Patient evaluation on intake

54-year-old man was admitted to the hospital for an MDE

Experienced his first MDE at age 30; since then has had periodic MDEs of two-to-three months duration almost every fall/winter

Psychiatric history

At age 37 had first inpatient psychiatric admission

Admitted again as an inpatient at ages 43 and 45

However, received no psychopharmacologic treatment other than sporadic St. John’s Wort for any of these episodes; he seemed to respond to this treatment plan

At age 47 was again hospitalized with an MDE

• – Characterized by depressed mood, psychomotor retardation, cognitive impairment, reduced drive, sleep problems, delusions of guilt, and suicidal thoughts

Social and personal history

Smokes cigarettes regularly, does not drink or use illicit drugs

Is single and does not have any children

Medical history

There are no current medical problems

Family history

He does not have any significant family history of psychiatric disorder

Medication history

At this admission to the inpatient unit, he was treated with prescription psychotropic medications for the first time

• – Mirtazapine (Remeron) 45 mg/d (NaSSA)

• – Risperidone (Risperdal) 3 mg/d (atypical antipsychotic)

• – Valproic acid (Depakene) 2000 mg/d (mood stabilizer)

• – Lorazepam (Ativan) 2.5 mg/d (BZ)

Experienced slight improvement but continued to have reduced drive, concentration deficits, psychomotor retardation, and suicidal thoughts

He developed EPS with risperidone treatment and was switched to another atypical antipsychotic, quetiapine (Seroquel) 400 mg/d, still with only partial MDD improvement

Mirtazapine (Remeron) was then switched to the SSRI sertraline (Zoloft) 200 mg/d and experienced some additional improvement in his mood but not in his concentration or fatigue

Next, received a series of 18 ECT sessions, while continuing only sertraline (Zoloft)

He obtained full remission status post-ECT and was discharged, with maintenance ECT and continuation of his SSRI recommended

Upon ECT service discharge, he was sent to outpatient psychiatry clinic for follow-up care

Patient evaluation on initial visit

Presents now, at age 54, with depressed mood, severe lack of drive, concentration deficits, memory problems, slow thinking, extreme fatigue, rigid facial expressions and gestures, and suicidal thoughts

His symptoms could be characterized in part as “psychiatric parkinsonism” with lack of drive and problems with concentration and memory, psychomotor retardation, slower thinking (bradyphrenia), and problems with facial expression and emotional gestures

• – These Parkinson’s-like symptoms are caused by his MDD

He is not currently taking any medications as he stopped sertraline (Zoloft) after inpatient care but before his visit to outpatient department

Question

Based on this patient’s history and current symptom profile, testing of which of the following genes might be useful?

SLC6A4 (SERT)

SLC6A4 and COMT

SLC6A4, COMT, and methylenetetrahydrafolate reductase (MTHFR)

SLC6A4, COMT, MTHFR, and calcium channel voltage-dependent L-type, alpha-1c subunit (CACNA1C)

SLC6A4, COMT, MTHFR, CACNA1C, and D2 receptor (DRD2)