Good op-ed out in Science by Hans-Ulirch Wittchen, an esteemed clinical psychologist in Germany, on the burden of mood disorders in industrial societies. He highlights the secondary or indirect costs of mood disorders, which are not as apparent as the more direct costs of something like heart disease.
Wittchen also calls for an interdisciplinary approach for intervention and health services:
Improved integrative models, based on research in the behavioral, social, and neurosciences, are urgently needed that better reflect the heterogeneity and complexity of mood disorders. The goal is to provide a range of effective interventions within a personalized perspective, taking into account the vulnerability and risk factors responsible for one´s clinical trajectory to illness, its duration, and remission, in addition to pharmacogenomic and other biomarker approaches. Early interventions based on personalized approaches have the most promise.
Improved integrative models do matter. The question then becomes what type of integrative model. Is it an epidemiological model, where the approach is to measure different “risk factors” in behavioral, social, and neural domains? That can atomize the person, and reduces important formative processes like human development and culture from systemic attributes to token measures.
Or is it a consilience model, where reductive neuroscience is placed in the lead position, the frame of reference for trying to do integration? That often happens, going from consilience to con-silenced.
Or is there some sort of dynamic systems model, a we-can-all-get-along approach because there are emergent properties which somehow bring it all together? That often lacks the specificity a clinician like Wittchen wants, an ability to focus on specific problems and processes that can readily make a difference in people’s lives.
I don’t have a good answer today. Wittchen recommends looking at Roamer, Europe’s three-year project to build road maps for mental health research, which favors the epidemiological approach. My suspicion is that full integration will involve all three approaches, with an additional fourth one that brings to bear historical, cultural, and critical considerations. But I do want to comment on one idea that struck me vis-a-vis neuroanthropology and Wittchen’s op-ed.
Wittchen lauds personalized medicine as an approach to improve interventions. Many social scientists, anthropologists included, would object. Somatosphere’s excellent coverage of Global Mental Health and Its Discontents gives us a direct sense of that debate.
Discussion about the nature and vision of the GMH agenda oscillated between two antagonistic poles. One described it as a bottom-up, public health movement driven by local knowledge and priorities, with the aim of providing access to mental health care for everyone. On the other end of the spectrum, GMH was seen as a top-down, imperial project exporting Western illness categories and treatments that would ultimately replace diverse cultural environments for interpreting mental health.
A social approach to dealing with mental health issues at the community level, rather than a focus on personalized medicine and its biomedical tenets, was something directly advocated at the McGill Conference on Global Mental Health.
Hilary Robertson-Hickling, a behavioural scientist at the University of the West Indies in Jamaica, questioned whether mental health work should actually be taken out of a medical framework, pointing out that “psychiatry does not do humanity work due to its obsession with pathologies” – a focus which distracts from social processes and the question of “what can we do together?”
Neuroanthropology certainly embraces that side. The social matters. Yet I was struck by the thought too of whether neuroanthropology could change the notion of “personalized medicine” as well. The nervous system is at once individual and personal, yet encultured and trained. As Greg Downey and I argue in The Encultured Brain: An Introduction to Neuroanthropology, neural enculturation means that Witthchen’s “personalized perspective” wouldn’t be accurate if restricted to individual risk factors and biomarkers.
With the nervous system, personalization inevitably happens through familial, social, and cultural relations, contexts and meanings. At the same time, the personalization involves neural wiring, epigenetic mechanisms, and developmental canalization. It is biocultural in the utmost sense of the word. And trying to make sense of these mutual dynamics is one of the main themes of the Culture, Mind and Brain conference that will take place in Los Angeles in a couple weeks.
In other words, “personalized medicine” cannot be disembodied medicine, forgetting the reciprocal interactions between the person’s nervous system and the developmental and social processes that help define who that person is, not just in the sense of identity but also at the level of basic neurological function. Personalized inevitably is social; personalized medicine should be too.