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Illustration: Shoshana Gordon/Axios

Psychiatrists and neuroscientists are trying to use biological markers in the brain for depression and other psychiatric disorders to sharpen diagnoses and find more precise treatments.

Why it matters: Mental health disorders affect an estimated 1 in 4 adults in the U.S. each year. More than half don't receive treatment, and for those that take medication, finding the most effective one can be a trial-and-error process.

  • Proponents of precision psychiatry argue the approach can help — but how much is debated.

Background: The Diagnostic and Statistical Manual of Mental Disorders (DSM), first published by the American Psychiatric Association in 1952 with four subsequent updates, describes criteria for diagnosing psychiatric disorders, largely based on behavioral symptoms.

  • The manual introduced a shared language to the field of psychiatry that continues to guide diagnosis and, just as importantly, insurance and billing codes, and also frames research questions.

But there's ongoing debate about how reliable the DSM's symptom criteria are for diagnosis and whether a diagnosis successfully predicts how someone will respond to treatment.

  • A recent study from the nonprofit Sapien Labs used mental health symptoms self-reported by more than 100,000 adults to see whether the DSM meaningfully separates people by their symptoms.
  • They found, for example, the symptoms of two people grouped as having autism spectrum disorder may be as different as those for a person in that group and one categorized as having ADHD.
  • The fact that different symptoms patterns in different people can end up with different diagnoses is "a strength that recognizes the heterogeneity of the disorders we are talking about," says Paul Appelbaum, a professor of psychiatry at Columbia University who chairs the DSM steering committee.
  • But,"recruiting people into clinical trials based on more homogeneous symptom profiles rather than the heterogeneous profiles of the DSM can help the search for biological markers of disorders," says Tara Thiagarajan, a neuroscientist and founder of Sapien Labs who is an author of the paper.

The National Institute of Mental Health invested in trying to find biomarkers that former director Tom Insel in 2017 said, in an often cited quote, didn't move the needle on outcomes for people with mental disorders.

  • One issue, says Insel, who is an adviser to Alto Neuroscience, is that some biomarkers would be dismissed if they were found in only a fraction of people characterized by DSM criteria for disorders.
  • "It's better to follow the biomarker data and create clusters based on that data than assume symptoms will map onto the biology," he says.

What's happening: In recent years, researchers have found some biological markers of schizophrenia, major depressive disorder and PTSD.

  • "But none of them have yet reached the point where anyone has been able to demonstrate their value for psychiatric diagnosis per se," Appelbaum says.
  • The DSM-5, published in 2013, explicitly says it hopes reliable and precise biomarkers can be incorporated into diagnostic criteria, he adds.

Aside from diagnosis, some biomarkers are now being assessed to try to predict better treatment outcomes for people, including by two startups that emerged in October —Neumora Therapeutics and Alto Neuroscience.

  • They are using a variety of biomarkers — including imaging of the brain's networks, genetics, EEG brain wave measurements and behavioral data from tests or wearable devices — to try to determine who might have a better outcome from a drug or other treatment.
  • The approach is nascent, but Amit Etkin, Alto's founder and CEO, hopes that over the next 10 years psychiatry will make the kind of progress oncology has by using genomics to better understand cancer mutations and harnessing that information to match therapies to individuals.
  • "Psychiatry is stuck in the '90s and with the myth of the silver bullet" of a single drug or treatment that works for everyone determined to have a disorder, Etkin says.

The big picture: Critics say precision psychiatry puts too much emphasis on the biological underpinnings of disease and not enough on the experiences and environment that shape it.

  • In his forthcoming book, "Healing: Our Path from Mental Illness to Mental Health," Insel argues "the problems are indeed medical but the solutions are social, relational, environmental, and political."
  • "If the goal is to improve outcomes and increase the chances someone will recover, we need to know much more than their symptoms and biology," he says.

Go deeper

Tina Reed, author of Vitals
Dec 14, 2021 - Health

Axios-Ipsos poll indicates long COVID prevalence

Expand chart
Data: Axios/Ipsos poll; Chart: Kavya Beheraj/Axios

About one in seven Americans who experienced COVID say they had symptoms at least a month later, according to a new Axios-Ipsos poll.

The big picture: While it's still hard to pin down how many people experience long COVID, the poll offers additional evidence of its widespread impact.

Updated 28 mins ago - Energy & Environment

Bomb cyclone prompts blizzard warnings from Virginia to Maine

Computer model projection showing the intense storm off of Cape Cod on Jan 29, 2022, with heavy snow and strong winds lashing the coastline. (Weatherbell.com)

Blizzard warnings are in effect for 11 million people from coastal Virginia to eastern Maine as a potentially historic winter storm is set to slam the Mid-Atlantic and Northeast beginning Friday.

Why it matters: The storm will bring hazards ranging from zero visibility amid hurricane force wind gusts and heavy snow, to coastal flooding that will erode vulnerable beaches and threaten property from the Jersey shore to coastal Massachusetts.

Updated 4 hours ago - Politics & Policy

Swastikas found outside Union Station in D.C.

People walk through Union Station on Jan. 16 in Washington, D.C. Photo: Spencer Platt/Getty Images

Drawings of swastikas appeared etched around the entrance to Union Station in Washington, D.C., on Friday morning.

Driving the news: "An investigation is underway with Amtrak Police and the Metropolitan Police Department after swastikas were reported on the exterior of Washington Union Station on Friday," Amtrak spokesperson Kimberly Woods said in a statement to Axios.