How do we classify and diagnose mental disorders?
In the coming era of Precision Medicine, we'll all want customized treatments that “take into account individual differences in people’s genes, environments, and lifestyles.” To do this, we'll need precise diagnostic tools to identify the specific disease process in each individual. Although focused on cancer in the near-term, the longer-term goal of the White House initiative is to apply Precision Medicine to all areas of health. This presumably includes psychiatry, but the links between Precision Medicine, the BRAIN initiative, and RDoC seem a bit murky at present.1
But there's nothing a good infographic can't fix. Science recently published a Perspective piece by the NIMH Director and the chief architect of the Research Domain Criteria (RDoC) initiative (Insel & Cuthbert, 2015). There's Deconstruction involved, so what's not to like? 2
In this massively ambitious future scenario, the totality of one's genetic risk factors, brain activity, physiology, immune function, behavioral symptom profile, and life experience (social, cultural, environmental) will be deconstructed and stratified and recompiled into a neat little cohort. 3
The new categories will be data driven. The project might start by collecting colossal quantities of expensive data from millions of people, and continue by running classifiers on exceptionally powerful computers (powered by exceptionally bright scientists/engineers/coders) to extract meaningful patterns that can categorize the data with high levels of sensitivity and specificity. Perhaps I am filled with pathologically high levels of negative affect (Loss? Frustrative Nonreward?), but I find it hard to be optimistic about progress in the immediate future. You know, for a Precision Medicine treatment for me (and my pessimism)...
Yes, RDoC is ambitious (and has its share of naysayers). But what you may not know is that it's also trendy! Just the other day, an article in The Atlantic explained Why Depression Needs A New Definition (yes, RDoC) and even cited papers like Depression: The Shroud of Heterogeneity. 4
But let's just focus on the brain for now. For a long time, most neuroscientists have viewed mental disorders as brain disorders. [But that's not to say that environment, culture, experience, etc. play no role! cf. Footnote 3]. So our opening question becomes, How do we classify and diagnose
Our colleagues in Asia and Australia and Europe and Canada may not have gotten the funding memo, however, and continue to run classifiers based on DSM categories. 5 In my previous post, I promised an unsystematic review of machine learning as applied to the classification of major depression. You can skip directly to the Appendix to see that.
Regardless of whether we use DSM-5 categories or RDoC matrix constructs, what we need are robust and reproducible biomarkers (see Table 1 above). A brief but excellent primer by Woo and Wager (2015) outlined the characteristics of a useful neuroimaging biomarker:
1. Criterion 1: diagnosticity[Then the authors evaluated the performance of a structural MRI signature for IBS presented in an accompanying paper.]
Good biomarkers should produce high diagnostic performance in classification or prediction. Diagnostic performance can be evaluated by sensitivity and specificity. Sensitivity concerns whether a model can correctly detect signal when signal exists. Effect size is a closely related concept; larger effect sizes are related to higher sensitivity. Specificity concerns whether the model produces negative results when there is no signal. Specificity can be evaluated relative to a range of specific alternative conditions that may be confusable with the condition of interest.
2. Criterion 2: interpretability
Brain-based biomarkers should be meaningful and interpretable in terms of neuroscience, including previous neuroimaging studies and converging evidence from multiple sources (eg, animal models, lesion studies, etc). One potential pitfall in developing neuroimaging biomarkers is that classification or prediction models can capitalize on confounding variables that are not neuroscientifically meaningful or interesting at all (eg, in-scanner head movement). Therefore, neuroimaging biomarkers should be evaluated and interpreted in the light of existing neuroscientific findings.
3. Criterion 3: deployability
Once the classification or outcome-prediction model has been developed as a neuroimaging biomarker, the model and the testing procedure should be precisely defined so that it can be prospectively applied to new data. Any flexibility in the testing procedures could introduce potential overoptimistic biases into test results, rendering them useless and potentially misleading. For example, “amygdala activity” cannot be a good neuroimaging biomarker without a precise definition of which “voxels” in the amygdala should be activated and the relative expected intensity of activity across each voxel. A well-defined model and standardized testing procedure are crucial aspects of turning neuroimaging results into a “research product,” a biomarker that can be shared and tested across laboratories.
4. Criterion 4: generalizability
Clinically useful neuroimaging biomarkers aim to provide predictions about new individuals. Therefore, they should be validated through prospective testing to prove that their performance is generalizable across different laboratories, different scanners or scanning procedures, different populations, and variants of testing conditions (eg, other types of chronic pain). Generalizability tests inherently require multistudy and multisite efforts. With a precisely defined model and standardized testing procedure (criterion 3), we can easily test the generalizability of biomarkers and define the boundary conditions under which they are valid and useful.
