RESEARCH IN MENTAL HEALTH
The presentation that the organisers of this meeting have asked me to give today is entitled
“The Stakes of Competitive Research in Mental Health.” It will first look at some recent
findings in Mental Health Policies from both international and Belgium sources. This will
lead me to some thoughts about the field of Mental Health research. A particularly important
conference was held in Helsinki at the beginning of 2005, from the 12th to the 15th of January.
Its conclusions should, in the medium term, lead to some important developments. The
conference brought together the ministers for public health of Europe’s fifty-two regions to
discuss the state of Mental Health Policy and the essential future developments required. A
common declaration was issued and a common Action Plan agreed on.
Beyond the symbolic aspects of these declarations of intent, to which international institutions
and health organisations, in particular, have gotten us accustomed to, there is now truly a
commitment to “moving things forward.”
Here, briefly, is a list of the twelve action points.
1. Promote mental well-being for all
2. Demonstrate the centrality of mental health
3. Tackle stigma and discrimination
4. Promote activities sensitive to vulnerable life stages
5. Prevent mental health problems and suicide
6. Ensure access to good primary care for mental health problems
7. Offer effective care in community-based services for people with severe mental health
problems
8. Establish partnerships across sectors
9. Create a sufficient and competent workforce
10. Establish good mental health information
11. Provide fair and adequate funding
12. Evaluate effectiveness and generate new evidence
So, you see that research was not overlooked as the twelfth point deals with it explicitly, with
the following commentary :
Considerable progress is being made in research, but some strategies and interventions still
lack the necessary evidence based meaning that further investment is required. Furthermore,
investment in dissemination is also required, since the existing evidence concerning effective
new interventions and national and international examples of good practice are not known to
many policy-makers, managers, practitioners and researchers. The European research
community needs to collaborate to lay the foundations for evidence-based mental health
activities. Major research priorities include mental health policy analyses, assessment of the
impact of generic policies on mental health, evaluations of mental health promotion
programmes, a stronger evidence base for prevention activities and new service models and
mental health economics.
Moreover, over the past months, the European Commission has in turn taken over this
important dossier to manage implementation of the action plan. The document, now published
as a Green Paper is entitled : “Improving the mental health of the population : Towards a
strategy on mental health for the European Union”. It has, among others, recommended that
the European Governments should :
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 Support national research strategy at a coordinated and national level
 Bridge the knowledge gab between research and practice
 Insure that research program include long-term evaluation
 Invest in training in mental health research
So, the objectives are clearly stated.
In Mental Health issues, as in other medical disciplines, before programming care and
research, it is obviously necessary to have a minimum amount of data about the scope of
existing mental health problems, the nature of available care addressing them, and the nature
and extent of research available in any given region. A relatively reliable description of the
extent of problems, in epidemiological terms, and of the care network available for mental
health patients, is now beginning to emerge. Based on information provided by a number of
European countries, WHO recently published the 2005 edition of its Mental Health Atlas
(the first edition was issued in 2001). The 2005 atlas, entitled “The Mental Health Atlas
2005 - World Health – Geneva” is much more complete than the previous one. In general, the
news gathered in most European countries is positive: it includes a growing interest and
preoccupation on the part of politicians and local organisations with mental health, with better
organisation, with regard to the needs of populations and, especially, with the dissemination
of therapeutic information and directions based on scientifically validated data. Less positive
data shows, however, that, in most regions, including in western countries, there is a great
deal of work remaining to be done because available care is a far cry from the needs of
populations and in particular of that portion which suffers from mental health pathologies.
On the other hand, an inventory of mental health research is excessively difficult to establish
and can only be based on a few partial estimates, as will be seen further on. Mental health
problems in Europe and their repercussions on the general well-being of populations have
already been widely proven by the European ESEMED investigation. Recently, the ECNP
Task Force on “Size and Burden of Mental Disorders in Europe” has also widely confirmed
this finding. In the conclusion of this major project, led by Professor Wittchen in Germany, it
is stated that “during any given year, 82 million people, i.e. 27 % of the EU population,
experience at least one mental disorder such as depression, bipolar disorder, schziophrenia,
alcohol, drug dependence, social phobia, panic disorders, generalized anxiety, obsessivecompulsive and somatoform disorders or dementia. Concerning the question : Is, over the last
years the prevalence of mental disorders increasing ? The answer is : except for depression
and variations in drug use patterns, the Task Force finds little indirect evidence that the
prevalence of mental disorders overall has been increasing in the past decade”. Some
special aspects and findings are highlighted. Over 50 % of the mental disorders are comorbid. Most frequent are co-morbidity patterns like anxiety and depression, anxiety and
substance abuse or somatoform and depressive disorders. These co-morbid patterns bear
important implications for treatment disability and etiology”. All the findings are that the
“majority of mental disorders go unrecognized and untreated. With little variation of country,
only 26 % of all mental disorders receive any or even fewer adequate treatment. Except for
psychosis and the more severe depressions and those with complex co-morbid patterns, many
years and sometimes even decades go by before a first treatment is eventually initiated. This
alarmingly low treatment rates of mental disorders unseen for any other area of medicine are
unlikely to be explained entirely by effects of stigma still sometimes attached to mental
disorders. Concerning burden and costs, there is gain to conclusion that all mental disorders
by their diagnostic definition are impairing and disabling, and the source of subjective
suffering and disruption . A specific problem is emerging : the bulk of the total health
economic costs of mental disorders is not in direct health care costs but in indirect costs.
