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Nurses turn to DNA testing to help patients being treated with psychotropic drugs

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Linda Gable-Gaston, APN

Six months ago, psychiatric nurse practitioner Laura Leahy decided to try a little-used kind of testing to help a patient who had suffered from profound depression for more than 30 years.

Leahy, RN, MSN, APN, PMHNP/CNS-BC said the patient cried daily, had regular migraines and fatigue, didn’t want to get out of bed and had lost the will and energy to enjoy life.

She had tried numerous therapists, multiple medications and 18 electroconvulsive therapy treatments.

So Leahy, who has a private practice called APNSolutions in Vineland, N.J., sent a saliva sample to Genomind in Chalfont, Pa., for a genetic test to check the patient’s DNA for clues.

Two “aha” moments followed.

One was for Leahy, who discovered the patient’s genetic makeup indicated the way she metabolized psychotropic drugs meant her current treatments were likely to fail. The second was for the patient, who finally knew “it wasn’t all in her head,” Leahy said.

Leahy lowered the dose of the antidepressant and added a psychostimulant, and now “she’s a new woman,” said Leahy, who said that in late July, the patient related her latest night out. “She was supposed to meet a friend to do karaoke. Her friend ended up not showing, and she spent four hours doing karaoke by herself.”

How a patient metabolizes drugs
Using a person’s DNA to predict how they will react to psychotropic drugs takes some of the trial and error out of determining which drug is best for which patient.

Pharmacogenetic testing involves a swab or a blood or saliva sample sent to a lab that analyzes patients’ DNA — specifically cytochrome P450, the enzymes that metabolize medication — to find out how they metabolize a certain drug. That can influence which drugs are prescribed and in what amounts.

The testing is not yet widely used among hospitals. Physicians and nurses familiar with the testing say this is because hospital systems aren’t generally convinced the tests are cost-effective or are not familiar enough with the procedure to make that determination.

At Zucker Hillside Hospital in Glen Oaks, N.Y., research nurse Brian Cantley, RN, is part of a team studying whether genetic testing can help in treating schizophrenic patients who use one of the most widely prescribed atypical antipsychotic agents, risperidone (Risperdal).

Researchers theorize that poor metabolizers who are treated with a low dose and slow titration of risperidone will better tolerate its side effects and show more clinical improvement compared with those treated with usual dose and titration.

The interest in the test came after large-scale clinical trials had shown a substantial percentage of patients with schizophrenia stop taking their antipsychotic medicines because they see them as ineffective or they can’t tolerate the side effects.

Cantley said side effects of antipsychotic drugs can include akathisia, a restlessness often described as feeling like you’re crawling out of your skin; myoclonus, or quick involuntary muscle twitches; dystonia, or muscle contractions that cause uncontrollable twisting; and weight gain.

There can be sexual side effects as well, Cantley said. “In men, they (can be) unable to get an erection or to ejaculate.” Women may see a drop in estrogen and may have irregular or absent periods, infertility, breast discharge and menopausal symptoms.

Though risperidone is probably the most popular treatment for schizophrenia, there are other medication options, Cantley said.

In addition to costs for the tests, he said, the time it takes to get DNA testing results — two to three days in his case — may be a negative for hospitals.

“It’s not a quick thing,” Cantley said.

Leahy said it typically takes a week to get the results from Genomind.

Test often follows multiple trials
Linda Gable-Gaston, APN, MSN, said she has used the tests for many patients in her private practice, Introspection Mind, Body & Spirit Center, in Bloomfield, N.J.

Gable-Gaston does an evaluation to gather patient history and medication history. If she thinks the genetic testing would be beneficial, she sends a DNA swab to the lab. When results come back, she and the patient go over them and Gable-Gaston makes a recommendation for medications.

Both Cantley and Gable-Gaston said they use AssureRx Health lab. Gable-Gaston said she chose that company partially because they make results easy for the patient to understand.

Genetic testing usually comes after multiple trials for psychotropic drugs haven’t produced the desired results.