Should we try to improve on a neuroimaging biomarker (or “neural signature”) for classic disorders in which “Neuroanatomical diagnosis was correct in 80% and 72% of patients with major depression and schizophrenia, respectively...” (Koutsouleris et al., 2015)? That study used large cohorts and evaluated the trained biomarker against an independent validation database (i.e., it was more thorough than many other investigations). Or is the field better served by classifying when loss and agency and auditory perception go awry? What would individualized treatments for these constructs look like? Presumably, the goal is to develop better treatments, and to predict who will respond to a specific treatment(s).
OR should we adopt the surprisingly cynical view of some prominent investigators, who say:
...identifying a genuine neural signature would necessitate the discovery of a specific pattern of brain responses that possesses nearly perfect sensitivity and specificity for a given condition or other phenotype. At the present time, neuroscientists are not remotely close to pinpointing such a signature for any psychological disorder or trait...
If that's true, then we'll have an awfully hard time with our resting state fMRI classifier for neuro-nihilism.
1 Although NIMH Mad Libs does a bang up job...
2 Derrida's Deconstruction and RDoc are diametrically opposed, as irony would have it.
3 Or maybe an n of 1... I'm especially curious about how life experience will be incorporated into the mix. Perhaps the patient of the future will upload all the data recorded by their memory implants, as in The Entire History of You (an episode of Black Mirror).
4 The word “shroud” always makes everything sound so dire and deathly important... especially when used as a noun.
5 As do many research groups in the US. This is meant to be snarky, but not condescending to anyone who follows DSM-5 in their research.
Insel, T., & Cuthbert, B. (2015). Brain disorders? Precisely. Science, 348 (6234), 499-500 DOI: 10.1126/science.aab2358
Woo, C., & Wager, T. (2015). Neuroimaging-based biomarker discovery and validation. PAIN, 156 (8), 1379-1381 DOI: 10.1097/j.pain.0000000000000223
Below are 34 references on MRI/fMRI applications of machine learning used to classify individuals with major depression (I excluded EEG/MEG for this particular unsystematic review). The search terms were combinations of "major depression" "machine learning" "support vector" "classifier".
Here's a very rough summary of methods:
Structural MRI: 1, 14, 22, 29, 31, 32
DTI: 6, 12, 18, 19
Resting State fMRI: 3, 5, 8, 9 11, 16, 17, 21, 28, 33
fMRI while viewing different facial expressions: 2, 7, 10, 24, 26, 27, 34
comorbid panic: 13
verbal working memory: 25
guilt: 15 (see The Idiosyncratic Side of Diagnosis by Brain Scan and Machine Learning)
Schizophrenia vs. Bipolar vs. Schizoaffective: 16
Psychotic Major Depression vs. Bipolar Disorder: 20
Schizophrenia vs. Major Depression: 23, 31
Unipolar vs. Bipolar Depression: 24, 32, 34
This last one is especially important, since an accurate diagnosis can avoid the potentially disastrous prescribing of antidepressants in bipolar depression.
Idea that may already be implemented somewhere: Individual labs or research groups could perhaps contribute to a support vector machine clearing house (e.g., at NTRIC or OpenfMRI or GitHub) where everyone can upload the code for data processing streams and various learning/classification algorithms to try out on each others' data.
Brain. 2012 May;135(Pt 5):1508-21. doi: 10.1093/brain/aws084.
Multi-centre diagnostic classification of individual structural neuroimaging scans from patients with major depressive disorder.
Mwangi B Ebmeier KP, Matthews K, Steele JD.
Bipolar Disord. 2012 Jun;14(4):451-60. doi: 10.1111/j.1399-5618.2012.01019.x.
Pattern recognition analyses of brain activation elicited by happy and neutral faces in unipolar and bipolar depression.
Mourão-Miranda J Almeida JR, Hassel S, de Oliveira L, Versace A, Marquand AF, Sato JR, Brammer M, Phillips ML.
PLoS One. 2012;7(8):e41282. doi: 10.1371/journal.pone.0041282. Epub 2012 Aug 20.
Changes in community structure of resting state functional connectivity in unipolar depression.
Lord A Horn D, Breakspear M, Walter M.
Neuroreport. 2012 Dec 5;23(17):1006-11. doi: 10.1097/WNR.0b013e32835a650c.
Machine learning classifier using abnormal brain network topological metrics in major depressive disorder.
Guo H Cao X, Liu Z, Li H, Chen J, Zhang K.
PLoS One. 2012;7(9):e45972. doi: 10.1371/journal.pone.0045972. Epub 2012 Sep 26.
Increased cortical-limbic anatomical network connectivity in major depression revealed by diffusion tensor imaging.
Fang P Zeng LL, Shen H, Wang L, Li B, Liu L, Hu D.
