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The Massachusetts General Hospital Guide to Depression pp 109–121Cite as

Personalized Medicine

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Part of the book series: Current Clinical Psychiatry ((CCPSY))

Abstract

Personalized medicine can be defined as the use of specific patient characteristics to guide treatment decisions. This ancient concept, that the cure should fit the patient, has evolved as we learn more about the biological processes underlying psychiatric disease. Our current toolbox for practicing personalized medicine combines understanding the patient’s demographics, history, and environment with the use of modern techniques such as neuroimaging, pharmacogenomics, cellular and molecular phenotyping, and database mining. In this chapter, we will discuss the historical background of personalized medicine, specifically how it relates to psychiatry and to the pharmacological treatment of patients with major depressive disorder (MDD). We will emphasize recent advances in molecular, cellular, and imaging phenotyping in MDD, with a focus on pharmacogenetics and peripheral biomarkers. We will then give some practical recommendations for personalizing treatment of depressed patients and prospects for making individualized treatments more effective.

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Authors and Affiliations

  1. Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

    Simmie L. Foster, Samuel R. Petrie, David Mischoulon & Maurizio Fava

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  1. Simmie L. Foster
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  2. Samuel R. Petrie
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  3. David Mischoulon
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  4. Maurizio Fava
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Correspondence to Simmie L. Foster .

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Editors and Affiliations

  1. Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

    Benjamin G. Shapero

  2. Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

    David Mischoulon

  3. Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

    Cristina Cusin

FAQs: Common Questions and Answers

FAQs: Common Questions and Answers

  • Q1. When should a provider consider ordering a pharmacogenetic test?

  • A1. The value of ordering genetic tests is still somewhat equivocal, since pharmacogenetic data in MDD are preliminary and must be considered in tandem with other biomarkers and clinical assessment. Still, if the history is suggestive of ultrarapid metabolism (many adequate trials with no response) or poor metabolism (high side effect burden at minimal doses), then it may be useful to employ a lower-cost commercial kit. Available commercial genetic tests for antidepressant response include Avera Health’s GeneFolio, Genomind, GeneSight, and Roche’s AmpliChip test. It is important for a clinician to educate their patients on the utility of these tests and the meaning of the outcomes. Patient expectations also need to be managed carefully, e.g., by reminding the patient that, say, a pharmacogenomic profile is essentially a “probability marker” of success or failure of a certain treatment or treatments, but not a guarantee of either [130].

  • Q2. What is the role of psychotherapy in personalization of therapy for depression?

  • A2. Psychotherapy has been shown in many settings to be as effective as pharmacotherapy for depression and intuitively has great promise for personalization. However, reliable guidelines for personalizing psychotherapy are still lacking. For example, a recent meta-analysis suggests that it would take a substantial amount of time and resources to personalize psychotherapy [131]. However, there are numerous investigations that identify individual moderators of treatment response to therapies such as cognitive-behavioral therapy for depression. A lack of precision in selecting a type of therapy that will work for a specific individual could partly be due to common factors in psychotherapy research. For instance, many active therapies are effective for depression, which could be due to non-specific factors like therapeutic alliance, a supportive environment, and shared goals for treatment. Taken together, similar to the state of the research in pharmacological treatments for depression, personalized psychotherapy approaches are limited, and more research is needed to make firm conclusions or treatment recommendations.

  • Q3. How does patient preference play a role in individualization?

  • A3. Even a treatment predicted by the most sophisticated personalization algorithm won’t work if the patient doesn’t accept it. Therefore any algorithm or treatment plan should include an active discussion of the patient’s expectations and preference.

  • Q4. How can we personalize medicine for patients who don’t respond to any treatment?

  • A4. Even with our current optimized treatments, about 30% of patients with MDD do not respond. The goal of our current method of personalizing medicine is to predict a priori which of our available treatments will be most effective for a patient. Although this method of personalization will likely reduce “non-responders” to some degree (that remains to be determined), it is limited to the treatments and mechanistic targets we currently have available. Then the question becomes—what about the patients who have a distinct mechanism of disease, one that cannot be helped by our current treatments? Here is where the power of personalization to determine mechanisms comes in—with a goal to tailor the treatment to the patient. The physiological biomarkers we identify as being associated with disease in a particular patient can then be tested for their role in contributing to disease. This approach is more similar to the method of personalization in oncology, where the first step is to identify what are the particular mutations carried in a particular patient’s tumor and then (in the case of immunotherapy) develop a patient’s own immune cells to target the tumor. We are still working out ways to do this research in a productive manner in psychiatry. The future holds promise for such an approach.

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Foster, S.L., Petrie, S.R., Mischoulon, D., Fava, M. (2019). Personalized Medicine. In: Shapero, B., Mischoulon, D., Cusin, C. (eds) The Massachusetts General Hospital Guide to Depression. Current Clinical Psychiatry. Humana Press, Cham. https://doi.org/10.1007/978-3-319-97241-1_8

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