Elevating the field for applying neuroimaging to individual patients in psychiatry

Abstract

Although neuroimaging has been widely applied in psychiatry, much of the exuberance in decades past has been tempered by failed replications and a lack of definitive evidence to support the utility of imaging to inform clinical decisions. There are multiple promising ways forward to demonstrate the relevance of neuroimaging for psychiatry at the individual patient level. Ultra-high field magnetic resonance imaging is developing as a sensitive measure of neurometabolic processes of particular relevance that holds promise as a new way to characterize patient abnormalities as well as variability in response to treatment. Neuroimaging may also be particularly suited to the science of brain stimulation interventions in psychiatry given that imaging can both inform brain targeting as well as measure changes in brain circuit communication as a function of how effectively interventions improve symptoms. We argue that a greater focus on individual patient imaging data will pave the way to stronger relevance to clinical care in psychiatry. We also stress the importance of using imaging in symptom-relevant experimental manipulations and how relevance will be best demonstrated by pairing imaging with differential treatment prediction and outcome measurement. The priorities for using brain imaging to inform psychiatry may be shifting, which compels the field to solidify clinical relevance for individual patients over exploratory associations and biomarkers that ultimately fail to replicate.

Information-based TMS to mid-lateral prefrontal cortex disrupts action goals during emotional processing

“…Collectively, these results suggest the import of parsing inter-individual heterogeneity in mid-LPFC function 42 – 48 and offer support for an individualized, functional-based approach to brain stimulation aimed at understanding causality in brain-behavior relationships 28 , 39 , 40 , in alignment with a growing emphasis on precision neuroimaging 61 , 62 and precision psychiatry for brain stimulation 63 , 64 . Early work systematically comparing individualized vs. group-based TMS targeting approaches demonstrated the increased potency of individualized, fMRI-guided TMS for altering behavior 40 , and recent studies of TMS as a treatment for depression have embraced individualized, fMRI-based targeting, serving as the basis for the first FDA-approved individualized fMRI-based TMS protocol for depression treatment 63 , 65 , 66 . Note, however, that the current study did not directly test whether individualized targeting of multivariate representations per se was required for the observed findings, as they were examined relative to the active control TMS site (S1) and baseline sessions (rather than relative to a group-coordinate based mid-LPFC TMS site).…”

“…Note, however, that the current study did not directly test whether individualized targeting of multivariate representations per se was required for the observed findings, as they were examined relative to the active control TMS site (S1) and baseline sessions (rather than relative to a group-coordinate based mid-LPFC TMS site). Therefore, future methodological work systematically quantifying the impact of distinct individualized vs. group-based TMS-targeting strategies (guided by univariate, multivariate, and/or functional-connectivity-based signals)—ideally conducted within subjects—will be required to more fully characterize their differential efficacy in modulating neural activity and behavior, and inform translational neuroscience efforts, including personalized brain stimulation strategies that are increasingly embraced in the clinic 41 , 63 , 64 .…”