack of support for mental attempt, it is essential to detect suicide risk health research. Research, and experience among all depressives as early as possible (i.e. from a variety of programmes, showed that during the first depressive episode) and to stigma related to mental illness can be reduced intervene prior to the patient’s first suicidal act and that knowledge about the biological and (Rihmer, 2007). In European studies, changes in psychosocial causes of mental illness – when suicide rate did not correlate with changes in provided as part of comprehensive anti-stigma GDP, unemployment rate or divorce rate and programmes – can play an important role in there has been no consistent pattern in suicide the prevention or reduction of stigmatisation rates as a result of political and economic (Baker and Menken, 2001; Sartorius and changes in Eastern and Central Europe. The Schulze, 2005). The scientific community only consistent correlation in the reported has the responsibility to produce relevant studies has been a declining suicide rate with information and to advocate measures and increasing anti-depressant prescribing (Ludwig structures to use this information (Arboleda et al. 2009). Although it is difficult to measure Florez and Sartorius, 2008). the quality of treatment of depressed patients at the national level, it can be generalised 4.2.2 Suicide that increasing utilisation of antidepressants Suicide is commonly used as a measure of is a proxy marker of their improved and more serious mental health problems. The role extensive care. Indeed, better recognition of biological factors in suicide had been of depression in the population (Rihmer et considered relatively rarely but a recent issue al. 1990) and better access to health care of “European Psychiatry”, focusing on the (for example, Kapusta et al. 2009) correlates genetic basis of mental disorders in relation with lower suicide rates. Clinical studies to suicide (Wasserman and Terenius 2010), show that successful acute and long-term describes a growing momentum in biological pharmacotherapy of patients with depressive characterisation. 10 disorders markedly decreases suicide mortality to develop new models for early recognition and morbidity even in a high-risk population and intervention, to introduce better tools to (Baldessarini et al. 2006, Zisok et al. 2009). The measure stress, to agree standards for good importance of health care workers in suicide practice and, in aggregate, to accrue and prevention is underlined by the fact that use appropriate expertise in mental illness two-thirds of suicide victims contact their GP prevention services. or psychiatrist some weeks or months before suicide (Luoma et al. 2002). It is important to implement the research findings that supported employment For the policy maker, this growing evidence programmes are more likely to succeed base has implications for prescribing policy as (greater job placement and longer retention) well as for health and social care systems and where vocational and clinical staff are co- employment practices (4.2.3) and control of located or at least have very good systems addiction (4.2.4). There are also implications for coordinating their activities. Many people for public policy development for the built suffering from severe mental ill-health express infrastructure to deter suicide (for example, a wish to return to work. The approaches to safety barriers on bridges and railways) and fulfil this wish have progressively shifted away for restricting access to other commonly used, from sheltered employment and lengthy pre- highly lethal, methods, readily accessible in vocational training towards rapid job-finding households (Gunnell and Miller, 2010). and open employment in the competitive marketplace. In Europe, this movement has 4.2.3 Employment mainly focused on the creation of social firms Work and the workplace is an important in which at least a third of employees are determinant of mental health and the OECD people with a disability, all are paid the fair policy brief (2008) expresses the growing market wage for their work and the enterprise concern that employment patterns and competes with any other business (sometimes working conditions are evolving in ways that with government subsidy). Research in may aggravate mental illness. Karl Kuhn European countries show employment rates described how the majority of employers for people with severe mental illness as high underestimate the prevalence of mental as 60% compared to that in typical vocational health problems among their employees rehabilitation services of 20% (Burns et yet, for example, in 2007, 11% of all days al. 2008). lost through sickness in Germany could be attributed to mental and behavioural 4.2.4 Addiction disorders. Improving this situation requires Addiction is not viewed consistently across the changes in employment and health policy, EU as part of the mental health agenda, but some of which are underway, for example it is vital to understand the dual pathology the replacement of the “sick note” by the “fit of addiction and mental disorders in order note” focusing on what the employee can do. to determine more coherent treatment But other practical action supported by policy strategies. development is required by both employer and health systems: to provide better connectivity Using drugs and alcohol is a significant cause between the systems, to take account of of mortality in the EU. Isidore Pelc criticised particular challenges for smaller companies, a common assumption that “soft” drugs

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4 What should be covered in a broader mental health strategy?

