Towards precision psychiatry: initial foundations and future directions

Psychiatric disorders carry a major public health burden, yet advances in treatment have been slow to emerge, partly owing to reliance on traditional symptom-based diagnostic frameworks. In this Perspective, we explore the emerging paradigm of precision psychiatry, which seeks to align therapeutic development with underlying neural biology dysfunctions using biomarkers. Drawing lessons from the success of precision oncology and neurology, precision psychiatry utilizes patient-specific biological measures of brain function - such as electroencephalography, objective behavioural assessments, functional magnetic resonance imaging and peripheral biomarkers - to understand drugs' effects on the brain, define indications and stratify patient populations for targeted intervention development. We discuss mechanistic approaches that focus on excitation-inhibition balance, reward and aversion circuits, hippocampal-prefrontal neuroplasticity, and processing of social cues, highlighting how these frameworks can elucidate drug mechanisms and predict treatment responses. Proof-of-concept examples, including predictors of response to standard-of-care treatments, and patient subgroup-driven successes in postpartum depression and schizophrenia, underscore the potential of stratified trials to reduce development risks and improve clinical outcomes. We address ongoing and future regulatory, commercial and clinical considerations for integrating scalable and reproducible biomarkers into drug development. Precision psychiatry thus represents a new strategy to refine clinical trial design and develop biology-defined treatments, which may help to overcome longstanding challenges in psychiatric drug discovery.