Dr. Lena Palaniyappan, MD PhD

Dr. Lena Palaniyappan is an esteemed professor, researcher, and psychiatrist whose work wields a remarkable range of techniques and multidisciplinary approaches to understanding mental health. His contributions have significantly advanced early intervention strategies, offering valuable insights into how we can better address mental health challenges in younger populations. It is an honor to share his expertise with the ELePHiNt community in this, our first official ELePHiNt interview. Enjoy!

Q1: How does your work integrate neuroscience into early intervention strategy?

A1:

Dr. Palaniyappan outlines three main approaches employed by his team to integrate neuroscience into early intervention strategies.

The first approach focuses on studying the mechanisms underlying human experiences, particularly the symptoms frequently reported by patients. Dr. Palaniyappan explains that these experiences are often underpinned by neural abnormalities, making it essential to use neuroscientific tools for a deeper understanding. He stresses the importance of investigating the "neuroscientific building blocks of human experience," starting with clinical observations and expanding this knowledge using neuroscientific techniques.

The second approach is aimed at improving how these human experiences are measured. Dr. Palaniyappan highlights the challenging impact that distress can have on a patient's ability to accurately perceive their own symptoms. “In psychosis, we talk about lack of insight... Almost everything that is stigmatizing in mental health revolves around this issue: people don’t appreciate their problems as much as others do.” This gap in self-awareness indicates the need for better measurement methods, beyond self-reported responses. One strategy that Dr. Palaniyappan’s team uses is analyzing language. "We try to use language to capture speech as a verbal behavior... and analyze it in a very granular way to see if we can come up with more objective ways of quantifying human experiences."

The third approach focuses on preventing mental health problems before they become entrenched. “The word ‘cure’ doesn’t exist in psychiatry or psychology,” Dr. Palaniyappan notes. "Once these problems are entrenched, they are quite difficult to completely get rid of.” However, prevention presents its own costs and challenges. As Dr. Palaniyappan emphasizes, prevention requires two elements: a comprehensive understanding of underlying mechanisms to develop means of interception, and the ability to select people who are in the highest need of preventive interventions. “Unless we adopt a system-wide approach that combines all the different risk factors to target people who are most in need, we will not achieve prevention. So, the third thing we do is hone in and use all the neuroscientific tools we can to identify those people for whom a specific intervention would result in prevention.”

Q2: Has using all these tools, rather than committing to a single technology, led to unexpected successes or insights in your research that you might not have seen otherwise?

A2:

“I think the most important outcome [of clinical research] is improving a patient’s life”, says Dr. Palaniyappan.  “As a clinician, that’s where I start—I ask, ‘What needs to be done to improve a patient’s life?’ Asking that question, leads you to realize that none of the existing knowledge we have is independently sufficient to get to this outcome. Each approach we’ve taken so far has only brought us part of the way; it hasn’t allowed us to cover all of the distance.” He goes on to discuss their current focus on language research, which incorporates a wide range of disciplines. "When you delve into language, you delve into cognition, neuroimaging, speech and language therapy, psychology, sociolinguistics, migration, anthropology... the list goes on." Dr. Palaniyappan believes that combining such diverse perspectives creates fertile ground for breakthroughs. By blending goal-driven research with theory-driven approaches, like the ones grounded in linguistics, a new space opens for innovation. And, according to Dr. Palaniyappan, this multidisciplinary approach often leads to new insights. "Whenever a trainee encounters this broad approach, they immediately see the limitations of their prior understanding of science. They come to recognize that the field is an expansive playground, where one need not adhere to the conventional paths to attain desired outcomes. You have the liberty to forge your own path, something that can happen only when there is a convergence of multiple disciplines."

Q3: How do you implement patient perspectives into your research?

A3:

“The whole idea of integrating patient experience comes largely from sociology,” explains Dr. Palaniyappan, noting the influential research of Erving Goffman, an Albertan whose early life was spent in Manitoba. “[Goffman] studied the sociology of asylums. How do people behave daily in mental institutions? How do patients behave? How do staff behave? Why is there a uniform for patients, or a different place for eating for patients and a different place for staff? All these sociological musings really opened [our] eyes to the determinants and outcomes of mental illnesses.”