PLoS One. 2013;8(4):e60121. doi: 10.1371/journal.pone.0060121. Epub 2013 Apr 1.
What does brain response to neutral faces tell us about major depression? evidence from machine learning and fMRI.
Oliveira L Ladouceur CD, Phillips ML, Brammer M, Mourao-Miranda J.
Hum Brain Mapp. 2014 Apr;35(4):1630-41. doi: 10.1002/hbm.22278. Epub 2013 Apr 24.
Unsupervised classification of major depression using functional connectivity MRI.
Zeng LL Shen H, Liu L, Hu D.
Psychiatry Clin Neurosci. 2014 Feb;68(2):110-9. doi: 10.1111/pcn.12106. Epub 2013 Oct 31.
Aberrant functional connectivity for diagnosis of major depressive disorder: a discriminant analysis.
Neuroimage. 2015 Jan 15;105:493-506. doi: 10.1016/j.neuroimage.2014.11.021. Epub 2014 Nov 15.
Sparse network-based models for patient classification using fMRI.
Rosa MJ Portugal L Hahn T Fallgatter AJ Garrido MI Shawe-Taylor J Mourao-Miranda J.
Proc IEEE Int Symp Biomed Imaging. 2014 Apr;2014:246-249.
ELUCIDATING BRAIN CONNECTIVITY NETWORKS IN MAJOR DEPRESSIVE DISORDER USING CLASSIFICATION-BASED SCORING.
Sacchet MD Prasad G Foland-Ross LC Thompson PM Gotlib IH.
Front Psychiatry. 2015 Feb 18;6:21. doi: 10.3389/fpsyt.2015.00021. eCollection 2015.
Support vector machine classification of major depressive disorder using diffusion-weighted neuroimaging and graph theory.
Sacchet MD Prasad G Foland-Ross LC Thompson PM Gotlib IH.
J Affect Disord. 2015 Sep 15;184:182-92. doi: 10.1016/j.jad.2015.05.052. Epub 2015 Jun 6.
Separating depressive comorbidity from panic disorder: A combined functional magnetic resonance imaging and machine learning approach.
Lueken U Straube B Yang Y Hahn T Beesdo-Baum K Wittchen HU Konrad C Ströhle A Wittmann A Gerlach AL Pfleiderer B, Arolt V, Kircher T.
PLoS One. 2015 Jul 17;10(7):e0132958. doi: 10.1371/journal.pone.0132958. eCollection 2015.
Structural MRI-Based Predictions in Patients with Treatment-Refractory Depression (TRD).
Johnston BA Steele JD Tolomeo S Christmas D Matthews K.
Psychiatry Res. 2015 Jul 5. pii: S0925-4927(15)30025-1. doi: 10.1016/j.pscychresns.2015.07.001. [Epub ahead of print]
Machine learning algorithm accurately detects fMRI signature of vulnerability to major depression.
Sato JR Moll J Green S Deakin JF Thomaz CE Zahn R.
Neuroimage. 2015 Jul 24. pii: S1053-8119(15)00674-6. doi: 10.1016/j.neuroimage.2015.07.054. [Epub ahead of print]
A group ICA based framework for evaluating resting fMRI markers when disease categories are unclear: Application to schizophrenia, bipolar, and schizoaffective disorders.
Du Y Pearlson GD Liu J Sui J Yu Q He H Castro E Calhoun VD.
Neuroreport. 2015 Aug 19;26(12):675-80. doi: 10.1097/WNR.0000000000000407.
Predicting clinical responses in major depression using intrinsic functional connectivity.
Qin J, Shen H, Zeng LL, Jiang W, Liu L, Hu D.
J Affect Disord. 2015 Jul 15;180:129-37. doi: 10.1016/j.jad.2015.03.059. Epub 2015 Apr 4.
Altered anatomical patterns of depression in relation to antidepressant treatment: Evidence from a pattern recognition analysis on the topological organization of brain networks.
Qin J, Wei M, Liu H Chen J Yan R Yao Z Lu Q.
Magn Reson Imaging. 2014 Dec;32(10):1314-20. doi: 10.1016/j.mri.2014.08.037. Epub 2014 Aug 29.
Abnormal hubs of white matter networks in the frontal-parieto circuit contribute to depression discrimination via pattern classification.
Qin J, Wei M, Liu H Chen J Yan R Hua L Zhao K Yao Z Lu Q.
Biomed Res Int. 2014;2014:706157. doi: 10.1155/2014/706157. Epub 2014 Jan 19.
Neuroanatomical classification in a population-based sample of psychotic major depression and bipolar I disorder with 1 year of diagnostic stability.
Serpa MH, Ou Y Schaufelberger MS Doshi J Ferreira LK Machado-Vieira R Menezes PR Scazufca M Davatzikos C Busatto GF Zanetti MV.
