The usual person seeking treatment at Riggs has a range of disorders rather than just one. Probably the most typical person has a mood disorder (depression or bipolar disorder) that has been difficult to treat (a so-called “treatment-resistant” mood disorder) co-occurring with other disorders like a personality disorder, anxiety disorder, PTSD, substance use disorder, or another disorder that complicates the response to treatment. There is increasing recognition in the field that this kind of complex clinical picture is more the rule than the exception, especially among those with previous poor treatment response.

Mental health clinicians and researchers once hoped that decoding the human genome and clearly defining diagnostic categories in the American Psychiatric Association Diagnostic and Statistical Manual of mental disorders (we are currently using DSM-5–the 5th edition of the DSM), would allow researchers to discover the genes that cause these diseases. Now, with the human genome decoded and many very large studies of psychiatric genetics completed, we have learned that dozens to hundreds of bits of genetic material are involved in any given disorder (e.g., over 250 for schizophrenia and close to 100 for depression) and that many of these overlap across disorders.

Although heredity clearly plays a role in mental disorders, the genetics of mental disorders are complex and usually involve interaction between genes and environmental factors. Since it has become clear that mental disorders are not simply caused by genes, the previous hypothesis that “genes = disease” has been replaced with recognition that “gene-by-environment interaction = disease . . . and health. The old question of whether it is nature or nurture that matters most in mental disorders has been answered: they both matter.

We have learned that early adverse experiences, trauma and losses play a major role in causing mental disorders. Just as adverse environmental factors like these play a role in causation, positive environmental experiences, like trusting relationships, play a role in treatment and in achieving resilience. As is consistent with this learning, at Riggs, we do not limit our treatment focus to the diagnosis in question, but build trusting relationships that address the whole person and the underlying adverse experiences, trauma, and losses that are part of their story.