SAN FRANCISCO — It can be notoriously difficult for psychiatrists and patients to determine which antidepressant might be most effective, or which might cause side effects.
And so Color Genomics, a company that already sells genetic tests to determine someone’s risk of developing certain cancers, said this week that it will also begin to offer a DNA test to determine how well widely used antidepressants are likely to work for patients.
With the new test (part of a $249 product), Color joins several dozen companies probing patients’ DNA in search of insights to help inform decisions about which psychiatry medications patients should take. They’re touting applications for depression, bipolar disorder, attention deficit hyperactivity disorder, and post-traumatic stress disorder.
But some top psychiatrists say the evidence doesn’t support the commercial rush.
In a review published this past April, a task force of the American Psychiatric Association’s research council concluded that such genetic testing is not ready for prime time in their field. “Although some of the preliminary published data sound promising,” the task force members wrote, “there is insufficient evidence to support widespread use of combinatorial pharmacogenetic decision support tools at this point in time.”
Dr. Bruce Cohen, a Harvard Medical School psychiatrist who previously ran McLean Hospital and is now on staff there, told STAT he would not order Color’s test or any of the other comparable tests on the market for his patients. “They cost a lot of money, and they have absolutely no proven value,” he said.
Color’s test will initially look at two genes, CYP2D6 and CYP2C19, that the company says impact metabolism of 13 medications for mental health. Among the antidepressants it will report on are Zoloft, Paxil, and Lexapro.
A spokesperson for Color, based in the Bay Area, said the science behind pharmacogenetics for psychiatry “is sound and based on clear evidence and consensus statements.” The information Color provides is based on guidelines from the Food and Drug Administration and a consortium dedicated to implementing pharmacogenetics, the Color spokesperson said.
A pharmacogenetics initiative managed at Stanford also rated the two genes Color is analyzing as “very important” in how the body metabolizes and responds to certain drugs.
The psychiatry offerings from Color and other companies are part of a broader effort to try to use genetic testing to help inform medication choices for all sorts of different conditions. Leading hospitals including Mayo Clinic and Mount Sinai have programs to incorporate pharmacogenetics into clinical care. And the Cincinnati Children’s Hospital has been performing pharmacogenetic testing for neuropsychiatric medications for the last 14 years.
But compared with other fields, there’s relatively little evidence supporting pharmacogenetic testing in psychiatry.
Cohen drew a contrast between psychiatry and cancer. Oncology researchers have identified certain genes as major determinants in getting sick or responding to treatment. “In psychiatry, we don’t have that,” he said.
A 2013 meta-analysis looked at three studies that collectively gathered data on more than 2,200 patients, analyzing their genes and their response to psychiatric mediation. The result? “The authors identified no reliable predictors of antidepressant treatment outcome,” they wrote. They also ran an analysis that suggested that genetics may have accounted for between 1 and 2 percent of the differences in how patients responded. (Other research suggests the contribution is higher.)
The upshot: While genes seem to play some role in how well antidepressants work, factors like age, diet, and hormonal status may be far more influential.
Critics also say that research supporting the use of pharmacogenetics in psychiatry is flawed. Cohen co-authored an opinion article published last month in JAMA Psychiatry that looked at 10 published studies assessing the use of genetic testing to guide treatment for patients with major depressive disorder. They concluded that none of the studies “were adequately blinded and properly controlled” — features that are considered hallmarks of rigorous scientific research.
Another concern: Companies don’t share their secret sauce — how exactly they combine their analyses of different genetic variants to come up with an assessment of whether a drug is likely to work — so the formula can’t be independently reviewed.
Cohen said he understands that psychiatrists and patients are desperate for answers about which drug to try. But even basic questions about a patient’s symptoms, diet, and other medications will yield more insight than a genetic test, he said. “Why spend money on this when there’s a better way? Why not spend more time with the patient? Why not use the guidelines that are there? Why not get a consultation if you’re uncertain how to proceed?”