“Not everybody is a candidate for this,” Gable-Gaston said. “I reserve it for people who have been on multiple medications, continue to struggle or may have breakthrough symptoms, such as visual or auditory hallucinations.”

She said in her experience, the test is not only worth the cost, but can prevent bigger costs.

Gable-Gaston and Leahy said their patients usually end up paying only a copay for the service. Some, whose income falls below the poverty level, can get the copay waived, they said.

Gable-Gaston said in her experience, “It’s covered by private insurance, and it’s also covered by Medicare but not Medicaid.”

The test is one tool used in combination with patient history and lifestyle indicators to determine which drug will be best, Gable-Gaston said. For instance, smoking can interfere with a medication’s effectiveness.

Leahy said the test can tell her how a certain type of drug might interact with a woman’s birth control pills or a person’s blood pressure medication, based on the genetic profile of their liver enzymes.

Research at Mayo
Mayo Clinic in Rochester, Minn., is a pioneer for genetic tests in psychiatry. There, David Mrazek, MD, chair of the department of psychiatry and psychology, developed a federally funded psychiatric pharmacogenomics research program and implemented clinical psychiatric pharmacogenomics services.

Daniel Hall-Flavin, MD, a consultant in the department, said in his experience the costs of the tests run from $1,000 to $2,000, but noted those costs are likely to come down as technology advances.

When testing is more widespread, nurses will play important roles in working with physicians to assess whether patients could benefit from the tests, he said.

“It is the nursing staff that are able to spend the most time with patients,” he said. “With this in mind, monitoring patients’ response for effectiveness and untoward effects, helping the physician to assess the benefits and risk both proactively and retroactively in planning additional care, bringing new information to the physician that may not have been previously available, and working in research to better understand the applications of new interventions are all roles that nursing can play.”

Marcia Frellick is a freelance writer.

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  1. Charles O'Donnell, CRNP, Family PMHNP, BC on

    Hi Laura:

    Hello, it’s me, one of your big fan’s, & previous PMHNP student’s, class of 2011, Charles OD.

    I just finished reviewing your comments on the details of the genetic essay, over the last 2 & a half year’s I have been utilizing the genetic assay progressively within my practice getting advantageous results for the most part. The only real problem & obstacle I’ve experienced with its routine utilization/application have been issues surrounding its tremendous financial burden, related to the out of proportion financial expense related to its universal Insurance coverage, & high priced cost of co-payment demand issues, & weather or not Medicare,/Medicaid,/Social Security benefits will cover its cost, etc….

    So, things have been going back & forwards relating to how frequently I’m able to use the genetic assy.
    Its been crazy as about 6 months ago the genetic assay company I’ve been using exclusively reverted back to not accepting any Public Assistance at all, & they also in addition suddenly & abruptly dramatically increased their co-pay amounts when its covered by any of their preferred private Insurance carrier’s.

    So the topic of weather or not to use genetic assay’s issue has slowed down recently unfortunately due to out of pocket cash cost is this is the true bottom line as far as how often I use this amazing tool or not.

    But its interesting how there’s a small group of patients that will always refuse the use of the genetic assay due to either their scientific ignorance & or their religious belief system somehow prohibits the use of the application of any high tech material to their lives in anyway. There are some patients I’ve encountered will refuse the use of the genetic assay out of pure fear of anything that even have the words genetic in it. As I’ve had at least 20 to 25 patients, “no way, your not cloning me, I’m not even going to trust you or anyone with my genetic material.

    They’ll say, “No one’s taking my genetic material out of me & then taking it to some other scientific lab facility some where, as soon as they leave our office. Thinking that were interested in utilizing their genetic material to do various unknown scientific experiments, including but not limited to making an army of clones, that are complete & identical exact reproductions of themselves???? I’ve had a handful of patients say, “I know what your doing with that genetic material , your going to sell it to a lesbian couple so they can ,artificial in utero-implantation to give them the baby they so desperately, & they are willing to pay any price to make that happen???

