Chapter 1

My name is Hugh Nguyen. My Vietnamese name was Huy. I was born in Saigon, Vietnam, with a cataract in my left eye. As a result, my right eye has been my primary source of vision throughout my life.

My mother was a nurse. She came from a small town in Bình Định Province, a central coastal province of Vietnam. She was an excellent student, particularly in mathematics and biology. In my opinion, she worked so hard because she wanted to pass the high school exit examination, known as Tú Tài, and continue her education in Saigon, the capital of South Vietnam at the time.

My father was from Tân An, the largest town in Long An Province in southern Vietnam. He was also an excellent student. He passed the high school exit examination with honors and eventually became an officer in the Army of the Republic of Vietnam (ARVN), the armed forces of South Vietnam during the Vietnam War.

The war changed my father profoundly. He had once been a shy, studious young man from a devout Catholic family. But during his years as a soldier, he became an alcoholic. I imagine that, for many soldiers, alcohol may have provided a temporary escape from the stress and trauma of war.

One of my father’s sisters, my youngest aunt, was also different from the other members of our family. She rarely spoke, even when I met her as a child. Looking back many years later, after studying psychopharmacology in pharmacy school, I began to wonder whether there might have been a neurodevelopmental component in my father’s family that had influenced me as well. At the time, however, I had no understanding of genetics, neurodevelopment, or how complicated the relationship between heredity and mental health could be.

Chapter 2

My father met my mother when he was a patient at Chợ Rẫy Hospital, one of the largest hospitals in Saigon. He had come to the hospital because of a recurring wound related to his military service during the Vietnam War. My mother was the nurse who took care of him.

At the time, my mother was twenty-eight years old—an age when, in Vietnamese society, many women were already married and had children. There was also a Vietnamese superstition that men should avoid marrying women born under the zodiac sign of the tiger because such women were considered strong-willed and difficult to control.

My mother was from Bình Định, a province famous for its tradition of martial arts. In the eyes of some people, this only reinforced the stereotype of the strong and formidable Bình Định woman. As a result, many of the men who worked with my mother at the hospital were apparently hesitant to become romantically involved with her.

My father was different.

He was a former South Vietnamese soldier—the side that had lost the Vietnam War—and had recently been released from a reeducation camp. He was unemployed and trying to rebuild his life under the new Communist government. Yet none of that seemed to stop him from pursuing my mother.

In the fall of 1978, my parents were married with the blessings of both families.

Chapter 3

After their marriage, my mother was assigned a tiny apartment by her employer, Chợ Rẫy Hospital, in District 5, the Chinatown district of Saigon. The apartment was small, and my grandparents—farmers from Bình Định Province—quickly realized that it would not be large enough once my parents started having children.

So my grandparents began looking for a larger home.

They eventually found a relatively spacious house tucked away in an alley in Saigon. At the time, many houses in the city were narrow and tall, almost like vertical rectangles. But this house was different. Hidden inside an alley, it reminded my grandparents more of the homes they had known in rural Vietnam.

It turned out to be one of the best investments they ever made.

I was born shortly after they purchased the house, in the summer of 1979. A little more than a year later, my younger brother, David, was born.

For a while, life could not have been better for my father. Because he was unable to find work under the new Communist government, he became a stay-at-home father and took care of my brother and me while my mother became the family’s breadwinner.

But unemployment was difficult for my father.

During the 1980s, he continued to turn to alcohol as a way of coping with his circumstances. He had already experienced the psychological burden of war, military service, imprisonment in a reeducation camp, unemployment, and the loss of the life he had once known. Now he found himself at home, responsible for two young children, while my mother worked long hours to support the family.

As a child, I did not understand the forces acting on him. I did not know about trauma, addiction, depression, neurobiology, or the ways in which the brain responds to prolonged stress.

I simply knew that my father drank.

Looking back many years later, after studying pharmacy, pharmacology, and psychopharmacology, I began to see his drinking differently. I sometimes think of alcohol as his own form of an “antidepressant”—not a medication prescribed by a physician, of course, but a substance he used to temporarily change how he felt.

Alcohol could make him feel different, at least for a while. It could dull emotional pain, reduce anxiety, and provide an escape from thoughts and circumstances that were difficult to confront. But the relief was temporary, and the consequences could be devastating.

That observation eventually led me to a question that would become much more personal.

Why do substances and medications change the way people think, feel, and behave—and why do they work so differently from one person to another?

I would eventually encounter that question not only through my father, but through my own life.

Years later, I experienced depression and obsessive-compulsive disorder. Like millions of other people, I turned to medication in the hope that it would help. But I discovered something that many patients already know: finding an effective psychiatric medication can be an extraordinarily uncertain process.

A physician or psychiatrist may have several reasonable treatment options. Yet there is often no simple way to know, before treatment begins, which medication will work best for a particular individual.

The usual approach can involve what is essentially a process of trial and error.

A patient starts one medication. The dose is adjusted. Weeks may pass while everyone waits to see whether symptoms improve. If the medication does not work—or if the adverse effects become intolerable—the medication may be discontinued and another one tried.

Then the process begins again.

For someone suffering from depression, OCD, or another psychiatric disorder, these waiting periods are not merely an inconvenience. They represent time spent living with symptoms that may already be interfering with work, relationships, sleep, and everyday life.

There is another complication.

