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      A Framework for Advancing Precision Medicine in Clinical Trials for Mental Disorders

      1 , 2 , 1
      JAMA Psychiatry
      American Medical Association (AMA)

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          Clinical utility and prospective of TMS–EEG

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            Mapping the Heterogeneous Phenotype of Schizophrenia and Bipolar Disorder Using Normative Models

            This study uses normative modeling to map regional brain alterations to examine brain structural heterogeneity in adults with schizophrenia and bipolar disorder vs healthy individuals. Question Is the focus on the average patient disguising interindividual differences among patients with mental disorders? Findings In this study of magnetic resonance imaging data from 218 patients with schizophrenia spectrum disorders and 256 healthy control individuals, mapping of interindividual differences in brain structure revealed that only a few brain loci had the same abnormalities in more than 2% of patients with the same disorder despite robust group-level differences in multiple brain regions between patients and control individuals. Meaning These findings suggest that the idea of the average patient is a noninformative construct that falls apart when mapping interindividual differences and provide a framework toward precision medicine in psychiatry. Importance Schizophrenia and bipolar disorder are severe and complex brain disorders characterized by substantial clinical and biological heterogeneity. However, case-control studies often ignore such heterogeneity through their focus on the average patient, which may be the core reason for a lack of robust biomarkers indicative of an individual’s treatment response and outcome. Objectives To investigate the degree to which case-control analyses disguise interindividual differences in brain structure among patients with schizophrenia and bipolar disorder and to map the brain alterations linked to these disorders at the level of individual patients. Design, Setting, and Participants This study used cross-sectional, T1-weighted magnetic resonance imaging data from participants recruited for the Thematically Organized Psychosis study from October 27, 2004, to October 17, 2012. Data were reanalyzed in 2017 and 2018. Patients were recruited from inpatient and outpatient clinics in the Oslo area of Norway, and healthy individuals from the same catchment area were drawn from the national population registry. Main Outcomes and Measures Interindividual differences in brain structure among patients with schizophrenia and bipolar disorder. Voxel-based morphometry maps were computed, which were used for normative modeling to map the range of interindividual differences in brain structure. Results This study included 218 patients with schizophrenia spectrum disorders (mean [SD] age, 30 [9.3] years; 126 [57.8%] male), of whom 163 had schizophrenia (mean [SD] age, 31 [8.7] years; 105 [64.4%] male) and 190 had bipolar disorder (mean [SD] age, 34 [11.3] years; 79 [41.6%] male), and 256 healthy individuals (mean [SD] age, 34 [9.5] years; 140 [54.7%] male). At the level of the individual, deviations from the normative model were frequent in both disorders but highly heterogeneous. Overlap of more than 2% among patients was observed in only a few loci, primarily in frontal, temporal, and cerebellar regions. The proportion of alterations was associated with diagnosis and cognitive and clinical characteristics within clinical groups. Patients with schizophrenia, on average, had significantly reduced gray matter in frontal regions, cerebellum, and temporal cortex. In patients with bipolar disorder, mean deviations were primarily present in cerebellar regions. Conclusions and Relevance This study found that group-level differences disguised biological heterogeneity and interindividual differences among patients with the same diagnosis. This finding suggests that the idea of the average patient is a noninformative construct in psychiatry that falls apart when mapping abnormalities at the level of the individual patient. This study presents a workable route toward precision medicine in psychiatry.
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              A systematic review of relations between resting-state functional-MRI and treatment response in major depressive disorder.

              Resting-state functional magnetic resonance imaging (fMRI) is a promising predictor of treatment response in major depressive disorder (MDD).
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                Author and article information

                Journal
                JAMA Psychiatry
                JAMA Psychiatry
                American Medical Association (AMA)
                2168-622X
                July 01 2020
                July 01 2020
                : 77
                : 7
                : 663
                Affiliations
                [1 ]Washington University School of Medicine in St Louis, St Louis, Missouri
                [2 ]Washington University, St Louis, Missouri
                Article
                10.1001/jamapsychiatry.2020.0114
                32211837
                633569c9-9c4c-434f-814e-57f1660cda11
                © 2020
                History

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