Causes of treatment-resistance are reported in chronicity of illness, severity of symptomatology, psychiatric comorbidity [9, 10], physical comorbidity [11], personality traits [12] and molecular causes [13]. Other aspect of resistance is due to administration of inadequate treatment for dosage, time of response, compliance, absence or inadequate of augmentation support [4, 14-16].

At the light of these data, to find effective treatments takes particular importance, highlighting the need to improve therapeutic interventions. In this context, personalized psychiatry (PP) represents a way to come to the aid of these shortages.

PP is a branch of personalized medicine that seeks to define different aspects of psychiatric diseases, as vulnerability factors, accuracy of diagnosis and specific goals of treatments with the purpose to increase efficacy of interventions, considering the individual characteristics (e.g. genetic and epigenetic, physiological, psychological, physical, …). [17]

PP fills a wide areas of interest as biogenetic, epigenetic, studies about endophenotypes and biological markers, pharmacological approaches, educational and rehabilitation concerns, and environmental and social researches.

However specific publications about PP are not exhaustive, but they are constituted mainly by review and commentary [18]. Indeed, in literature, researches about PP can highlight two main lacks: 1) in spite of a large amount of research about genetic, pharmacogenetic and epigenetic of psychiatric diseases is published, a clear awareness of common aim, as PP concern, is missing; 2) PP fills mainly specific area disorders as mood and schizophrenia [17] [19], but investigations about other conditions are lacking.

For PP, studies of efficacy of treatments are of particular importance, especially on drug responses. Furthermore, the development of new technologies can improve genetic, genomic and neuroanatomic research focused on the study of new drugs and their efficacy [20]. PP encompasses both sorting who should get what type of treatment based on a personalized measure, but also custom intervention creation (eg customizing a brain stimulation approach).

Actually, PP is an early stage and could be empowered in order to increase healthy and welfare of patients, focusing not only on treatment, but also on prevention and reducing long-term costs, despite initial high economic investments and long procedures [19].

PP require interdisciplinary approach that favor a wide and holistic knowledge about diagnostic criteria, etiopathology and treatment intervention of mental disorders.

1. Quintero, J., et al., The evolving concept of Treatment- Resistant Schizophrenia. Actas Esp Psiquiatr, 2011. 39(4): p. 236-50.
2. De Fruyt, J., et al., Second generation antipsychotics in the treatment of bipolar depression: a systematic review and meta-analysis. J Psychopharmacol, 2012. 26(5): p. 603-17.
3. Sachs, G.S., et al., Effectiveness of adjunctive antidepressant treatment for bipolar depression. N Engl J Med, 2007. 356(17): p. 1711-22.
4. Sienaert, P., et al., Evidence-based treatment strategies for treatment-resistant bipolar depression: a systematic review. Bipolar Disord, 2013. 15(1): p. 61-9.
5. Abudy, A., A. Juven-Wetzler, and J. Zohar, Pharmacological management of treatment-resistant obsessive-compulsive disorder. CNS Drugs, 2011. 25(7): p. 585-96.
6. Pollack, M.H., et al., Novel treatment approaches for refractory anxiety disorders. Depress Anxiety, 2008. 25(6): p. 467-76.
7. Rosenbaum, J.F., Treatment-resistant panic disorder. J Clin Psychiatry, 1997. 58 Suppl 2: p. 61-4; discussion 65.
8. Eisendrath, S.J., et al., Mindfulness-based cognitive therapy (MBCT) versus the health-enhancement program (HEP) for adults with treatment-resistant depression: a randomized control trial study protocol. BMC Complement Altern Med, 2014. 14(1): p. 95.
9. Thase, M.E., Treatment-resistant depression: prevalence, risk factors, and treatment strategies. J Clin Psychiatry, 2011. 72(5): p. e18.
10. Seemuller, F., et al., Three-Year long-term outcome of 458 naturalistically treated inpatients with major depressive episode: severe relapse rates and risk factors. Eur Arch Psychiatry Clin Neurosci, 2014.
11. Amital, D., et al., Physical co-morbidity among treatment resistant vs. treatment responsive patients with major depressive disorder. Eur Neuropsychopharmacol, 2013. 23(8): p. 895-901.
12. Takahashi, M., et al., Personality traits as risk factors for treatment-resistant depression. PLoS One, 2013. 8(5): p. e63756.
13. Smith, D.F., Quest for biomarkers of treatment-resistant depression: shifting the paradigm toward risk. Front Psychiatry, 2013. 4: p. 57.
14. Elkis, H. and H.Y. Meltzer, [Refractory schizophrenia]. Rev Bras Psiquiatr, 2007. 29 Suppl 2: p. S41-7.
15. Leucht, S., et al., Second-generation versus first-generation antipsychotic drugs for schizophrenia: a meta-analysis. Lancet, 2009. 373(9657): p. 31-41.
16. Spijker, J., et al., Psychotherapy, antidepressants, and their combination for chronic major depressive disorder: a systematic review. Can J Psychiatry, 2013. 58(7): p. 386-92.
17. Ozomaro, U., C. Wahlestedt, and C.B. Nemeroff, Personalized medicine in psychiatry: problems and promises. BMC Med, 2013. 11: p. 132.
18. Holmes, M.V., et al., Fulfilling the promise of personalized medicine? Systematic review and field synopsis of pharmacogenetic studies. PLoS One, 2009. 4(12): p. e7960.
19. Alda, M., Personalized psychiatry: many questions, fewer answers. J Psychiatry Neurosci, 2013. 38(6): p. 363-5.
20. Moller, H.J. and D. Rujescu, Pharmacogenetics–genomics and personalized psychiatry. Eur Psychiatry, 2010. 25(5): p. 291-3.

This is good, since it allows us to avoid loosing time in analyzing everything in details and helps us to use our success/error continuous experience to quicken decisions. We listen to our “somatic marker”, that physical sensation that tells us is a thing is good or bad.

The big risk of this way of proceeding is that, while models are becoming stronger with experience, we believe they represent the truth and, slowly in a subtle way, only experiences that confirm our models are considered and those who disconfirm it is somehow refused (it is not really the same thing, it something of different, there should be a mistake and so on): in this way our big ego and the transformation of experiential models in beliefs will bring us to lose critical thinking.

Science, as candle in the dark (Carl Sagan), keeps our mind open to changes and helps to disconfirm our models, improving the possibility to build new models more near reality. Scientific methodology and research allows us to test ideas and models, helps to develop critical thinking and makes us all humble remembering us that we are not gods.

We need to think like a scientist and to reach this goal we need to become scientists. Thus only doing scientific research, being involving is research activity will allow to became fully aware on the role of science for our never ending process of learning and the weakness of our cognitive ability to build models.

In psychiatry, since brain and mind are the most tough enigma that science is trying to disentangle, the distance between our experience as personalized psychiatrists and the what science is able to explain in still big, to many of us choose to follow our models and give up the effort to be continuously updates, being persuaded that research is understanding only a standard model of patients that is far away from real patients, unable to capture their complexity, the complexity of a human being. Unfortunately this is often true.

Personalized medicine, allowed to look for specific anti-cancer drugs for specific patients with a unique genetic background allowing a incredible improvement of clinical responses. The same street might be followed by personalized medicine in psychiatry. No more “mean” patients, no more standardized patients, but each person with a mental disorder will be considered within his genetics, his child experiences, his temperament, his psychophysiology, his cognitive style and more personal features as possible to build up and understand each person within his personal life. The promise of personalized psychiatry is to build a science that will disentangle individual complexity to find out the best personal therapy for each patient helping us to become better personalized psychiatrists.

Giampaolo Perna,, Section’s Chair