Psychiatric medications can produce very different responses in different people. One person may experience substantial improvement from a particular antidepressant, while another may experience little benefit. A third person may experience troublesome adverse effects. Even when two people have the same diagnosis, the medication that works well for one may not work well for the other.

Why?

Part of the answer may lie in our biology.

Genetic differences can influence how the body absorbs, metabolizes, transports, and responds to medications. Genes involved in drug metabolism—such as some of the cytochrome P450 enzymes—can affect the concentrations of certain medications in the body. Other genetic differences may influence neurotransmitter systems, receptors, signaling pathways, and other biological processes involved in psychiatric illness and treatment response.

But genetics is only one piece of the puzzle.

Age, sex, other medications, medical conditions, environmental factors, adherence, previous treatment history, lifestyle, and the complexity of the underlying psychiatric disorder can all influence whether a medication helps.

This creates a frustrating paradox.

Modern medicine has enormous amounts of biological and clinical information, yet much of psychiatric prescribing still begins with a question that is difficult to answer:

“Which medication should we try first?”

And if the first medication does not work, the patient may have to start the process again.

This made me wonder whether we could approach the problem differently.

What if, instead of treating every patient as an isolated experiment, we could learn systematically from the experiences of millions of patients who had already taken these medications?

Imagine a secure, centralized, voluntary database in which people could choose to contribute information about their treatment experiences. With appropriate privacy protections and informed consent, participants could contribute information such as their diagnosis, medications taken, dosage, treatment duration, therapeutic response, adverse effects, relevant clinical characteristics, and—if they choose—genomic information.

The fundamental idea would be simple:

Learn from the people who came before us.

Suppose 100,000 people had taken the same antidepressant. Imagine that a subset of those individuals had also voluntarily contributed genomic data. We could potentially study whether particular genetic variants—or combinations of variants—were associated with treatment response, adverse effects, or medication metabolism.

Now imagine doing this across many medications and many psychiatric conditions.

Instead of asking only:

“What does the clinical trial tell us about the average patient?”

we could begin asking:

“What can we learn from the treatment histories of people who are biologically similar to this patient?”

That distinction could be important.

Traditional randomized clinical trials are indispensable because they allow researchers to determine whether a treatment works under controlled conditions. But clinical trials generally study relatively limited populations and are not designed to capture every possible combination of genetics, medical history, lifestyle, concurrent medications, and real-world circumstances.

A large, carefully designed real-world database could complement clinical trials by providing another layer of evidence.

The goal would not be to create an algorithm that simply says:

“You have this gene, therefore you should take this antidepressant.”

Biology is far too complicated for such a simplistic approach.

Instead, the goal would be to develop a probabilistic decision-support system.

For example:

“Among people with a similar clinical profile and genetic characteristics, Medication A was associated with a higher probability of response and a lower probability of experiencing Adverse Effect X than Medication B.”

That would not replace a physician or psychiatrist.

It would give them more information.

And perhaps that is where the future of psychiatric medicine lies—not in replacing clinical judgment, but in augmenting it with better data.

The idea also raises important ethical questions.

Who owns a person’s genomic information?

How should genetic information be protected?

Who should be allowed to access the database?

How do we prevent insurance companies, employers, pharmaceutical companies, or other organizations from misusing someone’s genetic or psychiatric information?

How do we prevent algorithms trained on biased data from making biased recommendations?

And perhaps most importantly, how do we ensure that people participate voluntarily and understand exactly how their information will be used?

These questions cannot be treated as technical details. They are central to the entire concept.

A genomic-treatment database would therefore have to be built around privacy, informed consent, transparency, security, and patient control. Participants should understand what information they are contributing, what research it may support, and what risks are involved.

The database could also become something larger than a tool for individual prescribing.

It could become a living research resource.

Researchers could study why some people respond to particular antidepressants while others do not. They could investigate patterns of adverse effects. They could examine interactions between genetics and environmental factors. They could potentially identify previously unknown biological pathways associated with treatment response.

Over time, the system could become increasingly informative as more people voluntarily contributed their experiences.

In that sense, every patient’s experience could become part of a larger scientific experiment—not an experiment imposed on the patient, but a collective learning system built from experiences people have freely chosen to share.

This idea brings me back to my father.

He never had access to modern psychopharmacology. He certainly did not have access to pharmacogenomics, artificial intelligence, or large-scale clinical databases. When he struggled emotionally, he turned to the substance that was available to him.

Alcohol.

Perhaps it helped him escape for a few hours.

But it did not solve the underlying problem.

Decades later, when I encountered my own struggles with depression and OCD, medicine had advanced enormously. We had hundreds of psychiatric medications, sophisticated neuroscience, genetic testing, and an extraordinary amount of scientific knowledge.

And yet one fundamental problem remained:

We still cannot reliably predict which medication will work best for a particular person.

That is the problem I want to explore.

Perhaps the next generation of psychiatric medicine will not simply be about discovering more medications.

Perhaps it will be about becoming much better at matching the right treatment to the right person.

And perhaps the experiences of patients themselves—combined with clinical data, pharmacology, genomics, and artificial intelligence—could help us get there.

My father’s generation taught me how devastating it can be when people have few effective ways to manage psychological suffering.

My own experience taught me that even when treatments exist, finding the right one can still be difficult.

Those two experiences eventually led me to a question:

What if we could use the collective experiences of patients to make psychiatric treatment more personal, more predictive, and less dependent on trial and error?