#16 Why we should be hopeful about the future of mental health
Cultural revolts, untapped understanding, technology and human resilience
“Remember. Hope is a good thing, maybe the best of things, and no good thing ever dies.” Andy Dufresne
Hi friends,
If you’ve been a subscriber for a while, you’ll know that my main focus is to share that helps mental health organisations succeed. I want to create the best insights, guides and deep-dives that will help teams achieve the impact and commercial outcomes they want.
But this week, we are doing something a little different.
Instead of doing a company deep-dive or analysis, I want to talk about hope. Specifically, I want to show you why we should be hopeful about the future of mental health.
Hope is unfortunately in short supply for us sometimes.
Every day, we see bad news about mental health. Rates of illness are increasing, the sector is underfunded, providers are burning out and startups are failing.
We see the impact of it up close too, in our own lives. A loved one struggling with depression, a patient not responding to treatment, a health system that won’t support us trying to make it better.
It can grind us down.
However, I am an optimist. And so, I am hopeful.
My optimism is sometimes irrational - I just have a blind faith in our ability as a species to make things better - but there are also a bunch of very rational reasons to be optimistic and I want to share these with you today.
In this article you’ll learn why we should be hopeful about the future of mental health, the potential of emerging treatments, societal trends creating healthier behaviours, quiet cultural movements fostering better mental health and more about Tuberculosis than you ever thought necessary.
Let’s get into it.
There are five reasons to be hopeful about the future of mental health.
1. A cultural revolt
A cultural revolt has been quietly building.
One that rebels against the mentally unwell world in which we often find ourselves.
People are tired of having poor mental health and watching their loved ones suffer. They are frustrated with the societal forces and organisations that are causing this suffering and are rebelling against them. They are ditching social media, binning their smartphones for dumb-phones and searching for new spaces of connection and meaning making. Things have gotten so bad that many people are reacting and trying to take back control of their own mental health.
If you want to understand this cultural revolt, go read Freya India’s work. Freya’s awesome because she has tapped into the frustrations of women and is providing brave recommendations for how they can make things better. She understands culture and how to tap into it to make change.
Last weekend I read her essay called “What happened to FOMO?” - it’s the best essay I’ve read this year and I’m now a paying subscriber to her newsletter called “Girls!”… funny old world.
Freya is one of the leaders of this cultural revolt. She is a welcome antidote to the TikTok influencers promoting mentally unhealthy lifestyles or the bogus PopPsych accounts whose advice does more harm than good.
“We should fear missing out on what’s happening in the real world. We should fear missing out on confidence, on social skills, on our own potential. And most of all, we should fear platforms that make us want to miss out on all of this. Reject platforms that make you want to watch others’ lives while letting yours pass by.”
Freya India
And Freya is popular! She has over 25,000 followers on Substack, evidence of the large numbers of people looking for a mentally healthier way to live.
There are more Freyas popping up all over the place. Jonathan Haidt is leading this revolution for parents, creating a movement around the Anxious Generation where he supports parents looking to improve the mental health of their children.
Side-note: any company building in mental health must be aware of this movement and should see it as a massive opportunity.
One of the reasons a cultural revolt is so powerful is because it can drive system level change - something we need to solve any public health crisis.
And this is happening in mental health.
Almost every government now recognises mental health as a significant issue. The US Surgeon General has recognised we are experiencing a loneliness epidemic and a youth mental health crisis.
Public Health systems also recognise the size of this issue and have made it a top agenda item for the vast majority of public health strategies.
Employers have recognised its importance and are doing much more to support the mental health of their employees. Sure, it’s not enough, but it’s a lot more than what they did ten or twenty years ago.
While “recognition” alone does little, it’s an incredibly important step.
The focus on mental health now permeates almost all elements of our society.
My local rugby club had a mental health round last year. In the dressing room before the game we sat around and chatted about the importance of looking out for each other. The school my mum works in provides mindfulness and meditation support to the children. I’ve worked with after school care services in Australia on a program to boost children’s social wellbeing. Every Friday on the beach near my house Fluro Fridays run a meetup where people dress up in bright fluro outfits, go for a surf and share stories to raise awareness of mental health.
Yes, I am lucky to live in a progressive city at the leading edge of this movement, but efforts to raise awareness and provide support around mental health exist in so many communities around the world - I guarantee you can think of some in your own community.
Culture is powerful.
It compels people and drives behaviour. It's the current in which we all swim. And as this current turns in a direction more supportive of mental health, we will all get pulled along.
2. A track record of problem solving
The human race has an incredible track record of solving hard problems. I mean seriously, human resilience and our ability to cooperate on large scale projects is bloody awe inspiring.
Over the last two centuries we’ve solved a bunch of public health crises that prove this point. Crises that at their height, seemed unsurmountable. We didn’t understand them and certainly didn’t know how to treat them.
Until we did.
So let’s look at a few of those examples for inspiration.
Tuberculosis: Here’s an absolutely crazy statistic; at the start of 19th century, tuberculosis (TB) had killed one in seven of all people that had ever lived.
