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Sedlakova J, Westermair AL, Biller-Andorno N, Meier CA, Trachsel M. Comparison of analog and digital patient decision aids for the treatment of depression: a scoping review. Front Digit Health 2023; 5:1208889. [PMID: 37744684 PMCID: PMC10513051 DOI: 10.3389/fdgth.2023.1208889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 08/18/2023] [Indexed: 09/26/2023] Open
Abstract
Introduction Patient decision aids (PDAs) are important tools to empower patients and integrate their preferences and values in the decision-making process. Even though patients with mental health problems have a strong interest in being more involved in decision making about their treatment, research has mainly focused on PDAs for somatic conditions. In this scoping review, we focus on patients suffering from depression and the role of PDAs for this patient group. The review offers an overview of digital and analog PDAs, their advantages and disadvantages as well as recommendations for further research and development. Methods A systematic search of the existing literature guided by the Cochrane Handbook for Systematic Reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses - extension for scoping reviews (PRISMA-ScR) was conducted. Three electronic literature databases with the appropriate thematic focus were searched (PubMed, PsycInfo, and Web of Science). The search strategy used controlled and natural language to search for the key concepts decision aids and depression. The articles were selected in a two-step process guided by predefined inclusion and exclusion criteria. We narratively synthetized information extracted from 40 research articles. Results We included 40 articles in our review. Our review revealed that there is more focus on digital PDAs in research than in clinical practice. Digitalization can enhance the benefits of PDAs by developing tools that are more efficient, interactive, and personalized. The main disadvantages of both types of PDAs for the treatment of depression are related to time, dissemination, and capacity building for the health care providers. Digital PDAs need to be regularly updated, effective strategies for their dissemination and acceptance need to be identified, and clinicians need sufficient training on how to use digital PDAs. There is more research needed to study which forms of PDAs are most appropriate for various patient groups (e.g., older adults, or patients with comorbidities), and to identify the most effective ways of PDAs' integration in the clinical workflow. The findings from our review could be well aligned with the International Patient Decision Aids Standards. Discussion More research is needed regarding effective strategies for the implementation of digital PDAs into the clinical workflow, ethical issues raised by the digital format, and opportunities of tailoring PDAs for diverse patient groups.
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Affiliation(s)
- Jana Sedlakova
- Institute of Biomedical Ethics and History of Medicine, University of Zurich (UZH), Zürich, Switzerland
| | - Anna Lisa Westermair
- Institute of Biomedical Ethics and History of Medicine, University of Zurich (UZH), Zürich, Switzerland
- Clinical Ethics Unit, University Hospital of Basel (USB), Basel, Switzerland
- Clinical Ethics Unit, University Psychiatric Clinics Basel (UPK), Basel, Switzerland
| | - Nikola Biller-Andorno
- Institute of Biomedical Ethics and History of Medicine, University of Zurich (UZH), Zürich, Switzerland
| | - Christoph A. Meier
- Department of Internal Medicine, University Hospital Zurich (USZ), Zürich, Switzerland
- Medical Faculty, University of Geneva, Geneva, Switzerland
| | - Manuel Trachsel
- Clinical Ethics Unit, University Hospital of Basel (USB), Basel, Switzerland
- Clinical Ethics Unit, University Psychiatric Clinics Basel (UPK), Basel, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
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2
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Rogojanski J, Zeifman RJ, Antony MM, Walker JR, Monson CM. Evaluation of a decision aid for the treatment of depression among college students. JOURNAL OF AMERICAN COLLEGE HEALTH : J OF ACH 2022; 70:1634-1643. [PMID: 32924861 DOI: 10.1080/07448481.2020.1817034] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 08/06/2020] [Accepted: 08/21/2020] [Indexed: 06/11/2023]
Abstract
Objective: Depression, and its treatment, is a concern among college students. Research indicates decision aids (DA) improve patients' treatment knowledge, decision making, and decisional conflict; however, it is unknown whether they are helpful for disseminating depression treatment information to college students. This study evaluated a DA for depression and its impact on college students' knowledge and treatment decision making. Methods: College students (N = 144) completed questionnaires pre-, post-, and at 1-month follow-up after reviewing an evidence-based DA for depression. Results: Participants rated the DA as highly acceptable and useful, and their knowledge increased at post-treatment and follow-up. However, treatment option presentation order influenced decision making. Conclusions: This DA is a useful and acceptable decision-making tool, and increased knowledge of depression and its treatment among college students. This study proposes a novel tool for educating college students about depression treatment, furthering our understanding of factors influencing treatment preferences.
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Affiliation(s)
| | | | - Martin M Antony
- Department of Psychology, Ryerson University, Toronto, Canada
| | - John R Walker
- Department of Clinical Health Psychology, University of Manitoba, Winnipeg, Canada
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Maruf AA, Bousman CA. Approaches and hurdles of implementing pharmacogenetic testing in the psychiatric clinic. PCN REPORTS : PSYCHIATRY AND CLINICAL NEUROSCIENCES 2022; 1:e26. [PMID: 38868642 PMCID: PMC11114389 DOI: 10.1002/pcn5.26] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 05/07/2022] [Accepted: 06/01/2022] [Indexed: 06/14/2024]
Abstract
Pharmacogenetic (PGx) testing has emerged as a tool for predicting a person's ability to process and react to drugs. Despite the growing evidence-base, enthusiasm, and successful efforts to implement PGx testing in psychiatry, a consensus on how best to implement PGx testing into practice has not been established and numerous hurdles to widespread adoption remain to be overcome. In this article, we summarize the most used approaches and commonly encountered hurdles when implementing PGx testing into routine psychiatric care. We also highlight effective strategies that have been used to overcome hurdles. These strategies include the development of user-friendly clinical workflows for test ordering, use, and communication of results, establishment of test standardization and reimbursement policies, and development of tailored curriculums for educating health-care providers and the public. Although knowledge and awareness of these approaches and strategies to overcome hurdles alone may not be sufficient for successful implementation, they are necessary to ensure the effective spread, scale, and sustainability of PGx testing in psychiatry and other areas of medicine.
