Grit alone brought Linda Greene through her husband's muscular dystrophy, her daughter's traumatic brain injury, and her own puzzling illness that lasted for three years, vomiting daily before the doctors realized the cause. But finally, after too many days crying at her desk, she went to her doctor for help.
He prescribed an antidepressant and referred it to a psychiatrist. When the first medication did not help, the psychiatrist tried another – and another and another – in the hope of finding one that made her feel better. Instead, Greene felt like a zombie and sometimes she hallucinated and could not sleep. At the worst moment, she was thinking about suicide.
"It was awful," she said. She has never had thoughts of suicide and was scared. She went back to her family doctor.
In the past, when Jeremy Bruce, Greene's physician in Cincinnati, treated patients for depression, he followed the same steps for almost all: Start the patient with an antidepressant and switch to another helped sometimes before When they had found the right treatment, the patient left his practice to seek a new doctor.
"They would normally be very angry," Bruce said.
But about three years ago, Bruce tried a new approach
For patients who did not respond well after trying one or two different antidepressants, he began sending DNA samples to a company stating that they could use an individual's genetics Combine them with the antidepressants that are most likely to work for them. Bruce said the test's recommendations seemed to help some of his patients, and now he offers the test to every patient with depression – even before they try the first antidepressant.
"Psychiatric drugs make people feel awful when they choose the wrong one." Bruce said. "And they feel great when you choose the right one."
In Greene's case, the genetic report she had recovered put all the medicine she had tried onto a list of drugs that were unlikely to work for her and she stopped taking it. She went to another psychiatrist who used the test results to prescribe something that was considered better for her genetic makeup and says the medications seem to work.
Increasingly use information about genes to reduce the potential risk of certain diseases, such as: B. BRCA genes associated with breast cancer and to determine the best drug treatment for diseases, including acute leukemia and HIV. However, the use of pharmacogenetics to treat depression remains controversial.
Doctors such as Bruce say they have seen promising results for patients, but others say there is not enough evidence that pharmacogenetics is suitable for the complexity of treating mental illness. Some laboratory tests have shown relationships between genes and the physical impact of a drug on the body, but studies on whether using this information would lead to better outcomes for patients were ambiguous.
Bruce Cohen, director of the Neuropsychiatric Research Program at McLean Hospital, a psychiatric treatment and research center in Massachusetts affiliated to Harvard Medical School, says studies have not yet shown that genetic testing to select antidepressants is better overall Results for patients.
"The differences are very small and there is no reason to believe that you could not have done better by following the standard protocols, which are free," he said. According to the National Institutes of Health, genetic testing can cost between $ 100 and $ 2,000.
Most genetic tests examine whether genetic changes are related to the metabolism of genes and how a person's body processes a drug. A faster metabolism can lead to lower drug concentrations in the body, while a slower metabolism can lead to higher levels. But factors such as age, diet and other substances in the body have a major impact on the processing of the drug.
"Metabolism is only part of the drug's response and is even determined by non-genetic factors," Cohen said. "I'm not saying that drug metabolism does not matter. It's a matter of degree, it's a question of how much a person's response to metabolism is determined, as opposed to other aspects of what happens to medication when you take it.
The NIH-funded International Organization, the Clinical Pharmacogenetics Implementation Consortium, classifies the strength of various gene-drug combinations based on reviews of published research and includes prescriptive guidelines. The guidelines recommend how existing genetic information should be used, not the fact that genetic testing needs to be ordered.
The co-founder of the consortium, Mary V. Relling, who owns a PhD in pharmacy and directs pharmaceutical sciences from the Department of St. Jude Children's Research Hospital, agreed that the elements listed by Cohen affect drug metabolism, but for some combinations of gene and drug genes dominated all other factors.
"Studies repeatedly show that this is the case Patients with [particular] genetic defects, for example, have higher levels of toxicity than patients who do not," says Relling, who examines the clinical application of pharmacogenetics and approaches to improvement Drug therapy investigates pediatric leukemia patients.
