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Anya: Hello and welcome to this episode of The Lancet Voice. This is one of four episodes linked to the spotlight on mental health. The Lancet 200 year anniversary. I'm Anya Sharman. A senior assistant editor at The Lancet, and today we will be talking about breaking down barriers in mental health services.
We will discuss the challenges that professionals face when working in mental health, particularly focusing on the stigma surrounding the profession and their role in scaling up mental health care services. Although this study of mental health has made great strides in recent years, unfortunately, there is still a stigma related to people working in this profession.
Some people still view psychiatry as a pseudoscience. And even among the scientific community, psychiatry is one of the least respected medical professions, with few medical students applying for psychiatry. According to the Royal College of Psychiatrists, many consultants are contemplating early retirement or leaving the profession entirely because of continuous staff shortages, burnout due to high workload, and poor work life balance.
And while mental ill health is on the rise, services to provide care need to be scaled up so that more individuals can be effectively treated. But again, challenges such as limited resources and lack of funding can hamper these initiatives. Joining me today to discuss this topic are Professor Pat McGorry.
The executive director of Origen, an NGO and research approved institute that targets the needs of young people with emerging serious mental illnesses and Professor Stefan Zipfel, the head and chair at the Department of Psychosomatic Medicine at the University of Tübingen and director of the Centre of Excellence for Eating Disorders.
Welcome and thank you both so much for joining me today. So first, I thought we could talk about scaling up mental health services. So, Pat, you have helped to establish Origin, and Stefan, the Centre of Clinical Excellence in Eating Disorders, and the German Centre for Mental Health. I was wondering if you could please tell our listeners a little bit about these organisations, and what inspired you to set them up.
So, Pat, perhaps we could start with you.
Pat: I suppose it's telling a story, really. I began My career, basically in early intervention for psychosis, schizophrenia and, and psychotic illnesses, and I was kind of very horrified when I, when I first got into psychiatry at the destructive pessimism that psychiatrists and the whole field had towards these young patients who were coming in, in great distress and turmoil with the onset of the illnesses.
And they were given the message you. of hopelessness, basically, a psychological death sentence. And it came, with apologies to Stefan, from German psychiatry 100 years ago, and was no longer justified, actually, because you know, even when you followed patients up with no treatment a proportion of them did actually recover.
And certainly with modern treatments, that they were used properly, and in a timely way, we thought that we might be able to change the course and improve the outcomes. So that's what I started focusing on. And it wasn't, it was very much common sense, but I, I did always have, as I became a researcher and a clinician, a sort of a desire to change the paradigm within psychiatry and, and didn't have, I suppose, the machinery or the platform to do that at first, but we built that over 30 years actually now, and it became what's now known as Origin, which is a much more broad spectrum of treatment.
Medical Research Institute linked to the University of Melbourne, but providing a lot of clinical services as well from primary care right through to tertiary care for young people in this critical period of transition from puberty through to the mid twenties when nearly all the major psychiatric disorders have their peak onset periods and, and, and so this is a crucial sort of insight, I think, Into the way mental health care should be provided if we're going to actually improve outcomes that we must actually Focus on the early stages of these illnesses including what Stefan's I'm sure going to talk about eating disorders.
It's another great example
Anya: Thanks very much for that introduction. I just want to ask Stefan now about, about what inspired you to set up your organizations.
Stephan: First of all, thank you very much for having me today. And perhaps the German way is a more special way because I'm trained as an internal medicine specialist.
part of my life and became an internist. And in the second part I was trained in psychosomatic medicine, and that's a very special, you know, speciality in Germany. And perhaps yeah, looking back over the last three phases of my personal and also the institutional development, perhaps the first 10 years.
We're marked by building up a new department at the medical faculty in Tübingen, and it's the department of psychosomatic medicine as a department of internal medicine. And my and our idea was bringing together clinicians and researchers from very different fields. with an interest in really biopsychosocial medicine and in particularly in the treatment of people with eating disorders in adulthood across the whole weight spectrum.
So from the very underweight spectrum to the very overweight spectrum. In addition to doctors yeah, these included psychologists, speciality trained nurses, nutritionists, art and body and music therapist. And in this first phase, we also implemented the largest outpatient psychotherapy trial for patients with anorexia nervosa, so called ANTOP study, which was then also published in the Lancet.
