PRIME Care (PRecision Medicine In MEntal Health Care)

Not Applicable

Completed

Brief Summary: The focus of this application is on the impact of providing depressed Veterans and their providers with the results of pharmacogenetic (PGx) testing for psychotropic medications. The project focuses on whether and how patients and providers use genetic test results given to them at the time an antidepressant is to be initiated to treat Major Depressive Disorder (MDD) and whether use of the test results improves patient outcomes. MDD is one of the most common conditions associated with military service and combat exposure, increases suicide risk, and worsens the course of common medical conditions, making it a leading cause of functional impairment and mortality. Validation of a PGx test to personalize the treatment of MDD represents an important opportunity to improve the healthcare of Veterans.

Detailed Description: Background: In the last several years, commercial pharmacogenetic (PGx) testing for psychotropic medications has become widespread as a means of implementing "precision medicine", with some insurers electing to cover the cost of testing. These developments have put increasing pressure on the Veterans Health Administration to implement a mental health focused PGxs program, especially for treating depression, but without sufficient scientific study to support the utility of clinical application.

Objectives: The investigators propose a program of research to evaluate the utility of PGx testing in treating Major Depressive Disorder.

Methods: The investigators plan a multi-site RCT (n=2000), patient/provider dyads will be randomly assigned to receive results of the PGx battery right after randomization (i.e. intervention group) or after 6 months of treatment as usual (i.e. delayed results group)The study will test the following hypotheses:

1. Veterans with MDD whose care is guided by the results of the PGx battery (the intervention group) will have a higher rate of remission of depression than the delayed results group. (Primary Hypothesis)

2. Provider/patient dyads in the intervention group will use fewer medications that have potential gene-drug interactions based on commercial PGx test results than dyads in the delayed results group (Primary Hypothesis).

Recruitment & Eligibility

Inclusion Criteria

PHQ-9 score 10 and a presumptive diagnosis of MDD per PHQ-9 criteria
at least one prior treatment exposure for MDD (psychotherapy or antidepressant
intent to start treatment of the MDD with an antidepressant, simple dose increases will not be considered inclusionary
willingness to provide signed, informed consent to participate in the study

Exclusion Criteria

current serious co-occurring psychiatric illness, i.e.:
- schizophrenia
- bipolar disorder
- psychotic major depression
- borderline or antisocial personality disorder
- eating disorder
active alcohol or other drug use disorder
current use of an antipsychotic medication
augmentation therapy, e.g.:
- use of two or more antidepressants at the time of randomization (trazodone at a dosage < 150 mg/day will not be considered augmentation and thus allowed)
patients requiring urgent care or inpatient hospitalization at the time of consent
currently incarcerated

Primary Outcome Measures

Name	Time	Method
Depression Remission	24 weeks post randomization	The investigators will use the Patient Health Questionnaire 9 (PHQ9) as a self assessed marker of depression remission. The scale ranges from 0 to 27 with lower scores indicating less depression severity. Remission was defined as a score of 5 or less at the endpoint. the reported number of participants are those reaching that threshold of symptoms.
Use of Fewer Medications That Have Potential Gene-drug Interactions	Over the first 30 days	The investigators will examine the proportion of antidepressants prescribed in the first 30 days of the trial that have the potential for gene-drug interactions. The chance for a gene-drug interaction was classified as 1. the subject did not have a prescription for an antidepressant during the initial 4 weeks of the trial (No Antidepressant), 2 the subject was prescribed an antidepressant with no known gene-drug interaction (No Gene Interaction), 3 the subject was prescribed an antidepressant with moderate gene-drug interactions (Moderate Interaction). These are also gene-drug interactions that do not have level A concordance. And 4. the subject was prescribed an antidepressant with substantial gene-drug interactions or gene-drug interactions that are considered to have a high level of evidence to support other prescribing.

Secondary Outcome Measures

Name	Time	Method
Depression Response	24 weeks	The investigators will use the Patient Health Questionnaire 9 (PHQ9) as a self assessed marker of depression remission. The scale ranges from 0 to 27 with lower scores indicating less depression severity. Response was measured by a 50% reduction in scores from baseline to each time point.
Depression Severity	24 Weeks	The investigators will use the Patient Health Questionnaire 9 (PHQ9) as a self-assessed marker of depression remission. The scale ranges from 0 to 27 with lower scores indicating less depression severity. This measure will use the PHQ9 as a continuous measure. The reported outcome is the difference in scores from baseline to 24 weeks.

Locations (24): Central Arkansas Veterans Healthcare System Eugene J. Towbin Healthcare Center, Little Rock, AR
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North Little Rock, Arkansas, United States
VA Palo Alto Health Care System, Palo Alto, CA
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Palo Alto, California, United States
San Francisco VA Medical Center, San Francisco, CA
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San Francisco, California, United States
VA Greater Los Angeles Healthcare System, West Los Angeles, CA
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West Los Angeles, California, United States
Rocky Mountain Regional VA Medical Center, Aurora, CO
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Aurora, Colorado, United States
VA Connecticut Healthcare System West Haven Campus, West Haven, CT
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West Haven, Connecticut, United States
Wilmington VA Medical Center, Wilmington, DE
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Wilmington, Delaware, United States
Miami VA Healthcare System, Miami, FL
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Miami, Florida, United States
Baltimore VA Medical Center VA Maryland Health Care System, Baltimore, MD
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Baltimore, Maryland, United States
VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA
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Boston, Massachusetts, United States
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Central Arkansas Veterans Healthcare System Eugene J. Towbin Healthcare Center, Little Rock, AR
🇺🇸North Little Rock, Arkansas, United States