One aspect of disagreement is how much clout various types of studies yield. Relling said studies showing a strong relationship between a gene and a drug should be sufficient to inform the prescribing guidelines. Cohen argues that simply observing a relationship at the genetic level is not enough and that studies have to prove that patients actually achieve better outcomes when the treatment is guided by genetics.
Relling says their consortium will only impose stringent evidence Some commercially available genetic panels for psychiatry include genes with less established interactions.
The Food and Drug Administration issued a statement in November warning patients and physicians about caution on genetic testing that has not been approved by the FDA, including those who do this. Instructions for prescribing antidepressants.
"The FDA has genetic tests that claim that doctors can use their results to determine which antidepressants are more effective or have side effects than other antidepressants," said the Directorate of the Center for Devices and Devices Radiological Health and the Center for Drug Evaluation and Research. "However, the relationship between DNA variations and the efficacy of antidepressants has never been established. In addition, the FDA is aware that, based on genetic test results, healthcare providers have made changes to patients' medication containing information on the personalized dosing or treatment regimens for some antidepressants that could potentially lead to patient injury. "[19659025GreenesagtesieseinichtbesorgtderTestbeidemsieeinAntidepressivumfandwarnichtvonderFDAzugelassenSiesagtedasssieverzweifeltnachHilfesuchtedieihrentgangenwarundsievertrautederklinischenErfahrungihresArztesSiesagtederTestkostetesierund400Dollar
Anthony Rothschild, professor of psychiatry at the University of Massachusetts Medical School and co-author of an industry-funded study, were found in the inconclusive results for patients, as genetic testing to prescribe antidepressants were prescribed. Such tests should only be considered as an instrument in the treatment of depression, especially in cases where patients have not responded to medication.
"I would say to the critics," Do you have any other suggestions at the moment? a person in your office and things do not seem to work? "He said. "I think it has a place at the moment. Maybe there's something else coming, that's better, but that's an important beginning.
Another patient of Bruce, Amanda Jostworth, 38, began taking an antidepressant last July when her husband recovered from illness and she was struggling with her condition, full time job and caring for her four children. She tried a single drug for about five months and found that all her motivation was full. She trains for marathons and could not bring herself to go for a walk, let alone make a run.
This year, Bruce recommended that she should take the genetic test. Based on the DNA report, he switched to another antidepressant. About a month later, she said, she felt better. "I've only been there for six weeks, but I feel incredible," she said.
Others did not have such good results.
After a suicide attempt at the age of 17, Adam James (now 29) was on a variety of different psychiatric medications in his early 20s. Everyone made him feel terrible, he said. A therapist recommended to do a genetic test. When he got the results back, he found that he had already tried some of the antidepressants and antipsychotics. The review was associated with little to moderate chances of poor genetic interaction.
The test also revealed that he had genes that could lead to a decrease in folic acid, but his family doctor said his level was good. "I took that as evidence against the test," he said. Now he has completely withdrawn psychotropic drugs. "I've been there before and I do not want to go down this street again," he said. He has tried a ketogenic diet that he believes could help him.
Nora Whelan, 33, had ordered her family doctor after her psychologist had suggested it, hoping to find a drug that treats the depressive symptoms of premenstrual dysphoric disorder. She wanted to avoid the often tedious attempt to try several medications before finding the right fit.
When she and her doctor received the results, they noticed that an antidepressant that had not worked well for them in college was supposedly good at gameplay for their genetics. She tried another recommended medication, but after a few weeks her symptoms were worse than ever. Now she is getting rid of this antidepressant drug and is relying on a drug she has already taken for anxiety, vitamin supplements, yoga, and diet changes to treat her symptoms.
She said the test's instructions might be helpful to other patients as well. It's hard for them to know which medicines are effective because everyone reacts differently.
Finally, she said, "After all, everyone is in the dark."