Integrating Genomics into Psychiatric Practice: Ethical and Legal Challenges for Clinicians

Genetically guided precision medicine clinical decision support tools: a systematic review

OBJECTIVES

Patient care using genetics presents complex challenges. Clinical decision support (CDS) tools are a potential solution because they provide patient-specific risk assessments and/or recommendations at the point of care. This systematic review evaluated the literature on CDS systems which have been implemented to support genetically guided precision medicine (GPM).

MATERIALS AND METHODS

A comprehensive search was conducted in MEDLINE and Embase, encompassing January 1, 2011-March 14, 2023. The review included primary English peer-reviewed research articles studying humans, focused on the use of computers to guide clinical decision-making and delivering genetically guided, patient-specific assessments, and/or recommendations to healthcare providers and/or patients.

RESULTS

The search yielded 3832 unique articles. After screening, 41 articles were identified that met the inclusion criteria. Alerts and reminders were the most common form of CDS used. About 27 systems were integrated with the electronic health record; 2 of those used standards-based approaches for genomic data transfer. Three studies used a framework to analyze the implementation strategy.

DISCUSSION

Findings include limited use of standards-based approaches for genomic data transfer, system evaluations that do not employ formal frameworks, and inconsistencies in the methodologies used to assess genetic CDS systems and their impact on patient outcomes.

CONCLUSION

We recommend that future research on CDS system implementation for genetically GPM should focus on implementing more CDS systems, utilization of standards-based approaches, user-centered design, exploration of alternative forms of CDS interventions, and use of formal frameworks to systematically evaluate genetic CDS systems and their effects on patient care.

Psychiatrists' perceptions of and reactions to a simulated psychiatric genetic counseling session

Psychiatric genetic counseling (pGC) has been demonstrated to have meaningful positive outcomes for people with psychiatric conditions and their families. However, it is not widely accessed, and clinical genetics services tend to receive few referrals for these indications. Little research has evaluated psychiatrists' perceptions of and experience with interfacing with pGC. Therefore, we invited Ontario-based psychiatrists to participate in a study in which they first watched a simulated pGC session (representative of typical practice: the patient had depression with no exceptionally dense family history of psychiatric conditions, no genetic testing is provided, and no family-based risk assessment is performed), then completed zoom-based qualitative semi-structured interviews. Interviews were recorded, transcribed verbatim and checked for accuracy. Using interpretive description to analyze interviews with 12 psychiatrists (data collection was stopped at this point, as theoretical sufficiency was achieved), we generated two theoretical models: the first described the decision-making pathway psychiatrists currently follow when determining whether and how to address genetics with a patient; the second described psychiatrists' ideas for integrating pGC into care models for the future. Our data shed light on how to facilitate the delivery of pGC for people with psychiatric conditions and their families.

The Ethics of Risk Prediction for Psychosis and Suicide Attempt in Youth Mental Health

OBJECTIVE

To identify potential clinical utility of polygenic risk scores (PRS) and exposomic risk scores (ERS) for psychosis and suicide attempt in youth and assess the ethical implications of these tools.

STUDY DESIGN

We conducted a narrative literature review of emerging findings on PRS and ERS for suicide and psychosis as well as a literature review on the ethics of PRS. We discuss the ethical implications of the emerging findings for the clinical potential of PRS and ERS.

RESULTS

Emerging evidence suggests that PRS and ERS may offer clinical utility in the relatively near future but that this utility will be limited to specific, narrow clinical questions, in contrast to the suggestion that population-level screening will have sweeping impact. Combining PRS and ERS might optimize prediction. This clinical utility would change the risk-benefit balance of PRS, and further empirical assessment of proposed risks would be necessary. Some concerns for PRS, such as those about counseling, privacy, and inequities, apply to ERS. ERS raise distinct ethical challenges as well, including some that involve informed consent and direct-to-consumer advertising. Both raise questions about the ethics of machine-learning/artificial intelligence approaches.

CONCLUSIONS

Predictive analytics using PRS and ERS may soon play a role in youth mental health settings. Our findings help educate clinicians about potential capabilities, limitations, and ethical implications of these tools. We suggest that a broader discussion with the public is needed to avoid overenthusiasm and determine regulations and guidelines for use of predictive scores.