In the second phase Yeah, colleagues and myself realized that it makes sense to work more closely together with colleagues from child and adolescent psychiatry, especially in the case of eating disorders, because particularly this group of patients start their illness and disorder during adolescence.
And this usually goes on also in young adulthood. We founded COMET, the Center of Excellence for Eating Disorders. Well, you were able to also inspire colleagues from other fields like gynecology, sports medicine, endocrinology, and also media science to cooperate. And in the later phase, we were also able to get involved patients and relatives in our center.
And just very recently, after a very competitive selection process by the German Federal Ministry of Education and Research. We are now one of a total of six centers that together form the so called German Center of Mental Health, of which I have been the co speaker of the Turing site since May, just for the last four weeks.
So that's pretty new. And this is responsible for a much broader spectrum which tries to come up with a research con concept about a translational cycle. Starting from risk and resilience in mental and physical health over the lifespan, looking for innovative, individualized interventions, and then also focusing on prevention, recovery, and participation in living environments.
So, and in a nutshell, I'm responsible for the so called GCPG Academy and also responsible for Relatively new area called Enhanced Psychotherapy Research.
Anya: Well, it's, it's truly interesting what you both have set up and achieved. Both of you have actually mentioned about the whole transitional side in your research and your centers and the youth aspect of it.
Why have you chosen to kind of focus on these particular individuals and youths and in the transitional area of medicine?
Pat: One of the main influences that I, I was lucky enough to be exposed to was a preventive mindset, preventive psychiatry. And I think the, the transitional period from from puberty through to the mid twenties is the best opportunity for early intervention and prevention because this is the onset period for the, these mental illnesses in the lifespan.
And also I suppose it's, it's, it's, it's, it's such a critical period of, of, of personal development as well. So it was kind of an obvious thing when you look at the epidemiology of, of mental illness, which is actually the mirror image of what you see in physical illness. Physical illnesses occur in children, younger children, and over 50s these days.
Adolescents and young adults have never been healthier in human history, physically. And, and yet their mental health is, is deteriorating rapidly actually over the last 15 years. So, so what we began has got, become even more important now. And traditional psychiatry didn't appreciate this at all. It focused on this distinction between child psychiatry on the one hand, child and adolescent psychiatry, and then adult psychiatry, which was pretty much middle aged people.
Originally the, the, the people who used to be in mental hospitals, when, when, before they were deinstitutionalized, it was a kind of a missing zone which was the most important zone of all, across the whole lifespan. And we gradually came to see that. After, after we, after we'd done about 10 years of work in early psychosis, just in one disorder area, we, and we realized there was a much bigger paradigm shift required.
It's amazing because I suppose early adopters, people, innovators and early adopters have really got on board with this in, in many parts of the research community. And I, I, I think you're going to ask me a bit more and Stefan about this, what challenges we faced. Of course, when you have, you know, a new paradigm, It, it's resisted either by passivity or inertia from probably the late adopters.
And then you have a bunch of people who try everything they can to, to hold back the progress and they fight very hard to defend the old paradigm. So this is one of the struggles we've had and we've tried to address it by a very strong commitment to two things. One is involving people with lived experience of, of mental illness in, in their youth and the families that Stephen mentioned.
And secondly, a real commitment to evidence based approaches, which are going to be sustainable. If, in other words, a scientific approach, so we're not just advocates, we're advocates in, you know, based on really the best possible evidence that we can, we can assemble. To guide, you know, the, the, the future of this field.
Anya: And Stefan, is there anything you would like to add to what Pat has just mentioned? Perhaps about the challenges you have faced in your work?
Stephan: Yes, and just to add to what Pat already said typical also in Germany that The healthcare system is subdivided in an adolescent youth and adolescent area and in an adult area.
That's one particular issue, and there is hardly any institution also in the field of eating disorders where it's pretty much obvious that you need to bridge this gap because usually more than 90 percent of eating disorders start patients start in, in their their childhood or adolescence.
And knowing that at least for anorexia nervosa, we know that at least more than half of these affected have a duration of more than six years with a illness. Then we know that It, yeah, bridges the gap with the illness into adulthood. And so there is still a traditional barrier also in the German system.
