Professor Eiko Fried wants to diagnose mental disorders in a radically different way
Inaugural lecture image: Pexels/Alex Green
Despite decades of research, the burden of mental disorders is not decreasing. According to Eiko Fried, professor of Mental Health and Data Science, this is due to the way we diagnose. In his inaugural lecture, he calls for a new approach to diagnosis.
Mental disorders are common, have a serious impact on people's lives and come with high costs. Despite decades of effort by scientists and clinicians, there has been little progress in reducing the disease burden and prevalence of mental disorders, Fried observes.
He has no single explanation for the lack of progress. According to him, societal developments play a role, with concerns around global peace and stability, the climate, and affordability. ‘So many students work part-time jobs alongside their studies. And much more so than 30 years ago, wealthy parents mean the difference between the opportunity for home ownership and a lifetime of paying rent’.
In his inaugural lecture, he focuses on diagnoses and research, in which people's personal circumstances have largely been left out of the picture. By paying more attention to these circumstances, he hopes to reduce the global burden of mental disorders.
One diagnosis, very different lives
Current diagnostic systems, such as the Diagnostic and Statistical Manual of Mental Disorders (DSM), have three shortcomings, according to Fried. First, they focus on symptoms, that is, on thoughts, feelings and behaviour, and not on a person's environment. Two people with depression can live in completely different circumstances: one with a supportive network and financial security, the other as a single parent without social support. 'The diagnosis is not really informative about what we need to do to help this person and where their problems come from.'
Second, the systems were developed mainly by clinicians and researchers, with little input from other professionals who use diagnoses—such as insurers or the judiciary—as well as people with lived experience and their caregivers. When a research study co-authored by Fried asked more than 3,000 people with experience of depression and their caregivers what a treatment should achieve, a reduction in 'mental pain' was often mentioned. 'That is not in any of the criteria of diagnostic systems for depression', the professor says.
Third, one system has to serve too many purposes at once: billing, access to care, criminal responsibility and treatment choice. 'It's not reasonable to assume that one categorisation of problems serves all these goals equally well.'
Different maps for different users
As an alternative, Fried compares a diagnosis to a map: it shows where a person is located in the landscape of mental health problems. Using statistical techniques, he groups together people who are similar. He uses more than just their symptoms. Physical conditions, life history, social environment, income and living environment are also taken into account. 'On the maps we are creating, we can put people in the same location. We can call it a suburb, a city, a region or a country.'
And different users of these maps, such as clinicians, researchers, or insurers, may need a different level of detail. 'A healthcare company doesn't need 500 cities', says Fried. 'I think a healthcare company needs to know three or four things, globally speaking.' Researchers who study brain mechanisms, on the other hand, may want the most detailed version.
Mental health problems as a system
Behind the maps lies a different view of mental health problems. A disorder is often seen as similar to the flu: the illness causes the symptoms, so you treat the illness. Like a growing number of his colleagues, Fried sees people as systems in which thoughts, feelings and behaviour influence each other over time. 'It's much more plausible that sleep problems cause concentration problems and fatigue, rather than depression causing all three.' In Fried's words, 'a person with a mental health problem is somebody who is stuck in a state of a system that is not good for them'.
Starting from scratch
Fried says his proposal is not a quick fix. Change is difficult: cohort studies sometimes run for 30 to 50 years using the same criteria, and changes to diagnostic criteria make those data less comparable. Even so, he sees signs of change. Many clinicians, including in the Netherlands, already work with what a client brings rather than with the label. More and more alternatives to the DSM are emerging. And the task group developing the DSM-6 acknowledged in its first publication that more stakeholders and more attention to the environment are needed.
'Most current solutions to the problems I sketch are ad hoc', says Fried. 'I'm just trying to find a more principled, long-term solution.' To that end, he wants to systematically ask insurers, patients and policymakers what they need from a diagnostic system, something that, according to him, has not been done in this way before.