Effect of Pharmacogenomic Testing for Drug-Gene Interactions on Medication Selection and Remission of Symptoms in Major Depressive Disorder: The PRIME Care Randomized Clinical Trial.

Importance: Selecting effective antidepressants for the treatment of major depressive disorder (MDD) is an imprecise practice, with remission rates of about 30% at the initial treatment. Objective: To determine whether pharmacogenomic testing affects antidepressant medication selection and whether such testing leads to better clinical outcomes. Design, Setting, and Participants: A pragmatic, randomized clinical trial that compared treatment guided by pharmacogenomic testing vs usual care. Participants included 676 clinicians and 1944 patients. Participants were enrolled from 22 Department of Veterans Affairs medical centers from July 2017 through February 2021, with follow-up ending November 2021. Eligible patients were those with MDD who were initiating or switching treatment with a single antidepressant. Exclusion criteria included an active substance use disorder, mania, psychosis, or concurrent treatment with a specified list of medications. Interventions: Results from a commercial pharmacogenomic test were given to clinicians in the pharmacogenomic-guided group (n = 966). The comparison group received usual care and access to pharmacogenomic results after 24 weeks (n = 978). Main Outcomes and Measures: The co-primary outcomes were the proportion of prescriptions with a predicted drug-gene interaction written in the 30 days after randomization and remission of depressive symptoms as measured by the Patient Health Questionnaire-9 (PHQ-9) (remission was defined as PHQ-9 ≤ 5). Remission was analyzed as a repeated measure across 24 weeks by blinded raters. Results: Among 1944 patients who were randomized (mean age, 48 years; 491 women [25%]), 1541 (79%) completed the 24-week assessment. The estimated risks for receiving an antidepressant with none, moderate, and substantial drug-gene interactions for the pharmacogenomic-guided group were 59.3%, 30.0%, and 10.7% compared with 25.7%, 54.6%, and 19.7% in the usual care group. The pharmacogenomic-guided group was more likely to receive a medication with a lower potential drug-gene interaction for no drug-gene vs moderate/substantial interaction (odds ratio [OR], 4.32 [95% CI, 3.47 to 5.39]; P < .001) and no/moderate vs substantial interaction (OR, 2.08 [95% CI, 1.52 to 2.84]; P = .005) (P < .001 for overall comparison). Remission rates over 24 weeks were higher among patients whose care was guided by pharmacogenomic testing than those in usual care (OR, 1.28 [95% CI, 1.05 to 1.57]; P = .02; risk difference, 2.8% [95% CI, 0.6% to 5.1%]) but were not significantly higher at week 24 when 130 patients in the pharmacogenomic-guided group and 126 patients in the usual care group were in remission (estimated risk difference, 1.5% [95% CI, -2.4% to 5.3%]; P = .45). Conclusions and Relevance: Among patients with MDD, provision of pharmacogenomic testing for drug-gene interactions reduced prescription of medications with predicted drug-gene interactions compared with usual care. Provision of test results had small nonpersistent effects on symptom remission. Trial Registration: ClinicalTrials.gov Identifier: NCT03170362.

Improvement of postinpatient psychiatric follow-up for veterans using telehealth.

PURPOSE: To describe the implementation and initial outcomes of a pilot interdisciplinary telehealth clinic, Allied Transitional Telehealth Encounters post-iNpatient Discharge (ATTEND), providing clinical pharmacy specialist follow-up for veterans transitioning from inpatient to outpatient mental healthcare in a Department of Veterans Affairs (DVA) hospital. SUMMARY: The ATTEND clinic's primary intervention was providing medication management appointments through clinical video telehealth (CVT) to patient discharge locations through a DVA-provided tablet. An interdisciplinary team supported care through on-unit inpatient training, secure messaging, and self-help applications. Clinical outcomes were measured through readmission rates, wait times, self-report measures, and follow-up interview at the completion of ATTEND services. Twenty patients completed on-unit training, and 16 unique patients were seen for at least 1 outpatient appointment. Inpatient readmission rates were lower for ATTEND patients than with standard care (5% versus 19%, respectively). Wait times until first postdischarge mental health appointment were reduced by a mean of 18.6 (S.D., 8.8) days. The pharmacist made medication interventions, including dosing changes, education on incorrect administration, and medication discontinuation. Self-reported psychological symptoms decreased during ATTEND participation. Post-ATTEND interviews indicated high levels of acceptance and interest in continued tablet-based care. Primary challenges included unique technological limitations and effective care coordination. CONCLUSION: The ATTEND telehealth clinic provided postinpatient mental health follow-up that was more prompt and convenient than conventional on-site appointments. Psychiatric self-report improved during ATTEND-facilitated transition to outpatient care, and the recidivism rate for ATTEND patients was lower than the general inpatient rate during the same time period.

A survey of pharmacists' perceptions of the adequacy of their training for addressing mental health-related medication issues.

INTRODUCTION: The purpose of this study was to conduct a survey of North Carolina pharmacists' perceptions of their pharmacy training in mental health-related medication issues and how this influenced their perceived ability to address these issues in the provision of pharmaceutical care to their patients. METHODS: A survey consisting of 17 questions was developed and emailed to licensed pharmacists in North Carolina. Surveys that were returned were analyzed to see if conclusions could be made regarding the pharmacists' perceptions about their mental health-related medication training and its influence on their practice. RESULTS: A total of 848 pharmacists completed the survey (response rate of 7.9%). Of the survey participants, 489 (58.2%) reported that pharmacy school training adequately prepared them to provide basic pharmaceutical care to patients taking mental health-related medications. However, 350 (41.4%) reported feeling less comfortable providing medication counseling for mental health-related medications compared to cardiac medications. DISCUSSION: Despite the volume of prescriptions that mental health-related medications represent in day-to-day practice, a significant portion of licensed pharmacists responding to our survey indicate that the emphasis on mental health in their training may have been inadequate.