And that's one issue. And the other barrier in the German system is that we do have outpatient therapists and we do have clinics. And again, that's a gap and With our center of excellence, we have tried to bridge this gap and have been a lot of hurdles because it's usually the first case against the system.
We are working against the system. Everyone is convinced that we need this. Yeah, life, looking at the lifespan and not only in, in sectors of life, but in the traditional medicine and particularly also in the German system, it's really a challenge to bridge that gap. But here in Tübingen and together also with colleagues from child and adolescent psychiatry, both of us were very convinced that we need to come up with a joint center.
which is also run by both departments. And after we have been committed to that, then it was quite easy to attract also other departments, other colleagues, because then the core of the center was established. And for the German center, it's perhaps a bit another challenge because in the first place, the Federal Bureau in Germany.
set up a proposal and asked for our proposals and more than 27 centers applied for that and Six of them were then decided in the first stage that they should build a network. And in the first place, we had the competition, and in the second place now, we had to build a common and joint network. And that took about a year or so.
But now I think also in terms of discipline. Disciplinaries it works pretty good because also in Germany we do have a kind of a tangents between doctors and psychologists and so, and now working in one center that's very helpful because we do have one common aim to build up one German center of mental health.
Anya: So you've talked a lot about bringing together these different professions, do you believe it's quite important to have different people's opinions, like bringing together, for example, mental health care nurses, psychiatrists, and everyone together in helping them? Mm hmm. tackle the same issue?
Stephan: Definitely in the field of eating disorders where we do have a lot of comorbidities.
We do have on the very low weight range problems with malnutrition. We need also nutritional specialists, but we need also endocrinologists we have to deal with gynecology issues. So, and if we really want to. To create better treatment options for those patients, we first have to understand these yeah, diseases better and the mechanisms behind.
And in the second yeah, the second issue is that we really have to work together and think at the cutting edge of all the different disciplines, how we can provide the best available options for the patients and also for the relatives.
Pat: I, I could, I could add to that, Anja, by saying that the problem with psychiatry, in history of psychiatry in, in, in recent decades has been that it's kind of swung from psychological reductionism on the one hand with psychoanalysis and, and, you know, purely psychological approaches to biological reductionism, where it's, it's just seen as just a brain problem.
They're just brain diseases and, and it doesn't do justice to the complexity of mental, mental illness and, and mental disorders and it's it requires really all of these different perspectives and, and the professions that are involved obviously reflect those. And most of the time they, they work pretty well together in a, in a collaborative multidisciplinary way, certainly in Australia and I'm sure in Germany too.
But I think in some other countries. particularly the U. S. I think they, they've struggled with that a bit to get that integration. And we have these ideological wars, you know, in psychiatry where you have the anti psychiatry people almost denying the biological dimension of things. And on the other hand, you have the fairly, you know, what's the word, blinkered You know, biological reductionists denying, you know, the importance of the psychological experience and life's life course and also the social environment, which is very powerful.
I mean, we've seen a 50 percent rise in prevalence of mental disorders in young people over the last 15 years or so, particularly eating disorders actually during the pandemic. And so social and environmental forces must be very important here. Megatrends in society the biology is probably the, the, the kind of one of the pathways that it gets expressed through, but having a sophisticated understanding of those things is very, very important, but the media and you know, many of the protagonists in the mental health field just love to have these, you know, sort of, I suppose, groundhog day type debates about our, our antidepressants are evil or not, you know, it's sort of, Yeah, Mindless sort of stuff that appears in the media all the time.
And it's very distracting actually. Especially if you're trying to build credibility, as you were saying in your introduction, for our field and, and, and the kind of respect that's needed for people who you know, are willing to devote their careers to it. And so they're constantly being attacked by ideologues on either side.
Anya: Absolutely. We are surrounded by technology and the media, and it can be hard to filter true science from the sensationalized science. And I can imagine it can be especially important what people read at the time when you're establishing credibility in your profession. So I was just going to ask, as a generation, obviously, we're very reliant on technology and I know that both of you have combined your areas of expertise with advances in technology.
I was just wondering if you'd tell our listeners how you think these Digital based therapies will impact the accessibility to mental health care and where you see these therapies going in the future.