Every year, in Europe, mental disorders cost almost 300 billion Euro in total costs, but the
majority of this cost 132 billion Euro is related to indirect costs : sick leave days, early
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retirement, premature mortality and reduced work productivity due to mental health problems.
Let say also that drug treatment cost – as the most frequent type of treatment applied, only
accounts for 4% of the total costs of mental disorders.
It is also possible to estimate the amount of investment given countries have allocated to a
particular problem, such as health, in that country, compared to the cost of that problem to
society, in terms of DALYS (Disability Adapted Life Years). We can also look at total global
investment, on one hand and, on the other, at the contribution to these investments made by
various sectors of society. I did research in the European Statistical Observatory
(EUROSTAT) and found data indicating that public spending for Health (all sectors of health)
in 2002, in Belgium, for example, was 9.1 % of the GDP. Other European data give a
description of the investments made for Mental Health by each country within the overall
framework of their Public Health. In Belgium, the portion set aside for Metal Health is 6% of
health spending. By comparison, other countries such as Luxembourg, England, Sweden,
Germany, Denmark and even Lithuania spend significantly more, nearly double: investment
rates are close to 12%. This latter number is interesting as it represents the weight borne by
the society for illnesses and in particular for mental illness. Experts (Mental Health
Economics European Network) generally agree that the weight attributed overall to mental
illness in western European countries is about 20% of the total of health related problems.
Remember that only 6% of public health money is earmarked for mental health in Belgium…
The effort required to understand investments made in Mental Health Research is much
more complex. As I have already pointed out, there is no exhaustive research available on the
subject either in Belgium or in any of its neighbouring counties. An indicative estimate can be
based on the work on drugs we recently completed in collaboration with Prof. De Ruyver of
the University of Ghent and Prof. Casselman of KUL. This project, financed by the Public
Department for Scientific Research is entitled “Drugs by the Numbers in Belgium”. It
required two years of detailed research to inventory all of the public monies allocated to drug
problems in Belgium. These data were then validated by the European Drug Observatory in
Lisbon in a report entitled “Public expenditure on drugs in the European Union 2000-2004”1.
Its overall conclusions indicate that public spending on drugs is split as follows: 54% is spent
on legal measures (law, enforcement) to control drugs and trafficking; 38% is spent on
treatment and assistance to drug users; 4% is spent on prevention, 3% on laws and 1% on
research. If the fact that drugs are a somewhat specialised field in which policing is relatively
important is taken into consideration, it is reasonable to double this figure for the mental
health care field overall and to estimate that, at the public level in any case, 2% of the overall
budget allocated to mental health is set aside for research.
This figure of 2% of the total budget allocated for mental health appears to be a fairly
frequently encountered indicator in other health care fields. It is considered low, given the
total for health care allocated to mental health (6% of the total). Finally, to finish off with
figures, one last bit of information might be of interest to you. It is also found in EUROSTAT
statistics and relates to spending by various sectors for research and development in general
(not specific to health). In addition to the public sector (industries), universities and the
private sector also invest. The private sector accounts for the highest proportion of investment
at 71% overall. The public sector provides only 7% and universities 22 %. These figures of
course represent investment not only in mental health, but also for research and development
in Belgium in general.
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EMCDDA – Strategies and Impact Programme, July 2004
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Les us quit these data which are a little bit boring and let us go to some more qualitative
comments about “The Decade of the Brain”, event borne in the United States based on an
initiative by President Georges Bush (father of the current president) in order to promote work
and research in the field of Mental Health. This event later spread to other continents and to
Europe in particular.
At the end of the period between 1990 and 2000, a number of comments were made. One of
these, found in an evaluation carried out by the Society for Neuroscience and entitled “The
Best Brains of the Decade” contains some interesting comments.
From the result of collection of 2.000 (two thousand) highly sciented neuroscience papers, ISI
identified the institutions, researches and journals that accounted for the greatest number of
high impact reports. Institutions appearing ranked both by total citation to high impact papers
and by citation per paper. At the top level, we find multidisciplinary journals like Science,
Nature, Journal of Neurosciences… It is interesting to see in this ranking that journals most
specifically related to psychiatry are the first one in the rank 9, in the rank 12, in the rank 14,
15 and 17.
