Thread by @evolutionarypsy

Yesterday Dr. Ongur was pretty down on genetic testing used in psych/psychopharmacology. He focuses on bipolar and schizophrenia and I don’t see much use for testing in those patients. Dr. Seiner who works with refractory depression is more mixed…

…it sometimes gives you ideas and things to think about, and current research involves a *lot* of genetic testing, and patients really like it, but not ready for prime time. Dr. Ongur was also under the impression it costs $3000 but for most patients it’s $350 or less or covered

I’ve found it helpful in my practice for treatment refractory depressed (with some overlap with OCD) patients, but not as any kind of Rosetta Stone, just gives you some direction to add to the history and physical and can also affirm pt’s prior experiences with meds

I much prefer one panel over the other though.

Also Dr. Seiner has some interesting info about deep TMS, apparently there is a “theta burst” (high intensity, short bursts) protocol that is only 3 minutes (compared to 37 minutes for the “old” neurostar surface TMS). One site did 10 treatments a day and had very fast response

…FDA did approve theta burst machines but sounds like people are still figuring out how to use them

ECT tech is changing, “new” (2008) ultrabrief pulse, optimal time to depolarize a neuron is 0.1ms so giving a 0.3ms pulse should work just as well as longer with a lot fewer side effects of memory loss. In practice sometimes you have to switch to older techniques for remission

Ketamine IV (off label): NMDA receptor antagonism, AMPA-R, BDNF, inhibiting eEF2, IGF-1

Esketamine (FDA approved for refractory depression, requires clinic administration) s-enantiomer of ketamine with 3-4 times the affinity for NMDA-R

Esketamine has more side effects (it’s stronger, uneven administration compared to IV), ketamine may work a little better too, but esketamine much more convenient and accessible in the US. 2 years of maintenance data for esketamine was impressive.

Esketamine has an additional approval for MDD + acute suicidal ideation and the data for ketamine/esketamine does show a tendency for quick and lasting anti-suicidal ideation effect.