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Bioethicist says mental illness is subject to biological and sociocultural factors

February 19, 2008

Biology is crucial to understanding psychosis, “but there is more to psychosis than mere biology,” says Jason Robert, an Arizona State University bioethicist and philosopher of science.

“Psychiatrists in particular appear to be grappling with the complexity of classification and diagnosis,” Robert explains. “But I am always worried that the prime material of the psychiatrist – often ill, unhappy people who behave in bizarre ways – will be ignored in favor of DNA tests results or brain images, with almost certainly negative impacts on patient well-being.”

Robert, an assistant professor in the School of Life Sciences at ASU’s College of Liberal Arts and Sciences, provided conceptual research and perspective to the subject of cross-cultural issues in defining mental illness during a presentation on Feb. 16 at the American Association for the Advancement of Science annual meeting.

“My claim is that gene maps and brain scans will likely not be able to offer universal, culture-free representations of the essence of mental illness. That is, mental illness is subject to biological and sociocultural factors, such that isolating any of these as core elements will almost always miss the mark at the expense of patient care,” he says.

Robert dissected the notion that personalized medicine is the wave of the future. “In many people’s minds, personalized medicine means medicine tailored to an individual’s genetic makeup. We have heard over and over again that genetics and neuroscience will revolutionize medicine, and these claims come with elaborate predictions about new taxonomies of disease, new diagnostic tools, and fabulous new treatments.

“None of these predictions have borne out, in part because they fail to grapple with the complexity of human beings – as brains, bodies, and, embedded in culture, steeped in history, and dynamically creating their own words,” he says.

“If we’re really going to have personalized medicine, we have to be focusing not just on the genome, but the person,” Robert says. He adds that this is an emphasis with medical students in the University of Arizona College of Medicine – Phoenix, in partnership with Arizona State University, where he holds a faculty joint appointment.

“We feel this newest generation of physicians have to be deeply well-trained in genetics and neuroscience, but not at the expense of a deep and meaningful training in interpersonal communication, interaction with actual people who really at the end of the day are your patients and your first priority,” Robert says.

Robert introduced the AAAS audience to the complexity of diagnosis and management of mental illness, from the perspective of the individual and across cultural boundaries.

“Within psychiatry, questions about the aetiology, classification, and diagnosis of complex disorders, such as schizophrenia, span cultural and national boundaries,” he says. “My take-home lessons are these: Classification and diagnosis are complex, interpretive and analytical tasks. These tasks are more complex in cross-cultural contexts, whether local (within the U.S.) or global.

“Genetics and neuroimaging may prove useful in simplifying these tasks, but only if integrated with clinical phenomenology – careful clinical description based on patient narratives, observation, and interpretation – to serve the needs of embodied and enculturated people, not disembodied brains or genomes.”

One major concern, according to Robert, is how to operationalize these philosophical and ethical ideas in the development of new diagnostic and classification manuals, such as the Diagnostic and Statistical Manual V and the International Classification of Disease – 11.

“While there is clearly a commitment to embrace an integrative and systems approach to mental illness in such efforts, it remains to be seen how this will affect the final products,” he says.

“A second major concern is how to educate mental health care professionals toward cultural competency in ways that are sensitive to the dynamic, constitutive nature of culture, rather than merely presenting so-called facts about ‘this is what Native Americans/Latinos/Ugandans believe about this, that, and the other thing,’” Robert says.

“We shouldn’t pretend that culture is any easier to understand than a person is; to understand that you can’t have caricature of culture in mind. What’s really critically important is understanding cultures dynamically, as complex, historic, social and political structures that dramatically influence people’s lives”

While Robert acknowledges that it’s certainly the case that DNA and brain scans are going to be important, “if you ignore everything else, you might never have the capacity to actually influence the well-being of the patient.”

Carol Hughes,
College of Liberal Arts and Sciences