formulating your personal MENTAL HEALTH story

and why we invested in FORMULATOR

JUNE 2022

by Sebastian Anastassiou

“A ticking time bomb.” This has become an increasingly common phrase used to describe the growing mental health crisis we are experiencing on a global scale. Crisis is the operative word here; and the COVID pandemic has poured fuel all over this fire. However, this fire started long ago, pre-dating COVID-19, and has slowly been building and building, while the means to contain and manage it have been lagging behind.

Some eye opening statistics from the WHO:

• Depression and anxiety, two of the most common mental health conditions, are believed to have an annual global cost burden of 1 trillion USD
• 20% of years lived in disability are caused by mental health conditions
• Globally, 20% of children and adolescents currently suffer from some form of mental health condition
• Suicide is the fourth most prevalent cause of death among people aged between 15–29 years old
• It is estimated that almost 50% of all mental health conditions go untreated, and are estimated to contribute to 13% of the total global burden of disease
• Loneliness can shorten life expectance by 15 years and can increase mortality risk by 26%
• It is projected that by 2030, depression will be the leading global cause of morbidity and mortality (a study carried out in 2011, a whole 10 years before the COVID pandemic)
• The COVID pandemic has triggered a 25% increase in prevalence of anxiety and depression worldwide, and has disproportionately affected children, young people and women the most

Mental health conditions affect all aspects of life including work, education, community, the ability to contribute to society, and most importantly, family and relationships. Mental health has a profound impact on not only the people suffering from these conditions, but also the people surrounding them. In fact, a 2015 survey concluded that the number one presenting problem for children and adolescents seeking mental health services was family relationships. Although there are certain mental health conditions for which there are genetic correlations, it is easy to see how adults with mental health conditions unintentionally create environments that have the potential to trigger similar problems in children and other affected family members, regardless of hereditary genetics. This vicious cycle, along with the growing prevalence of mental health problems in children and adolescents, are feeding the top-of-the-funnel of future demand for mental health services.

Despite all of these statistics and the very vocal recognition of the problem on a global scale, the global median government health expenditure allocated to address mental health is less than 2%. To put this in relative terms, 2% of the expenditure to address almost 20% of the burden.

Mental health care is riddled with problems

The existing (A) access to treatments, (B) availability of treatments, and (C) models of care all contribute to our healthcare system’s failure to adequately address the problems described above.

1. on access — There is a lack of healthcare professionals to deal with the rising demand, causing dangerously long waits for people to access care, resulting in further deterioration of a patient’s condition which becomes even more challenging to treat.
2. on availability — Furthermore, even getting onto any waiting list is a challenge in itself, particularly in national healthcare systems such as the NHS, where there is a certain “qualification” bar measured by poorly managed care pathways; unless you are on the verge of suicide, i.e. the worst case scenario, you do not qualify, and even then, patients still slip through the cracks. This threshold is currently high, and many people still experience stigma related to mental health.
3. on models of care —

• Current approaches are symptom-driven, including diagnostic and symptom “threshold scores”, which do not necessarily lead to the most effective care;
• Current approaches are clinician-centered, that is, revolve around the relationship with a therapist, representing a significant bottleneck in the care pathway, especially in the face of the growing, massive demand and limited supply;
• This symptom-driven and clinician-centered model makes it very difficult to manage the growing patient stream while ensuring consistent quality care.

All these point to one common indicator — that there is a dearth of solutions and tools available to timely and holistically assess the patient cases and care needs, especially at the very start of the care process. Mental health is extremely complex and contextual, which is almost impossible to reduce down to quantitative measures based on threshold scoring; qualitative approaches are absolutely necessary to effectively treat mental health.

So how does one even begin to solve these problems? There is no one-stop solution to this ticking mental health time bomb; though one opportunity stands out to drive change. It is predicated on the improvement of one important tool in the psych toolkit: the case formulation.

Case formulation

Effective mental health care starts with a good case formulation, which can include:

• underlying mechanisms,
• relevant historical, biological, and social factors,
• comorbidity diagnoses.

It provides a deep understanding of the person, their situation and their self-regulation methods (i.e. how they currently manage their own mental health), and how all this affects their life. It is also important to understand their motivation to change, as well as their resources. The capacity to formulate cases psycho-dynamically is a key clinical skill that all psychiatrists and mental health professionals should be ready to apply to their practice.

A case formulation is used by clinicians and is the cornerstone of successful care by increasing patient-centric care. High-quality case formulation ensures a more coherent understanding of the patient’s goals, tasks and commitment to care. It contains the essential psychological aspects for root cause understanding; it helps individuals understand themselves and set personal goals.

In the treatment of psychological disorders, precise case formulations allow therapists to make clinically appropriate decisions, personalize the intervention and gain insight into the patient’s subjective experience. Contrary to symptom-oriented surveys, which result in the patient having to “justify” talking about subjective experiences, better outcomes are expected when the patient and therapist agree on therapeutic goals and the processes to achieve these goals; this is difficult to do without good case formulation. There is an abundance of evidence that attests to this, particularly with studies on cognitive behavior therapy. Rather than structuring treatment based on diagnoses, case formulation–driven cognitive behavior therapy (CF-CBT) focuses on building an individualized formulation or map of how a patient’s presenting problems are being maintained and uses this formulation to guide treatment planning.

Case formulation is the cornerstone of successful care

So why is case formulation not already part of the solution?

Simply put, writing a good case formulation is hard. Unfortunately, the literature on ‘how’ to develop a formulation is limited, and for the trainees, psychiatric formulation remains a challenging task. Furthermore, not only is a good formulation difficult to do, it takes a lot of time for clinicians (typically 2–5 therapy sessions); time which, as we have hopefully made abundantly clear, is just not available within the current mental health care system.

There is a desperate need for solutions and tools to triage the patient stream to the best possible care, enable better utilization of existing resources, and complement human resources with digital and hybrid solutions. We need to shorten the waiting periods, widen access, and improve the treatment selection. The current system is simply not equipped, nor is it prepared, to face the looming mental health tsunami that has appeared on the horizon.

Enter FORMULATOR. A way to automate case formulation in order to improve access to and availability of quality mental health treatment.

References

1. https://www.who.int/health-topics/mental-health#tab=tab_1
2. who.int/news/item/02–03–2022-covid-19-pandemic-triggers-25-increase-in-prevalence-of-anxiety-and-depression-worldwide
3. mentalhealth.org.uk/statistics/mental-health-statistics-relationships-and-community#:~:text=Being%20happily%20married%20or%20in,people%20who%20are%20unhappily%20married
4. https://www.thelancet.com/pdfs/journals/lanpub/PIIS2468-2667(18)30203-2.pdf
5. https://www.ft.com/content/3982585c-d2f0-4dc7-8412-3679a62f3030
6. https://www.cambridge.org/core/journals/advances-in-psychiatric-treatment/article/teaching-psychodynamic-formulation-to-psychiatric-trainees-part-1-basics-of-formulation/D3982C2D63007365D0CBAF3806D77072
7. https://journals.sagepub.com/doi/abs/10.1177/15346501211041388 https://www.cambridge.org/core/journals/the-cognitive-behaviour-therapist/article/abs/integrating-cbt-and-cft-within-a-case-formulation-approach-to-reduce-depression-and-anxiety-in-an-older-adult-with-a-complex-mental-and-physical-health-history-a-single-case-study/2614A9E3FA9BC672E37023792716B1B7
8. https://www.frontiersin.org/articles/10.3389/fdgth.2020.578902/full