What is Precision Mental Health and how can it help with Depression?
Leanne Williams has a novel approach to depression treatment. Founding Director of Stanford University’s PanLab for Precision Psychiatry, Williams conducts brain scans and blood tests to determine precise symptoms of depression and then treats them differently depending on their specific condition. Treatments range from ketamine infusions and brain stimulation to conventional antidepressants. Depression is not a homogenous condition, she says, but manifests very differently in different peoples’ brains and lives. Prof. Williams has characterized eight different ‘biotypes’ of the illness – ranging from negative rumination to cognitive fog – and believes we need an urgent rethink in how we treat the condition.
What is Precision Medicine in the context of Mental Health?
The fundamental question: what does precision mean in the context of Mental Health mean? Essentially, a central motivation for precision medicine in mental health is to reduce the burden of disorder by getting the most effective treatments to each patient earlier. By integrating findings from basic and clinical neuroscience, as well as population-level data from clinical practice, the emerging field of precision medicine in mental health seeks to develop therapeutic approaches tailored for specific individuals with a specific constellation of health issues, characteristics, strengths, and symptoms.
Why does Precision Medicine mean in the context of depression?
Depression is an illness where we need a whole new framework. Like with any systemic illness, which affects multiple functions or areas of the body, depression can manifest in a full spectrum of ways. It’s very easy to dismiss the extreme end of depression, where just like with strokes and heart attacks, the spectrum runs from being absolutely debilitating to ultimately fatal. If we can accept that depression is not just one thing that manifests in one particular way, we can start to appreciate the need for a more precise approach in treatment plans, informed by measurement of multiple sources of information. We should think of depression like any other long-term health issue and manage it accordingly. To use the analogy of heart health: The biology of your heart also needs to be taken into account, meaning you could be healthy and make all the right lifestyle choices but if you have predisposing factors or have experienced chronic stressors, you could still develop hypertension, stroke, or heart disease. It’s easy to see how a one-size-fits all approach just doesn’t work.
If we apply that analogy to depression, having social connections, managing stress effectively and being able to recover from stressful events are really important because it affects the brain circuits that are relevant to normal emotional change and resilience. But, in some cases, if you are prone to developing the disease, it’s not going to completely protect you. Similarly, applying these important lifestyle factors are key to helping prevent depression but aren’t going to immediately undo serious depression if it occurs. This analogy is important because it can be all too easy to dismiss the illness state, in the same way that it can be easy to dismiss the lifestyle factors. Both matter and should be taken into account when looking at treatment options. This is fundamentally where a holistic approach becomes vital.
How have attitudes towards depression changed?
Back in 2006, when I was first doing research on psychosis, depression as a concept was becoming more publicly known. It became really obvious to me how many people with psychosis had depression and that it was causing them challenges with how they functioned socially. At the time, there was a backlash against antidepressants, whereas now the conversation has evolved. It was obvious depression needed to be studied well to understand what was actually the root of the disease–when do normal emotions become depression and so on. There has definitely been a shift towards recognising depression as a spectrum that can be tackled with a variety of treatments (not just antidepressants), as well as an understanding of the complexity of how it manifests in the brain.
What are the barriers facing traditional approaches to treating depression?
Right now, we don’t have a good way to identify depression and establish where you are in the course of the illness, unlike how we approach cancer for instance. With cancer, we say the stages are healthy, stage one, two, three four, or remittent. That’s really also how depression works. People might go in and out of states of depression as part of their normal emotions, but the ability to actually detect when it’s become a disease state, like stage one, we still don’t have a good test for. Currently, we wait until we’re in stage three or four–when someone’s actually in a collapsed state and needing some form of intervention, because the early issues haven’t been addressed. In the current framework of thinking, we’re just throwing together a one size fits all solution. It would be like telling someone: ‘You have cancer but we don’t know what type, so out of the 50 treatment options available, we’re just going to give you the one that we’re most familiar with and hope it works’. You can imagine what would happen. Why would you expect anything different with depression? The chances of getting better are going to be literally down to chance.
How effective are Precision Medicine approaches for treating depression?
The precision medicine approach is really different. If we go back to the analogy of heart disease, around 70 years ago we knew nothing about how the heart worked: we didn’t have any tests, we didn’t have any imaging or risk indicators, we didn’t know about cholesterol etc. There was an assumption that approximately half of older adults would die from heart disease just because that’s what the stats said. I think that we’re currently in a similar situation with depression, with a lot of people dying, particularly young people in their most productive years. Heart disease has improved dramatically since we’ve started taking into consideration the lifestyle factors at play and so, by taking the same approach with depression we can start to gather the same kind of information about the brain. The goal is to understand it in a lot of detail and to get that new model for how each individual person’s brain works and how it connects to their symptoms and experiences. From there, we can make more accessible tests and tailor treatment in a much more personalised way. The effectiveness can be attributed to approaching the problem from multiple angles and seeing the whole jigsaw rather than just one piece of the puzzle.
How are Precision Medicine approaches improving our understanding of depression?
Right now, we lump together so many different individual symptoms under the umbrella term of depression. These estimates vary, but if you take what are considered the main symptoms, you can see that there are in actuality about 1000 different profiles of symptoms found in individuals. By creating ‘biotypes’–effectively a collection of genetic profiles–we can take the first steps towards a more personalised approach to depression. Depending on how your brain is functioning, we can currently identify eight distinct types of depression–not just one. Although we expect that this stance will continue to evolve and refine as we collect more data and evidence. It’s an exciting field where there’s so much more to discover.