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Affiliation(s)
- Abdullah Al Maruf
- Rady Faculty of Health Sciences, College of PharmacyUniversity of ManitobaWinnipegManitobaCanada
- Children's Hospital Research Institute of ManitobaWinnipegManitobaCanada
- Centre on AgingUniversity of ManitobaWinnipegManitobaCanada
- The Mathison Centre for Mental Health Research & Education, Hotchkiss Brain InstituteUniversity of CalgaryCalgaryAlbertaCanada
- Departments of Psychiatry and Physiology & PharmacologyUniversity of CalgaryCalgaryAlbertaCanada
| | - Chad A. Bousman
- The Mathison Centre for Mental Health Research & Education, Hotchkiss Brain InstituteUniversity of CalgaryCalgaryAlbertaCanada
- Departments of Psychiatry and Physiology & PharmacologyUniversity of CalgaryCalgaryAlbertaCanada
- Department of Medical GeneticsUniversity of CalgaryCalgaryAlbertaCanada
- Department of Community Health SciencesUniversity of CalgaryCalgaryAlbertaCanada
- Alberta Children's Hospital Research InstituteUniversity of CalgaryCalgaryAlbertaCanada
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4
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Bousman CA, Oomen A, Jessel CD, Tampi RR, Forester BP, Eyre HA, Lavretsky H, Müller DJ. Perspectives on the Clinical Use of Pharmacogenetic Testing in Late-Life Mental Healthcare: A Survey of the American Association of Geriatric Psychiatry Membership. Am J Geriatr Psychiatry 2022; 30:560-571. [PMID: 34740522 DOI: 10.1016/j.jagp.2021.09.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 09/28/2021] [Accepted: 09/29/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To assess perspectives on pharmacogenetic (PGx) testing among members of the American Association of Geriatric Psychiatry (AAGP). DESIGN Cross-sectional survey. PARTICIPANTS Members of the AAGP. MEASUREMENTS Anonymous web-based survey consisting of 41 items covering experiences, indications, barriers, facilitators and ethical, legal and social implications for PGx testing. RESULTS A total of 124 surveys were completed (response rate = 13%). Most respondents (60%) had used PGx testing but an equal proportion (58%) was uncertain about the clinical usefulness of PGx testing in late-life mental health. Despite self-reported confidence in the ability to order and interpret PGx testing, 60% of respondents felt there was not enough clinical evidence for them to use PGx testing in their practice. This was compounded by uncertainties related to their ethical obligation and legal liability when interpreting and using (or not using) PGx testing results. Respondents strongly affirmed that clinical and legal guidelines for PGx testing in older adults are needed and would be helpful. CONCLUSION The findings suggest additional PGx research and physician education in late-life mental healthcare settings is required to reconcile uncertainties related to the clinical efficacy and ethico-legal aspects of PGx testing as well as address current knowledge barriers to testing uptake. These efforts would be further facilitated by the development of clinical practice guidelines to ensure equitable access to testing and standardized implementation of PGx-informed prescribing in older adults.
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Affiliation(s)
- Chad A Bousman
- Department of Medical Genetics, University of Calgary (CAB), Calgary, AB, Canada; Department of Psychiatry, University of Calgary (CAB), Calgary, AB, Canada; Department of Physiology & Pharmacology, University of Calgary (CAB), Calgary, AB, Canada; Alberta Children's Hospital Research Institute, University of Calgary (CAB, AO), Calgary, AB, Canada; Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary (CAB, CDJ), Calgary, AB, Canada.
