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Only Grit convinced Linda Greene of her husband's muscular dystrophy, her daughter's head trauma, and her own mysterious illness that lasted three years and left her vomiting every day before doctors identified the cause. But finally, after spending too many days working at her desk, she went to see her doctor for help.
He prescribed an antidepressant and referred him to a psychiatrist. When the first drug did not help, the psychiatrist tried another – and another – hoping to find one that would make him feel better. Instead, Greene felt like a zombie and sometimes she was hallucinating and could not sleep. At worst, she found herself contemplating suicide.
"It was horrible," she said. She had never had suicidal thoughts before and was terrified. She went back to her primary care doctor.
Previously, when Jeremy Bruce, Greene's doctor in Cincinnati, was treating patients with depression, he was following the same steps for almost everyone: start the patient with an antidepressant and switch to another one until something ugly. Sometimes, before finding the right treatment, the patient left his office to find a new doctor.
"They would usually be very angry," said Bruce.
But about three years ago, Bruce tried a new approach.
Linda Greene and her husband. She tried many antidepressants before her doctor offered her genetic tests to find a drug that would suit her. Doctors are using more and more information about genes to assess the potential risk of certain diseases and determine the best drug treatment. But the use of pharmacogenetics to treat depression remains controversial. (Family photo)
For patients who have not responded well after trying one or two different antidepressants, he has started sending DNA samples to a company that says they can use an individual's genetics to match them. antidepressants most likely to benefit him. Bruce said the test recommendations seemed to help some of his patients. He therefore offers the test to all patients with depression – even before trying the first antidepressant.
"Psychiatric medications make people feel horrible if you choose the wrong one," said Bruce. "And they feel good if you choose the right one."
In the case of Greene, the genetic report she found put all the drugs she had tried on a list of drugs that probably would not work for her. So she stopped taking them. She went to another psychiatrist, who used the test results to prescribe something better for her genetic makeup, and said the drugs seemed to work.
More than a third of US adults take prescription depression medications
Doctors are using more and more gene information to assess the potential risk of certain diseases, such as breast cancer-related BRCA genes, and to determine the best drug treatment for diseases such as acute leukemia. and HIV. But the use of pharmacogenetics to treat depression remains controversial.
Doctors such as Bruce claim to have found promising results for patients, but others argue that there is not enough solid evidence to show that pharmacogenetics can act on the complexities of treatment of mental health. Some laboratory tests have shown that the relationships between genes and the way a drug physically affects the body, but studies to determine whether the use of this information resulted in better results for patients were not conclusive.
Bruce Cohen, director of the Neuropsychiatric Research Program at McLean Hospital, a Harvard Medical School Massachusetts-based psychiatric research and treatment center, says studies to date have not shown that genetic testing to select antidepressants collectively improve outcomes for patients.
"The differences are minimal and there is no reason to think that you could not do better by simply following standard protocols, which are free," he said. According to the National Institutes of Health, genetic testing can cost between $ 100 and $ 2,000.
According to Cohen, most genetic tests check for variations in metabolism-related genes, affecting the way the body processes a drug. A faster metabolism can lead to lower drug levels in the body, while a slower metabolism can result in higher rates. But factors such as age, diet and other substances present in the body also have a major influence on the treatment of the drug.
"Metabolism is only part of the response to drugs, and even though it's more determined by non-genetic factors," Cohen said. "I'm not saying that the metabolism of drugs does not matter. It is a matter of degree, of how much of a person's reaction depends on metabolism, as opposed to other aspects of what happens to the drugs when they are taken. "
The Clinical Pharmacogenetics Implementation Consortium, an NIH-funded international organization, ranks the strengths of various drug-drug combinations based on published research reviews and provides prescribing guidelines. The guidelines advise on how to use the genetic information already available, rather than the circumstances under which a genetic test should be ordered.
The co-founder of the Consortium, Mary V. Relling, Ph.D. in Pharmacy and Chair of the Department of Pharmaceutical Sciences of the St. Jude Children's Research Hospital, admitted that the items listed by Cohen affect the drug metabolism, but for some gene-drug combinations. genes dominate all other factors.
