Case outcome: initial visit

No psychotherapy is offered outside core therapeutic skills, support, and education

No prescription is issued

She is deemed to be a low suicide risk and should be amenable to outpatient therapy

She is given advice about many medication and psychotherapy types to consider

The patient states that she wants you to “pick the treatment with the greatest likelihood of helping her in the short term and with the least chance of harming her”

In considering the potential future of psychopharmacology, the patient has a brain fMRI study completed. It is normal except that her right insula is noted to be hypoactive, the DLPFC is hypoactive, and the limbic system is hyperactive

In considering the potential future of psychopharmacology, the patient has her saliva sample/cheek swab analyzed

Like the previous two cases, red alleles in Table 30 are considered risky for depressive symptoms and drug responses

The patient is tested for these five genes and her results are shown in the table

Table 30.1. Genetic vulnerabilities in a patient with single-episode MDD

Pathway		Gene		Protein		Result
Serotonin		SLC6A4		SERT, also called serotonin reuptake pump, responsible for termination of serotonin action		S/S
Dopamine		DRD2		D2 receptor, target of antipsychotic drugs, theoretically overactive in psychosis and underactive in Parkinson’s disease		(Del/Del)
		COMT		Enzyme responsible for degradation of DA and NE		(Val/Val)
		Glutamate		CACNA1C		Voltage-gated channel for calcium		(A/A)
		Metabolism		MTHFR		Predominant enzyme that converts inactive folic acid to active folate		(T/T)

Question

Based on this patient’s symptoms, history, genetic testing, and fMRI results, which of the following would you prescribe?

SSRI

An atypical antipsychotic

Lithium

NDRI like bupropion

A noradrenergic TCA like desipramine

A mood stabilizer like lamotrigine

A folate-boosting product such as L-methylfolate

An SSRI

CBT

Attending physician’s mental notes: initial evaluation (continued)

Carrying potentially more risky alleles is problematic as it could diminish the usefulness of SSRI, SNRI, SSRI/5-HT receptor modulators, TCAs

• – Perhaps starting an MAOI as the first-line treatment will work

• – Perhaps sending the patient for ECT will work

• – Perhaps sending the patient for other neuromodulation will work, e.g., VNS, TMS

Having a hypofrontal right insular cortex is a novel finding

• – This endophenotypic finding might suggest a preferential response to psychotherapy, specifically CBT, and a future riddled with non-response to antidepressants

Case outcome: interim visit through 16 weeks

The patient is referred to an area CBT therapist and undergoes 12 weeks of manualized psychotherapy

She reports that most of the MDD symptoms resolved and feels she is still gradually improving