| | - Anita Oomen
- Alberta Children's Hospital Research Institute, University of Calgary (CAB, AO), Calgary, AB, Canada
| | - Chaten D Jessel
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary (CAB, CDJ), Calgary, AB, Canada
| | - Rajesh R Tampi
- Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University (RRT), Cleveland, OH; Department of Psychiatry, Yale School of Medicine (RRT), New Haven, CT
| | - Brent P Forester
- Division of Geriatric Psychiatry, McLean Hospital (BPF), Belmont, MA; Harvard Medical School (BPF), Boston, MA
| | - Harris A Eyre
- Neuroscience-inspired Policy Initiative, Organisation for Economic Co-Operation and Development (OECD) and PRODEO Institute (HAE), Paris, France; Institute for Mental Health and Physical Health and Clinical Translation (IMPACT), Deakin University (HAE), Geelong, Victoria, Australia; Global Brain Health Institute, University of California, San Francisco and Trinity College Dublin (HAE), Dublin, Ireland; Department of Psychiatry, Baylor College of Medicine (HAE), Houston, TX
| | - Helen Lavretsky
- Department of Psychiatry, Semel Institute for Neuroscience, University of California Los Angeles (HL), Los Angeles, CA
| | - Daniel J Müller
- Department of Psychiatry, University of Toronto (DJM), Toronto, Ontario, Canada; Centre for Addiction and Mental Health, University of Toronto (DJM), Toronto, Ontario, Canada
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Gunby JD, Lockhart JR. Clinical reasoning as midwifery: A Socratic model for shared decision making in person-centred care. Nurs Philos 2022; 23:e12390. [PMID: 35416380 DOI: 10.1111/nup.12390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 03/11/2022] [Accepted: 03/30/2022] [Indexed: 11/27/2022]
Abstract
Shared decision making has become the standard of care, yet there remains no consensus about how it should be conducted. Most accounts are concerned with threats to patient autonomy, and they address the dangers of a power imbalance by foregrounding the patient as a person whose complex preferences it is the practitioner's task to support. Other corrective models fear that this level of mutuality risks abdicating the practitioner's responsibilities as an expert, and they address that concern by recovering a nuanced but genuinely directive clinical role. Cribb and Entwistle helpfully categorize models of shared decision making as 'narrower' and 'broader' and praise the latter's 'open-ended and fully dialogical ways of relating'. However, they stop short of providing a philosophical account of how that dialogue works. In this paper, a nurse-midwife and a philosopher collaborate to argue that the Socratic model of dialogue offers a solution to the practitioner-patient dilemma. In the Theaetetus, Socrates compares dialogical reasoning to 'midwifery with all its standard features'. By means of a three-way analogy, elements of midwifery practice are used to illuminate features of Socrates' claim that his dialogue is like midwifery; those features are then translated into an approach to shared decision making as the 'midwifery of good thinking' which both midwives and physicians would do well to adopt. A key concept that emerges is the need for practitioners to make a risk-confidence assessment of the particular content of any decision to appropriately modulate their role in the practice of shared decision making.
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Affiliation(s)
- Julie D Gunby
- Albert Gnaegi Center for Health Care Ethics, Saint Louis University, St. Louis, Missouri, USA
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Bousman CA, Mukerjee G, Men X, Dorfman R, Müller DJ, Thomas RE. Encountering Pharmacogenetic Test Results in the Psychiatric Clinic. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2022; 67:95-100. [PMID: 34783587 PMCID: PMC8892046 DOI: 10.1177/07067437211058847] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Chad A Bousman
- Departments of Medical Genetics, Psychiatry, Physiology & Pharmacology, and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada.,Department of Psychiatry, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | | | - Xiaoyu Men
- Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada
| | - Ruslan Dorfman
- GeneYouIn Inc, Toronto, Ontario, Canada.,Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Daniel J Müller
- Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Roger E Thomas
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
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7
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Pharmacogenetic Testing in an Academic Psychiatric Clinic: A Retrospective Chart Review. J Pers Med 2021; 11:jpm11090896. [PMID: 34575674 PMCID: PMC8470368 DOI: 10.3390/jpm11090896] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 09/03/2021] [Accepted: 09/04/2021] [Indexed: 12/21/2022] Open
Abstract
Pharmacogenomic (PGx) testing is being increasingly recognized by clinicians as an essential tool to guide medication decisions for treatment of psychiatric illnesses. Extensive implementation of PGx testing, however, varies by setting and location. In this retrospective study, we reviewed charts from 592 patients diagnosed with a psychiatric disorder at the Loyola University Medical Center, for whom PGx testing was performed. Information collected included demographics at the time of testing, psychiatric diagnosis, medical and psychiatric history and medications prior and after PGx testing. Of the 592 charts analyzed, the most common primary diagnoses were depression (52%) and anxiety (12%). Prior to PGx testing, 72% of patients were prescribed three or more medications, whereas, after testing, only 44% were prescribed three or more medications included in the test panel (p < 0.0001). The most common clinical consideration on the PGx reports was recommendation to reduce dosages (33%). After PGx testing, the proportion of patients taking incongruent medications decreased from 26% to 19% and that of patients taking congruent medications increased from 74% to 81% (p = 0.006). The results from this retrospective data analysis demonstrated a reduction in polypharmacy and an increase in recommendation-congruent medication prescribing resulting from implementation of PGx testing.
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8
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Borczyk M, Piechota M, Rodriguez Parkitna J, Korostynski M. Prospects for personalization of depression treatment with genome sequencing. Br J Pharmacol 2021; 179:4220-4232. [PMID: 33786859 DOI: 10.1111/bph.15470] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 03/22/2021] [Accepted: 03/24/2021] [Indexed: 12/20/2022] Open
Abstract
The effectiveness of antidepressants in the treatment of major depressive disorder varies considerably between patients. With these interindividual differences and a number of antidepressants to choose from, the first choice of treatment often fails to produce improvement in the patient's condition. A substantial part of the variation in response to antidepressants can be explained by genetic factors. Accordingly, variants related to drug metabolism in two pharmacogenes, CYP2D6 and CYP2C19, have already been translated into guidelines for antidepressant prescriptions. The role of variants in other genes that influence antidepressant responses is not yet understood. Furthermore, rare and individual variants account for a substantial part of genetic differences in antidepressant efficacy. Recent years have brought a tremendous increase in the accessibility of genome sequencing in terms of data availability and its clinical use. In this review, we summarize recent developments and current issues in the personalization of major depressive disorder treatment through pharmacogenomics.
