May 11, 2016

Can precision medicine break the chain of mental health co-misery?


Mental health research excels at linking bad experiences to poor outcomes, writes Dr. Greg Simon. Here’s how to focus on recovery and resilience instead.

by Greg Simon, MD, MPH, Group Health psychiatrist and Group Health Research Institute senior investigator

For years, mental health advocates and consumers of care have asked for more studies—and more treatments—focused on resilience and recovery. I admit that my field neglects this area of care. It sometimes seems that half the papers in mental health research journals focus instead on what I call the co-occurrence of misery. By this I mean the link between having risk factor or condition X, and experiencing disadvantage or adversity Y, all of which might lead to being more likely to have bad outcome Z.

Let me give you an example. Mental health researchers know that people with bipolar disorder who experienced childhood trauma are more likely to consider suicide. Or children with autism-spectrum disorder who also experience attention-deficit symptoms have greater behavioral disturbance. My colleague Dr. Evette Ludman and I sometimes joke that we should start a new journal exclusively devoted to this scientific genre. Drawing on a biblical reference, we would call it the Journal of Job, after the devout man tested by theft, followed by fire, followed by boils. The co-occurrence of misery is not just an old story. It's an Old Testament story.

I’m not making light of people who have multiple risk factors for mental illness. Their stories are true in every sense of that word. The co-occurrence of misery is both a repeatedly confirmed scientific fact and, for many people with mental health conditions, a daily lived experience. Speaking that truth is often necessary to motivate efforts to prevent disadvantage and adversity—especially societal disadvantages such as unequal access to health care.

Unfortunately, the narrative of co-occurring misery is usually not a hopeful one. And for researchers who aim to improve the effectiveness of mental health care, that seamless narrative does not offer much guidance or encouragement. Like the original Book of Job, stories of misery begetting misery begetting more misery offer little hope for recovery other than dramatic divine intervention.   

Finding exceptions with precision medicine

The opportunity for mental health research to progress beyond the Journal of Job comes, unexpectedly, from the Precision Medicine Initiative (PMI) from the White House and the National Institutes of Health (NIH). To quote NIH Director Francis Collins, "PMI is not just Human Genome Project Redux”: It’s more than just sequencing DNA. PMI has a broad scope that includes studying a wide range of positive and negative environmental and behavioral influences on health. 

From my experience on a PMI advisory panel, I’ve learned that one of our central goals is identifying and explaining exceptions to the co-occurrence of misery. We hope to identify people with diagnosis X who experience adversity Y but without then suffering bad outcome Z. If we can understand why some people with bipolar disorder and childhood trauma don’t have suicidal ideation, maybe we can help those who do. The PMI is part of a broader effort to reveal and clarify the causes leading from genes to brain circuits to mental illness symptoms and diagnoses. We hope to discover when and how those causal chains are sometimes broken—with the ultimate goal of breaking them more often. 

Research oriented toward resilience and recovery should attempt to understand and facilitate good outcomes in people who have multiple risk factors and adverse circumstances. I hope that the PMI will help us to tell that new story.