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Designing psychiatric care to precisely match patients’ biology

Using a new approach that harnesses the power of precision, Stanford Medicine researchers are devising new ways to treat depression.

Leanne Williams, PhD, a professor of psychiatry and behavioral sciences at Stanford Medicine, is a firm believer in something called precision psychiatry.

For most prescription-based psychiatric treatments, physicians opt for sort of a trial-and-error tactic, trying different medications until one seems to help. Precision psychiatry deviates from that mix-and-match approach, instead letting a patient's own biology determine the best treatment.

It all hinges on which of the brain's connections are disrupted in depression and anxiety, and which ones can be improved with different treatments. Using a functional MRI scan, Williams and her colleagues can analyze how a patient's brain responds while at rest and while performing certain tasks like identifying emotions, and use that information to sort that patient into one of eight biotypes, or categories of depression and anxiety.  

"If we already know some medications won't work, we will skip over them and offer patients a medication or other therapy that's more tailored to their type of depression," Williams said.

Williams, founding director of the Stanford Center for Precision Mental Health and Wellness, is co-editor with colleague Laura Hack MD, PhD, of the book Precision Psychiatry, Using Neuroscience Insights to Inform Personally Tailored, Measurement-Based Care.

I spoke with Williams about her precision psychiatry and how she thinks it will change the field. The following is a lightly condensed and edited version of our conversation.

Why is it important now? 

Depression seems to be a new kind of silent killer and cause of disability. During the pandemic, the number of people suffering from depression doubled. Now it's about 2 in 5 adults, up from 1 in 5 the year before the pandemic. For teenagers, it's 1 in 6, which is also an increase.

Some of the difficulty in treating depression is the stigma around discussing mental illness. But we also haven't had the knowledge and the tools to inform choice of treatment. It's so fragmented. What's exciting about precision psychiatry is that we can now better personalize treatments.

If you were to go see your health care provider for another chronic condition, you'd expect some sort of test -- a blood test or, if you broke your leg you'd expect to get some sort of X-ray or scan.

Psychiatrists and psychologists have to rely on clinical judgment and asking questions. It's a trial-and-error process.

Each time they prescribe a new medication, it's usually eight to 10 weeks or a couple of months before the patient knows if it works and, if it doesn't, you try another one or add one. Two-thirds of people don't respond to the first medication that is tried. That's a lot. And if the drug isn't right the first time, the patient sees diminishing returns with each different drug they try.

What would a visit look like for a patient seeking precision psychiatry?

First, they see a psychiatrist, who gathers the patient's life and mental health history. As part of that visit, our center has established a standardized system for quantifying MRIs for psychiatry and a partnership with neuroradiology. In one integrated visit, the psychiatrist would order a particular psychiatry functional MRI. The patient would be in the scan for about 40 minutes. We aim to make the whole visit less than one hour.

As results are processed, the neuroradiologist rules out physical causes for the depression, such as tumors or brain damage. Then the psychiatrist receives a report of the patient's MRI and interprets the biotype -- one of the eight types of depression in precision psychiatry, and meets the patient again and, using clinical judgment and information from the scan, decides the best treatment.

If the treatment included prescribing medication, the psychiatrist would typically order new scans after eight weeks to see if the patient's brain has changed. Once an effective treatment is found, the patient returns twice a year for monitoring.

Are you optimistic about the use of precision psychiatry?

I'm extremely optimistic and realistic. This is a true mission for me. I want to see this change happen in my lifetime - and I'm determined to make it happen. There's such a will for it -- from the patients themselves and from the new generation of health professionals. That gives me optimism and the determination to push through. 

I also have personal motivation: My life partner took his own life in 2015. He was an emergency room doctor who, because of the stigma, didn't feel like he could get treatment because it would go on his record. I hear that story over and over again, in different forms, in so many people. 

I was always on this mission, but that experience made it especially personal.

Photo by agsandrew

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