Pat: Origin Digital, led by my colleague Mario Alvarez, it has 130 people working on different aspects of digital mental health for this age group as well.
Including diagnostic specific support but also, you know, I suppose positive psychology based interventions and whole range of things, actually, including a social network for young people with mental illness. So, we are embracing technology as a therapeutic sort of platform and dimension.
Stephan: Yeah, perhaps just to add technology and particularly tech digital technology can help to reduce barriers or individualize therapy.
And just two examples we are, we are just doing a large trial at the moment called StarKids. And StarKids is about. Obesity in child and adolescence, and here we have implemented serious games digital serious games for the kids, but also for the parents and what we really try to. And Hans is that parents are also taking over responsibility also for parts of preparing meals and all this usually yeah, that's parents responsibility and on the other hand, to, to talk about a body image or a body image related issues is also an issue, which is very a sensitive issue in families. And so this is also part of this digital tool. And, we are doing that at the moment in 1000 kids and their families in our state and the interesting issues always the kids are very interested to play around and we could already.
Demonstrate that in terms of the educational properties that helped a lot. So what is not only healthy weight, but healthy food and what is also an appropriate physical activity and how can you cope with stressful situations. And so, and at the moment we are trying to To expand this study also on a new level, because we just were grounded with the new ground.
And that's an interesting issue, because now we have to transfer the content. From our German yeah, environment to European, to Spanish, to Polish, to Danish yeah, environment, and it helped us a lot also understanding yeah, or discussing more the cultural socio cultural backgrounds.
also of nutrition and lifestyle issues. So, that's one issue. And the other issue is about body self avatars, because here in Tubing we do have three Max Blankets Institutes and they do have very impressive setups where they can also play around with self avatars and And use the self avatars also to morph.
And that's a very interesting issue because particularly in anoxia nervosa patients, they do have body image disturbance and you can morph your body then to a healthy weight. And usually if If patients are exposed to their healthy weight image, then this is a fearful and stressful experience. And we are doing that to learn about more about this core phenomenon of eating disorder, but also building up adjunct treatment approaches for these patients.
And that worked out pretty well in a study we've just published some weeks ago. So using technology also in, in this respect, and interestingly patients were found these technology based approach very helpful. So they were much more engaged than in our usual mirror exposure therapies.
So technology was more or less in this particular. group yeah, not only an enhancer, but an enabler of therapy. And if this is the case, then technology might be helpful.
Anya: That's really interesting how it's an enabler. And you also mentioned how there's an issue or like a bit of a barrier in terms of using this in different countries.
I was wondering how, for example, your different projects can be implemented in low income countries, middle income countries and. Especially with regards to technology or anything else, for example, that you're working on.
Pat: Well a few years ago, before, just before the pandemic, Origin had a partnership with the World Economic Forum and we developed a global framework for youth mental health which had a lot of input from low and middle income countries.
And definitely there's a lot of potential in those countries for, where you don't have a lot of mental health professionals. There are, the two things they do have and advantage in our people. There's lots of people and you can train, you know, lay people to take on some of the tasks of substitution type roles.
And the best example of that is probably the friendship bench idea from Zimbabwe. But it's got a lot of potential. There. And the other thing is obviously digital, because even in poor countries, it appears that quite a lot of people have still got smartphones. And so we, we could do a lot more there.
And I think Maro's work with the, the most program, the moderated online social therapy is definitely modifiable. And it obviously would need some co design from, from different cultures and different parts of the world, which we are starting to look at as well. It, it needs someone to, to basically fund this, I think so we have the framework developed, but it's still, it's mainly high level principles rather than, you know, and it's very hard to find people who will fund these sorts of even research, but certainly, you know, service reform, every country is selfish, you know it looks at its own people, and Now there is a global health and global mental health movement, but they're, they're weak.
Bill Gates and all of these people, they're, they're great at sort of tackling HIV and malaria and these things, but, but mental health is low down on their pecking order too, so. I think it's a, it's a human rights issue, it's it's a values issue, and it's a, it's a big mistake, you know, that these people are making.
