Preferences regarding targeted education and risk assessment in people with a family history of major depressive disorder.

Genetic testing for susceptibility to major depressive disorder (MDD) is not available for clinical use at present. Given this, family history remains the best predictor for development of MDD, and family-history-based risk assessment and information about familial aspects of MDD may be useful to clients at increased risk for MDD attending for genetic counseling. This study uses a mixed-methods design to assess the information needs and preferences of people at increased familial risk for MDD. Telephone interviews were conducted with 23 individuals, who had at least one first-degree relative with MDD and were recruited through advertisements placed on depression education websites. The most preferred way to access depression information was via the internet (87 % of participants), although this preference may have been due to the internet-based recruitment method. The second most preferred dissemination strategy (56 %) was face-to-face delivery through a health professional, including genetic counselors. Individuals reported a need for information about etiology and development of MDD, reproductive decision-making, early detection of symptoms and risk-reducing strategies. Nearly all participants expressed an interest in risk assessment. The present study found evidence of a high level of interest for information targeted to people at increased familial risk for MDD. Genetic counselors are likely to be called upon increasingly to provide supportive counseling to assist clients at increased familial risk in interpreting and contextualizing such information once it becomes available.

Implications of the use of genetic tests in psychiatry, with a focus on major depressive disorder: a review.

Advances in technology have enabled research to link many genetic markers to specific disease risk. This has led to the commercialization of genetic tests across a wide range of medical disorders. Public interest in one's own future health and an increasing desire for autonomy over one's health care have facilitated a large and growing market for such genetic tests to be sold direct to the consumer (DTC). Amidst a plethora of tests for a broad range of medical conditions, DTC genetic tests currently include a number of tests related to risk for various psychiatric illnesses including major depressive disorder (MDD), bipolar disorder, schizophrenia, and obsessive-compulsive disorder and also for prediction of individual response to psychotropic medication. Although a large number of studies show that there is strong public interest in genetic susceptibility testing for psychiatric disorders, little is known about the impact on individuals of receiving the results of genetic tests. Moreover, the low predictive power and uncertain clinical validity and utility of DTC genetic tests for psychiatric disorders have led to both controversy and difficulties of interpretation of results. This review summarizes the rationale for using genetic risk tests in psychiatry, as an intervention for protective cognitive and behavioral change, and to predict medication response, with a focus on MDD. Since genetic risk information has the potential to influence major life-changing health decisions, there is an imperative to ensure that there is an appropriate evidence base to support the use of such genetic tests.

Cluster randomized controlled trial of a psycho-educational intervention for people with a family history of depression for use in general practice.

BACKGROUND: The strongest risk factor for depression is having a family history of the condition. Many individuals with a family history of depression are concerned about their personal risk for depression and report unmet educational and psychological support needs. No supportive and/or educational interventions are currently available that target this group of individuals. In this study we will develop and evaluate the first online psycho-educational intervention targeted to individuals with a family history of depression. Genetic risk information and evidence-rated information on preventive strategies for depression will be provided to such individuals in a general practice setting. The intervention will also incorporate a risk assessment tool. The content and delivery of the intervention will be pilot-tested. METHODS/DESIGN: The proposed intervention will be evaluated in the general practitioner (GPs) setting, using a cluster randomized controlled trial. GP practices will be randomized to provide either access to the online, targeted psycho-educational intervention or brief generic information about depression (control) to eligible patients. Eligibility criteria include having at least one first-degree relative with either major depressive disorder (MDD) or bipolar disorder (BD). The primary outcome measure is 'intention to adopt, or actual adoption of, risk-reducing strategies'. Secondary outcome measures include: depression symptoms, perceived stigma of depression, knowledge of risk factors for development of depression and risk-reducing strategies, and perceived risk of developing depression or having a recurrence of family history. Over the course of the study, participants will complete online questionnaires at three time points: at baseline, and two weeks and six months after receiving the intervention or control condition. DISCUSSION: This novel psycho-educational intervention will provide individuals with a family history of depression with information on evidence-based strategies for the prevention of depression, thus, we hypothesize, enabling them to make appropriate lifestyle choices and implement behaviors designed to reduce their risk for depression. The online psycho-educational intervention will also provide a model for similar interventions aimed at individuals at increased familial risk for other psychiatric disorders. TRIAL REGISTRATION: The study is registered with the Australian and New Zealand Clinical Trials Group (Registration no: ACTRN12613000402741).

