A patient is psychonalised in a psychiatric clinic, in an undated image.Hulton German (GETTY IMAGES)
It is a concern that is particularly familiar to anyone who has ever had to seek psychiatric consultation. Will the day come when mental disorders will be measured partially or completely using objective parameters? Will psychiatrists stop interpreting subjectively, improvising, and operating by trial and error? These are not easy questions; still wasteland. These are questions that, albeit timidly and late, are managing to emerge from their traditional ivory towers: laboratories, universities and research circles. But will they ever be able to reach psychiatric hospitals? To take a look at the future of psychiatry, it is necessary to talk about personalized medicine and precision psychiatry.
Personalized medicine is a medical approach that aims to include as many individual parameters or variables as possible in diagnoses and treatments. That is, moving from a generic treatment for everyone who has a specific symptom or disease to a treatment tailored to the person. It’s nothing new; always leaned towards this model. Hippocrates was already working in the 5th century BC. BC in this way and felt what proportion of blood, mucus, yellow bile or black bile was changed in each patient. Claude Bernard explained in the 19th century: “A doctor is not a doctor for living beings, not even for humanity, but a doctor for the person; and more than that, a physician for a person in certain, particular states of disease, in his peculiarity.”
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The inclusion of fully objective variables in this personalization intent is more recent. A good example of this is the Framingham Study, a research project that began in 1948 in the city of the same name in the US state of Massachusetts and is still ongoing! Thanks to their results, cardiologists are able to classify their patients into different cardiovascular risk groups and thus predict the likelihood of events such as a heart attack. To do this, they take into account clinical variables (such as blood pressure), environmental variables (such as smoking) and biochemical variables (such as cholesterol). Currently, in areas such as oncology, knowing the genetic lineage of the cancer in question is far more crucial to treatment than describing its symptoms or even its precise location. Defining these groups based on a specific biology, defined beyond external symptoms or phenotypes (from Greek phanein, “to appear,” “to show”), allows us to know what is happening to each person and the best treatment to choose for you.
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And what role does psychiatry play in this? Mental disorders and objective measurements. Psychiatry and analytics. Aren’t these great oxymoronic couples? In fact, the sofa is traditionally associated with something subjective. Let’s start with psychoanalysis: what does this dream or symptom mean to you? Or enter a question today: How is your mood? This approach is not necessarily bad, nor is it necessarily good. That’s it: subjective and also very current.
On the other hand, in our collective imagination, the laboratory embodies all the parameters called targets: grams of glucose per deciliter of blood; Millimoles of sodium per liter of blood. They are all immutable and measured with undeniable precision, reliability and validity. Something that is typical of so many other medical specialties.
This is where precision psychiatry comes into play. This term, first used in 2015 by Dr. Coined by Eduard Vieta, it reflects this personalized medicine applied to the study of mental disorders. There are several variables that have come to the fore with a clear message: “I am the one who will let you know what is happening with the patient”; “I will tell you how to treat him.” But often we cannot trust them. Most were rejected outright, others were left out and some are still there trying to convince us. I am thinking, for example, of genetic analysis techniques such as cytochrome P450 genotyping, which have been established with more or less success and are currently used to predict the tolerability of certain medications. I also refer to polygenic risk scores, which examine the influence of hundreds of different mutations on the development of a particular mental disorder. And quite banally, I’m also thinking about all the data that will soon be collected via our smartphones: quantity and quality of sleep, activity patterns during the day and more.
One way or another, no one realizes that these huge, almost infinite data sets will require new and more powerful statistical analysis tools. Indeed, it seems time for artificial intelligence and the newly emerged computational psychiatry; Tools that, from their black box, help us interpret what the human mind apparently lacks the necessary algorithmic power for.
Now that we have reached 2023, scientific progress appears to have reached levels that were unimaginable until recently. One of the most promising areas of research is extracellular vesicles (ECVs), microscopic fat droplets that are continuously released from all cells in our body and contain molecular information (proteins, nucleic acids and lipids) from their place of origin. The important point, our narrative twist, is that in recent years we have learned to isolate from the blood those that come from the brain, “explode” them and analyze their contents. This, in turn, gives us live information about what is specifically happening in our neurons: Are they inflamed? Is there a change in their glucose intake? Is it more of a problem with the function of her mitochondria or another of her mitochondria? Components? The vesicles act as a kind of liquid biopsy and provide us with data directly from our royal organ. And the thing is, many of the parameters that we have measured in blood so far have been general and systemic in nature and could tell us about problems that originated in other places; Maybe in the kidney, maybe in the liver, but it always causes some confusion. VECs change the landscape of variables we can capture and use; a phrase that is not only quantitatively more precise, but also qualitatively different.
In short, this new type of measurement, much more specific and therefore scientifically valid, will greatly facilitate the transition from psychiatric phenotypes (patterns of thoughts, feelings and behavior, as when we speak of “major depressive disorder”) to endophenotypes and biotypes (our biological characteristics). By endophenotyping patients with mental disorders (especially severe ones), we can classify them into biological categories and it will be easier (and more consistent) to limit pharmacological treatment. A blood test can be crucial in determining the right psychotropic medication. A change that could take the following format in queries:
Reason for consultation: “Doctor, I feel so bad that I can’t leave the house, and we’ve already tried five medications.”
The doctor, currently: “I see, let’s change the drug” (next to the relevant clinical guide, prepared according to clinical trials designed according to the phenotypes).
The doctor, in a few years: “I see, let’s order an analysis, analyze your endophenotype and select treatment based on the results.”
Is a revolution imminent? I don’t know it. However, it is clear that there is a new player in the card game of personalized medicine: precision psychiatry. And even though she’s young and inexperienced, she might have the best hand. Take a seat and hold on tight; The show will begin.
This is a text written by the psychiatrist and biologist Cristian Llach after the publication of his book “In the Labyrinth” (Ariel).
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