Sorry what?!
TB had been around for millennia with evidence of its existence found in the spines of Egyptian mummies and in the remains of bison dated to around 19,000 BCE. For all that time, humans had been afflicted by the disease.
In the 1800s it caused nearly 25% of all adult deaths in Europe.
But we basically had no idea what it was, how it worked or how to treat it. Apparently people often associated it with the presence of vampires. Spooky.
As it became an increasing concern of the public, more scientists began to research the topic and then in 1882, Robert Koch identified and described the bacillus causing tuberculosis. It was determined to be contagious and a number of initiatives were introduced to improve sanitation and housing conditions. The pasteurisation process of milk was created to reduce transmission of the disease from cows. In 1906, we saw the first success in immunisation and then in the 1940s, Streptomycin was developed as an antibiotic, transforming TB from a death sentence to a treatable condition.
Deaths from the disease tumbled.
While TB has been largely eradicated in rich countries, it unfortunately is still present in low and middle income countries and is responsible for about 1.3 million deaths per year (2022).
But humans transformed the outcomes of this disease. We figured out what it was, where it came from, implemented social policies to combat it and developed vaccines and antibiotics to treat it.
We see similar trends in other public health crises over the years.
Smoking and Lung cancer: We’ve cut lung cancer mortality almost in half, primarily by reducing cigarette consumption.
Cardiovascular disease: from 1950 to 2022, we reduced the death rate from cardiovascular disease in the US by approximately 75%.
I particularly love this story of cardiovascular disease because of the breadth of solutions that were required to achieve it. We improved screening, diagnosis, monitoring and treatments. We invented medical devices and created new surgical procedures. We implemented public health initiatives to encourage healthier behaviours, like not smoking. And guess what, it freaking worked!
Can’t we do the same in mental health?
Of course we can!
3. The upside of untapped understanding
As a Psychology Today article put it;
“Mental illness remains deeply enigmatic, its causes generally unknown, its cures undiscovered. Despite the overwhelming body of research to which new findings are added almost every day, we scientists still don’t understand what happens in the brains of mentally ill people.”
While this statement is perhaps a bit extreme (we do understand quite a bit about mental illness), we can all agree that there is also a lot that we still don’t understand.
Our epidemiological understanding of mental disorders is limited and our diagnostic methods rely on the assessment of symptoms without any physiological tests.
There is substantial room to improve treatment efficacy as evidenced by the results from a meta analysis of the most common treatments for depression;
- 54% of adults show improvement after antidepressant medication compared with 35–40% of adults showing improvement after a pill placebo in randomised trials. Source
- 62% of adults show improvement after psychotherapy compared with 43% of adults showing improvement in care-as-usual control groups of psychotherapy trials. Source.
- 25–40% of patients who recover from depression after treatment will have another depressive episode within 2 years, 60% after 5 years, and 85% after 15 years. Source
Why is this the case? Because mental illness is a particularly tricky disease to study and to understand and also because the volume of research has lagged behind the relative size of the disease burden.
“While mental health disorders represent roughly 12% of the EUR31 [31 countries in Europe] overall burden of disease, they represented only 5% of its biomedical research output.“
Begum et al.
“Steve, I thought you said this article was about hope??”
Yes. You’re right!
You see that’s the thing. The reason to be hopeful here is that we have so much room to increase our understanding of these diseases and use that understanding to get better at preventing and treating them.
It’s all upside.
Perhaps it’s an over-simplistic comparison to say that we are at the point where TB was in the 1850s, where smoking was in the 1950s or where cardiovascular disease was in the 1940s. But there is certainly some element of truth in it.
We have been steadily increasing the volume of research on mental health. The chart below shows how the number of research articles published on depression almost quadrupled from 2004 to 2019. This research is leading to greater understanding and the development of new treatments. Yes, the translation of that research takes time, but it’s happening and trending in the right direction.
If we already knew everything about mental disorders and were still seeing the rates of illness that we have today, I would be a lot more worried (and a lot less hopeful) about what future years will bring.
4. Supportive trends in lifestyle and behaviour
Although it mightn’t always feel like it, there are some societal and lifestyle trends moving in our favour.
Stigma has been steadily reducing.
The measures used on the chart below are a bit complicated, but essentially, people are becoming a lot more comfortable with mental health. My own life experience and other studies validate this too.
People are becoming more empathetic to those living with mental health challenges.
Many lifestyle trends are supportive of improved mental health. Specifically, alcohol consumption and illicit drug use has been decreasing significantly in young people.
Child abuse has been decreasing. Since 1990, in the US there has been a steady decline in the rates of abuse of children - a significant risk factor for mental health challenges.
Look, I understand that there are lifestyle and societal factors that are moving in the wrong direction and we have to pay attention to those.
But I’m permitting myself to cherry-pick here. This is not a thorough analysis of the crisis to try and understand the state and trajectory of the problem. It’s about finding reasons for hope and there are some interesting positive trends in our society that give me that hope.