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Affiliation(s)
- Malgorzata Borczyk
- Laboratory of Pharmacogenomics, Department of Molecular Neuropharmacology, Maj Institute of Pharmacology, Polish Academy of Sciences, Kraków, Poland
| | - Marcin Piechota
- Laboratory of Pharmacogenomics, Department of Molecular Neuropharmacology, Maj Institute of Pharmacology, Polish Academy of Sciences, Kraków, Poland
| | - Jan Rodriguez Parkitna
- Laboratory of Pharmacogenomics, Department of Molecular Neuropharmacology, Maj Institute of Pharmacology, Polish Academy of Sciences, Kraków, Poland
| | - Michal Korostynski
- Laboratory of Pharmacogenomics, Department of Molecular Neuropharmacology, Maj Institute of Pharmacology, Polish Academy of Sciences, Kraków, Poland
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Treatment-Resistant Depression Revisited: A Glimmer of Hope. J Pers Med 2021; 11:jpm11020155. [PMID: 33672126 PMCID: PMC7927134 DOI: 10.3390/jpm11020155] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 02/18/2021] [Accepted: 02/18/2021] [Indexed: 12/20/2022] Open
Abstract
Major Depressive Disorder (MDD) is a highly prevalent psychiatric disorder worldwide. It causes individual suffering, loss of productivity, increased health care costs and high suicide risk. Current pharmacologic interventions fail to produce at least partial response to approximately one third of these patients, and remission is obtained in approximately 30% of patients. This is known as Treatment-Resistant Depression (TRD). The burden of TRD exponentially increases the longer it persists, with a higher risk of impaired functional and social functioning, vast losses in quality of life and significant risk of somatic morbidity and suicidality. Different approaches have been suggested and utilized, but the results have not been encouraging. In this review article, we present new approaches to identify and correct potential causes of TRD, thereby reducing its prevalence and with it the overall burden of this disease entity. We will address potential contributory factors to TRD, most of which can be investigated in many laboratories as routine tests. We discuss endocrinological aberrations, notably, hypothalamic-pituitary-adrenal (HPA) axis dysregulation and thyroid and gonadal dysfunction. We address the role of Vitamin D in contributing to depression. Pharmacogenomic testing is being increasingly used to determine Single Nucleotide Polymorphisms in Cytochrome P450, Serotonin Transporter, COMT, folic acid conversion (MTHFR). As the role of immune system dysregulation is being recognized as potentially a major contributory factor to TRD, the measurement of C-reactive protein (CRP) and select immune biomarkers, where testing is available, can guide combination treatments with anti-inflammatory agents (e.g., selective COX-2 inhibitors) reversing treatment resistance. We focus on established and emerging test procedures, potential biomarkers and non-biologic assessments and interventions to apply personalized medicine to effectively manage treatment resistance in general and TRD specifically.
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Forester BP, Parikh SV, Weisenbach S, Ajilore O, Vahia I, Rothschild AJ, Thase ME, Dunlop BW, DeBattista C, Conway CR, Shelton RC, Macaluso M, Li J, Traxler P, Logan J, Brown L, Dechairo B, Greden JF. Combinatorial Pharmacogenomic Testing Improves Outcomes for Older Adults With Depression. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2021; 19:76-85. [PMID: 34483773 PMCID: PMC8412149 DOI: 10.1176/appi.focus.19107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
(Reprinted with permission from Am J Geriatr Psychiatry 2020; 28:933-945).
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11
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Forester BP, Parikh SV, Weisenbach S, Ajilore O, Vahia I, Rothschild AJ, Thase ME, Dunlop BW, DeBattista C, Conway CR, Shelton RC, Macaluso M, Li J, Traxler P, Logan J, Brown L, Dechairo B, Greden JF. Combinatorial Pharmacogenomic Testing Improves Outcomes for Older Adults With Depression. Am J Geriatr Psychiatry 2020; 28:933-945. [PMID: 32513518 DOI: 10.1016/j.jagp.2020.05.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 05/01/2020] [Accepted: 05/04/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Evaluate the clinical utility of combinatorial pharmacogenomic testing for informing medication selection among older adults who have experienced antidepressant medication failure for major depressive disorder (MDD). DESIGN Post hoc analysis of data from a blinded, randomized controlled trial comparing two active treatment arms. SETTING Psychiatry specialty and primary care clinics across 60 U.S. community and academic sites. PARTICIPANTS Adults age 65 years or older at baseline (n = 206), diagnosed with MDD and inadequate response to at least one medication on the combinatorial pharmacogenomic test report during the current depressive episode. INTERVENTION Combinatorial pharmacogenomic testing to inform medication selection (guided-care), compared with treatment as usual (TAU). OUTCOMES Mean percent symptom improvement, response rate, and remission rateat week 8, measured using the 17-item Hamilton Depression Rating Scale; medication switching; and comorbidity moderator analysis. RESULTS At week 8, symptom improvement was not significantly different for guided-care than for TAU (∆ = 8.1%, t = 1.64, df = 187; p = 0.102); however, guided-care showed significantly improved response (∆ = 13.6%, t = 2.16, df = 187; p = 0.032) and remission (∆ = 12.7%, t = 2.49, df = 189; p = 0.014) relative to TAU. By week 8, more than twice as many patients in guided-care than in TAU were on medications predicted to have no gene-drug interactions (χ2 = 19.3, df = 2; p <0.001). Outcomes in the guided-care arm showed consistent improvement through the end of the open-design 24-week trial, indicating durability of the effect. Differences in outcomes between arms were not significantly impacted by comorbidities. CONCLUSIONS Combinatorial pharmacogenomic test-informed medication selection improved outcomes over TAU among older adults with depression.