    *But I would appreciate it if you could share any detailed information with me regarding the companies you most use to do your genetic assay’s, or
    *list of any genetic assay companies you think highly of, & brief explanation of why you think the way you do about them.
    *a list of the genetic assay companies that give the most $$$ brakes to patients, or
    *just a list of the genetic assay companies you use the most regardless of your rationale’s, accompanied by a brief explanation on how much they charge your patient’s, & any other pertinent info you might have that you think would be helpful for me.

    I believe the use of the genetic assay should be mandatory for all patients in a perfect world, maybe that day
    is in the near horizon, hopefully, right?

    Its obvious in many patient care scenario’s how much using the genetic assay does save the patient.

    I think the genetic assay is more than worth its weight in gold using it especially in regards to its efficacy in patient care advancements within the areas of how much time is gained with the direct avoidance of lost efficacy medications for that patient, & to be armed with the scientific knowledge to not use medications that the genetic assay reports as being poor metabolizer medications, etc…, & only prescribing high yield, safe, efficient for the patient medications.

    The most respected advantage to using the genetic assay is how when using the genetic assay, it literally saves the patient in the way of how the assay results can indicate the medication classes/groups that will most likely be harmful or are indicated as having the potential for having a high risk for creating potential allergic or undesirable, inefficient effects or poor responses in any way for that particular patient, etc…,
    It just feels great to possess the knowledge to be capable to just purely refuse to prescribe any medications that are not advantageous for that patient, & the be able to avoid using any medicine the treatment process at all.

    So, yes, I’d love any info you can share in clinical applications or anything else related to the details of utilizing the genetic assay & how I can become more of a active utilizer of assay’s not are, right?

    If we can eliminate even a small fraction of the wasted time, & money & unnecessary suffering & risk to loss of life, etc.., that’s involved when the genetic assay’s not utilized in treatment. of course, I’m all for doing what ever I can to promote anything I can, including supporting the development of laws set up by the government supporting complete universal public access to genetic assay use with government assistance to pay for co-pays, etc….

    I found your perspective on the use & applications, advantages & disadvantages, of the slowly but surely coming into the main stream use of the genetic assay, very stimulating & comforting which has been the general response I’ve experienced whenever on the receiving end of your creative energies Laura.

    The truth is Laura, literally on day number ONE of your Psychopharmacology class at Penn, I was very impressed with & felt an almost instant connection & kinship with you as an individual, which was the first time anything of this nature happened to me during my entire time in Penn’s Family PMHNP program, this resulted in me experiencing a genuinely refreshing sense of relief generating an increased sense of belonging, “feeling that I’m now, for the 1st time, a true part of the Penn family/community.

    furthermore, after connecting with you I felt s though, I am now & will always be a significant member of the Penn Psych., NP family & community. This connection created in me a deeper sense of feeling like I was finally being accepted & valued for who I am constitutionally, resulting in having more freedom to confidently & spontaneously express & share my unique attributes & innate abilities & ideas in general, with more self confidence because I then felt was now a member of the Penn family/community & that I at that point had the resources & support to be creative & fearless in the process of taking more risk that had as their goals affecting greater universal change, stimulating new advances, & bringing about deeper & broader awareness’s within the entire profession of Psychiatry & maybe even attaining new application relating to treatment & detailed plans of care that centered on increased utilizations of increased incorporation of the role of the Family PMHNP into the future of Psychiatric Mental Health Treatment, plans.

    Yep, I can still remember that day vividly as you kicked off that semester, that day, which was actually held right around this same time of the summer in 2011, with a little friend you brought to some classes with you that semester, (you were accompanied & assisted by your current intern in training, or I believe some one jokingly called him your administrative assistant & bottle washer, who also happens to be your biological son, who by the way is adorable & was extremely respectful, quiet, & considerably well behaved, young son. I can’t remember exactly how old he would be today, but I’m guessing at this point in time he’s somewhere around 10 to 13 year’s old? Am I close? He really is a sweet boy.)