And it's really touching on maybe what you're going to get into before we finish. The issue of discrimination and stigma against the mentally ill, and against I suppose the inequalities around the world, not just between countries, but between people within countries. I, I went to a forum in London on the weekend, the progressive economics forum, and the, the rising levels of inequality and, and, and wealth inequality.
in, in, in higher income countries are just staggering in in the last few years. And then the pandemic's made it worse. So these sort of geopolitical issues are affecting the mental health of the world. So
Anya: do you believe funding is one of the challenges in reforming psychiatry then?
Pat: Yeah. There's an international association of mental health research funders, which has been formed by the Graham Beck Foundation based in Montreal.
They're trying to bring the big funders together and I must say Wellcome Trust have been extraordinary in the UK in prioritizing mental health. They've set a great example but all the other funders should be ashamed because, you know, it's a major cause of burden of disease and they underfund it in research everywhere.
Whether it's NIH, whether it's MRC in the UK, I don't know about Germany, probably the same. It's certainly the case in Australia. It's funded at at least half the level that should be funded on terms of its importance to society.
Stephan: In September next year, 2024, we are responsible here in Tubing for the World Congress on Psychosomatic Medicine and The issue of the global perspective on the, of mental health is one of the key issues and Vikram Patel will be the keynote speaker and we will discuss particularly the issues Patrick just mentioned because working with particularly the field of eating disorders that's seen from a lot of people as a whole.
Purely a westernized problem and not a global mental health issue. And we are, besides the European level, we are just thinking about also building avatars, which fit much more into other they are not only healthcare system, but also ethnicities. And interestingly, I learned over the last month that particularly also in the global South, most young people have their smartphones, so you could do digital based interventions.
So also these perhaps more fancy things like, in the first place, fancier things like Avatar exposure things, which in the first place, I think that you can do that only in the first world. It's, it's easily transferable and we are just doing that in a, in a pilot study with colleagues from from the middle African states.
And, and that's one option to transfer, but on the other side, we really want to learn. What they are, what they see as needs for their system and not only transferring. ideas from our healthcare system into their healthcare system. And Pat just mentioned project with the bank from, it was Uganda in the first place, I think.
And I think we learned a lot that we need space just for exchange with. Patients and have a very low barrier situation where you also can just chat with patients and learn about their views on treatment options on the environment options in your clinics or hospital. So we really try to learn from both ends.
Pat: Maybe in support of the great work Stephan is doing. I've got very interest in eating disorders in recent years as we broadened our diagnostic focus in, in, in beyond, you know, psychosis to include all these emerging disorders. I agree with him that it's a classic emerging adult disorder, you know adolescence and early adult life.
You want, so we are moving the boundary of our services across Australia from 18 to 25 is the transition point to adult to adult services. So, but I, I was very struck. I, I actually chaired the National Eating Disorders Consortium for a few years, even though it wasn't my area of expertise, but I learned a lot.
And what I learned was that the field was so under supported in terms of research. I went to the international meetings and, you know, coming from schizophrenia where, you know, we do complain about the lack of funding in schizophrenia research too, but eating disorders are very, very neglected in terms of medical research support.
despite being a very serious collection of illnesses and, and, and with the surge in new, new incidents in recent years, and especially during the pandemic, I think people are starting to realize how important it is and how little, little knowledge we have, you know, in terms of treatments, you know, we, we don't have enough treatments to, to effectively help these young people.
And so I would say it's a very high priority for. new investment especially anorexia nervosa.
Anya: Why do you believe there hasn't been enough attention drawn towards it?
Pat: Well, I'd love to hear what Stefan thinks, but I think it's because it's fallen between, you know, the cracks of pediatricians on the one hand or, or, or, and I did a lot of internal medicine before I did psychiatry too, between the, the, the physical medicine people and the psychiatry people who, So it's, it's, it's like it's, it's been a bit of an orphan in some ways, and so what you described, what you've done sounds fantastic in terms of bridging that gap, and, and So I don't think anyone's really been the parent of it in terms of advocating for it properly, and, and, and there's been a lot of shame and stigma and around it, just like with other Illnesses and so people haven't found their voice.
I mean, imagine if these, if, if cancer was as neglected as, as, as the illnesses we're talking about. The politicians wouldn't last five minutes, you know, and even now they're spending many millions of dollars on end of life care for cancer patients at the expense of, of young people who are losing their lives, you know, and their futures.