Just as with the spit kits marketed to people curious about their ancestry, Color’s customers mail in a saliva sample. But Color’s tests must be ordered by a physician — unlike genetic tests offered by direct-to-consumer companies like 23andMe — and factor genetic counseling into their price.
The venture-backed company launched in 2015 with a test analyzing 19 genes associated with common cancers that have a genetic component, including BRCA1 and BRCA2, the genes linked to elevated risk for breast and ovarian cancers. Color has since moved into genetic testing for cardiovascular risk: Last year it started testing for risk of high cholesterol, and earlier this year it expanded into testing for genetic predisposition to inherited heart conditions like cardiac arrhythmias.
Color announced on Thursday that it’s wrapping its cancer and heart tests into one product that also includes two new features: One is the 23andMe-style report on traits with no bearing on health, including whether you’re wired to like the taste of cilantro. The other is the report on what your genes say about how you’re likely to respond to medication; it will initially report on psychiatry drugs but expand in the coming months to include heart and pain medications.
The company is not accepting insurance for the new product.
Some psychiatrists may prove receptive to Color’s new pitch.
Dr. Erika Nurmi, a UCLA psychiatrist and neuroscientist who studies the genetic basis of psychiatric disorders and personalized medicine in psychiatry, has been an outspoken critic of companies that she says overhype the promise of pharmacogenetics in her field.
But Nurmi said she might consider ordering Color’s test if she suspected that a patient might have a drug metabolism problem, based on multiple medications not working or causing side effects. The goal, she said, would be to inform the dosing levels she prescribes. She added that she was pleased to see that Color is only basing its reports on genetic variants that she considers to be vetted.
“This is an example of where the industry needs to go to protect patient health,” she said.
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Looking forward to have generic test done for antidepressants
I appreciate your thoughtful article about this implied, popular illusion, that illness and health are all about genes. I am also reassured that other professionals are vocal about their scepticism. While our science model invites a one-stop answer, like a missing vitamin, hormone, or neurotransmitter, we already know our healthy functioning is more complex.
Metabolism (enzyme activity) has little to do with why one antidepressant is effective and another isn’t. Tests touted to predict medication side effects are not likely tied to whether they prove effective.
The “brutal” reality is we don’t know. People’s brain chemistries differ individually from one and anothers and in health and illness. We don’t know what role brain chemistry plays in mental disorders, whether the “ups” and/or “downs” are the results, the causes, or an incidental findings with emotional disorders. The absolutely amazing thing is that medications work at all for some, and occasionally magnificently for others.
We would do better to accept our ignorance, keep an open mind, and be grateful anything works.
Peggy Finston MD
Acu-Psychiatry.com
Dr, It is kind of late for all of that. They have been using these drugs experimentally for decades. They are drugging foster children, and low income kinds from horrific circumstances. Not much if any research was done on the long term consequences. It is as if these children, and young adults were already disposable. The lack of research and follow up, was all by design. The pharma marketers, lawyers, and lobbyists are very aware that facts, data, and research could cut into profits.
We are living in a Dystopia now. The people that were medicated years ago, and survived, are broken. There is no way to gauge the damage, the people who have observed this over 5 decades are never consulted. The ones who have family members, that they have seen decline over the years. Even now there is no indicator of effectiveness or anything to compare any of this to.
There are people who live in fear of the next episode, because there was no real diagnosis, and the medicated patient, only spent 5 minutes with the prescriber a year ago.
In Post fact America, marketing and public relations are more important than fact based information. These medications are proof, there was not much though put into the ramifications. The drug industry decided that tracking any of this over time, was unimportant. The number of people with tics, lost teeth, and lost lives are just inconvenient. Psychiatrists, who believed, or took money from the marketers, refused to apply any kind of Ethical standards. You seem to be unaware of how they are medicating children at our Border, the ones traumatized by being taken away from their parents. No Psychiatrists stood up when medication became the norm for all children in adverse circumstances in the US. Counting the dead, brain damaged and ruined lives was bad for business.