Psychiatry Res. 2013 Dec 30;214(3):306-12. doi: 10.1016/j.pscychresns.2013.09.008. Epub 2013 Oct 7.
Identifying major depressive disorder using Hurst exponent of resting-state brain networks.
Wei M Qin J, Yan R, Li H, Yao Z, Lu Q.
J Psychiatry Neurosci. 2014 Mar;39(2):78-86.
Characterization of major depressive disorder using a multiparametric classification approach based on high resolution structural images.
Qiu L Huang X Zhang J Wang Y Kuang W Li J Wang X Wang L Yang X Lui S Mechelli A Gong Q2.
PLoS One. 2013 Jul 2;8(7):e68250. doi: 10.1371/journal.pone.0068250. Print 2013.
Convergent and divergent functional connectivity patterns in schizophrenia and depression.
Yu Y Shen H, Zeng LL, Ma Q, Hu D.
Eur Arch Psychiatry Clin Neurosci. 2013 Mar;263(2):119-31. doi: 10.1007/s00406-012-0329-4. Epub 2012 May 26.
Discriminating unipolar and bipolar depression by means of fMRI and pattern classification: a pilot study.
Grotegerd D Suslow T, Bauer J, Ohrmann P, Arolt V, Stuhrmann A, Heindel W, Kugel H, Dannlowski U.
Neuroreport. 2008 Oct 8;19(15):1507-11. doi: 10.1097/WNR.0b013e328310425e.
Neuroanatomy of verbal working memory as a diagnostic biomarker for depression.
Marquand AF Mourão-Miranda J, Brammer MJ, Cleare AJ, Fu CH.
Biol Psychiatry. 2008 Apr 1;63(7):656-62. Epub 2007 Oct 22.
Pattern classification of sad facial processing: toward the development of neurobiological markers in depression.
Fu CH Mourao-Miranda J, Costafreda SG, Khanna A, Marquand AF, Williams SC, Brammer MJ.
Neuroreport. 2009 May 6;20(7):637-41. doi: 10.1097/WNR.0b013e3283294159.
Neural correlates of sad faces predict clinical remission to cognitive behavioural therapy in depression.
Costafreda SG Khanna A, Mourao-Miranda J, Fu CH.
Magn Reson Med. 2009 Dec;62(6):1619-28. doi: 10.1002/mrm.22159.
Disease state prediction from resting state functional connectivity.
Craddock RC Holtzheimer PE 3rd, Hu XP, Mayberg HS.
Neuroimage. 2011 Apr 15;55(4):1497-503. doi: 10.1016/j.neuroimage.2010.11.079. Epub 2010 Dec 3.
Prognostic prediction of therapeutic response in depression using high-field MR imaging.
Gong Q Wu Q, Scarpazza C, Lui S, Jia Z, Marquand A, Huang X, McGuire P, Mechelli A.
Neuroimage. 2012 Jun;61(2):457-63. doi: 10.1016/j.neuroimage.2011.11.002. Epub 2011 Nov 7.
Diagnostic neuroimaging across diseases.
Klöppel S Abdulkadir A, Jack CR Jr, Koutsouleris N, Mourão-Miranda J, Vemuri P.
Brain. 2015 Jul;138(Pt 7):2059-73. doi: 10.1093/brain/awv111. Epub 2015 May 1.
Individualized differential diagnosis of schizophrenia and mood disorders using neuroanatomical biomarkers.
Koutsouleris N Meisenzahl EM Borgwardt S Riecher-Rössler A Frodl T Kambeitz J Köhler Y Falkai P Möller HJ Reiser M Davatzikos C.
JAMA Psychiatry. 2014 Nov;71(11):1222-30. doi: 10.1001/jamapsychiatry.2014.1100.
Brain morphometric biomarkers distinguishing unipolar and bipolar depression. A voxel-based morphometry-pattern classification approach.
Redlich R Almeida JJ Grotegerd D Opel N Kugel H Heindel W Arolt V Phillips ML Dannlowski U.
Brain Behav. 2013 Nov;3(6):637-48. doi: 10.1002/brb3.173. Epub 2013 Sep 22.
A reversal coarse-grained analysis with application to an altered functional circuit in depression.
Guo S Yu Y Zhang J Feng J.
Hum Brain Mapp. 2014 Jul;35(7):2995-3007. doi: 10.1002/hbm.22380. Epub 2013 Sep 13.
Amygdala excitability to subliminally presented emotional faces distinguishes unipolar and bipolar depression: an fMRI and pattern classification study.
Grotegerd D Stuhrmann A, Kugel H, Schmidt S, Redlich R, Zwanzger P, Rauch AV, Heindel W, Zwitserlood P, Arolt V, Suslow T, Dannlowski U.
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