So that the, and David Haslam, who was the chair of NICE has written an amazing book called Side Effects Riskly. talking about how health care can be sustainable. And it's definitely shifting towards primary care, community care, early intervention, prevention, and, and, and, and basically having a more rational approach to what illnesses are prioritized here.
Because we can't, we can't go the way we're going trying to do everything and and expending lifespans indefinitely. If you want to extend life expectancy The easiest way to do it would be to treat mental illness in young people more effectively and then they wouldn't die earlier from physical illnesses.
And Caspi and Moffat have written a great paper about that in recent years.
Stephan: Just to add one aspect, I think you mentioned most of them already, but sometimes also, not only the governments, but also people think that this is a lifestyle issue and not a proper disorder and knowing that particularly anorexia nervosa is still a problem.
One of the psychological disorders with the highest mortality rates and also with the highest morbidity rates. And that's one of the things I really try to also discuss with politicians, but also with advocates because it's not a completely neglected area, but in, in terms of funding, it's still very hard to get funding in this area.
And, just four or five years ago, we wrote an article in Lancet Psychiatry about the imbalanced funding for also in the psychiatry field. And also again, eating disorders were on, on the very low funding side. Yep. It's not great
Anya: at all. More funding needs to be put into so many things, but especially eating disorders, especially when it's on the rise after COVID.
So I'd like to move on and talk about stigma as one of the barriers in mental health. So as I have mentioned, there is an insidious stigma that's related to mental health that's not only targeted towards those with mental illnesses, but it somehow manages to infiltrate its way into the healthcare system affecting the healthcare professionals themselves.
And I've spoken to people before and they've said that when they, for example, mentioned that they're a psychiatrist or a therapist, for example, at a dinner, a dinner party, it is a conversation killer. And I was and I was wondering if you have ever experienced these negative attitudes because of your profession?
Pat: Oh, look, that's a great question. Not so much at dinner parties. Probably people start to get a bit careful about what they say next. But when I first started, I also, like Stefan, I did a number of years of internal medicine. And when I decided to change from that, I hadn't quite finished my training as a physician, but I was, I was always very interested in, in mental illness because it was just so fascinating and, and, and such a human rights issue the way people were treated even back, what, 40 years ago and I had all my physician colleagues registrars and, and consultants queuing up to try to talk me out of it.
They said things like, Don't waste your career. Don't waste your life on quote unquote these people, which is by the way, is nearly 50 percent of the population. The prejudice and discrimination was just rampant actually. And I asked a bunch of trainee psychiatrists about maybe five years ago, had they had any similar experiences when they decided to train?
And quite a few of them said yes, they'd had exactly the same experience. So I think doctors and the, and the health profession, and this is why I was saying earlier that the medical research establishment and, and, and the people, the CEOs of big hospitals, they are, still have those attitudes.
They discriminate against the mentally ill. They, they control the budgets. They, they, they steal the money that's intended for mental health care and they put it into other things. I've seen this happen throughout my career. So I think to say it's just stigma is, is, is getting, is letting them off the hook.
It's absolutely, it's more serious than that. It's the sort of thing that we have to fight against with sexism and racism and these sorts of things. It's got to be called out and, and psychiatrists are politically weak in, in these systems and they, they really have the kind of I don't know, courage or mandate to do it.
And our professional organizations, the colleges of psychiatrists are also to blame here. There's been a failure of leadership in our profession, I think. In, in many countries at least to do this, we all want to work together in healthcare and medicine, but we've, we've got to be treated fairly and we, and we've got to stand up for it.
Not, not for ourselves so much. I don't think that's the issue. It's, it's more the patients the ones that will suffer in many, many ways and the patients of the public, you know you know, 45 percent of people will develop a mental illness across the lifespan at some point, maybe higher if you look at the Dunedin study.
So. So it's in all our interests to deal with this, and we've got, and I think maybe we're getting better, that maybe we're getting better at that, but, and the Lancet has done a great job, by the way, just to give a plug to the Lancet. The Lancet's given, given a great big up I think, to mental health care, thanks to your great editor and, and all the, all the people working on the Lancet, including Lancet Psychiatry, so the Lancet has played a very positive role.