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Affiliation(s)
- Brent P Forester
- Division of Geriatric Psychiatry (BPF, IV), McLean Hospital, Harvard Medical School, Belmont, MA.
| | - Sagar V Parikh
- University of Michigan Comprehensive Depression Center and Department of Psychiatry (SVP, JFG), National Network of Depression Centers, Ann Arbor, MI
| | - Sara Weisenbach
- Stony Brook University, Department of Psychiatry & Behavioral Health (SW), Stony Brook, NY
| | - Olusola Ajilore
- University of Illinois at Chicago, School of Public Health/Psychiatric Institute (OJ), Chicago, IL
| | - Ipsit Vahia
- Division of Geriatric Psychiatry (BPF, IV), McLean Hospital, Harvard Medical School, Belmont, MA
| | - Anthony J Rothschild
- University of Massachusetts Medical School and UMass Memorial Healthcare (AJR), Worcester, MA
| | - Michael E Thase
- Perelman School of Medicine of the University of Pennsylvania, the Corporal Michael Crescenz VAMC (MET), Philadelphia, PA
| | - Boadie W Dunlop
- Emory University School of Medicine, Department of Psychiatry and Behavioral Sciences (BWD), Atlanta, GA
| | - Charles DeBattista
- Stanford University School of Medicine, Department of Psychiatry and Behavioral Sciences (CDB), Stanford, CA
| | - Charles R Conway
- Washington University School of Medicine, Department of Psychiatry, and the John Cochran Veteran's Administration Hospital (CRC), St. Louis, MO
| | - Richard C Shelton
- The University of Alabama at Birmingham, Department of Psychiatry and School of Medicine (RCS), Birmingham, AL
| | - Matthew Macaluso
- University of Kansas School of Medicine-Wichita, Department of Psychiatry and Behavioral Sciences (MM), Wichita, KS
| | - James Li
- Assurex Health, Inc./Myriad Neuroscience (PT, LB), Mason, OH
| | - Paul Traxler
- Assurex Health, Inc./Myriad Neuroscience (PT, LB), Mason, OH
| | | | - Lisa Brown
- Assurex Health, Inc./Myriad Neuroscience (PT, LB), Mason, OH
| | | | - John F Greden
- University of Michigan Comprehensive Depression Center and Department of Psychiatry (SVP, JFG), National Network of Depression Centers, Ann Arbor, MI
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Ternes K, Iyengar V, Lavretsky H, Dawson WD, Booi L, Ibanez A, Vahia I, Reynolds C, DeKosky S, Cummings J, Miller B, Perissinotto C, Kaye J, Eyre HA. Brain health INnovation Diplomacy: a model binding diverse disciplines to manage the promise and perils of technological innovation. Int Psychogeriatr 2020; 32:955-979. [PMID: 32019621 PMCID: PMC7423685 DOI: 10.1017/s1041610219002266] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Brain health diplomacy aims to influence the global policy environment for brain health (i.e. dementia, depression, and other mind/brain disorders) and bridges the disciplines of global brain health, international affairs, management, law, and economics. Determinants of brain health include educational attainment, diet, access to health care, physical activity, social support, and environmental exposures, as well as chronic brain disorders and treatment. Global challenges associated with these determinants include large-scale conflicts and consequent mass migration, chemical contaminants, air quality, socioeconomic status, climate change, and global population aging. Given the rapidly advancing technological innovations impacting brain health, it is paramount to optimize the benefits and mitigate the drawbacks of such technologies. OBJECTIVE We propose a working model of Brain health INnovation Diplomacy (BIND). METHODS We prepared a selective review using literature searches of studies pertaining to brain health technological innovation and diplomacy. RESULTS BIND aims to improve global brain health outcomes by leveraging technological innovation, entrepreneurship, and innovation diplomacy. It acknowledges the key role that technology, entrepreneurship, and digitization play and will increasingly play in the future of brain health for individuals and societies alike. It strengthens the positive role of novel solutions, recognizes and works to manage both real and potential risks of digital platforms. It is recognition of the political, ethical, cultural, and economic influences that brain health technological innovation and entrepreneurship can have. CONCLUSIONS By creating a framework for BIND, we can use this to ensure a systematic model for the use of technology to optimize brain health.
