December 2019

In This Issue: Advancements in VA Mental Healthcare
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Precision Medicine in Mental Healthcare (PRIME Care)

Feature Article

Despite a compelling epidemiological imperative, the treatment of depression is often inadequate. As shown now in many studies, many depressed patients do not achieve remission with standard therapies. Patients and providers sometimes need to be persistent and try multiple treatments until they find one that is both tolerable and effective. However, with each unsuccessful round of treatment, there is some chance that the depressed patient will become discouraged or frustrated and drop out of the process. In the last several years, pharmacogenetic (PGx) testing for psychotropic medications has become a commercially available means of implementing "precision medicine," with some insurers electing to cover the cost of testing. These developments have put increasing pressure on VA to implement a mental health-focused commercial pharmacogenetics program, especially for treating depression, but without sufficient scientific study to support the utility of clinical application.

The objectives of this ongoing HSR&D study (July 2016 – June 2022) are to evaluate the utility of PGx testing in treating major depressive disorder (MDD). Investigators plan a multi-site randomized clinical trial (n=2000), with patient/provider dyads randomly assigned to receive results of the PGx battery right after randomization (i.e., intervention group) or after six months of treatment as usual (i.e., delayed results group). Study investigators will assess whether Veterans with MDD whose care is guided by the results of the PGx battery (the intervention group) have a higher rate of remission of depression compared with Veterans with MDD in the delayed results group. Investigators also will evaluate whether provider/patient dyads in the intervention group use fewer contraindicated medications based on established PGx criteria compared with provider/patient dyads in the delayed results group. 

Findings

While results for the primary outcomes are yet to be determined, early findings include:

• To date, of those patients actively taking an antidepressant, 20% are on an antidepressant that is highly genetically influenced and should have had a dose adjustment. This finding underscores the value of testing in a high proportion of patients who are not responding to their current medication.
• Analyses of providers’ PGx perceptions suggest limited familiarity with the potential use of PGx for psychiatric prescribing. Primary care providers report being less comfortable with using PGx for this purpose than do mental healthcare providers. All providers are concerned about how to fit PGx testing into their workflow. 

These early findings suggest that education focused on how to use PGx efficiently will be important to future implementation.

Impact

Replication of the results from other studies of PGx that have been conducted to date could usher in a new era in the treatment of major depressive disorder – and provide an impetus for early diagnosis and treatment, resulting in more rapid and higher rates of remission.

Principal Investigator: David Oslin, MD, is the director of the VISN 4 Mental Illness Research, Education, and Clinical Center (MIRECC) and part of HSR&D’s Center for Health Equity Research & Promotion (CHERP) in Philadelphia, PA.

Publications

Hull L, Lynch K, and Oslin D. VA primary care and mental health providers' comfort with genetic testing: Survey results from the PRIME Care Study. Journal of General Internal Medicine. June 2019;34(6):799-801.

View study abstract