Stephan: Yeah, and just from my personal development, as I just mentioned, I was trained in internal medicine and I've done my PhD in heart transplantation. So, and then I decided to move the field. But I, it, it was an excellent decision because as just Pat mentioned, I think yeah, being a researcher and a clinician.
Dealing with yeah, people's not only disorders, but also with their personal histories and having time also to talk with them and giving and face to, to develop That is one of the most yeah, from my perspective, positive decisions I have done. So, I am, I'm also the dean of the medical school for the last 15 years, and it's one of the issues where I also try in the very early stage of the career of our students.
We do have more than 5, 000 different studies from medicine to biomedicine and so on. But to, to give them very early an idea that mental health matters and is part of one health and not a separate health. And if yeah, the, the young students are involved in their early career stage, that then they are very positive and interested in in mental health issues also in communication skills, interestingly, but we've done longitudinal studies also in terms of how young doctors and experienced doctors communicate.
And we learned that young doctors are much more engaged, but sometimes, there is a kind of a peak and then the decline in their communication skills because of the pressure in the system and all the deviation of the professional things where it's much more complicated. It looks like that it's more important to, to have a very quick set up of instrumental things like diagnostics, like technology based diagnostics and so on.
So I, I just wouldn't say it's stigmatization, but also in Germany, it's perhaps not a coincidence that the German Center of Mental Health, interestingly, together with the German Center of Child Health are the last. German centers of health which were set up. So all the others, starting from cardiology, infectious disease, also they started 20 years ago.
So, yeah.
Anya: Yeah, so they're the lowest priority. Have people's attitudes changed at all during your career?
Pat: Well, in Australia, we had a thing called Beyond Blue, which was set up 20 years ago, and, and it's definitely improved understanding and attitudes towards depression and anxiety. It's sort of a nice mental illnesses, you know and, and and, and that's positive.
And I'd probably, I would say probably in a number of countries, there's a lot more openness about discussion and awareness, but there's a woman in, in, in the UK called Lucy Fuchs with whose book I've read and she, and she actually points out not exactly what I'm going to say, but something similar that awareness on its own is, is, is, is probably a mixed blessing.
Yeah. At least because For two reasons. One is that it might actually shift the focus on, on to people that probably just need maybe less professional support, but just more support and more simple sort of things, you know, to help them deal with it. It might shift the focus away from more serious mental illnesses.
I mean, it could, it could do both if it was done properly. But I think what has happened is that we've, we've stayed down the shallow end of the pool, if I can put it that way. Second thing that she says is that And, and I, I think this is very true is that awareness creates the impression that something is being done about the problem, you know, and actually we haven't seen any real improvements in funding for mental health proportionate to other major disease areas.
We have seen more funding, but it hasn't grown as rapidly as, as other areas in the health system and, and, and medical research. So we feel like maybe it's improving a bit, but not, not at the same pace as other areas of health. And awareness. It gets the politicians off the hook, you know and the, and the, and the, even the society, because, you know, everyone think in the pandemic in Australia, they spent a lot of money on just information campaigns and, and, and helplines, but the actual services imploded really, and we're completely overwhelmed and the services were not helped the government managed to create the impression that really they'd done quite a lot in mental health, whereas actually there was a lot of smoke and mirrors, you know, And I think that's what a lot of these awareness campaigns turn out to be, smoke and mirrors and there's not much substance behind the reform.
Anya: Yeah, that's interesting that when you think about it, awareness doesn't really mean action, so. I
Pat: mean, you assume that awareness is going to lead to, you know, action, but it, it doesn't seem to have, certainly not, nowhere near to the proportion that this is needed.
Anya: Obviously, hope, but in reality, it's not.
Stephan: To add participation perspective, because in Germany, I think it's one of patients and relatives where relatively lately organized in, in the mental health field.
But now, particularly for the German Center of Mental Health, they played a very crucial role, much more important so than in the cancer field, where they started to be advocates for research. And that was one of the very interesting issues I learned over the last two or three years when we started WIPA.