    During our 1st class you initially sharing with us your very casual & informal but still personal type of professional & Academic history, basic introducing yourself, as you then rolled into a brief but potent commentary on the state of the union of Psychiatry, (i.e.: Psychiatry’s present condition, how fewer& fewer medical students are deciding to go into Psychiatry as a specialty every year & how the Psychiatrist shortage has been at crises levels for many years now, & how this Psychiatrist shortage is not showing any signs of ever being resolved & how its been creating more opportunities for PMHNP’s every year, & what the reality of being a Psychiatric Clinical Care Provider truly is all about, (How we have exciting. That by its very definition the current state of affairs, ie: the Psychiatrist shortage crises, labels us as being, (i.e. – Family PMHNP’s,) the world of Psychiatry’s new pioneer’s, leader’s,& inventor’s, & to do all each one of us possible can to be as aware, & alert, as possible, to be alive & awake, then to maintain a state of consciousness where one would be considered to be, alive & awake to being, alive & awake, never making the mistake of being passive, permissive, ignorant & or – as we, (each one of us,), for an infinite degree & diverse variety of reasons we have been chosen, (very long ago,) to be the specific individual’s, placed, & installed in the advantageous positions, into one of the history of Psychiatry’s most , dramatically opportune, powerful, meaningful, influential, delicate, labile, venue defining, game changing, paramount, positions within the History of the, World of Psychiatry.

    As a result of the above mentioned information relating to the Psychiatrist shortage crises, we, PMHNP’s, are on forefront & directly within the Eye of the hurricane evolving rapidly & at times erratically developing, changing, expanding, deconstruction, redefining of the many incarnations of the Psychiatric & Mental Health Profession. Then you commented on the topic were at a unique time in the social evolutionary process & how you personally made the commitment to the entire class informing us all that today is just the beginning of a period of good fortune for PMHNP’s within the general history within Psychiatry over all & we must seize the moment, & maximize this great opportunity for us, making the most of this great experience, stating how we are all going this journey together, & how the world of a freshly graduated, brand spanking new Family PMHNP can be a frightening, intimidating, lonely & scary place, & how important it is to establish strong relationships with any of your Penn Professors possible to develop a long term, life long if possible mentor/mentee relationship, one that’s a balance of give & take.

    Laura you then stated how you were going to commit to continue to make yourself available to those you connected with, & after class you mentioned & acknowledged how you would be a support for me & I can contact you if any questions in the future. Which I have done so, as I’ve reached out to you at this point at least 10 different times since graduation in 2011, each time was directly relating to questions I had regarding complicated for me, medication prescribing questions, or complicated legal patient treatment issues or complex clinical scenarios, & you had a solid immediate response that was the correct solution once I actively applied your clinical advice, which I did 100% every time, applying your advice within )NE hour or less. Clinical Results of your advice has ben exceptionally correct, as your response each & every time had an outcome that was perfect, & I thank you for that Laura.
    Yes, your prescribing & patient treatment plans, that were your response to the Tx, Plan, Legal & Safety Patient Care question scenario’s I would call & present you with as I was actively in the office actively in treatment with the patient. But your response have been 100%, relating to the out comes after applied to the actual reality of the live patient scenario, & how responsive you’ve been been each & every time I’ve ever called on you, for clinical advice, & I thank you for this, Laura, really.

    I’ve maintained a consistent contact/communication with you & by doing so today I feel I always have someone in my corner that I can call on for clinical prescribing advice. You’ve proven yourself to be a highly responsible rapid responder every time I’ve ever called you, weather I call your cell, your office or weather I e-mail you. Your responses are always handled via a very, “STAT,” type manner.

