In Practice

A practicing doctor's views on psychiatry and contemporary culture.

Plus ça change department: genome edition

Personalized medicine? Not yet.
You might as well read Stephen Pinker's cover story in this morning's New York Times Magazine on his genes and yours; it's reasonably entertaining. But for an author like Pinker, who usually packs his essays with fascinating factual nuggets, the piece is also surprisingly content-free. The fault is not Pinker's. The truth is that, despite the remarkable progress that's been made in sequencing the genome and characterizing genes, unless you come from a particular population where certain specific questions are relevant - will I inherit my father's Huntington's disease? or, am I descended from Thomas Jefferson's slave? - this cutting-edge science has little new to tell you. To take an example that recurs in Pinker's essay, a look at his genes suggests that he has some minor resistance to prostate cancer - unless different research evidence is brought to bear, in which case he has a slightly heightened vulnerability.

Especially when it comes to behavioral issues, expert knowledge, while fascinating, hardly adds up to "personalized medicine." In Against Depression, I reviewed much of the material Pinker covers here. It is of great theoretical import - informing our view, say, of how depression develops as a disease. But most of what you need to know in terms of your own susceptibility (like most of what you need to know about your capacities as an athlete) has long since been played out in your life. And most of what you would like to know as a parent about your child - should I strive to provide an enriched and secure environment? - can be answered in advance of anything you will learn from a gene profile.

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In time, our agnosticism will wane; someday, we will all be believers in personalized medicine. But it is also sobering to think how little has changed in recent decades. In a prior column, I suggested that there is no past golden age in psychiatry, but it is equally true that in the last half century progress has been slow. In mental health care, practical applications for genetic testing remain limited. Overall, the capacities of our pharmacopoeia have improved only modestly. Much the same can be said about our sophistication in applying specific medications to particular people in particular circumstances. The news about psychotherapy is probably worse. Psychologists, psychiatrists, and social workers today will have received training in a narrower range of approaches for shorter lengths of time; meanwhile, insurance coverage got unconscionably bad before it got marginally better, for those who are covered at all.

Research has altered our understanding of mental illness. Regarding depression, we know more about the course of the disease, treated and untreated, and more about associations with other illnesses . For better and sometimes for worse, doctors are more facile at combining medications in treating both mood and thought disorders. Computers, which make large-scale surveys easier, bear some responsibility for both changes, but the more important factor is a shift in the Zeitgeist (itself influenced by technology) toward an interest in data-based evidence. In truth, for readers with any propensity for cynicism, roundup pieces like Pinker's serve mainly to underscore how little influence progress in genetics wields on the everyday practice of psychiatry and, for that matter, medicine in general.

Peter D. Kramer is a psychiatrist and author. His books include Against Depression and Listening to Prozac.

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