The times they are a-changin’

The first issue of Evidence-Based Mental Health (EBMH) is celebrating the 20th anniversary. Readers were welcomed to EBMH in 1998, which was designed to assist ‘mental health clinicians stay up to date with the best available evidence as it is published’.¹ EBMH has remained committed to this aim, building on the changes and developments in the field, helping clinicians via numerous resources use the strategies of evidence-based practice: ‘working every day to stimulate a critical approach to evidence-based practice’.² EBMH has evolved to include important editorial members with expertise in adult, old age and child and adolescent mental health, and in forensic psychiatry and statistical methodology, and we have now a new section editor for health economics, Judit Simon, who is Professor of Health Economics and Head of Department at the Medical University of Vienna. We also plan to develop ways to harness the expertise from junior members of the field. EBMH recognises that the younger generation of mental health professionals ‘are more open to the challenges of practicing EBM in an innovative way’, and ‘want younger readers to become the best EBMH contributors of the future’.³

The anniversary of EBMH comes at time of great importance, as the UK marks 70 years of the National Health Service (NHS), transforming the health and well-being of the nation, while becoming a global envy. We have seen the development and implementation of the NHS Five Year Forward View Plan ⁴ and the more recent Stepping Forward to 2020/21 Plan,⁵ recognising mental health as a major national problem. With these plans the NHS is now delivering one of the biggest expansions in access to mental health services currently ongoing in Europe. However, only 11% of the overall UK NHS budget is spent on mental health services, despite mental health accounting for 23% of the estimated burden of disease in the UK.⁶

The past two decades have seen a vast expansion in knowledge and understanding of various mental health disorders, which has led to the development of the updated version of the Diagnostic and Statistical Manual of Mental Disorders.⁷ More recently, the International Classification of Diseases (ICD) has launched the new ICD-11, with a key goal of helping countries to reduce their burden of mental health. ICD-11 has been described as ‘having been designed in way recognizing the global digital age, it is an onscreen, multipurpose, multilingual database interconnecting with other operating systems—including electronic hospital records’.⁸ A key example of a relevant change includes a new chapter on sexual health that incorporates conditions previously controversially classified (eg, transgender disorder, newly classified as gender incongruence and no longer classified as a mental health disease).

Mental health is now recognised as an important global diagnostic challenge, and an extensive economic burden, and not only have the diagnostic criteria continued to evolve, but so have the ways of collecting and synthesising data on mental health. The WHO’s Mental Health Atlas Project was first developed in 2001 to collect, accumulate and disseminate data on mental health resources across the world.⁹ The Atlas Project is now considered the ‘most comprehensive resource of global information on mental health’.⁹ The Atlas Project continually updates to inform new services, and the most important update came a couple of months ago (http://www.who.int/mental_health/evidence/atlas/mental_health_atlas_2017/en/), delivering information and key data on the progress towards the achievement of objectives and targets of the WHO Comprehensive Mental Health Action Plan 2013–2020.⁹ The Mental Health Atlas 2017 has revealed there is a global shortage of adequately trained mental health workers, and that there still remains an urgent global need for greater investment in community-based mental health facilities.

Ways to move forward in global mental health is an area of considerable discussion. One way forward could see the introduction of precision medicine, a key concept now emerging in mental health. This concept works on the notion that every patient is different, and therefore each individual patient needs to be treated differently. The exciting debate for the future is exploring how best to apply this concept in clinical practice. In other fields, for instance in oncology, new tools exist that extract information from cancer genomes, including both the mutations that occur somatically, and the functional changes that result from both these mutations and epigenetic events.¹⁰ In psychiatry, most disorders are polygenic, but with individual genes having very small individual effects. Therefore, we still lack the clinical markers and predictors of illness course or treatment response.¹¹ Importantly, however in psychiatry, there have been large numbers of patients randomised in clinical trials, and pooling an analysis of these data from clinical trials can be used to provide ‘personalised’ estimates of comparative effectiveness, including the possibility of stratified estimates for specific subgroups of patients.¹² Is it now time to move away from a ‘one size fits all approach’ and move towards precision mental health, providing the most appropriate care to our patients individually?