Exploring culture-specific differences in beliefs about causes, kinship and the heritability of major depressive disorder: the views of Anglo-Celtic and Chinese-Australians.

The aim of this study was to explore cultural differences in causal attributions and beliefs about heritability of major depressive disorder (MDD). Face-to-face interviews with Anglo-Celtic- and Chinese-Australians community members with a family history of MDD were conducted and subjected to a rigorous qualitative analysis, using the computer software NVivo. Sixteen Anglo-Celtic-Australians and 16 Chinese-Australians were interviewed. Both groups believed that a combination of genetic and environmental factors contributed to MDD, that stress was an important cause of MDD, and that coping factors were significant moderators of the impact of stress on MDD. Both cultural groups believed that the causes of MDD affecting multiple family members included a shared family environment and a "contagion effect", in addition to genetics. Unique to the Chinese-Australian group was the beliefs that parental pressures to exceed academically contributed to MDD; this cultural group also reported beliefs that depression was due to God's will or alternatively fate, which in turn was related to attributions to feng shui and auspicious dates. This study documented key culture-specific differences in beliefs about causes and inheritance of MDD; such differences have major implications for clinician-patient communication about genetic risk associated with having a family history of MDD.

Portrayal of psychiatric genetics in Australian print news media, 1996-2009.

OBJECTIVE: To investigate how Australian print news media portray psychiatric genetics. DESIGN AND SETTING: Content and framing analysis of a structured sample of print news items about psychiatric genetics published in Australian newspapers between 1996 and 2009. MAIN OUTCOME MEASURES: Identify dominant discourses about aetiology of mental illness, and perceived clinical outcomes and implications of psychiatric genetics research. RESULTS: We analysed 406 eligible items about the genetics of psychiatric disorders. News coverage of psychiatric genetics has steadily increased since 1996. Items attributing the aetiology of psychiatric disorders to gene-environment interactions (51%) outnumbered items attributing only genetic (30%) or only environmental factors (20%). Of items that referred to heritability of mental illness, frames of genetic determinism (78%) occurred more frequently than probabilistic frames (22%). Of frames related to genetic prophesy, genetic optimism frames (78%) were used more frequently than frames of genetic pessimism (22%). Psychosocial and ethical implications of psychiatric genetics received comparatively relatively little coverage (23%). The analysis identified 22 predictions about psychiatric genetic discoveries and the availability of molecular-based interventions in psychiatry, most of which (20/22, 91%) failed to manifest by the predicted year. CONCLUSIONS: Excessive optimism about the power of genetic technology in psychiatric health care, perceived clinical benefits, and largely unfulfilled predictions about availability of these benefits could encourage unrealistic expectations about future molecular-based treatment options for mental health.

Management of severe traumatic intrusion in the permanent dentition.

Traumatic intrusion is considered one of the most severe luxation injuries to the permanent dentition. There are limited studies based on minimal evidence supporting suggested management protocols, owing to the rare occurrence of intrusion. The following case report details the multidisciplinary management and 18-month follow-up, in line with current UK guidelines, of a 23-year old adult male who sustained severe intrusion injuries to both permanent maxillary central incisor teeth. Timely, accurate diagnosis and subsequent appropriate management correlates with improved outcomes for traumatic injuries and it is therefore imperative those involved with the acute and long-term management of dentoalveolar trauma are aware of current guidelines.

Community attitudes towards mental health interventions for healthy people on the basis of genetic susceptibility.

