Abstract
The authors tested the hypothesis that pharmacogenomic genotype knowledge is associated with better clinical and cost outcomes in depressed patients, after controlling for other factors that might differentiate tested and non-tested patients. Medical records of 251 patients, seen in the Mayo Clinic Rochester outpatient psychiatric practice, who had patient health questionnaire-9 (PHQ-9) scores before and after consultation, were reviewed. Comparisons of differences in pre-consultation and post-consultation depression scores and slopes between tested and non-tested patients and between genotype categories of tested patients, were evaluated, along with healthcare cost and utilization comparisons between tested and non-tested patients, using Kruskal–Wallis tests, Wilcoxon rank-sum tests and group mean comparisons, controlling for significant univariate demographic and clinical differences. Tested patients had significantly higher depression diagnosis frequency, baseline PHQ-9 scores, family history of depression, psychiatric hospitalization history, and higher numbers of antidepressant, mood stabilizer and antipsychotic medication trials. After controlling for these differences, there were no differences between tested and non-tested patients in post-baseline depression scores or slopes for CYP genotype categories. For patients with 5-HTTLPR testing, there was significantly more depression score improvement for patients with the long/long genotype at time 4 (N=55, χ2-value=8.0492, P=0.018) and at time 5 (N=44, χ2-value=6.1492, P=0.046). For a subgroup (n=46) with ⩾two pre- and ⩾two post-baseline PHQ-9 scores, the mean difference between pre-baseline and post-baseline PHQ-9 score slopes for tested patients was −0.08 (median −0.01; range −1.20 to 0.15) compared with 0.13 (median 0.02; range −0.18 to 2.16) for non-tested patients (P=0.03). Among genotype categories, mean differences between pre-consultation and post-consultation slopes were significantly better for poor CYP2D6 metabolizers than intermediate or extensive metabolizers (P=0.04); there was a trend for slope differences to be better for 5-HTTLPR long/long genotype patients (P=0.06). Subsets of local tested and consultant-adjusted non-tested controls (n=19), who had 8 years of longitudinal care within the health system, had similar overall mean healthcare costs before and after testing; however, tested patients on average had significantly fewer time-adjusted post-baseline psychiatric admissions (0.8 vs 3.8, P=0.04) and fewer time-adjusted psychiatric consultations and comprehensive mental health-specialty evaluations (4.2 vs 9.9, P=0.03). Prospective study is indicated as to whether and how pharmacogenomic testing in a psychiatric consultation practice may improve clinical and cost outcomes.
Highlights
Pharmacogenomic testing might be most useful in psychiatric patients who have treatment resistance, intolerable adverse effects or the potential for problematic drug–drug or drug–disease interactions.[1,2,3,4,5,6,7,8,9] Mayo Clinic, Rochester, MN, USA has an outpatient consultative psychiatry practice that collects a standard set of clinical data for each patient seen in consultation, including a standard method for recording historical psychotropic medication trials
When mean pre-baseline healthcare costs are compared with post-baseline costs, there is a
Pharmacogenomic testing may have increased some costs (for example, laboratory and outpatient psychotherapy costs) and decreased others (for example, costs related to decreased admissions)
Summary
Pharmacogenomic testing might be most useful in psychiatric patients who have treatment resistance, intolerable adverse effects or the potential for problematic drug–drug or drug–disease interactions.[1,2,3,4,5,6,7,8,9] Mayo Clinic, Rochester, MN, USA has an outpatient consultative psychiatry practice that collects a standard set of clinical data for each patient seen in consultation, including a standard method for recording historical psychotropic medication trials. Patients sometimes receive pharmacogenomic tests as a part of their consultation and results obtained are used in management recommendations.[5,6] This study sought to examine the hypotheses that pharmacogenomic genotype knowledge is associated with better clinical, cost and healthcare utilization outcomes, after controlling for other clinical variables that might differentiate tested and non-tested patients
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