The arrival of preemptive psychiatry

Research over the past two decades has changed our understanding of mental disorders. Based on revolutionary technologies from genomics, imaging and neuroscience, mental disorders have become increasingly understood as brain disorders. Epidemiological and longitudinal studies have revealed that mental disorders are also developmental disorders, emerging while the brain is still developing and evolving often into a chronic and disabling course. While research has transformed our understanding of mental disorders, interventions have lagged behind. Treatments in 2007, like treatments in 1907, remain episodic and palliative. Yes, there are medications and psychosocial treatments of demonstrable efficacy in randomized clinical trials. But, the reality of treatments for schizophrenia, mood and anxiety disorders in 2007 is that: (a) most patients are better but not recovered (b) many patients are not responding to available treatments, and (c) many treatments are not accessible to those who need them. Lest one feel that this view is overly cynical, the outcome data for depression are not profoundly different from the results in many other chronic illnesses, such as hypertension and diabetes. The difference in psychiatry is that we expect less of our treatments. Antidepressants that relieve symptoms 40% after 6 weeks are considered ‘effective’ and antipsychotics that reduce the hallucinations but not the cognitive deficits of schizophrenia are labelled as a revolutionary ‘advance’ in treatment. Going forward, the vision of clinical care for psychiatry must resemble the vision of clinical care in the rest of medicine, best characterized as the 4P’s: participatory, personalized, predictive and preemptive. Participatory means that treatments are collaborative with patients and their families. The Internet has already opened up a world of medical information to the public. Patients and their families are better informed than ever before and increasingly prepared to participate in decisions about their care. Personalized means that treatments are selected based on individual needs. In contrast to efficacy trials that report results on groups of patients, we need outcomes that inform clinicians and patients about individual outcomes. In other words, we have evidence-based treatments, but we do not know whom those evidence-based treatments are for. Should a specific patient receive SSRIs or CBT? Who will develop metabolic syndrome on an atypical antipsychotic? Who will develop agranulocytosis on clozapine? Answers to these questions should allow clinicians to personalize care, optimizing current treatments. Predictive tools and preemptive medicine are our future. Predictive tools such as biomarkers are already in broad use in the rest of medicine. Genomic biomarkers for breast cancer risk or protein biomarkers for tracking relapse of prostate cancer are routine. While psychiatry does not yet have analogous tools, one can imagine that the next few years will yield a genomic biomarker to predict autism, an imaging biomarker to identify risk for schizophrenia, or a plasma protein predicting relapse of depression. Predictive tools will ultimately permit preemptive psychiatry, the most exciting vision for the future of our field. As noted above, current treatments are necessary but not sufficient. New treatments may yield greater palliative effects, but one can imagine that our best hope for a ‘cure’ for schizophrenia or autism or mood disorders will come from preemptive interventions. Of course, this is the recent history of coronary artery disease: prediction of risk based on plasma lipids and family history, early detection based on imaging, and preemption of myocardial infarction with stents, medication, and lifestyle changes. In the USA, NIH estimates that these and other life saving approaches have rescued nearly 1 million people who would have died of heart disease last year based on historical trends. One can only imagine how the same revolutionary technologies applied early in the prodrome of schizophrenia might preempt a first psychotic episode and reduce the morbidity of this chronic illness. Preempting schizophrenia will require not only early detection with reliable predictive tools, but also novel interventions that prevent or forestall psychosis. We do not know whether these interventions will be medications, psychosocial treatments, or some combination thereof. But we do know that the road to preventive interventions, like the road to any new direction in our field, will begin with a novel, exciting set of ideas. The publication of a new journal, Early Intervention in Psychiatry, dedicated to this topic is an important milestone for the field. This is the beginning of an exciting new direction for psychiatry, towards strategic interventions that promise even greater public health benefits than currently available treatments.