AUSTIN, Texas—Genetic testing and the insights it may provide have a profound potential to change the field of psychiatry, a Mayo Clinic expert told attendees at the Elevate by Psych Congress conference.
“This is an area that will transform our practice. The question is at what speed and specifically how,” said featured speaker Mark A. Frye, MD, professor and chair of the psychiatry and psychology department, and director of the depression center, at the Mayo Clinic in Rochester, Minnesota.
He sees great promise in the potential of genetic information to one day help inform clinicians’ decisions of which antidepressants to prescribe. Researchers have come to believe that genetic variation may contribute to the risk/benefit ratio each drug has, but that contribution needs to be better understood, he said.
Selective serotonin reuptake inhibitors have “unequivocally transformed” patients’ lives since fluoxetine’s 1987 approval, Dr. Frye said, and Mayo Clinic research shows there are now 20 medications approved to treat major depressive disorder. There is, however, little to guide clinicians on which antidepressant to choose, despite antidepressants being the second most commonly prescribed class of drugs.
“I am not able to pull a biological piece of information from my patient to help guide treatment selection, and that is very different than our colleagues who practice in … every other field of health care in this country,” Dr. Frye said.
“I think there’s great value in trying to understand if there’s a piece of biology from my patient that I can have in real time that’s going to help me give greater precision to the antidepressant medication that I’m going to recommend,” he added.
In addition, there are ways that pharmacogenetic testing is already touching the practice of mental health care, and Dr. Frye said clinicians need to be aware and mindful of the developments. For example, some revisions which the US Food and Drug Administration (FDA) has issued to drug warning labels are based on pharmacogenetic information.
Dr. Frye pointed to a paper from a Mayo Clinic researcher, which has been accepted for publication, that shows the highest number of FDA warning label revisions is in psychiatry. The majority of those warnings is related to QT prolongation and the risk of fatal cardiac arrhythmia.
“There is a piece of risk that is related to genetics and we need to mindful of that as clinicians,” he said.
More warning label revisions and other examples of ways in which genetics can impact treatment choices are already in place. However, Dr. Frye noted that tests do not have an immediate turnaround, which may limit their usefulness in certain clinical settings. Preemptive testing could be a solution, he said, but then cost becomes a concern.
At the Mayo Clinic depression center, a “significant minority” of patients receive genetic testing, but not all that request it do. There has to be a specific rationale to have the testing done, Dr. Frye said.
Genetics will not automatically provide a surefire way to help patients feel better, and clinicians need to manage patients’ expectations, he said.
At the same time, clinicians need to remember that if they do use genetic testing, is just one part of their patient care toolkit, Dr. Frye said.
“Being a comprehensive diagnostic clinician, really thorough in your work, is still necessary for optimal clinical practice,” he said. “Biological information is great, but it should not replace your work as an astute, obsessive clinician.”
“Understanding Genetic Testing and the Future of Mental Health Treatment.” Presented at Elevate by Psych Congress: Austin, TX; February 25, 2018.