The science of precision medicine has made leaps in the last two decades. It helps doctors use genetics and other data to figure out how to treat individual patients for a number of diseases, including cancer and cystic fibrosis.
But one exception is mental illness.
A group of Massachusetts-based researchers hopes to change that.
jehannine austin he suffers from anxiety and depression, and as someone who works in health care, as a genetic counselor, he is open to a variety of treatments.
“I’ve talked to so many people over the years who have said, ‘Oh, well, you know, mindfulness meditation or whatever really works for me,’” Austin said.
So Austin, who uses pronouns, went to a meditation class. But with all the quiet time sitting cross-legged, breathing deeply and soaking up his own thoughts, “I basically ended up having a panic attack,” Austin said.
Clearly they would have to try another approach, maybe medication, maybe talk therapy, and it might take a while to find it.
This is the kind of trial and error that is the backbone of the psychiatric profession, and yet many in the field say that should not be the case.
For more than a decade, researchers have been pursuing what is called precision or personalized psychiatry.
“The foundation of precision medicine is harnessing individual differences in our genes, biology, lifestyle, and environment to improve diagnosis, treatment, and prevention,” said Dr. Jordan Smoller of Harvard University, a leader in field.
But even Smoller said that the precision field psychiatry it is still in its infancy, a view held by many others.
“I think we’re not where we are for oncology, infectious diseases, maybe cardiovascular medicine,” said Dr. Tom Insel, former director of the National Institute of Mental Health and now an entrepreneur. “But we are making progress.”
In a virtual conference last month, Insel said that precision psychiatry could help address the current mental health crisis, eventually.
“But my goodness, that’s a slow burn,” Insel said. “And it doesn’t really answer the urgency that so many people are feeling right now, especially through the pandemic.”
As a way to boost research, Smoller and others have launched the Precision Psychiatry Center at Massachusetts General Hospital in Boston, which sponsored the conference.
Part of the center’s work focuses on genetics and part on brain imaging, large data sets, including some animal models.
One goal is to develop new drugs to treat psychiatric disorders, as the field still uses drugs that came on the market decades ago.
But scientists say the complex nature of mental illness, including the elusiveness of clear biomarkers, has made that goal tricky.
“There are thousands of (genetic) variations,” Smoller said. “There is not just one gene for one thing.”
Smoller said researchers have begun to identify gene combinations for major disorders such as schizophrenia and bipolar disorder, but “when it comes to the prospect of … clinical implementation, progress has been somewhat slower.”
Scientists and pharmaceutical companies hope to develop genetic “risk scores” to help predict who will get sick and how an individual might react to a treatment, such as how the body metabolizes certain drugs.
Ideally, that would reduce the trial-and-error time spent on treatments that don’t work, prevent some side effects and, in one of the most active areas of research, even help predict who is most at risk of attempting suicide.
But clinical trials to match genetic profiles to treatment have had mixed results and have yet to lead to a new class of drugs.
Some scientists point out that drug companies may be wary of precision psychiatry because narrowing the pool of people likely to benefit from a drug could reduce their number of clients.
“Of course, the larger the population you can treat with your drug, the greater the commercial opportunity,” said Dr. Morgan Sheng, a scientist at the Cambridge-based Broad Institute, as well as a stakeholder in several pharmaceutical companies. “But… I prefer to sacrifice population size for a high level of efficacy in a smaller population.”
Sheng added that, “If you have a drug that is very effective, you can charge more for it compared to a drug that is less effective. So you can get some benefits from precision medicine, even if you have a smaller population.”
But for now, using genetic profiling to find out who will develop severe mental illness remains difficult.
“The thing is, the tests that we develop that way are never going to be completely accurate,” said Austin, who also spoke at the conference. “There are too many variables in what leads to those results, beyond genetics.”
Those variables include sleep, nutrition, social support and stress management.
Austin, who works at the University of British Columbia, uses family history, rather than genetic testing, to determine if someone has inherited a risk for mental illness. But the risk does not make the outcome inevitable.
“Could we end up in a situation where we have genetic tests that say you’re more likely to benefit from this or that? Yeah, yeah, probably,” Austin said. “But should that supersede other things like clinical judgment or common sense? No, maybe not. It’s something to take in the big picture.”
That’s what researchers at the new center in Boston say they’re trying to do: search for mental health biomarkers, use artificial intelligence and mine other data to advance precision psychiatry, while acknowledging it has a ways to go.