OBJECTIVES: The aim of the present study was to evaluate, using serotonin transporter genotyping as an example, the preparedness of individuals from an urban general population identified with hypothetical genetic risk for a depressive disorder to moderate risk through cognitive or behavioural intervention. It also evaluated endorsement of genetic and environmental causal attributions of mental illness. METHOD: A qualitative approach using focus group methodology was selected as most appropriate because these issues are relatively unexplored. Participants (n=36) aged > or =18 years from metropolitan Sydney discussed their understanding of the role of genetic and environmental risk factors in mental illness and attitudes towards pre-symptomatic interventions based on genetic risk information. RESULTS: Thirty-six participants attended four focus groups involving 8-10 participants per group. Participants predominantly viewed genetic risk factors for depression as predisposing rather than causal, with environmental risk factors acting as triggers. Hypothetical identification with a genetic variant suggesting predisposition to depression prompted strong interest in seeking further information about predictive genetic testing from medical professionals, willingness to reduce life stress, drugs and alcohol intake, willingness to increase exercise, and willingness to undertake cognitive and behavioural interventions at a pre-symptomatic stage. Mixed views prevailed as to whether stress was a modifiable risk factor. Preventive intervention at a presymptomatic stage of depression was viewed negatively in a minority of participants due to a fatalistic attitude towards a genetic predisposition and attitudes that intervention was futile in the absence of symptoms. CONCLUSIONS: There is a likely public demand for preventive mental health interventions for healthy people on the basis of genetic susceptibility if predictive genetic testing becomes available in psychiatry. The findings have implications for general practitioner and public education about predictive genetic testing for susceptibility to common multifactorial disorders for at-risk groups.

Attitudes of medical genetics practitioners and psychiatrists toward communicating with patients about genetic risk for psychiatric disorders.

OBJECTIVES: The aim of this study was to examine the self-rated competencies and perceived roles of medical geneticists, genetic counselors, and psychiatrists in the communication of genetic risk for psychiatric disorders to patients and families at an increased risk for schizophrenia, bipolar disorder or major depressive disorder, and their perspectives on training needs in this field. MATERIALS AND METHODS: Clinically active members of the Human Genetics Society of Australasia (HGSA) and the Royal Australian and New Zealand College of Psychiatrists (RANZCP) were invited to complete the online survey. A total of 157 responses were included in data analysis: 17 medical geneticists, 36 genetics counselors, and 104 psychiatrists. RESULTS: In all, 34.4% of the respondents disagreed that their professional training had prepared them to discuss genetic information about psychiatric illnesses with patients. Medical geneticists perceived significantly higher levels of self-rated competency to discuss with patients and families genetic information on psychiatric disorders compared with genetic counselors and psychiatrists (t=-0.61, P=0.001; ß=0.33, 95% confidence interval 0.16-0.49, P<0.001). CONCLUSION: Findings suggest deficiencies in education and training programs on how to best communicate psychiatric genetic risk information to patients, suggesting that specialist programs are needed to better support health professionals. As self-rated competencies differed among the professional groups, training programs need to be tailored to participants' professional backgrounds.

Community attitudes to genetic susceptibility-based mental health interventions for healthy people in a large national sample.

BACKGROUND: Despite an apparent high interest in predictive genetic testing for common multifactorial disorders, few data describe anticipated health behaviour as a consequence of such testing. METHODS: A large population-based public survey with community dwelling adults (N = 1046) ascertained through random digit dialling. Attitudes were assessed via structured interviews. RESULTS: Intention to start therapies or courses to learn to develop better strategies to cope with stress (80%) was significantly and positively associated with self-estimation of risk for major depressive disorder as higher than average (ß = 0.12, p = 0.001); endorsement of family environment as a causal attribution (ß = 0.11, p < 0.001); and endorsement of gene-environment interaction as a causal mechanism of mental illness (ß = 0.12, p = 0.017). Intention to modify potential life stressors (84%) was significantly and positively associated with self-estimation of risk for depression as higher than average (ß = 0.07, p = 0.029); endorsement of 'abuse' as a causal attribution (ß = 0.10, p = 0.003); and endorsement of 'gene-environment interaction' as a causal mechanism (ß = 0.10, p = 0.002). LIMITATIONS: The hypothetical nature of the genetic risk scenario may have weakened participants' sensitivity to the potential personal impact of such a genetic test result. CONCLUSIONS: Perceptions that modifiable environmental factors strongly contribute to overall risk of major depressive disorder appeared to drive willingness to engage in risk-modifying interventions in the hypothetical scenario of a genetic predisposition. Our results suggest that screening for genetic risk in consort with environmental risk factor assessment has potential community acceptability and clinical value as an early intervention and preventive tool for high risk groups.

