Bringing Precision to Psychiatry

Dr. Hugh Marston and Dr. Vikas Mohan Sharma discuss what precision psychiatry entails and how it can enable people living with mental health conditions to thrive.

Dr. Hugh Marston and Dr. Vikas Mohan Sharma discuss how precision psychiatry can enable people living with mental health conditions to thrive.

The scale of the mental health challenge

It is estimated that globally, one in 10 people lives with a mental health condition – that’s almost 800 million people.¹ Furthermore, the challenges posed by the COVID-19 pandemic and social distancing have significantly increased the number of individuals experiencing symptoms of mental illness.² Beyond the personal challenges, it is recognized that these conditions can significantly impact loved ones, caregivers and wider society.

From an economic standpoint, mental health conditions are associated with large direct and indirect costs for individuals and society, including the provision of health and social care and lost employment.³ For example, depression and anxiety disorders cost the global economy $1 trillion US Dollars in lost productivity each year.⁴ Additionally, the financial burden of poor mental health is growing, with the estimated cost of $2.5 trillion US Dollars per year in 2010 due to disability and reduced productivity projected to rise to $6 trillion US Dollars by 2030.^5,6

Bridging the gap between neurobiology and psychiatry

Considering the significant global burden of poor mental health, as researchers and physicians in this field, it is promising to see mental health become an increasingly important topic, similar to physical health. However, the pace of change must continue to increase, as we advance our knowledge of how to overcome key challenges around the current approach to diagnosis and treatment and move towards a more precise and biologically based treatment approach for those living with mental health conditions.

Due to the complexity of the human brain, existing classifications of mental health conditions lack objective biomarkers, meaning they are based purely on clustering observed symptoms rather than the underlying neurobiology.⁷ Healthcare professionals are restricted to working within the standard classifications and diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) or the International Statistical Classification of Diseases and Related Health Problems (ICD-10). Often, the use of these classifications to diagnose a condition can oversimplify human behavior and can result in an increased risk of misdiagnosis or over-diagnosis. Furthermore, it can group individuals that behaviorally and symptomatically ‘look’ the same under the same label or classifications, even though their symptoms stem from different biological causes.

It is recognized that the DSM-5 and ICD-10 have their limitations, but through advances in our understanding of the brain, we are revealing new ways to classify and identify the underlying malfunctions that lead to some of the most life-limiting aspects of mental health disorders.

Significant advances in our knowledge over the past half century are starting to help us bridge the gap between neurobiology and psychiatry. It is Boehringer Ingelheim’s goal to challenge traditional classifications and uncover connections between specific brain circuit dysfunctions and the emotions and behaviors experienced by a person with a mental health condition. Promisingly, this is allowing us to move away from the constraints of syndrome-based diagnosis and treatment.^8,9 It is allowing us to be more precise and support our goal to enable people living with mental health conditions to thrive.

The meaning of ‘precision’ in the context of psychiatry

‘Precision’ is not an entirely novel approach in healthcare. Precision oncology, for example, is an established form of cancer treatment, where the unique biology of a patient’s disease is used to make tailored and targeted treatments for them.

In the context of psychiatry, in our view ‘precision’ comes from addressing the precise unmet needs people living with mental health conditions experience, in a meaningful way, to enable them to thrive. Precision psychiatry is about taking individual variability into account, including physiology, environment, lifestyle, genetics, and individual preferences.

At its core, precision psychiatry is an approach that focuses on understanding the underlying neurobiological mechanisms that cause the symptoms of mental health conditions. Using this understanding, we aim to develop therapies that can target these mechanisms, which in turn will address previously untreatable aspects of mental health conditions by providing more specific symptom control and possibly altering the trajectory of the disease process.

For example, rather than developing a medicine for schizophrenia as a whole (i.e. a syndrome-based treatment), we want to develop solutions, pharmacological or otherwise, that can alter the specific biological processes that lead to the manifestation of symptoms and behaviors. This is critical because mental health conditions are collections of many different processes that interact across time to develop the unique pattern of symptoms that are experienced by an individual. Therefore, not everyone living with a given condition experiences the same set of symptoms, and even within an individual this set can alter day by day.

