September 2010

Personalized Medicine
Even before genomic advances are ready for clinical use, "low-tech" aspects of personalized medicine can enhance psychiatric treatment.

Treating Patients with Schizophrenia: The Importance of Adherence
Antipsychotics can't work if patients don't take them. Nonadherance is a major cause of relapse among patients with schizophrenia.

Valproic Acid and Congenital Malformation
Exposure to valproic acid in the first trimester of pregnancy increases the risk of many congenital malformations in newborns.

In Brief
Bone Mineral Density Is Lower in Depressed than Nondepressed People; Few Adolescents Who Die by Suicide Have Had Recent Exposure to SSRIs

IV Ketamine Infusion Decreases Suicidal Ideation
In a study of treatment-resistant inpatients with major depressive disorder, a single IV infusion of ketamine rapidly decreased suicidal ideation.

SSRIs May Increase the Risk of Cataracts
In a pharmacoepidemiologic study, the use of selective serotonin reuptake inhibitor (SSRI) antidepressants was associated with a greater risk of cataracts among elderly patients.

Personalized Medicine

September 2010

"Personalized medicine" is a mainstay of the National Institutes of Health roadmap for the future of medicine. The hope for personalized medicine rests to a substantial degree on expectations for exploiting the human genome project. In cancer research, understanding genomic signatures of some neoplasms has resulted in greater diagnostic specificity, more targeted treatments, better outcomes, and lower toxicity. If the brain similarly yields its secrets to exploration of the genome, psychiatric disorders may be broken into biologically distinct abnormalities that can be cured and, ultimately, prevented through the use of highly targeted interventions. Even before we can re-sequence abnormal DNA, we may be able to modify epigenetic factors and thereby counteract the effects of some "bad genes."

Although we are not yet in that era, there are elements of personalized treatment that psychiatrists and other clinicians can use today to enhance our therapeutic armamentarium. Personalizing medicine means, among other things, taking a patient's socioeconomic and cultural status into consideration when recommending and prescribing treatments—a "low-tech" but effective set of strategies. Does the patient have beliefs that may affect his or her willingness to engage in and remain on a specific treatment? What does the diagnosis and treatment mean to the patient and how does it affect the patient's view of self and the world? Can the patient afford the treatment? Can he or she read the prescription label and open the bottle? Are there financial, childcare, mobility, or transportation issues that make it difficult for a patient to come to therapy sessions?

Preferences are important too. We often mention exercise as possibly promoting mental health (and certainly enhancing health in general), as well as preventing and attenuating the weight gain that may be caused by psychiatric illnesses and medications. Like medications and psychotherapy, exercise brings no benefit if it is not employed. What does your patient like to do? Is he or she able to run? Does the patient find some activities boring? Simply asking these questions and assessing a patient's willingness to engage in exercise will increase the likelihood that the patient will adhere to a treatment regimen.

In today's medical climate, personalizing treatment as discussed here usually requires more than an individual practitioner. A team approach allows greater opportunity for discussion with and education of patients and families. Written material, which can be delivered electronically as well as on paper, can greatly enhance patients' knowledge and their willingness to engage in and adhere to treatments over time.

These aspects of personalizing medical treatment are old and traditional. Today we have many complex therapeutics, which may be difficult for patients to understand and often carry adverse consequences. In addition, we live in a world of constrained resources and limited time. Finding the right formula that works in individual treatment settings requires thought, work, and usually system redesign.