Primary care and mental health providers’ perceptions of implementation of pharmacogenetics testing for depression prescribing

Abstract

Background Pharmacogenetic testing (PGx) has the potential to improve the quality of psychiatric prescribing by considering patients’ genetic profile. However, there is limited scientific evidence supporting its efficacy or guiding its implementation. The Precision Medicine in Mental Health (PRIME) Care study is a pragmatic randomized controlled trial evaluating the effectiveness of a specific commercially-available pharmacogenetic (PGx) test to inform antidepressant prescribing at 22 sites across the U.S. Simultaneous implementation science methods using the Consolidated Framework for Implementation Research (CFIR) are integrated throughout the trial to identify contextual factors likely to be important in future implementation of PGx. The goal of this study was to understand providers’ perceptions of PGx for antidepressant prescribing and implications for future implementation. Methods Qualitative focus groups (n = 10) were conducted at the beginning of the trial with Primary Care and Mental Health providers (n = 31) from six PRIME Care sites. Focus groups were audio-recorded and transcribed and data were analyzed using rapid analytic procedures organized by CFIR domains. Results Analysis revealed themes in the CFIR Intervention Characteristics domain constructs of Evidence, Relative Advantage, Adaptability, Trialability, Complexity, and Design that are important for understanding providers’ perceptions of PGx testing. Results indicate: 1) providers had limited experience and knowledge of PGx testing and its evidence base, particularly for psychiatric medications; 2) providers were hopeful that PGx could increase their precision in depression prescribing and improve patient engagement, but were uncertain about how results would influence treatment; 3) providers were concerned about potential misinterpretation of PGx results and how to incorporate testing into their workflow; 4) primary care providers were less familiar and comfortable with application of PGx testing to antidepressant prescribing than psychiatric providers. Conclusions Provider perceptions may serve as facilitators or barriers to implementation of PGx for psychiatric prescribing. Incorporating implementation science into the conduct of the RCT adds value by uncovering factors to be addressed in preparing for future implementation, should the practice prove effective. Trial registration ClinicalTrials.gov ID: NCT03170362; Registered 31 May 2017

What Are the Barriers and Enablers to the Implementation of Pharmacogenetic Testing in Mental Health Care Settings?

“…Of the included studies, seven were conducted in the United States ( Shishko et al, 2015 ; Thompson et al, 2015 ; Goodspeed et al, 2019 ; Liko et al, 2020 ; McCarthy et al, 2020 ; Vest et al, 2020 ; Kastrinos et al, 2021 ), with the remaining studies being conducted in Canada ( Walden et al, 2015 ), France ( Laplace et al, 2021 ), Singapore ( Chan et al, 2017 ), and New Zealand ( Dunbar et al, 2012 ). Three of the studies gathered patient perspectives about PGx ( Liko et al, 2020 ; McCarthy et al, 2020 ; Kastrinos et al, 2021 ), while the remaining studies gathered HCPs viewpoints on PGx ( Dunbar et al, 2012 ; Shishko et al, 2015 ; Thompson et al, 2015 ; Walden et al, 2015 ; Chan et al, 2017 ; Goodspeed et al, 2019 ; McCarthy et al, 2020 ; Vest et al, 2020 ; Laplace et al, 2021 ).…”

“…Of the included studies, seven were conducted in the United States ( Shishko et al, 2015 ; Thompson et al, 2015 ; Goodspeed et al, 2019 ; Liko et al, 2020 ; McCarthy et al, 2020 ; Vest et al, 2020 ; Kastrinos et al, 2021 ), with the remaining studies being conducted in Canada ( Walden et al, 2015 ), France ( Laplace et al, 2021 ), Singapore ( Chan et al, 2017 ), and New Zealand ( Dunbar et al, 2012 ). Three of the studies gathered patient perspectives about PGx ( Liko et al, 2020 ; McCarthy et al, 2020 ; Kastrinos et al, 2021 ), while the remaining studies gathered HCPs viewpoints on PGx ( Dunbar et al, 2012 ; Shishko et al, 2015 ; Thompson et al, 2015 ; Walden et al, 2015 ; Chan et al, 2017 ; Goodspeed et al, 2019 ; McCarthy et al, 2020 ; Vest et al, 2020 ; Laplace et al, 2021 ). Data collection methods varied with some studies opting for focus groups ( Goodspeed et al, 2019 ; Vest et al, 2020 ), while one conducted semi-structured interviews ( Liko et al, 2020 ) and other studies collected data using a survey ( Shishko et al, 2015 ; Thompson et al, 2015 ; Walden et al, 2015 ; Kastrinos et al, 2021 ) or questionnaire ( Dunbar et al, 2012 ; Chan et al, 2017 ; McCarthy et al, 2020 ; Laplace et al, 2021 ).…”

“…Three of the studies gathered patient perspectives about PGx ( Liko et al, 2020 ; McCarthy et al, 2020 ; Kastrinos et al, 2021 ), while the remaining studies gathered HCPs viewpoints on PGx ( Dunbar et al, 2012 ; Shishko et al, 2015 ; Thompson et al, 2015 ; Walden et al, 2015 ; Chan et al, 2017 ; Goodspeed et al, 2019 ; McCarthy et al, 2020 ; Vest et al, 2020 ; Laplace et al, 2021 ). Data collection methods varied with some studies opting for focus groups ( Goodspeed et al, 2019 ; Vest et al, 2020 ), while one conducted semi-structured interviews ( Liko et al, 2020 ) and other studies collected data using a survey ( Shishko et al, 2015 ; Thompson et al, 2015 ; Walden et al, 2015 ; Kastrinos et al, 2021 ) or questionnaire ( Dunbar et al, 2012 ; Chan et al, 2017 ; McCarthy et al, 2020 ; Laplace et al, 2021 ). The study setting varied also, with the majority of studies being conducted in secondary care settings ( Dunbar et al, 2012 ; Shishko et al, 2015 ; Thompson et al, 2015 ; Walden et al, 2015 ; Chan et al, 2017 ; Goodspeed et al, 2019 ; Liko et al, 2020 ; McCarthy et al, 2020 ), while one was carried out in both primary and secondary care settings ( Vest et al, 2020 ), and two studies were unspecified ( Kastrinos et al, 2021 ; Laplace et al, 2021 ).…”

Pharmacogenomics in the era of next generation sequencing – from byte to bedside

“…If a specialist believes the primary care physician should act on the pharmacogenetic results, and vice versa, appropriate action could become lost in translation, with potentially detrimental outcomes for patients. A recent study reported that healthcare providers report limited knowledge and experience with pharmacogenetic testing and are concerned about the potential misinterpretation of results when integrating pharmacogenetic testing into their workflow 182 . However, they appeared hopeful that pharmacogenetically guided treatment could improve treatment outcomes.…”

Pharmacogenetic-Guided Antidepressant Selection as an Opportunity for Interprofessional Collaboration: A Case Report

“…However, despite the already compiling evidence, especially for SSRIs and tricyclic antidepressants [ 6 , 7 ], pharmacogenetic (PGx) analysis is not yet routinely applied when prescribing these antidepressants. Underlying reasons are diverse and barriers to the implementation of PGx services include fragmentary evidence from prospective clinical trials, limited reimbursement from basic health insurance (which, in Switzerland, is currently only possible if clinical pharmacologists prescribe the specific testing), missing established procedures and, in general, a lack of education and experience among mental health care providers [ 12 , 13 ]. An approach to overcome some of these barriers, to efficiently enable individualized PGx information processing for antidepressant selection and dosing, might involve the interprofessional collaboration of psychiatrists and clinical pharmacists.…”