Importantly however, it’s not just about the solution. It’s about the approach we take to reaching these meaningful solutions. There is a need for a more holistic and integrated approach to treating mental health conditions that encompasses their social, psychological, and biological aspects.¹⁰ Precision psychiatry requires us to think beyond current diagnosis and treatment approaches – it requires us also to think beyond the pill.

Achieving a more holistic and integrated approach

Cognitive behavioral therapy is considered the gold standard of psychosocial therapy. In 2021, the National Institute for Health and Care Excellence (NICE) altered its recommendations to put behavioral therapy as the first line of treatment before pharmacological treatment. However, only one in 10 people with a mental health condition has access to regular psychotherapy.^11,12Furthermore, the mental health field has traditionally lacked the diagnostic and therapeutic technologies that form an integral part of other clinical specialties.¹³

Therefore, Boehringer Ingelheim’s mental health approach is different by innovating beyond pharmacological treatments to provide patients with a wider spectrum of support. We are looking to the future of care in mental health by developing digital therapeutics to complement pharmacotherapy, combining the benefits of psychosocial treatments with the accessibility of mobile technology to reduce the personal and socioeconomic burden of poor mental health.¹⁴

Digital therapeutics use the strength of mobile technologies to deliver accessible, clinically validated, and individualized treatment straight to a person’s digital device. To date, they have been shown to be effective at reducing the symptoms of mental health conditions including depression,¹⁵ borderline personality disorder¹⁶and schizophrenia.¹⁷ This could be, at least in part, because combining the benefits of psychosocial treatments with the accessibility of digital technology can improve adherence to medication, improve functional and cognitive symptoms, and improve patients’ knowledge of their condition and treatment.^18,19

Bringing precision to psychiatry through global collaboration

At present, precision psychiatry is still in its infancy. There is much excitement and discussion amongst the mental healthcare community about what it is, and how it could revolutionize psychiatry. However, there has yet to be a clear definition as to what it means and how to approach it in a systematic way.

Boehringer Ingelheim is partnering with experts in academia and research from around the globe, applying this approach to drug discovery and development, with the goal to serve the needs of patients and other stakeholders. Together we are investigating the root neurobiological causes relating to specific symptoms that remain overlooked and untreated, despite posing significant challenges on daily life.

We joined forces with King’s College London to produce a comprehensive clinical research program in major depressive disorder and schizophrenia, building upon our circuitry-based approach to precision psychiatry. Through this partnership in particular, we are aiming to identify more patient-specific biomarkers, improving the development of therapies for cognitive impairment.

We are partnering with the Innovative Medicines Initiative (IMI) on their PRISM project, with the aim of identifying quantitative biological measures to enable the development and discovery of specific treatments for multiple mental health conditions. Other collaborations include the Lieber Institute for Brain Development and Stanford’s Center for Precision Mental Health and Wellness.

Ultimately, with every partnership, we want to translate our collaborative findings into practice and bring precision psychiatry into the clinic to alleviate the burden on people living with mental health conditions, their loved ones, and society.

References

1. Ritchie H & Roser M. Mental Health. 2018. Available at: https://ourworldindata.org/mental-health

2. Xiong J et al. J Affect Disord 2020 ; 277 :55-64

3. https://www.mentalhealth.org.uk/statistics/mental-health-statistics-economic-and-social-costs

4. Chisholm D, et al. The Lancet Psychiatry 2016; 3(5):415-424. Available at: https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(16)30024-4/fulltext

5. Knapp M and Wong G. World Psychiatry 2020; 19:3–14.

6. Editorial. The Lancet Global Health 2020; 8:e1352.

7. Nature Neuroscience Editorial. Nat Neurosci 2016; 19:1381–1382.

8. Altimus CM, et al. J Neurosci 2020; 40:101–106.

9. Williams LM. Lancet Psychiatry 2016; 3:472–480.

10. Sarris J, et al. Adv Int Med 2014; 1:9–16.

11. David D et al. Front Psychiatry 2018; 9:2–3.