(including alcohol) are safe (see also Pelc level and single parent or step-parent families. 2006). Research on the brain reward system These risk factors and other environmental demonstrates that there is cross-sensitisation influences are mediated by effects on between drugs and that all drugs can induce brain development. In his presentation to loss of control of consumption – crucial in the Prague conference, Jean-Luc Martinot addictive behaviour and alteration of social reviewed the rationale for biological research function. More evidence is needed in several and intervention targeted to specific child critical areas; for example, to develop better and adolescent sub-populations, for example quantitative indices of harm attributable to using neuroimaging (see section 4.3.2). Such drugs and to clarify the factors influencing research is less advanced in the EU than in the risk-taking and protective behaviour in young USA. The identification of priority research people. By identifying the determinants needs is complicated by co-morbidities, that – whether environmental or genetic – of are frequent in children, and by continuing substance abuse, it becomes possible to controversy on diagnostic classification formulate strategies for mitigating their (for example, the recent debate on Autism effect. Particular attention should also be Spectrum Disorder within DSM). Taking given to supporting the development of basic account of the views expressed by adolescents psychological capacities in young people, themselves (where collated by NIMH), for example relating to self esteem and Martinot used a cross-symptom approach assertiveness. to derive a classification that comprises: (i) Emotional dysregulation, (ii) Cognitive By clarifying the causes and quantifying the function deviations, (iii) Addictions, and (iv) impact, it is possible to attract greater political Aggression and impulsivity, underpinning attention to the problem. The UK Academy of maladaptive behaviour throughout the Medical Sciences (2008) has proposed creation range of clinical diagnoses. This analysis of a European Institute for Addiction Research informs the research priorities to understand to provide the critical mass to fill gaps in the transition phases in infancy and adolescence current evidence base and, thereby, to inform (and their deviation in psychopathology) and policy making. the use of EU-integrated databases (section 4.3.2) to compare, for example, emotional 4.2.5 Mental health in children and and cognitive disorders. A meta-analysis of adolescents more than 250 brain-imaging publications Research funded by the US National Institute on children and adolescents over the period of Mental Health (NIMH) found that up 2005-2008 (Mana et al. 2010) suggests that to 50% of all adult mental disorders have the proposed classification corresponds to their onset in adolescence and that, despite localised changes in both brain function and effective treatments there are long delays, structure. But, the relationships between brain sometimes decades, between the onset of maturation and behavioural deviations are symptoms and the time when the subject little understood and require longitudinal seeks and receives treatment. Much is now imaging studies. known about socio-economic influences: mental illness in childhood and adolescence is The European Commission’s priority on mental associated with parental unemployment, low health of children and young people (Box 1) family income, lower parental educational places its emphasis on the role of the health

