Next Decade Could Usher in Precision Medicine in Psychiatry

October 1, 2020

This edition from the 10 Year Plan features perspective from leadership at APA and AADPRT, as well as survey results from psychiatrists.

Everything can work exactly as planned: the patient gets screened for and diagnosed with a psychiatric disorder like generalized anxiety disorder (GAD) and the doctor develops a therapy and medication plan.

However, the success of this plan often relies on an educated trial and error type decision regarding which antidepressant drug will be effective on a given patient and for many it takes several different medications before the correct 1 is selected.

But change could be on the way in the next decade as many in the industry feel personalized and precision medicine is a realistic possibility by 2030 as advancements in the understanding of biomarkers could usher in a brand new era of medicine at a time where it might be needed the most.

“One of the biggest challenges we have in psychiatry is that we have a steadily growing range of good evidence based treatments, but they work for a relatively small percentage of people,” Jonathan E. Alpert, MD, PhD, Montefiore Medical Center said to HCPLive®. “I think we'll be a good deal further toward precision medicine a decade from now in being able to identify subsets of people who have a very high probability of responding to a given treatment, that might only work in a third of people if we're looking at a large population, but would work very well in that particular subset of people.”

An example of this is found in major depressive disorder (MDD). While there are dozens of US Food and Drug Administration (FDA) approved antidepressants available to patients suffering from MDD, there is only about a 33% chance that an individual will respond to that treatment.

“For the other two-thirds of people, they often need to go on to many of the treatments, and a lot of those treatments are chosen by thoughtful trial and error,” Alpert, who also serves on the Council on Research for the American Psychiatric Association (APA), said. “So we know a lot about effective treatments, we know a lot about conditions like depression, but in terms of matching our treatments to the people who would most benefit and skipping over those people who won't benefit from treatment A but would benefit from treatment C, we still have a long way to go.”

The trial and error period currently used in medicine can be life-threatening for many patients. The wrong treatment could have a major impact on occupational function or education for the patient, leading to frequent changes in employment, disruptions in relationships, or the potential to drop out of high school or college.

Alpert said the industry is gathering more and more data both on what clinical features predict response to medications or psychotherapy treatment and beginning to try to put them together. This advancement includes neuromodulation stimulation treatments with biomarkers to predict whether there are genetic biomarkers, neuroimaging biomarkers or biomarkers of inflammation and to begin and try to put it all together to make a more cohesive treatment plan.

The crossroads between genetics and neuroscience could be what breaks open the floodgates for personalized or precision medicine.

“Compared to 10 years ago, we know a lot more about how individuals can be different based on your cytochromes, where you might be more sensitive to a medication versus if it started on me because of our ancestry,” Rashi Aggarwal, MD, co-chair of the American Association of Directors of Psychiatric Residency Training workforce task force, said. “There's some development there that had laid the groundwork for future development and then there is a lot of research that has happened in neuroscience to really sort understand the brains of our patients a lot more than we did 10 years ago.”

More Treatment Options on the Horizon

Treatments are getting better in various psychiatric conditions, including schizophrenia and anxiety disorders, Alpert explained. There is now a stable of evidence-based treatments—both psychotherapy and forms of talk therapy and neurostimulation treatments.

The history of treating depression dates back to the 1950s and 1960s with the advent of antidepressants. Since then most of the newer treatments have been based on the original medications. However, in the past 2 years there have been a number of new antidepressants that work by novel mechanisms.

These treatments, including esketamine and brexanolone, also work very rapidly, while the majority of past antidepressants take some time for effectiveness.

Integrated Strategies

While better medicine will continue have a major impact, integrating strategies could emerge as a popular tool in the next decade, where internists call on specialists like psychiatrists to provide additional add to patients who might be suffering from mental health issues.

Implementing integrated strategies ultimately could have an impact on personalized medicine.

“It's called collaborative care and that model sort of addresses both the shortage to some degree and the cooperation and collaboration,” Aggarwal said. “In the physical model, what works is that you have a primary care provider, and in their clinic or in a couple of their clinics, there's also a mental health specialist or behavioral health specialist who could be social work or nursing and then they have a psychiatrist who is a collaborate care specialist.”

In this model, the psychiatrist might never physically see the patient, but can impact care of that patient.

Geriatric Psychiatry

Personalized medicine might be especially important in geriatric psychiatry in the next 10 years.

The population is aging and the “baby boomer” generation will soon be entering into their senior years, increasing the demand for psychiatrists that specialize in geriatrics. However, generally fewer psychiatrists specialize in geriatrics, meaning that every psychiatrist should begin to have training so they can handle the unique nature of the aging population within their general practice.

While Alpert said the next decade might include workforce shortages in general, medical students are going to need to learn how to treat geriatric patients before entering the field.

“All psychiatrists will need to know something about geriatric psychiatry, because the median age of the patients that psychiatrists treat will be higher than it than it has been,” he said. “And when we look at the prevalence of disorders like dementia, they're very much age related, not surprisingly and over a third of people aged 85 or above have some form of dementia.”

Despite pessimism about the current state of psychiatry, the field scores well (8.1/10) in terms of optimism for the future.