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Affiliation(s)
- Kylie Ternes
- School of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Vijeth Iyengar
- U.S. Administration on Aging/Administration for Community Living, U.S. Department of Health and Human Services, Washington, DC, USA
| | - Helen Lavretsky
- Department of Psychiatry, Semel Institute for Neuroscience and Human Behavior, UCLA, Los Angeles, California, USA
| | - Walter D Dawson
- Memory and Aging Center, School of Medicine, UCSF, San Francisco, California, USA
- Global Brain Health Institute, San Francisco, California, USA
- Trinity College Dublin, Dublin, Ireland
- School of Medicine, Oregon Health and Science University, Portland, Oregon, USA
- Institute on Aging, School of Urban and Public Affairs, Portland State University, Portland, Oregon, USA
| | - Laura Booi
- Global Brain Health Institute, San Francisco, California, USA
- Trinity College Dublin, Dublin, Ireland
| | - Agustin Ibanez
- Memory and Aging Center, School of Medicine, UCSF, San Francisco, California, USA
- Global Brain Health Institute, San Francisco, California, USA
- Trinity College Dublin, Dublin, Ireland
- Institute of Cognitive and Translational Neuroscience (INCYT), INECO Foundation, Favaloro University, Buenos Aires, Argentina
- National Scientific and Technical Research Council (CONICET), Buenos Aires, Argentina
- Center for Social and Cognitive Neuroscience (CSCN), Universidad Adolfo Ibanez, Santiago, Chile
- Universidad Autónoma del Caribe, Barranquilla, Colombia
- ARC Centre of Excellence in Cognition and its Disorders, Sydney, Australia
| | - Ipsit Vahia
- McLean Hospital, Belmont, Massachusetts, USA
- Harvard Medical School, Cambridge, Massachusetts, USA
| | - Charles Reynolds
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Steven DeKosky
- McKnight Brain Institute and Department of Neurology, College of Medicine, University of Florida, Miami, Florida, USA
| | - Jeffrey Cummings
- Department of Brain Health, School of Integrated Health Sciences, Cleveland Clinic Lou Ruvo Center for Brain Health, UNLV, Las Vegas, Nevada, USA
| | - Bruce Miller
- Memory and Aging Center, School of Medicine, UCSF, San Francisco, California, USA
- Global Brain Health Institute, San Francisco, California, USA
- Trinity College Dublin, Dublin, Ireland
| | - Carla Perissinotto
- Division of Geriatrics, School of Medicine, UCSF, San Francisco, California, USA
| | - Jeffrey Kaye
- School of Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Harris A Eyre
- Innovation Institute, Texas Medical Center, Houston, Texas, USA
- Department of Psychiatry, University of Melbourne, Melbourne, Victoria, Australia
- IMPACT SRC, School of Medicine, Deakin University, Geelong, Victoria, Australia
- Brainstorm Laboratory for Mental Health Innovation, Department of Psychiatry, Stanford University School of Medicine, Palo Alto, California, USA
- Discipline of Psychiatry, School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
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13
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Maruf AA, Fan M, Arnold PD, Müller DJ, Aitchison KJ, Bousman CA. Pharmacogenetic Testing Options Relevant to Psychiatry in Canada: Options de tests pharmacogénétiques pertinents en psychiatrie au Canada. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2020; 65:521-530. [PMID: 32064906 PMCID: PMC7492886 DOI: 10.1177/0706743720904820] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To identify and assess pharmacogenetic testing options relevant to psychiatry in Canada. METHOD Searches of published literature, websites, and Standard Council of Canada's Laboratory Directory were conducted to identify pharmacogenetic tests available in Canada. Identified tests were assessed on 8 key questions related to analytical validity, accessibility, test ordering, delivery of test results, turnaround time, cost, clinical trial evidence, and gene/allele content. RESULTS A total of 13 pharmacogenetic tests relevant to psychiatry in Canada were identified. All tests were highly accessible, and most were conducted in accredited laboratories. Both direct-to-consumer and clinician-gated testing were identified, with turnaround times and cost ranging from 2 to 40 days and CAD$199 to CAD$2310, respectively. Two tests were supported by randomized controlled trials. All tests met minimum gene and allele panel recommendations for psychiatry, but no 2 panels were identical. No test was unequivocally superior to all other tests. CONCLUSIONS Pharmacogenetic testing in Canada is readily available but highly variable in terms of ordering procedures, delivery of results, turnaround times, cost, and gene/allele content. As such, it is important for psychiatrists and other health-care providers to understand the differences between the available tests to ensure appropriate selection and implementation within their practice.
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Affiliation(s)
- Abdullah Al Maruf
- The Mathison Centre for Mental Health Research & Education,
Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,
Alberta, Canada
- Department of Psychiatry, University of Calgary, Alberta,
Canada
| | - Mikayla Fan
- Cumming School of Medicine, University of Calgary, Alberta,
Canada
| | - Paul D. Arnold
- The Mathison Centre for Mental Health Research & Education,
Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,
Alberta, Canada
- Department of Psychiatry, University of Calgary, Alberta,
Canada
- Department of Medical Genetics, University of Calgary, Alberta,
Canada
| | - Daniel J. Müller
- Pharmacogenetics Research Clinic, Campbell Family Mental Health
Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario,
Canada
- Department of Psychiatry, University of Toronto, Ontario,
Canada
| | - Katherine J. Aitchison
- Department of Psychiatry, University of Alberta, Edmonton, Alberta,
Canada
- Department of Medical Genetics, University of Alberta, Edmonton,
Alberta, Canada
| | - Chad A. Bousman
- The Mathison Centre for Mental Health Research & Education,
Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary,
Alberta, Canada
- Department of Psychiatry, University of Calgary, Alberta,
Canada
- Department of Medical Genetics, University of Calgary, Alberta,
Canada
- Department of Physiology and Pharmacology, University of Calgary,
Alberta, Canada
- Alberta Children’s Hospital Research Institute, University of
Calgary, Alberta, Canada
- Chad A. Bousman, MPH, PhD, Department of
Medical Genetics, University of Calgary, 270 HMRB, 3330 Hospital Drive NW,
Calgary, Alberta, Canada T2N 4N1.