One important lesson that emerged from this movement, says Dr. Palaniyappan, is that “no one single group of professionals could be experts in mental health […] you must have a multi-domain expertise to solve the problem of mental health. And one [form of] expertise that often gets overlooked is the expertise that patients bring themselves.” One reason for this, he adds, is the generational, cultural and epistemic divide that often exists between patient and caregiver. “To address this divide, to really get on the same level as the sufferer, it's important that the provider understands how much they do not know about the sufferer and every shaping force that brought them to the present moment. The same humility is also needed for researchers: we need to reflect on how much we do not know about the suffering we purport to address with our efforts.”

Regarding how these perspectives play into his research, Dr. Palaniyappan notes that much of his work is guided by patient experiences. For example, his work on speech and language is shaped by the question: “Why do people come to see clinicians? To do what? Most often, they come to us to speak with us, not for anything else. Psychotherapy is thoughtful talking. This makes speech a natural object of enquiry for mental health. So really, all of these questions about what tools we use and what questions we ask are dictated by patient perspectives, at least for our research program. And I quite enjoy that. Every time they tell us something new, they guide us in a different direction. And it's worked well so far.”

However, one challenge with this approach is bridging the communicative gap between scientists and patients—addressing this, by effectively communicating complex scientific concepts, is critical to encourage motivated patients to engage in research. “The concepts we refer to when undertaking scientific endeavors is very different from the concepts people refer to when they go through mental health experiences. How do we train ourselves as scientists to speak the language of patients? I think if we bridge that gap systematically, the questions we ask will be much more refined, ideals more aligned and the answers more relevant to the daily lives of patients.”

Q4: How do you ensure that the findings of your research are translated into interventions that are culturally sensitive and accessible to diverse populations? In other words, how do you ensure that your research supports the development of generalizable interventions?

A4:

“I think generalizability has been oversold,” says Dr. Palaniyappan, expressing that he believes it should not be the holy grail. “When you measure something like hemoglobin”, says Dr. Palaniyappan “you go to a lab, and if your value is within a certain range, it is considered normal. This is a very common clinical assessment, but the 'range' can vary depending on the lab, the specific tests they perform, or even your ethnicity. There is no singular 'healthy range' for hemoglobin, and this applies to everything that we measure. There’s no singular healthy range for any aspect of human health.”

Dr. Palaniyappan stresses that generalizability in mental health research should be viewed with this in mind. “When we talk about generalizability, we need to acknowledge that there won’t be a single acceptable measure, tool or approach for any mental health experience that we want to address.”

Instead, Dr. Palaniyappan advocates for a focus on understanding the contextual factors that influence these metrics. "For example, if I measure someone's coherence in speech, I want to know: Is this affected by gender? If I know this, I can qualify my measurements with statements that give clinicians context to better interpret the reading. Seeking counterfactual explanations must be encouraged more in psychiatric research."

Q5: Are there any current projects that you’re particularly excited about?

A5:

“We’re quite excited about the Bloom cohort”, says Dr. Palaniyappan, describing the project as a cohort of young people, aged nine to 25, who are at high risk of developing mental health issues. "We bring them in every year and assess [their] entire family's behavior and experiences. Psychiatric and psychological assessments are done for everyone, and we also conduct extensive biomarker research." The core idea behind the project, he explains, is to integrate biological, sociological, symptomatic, and experiential data from individuals in challenging environments, to track their progress over time. This work aims to offer insights into the biological and developmental profiles of both at-risk and resilient individuals and may help identify key biomarkers for severe mental illness.

Another exciting aspect of Bloom is its potential for early intervention, which could lead to the prevention or delay of mental illness onset. "Delaying an illness, in itself, is a wonderful outcome. If you can't prevent it, delaying it, say by three years, can allow someone to finish university, get their first job, or meet their partner. So many positive things can happen if you simply postpone the onset of mental illnesses.”

Interview conducted by: Georgia Kruck

Blog post written and edited by: Dominique Lumley