12 services in promotion and prevention, noting Box 2: Schizophrenia – a case study in chang- that treatment alone can achieve only a ing concepts limited reduction of the burden of mental disorders. While FEAM agrees that, of course, Schizophrenia has been an important clinical prevention is critically important, it must also concept in psychiatry for almost a hundred years. be appreciated by policy-makers that much Despite progressive narrowing of the concept to of the current weakness in mental health enhance its reliability and validity, schizophrenia services can be attributed to poor diagnosis still presents a significant challenge for clinical and treatment. Improved interventions in practice and research. Schizophrenia is a disorder childhood and adolescence depend on better with a complex and comparatively high herit- understanding of the developmental biology ability that is most likely based on small effects of mental disease. of common allelic variants, their interaction and epistatic effects (International Schizophre- 4.3 Clarifying research policy: Disease nia Consortium, 2009). Recent research using characterisation and aetiology neuroimaging, electrophysiology and the study of neurochemical changes in neurotransmission 4.3.1 Priorities for basic and translational is helping to clarify the core dysfunctions but the research aetiology can still best be described as complex The EU funding for research on the brain and and multifactorial. This aetiological, pathogenic its diseases is disproportionately low relative and clinical complexity reflects a need to redefine to the importance of this area in human the diagnosis, explain its variability and the health (Arango, 2010). Several speakers in relationship to diagnoses with uncertain status. Prague presented case studies where recent The stigma carried by the term schizophrenia, to- research is helping to clarify the causes of gether with the reliability and variability problems mental disorders. Sophia Frangou described in psychiatric practice have inspired suggestions the cognitive, brain structural and functional to abandon the term and, maybe, the concept correlates of genetic risk and phenotypic as well: for example, the diagnostic concept of a expression in bipolar disorder. Such research “salience syndrome” was proposed as a replace- may also help to provide the basis for new ment (van Os, 2009). Schizophrenia needs more therapies, and this is a challenge across the research focused on the biological mechanisms spectrum of mental disorders. Jan Libiger of schizophrenia models, on dimensions that are described how gaps in understanding of the beyond clinical psychopathology of the disor- causes of schizophrenia limit the success of der. Research in social psychiatry may benefit clinical intervention (Box 2) from epidemiological studies of the factors that increase resilience and prevent perpetuation of the schizophrenic process and its dysfunctional outcome.

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4 What should be covered in a broader mental health strategy?

Celso Arango, drawing on the work of gene 1 was associated with protection against the European Brain Council, called for a adult depressive symptoms in those who were coordinated approach in schizophrenia to maltreated as children (Polanczyk et al. 2009). promote and integrate research on the biological, epidemiological and social aspects 4.3.2 Strengthening research (see also Arango, 2010). The translational infrastructure research agenda must also encompass feedback Filling the research gaps is not just a matter of to basic research from the lessons learned with defining individual disease research priorities medicines in the clinic – as Jan Libiger observed, but also entails building linkages across the the variable efficacy response to antipsychotic disciplines and making best use of limited drugs helps to elucidate pathogenesis in terms research infrastructure. For example, in of neurochemistry and neurophysiology. illustrating the value of diagnostic imaging tools (particularly MRI), Jean-Luc Martinot Historically, research on the determinants of made the case for creating large neuroimaging mental health and illness has been divided databases as part of the longitudinal between nature and nurture with social evaluation of pathophysiology during brain scientists and geneticists making contradictory development and in response to therapeutic claims about causation. More recently, it intervention (exemplified by investigations on has become clear that joint consideration of cognitive malfunction, affective disorders and measured genetic variants and environmental psychomotor disorders). influences can help to elucidate complex causal pathways to mental illness. Rudolf One other policy issue associated with Uher reviewed the current evidence and neuroimaging infrastructure in the USA methodological challenges in establishing is the increasing potential for its use in these complex causal pathways. Replicable forensic psychiatry, i.e. to provide evidence gene-environment interactions have been in legal cases (Hughes, 2010). Judging from a found to play an important role especially in comprehensive review of forensic psychiatry, the more common mental health problems, there is little evidence to show this is a major including depression (Caspi et al. 2010), issue yet for the EU (Frangou et al. 2009). antisocial behaviour (Taylor and Kim-Cohen, 2007) and schizophrenia, as described by Jan There appears to be increased understanding Libiger. To establish causal pathways, future of the importance of integrated infrastructure research must extend beyond the few well for research, at least at the Member State known candidate genes and make better level. In recent years, several national use of standardised methodologies with governments in the EU have taken the accurately-measured environmental exposures. strategic step of funding formal, nationwide Longitudinal cohorts with prospectively mental health research networks with the ascertained exposures and complete follow- general aim of improving research capacity up and accessible genetic material are and quality. Typically, these networks provide especially valuable and represent an important an infrastructure linking health service sites investment in future research. One example and universities, making it possible to run of what can be achieved was the presentation large-scale studies as well as emphasising by Rudolf Uher of results from two general translational research. Reviewing initiatives population cohorts where variation in such as CIBERSAM, the Spanish Mental corticotropin-releasing hormone receptor Health Network1, Celso Arango emphasised

