Comparative Effectiveness of Pharmacogenomics for Treatment of Depression
Condition: Major Depressive Disorder
MeSH terms: Depression; Depressive Disorder; Depressive Disorder, Major
Study type: Interventional

Summary: 
      The overall goal of this study is to assess the effectiveness of a widely available and
      widely used combinatorial pharmacogenomic (PGx) test for the treatment of major depressive
      disorder. Pharmacogenomic tests use genetic information to guide medication treatment
      decisions. The tests inform clinicians and patients of potential gene-drug interactions by
      analyzing pharmacokinetic (PK) genes (how drugs are metabolized) as well as pharmacodynamic
      (PD) genes (how drugs work). While combinatorial PGx testing is attractive to clinicians,
      patients, healthcare systems, and insurers, limited data demonstrate that PGx testing will
      result in better outcomes compared to evidence-based guideline treatment. Therefore, the
      investigators will conduct a prospective randomized comparative effectiveness study of best
      practice guidelines plus combinatorial PGx-guided treatment versus best-practice guideline
      concordant treatment alone.
    

Detailed description: 
      Depressive disorders are the fourth leading cause of the burden of disease worldwide and is
      projected to be the first cause by 2030 1. According to the World Health Organization
      depression carries the greatest burden of disability among all mental and behavioral
      disorders. Specifically, depression accounts for 3.7% of all U.S. disability-adjusted life
      years and 8.3% of all U.S. years lived with disability. In 2014, it was estimated that 15.7
      million adults in the United States had at least one major depressive episode in the past
      year and 43% people with severe depressive symptoms reported serious difficulties in work,
      home, and social activities 2. The current standard of care is based on trial-and-error of a
      multitude of medications; this approach often leads to patient and clinician frustration
      after each treatment failure (side effects or non-response) and can decrease compliance and
      engagement in treatment. One way to reduce this trial-and-error process, is to use
      pharmacogenomic (PGx) testing to guide medication treatment and increase the likelihood of
      response by reducing the number of ineffective medication trials.

      Pharmacogenomics, the use of genetic information by patients, clinicians, and healthcare
      systems to match patients with pharmacologic treatments, is an important step towards
      precision/personalized medicine. Pharmacogenomics can make the practice of medicine more
      efficient by giving the right medications specifically to those who are most likely to
      benefit from them and to avoid giving the wrong medications to those who are most likely not
      to benefit based on each patient's individual genetic makeup. The PGx test for the treatment
      of depression is now commercially available and is reimbursable by insurance, including
      Medicaid and Medicare. A recent comprehensive overview of the state of PGx testing for
      depression, its promise, and limitations concluded that more research is needed in this
      rapidly-developing field3. Specifically, the gap is that while PGx-guided antidepressant
      treatment results in better outcomes compared to treatment as usual in tightly controlled
      clinical trials, it has not yet been tested in real world settings, nor has it been compared
      to best practice guidelines. It is less clear how well PGx tests make a difference in short
      and long-term patient-centered outcomes compared to guideline-concordant care of depression.

      For this study, the investigators are collaborating with Assurex Health and their product
      GeneSight® Psychotropic powered by CPGx® technology, the only test for depression
      reimbursable by Medicaid and Medicare. GeneSight® is a neuropsychiatric, combinatorial, PGx
      test that provides recommendations for psychotropic medications (antidepressants, mood
      stabilizers, hypnotics for insomnia, and antipsychotics) based on a patient's individual
      genetic profile. The test combines pharmacokinetic (PK) metabolism genes (how drugs are
      metabolized) as well as pharmacodynamic (PD) genes (how drugs work) to predict dosing
      adjustments and response.

      GeneSight® classifies medications based on the severity of the gene-drug interactions in
      color-coded categories: green "use as directed," yellow "moderate gene-drug interaction," and
      red "significant gene-drug interaction." The results are presented in a report which is
      easily understandable by patients and clinicians. Furthermore, GeneSight® addresses concerns
      reported by individuals in MoodNetwork: alleviating symptoms, identifying effective
      alternative treatments, reducing barriers to care/treatment, and using genetic studies to
      identify responders to treatment. This study answers questions that patients and clinicians
      care about and has the potential to improve outcomes.

      Cogito, Inc. is the industry leader in the mobile sensing technology of mood. Cogito has
      developed a mobile phone application that assesses depression by tracking everyday usage of
      mobile phones, without the need to actively input data (e.g., rating depression). The
      application uses indicators such as phone call/text frequency or voice parameters to deduce
      depression severity. To date, this application has been tested in two studies: Defense
      Advanced Research Projects Agency (DARPA) funded a study in 73 patients with major depression
      and PTSD3, and a more recent NIMH funded study with 200 patients with major depression and
      bipolar disorder in collaboration with the MoodNetwork PPRN. The application is highly
      sensitive and specific in detecting depression. However, given the preliminary nature of
      these findings, the study investigators will use the Cogito platform as a secondary (more
      exploratory) outcome measure and the use of this application will be optional. The use of
      passive sensing technology has the advantage that it does not rely on patients' self-report
      and can be used for low cost longitudinal monitoring of patients for the changes in
      depression symptoms.

      If a study clinician meets with one of their patients and determines that they may be
      eligible for the study, a member of the study staff (i.e. site PI, treating clinician, or
      research assistant) will describe the study to the patient and answer any questions. If the
      participant is interested, they will complete the consent form accessed via MoodNetwork.org.
      Patients will be offered to take home the Consent Form and call back if they wish to
      participate. If they decide to participate, they will contact the member of the research team
      and will be given the study website link to sign consent. Following their consent,
      participants will be prompted to complete questionnaires to determine study eligibility on
      MoodNetwork.org. If the patient is eligible for the study, they will be informed of the
      option to use the Cogito Companion mobile app and if they want to use it, they will be asked
      to download the mobile app (so that the study team can passively monitor any potential
      depressive symptoms throughout the course of the study) and they will be randomized to either
      the PGx-guided psychiatric treatment arm or the best practice guidelines arm. A member of
      study staff will then administer the PGx test (i.e., a buccal swab). If the participant is in
      the PGx-guided psychiatric treatment arm, the treating clinician will receive their results
      within two business days and contact the participant to inform them of the results and
      discuss any medication changes. If the participant is in the best practice guidelines arm,
      the treating clinician will not receive the PGx test results until after the follow-up phase
      (one year). The clinician, however, will still contact the patient to discuss medication
      changes (in line with the Canadian Network for Mood and Anxiety Treatments (CANMAT)
      guidelines instead of the GeneSite test results).
    

Intervention name(s): GeneSight Psychotropic test; Canadian Network for Mood and Anxiety Treatment (CANMAT) Best Practice Guidelines
Intervention type(s): Other; Other
Intervention description(s): GeneSight® Psychotropic powered by CPGx® technology, the only test for depression reimbursable by Medicaid and Medicare. GeneSight® is a neuropsychiatric, combinatorial, PGx test that provides recommendations for psychotropic medications (antidepressants, mood stabilizers, hypnotics for insomnia, and antipsychotics) based on a patient's individual genetic profile.; Guidelines for treatment
Intervention MeSH terms: Psychotropic Drugs
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Investigators will prospectively randomize 400 participants with DSM-V major depressive disorder to best practice guidelines plus PGx- guided psychiatric treatment (n=200) or best practice guidelines alone (n=200) and follow them for one year.
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Depression; Major Depressive Disorder; Pharmacogenomic testing