Public interest in predictive genetic testing, including direct-to-consumer testing, for susceptibility to major depression: preliminary findings.

The past decade has seen rapid advances in the identification of associations between candidate genes and a range of common multifactorial disorders. This paper evaluates public attitudes towards the complexity of genetic risk prediction in psychiatry involving susceptibility genes, uncertain penetrance and gene-environment interactions on which successful molecular-based mental health interventions will depend. A qualitative approach was taken to enable the exploration of the views of the public. Four structured focus groups were conducted with a total of 36 participants. The majority of participants indicated interest in having a genetic test for susceptibility to major depression, if it was available. Having a family history of mental illness was cited as a major reason. After discussion of perceived positive and negative implications of predictive genetic testing, nine of 24 participants initially interested in having such a test changed their mind. Fear of genetic discrimination and privacy issues predominantly influenced change of attitude. All participants still interested in having a predictive genetic test for risk for depression reported they would only do so through trusted medical professionals. Participants were unanimously against direct-to-consumer genetic testing marketed through the Internet, although some would consider it if there was suitable protection against discrimination. The study highlights the importance of general practitioner and public education about psychiatric genetics, and the availability of appropriate treatment and support services prior to implementation of future predictive genetic testing services.

Predictive and diagnostic genetic testing in psychiatry.

The recent advent of commercially available genetic tests for the diagnosis of several mental illnesses has led to intense controversy amongst the psychiatric research community. In this article the authors review these developments, and contrast these with the growing evidence from genomewide association studies that highly heritable psychiatric conditions such as schizophrenia are due to the contributions and interaction of multiple allelic variants, each of small effect size. There is also evidence for the contribution of some highly penetrant rare de novo copy number variants, though the lack of disease specificity for these is of concern. This article outlines the prerequisites for predictive and diagnostic genetic tests, such as clinical validity and utility, and reviews the opportunity that genetic tests for mental illnesses present. As the scientific discourse on genetic tests for complex disorders is not limited to psychiatry, the authors outline current thoughts on the significance of genome-wide association studies across health, and the phenomenon of direct-to-consumer tests in medicine. The attitudes and understanding of patients, families, and clinicians about the future (currently hypothetical) scenario of psychiatric genetic tests are discussed, as is the potential for such testing to increase, rather than diminish stigma. Finally, recommendations on the future development and availability of genetic tests in psychiatry are provided.

Predictive and diagnostic genetic testing in psychiatry.

The recent advent of commercially available genetic tests for the diagnosis of several mental illnesses has led to intense controversy amongst the psychiatric research community. In this article the authors review these developments, and contrast these with the growing evidence from genome-wide association studies that highly heritable psychiatric conditions such as schizophrenia are due to the contributions and interaction of multiple allelic variants, each of small effect size. There is also evidence for the contribution of some highly penetrant rare de novo copy number variants, though the lack of disease specificity for these is of concern. This article outlines the prerequisites for predictive and diagnostic genetic tests, such as clinical validity and utility, and reviews the opportunity that genetic tests for mental illnesses present. As the scientific discourse on genetic tests for complex disorders is not limited to psychiatry, the authors outline current thoughts on the significance of genome-wide association studies across health, and the phenomenon of direct-to-consumer tests in medicine. The attitudes and understanding of patients, families, and clinicians about the future (currently hypothetical) scenario of psychiatric genetic tests are discussed, as is the potential for such testing to increase, rather than diminish stigma. Finally, recommendations on the future development and availability of genetic tests in psychiatry are provided.