The Pharmacogenetic Tool Kit to Guide Depression Treatment Decisions?

Summary and Comment |
June 2, 2016

The Pharmacogenetic Tool Kit to Guide Depression Treatment Decisions?

  1. Peter Roy-Byrne, MD

Commercially available tool kits are not yet ready for widespread adoption.

  1. Peter Roy-Byrne, MD

With the suboptimal response to many psychiatric treatments given by trial and error, clinicians and patients await the “personalizing” of treatment. Commercially available support tools for pharmacogenetic decision making are now being marketed to psychiatrists and, in the U.S., are reimbursed by some insurers. In an excellent review, these authors focus on tools offered by 22 companies.

The tools usually include multigene panels, based on single nucleotide polymorphisms, and are heavily focused on pharmacokinetic genes, less so on pharmacodynamic genes. For three support tools, published studies suggest improved clinical outcomes in depressed patients when prescribers follow the gene-based proprietary recommendations to prioritize the selection of specific medications. However, most studies were uncontrolled, and the combinatorial algorithms behind these recommendations were unpublished. Only a small number of included genes have been shown to singly have pharmacological implications. None of the tools included environmental factors potentially affecting therapeutic response or accounted for well-known ancestry effects.

Comment

This excellent review should be read by any psychiatrists wanting to use this kind of testing in their patients. In my own inspection of some of the published papers, the mean differences between groups had significant overlap, and no sensitivity or specificity analyses were provided.

Although some clinicians may argue that such testing “can't hurt and might help,” current psychopharmacological practice is complex, usually including combinations of multiple medications, and patients can have multiple comorbidities, both psychiatric and medical. Hence the meager available evidence, although promising, does not support routine use of these kits (although testing in some treatment-resistant patients might be reasonable). Even in medical specialties (e.g., oncology) that are much farther along in the understanding of genetic factors in illness pathophysiology, genetic testing to guide treatment is still in its infancy.

Editor Disclosures at Time of Publication

  • Disclosures for Peter Roy-Byrne, MD at time of publication Equity Valant Medical Solutions Grant / Research support NIH–National Institute of Mental Health Editorial boards Depression and Anxiety; UpToDate Leadership positions in professional societies Anxiety Disorders Association of America (Ex-Officio Board Member); Washington State Psychiatric Society (Immediate Past-President)

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