14 1 CIBERSAM, www.cibersam.es. the importance of multi-disciplinary studies additional funding in new research to fill the linking basic, clinical and population research, knowledge gaps. Psychiatric disorders present requiring significant infrastructure within a a unique challenge even relative to other brain country, including tissue and DNA banks and disorders because so much less is known about imaging databases. It is possible that initiatives the underlying genetic, molecular and cellular such as CIBERSAM could provide a useful causes or even the primary anatomical sites of model for building critical mass and sustained the brain deficit. A case can be made to build commitment between centres of excellence critical mass by pooling research resources across the EU: one major issue in developing internationally, in particular to combine new options for EU funding is the imperative genomics and neural circuit analysis (Akil to provide longer-term continuity. The EU can et al. 2010). also do more to support the development of human post mortem brain banks: progress in FEAM recommends that mental health be standardising the conditions for tissue access considered as a “Grand Challenge” for now provide an opportunity for improved increased support in the eighth Framework collection and exchange of tissue at the Programme; in the broader international European level. context, growing the EU commitment should take account of the US NIMH strategic research A number of experts have recently agreed plan that focuses on neural circuitry, early that the best response to the European diagnosis and personalised medicine4. There Parliament’s Resolution on Mental Health must be more emphasis on research using is to work towards the organisation of a humans: the current focus on cell culture and coordinated and integrated approach on the animal models is insufficient. European scale to promote research on the biological, epidemiological, social and public 4.4 Building innovation policy: health aspects2. The further development of Improving treatment coordinated research initiatives across the EU is a challenge for the currently fragmented 4.4.1 Tackling undertreatment research support systems but should be Graham Thornicroft highlighted the problem a priority for the European Commission’s of undertreatment of patients with mental research strategy to capitalise on the growing illness, arising from the stigmatisation momentum3. In the recent Call in the Health discussed by Norman Sartorius but also Theme of the Seventh Framework Programme, associated with other factors, in particular project proposals were invited to determine in low income groups of the population. “A roadmap for mental health research in Understanding and tackling the determinants Europe” to progress a coordinated approach of undertreatment is a priority for health to research in the biological, epidemiological, services research although the problems social and public health aspects. Effort to inherent in attempting to conduct randomised improve coordination in existing research clinical trials to assess the elements in is to be welcomed but DG Research must optimal health services delivery should not be also realise that there is significant need for underestimated. Among other current health

2 International Mental Health Research Network. Madrid Declaration, May 2010. Available on www.cibersam.es/MadridDeclaration. 3 Other Member States are now also beginning to make significant efforts to build their mental health research strategic framework (for example in the UK, www.mrc.ac.uk/Newspublications/News/MRC006851, announced May 2010). 4 The NIMH plan calls for research to: (i) define the pathophysiology of mental disorders, from genes to behaviour; (ii) map the trajectory of ill- ness to determine optimal interventions; (iii) develop new interventions in personalised medicine and (iv) strengthen the public health impact of new research by improving dissemination of scientific knowledge and focusing on disparities in care (Insel 2009). 15