Despite particularly important developments in the field of neuroscience close to the concerns
of Mental Health, many commentators pointed to the fact that knowledge of the phenomena
of consciousness had nevertheless not greatly advanced. As a result we find the following
comment : « Left largely untouched was one of science's grand challenges, ranking in
magnitude with cosmologists' dream of finding a way to snap together all the fundamental
physical forces: we are still nowhere near an understanding of the nature of consciousness.
Getting there might require another century, and some neuroscientists and philosophers
believe that comprehension of what makes you you may always remain unknowable. Pictures
abound showing yellow and orange splotches against a background of gray matter--a snapshot
of where the lightbulb goes on when you move a finger, feel sad, or add two and two. These
pictures reveal which areas receive increased oxygen-rich blood flow. But despite pretensions
to latter-day phrenology, they remain an abstraction, an imperfect bridge from brain to mind.
Neuroscience, the attempt to deduce how the brain works, has succeeded in unraveling critical
chemical and electrical pathways involved in memory, movement and emotion. But reducing
the perceptions of a John Coltrane solo or the palette of a Hawaiian sunset to a series of
interactions among axons, neurotransmitters and dendrites still fails to capture what makes an
event special. Maybe that's why neuroscience fascinates less than it should. Maybe that's also
why the Decade of the Brain passed with little notice. It's just too early to tackle this really big
question. Without doubt, we are on the good way.
The most important realization to emerge during the Brain Decade is that the brain being
feted is more changeable than we ever thought. Even in maturity, some areas of the brain
can renew themselves--a fact astonishingly contrary to a century of neurologists' dogma.
That certain areas of the adult brain can generate new cells holds important ramifications for
drug development and clinical practice. Careful reactivation of the molecules that foster
such neurogenesis might counter the death of neurons that occurs in Alzheimer's and
Parkinson's disease.
Effectively, neural plasticity is a reality at any age.
This clearly confirms that in the field of mental illness an important place must be given to the
re-education of mental functions which are inhibited in people with psychic disturbances
concurrently to the correction of neurobiological problems through drug treatment. Additional
psychotherapy therefore comes into its own. The difficulty remains in correctly assessing
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psychotherapy prescriptions and in making the right choice among the many existing
psychotherapeutic treatment options.
The Brain Decade also engendered many virtual symposia where eminent researchers
working on advanced aspects of mental functions held discussions. I pinned down one on the
progress made in the virtual Symposium “Neurobiology of Emotions”, organised by The
Brazilian Society of Neuroscience and Behavior.
Four basic questions were debated: 1) What are the most critical issues/questions in the
neurobiology of emotion? 2) What do we know for certain about brain processes involved in
emotion and what is controversial? 3) What kinds of research are needed to resolve these
controversial issues? 4) What is the relationship between learning, memory and emotion?
The focus was on the existence of different neural systems for different emotions and the
nature of the neural coding for the emotional states. Is emotion the result of the interaction of
different brain regions such as the amygdala, the nucleus accumbens, or the periaqueductal
gray matter or is it an emergent property of the whole brain neural network? The relationship
between unlearned and learned emotions was also discussed. Are the circuits of the former the
underpinnings of the latter? The learning and memory relationship with emotions was also
discussed in terms of conditioned and unconditioned stimuli, innate and learned fear,
contextual cues inducing emotional states, implicit memory and the property of using this
term for animal memories. In a general way, and as a conclusion of all these eminent
experts of this symposium, it could be said that learning modifies the neural circuits
through which emotional responses are expressed.
Here too, we find the importance in treatment of training or re-training patients in emotional
expression which is often blocked or perturbed by mental pathologies. Last but not least, let
us underline the fact that dissemination of mental research is poor in clinical environments,
and sometimes even in academic ones. This obviously creates a significant delay in the
application of new, correctly formulated treatment strategies, and a gap between research and
practice.
As mentioned earlier, an exhaustive inventory of the research carried out in field of Mental
Health has not yet been satisfactorily completed. It is under these conditions that we have set
up a permanent work group called “Mental Health Research and Development: inventory,
critical analysis and recommendations” within the High Council for Hygiene of the Ministry
for Public Health. One of the first meetings was dedicated to the application of evidencebased medicine in Mental Health. This fundamental concept was introduced by our
colleague Dr Guido Pieters, from Saint-Joseph University Clinic in Kortenberg. A few aspects
have been emphasised:
 Definition taken from Sackett (2000): the conscientious explicit and judicious use of the
current based-evidence in making decisions about the care of individual patients.
 Contrary to what is usually understood, a clinical decision based on evidence takes into
account research data, clinical experience and the choices of patients (we could also add
“the choices of the care-giver, in a number of instances”).
