Tuesday, November 30, 2021

Is Precision Psychiatry Realistic?

Fig. 1 (Fernandes et al., 2017). Domains related to ‘precision psychiatry’.

The right drug for the right patient” was a catch phrase in the early years of the personalized medicine movement (2000), represented by the emerging field of pharmacogenomics. No more “one size fits all” prescribing — the Human Genome Project will allow doctors to predict how you will respond to any given medication.

The last time I went to the drug store, I picked up my cheap generic prescription without the benefit of genomic testing.

The term “personalized medicine” was outdated by 2011. The National Research Council (PDF) preferred the new and improved “precision medicine” brand because...

...there was concern that the word "personalized" could be misinterpreted to imply that treatments and preventions are being developed uniquely for each individual; in precision medicine, the focus is on identifying which approaches will be effective for which patients based on genetic, environmental, and lifestyle factors.

What is Precision Psychiatry?

If you believe the hype (circa 2017), it's a paradigm shift! It's perfection! [yes, really]...
...a high level of exactness in measurement will be achieved such that, eventually, it will be personalised. It can be conceptualised as a highly sophisticated and intricate classification system, where infinitesimal categories will, ideally, attain perfection in a detailed multidimensional classification.

...It's quixotic (if taken to those lofty extremes). Precision psychiatry is an incredibly popular topic for review papers, but don't hold your breath awaiting its implementation. Especially if you're a patient. 

What is Stratified Psychiatry?

Fig. 1 (Arns et al., 2021). An infographic summarizing the more ‘diagnostic based one-size-fits-all psychiatry’ that is currently in use (left), to more ‘prognostic’ models such as Stratified Psychiatry (right-top) and Precision Psychiatry (right-bottom).

Perhaps Stratified Psychiatry is more realistic, where subgroups of patients with similar biomarker profiles are assigned to treatments predicted to show a higher probability of clinical response. But the infographic above may be conflating precision psychiatry and personalized psychiatry (it seems that way in the text as well). So is stratified psychiatry a more modest version of precision psychiatry, with only a few biomarkers (vs. 35 or so)? Without the grandiosity of anticipating infinitesimal categories with perfect diagnostic accuracy or the absolute faith in RDoC (NIMH Research Domain Criteria)? 

In the end, making promises you can't keep helps no one (see The Lie of Precision Medicine).


Arns M, van Dijk H, Luykx JJ, van Wingen G, Olbrich S. Stratified psychiatry: Tomorrow's precision psychiatry? European Neuropsychopharmacology. 2022 Feb 1;55:14-9.
Fernandes BS, Williams LM, Steiner J, Leboyer M, Carvalho AF, Berk M. The new field of ‘precision psychiatry’. BMC medicine. 2017 Dec;15(1):1-7.

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