4 What should be covered in a broader mental health strategy?

services research priorities are (a) evaluation development of new therapies in the EU is of “task shifting” (interventions delivered by a not promising: in 2010 both GlaxoSmithKline non-health professional) and (b) evaluation of and AstraZeneca reduced their European the scale-up of interventions to the population R&D investment in mental illness. There is level. There is much to be done to bridge the considerable concern that the recent lack of gap between clinical trials and health service innovation in nervous system disorders will practice. But to what extent are research be exacerbated by company retrenchment findings and modelling assumptions from one and it may be that some companies perceive Member State applicable to others in the EU? psychiatric drugs as a bigger gamble Countries differ in their available resources, than drugs for neurological conditions inequities in their distribution of resources and (Miller, 2010). inefficiencies in their use. These differences have implications for the research agenda, Many of the speakers in Prague alluded to the professional training, guideline development need for improved drug regimens to overcome and implementation procedures. current limitations of partial efficacy, frequent side effects (with the consequence of poor One other broad issue for the research agenda compliance) and inappropriate usage. relating to undertreatment is the need to pay The work of the European Brain Council more attention to mental health conditions emphasises the need to identify and tackle the associated with aging. Without distracting obstacles in new medicine development that from the imperative to tackle those disorders slow the progress from molecule to treatment. currently accounting for the high burden of mental illness, the progressively aging There are multiple policy issues that may not, EU population will bring new challenges, of course, be confined to mental health. In potentially compounded by the age other work, FEAM has discussed the problems discrimination in access to specialised mental arising from implementation of the Clinical health services. Trial Directive increasing bureaucracy and costs associated with doing clinical research It is also important to tackle over-treatment in the EU5. These problems can be acute for associated with poly-pharmacy, when multiple academic researchers and it will be difficult neuroleptics, antidepressants and anxiolytics to reverse the progressive loss of clinical are prescribed for the same patient. This can research from the EU. But it is also important become a particular problem in the elderly, to extract the maximum value from the clinical where reduced rates of drug metabolism research that has already been completed. increase the risk of adverse effects FEAM recommends that the EU creates an accessible European/international database 4.4.2 Accelerating access to new of clinical trial protocols and results. This treatments would help to build the culture of research There have been no major breakthroughs in transparency, would be a valuable resource for the treatment of schizophrenia in the last meta- or other analysis and would ensure that 50 years and no major breakthrough in the Europe capitalises efficiently on the original treatment of depression in the last 20 years investment in that clinical research. (Akil et al. 2010). The prospect for commercial

16 5 FEAM Statement on reform of the EU Directive on clinical trials, published August 2010. Other problems for developing new drugs and targeted recognition of the most can be traced, in part, to the lack of new common warning signs of relapse by using biological mechanisms to serve as drug targets. modern communication and information This information can only come from a strong technology: participants interact with the academic research sector supported by a health care professional by mobile phone, national/EU infrastructure capable of large- reporting prodromal symptoms of relapse. scale collection of clinical, genetic, imaging If a weekly report detects worsening of and tissue samples. These challenges for early warning signs then pharmacological mental health drug research are discussed intervention is triggered in accordance with in detail in the report from the UK Academy an early intervention algorithm. The regular of Medical Sciences (2008). Establishing an monitoring of patients (and their families) academic speciality of experimental medicine for the early warning signs of relapse has in psychiatry might be one important step. resulted in less hospitalisation, as measured in In addition, however, better connections follow-up evaluation of clinical effectiveness between academia and industry are vital, (Spaniel et al. 2008a,b) and improved the for example through jointly-funded clinical relationship between patient and psychiatrist. training posts, publicly-funded research Furthermore, as the OECD (2008) observed, collaboration between the sectors and a more reducing hospital re-admission rates can have flexible attitude within industry to providing a substantial effect on mental health spending compounds for academic experimentation – underlining the importance for society in pre-competitive consortia. There is as well as for patients and their families in significant progress being made in developing providing better treatment programmes. Thus collaborations. The current partnership ITAREPS represents an innovative, user-friendly between the EU pharmaceutical sector and easily implementable and highly cost-effective European Commission in the Innovative approach towards relapse prevention in Medicines Initiative includes neuroscience schizophrenia, that might also provide a model research. But much more is needed. There for optimising service provision in other areas is also a particular, urgent, need for more (for example depression, Spinney 2009) and, research into the metabolism and action of thereby, tackling the challenge of under- psychiatric medicines in children as well as, treatment (section 4.4.1). more broadly, in developmental biology. In this context, it would be useful for the European Commission to assess the impact of the EU Paediatric Regulation on mental health research.