    Well today, I happened to be navigating through your website, as I’ve been keeping an eye on your professional growth & development I’ve found that by doing so, the effects of your unintentional role modeling via, (just by, on a bimonthly bases reviewing your sophisticated, classy, & intelligently constructed & designed web page,) its apparent for anyone to observe consistently evolving web page continue to be one of my core sources of inspiration, where I gather much strength & self confidant, inspiring , encouraging, & stimulating I keep tabs on you professional development, noticing the patterns & common underlying themes. There are always clearly observable markers of your development via the fact that there’s consistently a few common threads of observable measurable data either on your web page, or relating to a conference your just spoke at or within an article you’ve written. Your career activity demonstrates your directions & clinical interest of the month & particular clinical path your currently interest in developing, as its will appear consistently & reveal itself some where, as it becomes a consistent theme, that’s traveling through your investigative learning process that you usually develop & eventually transform into some form of teaching/learning tool, & its always specifically focused on your area of interest into your next conference topic or web page targeted area of development. through a , forging onward marching momentum that your career to the next level, within a process you implemented in a manner that’s final product worked & pushed to its completion, evolved into a level that’s not only highly refined polished & done so on a professional level, but mat least 75% of the time, you discover a way to turn that project into pure profit, i.e.: it into a book that sells on-line for purchased by NP students, NP peers, Psych Patients, NP Professors, etc…,

    Your consistent theme I find interesting is how you always find a way to turn your ideas into CASH $$$!!!!

    This according to my opinion is a feature I seek to emulate within my life & Psych NP career/practice.

    I feel its just excellent being able to actually observe your process & see from a distance where you are in any given particular process as your ideas, & general attitudes become the most observable elements of your process.. As your activates are always grouped in organized groupings that have a identifiable Trend of thought, accompanied by creatively new & fresh ideas & presentation style.

    The underlying elements with each of your projects apparently are primarily composed the fact you have or wish to have an inexhaustible ability to perceive life & the situations surrounding your life & the life of your relationship with your husband & the details of the lives of your children. The messages in your stories consistently have as their endings endless themes where the answer is always wrapped up in a security blanket of standing up for the truth in this life a& everything else is foolishness, as you make it clear that only unconditional love is the answer, anything else is a just childishness, selfishness, & winds up becoming a highly costly & foolish mistake that eventually steals & corrosively extracts the joy from anyone related to that particular element of the story. In the end of you stories Laura, faithfulness in uncompromising love & its related journey of optimism until bust, no matter how difficult things get worn down, never let go, as while simultaneously giving at one end, the universe is taking good care of you even as you & your husband sleep. The moral to the story is, maintenance of the status of your Unconditional Love is not for a job for pussies. The cost is steep, & the rewards are priceless & the Benefits of Loving that special mate, on all levels, when ever the demand or request is even halfway requested, weather it be on all 3 levels, or just the body, or the body & the Spirit or in any configuration possible, The only correct answer is YES!!!! Just say yes to your mates request for your body, mind, & or spirit & once your called on to give, stick around for the 2nd wind experience as this could be where the true power is hiding itself. We always know the voice of our solitary Unconditional Love person/mate, as welcome so close at times its hard to see where they end & you begin, but again no one ever compline’s when in service of satisfying the call of the Unconditional Lover, as the end product of deep & quiet joy always wins out in the end, this is where true bliss & ancient Wisdom live,, as the Unconditional Lover the Unconditional Lovee, are identified as being ONE, as they gravitate towards the others central core. only desiring absolute ONENESS, Unconditionally all satisfaction will be yours & you will fill your mates cup to overflowing as he satisfies your in ways you still aren’t aware even have emotion & sensual receptors yet.

    Your stories are surrounded with family values but all your deepest secrete sensualities fantasy & desires are more than satisfied at home completely & Unconditionally as this is where the HEART on fire!!!!!!!!!!!!!!!!

    Your commitment to reflecting & becoming LIVING WALKING STORY LINE OF how unconditional love look’s IN THE MORNING BEFORE IT PUTS ON ITS MAKE UP & BEFORE ITS 2ND CUP OF EXPRESSO, Becomes the how to instruction manual booklet on how to Love your Partner Unconditionally, & reach Nirvana without really trying, all while laughing & having the most fun of your life time every day, As this is the place of your deepest state of excitement & all desires will spring up & become fully satisfied there, & they all will produce many more benefits as a result of your Living for the other & achieving the attainment of the great ONENESS.

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