The all‐encompassing perspective of the mental health care patient
Authors: Bart Groeneweg
Journal: World Psychiatry (2019)

In his paper, Cuijpers1 clearly describes the current state of the art of psychotherapeutic treatments for adults with a mental disorder. As he indicates, what the most important targets and outcomes are depends on whom you ask this question. Because of my personal experience of enduring severe depression, I tend to take the perspective of the patients when considering this issue. When a depressive episode emerges, symptoms like rumination, indefinable anxiety and insomnia will manifest, and the patient's focus will be on feeling better and getting away from fatalistic thoughts. Obviously, patients want to spend energy on symptom reduction, because mental disorders are very disruptive. In theory, I know that regaining mental well-being is not a goal in itself, since other life areas should receive some attention as well, such as the patient's family and relationships, occupation, social contacts and financial problems. Everything should be aimed at regaining a full-fledged and meaningful life. However, in ordinary practice, this integrated approach is hardly ever applied, despite the fact that, for example, stress about unemployment or financial issues can be extremely problematic and may very well interfere with the patient's recovery. It is also far from common to involve romantic partners, parents, or other loved ones in treatment, while they are often heavily burdened and very much in need of support and help to understand the situation. In his paper, Cuijpers concludes that most research on the outcomes of psychotherapy focuses on symptom reduction. There is hardly any research on the preferred targets and outcomes that are defined by patients. Reference is made, however, to a study by Battle et al2, in which they report on how patients and therapists each set specific targets for the outcome of treatment and afterwards evaluated the achievement of the targets they had set. This is, in my opinion, the core of psychotherapeutic treatments: setting goals together, defining outcomes, and regular evaluation of the goals and outcomes set. In the Netherlands, Routine Outcome Measurement (ROM) is used to facilitate this. All patients in specialized mental health services are expected to fill in a questionnaire to assess their mental health problems and monitor their progress during treatment. There is an ongoing debate among clinicians about the usefulness of this system. Patients, however, often wish to implement this procedure, because it offers guidance in shared decision making and helps to structure the treatment. I myself, however, was never asked to fill in such a questionnaire before or during treatment, while I think my outcome could have benefitted from it. I think this indicates that Dutch mental health care, and probably mental health care in many other parts of the world, can be improved considerably. From a patient's perspective, it is daunting to read about the state of affairs with regard to the limited effect that psychotherapeutic treatment has on depression and other mental disorders. In addition, it is clear that the effects of antidepressants are also limited3. It is disheartening that the real causes of mental disorders are not yet well understood, and as a result the development of new medications has stagnated for years. Meanwhile, many patients continue to suffer from side effects of their medications. All this creates considerable confusion among patients: whom should they trust now? Are both psychotherapy and medications just not so good? Perhaps the individual attention by the therapist and the therapeutic relationship still yields some results, but apparently any improvement of the disease in the patient cannot be attributed to the therapeutic method itself. The current state of affairs in the treatment of mental disorders leads many patients to opt for interventions that have no demonstrable effect. I am not a researcher, but as a patient I am interested in the developments in the field of treatment of mental disorders, and especially depression. Research evidently shows that a combination of two treatment methods (e.g., “drugs and talking”) shows the greatest response and remission rates in depressed patients. This has been known for a long time, but still the effects are limited and it is necessary to develop new forms of combined treatment. Cuijpers points out that progress towards improved outcomes is slow. And he thinks that new systems are needed to better understand mental illness. He refers to the US National Institute of Mental Health's Research Domain Criteria (RDoC) project. The points of reference there are the brain functions and the neural systems that are involved in behavioral functions (and dysfunctions). In line with this, I believe that many promising developments are to be expected in the area of neuropsychology. Personally I got involved in research on the effect of repetitive transcranial magnetic stimulation (rTMS). This treatment can be implemented in combination with psychotherapy. It could be an effective method in treating depression without side effects. rTMS is, in my opinion, a good example of a treatment that many patients are waiting for and that requires more research into its effects and potential to improve outcomes. Overall, I agree with the conclusions drawn by Cuijpers. It does not appear to be easy to identify the best targets and outcomes of psychotherapy; the perspective you take to look at the issue matters quite a lot. As a patient I primarily care about symptom reduction. I think many patients will agree with me because we just want to get rid of those dark moods, sleep disorder, fears, suicidal thoughts, etc.. On the other hand, acting from an all-embracing perspective may eventually lead to a better quality of life. I have not, however, seen examples of such an approach. As patients we still have a lot to wish for.