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The Future Of Psychiatry - Precision And Stratification

"Precision psychiatry" has been a buzzword for a few years now. Having been hailed the future of psychiatry, the development of a "stratified" approach, on the other hand, has received less attention.  Like precision psychiatry, it promises better and longer-lasting patient outcomes. The future is already here, according to a group of authors, introducing a 'stratified' approach to help patients suffering from conditions such as depression and attention-deficit hyperactivity disorder (ADHD).

How New Approaches Are Changing Traditional Psychiatry

Traditional psychiatry has been on a journey of transition for a few years now. The goal is to move away from a uniform, one-size-fits-all approach to the treatment of conditions like depression and ADHD. Research suggests that a more personalized approach is likely to be more successful.

Scientists are considering several approaches, including the research domain criteria (RDoC) approach. Introduced around ten years ago, the framework behind this approach aims to integrate different fields. The RDoC approach considers genetics, cells, molecules, circuitry, physiology, behaviour, and self-report. However, despite this approach being studied widely in various pieces of research, it is not yet being implemented in clinical practice.

Instead, clinicians handle psychiatric disorders the same way they have done for decades. Apart from personal clinical experience, their decisions are based on average efficacy, the occurrence of side effects, and the patient’s medical history which can be prone to error.

Looking after patients day-to-day, psychiatrists tend to implement a “stepped care” model. We choose treatments because of their initial efficacy and known side effects. For example, patients suffering from depression are generally treated with psychotherapy and medication first. At the extreme end of the treatment spectrum sit deep brain stimulation and electroconvulsive therapy.

The problem with this approach is that it is centred on the side-effect profile rather than on the likelihood of the patient responding.  Studies have shown that none of the treatments available today is de facto superior to another. In fact, assigning treatments can be like flipping a coin, according to the authors of the stratification paper.

 

Where A Stratified Psychiatry Approach Excels

Stratified psychiatry takes a more personalised and science-based approach. Whilst a truly personalised approach to treating depression and ADHD remains in the future, using biomarkers today can pave the way to personalised psychiatry.

Biomarkers are particular characteristics of the body which clinicians and researchers can use to measure.. In the field of psychiatry, biomarkers are often measured by way of electrophysiological features. Electroencephalograms (EEG) are one of the most effective tools the psychiatric community has today to decide what the best treatment is for a patient. Recent studies have made it clear that biomarkers can be specific to males and females, the class of drug used to treat a patient, and the individual drug.

Using biomarkers, we are already able to predict a patient’s response to a certain type of treatment. Even better, we can predict whether someone is more likely to respond to drug A as opposed to drug B. Stratifying treatment in this way means that clinicians and patients no longer have to factor in a phase of “trial and error” when it comes to selecting the most suitable treatment.

Stratified psychiatry is an important step towards precision psychiatry.

 

The Impact On Depression And ADHD Treatment

Biomarkers measured through EEG are already having an impact on the treatment of major depressive disorder (MDD) and ADHD.

Using the results of EEGs, clinicians can choose more easily between types of medication to treat MDD. Without wanting to minimise the importance of clinical experience, backing up the experience with a scientific way of predicting a successful outcome is better for doctors and patients. Being able to prescribe the most suitable medication based on data gathered directly from the patient leads to the best possible outcome quickly.

Where ADHD is concerned, several studies connected one specific biomarker with a poor response to medication treatment. The same biomarker has now been connected to a successful response to neurofeedback therapy. The findings did not only apply to the initial response but also applied to remission from ADHD.

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Putting It Into Clinical Practice

Stratified psychiatry allows clinicians to make a better-informed choice between established treatments for their patients. Compared to the traditional one-size-fits-all approach there are simply no disadvantages. Using a stratified approach, clinicians can do no harm.

They can avoid a non-response. If doctors know that someone is highly unlikely to respond to one specific treatment, they also know that this patient has a better chance to respond favourably to another.

There may not be an effective treatment for every depression or ADHD patient yet, but a stratified approach allows clinicians to choose the approach most likely to succeed. Taking into account biomarkers as well as individual symptoms and sleep habits allows clinicians to assess a patient more holistically.

Researchers concede that there are numerous factors still to be explored. None of those should stop clinicians today from offering their patients the best possible treatment. At neurocare, we routinely include quantified electroencephalograms (QEEG) in our patient assessment and offer stratified treatments. Our goal is to help you achieve the best possible, long-lasting outcome.

Stratification helps us achieve this now, and it paves the path towards the precision psychiatry of the future.

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