5. The promise of technology
Many of you reading this get up in the morning because you believe in the promise of technology. You believe that there is huge potential to deliver new technologies that transform population mental health.
And I believe that too.
I use the term of technology in it’s broadest sense here, meaning “the application of scientific knowledge for practical purposes” and in mental health that includes pharmacology, digital therapies, psychology, psychiatry, medical devices and more. Across all of these areas, there is is a tonne of innovation happening and it’s bloody exciting.
If these technologies reach their true potential, they will not just improve mental health, they will completely revolutionise it.
Here are some of the technologies I’m most excited about;
- Telehealth: OK, nothing too revolutionary here but telehealth has increased the accessibility of mental health treatment for large segments of the population. It still has a lot of untapped potential too, especially in low and middle income countries.
- Psychedelics: This is one of the most divisive topics in mental health right now and I must admit, it’s hard to find a reliable source of truth on itdue to the embedded interests of many of the parties involved. But, from all the research I’ve conducted, it’s clear that psychedelics hold massive potential for the future of mental healthcare. Deciding whether or not they are currently ready for regulatory approval and to be provided as wide-scale treatment for mental disorders is a decision I’m glad I’m not responsible for. But it’s hard to argue against the long term potential of this class of drug. Research on Psilocybin has demonstrated anti-depressant effects and data suggests potential efficacy for substance use disorders and other disorders. MDMA, Ketamine and LSD all have studies which demonstrate potential efficacy on a wide range of mental disorders. Despite these compounds being around for a while, the regulatory and commercial landscapes for them are still emerging - and a bit all over the place. Australia has approved both MDMA and Psilocybin whilst the FDA just last week rejected an application from Lykos Therapeutics to use MDMA-assisted therapy for PTSD treatment. It’s going to be a wild few years for the psychedelic field but with the approval they already have in countries like Australia and the amount of research being undertaken, we will start to know a lot more very soon. And I’m very excited about that.
- Digital Therapeutics: Despite the high-profile commercial failure of some Digital Therapeutic (DTx) companies, the underlying category remains a reason to be extremely hopeful. Both Pear and Akili developed DTxs built digital products that could treat mental disorders. There is a bunch of exciting research happening in this place and some very cool companies working on bringing that research to market - I’m doing a deep-dive on one of them soon!The best part about DTx is the potential for scalability. Make one, prove that it works and you can theoretically have it in the hands of millions of patients with negligible marginal cost - how many other treatments can you say that for? We just need to get around the reimbursement challenges but that’s a solvable problem.
- Neurotechnology: Medicine has already reaped huge benefits from neurotech advances. EEG and MRI have given us helpful insights into brain activity. Deep Brain Stimulation (DBS) has been used to reduce symptoms of Parkinsons and devices like cochlear implants have restored people’s hearing. Of course, there are a bunch of use cases for neurotech in mental health too, from Transcranial Magnetic Stumulation (TMS) to Transcranial Direct Current Stimulation (tDCS) and even Brain Computer Interfaces (BCIs). Many of these have shown great potential in diagnosis, prognosis and treatment of mental disorders. Many of them are already used in clinical settings and I see lots of great people building companies in this space.
- Precision psychiatry: Precision Psychiatry is an exciting form of psychiatry that takes into account each individuals variability in genes, environment, and lifestyle to more effectively diagnose and treat mental disorders. It’s perhaps the most important trend in mental health and our biggest reason for hope. Why? Because as a field, psychiatry has “not yet benefited from the advanced diagnostic and therapeutic technologies that form an integral part of other clinical specialties” source. To see the fruits of this movement, we need a bunch more research to allows us to better understand mental disorders as well as inventions in all the categories above to facilitate its implementation. It’s a field I’m incredibly excited by and hopeful about what it will bring to people’s lives.
Talent and capital is flooding in to develop these technologies, accelerating their transition from the lab to the patient and I’m so excited about that.
Every week, I chat to someone incredible who is trying to build some new technology. Sure, not all of them will work, but in aggregate, they will create and deliver meaningful solutions that will improve mental health.
Across all of these areas, there are a bunch of incredibly passionate, caring, clever people working hard to improve people’s lives. From front line clinicians to researchers, to the staff of mental health companies. Above all, it’s these people that give me hope. Because if we have our best and brightest working together, I know we can solve this thing.
I hope I’ve given you a reason to be positive about the future here.
There are cultural and political waves we can surf. New technologies hold massive potential. We have so much left to learn about mental health and when we do, we can translate that into better prevention and treatment.
As Patrick McGorry put it recently;
“It's not as though we don't have a solution. This is not a wicked problem, this is something we can actually deal with.”
We can do this. We’ve done it before and we will do it again.
Hope may not be a strategy. But a strategy without it, is doomed to fail.
Know someone who might need a dose of hope today? Feel free to share this with them, it would mean a lot.
That’s all for this week.
Keep fighting the good fight!
Steve
Founder of The Hemingway Group
P.S. feel free to connect with me on LinkedIn