 The use of evidence-based can be formulated as follows: in the event of a clinical problem,
a question is formulated which requires an answer. Evidence is sought through scientific
research and clinical experience. The evidence is submitted to critical review and then the
data gathered in this way is adjusted to the particular patient whenever necessary and to
the values which are important to him.
 Also taken into consideration, following Fullford is evidence-based practice, practicebased evidence and value-based medicine.
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However, in the field of Mental Health, evidence-based medicine often comes across
difficulties and substantial resistance more often than does somatic medicine:
 It is sometimes difficult to undertake controlled trials given that patients often live in very
varied environments. The impact that environmental factors can have on the reactions of a
patient is well known.
 Resistance is also due to the fact that a number of Medical Health practitioners received
theoretical and practical training limited to a single psychopathological model and, as a
result, find it difficult to take into account other scientific evidence from other
psychopathological models.
 A significant amount of criticism has been voiced because it is felt erroneously that
evidence-based medicine only takes into account quantitative and statistical aspects and
not qualitative and subjective ones. This is incorrect.
In fact these considerations, as pertinent as they may be in a certain number of instances, take
nothing away from the usefulness of an approach based on evidence in both Mental Health
and Somatic Medicine.
One aspect that is quite specific to Mental Health resides in the fact that, if Mental Health
problems are obviously the responsibility of Public Health competencies, many patient needs,
caused by mental illness reside outside of the competency of Public Health. These are
employment, lodging and various assistance programs which mental patients need and to
which they have no easy access given the stigma attached to mental illness. Some countries
have removed Mental Health from the field of competency of Public Health and have handed
it over to their Ministry for Social Affairs. Personally, I do not believe that this radical
approach should be followed. Mental Health is a concern of both Public Health and other
related competencies. this is also the view of the WHO.
To close, I would like to remind you, for illustrative purposes and very briefly, of the various
steps that were required to adequately improve the care provided to schizophrenia patients. Of
course, multiple research projects were required. It was also necessary to take into account
and to improve patients’ living conditions, to provide support to those close to them, to
change the way this terrible disease is viewed socially, often to inspire caregivers with new
approaches and to influence political decision-makers so that they would pay greater attention
to this illness and to those suffering from it.
I adapted this scenario from a personal paper from Professor Damien Lecompte, one of our
best specialists in this field.
Since 1930, basic research, has led from various shock treatments to the discovery of
dopaminergic receptors and the creation of conventional antipsychotic drugs. This, as you
know, led to a search for extended receptor areas, for partial D2 agonists in particular and to
the development of so-called atypical neuroleptics. Today, new research is moving in the
direction of specific transduction signals.
At the pre-clinical and clinical levels initial concerns resided with the elimination of positive
symptoms, socially unacceptable hallucinations and delirium. More recently, action against
negative symptoms has been favoured while, at the same time, new research into the cognitive
abilities of patients opened up. This of course included the reduction of secondary effects and,
in particular, of extrapyramidal symptoms. The multitude of clinical study protocols
performed under controlled and real life conditions which led to the objectivation of treatment
effectiveness and later their efficiency, is well known. The evaluation of efficiency required
studies of compliance, tolerance, usage safety and quality of life improvements.
The chronic nature of the disease has also required new strategies related to access to
treatment, continuity of care and, of course, financial accessibility of treatment. As the state of
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patients evolved within treatment, we were able to distinguish between those whose condition
stabilised, those who are in remission and those who are recovering. In stabilisation, there is
less external impact of positive symptoms. Patients can be in remission, where only a few
symptoms, whether positive or negative, could be seen at all. Some studies talk over recovery
when, for at least one year, there is no manifestation of any positive symptoms, and other
symptoms are present only at a very low level.
It is perhaps surprising to discover through meta-analyses that functional improvements and
improvements in the overall quality of life of schizophrenic patients are possible. Some
studies of patients carried out over at least 15 years state that 40% of those patients are
considered stabilised.
It can therefore be seen clearly, and this is simply one example among others, that in the field
of Mental Health much more than in that of Somatic Medicine, basic and clinical research are,
of course, necessary; but they have to be supported by a series of positive measures aimed at
patients’ close relations, at society and at political decision-makers, in order for matters to
finally move in the right direction.
Providing easier access to treatment for the ill and enabling quality research on a consistent
and systematic basis, discussions between specialists on controversial topics, dissemination of
results obtained from actors in the health and other, less specialised fields, creation of a
climate of greater tolerance and acceptance of people with psychiatric problems are all selfevident goals which nevertheless require investment and a constant flow of energy to
mobilise those concerned in order to move things forward.
The granting of research monies which will enable young researchers to explore horizons
other than those they are used to is a good example of this.
Thank you very much for you attention.
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