Biomarkers for Psychiatric Drug Toxicity. Oct 24, 2008 Thomas R. Insel, M.D. Director, NIMH

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1 Biomarkers for Psychiatric Drug Toxicity Oct 24, 2008 Thomas R. Insel, M.D. Director, NIMH

2 Burden of Disease (DALYs) U.S., Canada, and Western Europe years old Mental Illness* Injuries, including self-inflicted Alcohol and drug use Malignant neoplasms (cancer) Cardiovascular disease Respiratory disease Musculoskeletal disease Sense organ disease Digestive disease Source: WHO World Health Report 2002

3 Burden of Disease by Specific Illness DALYs United States, Canada, and Western Europe years old Unipolar depression Alcohol use Road traffic accidents Drug use Self-inflicted injuries Bipolar disorder Migraine Schizophrenia Hearing loss COPD Source: WHO World Health Report 2002

4 Mental Disorders: Mortality Over 30,000 suicides per year (in the U.S.) -90% related to mental illness For context: 18,000 homicides 20,000 AIDS deaths only 3 forms of cancer > 30,000

5 Public Health Impact: Early Mortality in Individuals with Major Mental Illness (MMI) Data from outpatient and inpatient clients diagnosed with MMI Average age at time of death : 56 years Increased likelihood of dying from suicide Decreased likelihood of dying from cancer Years of Potential Life Lost Average Arizona Missouri Oklahoma Rhode Island Texas Utah Adapted from Colton and Manderscheid, 2006, PrevChronic Dis

6 Average Medicine Assumes homogeneity Classic RCT Results based on group means Recommendations are generic Personalized Medicine Assumes heterogeneity Moderator trials Results focus on variance and individpatterns Recommendations are specific Implications: Clinical research based on individual risk and response

7 Personalized Medicine for Mental Disorders Mental disorders can be understood as developmental brain disorders: chronic, early onset, heterogeneous. Current treatments, at best, ameliorate symptoms, but there is variation in response, adverse events, adherence, and access.

8 Personalized Medicine: Where is the need? Depression: Highest burden of illness ages (WHO, 2002) 50-70% of pts respond to SSRIsor CBT Side-effects of medication reduce effectiveness Which treatment for which patient? Schizophrenia: Deficits precede psychosis Rx s have serious side effects, poor adherence Identifying individual risk, preemptive Rx s. Which treatment for which patient?

9 Personalized Medicine: Where is the need? PTSD: Increasing prevalence ( failure of recovery ) Rx helpful Identifying individual risk, preemptive Rx s Which treatment for which patient? Bipolar Disorder: Medical and psychiatric co-morbidities Lithium effective for some but underutilized Which treatment for which patient?

10 Approaches to Pharmacogenomics of Psychiatric Medications Absorption Individual variation in choice, Distribution response, toxicity, Central Target adherence Individual Genomic Variation Metabolism Toxicity

11 Genomics of SSRI Response Absorption and distribution Neuron, 2007 Citalopram, paroxetine, amitriptyline, venlafaxine use P-gp (P-glycoprotein) an ATP-binding cassette transporter protein encoded by ABCB1 on Chr 7

12 Genomics of SSRI Response CNS Targets SLC6A4, 5HT2a, 5HT3a, Glutamate Rec Complex Arch Gen Psych 2007

13 Inverse Sum of Ranks remission response rs p<3.7 x SNPs Ordered by Physical Position rs The allele associated with better outcome was ~7 times more common in whites than blacks Afr-Am. also had a less favorable outcome, overall, than Cauc. in this sample

14 Genomics of SSRI Response Metabolism CYP450: CYP2D6, CYP2C19, CYP3A4, CYP3A5 STAR*D data: Discovery sample:831 Validation sample: 1,046

15 Treatment-Emergent Suicidal Ideation Worrisome phenomenon that occurs in ~5% of people receiving SSRIs Led to a Black Box warning on all antidepressants in adolescents Design in STAR*D: Participants who scored 0 at baseline (before citalopram treatment) and later scored 1, 2 or 3 on the same item at least once while on citalopram (n=120) Comparison group (n=1742): all participants who denied suicidal ideation emerging during treatment

16 Odds Ratio Genomics of SSRI Response Adverse events: Treatment-emergent suicidal ideation Out of 1915 patients with depression treated with citalopram, 120 developed suicidal ideation. Lahe et al, AJP, 2007

17 Approaches to Pharmacogenomics of Psychiatric Medications Absorption Individual variation in choice, Distribution response, Central Target toxicity, adherence Individual Genomic Variation Metabolism Toxicity

18 Neuroimaging: A Predictive Biomarker? Fluoxetine Responders F9 hc Cg25 hc Cg25 pcg31 Cg25 p Non- Responders F9 hc hc F9 pcg31 Mayberg, 2006

19 MEG: A Predictive Biomarker? Zarate et al, Biol Psych, 2008

20 Defining Depression Circuits Response Pathways PF MCC Cognition (attention-appraisal-action) MF PF9/46 PM6 Par40 hc CBT MCC PCC Self-awareness insight mf9/10 of11 pacc24 na-vst amg thal mb-vta Mood state sacc25 Salience Motivation MEDS Br Med Bul 65: , 2003 Arch Gen Psych 61: a-ins hth bstem Interoception (drive-autonomic-circadian) PF P Meds Cg25 PCC BS

21 Predictors of efficacy or adverse events Clinical Data Genomic Profile Proteomic Biomarker Imaging Biomarker Biosignature

22 Pathways to Personalized Medicine Discovery Moderators Clinical history Genomics Physiology Proteomics Imaging Clinical Trial Comparative efficacy with multiple outcomes Exploratory Analysis Identify predictors - response or adverse events Development Stratify by predictor Prospective Trial Assess value of stratification Dissemination Qualification of predictor Practice guidelines

23 Research for Prevention, Recovery, and Cure