Prof. Jim van Os

Debate	Is it possible and useful to move towards precision psychiatry?
Talk	Position NO
Date	Thursday, April 20th, 2023
Time	16:10 - 16:50

Prof. Dr. Jim van Os is Professor of Psychiatry and Chairman of the Division Neuroscience at Utrecht University Medical Centre. He is also Visiting Professor of Psychiatric Epidemiology at King’s College in London.

He has been a member of the Royal Netherlands Academy of Arts and Sciences (KNAW) since 2011 and was appointed Fellow of King's College of London in 2016. Van Os has been appearing on the Thomson-Reuter Web of Science list of 'most influential scientific minds of our time' since 2014.

https://publons.com/researcher/3067797/jim-van-os/

He works at the interface of critical neuroscience, health services research, art and subjective experiences of people with 'lived experience' in mental healthcare.

The Improbability of Precision Medicine in Psychiatry

Precision medicine has revolutionized a limited area of the medical landscape, particularly in areas such as oncology, by tailoring treatment to the individual patient's genetic and molecular profile. However, even in oncology, this type of precision does not extend to more than 5% of activity. The applicability of precision medicine to psychiatry is highly unlikely due to the complexity of psychiatric disorders, the current state of psychiatric diagnostics, and the lack of a clear biological basis for many mental health conditions.

First, the complexity of psychiatric disorders poses a significant barrier to implementing precision medicine. Mental health conditions are multifaceted and heterogeneous, with numerous factors such as genetics, environment, and individual experiences playing a role in their development and manifestation. These factors interact in complex ways, making it difficult to pinpoint specific molecular or genetic targets for personalized interventions. Moreover, patients with the same diagnosis can present with vastly different symptoms, adding to the challenge of developing targeted treatments. Second, the current state of psychiatric diagnostics is insufficient for precision medicine. Diagnostic tools in psychiatry rely primarily on clinical observation and self-report, which are subjective and prone to bias. In contrast, precision medicine relies on objective biomarkers that can guide treatment decisions. Without a robust and reliable set of biomarkers, it is improbable that precision medicine can be applied to psychiatry. While research is ongoing to identify such biomarkers, progress has been slow and no consensus has been reached.

Third, the lack of a clear biological basis for many mental health conditions impedes the development of targeted treatments. Unlike other fields where precision medicine has made significant strides, such as oncology, the biological underpinnings of psychiatric disorders remain poorly understood. For example, the etiology of major depressive disorder is not yet fully known, with hypotheses ranging from genetic predisposition to neurotransmitter imbalances. This uncertainty complicates the identification of molecular targets for drug development and hampers the translation of precision medicine principles into psychiatric practice. Fourth, the emergent nature of mental states poses a severe problem for the idea of precision medicine being applicable to psychiatry. Mental states, such as thoughts, emotions, and consciousness, are considered emergent phenomena arising from complex interactions between lower-order biological factors, including neural networks, neurotransmitters, and genetic factors. Due to their emergent nature, mental states cannot be easily measured or quantified in the physical domain, posing a considerable challenge for tracing them to specific lower-order biological factors.

Emergent phenomena are characterized by properties that cannot be reduced to the properties of their constituent parts. In the context of psychiatry, this means that mental states cannot be simply attributed to individual genes, neurotransmitters, or neural circuits. Instead, they arise from the collective interactions of these components, which are highly dynamic and difficult to predict or manipulate. This inherent complexity hampers the identification of specific biological targets for personalized interventions, making the application of precision medicine in psychiatry highly unlikely.

Moreover, the emergent nature of mental states implies that even if we could map out the entire biological architecture of an individual, we might still be unable to accurately predict or treat their mental health condition. This is because emergent phenomena often exhibit nonlinearity and are influenced by various external factors, such as environmental and social circumstances. As a result, a reductionist approach that attempts to trace mental states to lower-order biological factors may not be sufficient for developing targeted, personalized treatments in psychiatry.

In conclusion, the emergent nature of mental states further complicates the application of precision medicine to psychiatry. Mental states cannot be easily traced to lower-order biological factors, and their complexity, nonlinearity, and sensitivity to external influences pose significant challenges for the development of personalized treatments. This argument, in conjunction with the previously discussed issues of psychiatric disorder complexity, diagnostic limitations, and unclear biological basis, makes the prospect of precision medicine in psychiatry highly unlikely.

[Full paper] van Os J, Guloksuz S, Vijn TW, Hafkenscheid A, Delespaul P. (2019). The evidence-based group-level symptom-reduction model as the organizing principle for mental health care: time for change? World Psychiatry. 2019 Feb;18(1):88-96. doi: 10.1002/wps.20609. PMID: 30600612; PMCID: PMC6313681.

[Full paper] Köhne ACJ, van Os J. (2021). Precision psychiatry: promise for the future or rehash of a fossilised foundation? Psychol Med. 2021 Jul;51(9):1409-1411. doi: 10.1017/S0033291721000271. Epub 2021 Feb 22. PMID: 33612128.

[Full paper] van Os J, Guloksuz S. (2022). Schizophrenia as a symptom of psychiatry's reluctance to enter the moral era of medicine. Schizophr Res. 2022 Apr;242:138-140. doi: 10.1016/j.schres.2021.12.017. Epub 2022 Jan 3. PMID: 34991949.