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14
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Manchia M, Pisanu C, Squassina A, Carpiniello B. Challenges and Future Prospects of Precision Medicine in Psychiatry. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2020; 13:127-140. [PMID: 32425581 PMCID: PMC7186890 DOI: 10.2147/pgpm.s198225] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 04/14/2020] [Indexed: 12/21/2022]
Abstract
Precision medicine is increasingly recognized as a promising approach to improve disease treatment, taking into consideration the individual clinical and biological characteristics shared by specific subgroups of patients. In specific fields such as oncology and hematology, precision medicine has already started to be implemented in the clinical setting and molecular testing is routinely used to select treatments with higher efficacy and reduced adverse effects. The application of precision medicine in psychiatry is still in its early phases. However, there are already examples of predictive models based on clinical data or combinations of clinical, neuroimaging and biological data. While the power of single clinical predictors would remain inadequate if analyzed only with traditional statistical approaches, these predictors are now increasingly used to impute machine learning models that can have adequate accuracy even in the presence of relatively small sample size. These models have started to be applied to disentangle relevant clinical questions that could lead to a more effective management of psychiatric disorders, such as prediction of response to the mood stabilizer lithium, resistance to antidepressants in major depressive disorder or stratification of the risk and outcome prediction in schizophrenia. In this narrative review, we summarized the most important findings in precision medicine in psychiatry based on studies that constructed machine learning models using clinical, neuroimaging and/or biological data. Limitations and barriers to the implementation of precision psychiatry in the clinical setting, as well as possible solutions and future perspectives, will be presented.
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Affiliation(s)
- Mirko Manchia
- Section of Psychiatry, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.,Unit of Clinical Psychiatry, University Hospital Agency of Cagliari, Cagliari, Italy.,Department of Pharmacology, Dalhousie University, Halifax, NS, Canada
| | - Claudia Pisanu
- Department of Biomedical Sciences, Section of Neuroscience and Clinical Pharmacology, University of Cagliari, Cagliari, Italy
| | - Alessio Squassina
- Department of Biomedical Sciences, Section of Neuroscience and Clinical Pharmacology, University of Cagliari, Cagliari, Italy.,Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
| | - Bernardo Carpiniello
- Section of Psychiatry, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.,Unit of Clinical Psychiatry, University Hospital Agency of Cagliari, Cagliari, Italy
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15
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Brown L, Vranjkovic O, Li J, Yu K, Al Habbab T, Johnson H, Brown K, Jablonski MR, Dechairo B. The clinical utility of combinatorial pharmacogenomic testing for patients with depression: a meta-analysis. Pharmacogenomics 2020; 21:559-569. [PMID: 32301649 DOI: 10.2217/pgs-2019-0157] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Aim: To perform a meta-analysis of prospective, two-arm studies examining the clinical utility of using the combinatorial pharmacogenomic test, GeneSight Psychotropic, to inform treatment decisions for patients with major depressive disorder (MDD). Patients & methods: The pooled mean effect of symptom improvement and pooled relative risk ratio (RR) of response and remission were calculated using a random effect model. Results: Overall, 1556 patients were included from four studies, with outcomes evaluated at week 8 or week 10. Patient outcomes were significantly improved for patients with MDD whose care was guided by the combinatorial pharmacogenomic test results compared with unguided care (symptom improvement Δ = 10.08%, 95% CI: 1.67-18.50; p = 0.019; response RR = 1.40, 95% CI: 1.17-1.67; p < 0.001; remission RR = 1.49, 95% CI: 1.17-1.89; p = 0.001). Conclusion: GeneSight Psychotropic guided care improves outcomes among patients with MDD.
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Affiliation(s)
- Lisa Brown
- Department of Medical Affairs, Myriad Neuroscience, Mason, OH 45040, USA
| | - Oliver Vranjkovic
- Department of Medical Affairs, Myriad Neuroscience, Mason, OH 45040, USA
| | - James Li
- Department of MMM Informatics, Myriad Genetics, Mason, OH 45040, USA
| | - Kunbo Yu
- Department of MMM Informatics, Myriad Genetics, Mason, OH 45040, USA
| | - Talal Al Habbab
- Department of Medical Affairs, Myriad Neuroscience, Mason, OH 45040, USA
| | - Holly Johnson
- Department of Medical Affairs, Myriad Neuroscience, Mason, OH 45040, USA
| | - Krystal Brown
- Department of Clinical Development, Myriad Genetics, Salt Lake City, UT 84108, USA
| | | | - Bryan Dechairo
- Department of Clinical Development, Myriad Genetics, Salt Lake City, UT 84108, USA
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16
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Getting to precision psychopharmacology: Combining clinical and genetic information to predict fat gain from aripiprazole. J Psychiatr Res 2019; 114:67-74. [PMID: 31039482 PMCID: PMC6546502 DOI: 10.1016/j.jpsychires.2019.04.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 04/12/2019] [Accepted: 04/18/2019] [Indexed: 11/20/2022]
Abstract
INTRODUCTION All atypical antipsychotics are associated with some degree of weight gain. We applied a novel statistical approach to identify moderators of aripiprazole-induced fat gain using clinical and genetic data from a randomized clinical trial (RCT) of treatment resistant depression in older adults. MATERIALS AND METHODS Adults aged ≥60 years with non-response to a prospective trial of venlafaxine were randomized to 12 weeks of aripiprazole augmentation (n = 91) or placebo (n = 90). Dual energy x-ray absorptiometry (DEXA) measured adiposity at baseline and 12 weeks. Independent moderators of total body fat gain were used to generate two combined multiple moderators, one including clinical data alone and one including both clinical and genetic data to characterize individuals who gained fat during aripiprazole augmentation. RESULTS The value of the combined genetic + clinical multiple moderator (Mcg) was 0.57 [95% CI 0.46, 0.68] (effect size: 0.57), compared to the combined clinical moderator (Mc) value of 0.49 [0.34, 0.63] (effect size: 0.49). Individuals who gained adiposity in this study were more likely to be female and younger in age, have lower weight, fasting glucose and lipids at baseline and positive for the HTR2C polymorphism. DISCUSSION These results demonstrate a combined multiple moderator approach, including both clinical and genetic moderators, can be applied to existing clinical trial data to understand adverse treatment effects. This method allowed for more specific characterization of individuals at risk for the outcome of interest. Further work is needed to identify additional genetic moderators and to validate the approach.
