Pharmacogenetic testing can help those with mental health issues

By Tony Poland, LegalMatters Staff • With the ability to determine a patient’s potential response to medications based on their genetics, pharmacogenetic testing is a worthy investment that would quickly pay for itself, predicts Ontario disability insurance lawyer Courtney Mulqueen.

Mulqueen, principal lawyer of Mulqueen Disability Law Professional Corporation, says pharmacogenomics combines the sciences of genetics and the study of drugs to determine how people react to medication.

“Drugs interact with your body in different ways. Essentially, pharmacogenomics lets you know whether a medication is going to improve your condition or lead to side effects,” she tells LegalMattersCanada.ca. “For those dealing with a mental health issue, some medication can be potentially addictive or exacerbate their condition.”

The Centre for Addiction and Mental Health (CAMH) states pharmacogenetics is based on the assumption that each person may respond to medications in different ways based on their genetic profile. 

Customized genetic testing

“That can mean that patients given the same dosage of an anti-depressant medication may have very different levels of it in their bodies, or that some patients may be able to tolerate higher doses of a drug without debilitating side effects based on their genetics,” according to CAMH. “Through customized genetic testing via a cheek swab, pharmacogenetics can help select appropriate drugs and dosages for each patient with the fewest side effects in the shortest period of time.”

The Centre cited the case of one woman who turned to pharmacogenetics after not responding to a variety of medications for depression and anxiety. Genetic testing determined her body could tolerate and needed three times the standard dose of an anti-depressant drug. Within two months her mood improved dramatically, they reported.

“I have this very specific memory of one day just opening up my back door to let my dog out, just an ordinary thing, and I felt that feeling of happiness that starts in your gut for the first time in a really long time,” she told CAMH.

The Canadian Medical Association Journal notes that more than 35 antidepressant medications are available in Canada but only 40 per cent to 60 per cent of patients respond to the antidepressant initially prescribed and about 27 per cent report adverse effects.

Mulqueen says misconceptions about medications prevent people from trying a drug prescribed for their mental health issues.

May be concerns about medication

“There can be concerns it is potentially addictive or has side effects that could make their condition worse,” she says. “My understanding is that in some cases it can take several weeks before it is even known if the drug that has been prescribed will be effective. People may be told they need to push through that initial period and try and manage the side effects until they know whether the drug is going to be effective.

“I have heard some people say they were depressed and took medication but then became suicidal,” Mulqueen adds.

There are also concerns about the cost of medications, she says. If someone is off work on long-term disability (LTD) they may no longer be receiving benefits under a drug plan, Mulqueen says.

“Insurance policies differ. Some employers may provide coverage,” she explains. “In other cases, the employee may have to pay the premiums themselves. However, since they are on LTD, they will only receive a percentage of their salary.”

Mulqueen says prescription medication can be pricey and some people find the cost prohibitive. 

“If you have to take different types of medication that are changing constantly to find something that works, it can get extremely expensive,” she says. “Some people are less inclined to pay for something if they don’t know if it is necessarily going to work.”

The cost of getting better can then become beyond the reach of those struggling to pay their bills while on disability, Mulqueen says.

‘How do they afford treatment?’

“I have always found it troubling that people on LTD may not be able to afford treatment because they have little money coming in or their benefits have been terminated or denied,” she says. “How do they afford treatment? And if they can’t afford to pay for expensive prescriptions because they are no longer covered under a drug plan, the insurance companies can claim that person is not receiving the appropriate treatment and deny their disability benefits.”

There can also be a stigma associated with taking drugs for a mental health issue, Mulqueen notes.

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“Many people don’t want to take what is being prescribed. They may have anxiety about taking medication for whatever reason and want to try other treatments first,” she says. “However, I believe that having some science that says ‘This is the one that will likely work for you’ will go a long way in terms of destigmatizing the concept of taking medication for a mental health illness and alleviating some concerns.

“If you have an indication of how you will react to the medication, you are more likely to feel much more secure,” Mulqueen adds, “It can give you more confidence to try to push through the initial period even if there are some side effects.”

Like anything else there is a price to pay with pharmacogenomics, she says. Some estimates peg the cost at $300 to $2,500.

Currently not covered by public health plans

“Pharmacogenetic tests are currently not covered by public health plans in Canada,” says Dr. James Kennedy, head of the Tanenbaum Centre for Pharmacogenetics at CAMH. “The average healthcare savings following pharmacogenetic testing, per depression patient, are over $3,000. If half of the 1.6 million Canadians with depression could get the test, savings could total $2.4 billion per year. Patient suffering during trial-and-error prescribing would be reduced.”

Mulqueen says those on disability might find it difficult to pay for the tests but picking up the bill would likely benefit insurance providers in the long run.

“For insurers and, obviously, the person on disability, returning to work as quickly as possible is the goal,” she says. “Even if it costs $2,500 for a test, think about what insurance companies are paying each month to people on long-term disability.

“Finding the right medication quickly will help the claimant get better faster so they return to their job months sooner,” Mulqueen adds. “It is a very small price to get huge cost savings.” 

Privacy and how the results are used present a concern if insurer companies decide to pay for the tests, she says.

“Whenever there is something new like this my concern is balancing the potential benefits with people’s right to privacy,” says Mulqueen. “There is a risk that the information gathered from genetic testing could be used to deny insurance claims or simply cut people off.”

People may refuse to take a genetic test because they are not comfortable sharing the results with the insurer that paid for them, she says.

‘Results should be only going to the treating physician’

“The risk of that is the insurer can say you are not complying with treatment recommendations or not doing everything possible to mitigate or improve your circumstances so your benefits are being terminated,” Mulqueen says. “Practically speaking, these results should be only going to the treating physician who is deciding the treatment.”

She says it is important to remember that there is no one-size-fits-all solution to treating mental health illness.

“Pharmacogenomics may seem like the ideal quick fix,” says Mulqueen. “However, any sort of mandated testing or treatment that is dictated by an insurer is always a concern to me. I believe it should be evaluated on a case-by-case basis, particularly when it comes to mental health because this issue is so complex.

“Ultimately, the treating physician or specialists such as psychiatrists should be the ones recommending testing and the resulting treatment.” 

Still, the benefits of genetic testing to treat mental health issues outweigh the concerns, she says.

“Those concerns can be addressed either by legislation or in insurance regulation,” says Mulqueen. “Pharmacogenomics can help people get better sooner, which should be everyone’s goal.”