Pharmacogenetic testing in psychiatric inpatients with polypharmacy is associated with decreased medication side effects but not via medication changes

In psychiatric patients, medication adverse effects are regularly attributed to psychosomatic causes. However, many psychotropic medications are metabolized by cytochrome P450 (CYP450) enzymes. In the setting of polypharmacy, the activity of these enzymes may produce unfavorable drug-drug interactions (DDI) and drug-genotype interactions (DGI) that contribute to morbidity and mortality. This study sought to estimate the risk of adverse DDI and DGI in psychiatric inpatients with polypharmacy. We assessed whether medication changes made after pharmacogenetics (PGx) testing correlated with changes in side effects and overall improvement. Adult psychiatry inpatients with polypharmacy, defined as 5 or more scheduled prescription medications, completed the 24-item Antidepressant Side Effect Checklist (ASEC) questionnaire on enrollment and underwent PGx testing. Analysis of PGx results focused on whether the CYP2D6 and CYP2C19 phenotypes were "extreme," defined as poor, poor to intermediate, or ultrarapid. Approximately 30 days after PGx results were sent to outpatient providers, patients were contacted to obtain their current medication list and ASEC and Clinical Global Impression Improvement (CGI-I) scores. A total of 80 patients were enrolled, and 52 (65%) completed follow-up. ASEC scores improved from 11.5 (±8.1) to 7.2 (±6.0) (p = 0.0009). Mean CGI-I score was 2.7 (±1.4), between "minimal" to "much improved." However, linear regression revealed that these improvements were not correlated with whether medications were changed. We concluded that the impact of drug-genotype interactions in this small sample of inpatients with polypharmacy was low, and that patient improvement was related not to PGx-guided medication changes but to other treatments during hospitalization.

Feasibility Study of Stress Management and Resiliency Training (SMART) in Patients With Major Depressive Disorder

Objective

Stress is associated with the onset, maintenance, and recurrence of depression. This study investigated the feasibility of stress management and resiliency training (SMART) for enhancing resiliency in a group of patients with major depressive disorder.

Methods

In an open-label study, patients with major depressive disorder were invited to participate in an adjunctive 8-week group therapy of SMART (from June 2017 to June 2018) that encompassed attention training and practice of gratitude, compassion, higher meaning, acceptance, and forgiveness. The primary outcome measure was baseline-to-endpoint change in resilience as measured by the Connor Davidson Resilience Scale (CD-RISC). Secondary outcome measures included baseline-to-endpoint change in stress using the Perceived Stress Scale (PSS) and in depression using the 17-item Hamilton Depression Rating Scale (HDRS-17) and 9-item Patient Health Questionnaire (PHQ-9).

Results

Twenty-three participants enrolled in the study (mean ± SD age = 46 ± 13 years, female = 91%). Baseline ratings of mood were of mild-to-moderate symptom severity (mean HDRS-17 score = 14.5 and PHQ-9 score = 12), resilience (mean CD-RISC score = 53.8), and perceived stress (mean PSS score = 23.5). Of the participants, 74% were study completers (attended ≥ 6 sessions). In an intention-to-treat analysis, at study endpoint there was a significant improvement in resilience (mean CD-RISC score = 61.1, P = .03), reduction in perceived stress (mean PSS score = 19.4, P = .002), and improvement in depression (mean HDRS-17 score = 9.1 and PHQ-9 score = 7.6, both P < .001).

Conclusions

A resilience training program focused on wellness is feasible for patients who are currently symptomatic with major depressive disorder. A larger randomized controlled trial is needed to establish efficacy of this intervention and explore the long-term impact of stress management and resilience training in depression.

Trial Registration

ClinicalTrials.gov identifier: NCT03275961.