21 December 2009
Head Occupational Therapist for Newham at East London NHS Foundation TrustAppeared in BioNews 539
Controversies around psychiatric medication continue. Trial and error continues to be a significant route to arriving at a satisfactory combination of drugs. Side effects still cause dissatisfaction and impair functioning as well as put people off taking medication at all. And while a greater range of non-drug treatments are now becoming available to service users, their application to those most severely affected remains unsatisfactory. Medication and compulsion continue to be the overriding experience of mental health services for many in this group.
Anyone seeking some kind of explanation for their difficulties remains likely to hear a vague reference to imbalanced brain chemicals or a 'biopsychosocial' model that covers all the bases but explains little. If they do get something more specific, it is likely it will be contradicted by the next professional they see. In all these areas mental health compares badly with other areas of healthcare.
At present there is little discussion on the 'shop floor' of the latest advances in genetic and epigenetic research. This is not surprising since, for all the promise and impressively large scale research projects, developments are still in their early stages. Any discussion of what these developments will mean must therefore be speculative, at least to some extent.
It is clear, however, that the interaction of genes and other factors is a complex process. For the major mental health problems there are not single genes that determine outcomes. The new work underscores this as well as providing some routes to understanding how, for example, multiple genetic and environmental factors might interact. The current genetic tests on the market are therefore to a large extent red herrings, and not actually in keeping with the research that has made them possible. On their own they tell us next to nothing.
Better models of the control of gene expression, through environmental influences (including the impact of some potential social factors) and including impacts and influences on development provide rich ground for speculation on improvements to care that might flow from them. This appears to have most potential in clarifying some diagnostic issues, for example raising some questions about the distinction between schizophrenia and bipolar affective disorder. If this helps dispense with unhelpful diagnostic mystification and instead focus on reducing symptoms then that will be to the good.
More widely, in terms of understanding the causes of mental health problems, there is a general benefit to a positive discussion around mental health focused research. This could provide a stimulus to debate and understanding of mental health problems and their causes. Increased clarity around genetic factors provides a challenge to produce clarity around the non-genetic factors too.
Treatment advances stemming from the new work seem still to be some way off. The complexity of the factors involved and the difficulty of finding appropriate methods of delivery are formidable obstacles. While successful treatment remains elusive direct benefits of the new genetic research for people with mental health problems will be scarce. However, indirect benefits may occur - the possibility of treatment, of recovery, will sustain hope (both for the individual and for healthcare providers). Furthermore, high profile discussions focused on (at least) the possibility of understanding mental health problems will help to reduce stigma.
The question of meaning within human social and cultural contexts will continue to be important and need further examination. Hypothetically speaking, we could arrive at a situation where we have a full understanding of how stress impacts at the level of gene expression. We would still then need to understand, potentially at the very specific level of the individual's experience how the stress came about.
It seems likely then that whatever the genetic research outcomes, we will continue to need to intervene at the many levels that we already do - biological, psychological and social - though we may be better guided as to what is likely to work well. At the level of culture, we also need to examine how phenomena such as medicalisation sit with new genetic understandings. If, for example, we accept that there are current cultural factors that make it more likely that people experience problems in the form of psychological distress, then we need to find a way of reconciling this (or not) with the genetics. It is interesting that two conditions where some have argued that problems are being medicalised - autism and ADHD (Attention Deficit Hyperactivity Disorder) - are also those being scrutinised at the genetic level. It should provide fertile ground for new ideas.
Fenno Outen will be speaking at the free-to-attend Progress Educational Trust/Royal Society of Medicine (PET) debate Marked for Life: Are Genetic Markers Helpful in Understanding Psychological Disorders? in London from 6.30pm to 8pm on the evening of Wednesday 3 March 2010. Email Sandy Starr at if you are interested in attending.