Genetic information is slowly working its way into psychiatric practice and our patients’ daily lives. Pharmacogenomic panels can be ordered by psychiatrists, and genetic testing is being sold to the general public without any involvement of physicians or genetic counselors. The practicing psychiatrist needs to be informed about both of these types of services.
Genetic panels marketed to psychiatrists
When pharmacogenomic panels started to hit the market about 5 years ago, most general psychiatrists greeted this option with understandable skepticism. Now the use of these tests is growing, both in numbers of genes tested and in the number of psychiatrists utilizing them.
According to Daniel Dowd, PharmD, Vice President of Medical Affairs at Genomind, one of the two leading commercial pharmacogenomic services, close to 5000 clinicians are currently using Genomind’s panel, and the company has recently logged its 100,000th test. “What we’re actually seeing in practice is most psychiatrists are ordering this for the treatment-resistant patients with 2 or more treatment failures,” says Dr. Dowd. “But in the pediatric patient population, they’re more likely to order it for treatment-naive patients.”
John A. R. Grimaldi Jr, MD, Instructor at Harvard Medical School (HMS) and attending outpatient psychiatrist at Brigham and Women’s Hospital (BWH), says he has had many patients ask about these genetic panels, and 2 patients brought in genetic panels ordered by their previous psychiatrist. “There is a real need for guidance about the use of these ‘assays’,” says Dr. Grimaldi. “I can imagine that ‘genetic assays’ would be useful with treatment-resistant patients, if the assay were paid for by insurance and if there were an evidence base to support interpretation.”
As a new neuropsychiatry fellow, I started to use pharmacogenomic testing for some of my patients last year when I inherited and started to collect a patient caseload filled with very complicated people. Some had tried many different psychiatric medications with little effect, or with significant and sometimes surprising adverse effects.
My supervisor and mentor, Barry Fogel, MD, Professor of Psychiatry at HMS and staff neurologist and psychiatrist at BWH, had asked me if I had considered pharmacogenomic testing. I objected that I did not know anyone who had ever used this testing, and that I did not know how to order it or how much this would cost my patients. Dr. Fogel gently pointed out that these were not insurmountable barriers.
Options for testing
When I looked into the options for pharmacogenomic testing, I found multiple companies offering similar panels, some of which had booths at the American Psychiatric Association meeting in May 2017. The biggest and most well-established providers of pharmacogenomic testing are GeneSight and Genomind.
GeneSight currently offers 4 panels: psychotropic, analgesic, ADHD, and methylene tetrahydrofolate reductase (MTHFR). The GeneSight website states that its “Psychotropic laboratory developed test analyzes how patients’ genes may affect his/her metabolism and response to FDA-approved medicines . . . .”
Dr. Allen is a Clinical Fellow in Neuropsychiatry, Brigham and Women’s Hospital, Boston, MA. Dr. Allen reports no conflicts of interest concerning the subject matter of this article.
1. Serretti A, Calati R, Mandelli L, et al. Serotonin transporter gene variants and behavior: a comprehensive review. Curr Drug Targets. 2006;7:1659-1669.
2. Fox E, Zougkou K, Ridgewell A, Garner K. The serotonin transporter gene alters sensitivity to attention bias modification: evidence for a plasticity gene. Biol Psychiatry. 2011;70:1049-1054.
3. Porcelli S, Fabbri C, Serretti A. Meta-analysis of serotonin transporter gene promoter polymorphism (5-HTTLPR) association with antidepressant efficacy. Eur Neuropsychopharmacol. 2012;22:239-258.
4. Ng CH, Bousman C, Smith DJ, et al. A prospective study of serotonin and norepinephrine transporter genes and the response to desvenlafaxine over 8 weeks in major depressive disorder. Pharmacopsychiatry. 2016;49:210-212.
5. Seripa D, Pilotto A, Paroni G, et al. Role of the serotonin transporter gene locus in the response to SSRI treatment of major depressive disorder in late life. J Psychopharmacol. 2015;29:623-633.
6. Hall-Flavin DK, Winner JG, Allen JD, et al. Utility of integrated pharmacogenomic testing to support the treatment of major depressive disorder in a psychiatric outpatient setting. Pharmacogen Genom. 2013;23:535-548.
7. Brennan FX, Gardner KR, Lombard J, et al. A naturalistic study of the effectiveness of pharmacogenetic testing to guide treatment in psychiatric patients with mood and anxiety disorders. Prim Care Companion CNS Disord. 2015;17(2). doi: 10.4088/PCC.14m01717.
8. McMichael AJ, Boeri M, Rolison JJ, et al. The influence of genotype information on psychiatrists’ treatment recommendations: more experienced clinicians know better what to ignore. Value Health. 2017;20:126-131.