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17
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Roberts R, Neasham A, Lambrinudi C, Khan A. A thematic analysis assessing clinical decision-making in antipsychotic prescribing for schizophrenia. BMC Psychiatry 2018; 18:290. [PMID: 30200923 PMCID: PMC6131851 DOI: 10.1186/s12888-018-1872-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 08/30/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND In recent decades atypical antipsychotics have increased treatment options available for schizophrenia, however there is conflicting evidence concerning the trade-off between clinical efficacy and side effects for the different classes of antipsychotics. There has been a consistent increase in atypical antipsychotic prescribing compared to typical, despite evidence showing that neither class is superior. This leads to the question of whether prescribers are selective in their uptake of research evidence and clinical guidelines and if so, what influences their choice.. This study aims to identify the factors that contribute to the prescribing choice and how these can be used to aid knowledge translation and guideline implementation. METHODS A thematic analysis study was conducted using data from 11 semi-structured interviews with clinicians with experience in prescribing for schizophrenia. RESULTS The analysis identified five themes underpinning prescribing behaviour: (1) ownership and collaboration; (2) compromise; (3) patient involvement; (4) integrating research evidence; and (5) experience. CONCLUSION The themes mapped to various degrees onto current models of evidence-based decision making and suggest that there is scope to re-think the guideline implementation frameworks to incorporate recurring themes salient to clinicians who ultimately use the guidelines. This will further translation of future evidence into clinical practice, accelerating clinical progress.
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Affiliation(s)
| | - Abigail Neasham
- 0000 0001 0807 5670grid.5600.3Cardiff University, Cardiff, UK
| | | | - Afshan Khan
- grid.440486.aBetsi Cadwaladr University Health Board, Bangor, UK
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18
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Blasco-Fontecilla H. Clinical utility of pharmacogenetic testing in children and adolescents with severe mental disorders. J Neural Transm (Vienna) 2018; 126:101-107. [PMID: 29626260 PMCID: PMC6373261 DOI: 10.1007/s00702-018-1882-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 04/02/2018] [Indexed: 12/03/2022]
Abstract
This is a retrospective cohort study of 20 children and adolescents to evaluate the clinical utility of a pharmacogenetic decision support tool. Twenty children and adolescents underwent pharmacogenetic testing between June 2014 and May 2017. All children and adolescents were evaluated at Puerta de Hierro University Hospital-Majadahonda (Madrid, Spain). We report the proportion of patients achieving clinical improvement, amelioration of side effects, and changes in number of drugs. Data normality was assessed with the Shapiro–Wilk test, and changes of pre- and post-pharmacogenetic testing were analyzed with the Wilcoxon test for paired samples. A two-sided p value threshold of 0.05 was considered for significance. Pharmacogenetic testing helped to improve the clinical outcome as measured by the Clinical Global Impressions (CGI) Scale in virtually all children (95%; 19 out of 20 children). The CGI improvement (CGI-I) was 2 (0.79) (range 1–4), 2.1 (0.56) (range 1–3), and 1.9 (0.99) (range 1–4) in foster and non-foster care children, respectively. Pharmacogenetic testing also helped to reduce the number of children using polypharmacy (from 65 to 45%), the mean number of drugs per children (from 3.3 to 2.4 drugs, p = 0.017), and self-reported relevant side effects (p = 0.006). Pharmacogenetic testing helped to improve the clinical outcome, and to reduce polypharmacy and the number of drugs used in children and adolescents with severe mental disorders. More evidence using robust (i.e., clinical trials) independent studies is required to properly determine the clinical utility and cost-effectiveness of pharmacogenetic testing tools in children and adolescents with mental disorders.
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Affiliation(s)
- Hilario Blasco-Fontecilla
- Department of Psychiatry, Segovia de Arana Health Research Institute (IDIPHISA)-Puerta de Hierro University Hospital, Avenida Manuel de Falla s/n, Majadahonda, Madrid, Spain.
- Autonoma University, Madrid, Spain.
- Biomedical Research Centre in Mental Health Net (CIBERSAM), Madrid, Spain.
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