Pragmatic Precision Psychiatry—A New Direction for Optimizing Treatment Selection

Kessler, Ronald C.; Luedtke, Alex

doi:10.1001/jamapsychiatry.2021.2500

Cited by 44 publications

(29 citation statements)

References 79 publications

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“…Instead, certain patient characteristics cause variance in the effect of available treatments. This is reflected by the variance of the individual treatment effect, which the literature refers to as the heterogeneity of treatment effects (HTE; Kessler & Luedtke, 2021; Luedtke & Kessler, 2021). The assumption that not every patient shows the same treatment effect is by no means self-evident.…”

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confidence: 99%

Heterogeneity of treatment effects in trials on psychotherapy of depression.

Kaiser¹,

Volkmann²,

Volkmann³

et al. 2022

Clinical Psychology: Science and Practice

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Practitioners and researchers alike assume that there is individual variability in the effects of treatments for mental disorders. However, for psychotherapy, up to now this assumption has never been empirically tested. Using a large database of randomized-controlled trials on psychotherapy of depression in adults (306 trials including a total of 51,853 patients), we performed a Bayesian variance ratio metaregression. For the entire sample, we found a 9% higher variance in the intervention groups compared with the control groups. Depending on the depression scale used, this corresponds to a standard deviation of the individual treatment effect of 3 to 4 points. Subgroup analyses revealed that the effect variability of some types of therapy is larger than others. Our results are the first to indicate that patients do benefit differently from psychotherapy. We conclude that there is a sound basis for the paradigm of personalized psychotherapy, which brings about implications for both research and clinical practice. Public Health Significance StatementIn recent years, studies with high methodological quality have pointed out that the efficacy of psychotherapy in the treatment of depression is less satisfactory than previous research suggested. To optimize psychotherapy for non-responders, the paradigm of personalized therapy is coming into the research focus. In this study, we show for the first time that the effects of psychological interventions vary more than those of control conditions. This shows that differential response to treatments is inherent to intervention effects. Thus, it could indeed be beneficial to better tailor psychotherapy to individual patients. In practice, session-by-session outcome monitoring should be used to detect non-responding cases in ongoing treatments. Statistical methods guiding the selection of treatment components capitalize on the heterogeneity of treatment effects and are thus likely to improve outcomes. These findings pave the way for broad research and implementation of approaches that support personalization (e.g., monitoring and feedback systems) as well as a new shaping of training beyond the traditional schools of thought in psychotherapy.

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mentioning

confidence: 99%

Heterogeneity of treatment effects in trials on psychotherapy of depression.

Kaiser¹,

Volkmann²,

Volkmann³

et al. 2022

Clinical Psychology: Science and Practice

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“…In the case of psychiatric assessment, for example, we have elsewhere argued for the need for more work on post‐diagnostic assessments and measures that are consistent with measurement‐based care and that promote personalized psychiatry 251‐253 . In the case of psychiatric treatment, addressing the treatment and the research‐practice gaps will require more attention to expanding innovative delivery models that will reach more people in need 254 , systematic adoption and roll‐out of integrated evidence‐based interventions 255 , and an iterative discovery‐confirmation process to assess and improve efficacy 256 .…”

Section: Discussionmentioning

confidence: 99%

Psychiatric diagnosis and treatment in the 21st century: paradigm shifts versus incremental integration

et al. 2022

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Psychiatry has always been characterized by a range of different models of and approaches to mental disorder, which have sometimes brought progress in clinical practice, but have often also been accompanied by critique from within and without the field. Psychiatric nosology has been a particular focus of debate in recent decades; successive editions of the DSM and ICD have strongly influenced both psychiatric practice and research, but have also led to assertions that psychiatry is in crisis, and to advocacy for entirely new paradigms for diagnosis and assessment. When thinking about etiology, many researchers currently refer to a biopsychosocial model, but this approach has received significant critique, being considered by some observers overly eclectic and vague. Despite the development of a range of evidence-based pharmacotherapies and psychotherapies, current evidence points to both a treatment gap and a research-practice gap in mental health. In this paper, after considering current clinical practice, we discuss some proposed novel perspectives that have recently achieved particular prominence and may significantly impact psychiatric practice and research in the future: clinical neuroscience and personalized pharmacotherapy; novel statistical approaches to psychiatric nosology, assessment and research; deinstitutionalization and community mental health care; the scale-up of evidence-based psychotherapy; digital phenotyping and digital therapies; and global mental health and task-sharing approaches. We consider the extent to which proposed transitions from current practices to novel approaches reflect hype or hope. Our review indicates that each of the novel perspectives contributes important insights that allow hope for the future, but also that each provides only a partial view, and that any promise of a paradigm shift for the field is not well grounded. We conclude that there have been crucial advances in psychiatric diagnosis and treatment in recent decades; that, despite this important progress, there is considerable need for further improvements in assessment and intervention; and that such improvements will likely not be achieved by any specific paradigm shifts in psychiatric practice and research, but rather by incremental progress and iterative integration.

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“…The first of these two disaggregated components is related to the burgeoning research area of precision psychiatry [33][34][35][36][37][38][39] . Our results may add information to models aimed to guide the matching of patients to the treatment that is likely to be of most value to them.…”

Section: Discussionmentioning

confidence: 99%

Patterns and correlates of patient‐reported helpfulness of treatment for common mental and substance use disorders in the WHO World Mental Health Surveys

et al. 2022

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Patient‐reported helpfulness of treatment is an important indicator of quality in patient‐centered care. We examined its pathways and predictors among respondents to household surveys who reported ever receiving treatment for major depression, generalized anxiety disorder, social phobia, specific phobia, post‐traumatic stress disorder, bipolar disorder, or alcohol use disorder. Data came from 30 community epidemiological surveys – 17 in high‐income countries (HICs) and 13 in low‐ and middle‐income countries (LMICs) – carried out as part of the World Health Organization (WHO)’s World Mental Health (WMH) Surveys. Respondents were asked whether treatment of each disorder was ever helpful and, if so, the number of professionals seen before receiving helpful treatment. Across all surveys and diagnostic categories, 26.1% of patients (N=10,035) reported being helped by the very first professional they saw. Persisting to a second professional after a first unhelpful treatment brought the cumulative probability of receiving helpful treatment to 51.2%. If patients persisted with up through eight professionals, the cumulative probability rose to 90.6%. However, only an estimated 22.8% of patients would have persisted in seeing these many professionals after repeatedly receiving treatments they considered not helpful. Although the proportion of individuals with disorders who sought treatment was higher and they were more persistent in HICs than LMICs, proportional helpfulness among treated cases was no different between HICs and LMICs. A wide range of predictors of perceived treatment helpfulness were found, some of them consistent across diagnostic categories and others unique to specific disorders. These results provide novel information about patient evaluations of treatment across diagnoses and countries varying in income level, and suggest that a critical issue in improving the quality of care for mental disorders should be fostering persistence in professional help‐seeking if earlier treatments are not helpful.

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Pragmatic Precision Psychiatry—A New Direction for Optimizing Treatment Selection

Cited by 44 publications

References 79 publications

Heterogeneity of treatment effects in trials on psychotherapy of depression.

Heterogeneity of treatment effects in trials on psychotherapy of depression.

Psychiatric diagnosis and treatment in the 21st century: paradigm shifts versus incremental integration

Patterns and correlates of patient‐reported helpfulness of treatment for common mental and substance use disorders in the WHO World Mental Health Surveys

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