Maybe someday they will look back on all of this, and describe it as a slow Genocide. For a lot of kinds death was preferable to these horrific overused medications, that people like you prescribed without question.
Hype is a noisy, especially when it comes to genetic hype. The “visionaries” like to imagine genes know and determine all that unfolds about life
I appreciate your thoughtful article about this implied, popular illusion. I am also reassured that other professionals are vocal about their scepticism.
Metabolism (enzyme activity) has little to do with why one antidepressant is effective and another isn’t. Tests that are touted to predict medication side effects are also not useful. Lack of side effects has nothing to do with effectiveness.
The “brutal” reality is we don’t know. People’s brain chemistries differ individually from one and anothers and in health and illness. We don’t know what role brain chemistry plays in mental disorders, whether the “ups” and/or “downs” are the results, the causes, or an incidental findings with emotional disorders. The absolutely amazing reality is that medications work at all for some, and occasionally magnificently for others.
We would do better to accept our ignorance, keep an open mind, and be grateful anything works at all. No test we invent will tell us which medication will work and how if we can’t comprehend the brain and mind. This is bigger than chemistry.
Peggy Finston MD
Acu-Psychiatry.com
Meanwhile, there is very little cross-fertilization amongst medical specialties. Doctors know what they were taught, in Med School, but really do not represent the Hollywood idealized “Dr. House” that most people romantically believe exists in day-to-day medicine. Our family spent a quarter of a million dollars in psychiatric and medical treatments, over a decade, when our family member had a degenerative brain disease, which, if the mental health and medical community had been more aware, would have saved hundreds of doctor visits, useless psychiatric CBT, and residential drug treatment. Behavioral Variant Frontotemporal Degenerative Disease (bvFTD), and not a single psychiatrist or neuropsych, who evaluated my wife every brought it up. It took 60 Minutes, and a trip to a specialty clinic 800 miles away to provide illumination and a meaningful diagnosis. “Oh well”, you might say, “there is so much to know”! Right, I get it….but please quit pretending that you know so much, and are willing to take my hard earned money, while providing services, counseling, and treatment that is useless. A lost decade in time, mental anguish, and most of my retirement savings. Enjoy that nice lifestyle, while providing no help to our family dear psychiatric friends; I hope you can sleep well at night, while we are living our own nightmare! I accept humility and open mindedness, including my own extraordinary limitations; but I no longer accept the hubris and condescending attitudes of those who pretend to know, when they provide medical treatment to me, or my family. Bring on the science, I will study it, ask the questions, and find out what you, my medical provider, really know about your practice!
The genetic contribution to psychiatric conditions is very small.
The following article is also useful to read:
Zubenko, G. S., Sommer, B. R., & Cohen, B. M. (2018). On the Marketing and Use of Pharmacogenetic Tests for Psychiatric Treatment. JAMA psychiatry.
In the meantime millions of Americans are taking these over hyped pharmaceuticals without even seeing a Doctor. Children at our Border, are beig drugged, due to the emotional distress of being torn form their parents. the Industry lobbied to allow random NP’s and behavioral health workers to prescribe these drugs for any random reason. There is no reporting requirement whatsoever on the adverse events, which the industry described as a “Mindset” issue.
There have been no improvements in 50 years There are now drugs, but they are no more effective than the old ones. Millions of doses of these drugs were given to children, veterans, sick people, and most especially women. The FDA, and FTC failed to control the misleading marketing and lobbying.
The US is experiencing and Epidemic of Despair, the rates of Suicide are rising, STAT and you local ‘News’ did not cover that, by design. The pharma Industry turned every adverse “news” story into a marketing campaign. No agency anywhere is tracking the damage, that kind of data is not good for industry profits.
Mavis, you know so little. Medications have saved my life. The “bad guys” you finger are responsible for me being able to function on a daily basis. If genetics are to be ignored, why is depression hereditary? There is a genetic component and we should explore that. Good day to you and your ignorance.