Biomarkers in psychiatric disorders

Psychiatric disorders represent a significant socioeconomic and healthcare burden worldwide. Of these, schizophrenia, bipolar disorder, major depressive disorder and anxiety are among the most prevalent. Unfortunately, diagnosis remains problematic and largely complicated by the lack of disease specific biomarkers. Accordingly, much research has focused on elucidating these conditions to more fully understand underlying pathophysiology and potentially identify biomarkers, especially those of early stage disease. In this chapter, we review current status of this endeavor as well as the potential development of novel biomarkers for clinical applications and future research study.

Comparative neurogenetics of dog behavior complements efforts towards human neuropsychiatric genetics

Domestic dogs display a wide array of heritable behaviors that have intermediate genetic complexity thanks to a long history of human-influenced selection. Comparative genetics in dogs could address the scarcity of non-human neurogenetic systems relevant to human neuropsychiatric disorders, which are characterized by mental, emotional, and behavioral symptoms and involve vastly complex genetic and non-genetic risk factors. Our review describes the diverse behavioral "phenome" of domestic dogs, past and ongoing sources of behavioral selection, and the state of canine behavioral genetics. We highlight two naturally disordered behavioral domains that illustrate how dogs may prove useful as a comparative, forward neurogenetic system: canine age-related cognitive dysfunction, which can be examined more rapidly given the attenuated lifespan of dogs, and compulsive disorders, which may have genetic roots in purpose-bred behaviors. Growing community science initiatives aimed at the companion dog population will be well suited to investigating such complex behavioral phenotypes and offer a comparative resource that parallels human genomic initiatives in scale and dimensionality.

Genetic testing for psychiatric illness in children: ethical issues

PURPOSE OF REVIEW

Genetic and genomic technologies are showing great potential in the field of psychiatry. Genetic testing for psychiatric conditions poses a range of ethical challenges, many of which are likely to be exacerbated for paediatric populations. As a large proportion of psychiatric conditions present in late adolescence and early adulthood, testing in childhood may be considered in some circumstances. Synthesis of issues specific to psychiatric genetic testing in paediatric populations has been limited.

RECENT FINDINGS

Balancing the autonomy of the child and parents requires consideration and judging capacity may be complicated by the presence of psychiatric illness in the child and their family. Health professionals' limited understanding of psychiatric genetics may inhibit delivery of effective psychiatric care. Risk of stigma and discrimination associated with genetic diagnosis and psychiatric illness is compounded for children, who inherently cannot make their own decisions and for whom the impact of a genetic diagnosis is likely to be longest lasting.

SUMMARY

Although the current evidence base suggests genetic testing may not be appropriate for clinical use in psychiatric populations right now, when it is, appropriate pre-test counselling and informed decision making will be essential to support and protect children's developing and future autonomy.

Concerns about the use of polygenic embryo screening for psychiatric and cognitive traits

Private companies have begun offering services to allow parents undergoing in-vitro fertilisation to screen embryos for genetic risk of complex diseases, including psychiatric disorders. This procedure, called polygenic embryo screening, raises several difficult scientific and ethical issues, as discussed in this Personal View. Polygenic embryo screening depends on the statistical properties of polygenic risk scores, which are complex and not well studied in the context of this proposed clinical application. The clinical, social, and ethical implications of polygenic embryo screening have barely been discussed among relevant stakeholders. To our knowledge, the International Society of Psychiatric Genetics is the first professional biomedical organisation to issue a statement regarding polygenic embryo screening. For the reasons discussed in this Personal View, the Society urges caution and calls for additional research and oversight on the use of polygenic embryo screening.

Ethical challenges of cord blood banks: a scoping review

Cord blood is a rich source of hematopoietic stem cells used to treat many diseases of blood origin. Thus, storage banks were created to store and provide umbilical cord cells. With the development of diagnostic and therapeutic technologies and techniques in medicine, ethical issues have also become more widespread and complex. After the creation of the cord blood banks, efforts were made to address the ethical issues associated with such banks. The present study attempts to identify the ethical challenges in these banks in the published studies. Databases including PubMed, Scopus, Web of Science (WOS), Embase, Proquest, and Google Scholar were searched from January 1996 to January 2021. Then, the ethical challenges of the cord blood bank were extracted from the results section using thematic content analysis. 22 studies were selected based on inclusion and exclusion criteria. The ethical challenges raised in the studies included private or public ownership of the bank, fair access to banking services, informed and voluntary consent, failure to provide sufficient information to individuals about the process, confidentiality of user's information, conflict of interest of bank founders (who are commonly doctors). The findings of this study indicated that there are serious ethical concerns regarding umbilical cord blood banks. Responding clearly to these ethical challenges calls for the attention of policymakers and medical ethics professionals; this will require a clear statement of the various aspects of these banks for society.

