The Right Call

Genetic testing takes guesswork out of mental health treatment process.

The first chapter in the treatment of depression was written in 1958, when the first anti-depressant medication was introduced. The second chapter was written just before the turn of the new century, when clinicians learned that disorders such as depression and anxiety are the result of decreased neuroplasticity as well as a decrease in neurogenesis.

Advancements in pharmacogenomics have made it easier for psychiatrists such as Dr. Pollack to find the right medicine or treatment option for mental health patients.

“What the science is doing is helping me pick out the right medication or decide that I should try something like TMS instead of a medication,” -Dr. Pollack

The third chapter is being written right now with the help of genomics. In much the same way that cancer researchers have discovered that genetic makeup can determine how a cancer patient will respond to a specific drug, mental health researchers are learning how to treat patients with mental illness through genomics or, more precisely, genetic testing.

The ultimate goal of all this is something called precision medicine, a model that clinicians hope will ultimately eliminate the trial-and-error process of determining medication and treatment and allow
physicians to provide patients with what truly is a customized approach to healing.

“It’s already being done with a lot of cancer treatments, where they genotype the tumor and match the medication to the specific gene so that the tumor is killed at its source,” explains Robert Pollack, MD, of Psychiatric Associates of Southwest Florida. “And for those of us who are treating depression, the same type of phenomenon is not that far off.

“It’s right down the street. We’re very close to a point where we’re going to be able to pinpoint an illness and what the genetic structure is and then rewrite a piece of the gene so that we can deactivate it. That project is on the planning board right now, in many different places.

“For a long time now, finding the right medication or treatment for someone suffering from depression or anxiety or any mental health disorder has been a lot like trying to trap a ball of mercury under your thumb. It’s been very difficult, because it really has involved a lot of trial and error. But it’s a whole lot better now because of genomics.”

The Gene Pool

Genomics involves the study of all genes, which are made of DNA and are the most fundamental unit of heredity in our body. Every person has two copies of each gene, one from each parent, and while most genes are the same in everyone, some genes are different.

It is these differences or variations that determine hair color, eye color and other unique physical aspects. They also determine what illnesses or diseases an individual may be prone to developing and what medications may work best as a cure for those problems.

The science of understanding how genetic variants influence the way in which an individual will respond to a certain drug or treatment is called pharmacogenomics. It’s a field that is still in its infancy, but it’s already being used by Dr. Pollack.

For a few years now, Dr. Pollack has leaned on a variety of specific genetic tests, or assays, to assist him in the proper selection of psychiatric medication for his treatment of patients suffering from mental illnesses such as depression, bipolar disorder and post-traumatic stress disorder.

The results of these genetic tests can be learned within a week following a simple cheek swab collected by the doctor or an assistant in the doctor’s office. They can also be used as a guide for the treatment of a wide range of other psychiatric conditions, including attention deficit hyperactivity disorder (ADHD) and obsessive compulsive disorders.

Dr. Pollack says the genetic tests have greatly reduced the trial and error process associated with treatment and have allowed him to do a much better job of finding the right medication more quickly for his patients.

“Without the advantage of genomics,” Dr. Pollack explains, “a practitioner would normally examine a patient and then say, Well, my experience tells me that you have a depressive illness that could use a mood-elevating medication. So, they prescribe Medication A.

“Now, Medication A is not compatible with that patient, but they don’t know that. So, they give them the medication and learn that it makes them agitated. But instead of changing the medication, they treat the agitation by prescribing a second medication for that.

“Now, if that doesn’t work, then the practitioner may be inclined to prescribe a third medicine on top of the previous two. Either that or they’ll finally change out the original medication for something else that works for a while but doesn’t work for very long.

“In that case, they may give the patient what’s called an augmentation agent. But if the augmentation agent causes side effects or doesn’t work, maybe they try something like transcranial magnetic stimulation (TMS), theta burst stimulation (TBS) and or ketamine infusions.

“But what if these modulations aren’t right either? Well, now you’ve tried several different treatments and at no point have you hit the nail on the head and found the one that actually works. What genomics does is give practitioners a better chance to hit that nail on the head the first time.”

An example of just how helpful a genetic test that is designed to show how key genes in the body will respond to a certain drug or treatment comes from Dr. Pollack’s work with PTSD sufferers.

It is already known that carriers of a specific gene formation in the serotonin transporter gene SLC6A4 possess a greater susceptibility of developing PTSD, are at a greater risk for having more severe symptoms and may require more intensive treatments.

As it pertains to the treatment of patients with PTSD, what Dr. Pollack has found is that the presence of certain genes in those patients suggests that the use of either TMS or ketamine or possibly both may be the best approach in treating them.

“What the science is doing is helping me pick out the right medication or decide that I should try something like TMS instead of a medication,” Dr. Pollack states. “It also helps me to know what my chances of success are going to be after I’ve made those decisions.”

A Time and Money Saver

In addition to providing them with better treatments sooner, genetic testing can also help mental health patients save money, as it should reduce the cost associated with the trial-and-error process of choosing medications.

In fact, the results of a recent study published in Journal of Depression and Anxiety show that over a six-month period, mental health patients who were tested via the Genecept Assay prior to being treated saved more than $1,900 in health care costs.

The study concludes that the use of genetic tests thus carries with it the strong potential to help reduce not only the cost of medication but the likelihood of emergency room and doctor’s visits for patients suffering from mood and anxiety disorders.

“And they’re doing more and more with these tests all the time,” Dr. Pollack adds. “The companies that are doing them are very aggressive. They’re trying to get more and more out of them, which is good for the public.”

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