4.4.3 Evaluating and implementing new forms of care provision Filip Španiel reviewed an innovative programme aiming to prevent relapse in psychotic patients, “Information Technology Aided Relapse Prevention in Schizophrenia” (ITAREPS). This is aimed at the rapid

17 5 Conclusions

Contributors to this FEAM initiative have research infrastructure (brain banks, patient previously emphasised the need to increase information and DNA databases) and more the political profile and European coherence coordination across the biological, social and of mental health strategy: “..brain diseases, population sciences. of which mental illnesses are the most costly • Facilitating collaboration with pharmaceutical to European society, are not a high enough and biotech industry to identify and progress priority for politicians, the media, or the novel therapeutic approaches. general public” (Arango, 2010) and “It is a challenge for the respective bodies, both at the We recommend better linkages between the European and the national level, to establish objectives of DG Sanco and DG Research in the an active network for collaboration in mental search for new knowledge. It is also now time health research and policy…” (Höschl, 2009). for the European Commission to explore how it can take more responsibility to promote the In the present paper, we have described some sharing of data and to drive the attainment of of the newer developments in the social and consistently high standards throughout Europe biological understanding of mental illness. The in diagnosis and treatment. The creation scientific opportunities now coming within of the ECDC is making a real difference in range merit increased support from research infectious disease surveillance and public health funding bodies and other policy-makers. preparedness – to what extent might a similar Building on new initiatives at the Member State model be developed in mental health? level as well as capitalising on the growing interest in the European Parliament, FEAM In addition, FEAM acknowledges its recommends that the European Commission responsibilities to encourage the biomedical increase commitment to: community to become better engaged with the policy community and society-at-large. This (i) Prevent mental illness and promote mental requires academies to: health by better understanding of the risks and causes, and of the opportunities for prevention; • Provide better communication to the public and Parliaments about mental health and the (ii) Facilitate R&D to generate novel and risk factors for mental disorders. effective diagnostics and treatments for mental • Call on policy-makers to provide “joined-up” illness and its co-morbidities, and to optimise policy for mental health across the European their use in the health services across the EU. Commission and the Member States.

This requires:

• Generating improved statistics on the disease burden in EU and on the mapping of public health services. • Enhancing basic, translational, public health and multi-disciplinary research. There should be more investment in research priorities together with improved