Psychiatric genomics, mental health equity, and intersectionality: A framework for research and practice

The causal mechanisms and manifestations of psychiatric illness cannot be neatly narrowed down or quantified for diagnosis and treatment. Large-scale genome-wide association studies (GWAS) might renew hope for locating genetic predictors and producing precision medicines, however such hopes can also distract from appreciating social factors and structural injustices that demand more socially inclusive and equitable approaches to mental healthcare. A more comprehensive approach begins with recognizing that there is no one type of contributor to mental illness and its duration that should be prioritized over another. We argue that, if the search for biological specificity is to complement the need to alleviate the social distress that produces mental health inequities, psychiatric genomics must incorporate an intersectional dimension to models of mental illness across research priorities, scientific frameworks, and clinical applications. We outline an intersectional framework that will guide all professionals working in the expanding field of psychiatric genomics to better incorporate issues of social context, racial and cultural diversity, and downstream ethical considerations into their work.

Nanotechnology Approaches for Enhanced CNS Drug Delivery in the Management of Schizophrenia

Schizophrenia is a neuropsychiatric disorder mainly affecting the central nervous system, presented with auditory and visual hallucinations, delusion and withdrawal from society. Abnormal dopamine levels mainly characterise the disease; various theories of neurotransmitters explain the pathophysiology of the disease. The current therapeutic approach deals with the systemic administration of drugs other than the enteral route, altering the neurotransmitter levels within the brain and providing symptomatic relief. Fluid biomarkers help in the early detection of the disease, which would improve the therapeutic efficacy. However, the major challenge faced in CNS drug delivery is the blood-brain barrier. Nanotherapeutic approaches may overcome these limitations, which will improve safety, efficacy, and targeted drug delivery. This review article addresses the main challenges faced in CNS drug delivery and the significance of current therapeutic strategies and nanotherapeutic approaches for a better understanding and enhanced drug delivery to the brain, which improve the quality of life of schizophrenia patients.

Pharmacogenomics: A road ahead for precision medicine in psychiatry

Psychiatric genomics is providing insights into the nature of psychiatric conditions that in time should identify new drug targets and improve patient care. Less attention has been paid to psychiatric pharmacogenomics research, despite its potential to deliver more rapid change in clinical practice and patient outcomes. The pharmacogenomics of treatment response encapsulates both pharmacokinetic ("what the body does to a drug") and pharmacodynamic ("what the drug does to the body") effects. Despite early optimism and substantial research in both these areas, they have to date made little impact on clinical management in psychiatry. A number of bottlenecks have hampered progress, including a lack of large-scale replication studies, inconsistencies in defining valid treatment outcomes across experiments, a failure to routinely incorporate adverse drug reactions and serum metabolite monitoring in study designs, and inadequate investment in the longitudinal data collections required to demonstrate clinical utility. Nonetheless, advances in genomics and health informatics present distinct opportunities for psychiatric pharmacogenomics to enter a new and productive phase of research discovery and translation.

Ethics review of multicenter neuro-psychiatric & neurodevelopmental genetics research protocols: a case study of the NeuroDev & NeuroGap-Psychosis studies

Complex research such as neuropsychiatric genetics presents unique challenges for research ethics committees (REC), particularly in Africa where genetics research on mental & neurological disorders is still in its infancy. To reflect on these experiences of reviewing Neuropsychiatric Genetic studies we use two multicenter studies, the NeuroDev and NeuroGap-Psychosis studies. We explored the content of the national guidelines and regulatory frameworks and the processes for ethics review in the participating African countries, to identify regulatory challenges, and to recommend areas for improvement. We also held reflective discussions with REC members involved in the review of the two studies were interviewed discussing their experiences of reviewing the two studies from the point of view of an African REC/REC member who reviewed the studies. Across all sites, a distinct theme was that the RECs did not have adequate knowledge and expertise for reviewing genetics and genomics studies in general. The review of guidelines showed the need to proactively update guidelines to meet the increasing complexity of research, ensure awareness creation, and continual capacity building of REC members.

