The article Pharmacogenetic testing in primary care could bolster depression treatment: A value proposition from the medical journal Clinical and Translational Science brings up an interesting debate on pharmacogenetics and mental health in primary care.
In this article, the authors start the document with the following sentence – freely translated here – “Pharmacogenetic tests could reduce the time to identify a safe and effective drug for depression; however, they are underutilized in practice.” This phrase has an impact, and not only a clinical one, but also an economic one for public health; let’s understand it better? The original article can be downloaded at this link.
The study is from the United States, so it’s worth remembering that we’re not talking about a context linked to our Unified Health System or even our private health structure. However, we can extrapolate the study’s conclusions to better understand our situation on this issue.
We consider depression to be the “disease of the century” and this permeates all strata of Brazilian society. It can manifest itself as mild or moderate symptoms and, occasionally, it can become a persistent (or chronic) illness.
According to the Ministry of Health, depression is still a disease in which Brazil leads in prevalence compared to the rest of Latin America(see Link). Even though Brazil offers treatment through the SUS in primary care (e.g. UBSs and CAPS), and there is a lot of discussion about habits and non-pharmacological therapies to control depressive symptoms and anxiety, we still haven’t moved on from this gloomy lead when it comes to major depression, in particular. So how can we “think outside the box” to optimize these treatments and even save public money?
The authors of the study, which we’ll cover in this post, proposed that adapting the use of pharmacogenetic tests to the needs of psychiatrists, for various contexts, could go a long way towards establishing a generalizable value proposition and increasing the likelihood of adoption of the tests by these professionals.
Methodological summary:
- Interviews were conducted between April and December 2022 with two groups of healthcare institutions:
- Prescribers of mental health medication; and
- Administrators of the same institutes as prescribers.
- Snowball sampling approaches
- Individuals initially approached by the research group referred the team to other collaborators at the same institution whose administrative function involved implementing pharmacogenomic tests at their respective institutions.
- Once they had been interviewed, the prescribers of the institutions were e-mailed by the study coordinator so that they could be invited to take part in the study.
- Structured questionnaires considering different concepts in implementation science:
- Theoretical Domains Framework (TDF); and
- Consolidated Framework for Implementation Research (CFIR).
- Concepts addressed by the questionnaires: support, implementation climate, leadership engagement, available resources, skills (personal competencies, knowledge of procedures), benefits (beliefs about consequences and relative advantage), strength and quality of evidence (belief in the state of the evidence on pharmacogenetics for mental health) and whether they considered costs in their decision to use pharmacogenetic tests in clinical practice.
- Finally, a value proposition was defined, according to the “Triple Aim” – considered a reference model for health policies focused on three main metrics:
- better quality healthcare;
- results at a population level; and
- reduction in per capita costs.
Results obtained:
- Sample – 37 employees in 4 health institutions, 8 administrators (2 per institution) and 29 prescribers (4 to 12 per institution).
- 16 of the 29 prescribers used pharmacogenetic tests.
- Each institution that adopted the pharmacogenetic test was at different stages of implementing the tool.
- The authors divided the themes of the interviews with prescribers into three:
- The art of prescribing – addressing how pharmacogenetic tests affect the quality of prescriptions;
- Meeting patients’ needs – addressing how pharmacogenetic testing intersects with population health; and
- Considering the costs for patients – what are the cost implications of the tests?
The Art of Prescribing
This section addressed how prescribers determined the best treatment for each patient, using their personal judgment, even with existing guidelines.
Prescribers who adopted the tests consistently expressed positive feelings, while non-adopters showed varying feelings and opinions. The prescribers discussed the compatibility of pharmacogenetic tests with their beliefs and practices, recognizing that the tests increase patients’ confidence and engagement in treatment.
The prescribers made the following positive comments regarding the pharmacogenetic tests:
- The scientific aspect of the tests was valued by a primary care prescriber;
- The tests improved patient compliance and outcomes by taking preferences into account during informed consent;
- Financially privileged patients or younger patients value test information more and actively participate in treatment decisions;
- They said they preferred to use pharmacogenetic tests for new patients or those who did not respond well to initial treatment
The main concerns expressed by prescribers reluctant to adopt pharmacogenetic tests include:
- Potential lack of significant advantage;
- They feared that patients would expect to find the “right drug” through the tests, diminishing the interpersonal connection of the consultation and treatment;
- The test results can be confusing, leading to misunderstandings.
- Meeting patients’ needs:
Prescribers were asked about the usefulness of routine pharmacogenetic tests for mental health.
When it comes to primary care prescribers, they believe that testing can reduce inequalities in access to mental health care by providing additional information for making therapeutic decisions.
In contrast, some psychiatrists see limitations, suggesting that mental health should focus on the accuracy of diagnoses rather than medication.
Two prescribers with backgrounds in internal medicine and psychiatry, on the other hand, had divergent opinions: one sees subjectivity in diagnosis as a greater risk than time to test drugs, while the other considers tests advantageous for access to mental health and uses them selectively for patients with intolerance or failure to previous drugs.
- Considering the costs for patients:
This term, prescribers had very divergent opinions on the cost impact of pharmacogenetic testing.
Some adopters didn’t see costs as a barrier, leaving the decision up to patients to make, while others saw subsidized costs as a positive point, but not a determining one.
In contrast, non-adopting prescribers, due to a lack of perceived value or sufficient knowledge, did not feel that the testing information justified the cost to patients and uncertainty about health insurance coverage was also mentioned as an obstacle.
Study conclusions:
- The study suggests that pharmacogenetic testing can improve access to mental health care in primary care.
- Primary care prescribers see potential in the tests to provide additional information, while psychiatrists are more concerned with the accuracy of diagnoses.
- Collaboration between primary and specialist care is vital, and educating prescribers can increase the use of tests.
- The comfort of prescribers in discussing tests with patients is crucial for adoption.
- Personal experience with the tests and clearer guidelines on their use and application can help to better integrate pharmacogenetic tests into health systems.
Technical review: Dr. Carolina Dagli.
Conectgene’s pharmacogenetic test analyzes a variety of drugs used in psychiatry and routinely in primary care. Come and see the quality of our reports, with pharmacogenetic information with a high level of scientific evidence and we are the only laboratory that updates the reports with new drugs and new published evidence every 8 months.
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The information contained on this website is provided for general information purposes only and is not a substitute for professional medical advice, diagnosis or treatment from a qualified health professional. Always seek the advice of your doctor or healthcare professional when in doubt about your medication intake or health condition.
As informações contidas neste site são fornecidas apenas como divulgação de informações gerais e não substituem o aconselhamento médico profissional, o diagnóstico ou o tratamento de um profissional de saúde qualificado. Sempre procure o conselho de seu médico ou profissional de saúde quando tiver dúvida sobre ingestão de medicamente ou condição de saúde.
