Meds or Therapy? PET Scan Predicts Best Treatment

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A study published in JAMA Psychiatry suggests that a PET scan could replace the trial-and-error approach in determining whether therapy or medication is the best course of treatment for a patient suffering depression.

A multidisciplinary team at Emory University led by Helen Mayberg, MD, a neurologist and professor of psychiatry, neurology and radiology, sought a brain biomarker that could predict the best course of treatment for an individual patient.

Using a PET scanner, the researchers imaged the pre-treatment resting brains of 63 depressed patients, then compared the brain circuit activity of patients who achieved remission following treatment (with either cognitive behavior therapy or an SSRI-based antidepressant) with those who failed to improve in the study, funded by the National Institutes of health.

Low, pre-treatment resting brain activity in the insula signaled a significantly higher likelihood of remmision with CBT and a poor response to the antidepressant. Hyperactivity in the insula predicted remission with medication and a poor response to CBT.

Among several sites of brain activity that are related to outcome, the researchers pinpointed activity in the anterior insula as best predicting response and non-response to both treatments. Brain-mapping efforts have identified the anterior insula as significant in regulating emotional states, self-awareness, decision-making and other thinking tasks. Changes in insula activity have been observed in studies of various depression treatments, including medication, mindfulness training, vagal nerve stimulation and deep brain stimulation.

“For the treatment of mental disorders, brain imaging remains primarily a research tool, yet these results demonstrate how it may be on the cusp of aiding in clinical decision-making,” said NIMH Director Thomas R. Insel, MD, in a press release from the NIH.

Mayberg, who has used functional and anatomic imaging to pioneer the treatment for depression known as deep brain stimulation, characterized the study as a first step toward personalized medicine in depression. “If these findings are confirmed in follow-up replication studies, scans of anterior insula activity could become clinically useful to guide more effective initial treatment decisions, offering a first step towards personalized medicine measures in the treatment of major depression” she was quoted as saying in the NIH press release.