Privacy considerations for sharing genomics data

An increasing amount of attention has been geared towards understanding the privacy risks that arise from sharing genomic data of human origin. Most of these efforts have focused on issues in the context of genomic sequence data, but the popularity of techniques for collecting other types of genome-related data has prompted researchers to investigate privacy concerns in a broader genomic context. In this review, we give an overview of different types of genome-associated data, their individual ways of revealing sensitive information, the motivation to share them as well as established and upcoming methods to minimize information leakage. We further discuss the concise threats that are being posed, who is at risk, and how the risk level compares to potential benefits, all while addressing the topic in the context of modern technology, methodology, and information sharing culture. Additionally, we will discuss the current legal situation regarding the sharing of genomic data in a selection of countries, evaluating the scope of their applicability as well as their limitations. We will finalize this review by evaluating the development that is required in the scientific field in the near future in order to improve and develop privacy-preserving data sharing techniques for the genomic context.

Precision Psychiatry: Biomarker-Guided Tailored Therapy for Effective Treatment and Prevention in Major Depression

Depression contributes greatly to global disability and is a leading cause of suicide. It has multiple etiologies and therefore response to treatment can vary significantly. By applying the concepts of personalized medicine, precision psychiatry attempts to optimize psychiatric patient care by better predicting which individuals will develop an illness, by giving a more accurate biologically based diagnosis, and by utilizing more effective treatments based on an individual's biological characteristics (biomarkers). In this chapter, we discuss the basic principles underlying the role of biomarkers in psychiatric pathology and then explore multiple biomarkers that are specific to depression. These include endophenotypes, gene variants/polymorphisms, epigenetic factors such as methylation, biochemical measures, circadian rhythm dysregulation, and neuroimaging findings. We also examine the role of early childhood trauma in the development of, and treatment response to, depression. In addition, we review how new developments in technology may play a greater role in the determination of new biomarkers for depression.

International Society of Psychiatric Genetics Ethics Committee: Issues facing us

Psychiatric genetics research is improving our understanding of the biological underpinnings of neurodiversity and mental illness. Using psychiatric genetics in ways that maximize benefits and minimize harms to individuals and society depends largely on how the ethical, legal, and social implications (ELSI) of psychiatric genetics are managed. The International Society of Psychiatric Genetics (ISPG) is the largest international organization dedicated to psychiatric genetics. Given its history, membership, and international reach, we believe the ISPG is well-equipped to contribute to the resolution of these ELSI challenges. As such, we recently created the ISPG Ethics Committee, an interdisciplinary group comprised of psychiatric genetics researchers, clinical geneticists, genetic counselors, mental health professionals, patients, patient advocates, bioethicists, and lawyers. This article highlights key ELSI challenges identified by the ISPG Ethics Committee to be of paramount importance for the ethical translation of psychiatric research into society in three contexts: research settings, clinical settings, and legal proceedings. For each of these arenas, we identify and discuss pressing psychiatric genetics ELSI dilemmas that merit attention and require action. The goal is to increase awareness about psychiatric genetics ELSI issues and encourage dialogue and action among stakeholders.

Metabolomics Biomarkers for Precision Psychiatry

The treatment of psychiatric disorders remains a significant challenge in part due to imprecise diagnostic criteria and incomplete understanding of the molecular pathology involved. Current diagnostic and pharmacological treatment guidelines use a uniform approach to address each disorder even though psychiatric clinical presentation and prognosis within a disorder are known to be heterogeneous. Limited therapeutic success highlights the need for a precision medicine approach in psychiatry, termed precision psychiatry. To practice precision psychiatry, it is essential to research and develop multiple omics-based biomarkers that consider environmental factors and careful phenotype determination. Metabolomics, which lies at the endpoint of the "omics cascade," allows for detection of alterations in systems-level metabolites within biological pathways, thereby providing insights into the mechanisms that underlie various physiological conditions and pathologies. The eicosanoids, a family of metabolites derived from oxygenated polyunsaturated fatty acids, play a key role in inflammatory mechanisms and have been implicated in psychiatric disorders such as anorexia nervosa and depression. This review (1) provides background on the current clinical challenges of psychiatric disorders, (2) gives an overview of metabolomics application as a tool to develop improved biomarkers for precision psychiatry, and (3) summarizes current knowledge on metabolomics and lipidomic findings in common psychiatric disorders, with a focus on eicosanoids. Metabolomics is a promising tool for precision psychiatry. This research has great potential for both discovering biomarkers and elucidating molecular mechanisms underlying psychiatric disorders.