Jim center of mental health proposals, working together with patients and relatives and advocates. And I think. In Germany, that has not a long tradition, but now my impression is that they really play a powerful role also in terms of the funding bodies. Now they start to to, to give them not only a voice, but really they are part of our.
center and they do have, like, like speakers, they have the same rights and I think five years ago that wouldn't have happened. So in terms of the relatively short period of time, I was very impressed also by, by yeah, the patient and the relatives who were involved so far in, in this endeavor.
Anya: I'm glad to hear that.
So just one last question. What advice would you give to someone that is thinking about working in mental health? If I could start with you, Pat.
Pat: I can probably echo what Stefan said. I, I, I'm so pleased that I made the decision to, to work in psychiatry and mental health. I, I've had a life and a career that I couldn't have imagined in its kind of diversity and richness and meaning, you know, and, and also Just the, the, the incredible privilege of, of being part of people's lives as patients and, and helping them, you know yeah, I, I, I just think it's a, it's just a fabulous gift that, that I've been given to, to work in this field and, and, and we need, we need a lot more people that have got that, that sort of sense or affinity, you know, is the word I would use for, The suffering that comes with mental ill health and mental illness and got the gift to be able to respond to it.
We need those people desperately. Obviously, training is a very important part of producing a mental health professional, whatever their background. You know, it goes to the very deep vocation of medicine and healthcare. And you get a great opportunity in psychiatry to use, to be, to use yourself as a person, you know, helping.
As a therapeutic, you know, agent, which all, all doctors do, all health professionals could have this opportunity, but, but, but in our field, it's, it's so dependent on you as a human being and the way you are and the way you behave and the way you, you know relate to people. And so it's, I don't, I don't, you don't hear that, that positive message coming out of colleges of psychiatry or from the, from the professional field, you don't hear it.
It's expressed like that properly, I don't think, and many, many people working in it would be able to say the same thing that I've said, I think, and, and yes, we've been focusing on some of the negatives and the discrimination and the stigma we can, I think we can overcome it, you know, and especially, you know, like, as I said before, that things like this, the Lancet is doing, allowing us to talk about these things and publishing it in an equal way, you know I think, you know that, they get those, that message that the, the Lancers and journals like this are, are communication platforms and just getting those, those, those perspectives out into, into the, into the world is very, very important.
Like, we've got a huge need for workforces now with mental health care. Even when the governments give us much more money, like they are in Australia at the moment, we can't find, the talent, you know, and the gifted people to work in it, which is often enough of those people. So that's what we desperately need.
And you can promise them they will have a fulfilling and rewarding life. And as long as they get the right support.
Anya: Of course, it's important to have such platforms to be able to talk freely and openly about these things without a council culture.
Pat: Touching on an area where that's creeping in is this whole issue of transgender, which I think in particularly in the UK is it become very divisive.
And that's an area where. You can't have a castle culture, you've got to actually sort of look at the complexity of the issue and talk about it from a scientific and a human point of view and without the intolerance that you see, you know, having developed in that space, it's just really shocking. So, absolutely, I agree very much with what you just said.
Stephan: Yeah, and just certainly the working conditions in some institutions and sectors. must also continue to improve. But besides that, I find that our professional field of mental health is really exciting. So also compared with other fields, when I talk to my colleagues from surgery, they struggle the same way in terms of attracting young, smart minds to their field.
So I think it's, it's really An amazing field, and also if you look at the development in psychotherapy, neuroscience, but also in, yeah, in population based medicine in mental health over the last years that is really. A clear career option and what I would like to advise is always find somebody to talk to an experienced mentor or somebody and experience more experienced colleague and exchange ideas regarding training and career building and.
then I think it's all up to you.
Anya: Well, great. Thank you so much for talking with me today and talking about this really interesting topic and for voicing your opinions. It's been really great to have you both.
Pat: Thank you, Anya. Thank you, Stefan. Been a pleasure talking with you both and hope we can stay in touch.
Stephan: It was a great pleasure, also from my side. Thank you.
Gavin: Thanks so much for joining us for this episode of The Lancet Voice. This podcast will be marking The Lancet's 200th anniversary throughout 2023 by focusing on the spotlights with lots of different guest hosts from across The Lancet Group. Remember to subscribe if you haven't already, and we'll see you back here soon.
Thanks so much for listening.