If there’s one consistent truth in behavioral health treatment, it’s that one size does not fit all. Cookie-cutter treatment often doesn’t work, even if an accurate diagnosis has been made and standard-of-care interventions are applied.
In the case of major depressive disorder, for example, numerous options are available. In terms of pharmacotherapy, there are many medication treatments all with different mechanisms of action. Drug classes include selective serotonin reuptake inhibitors, norepinephrine-dopamine reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, and more. But not all patients with a diagnosis of depression will respond to all of these treatment options.
The truth is we are all different. Heterogeneity within a diagnostic group is the rule, not the exception. And, as a field, we are still in the early stages of trying to figure out what treatment is best for the patient.
In the real world, prescribers, like psychiatrists, often have to try several medicines, before finding the best one for a particular patient. Sometimes it takes weeks or months before we get an answer to the question of which medication is best for that individual. It’s an often-frustrating process of trial and error.
Therapists also struggle with a similar situation. Often trained in several modalities, we will often pick and choose from our various skill sets, trialing one kind of intervention, and then another, until finding the one that fits the person’s needs in front of us. Meanwhile, the patient’s life continues to unravel. Wouldn’t we all be better off if we better knew how to match treatments to a patient’s individual needs off the bat?
How Things Work Today: Where Your Behavioral Health Provider Is Coming From
When mental health practitioners first evaluate patients in their offices, we may spend the first session, or several, to identify any underlying diagnoses, based on the diagnostic bible, otherwise known as the Diagnostic and Statistical Manual. One of the primary reasons we do this is to inform our recommendations and treatment plan.
A diagnosis gives us a treatment direction. Once we know the diagnosis, we have an idea about the next steps; our training has taught us about the standard of care, and we already know the first-line treatments. If we don’t know, we can go to the literature to identify the treatments that are most likely to work best for this diagnosis.
Results from clinical trials, especially large, double-blind, randomized controlled trials, are the foundations of a psychiatrist’s decision-making about treatment. A typical study of this type takes a large group of people with a single diagnosis—say, major depressive disorder—and randomizes them to active treatment or placebo.
The patients are followed over time. Measurements of the patient’s clinical status, after weeks of treatment, are compiled and analyzed to answer the following question: Does the active treatment get people better faster than the placebo, and if so is it a statistically significant difference?
If so, then several more studies, in different populations, need to be done. If several studies show the medication to be effective, the field adopts that medicine or psychotherapy as a recommended standard of care intervention.
But, unfortunately, not all treatments work for all people. There is significant variability within each diagnosis, based on metabolism, brain chemistry and function, genetics, comorbidity, and any number of other factors. The fact is that individual patients respond differently than the populations in the drug studies do.
Many medicines have been studied and found, on the whole, to be effective within the categories of addictions, anxiety disorders, major depressive disorder, bipolar disorder, and psychotic disorders, to name just a few. Numerous psychotherapies, also growing in number, are also evidence-based within each diagnostic category.
So, in the face of numerous treatment options to choose from, providers don’t have much information on which one might be best for the patient. Sometimes they’ll go with experience, familiarity, and intuition. Occasionally, there is guidance from the literature about how to match treatment to the individual. But often times it’s just a guessing game.
To avoid the time-consuming and in some cases life-threatening trial and error process, where we pick treatments based on intuition and personal experience, we need better ways to know ahead of time what the individual in front of us needs most.
The Importance of Defining Subtypes to Inform Treatment
“Precision medicine” and “personalized medicine” have been high-priority research agendas for over a decade. These terms refer to medical care designed to optimize efficiency or therapeutic benefit for particular groups of patients and involve using genetic or other biomarker information to make treatment decisions. This is especially important as more and more treatment options are coming out.
Research to define subgroups within diagnostic categories, with the end goal to increase the efficiency and effectiveness of treatment, is a major focus of behavioral health research. Genetics, radiologic imaging measures, demographic information, blood tests (such as hormone levels), cognitive function, and behavioral traits are examples of markers that can be utilized to define these subgroups. Examples of disorders being studied using these methods include post-traumatic stress disorder, mood disorder, psychotic disorders (like schizophrenia), substance use disorders, and other addictions.
The more researchers explore the validity of subgroups, the closer we will come to being able to identify which medication is best for the individual patient in front of us—treatment matching—thereby improving the outcomes of patients and the efficacy of existing treatments, potentially saving lives.
Research in this area of behavioral health and addictions is still in its early phases. For major depressive disorder, there are some early signs of useable tools. Some facilities and providers are, for example, encouraging patients to do genetic testing to identify the medications to avoid, and the ones that are most likely to work with minimal side effects.
Some experts express concerns that these expensive tests are not yet ready for prime-time, because it is still not established whether they actually improve patient outcomes—i.e. that testing helps patients get better any faster. Yet other studies (many, it must be said, funded by the companies that produce these testing kits) have reported that they do have clinical benefits and cause overall cost savings. However, more research needs to be done to find affordable, accessible, and accurate ways for behavioral health providers to individualize treatment with medications.
In addictions—which will be the focus of my next four articles—there are some signs of affordable, accessible markers that can be deployed now. Although the work is preliminary, these potentially useful markers are not costly, and if clinicians are to have this information in mind when making decisions, it is unlikely to cause harm.
In this age of a ballooning number of treatment options, researchers have been working hard to identify the best ways to subtype people within a diagnostic category in order to pick the best medication.
A textbook, or several, could be written about sub-typing in behavioral health disorders to guide pharmaco- and psycho-therapeutic treatment for mental health and addictive disorders. I don’t have the space to cover it all.
Therefore, in the next group of articles, I’ll limit my review of the literature to three groups of clinical diagnoses: alcohol use disorders, other substance use disorders, and the debated topic of food addiction. I’ll also do an additional article on the promise of sub-tying using an addictions neuroscience framework. I’ll primarily be focusing on sub-typing to guide medication treatment rather than choosing between psychotherapeutic modalities.
That said, there is a growing (exciting) literature focused on treatment matching in psychotherapy, too, and in a few places (like in the article about the neuroscience-based sub-typing paradigm, and in the article about alcohol use disorders), I’ll occasionally reference treatment-matching in psychotherapy too.