"Time and time again, studies show that patients who have [particular] Genetic defects have more toxicity, for example, than patients who do not, "said Relling, who is studying the clinical application of pharmacogenetics and is studying ways to improve the pharmacotherapy of patients with pediatric leukemia.
One of the aspects of the disagreement concerns the influence to be given to the different types of studies. Relling said that studies showing a strong relationship between a gene and a drug should be enough to inform prescribing guidelines. Cohen says that simply observing a relationship at the genetic level is not enough and that studies need to prove that patients get better results when treatment is guided by genetics.
Relling said that while his consortium will release only evidence-based prescription guidelines, some commercially available genetic panels for psychiatry include genes with less established interactions.
In November, the Food and Drug Administration issued a statement urging patients and physicians to be cautious about non-FDA-approved genetic testing, including those guiding the prescription of antidepressants.
"The FDA is aware of the genetic tests according to which the results can be used by physicians to identify antidepressants that would have increased efficacy or adverse effects compared to other antidepressants," said the Director General of the Center for Devices and Radiological Health. the Center for Drug Evaluation and Research. "However, the relationship between DNA variations and the effectiveness of antidepressants has never been established. In addition, the FDA is aware that health care providers have modified patients' medications based on the results of genetic tests that purport to provide information on personalized dosages or regimens of certain antidepressants, which could potentially harm patients. "
Greene said she was not worried that the test she had used to find an antidepressant was not approved by the FDA. She said that she was desperate for help that had eluded her and that she trusted her doctor's clinical experience. She said the test cost her about $ 400.
Anthony Rothschild, professor of psychiatry at the University of Massachusetts Medical School and co-author of an industry-funded study, which revealed inconclusive results for patients when testing Genetics were used to prescribe antidepressants, said such tests should only be a tool of depression. Arsenal treatment, especially in cases where patients have not responded to medication.
"I would say to the critics," Do you have any other suggestions right now when you have someone in your office and things do not seem to work? "He said," I think it has its place at the moment, maybe something else will be better, but it's a good start. "
Amanda Jostworth, another 38-year-old female patient from Bruce, started taking an antidepressant last July, while her husband was recovering and struggling with the stress of her condition, her full-time job and taking care of their four children. She tried a drug for about five months and regained all her motivation. She trains for marathons and can not bring herself to walk, let alone run.
This year, Bruce recommended him to take the genetic test. On the basis of the DNA report, he has changed it to a different antidepressant. About a month later, she said, she already felt better. "It's only been six weeks, but I feel really good," she said.
Others did not have such good results.
After attempting suicide at the age of 17, today's 29-year-old Adam James was taking various psychiatric medications in his early twenties. They all let him feel very bad, he said. A therapist recommended that he undergo a genetic test. When he received the results, he found that he had already tried a number of antidepressants and antipsychotics that the test report, associated with the test report, associated risks. low to moderate low genetic interaction.
The test also revealed that he had genes that could lead to a decrease in folate levels, but his family doctor said his rates were good. "I took this as further evidence against the test," he said. Now he has completely gotten rid of the psychiatric drugs. "I've been there, I do not want to go back that way," he said. He tried a ketogenic diet that could help him.
Nora Whelan, 33, asked her doctor to prescribe the test at the request of her psychologist, hoping to find a drug to treat the depressive symptoms of premenstrual dysphoric disorder. She wanted to avoid the often lengthy process of trying several medications before finding the one that best suited her.
When she and her doctor got the results, they noticed that an antidepressant that had not worked well for her at the university was supposed to be a good deal for her genetics. She tried another recommended medicine, but after a few weeks her symptoms were worse than ever. Now, she is not taking this antidepressant and is relying on a medication she was already taking to relieve her anxiety, vitamin supplements, yoga, and changes in her diet to address her symptoms.
She said the test tips could potentially be helpful for other patients, even if it did not work for her. It is difficult to know which drug will work because everyone reacts differently.
In the end, she said, "They are all basically a hit in the dark."
Read more
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