Could schizophrenia treatment become personalised? Scientists look towards precision medicine

Schizophrenia treatment could eventually become far more personalised as researchers learn more about the different biological processes that may sit behind the condition, according to a major review of advances in understanding and managing the disorder.

Writing in The BMJ, researchers from Johns Hopkins University examine how understanding of schizophrenia has developed alongside new approaches to medication, psychological treatment, brain stimulation and digital health. One of the biggest challenges, however, is that two people who receive the same diagnosis may have considerably different symptoms, experiences and underlying biology.

Schizophrenia is a severe mental health condition that commonly begins during late adolescence or early adulthood. It can involve hallucinations, delusions and disorganised thinking, but people may also experience difficulties with motivation, social interaction, emotional expression and cognitive functions such as memory and attention. The way the condition affects someone’s life can therefore vary enormously from one person to another.

Scientists no longer view schizophrenia as having a single straightforward cause. The BMJ review describes a complex interaction between multiple genetic and environmental factors, with evidence suggesting that differences in brain development play an important role. This complexity is one reason why developing new treatments has proved so challenging.

Antipsychotic medicines remain central to treatment and can be particularly effective at reducing what clinicians describe as positive symptoms, including hallucinations and delusions. Preventing relapses is also important because repeated episodes of psychosis can have substantial consequences for someone’s health, relationships, education, employment and independence. However, existing medication does not work equally well for everybody and can cause significant side effects.

Treatment extends considerably beyond medication. Psychological and psychosocial interventions can help people manage symptoms, improve everyday functioning and reduce the likelihood of relapse, while early intervention following a first episode of psychosis can have an important influence on longer-term outcomes. Cognitive approaches may also help address some of the difficulties with thinking and information processing associated with schizophrenia.

Researchers are meanwhile investigating newer approaches, including neuromodulation techniques that seek to alter activity within particular brain networks and digital health technologies that could support monitoring or treatment. These remain developing areas of research, however, and considerably more evidence will be needed before some approaches become part of routine schizophrenia care.

Perhaps the most significant direction highlighted by the review is precision medicine. This approach is already transforming areas such as cancer treatment, where biological characteristics can sometimes be used to divide patients into subgroups and determine which therapy is most likely to work. Researchers hope that something similar could eventually become possible within psychiatry.

At present, schizophrenia is diagnosed primarily through patterns of symptoms and clinical assessment rather than through a blood test, brain scan or other biological test. The BMJ authors argue that this creates a major obstacle for drug development because researchers may effectively be studying a biologically diverse group of people under a single diagnostic label.

Finding reliable biomarkers could begin to change that. A biomarker is an objectively measurable biological characteristic that provides information about a disease or process occurring within the body. If researchers could identify meaningful biomarkers associated with different forms or mechanisms of schizophrenia, patients could potentially be divided into more biologically relevant groups.

That could have significant implications for treatment. Rather than relying predominantly on trial and error to discover which medication or intervention works best for an individual, clinicians might eventually be able to use biological information alongside symptoms and personal circumstances to guide decisions. It could also allow researchers developing new medicines to identify the particular groups of patients most likely to benefit from them.

Precision psychiatry is not yet at the point where a routine test can tell somebody with schizophrenia which treatment will work for them. Identifying biomarkers that are reliable, clinically meaningful and practical enough to use in everyday healthcare remains a considerable scientific challenge, and promising findings still need to be replicated and validated before they can influence routine care.

There is also a danger in viewing schizophrenia entirely through biology. People’s outcomes are influenced not only by what is happening within the brain but by housing, poverty, relationships, discrimination, employment, access to healthcare and the support available around them. An accompanying BMJ editorial argues that social and structural inequalities must remain central to schizophrenia management even as researchers pursue increasingly sophisticated biological treatments.

The direction of research nevertheless represents an important change in thinking. Instead of asking why one treatment fails to work for everyone diagnosed with schizophrenia, scientists are increasingly questioning whether expecting a single approach to work across such a biologically and clinically diverse condition was ever realistic.

For people living with schizophrenia, precision medicine remains a future ambition rather than a treatment available today. However, a better understanding of the different mechanisms underlying the condition could ultimately move psychiatry towards something medicine has achieved in other fields: treating not simply the diagnostic label, but the individual person and the particular biology contributing to their illness.

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