PLENTY OF MY patients come into my office wanting to feel better but are hesitant to start anxiety or depression meds. They’ve heard lots of things, especially how, for the more than 50 million people currently taking meds for their mental health, it often requires a little trial and error to find the right prescription.
That was the case with a patient I’ll call Ralph, a software engineer in his early 30s. At our first appointment, he asked me about a genetic test called GeneSight that promises to take some of the hit-and-miss out of how doctors prescribe mental-health meds, including stimulants (for ADHD) and antidepressants.
It’s true that the classic prescription-tinkering process can be time-consuming and frustrating. Only a little more than a quarter of people with depression see it resolve after trying their first med. You might also need more than one attempt with ADHD and anxiety meds, making time seem to drag on while symptoms persist.
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So genetic tests like GeneSight make sense. You do a cheek swab or blood test and a lab looks for gene variants that determine how enzymes in your liver metabolize medications. Some variants cause you to break down certain meds faster or slower. Others might cause you to absorb too much, or too little, of a particular med in your system. These tests are exciting because docs are into anything that helps people quickly identify the proper prescription.
If you’re considering a genetic test in hopes of getting to the right meds faster, here’s what you should know first.
Genes Don’t Tell the Whole Story
If your prescription isn’t working or if you’re having a side effect like weight gain, genetic testing may give your doctor information about what to try next. In fact, some of my trusted colleagues, including Austin psychiatrist Robin May-Davis, M.D., were early adopters of this technology and use it often. She just likes extra confirmation that what she’s recommending will really mesh with a person’s biology. But she’s also willing to look beyond what GeneSight indicates. You need to “treat the person, not the lab result,” she says.
I agree, because the test only goes so far. Patients often ask me, “How can you dispute a genetic test?” It’s essential to understand that genes are really important but they’re not the only determinant of how you’ll respond to a prescription. Illnesses like depression, anxiety, and ADHD, along with the meds that treat them, are also affected by your environment—factors including how you think, what you eat, and how often you move in a day matter, too. Genes can get “switched on,” so to speak, or stay as they are based on your behaviors. Even a genetic test can’t guarantee that one particular medicine will work better than another.
Medicine Is Still an Art
Despite how interesting the possibilities are, I don’t do much genetic testing in my practice. The science behind it isn’t totally cut-and-dried. One study about GeneSight suggests that using it doesn’t lead you to the right medication any faster than not using it. Other research on genetic tests has shown some promise, but we’re not at the ringing-endorsement stage yet. Even if the test does help steer someone to a certain type of medication, the list of options is still very long. GeneSight may also cost you hundreds of dollars, and insurance doesn’t always cover it.
Another psychiatrist colleague of mine, Daniel Hochman, M.D., points out that using genetic testing for your pharma cocktail “can lead to huge hopes for a medication and then fail to deliver,” which may complicate treatment. Then you have another set of issues to deal with.
In addition to genetic tests, various efforts have rushed in to try to improve the efficiency of the prescription process. For instance, when you plug your medical history into Me Again Meds, a web tool created at George Mason University, you get recommendations for the mental-health drugs that might work best for you. Thing is, that’s what psychiatrists like me are already doing.
After talking with a patient like Ralph, I might discover that his anxiety is keeping him up at night and therefore pick a medication like mirtazapine to help him sleep. Or if he’s depressed and having trouble concentrating, I’d recommend something like bupropion, an antidepressant that can make it easier to focus.
My patients ask me if there are meds that work faster so that they can move on to the next more quickly if needed. That’s not a slam dunk, either. An antidepressant called Auvelity, approved last August, worked more quickly than other antidepressants in the studies that were done on it. But it can be hard to convince insurance companies to pay for newer drugs unless people have tried all the older ones and gotten unfavorable results. So while we may dream of a day when precision psychiatry is the standard of care, we’re not there yet.
I’ll admit that trial and error is annoying for both doctors and patients. Still, I’m hopeful, because the available treatments—a psychiatrist who listens to your situation and prescribes appropriately, plus therapy and self-care—work very well even if finding the right med takes a couple tries.
This story originally appeared in the July/August issue of Men’s Health.
Gregory Scott Brown MD is a board-certified psychiatrist and Men’s Health advisor. He is an affiliate faculty member at the University of Texas Dell Medical School and author of The Self-Healing Mind: An Essential Five-Step Practice to Overcoming Anxiety and Depression, and Revitalizing Your Life.