Using actionable information in treatment decisions

My treatment philosophy for depression and other mental health conditions is that optimal mental health is achieved using the least medication at the lowest dose possible.

I have 20 years of experience in psychiatry. I’ve worked with patients in nursing homes, skilled nursing home facilities for the developmentally disabled, and in general psychiatry in an outpatient setting.

In my career, I have seen many treatment-resistant depression patients. Working with this population has been a privilege through which I have learned that there are always alternatives.

A lot of my patients have seen multiple providers, are taking multiple medications, and have multiple medical diagnoses. It’s not uncommon for me to see a patient who is taking six or more different psychotropic medications along with 20 different medications for other conditions. In these cases, I know I must be methodical and make these changes slowly, reducing the number of variables to ensure that I understand what changes are most effective for the patient.

Pharmacogenomic Testing

 When I first learned of pharmacogenomic testing – I’ll admit, I was very skeptical.

I truly didn’t have a full understanding as to how it could be used. In talking with others in my profession, the biggest misunderstanding is that it can choose the medication that’s going to work the best for the patient. That’s simply not true. But it is very helpful.

Pharmacogenomic tests like the GeneSight test give useful information that aids in making treatment decisions. It doesn’t remove the clinician’s role in treatment decisions – it provides personal information about a patient’s genetic code for more insightful decisions.

Once I understood the information presented on the GeneSight report, it was incredible. Importantly, as a clinician, you still have your decision tree. The GeneSight test results augment your treatment decision tree.

Helping End Trial and Error

 Medication failure is always a bad feeling as a provider, of course.

When I see a patient’s intake form and find a long list of medications that they have tried and failed, it’s a red flag.

So, if a patient has tried six medications and failed, I can try another, but how effective is the seventh medication trial going to be? In my experience, the more medication trials someone has had, the less effective the next medication is going to be.

In these cases, I tell my patients that I want to give them the GeneSight test. Most patients are shocked that a test like this actually exists.

For example, I had a patient who was taking six different psychotropic medications – and two of the medications were at a super high dosage. Yet, he was still symptomatic. Before I made a change, I asked if he would take the test. He agreed – and expressed his surprise that his previous psychiatrist had never shared that this test existed. His GeneSight test results showed that the two medications he was taking at super high dosages were in his significant gene-drug interaction category and were expected to be metabolized at a significantly different rate than normal.

I recommend the GeneSight test to my colleagues. In fact, I’m always shocked if I talk to a treater who is not interested in the test. Psychiatry can be vague. Symptoms can change and side effects can be hard to determine. I tell them that using a data-driven approach with actionable information in treatment decisions was an eye opener and has proven to be useful in so many ways.