18 6 References

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This FEAM Statement draws on presentations Professor Zoltán Rihmer and discussion from a scientific session on Mental Professor of Psychiatry, Department of Clinical Health organised as part of the FEAM Annual and Theoretical Mental Health and Department Conference, 17-18 September 2009 in Prague, of Psychiatry and Psychotherapy, Semmelweis Czech Republic. The scope and content of the University (Hungary) Statement were developed by a FEAM Working Professor Filip Španiel Group chaired by Professor Cyril Höschl and the draft Statement was reviewed by independent ITAREPS (Information Technology Aided Relapse expert referees and the Academies. Prevention in Schizophrenia), Prague Psychiatric Center (Czech Republic) Members of the Working Group Professor Rudolf Uher Clinical Lecturer, Social, Genetic and Professor Cyril Höschl (Chair) Developmental Psychiatry Centre, Institute Past President of FEAM, President of the Czech of Psychiatry, King’s College London (United Medical Academy, Director of the Prague Kingdom) Psychiatric Center (Czech Republic) Professor Jordi Alonso Reviewers Head of Health Services Research Unit (IMIM Professor Tom K. J. Craig - Parc de Salut Mar) and Professor of Public Professor of Social Psychiatry, Institute of Health, University Pompeu Fabra of Barcelona Psychiatry, King’s College London (United (Spain) Kingdom) Professor Celso Arango Professor Sophia Frangou CIBERSAM (Spanish Network of Mental Health, Psychosis Clinical Academic Group, Section Madrid) and Professor of Psychiatry, Universidad of Neurobiology of Psychosis, Institute of Complutense de Madrid (Spain) Psychiatry, King’s College London (United Professor Peter B. Jones Kingdom) Professor of Psychiatry, University of Cambridge Professor Norman Sartorius (United Kingdom) President of the Association for the Professor Jan Libiger Improvement of Mental Health Programmes (Switzerland) Department of Psychiatry, Charles University Medical School and Faculty Hospital Hradec Dr. Helena Silfverhielm Králové (Czech Republic) Medical Adviser to the National Board of Health Professor Jean-Luc Martinot and Welfare (Sweden) Director of Research Unit 1000 “Imaging and Professor Graham Thornicroft Psychiatry”, INSERM – CEA, Universités Paris Sud Professor of Community Psychiatry, Institute et Paris Descartes (France) of Psychiatry, King’s College London (United Professor Isidore Pelc Kingdom) Emeritus Professor of Medical Psychology and former director of the Laboratory of Medical Scientific secretariat Psychology, Université Libre de Bruxelles Dr. Robin Fears (Belgium) 21 This statement was endorsed by the Italy FEAM member Academies: Accademia Nazionale di Medicina Via Martin Piaggio, 17/6 Austria 16122 Genova Austrian Academy of Sciences Website: www.accmed.org Dr. Ignaz Seipel-Platz 2 1010 Vienna Portugal Website: www.oeaw.ac.at Academia portuguesa da Medicina Avenida de Republica 34 - 1º Belgium (French-speaking) 1000 Lisboa Académie royale de Médecine de Belgique Palais des Académies Romania Rue Ducale 1 Academia de Stiinte Medicale din Romania 1000 Bruxelles Sos. Stefan cel Mare Nr. 19-21 Website: www.armb.be Sector 2, Bucuresti Website:www.adsm.ro Belgium (Dutch-speaking) Koninklijke Academie voor Geneeskunde van Spain Belgie Real Academia Nacional de Medicina Palais des Académies C/Arrieta, 12 Hertoogstraat 1 28013 Madrid 1000 Brussel Website: The Netherlands www.academiegeneeskunde.be Royal Netherlands Academy of Arts and Sciences Czech Republic Het Trippenhuis Czech Medical Academy Kloveniersburgwal 29 Řehořova 10 1011 JV Amsterdam 130 00 Praha 3 www.knaw.nl Website: www.medical-academy.cz/cla/index.php United Kingdom France Academy of Medical Sciences Académie Nationale de Médecine 41 Portland Place Rue Bonaparte 16 London W1B 1QH 75272 Paris Cedex 06 Website: www.acmedsci.ac.uk Website: www.academie-medecine.fr

Germany and by the following national German National Academy of Sciences Academies: Leopoldina Emil-Abderhalden-Str. 37 Lithuania 06108 Halle/Saale Lithuanian Academy of Sciences Website: www.leopoldina-halle.de 3 Gedimino Ave 01103 Vilnius Greece Website: www.lma.lt Academy of Athens 28 Panepistimiou Street Poland 10679 Athens Polish Academy of Sciences Website: www.academyofathens.gr Palace of Culture and Science PO. Box 24 Hungary 00-901 Warsaw Hungarian Academy of Sciences Website: www.pan.pl Roosevelt Square 9 1051 Budapest Sweden Website: www.mta.hu The Royal Swedish Academy of Sciences Lilla Frescativägen 4 A 114 18 Stockholm 22 Web: www.kva.se Acknowledgements

This FEAM statement is published by the Prague Psychiatric Center and has been endorsed by the FEAM Officers and the national Academies listed on page 22.

FEAM warmly thanks the Chair, Professor Cyril Höschl, Past President of FEAM, President of the Czech Medical Academy and Director of the Prague Psychiatric Center, for undertaking this study; the members of the Working Group and the reviewers (listed page 21) for their input and instructive comments; the national Academies for endorsing this statement; and Dr. Robin Fears for its preparation.

FEAM is most grateful to the Czech Medical Academy and the Medical Research Council, UK for their financial contribution to the organisation of the meeting in Prague and the elaboration of this statement; and to the Prague Psychiatric Center for publishing it.

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