I remember working in a clinic affiliated with Brown University in Providence, Rhode Island, back in 2016. One day, a young Hispanic American client in her twenties came in for a follow-up visit. We were already on her third antidepressant trial, with very little or no response. This is not uncommon in psychiatry: despite proper dosage and duration, some clients simply don’t respond well to medications.
This visit was a little different. Her mother accompanied her and said, “None of your medications will ever work for her because I tried all of the same ones in my day, and they didn’t work for me either.”
I nodded in agreement, because I knew she wasn’t wrong. Treatment response often has a genetic basis. As a young physician who wanted to heal and fix things, I couldn’t help but feel a bit helpless in that moment, her words reflected something that psychiatry continues to grapple with: the limits of our predictive power.
As I considered her challenge, my client quietly pushed an envelope across the desk. “This is the result of the genetic test my last psychiatrist ordered,” she said.
I opened the results and found exactly what I suspected: the client was classified as a poor responder to most antidepressants, which aligned with what we were seeing clinically. She was an ultra-rapid metabolizer for many of the most prescribed medications. This meant she cleared the medications from her system too quickly to reach a therapeutic level.
The test also showed a small number of medications that had a better chance of being effective. I smiled and explained the results to both mother and daughter. It was validating for the family, and eye-opening for me.
A Helpful Tool, But Not a Magic Bullet
Although this was one of those rare “aha” moments where genetics offered a clear explanation, such results are not common. Clinical trials haven’t consistently shown dramatic improvements in outcomes based on pharmacogenetic testing. In fact, the number needed to treat (NNT) using genetic testing to achieve a better outcome can be as high as 17.
Learn more about NNT in psychiatry
This is comparable to the NNT for traditional antidepressants – still widely used despite that limitation.
In 2022, the American Psychiatric Association (APA) commissioned a panel to evaluate pharmacogenetic tests. The committee’s chair, Dr. Charles Nemeroff, stated at an APA meeting: “There is no evidence to support that commercial pharmacogenetic tests can improve patient care.”
Still, interest in the field continues to grow. For those unfamiliar with the basics of how these tests work, this Mayo Clinic overview provides a helpful introduction.
Using Genetic Testing Judiciously
Despite its limitations, I’ve encountered many clients over the years who are either poor responders or struggle with significant side effects. In such cases, I believe pharmacogenetic testing can still serve a role, but only when discussed openly and used thoughtfully.
When clients are curious, I explain the benefits and limitations honestly. I may order the test, but I caution against setting expectations too high. Testing might help guide us toward more tolerable or effective options, but it’s not a guaranteed solution.
If you’re receiving psychiatric care through our team at Bleuler Psychotherapy Center, you are always welcome to ask whether pharmacogenetic testing could be appropriate for your situation. (While we do not conduct genetic testing on-site, we can help guide the process if clinically indicated.)
Balancing Nature and Nurture in Mental Health Care
Ultimately, treating depression involves more than biology. It’s both nature and nurture – a combination of genetic factors, life experiences, and environmental influences.
Pharmacogenetic testing is not a replacement for sound clinical judgment. It’s another tool in the psychiatrist’s toolbox, one that may offer insights but shouldn’t overshadow the importance of careful listening, tailored care, and collaborative decision-making.
At Bleuler Psychotherapy Center, we emphasize client-centered treatment and shared decision-making. As our understanding of personalized medicine grows, so does our ability to support clients with empathy and precision. Science may still be catching up, but the potential is worth exploring – cautiously, responsibly, and always with the client’s well-being at the center of care.
