Catching Up with Dr. Sagar Parikh: Pharmacogenomics, College and Mental Health, and Much More!
Introduction
Happy New Year! This month we speak with Dr. Sagar Parikh, the John F. Greden Professor of Depression and Clinical Neuroscience at the University of Michigan as well as Medical Director of the National Network of Depression Centers. Dr. Parikh is a former primary care physician and long-time psychiatrist with extensive clinical and research experience across the US and Canada. We discuss the land mines to avoid in applying genetic tests in the context of antidepressant choice, pearls regarding the mental health crisis on college campuses, current key evidence on use of pharmacogenomic results to help tailor medication strategies, a recent publication he found to be critical in his own practice, and his thoughts on where we will be with pharmacogenomic treatment options in 10 years.
I spoke last month with Dr. Henry Nasrallah on the biggest challenge of treating (BPD) in 2022; most frustrating treatment issue; most promising and useful recent research in schizophrenia treatment; challenges in faculty development and mentorship; and most rewarding aspect of the job. If you missed it, click here!
Don’t Miss!
June 8-10, 2023; Marriott Marquis Chicago, Chicago, Illinois
· Full 2.5-day meeting with interactive presentations, discussion and networking opportunities, and in addition to the scientific sessions, there will be informative Bonus Presentations and an exciting Keynote speaker.
· Explore the latest advances in the treatment and management of Major Depressive Disorder, ADHD, Schizophrenia, and Bipolar Disorder, plus other clinically relevant hot topics: healthcare resilience, updates and innovations in fast-acting antidepressants, newly emerging digital therapeutics and updates in neuropsychiatry.
· Internationally renowned faculty present the most up-to-date, clinically relevant information to assist you in the treatment of your patients.
· Register here: https://events.medscapelive.org/ereg/newreg.php?eventid=720766
Keep up to date as well on current research with this month’s Psych Resource section, featuring articles from Clinical Psychiatry News, Current Psychiatry, MDEdge Psychiatry, New England Journal of Medicine, and JAMA Psychiatry—check them out below!
Thank you to Dr. Parikh for this month’s interview and a Suggested Reading as well! Please contact me at colleen@cmhadvisors.com with any comments. –Colleen Hutchinson
Interview
Dr. Parikh is a former primary care physician and long-time psychiatrist with extensive clinical and research experience across the US and Canada, and currently is the John F. Greden Professor of Depression and Clinical Neuroscience at the University of Michigan as well as Medical Director of the National Network of Depression Centers.
You recently commented, “Genetic tests are real, but applying them in the context of antidepressant choice is tricky.” What are the land mines for clinicians to avoid?
Dr. Parikh: About 20% of people may have genetic factors which influence their response to antidepressants. To use pharmacogenomic tests wisely, pick people who either have not done well with at least two antidepressants, or who have a history of marked side effects to medications in general, which may be a clue that their genetics are different and thus create more side-effect problems.
How would you summarize the existing key evidence on use of pharmacogenomic results to help tailor medication strategies?
Dr. Parikh: Several meta-analyses have confirmed that using pharmacogenomic tests can help patients achieve remission in depression, but these are usually on patients who have already demonstrated a lack of response to at least one antidepressant. Pharmacogenomic tests can also be critical when prescribing medications like lamotrigine or carbamazepine, both of which can provoke a variety of drug hypersensitivity reactions, such as Stevens-Johnson syndrome (a severe rash), which is strongly linked to the presence of a particular HLA variant.
In 2022, you published “Patients' recovery and non-recovery narratives after intravenous ketamine for treatment-resistant depression” in the Journal of Affective Disorders. This paper is among the first to look at qualitative outcomes from receiving IV ketamine for depression, years after the treatment. It showed that apart from the excellent immediate response to IV ketamine for depression, that many patients who didn’t benefit initially eventually did have some benefit and, more importantly, found the treatment to be an important step as part of their depression journey.
Are there any recent publications you have found to be critical in your own practice?
Dr. Parikh: In December 2022, JAMA published “Anxiety Disorders: A Review,” a relatively short but reasonably comprehensive review of all treatments for anxiety. It included many key concepts and definitions as well as details of the evidence for various treatments. I find it very accessible. (Szuhany KL, Simon NM. Anxiety Disorders: A Review. JAMA. 2022;328(24):2431-2445. doi:10.1001/jama.2022.22744)
Where do you see pharmacogenomic treatment options in 10 years?
Dr. Parikh: In 10 years, everyone will receive pharmacogenomic testing BEFORE starting psychiatric medications, because the tests will be relatively inexpensive and also will be very helpful in avoiding medications that might not work well with a particular patient. It will be like getting strep testing for a sore throat—a standard of care. And remember—the genes don’t change, so doing the test once is good for advice for years as well as across medication classes, not just psychiatric medications.
You published “Depression on College Campuses Conference: Addressing an Evolving Crisis” this past year. What are the main takeaways on this topic that are important for clinicians to be aware of?
Dr. Parikh: Everywhere, we hear about the mental health crisis on college campuses, both for students and increasingly for faculty and staff. We wrote this paper to understand key aspects of the evolving crisis, as captured by the themes and key messages emerging from the main national conference devoted to this problem, the Depression on College Campus Conference held annually at the University of Michigan for nearly 20 years. Sustained anti-stigma campaigns provided great benefit initially; brief and flexible treatments are what students want; and incorporating wellness into routine course planning and faculty activities are also critical steps.
KOL Suggested Reading
Article: Long-Term Cannabis Use and Cognitive Reserves and Hippocampal Volume in Midlife
Dr. Parikh: In this era of cannabis legalization and ever-increasing cannabis potency, it is “old-fashioned” to advise against cannabis. This paper by Meier MH, Caspi A, Knodt AR, et al, from the American Journal of Psychiatry followed regular cannabis users for decades and demonstrated both impaired cognition and hippocampal damage from cannabis use. So I am far more vociferous in telling patients—If you want to end up stupid, keep using cannabis daily. I appreciate that occasional cannabis is innocuous, and cannabis does have some role in certain conditions, at least for short-term use, but the widespread acceptance of it as almost a daily routine is clearly harmful in the long run.
Psychiatry Resource Section
JAMA Psychiatry Viewpoint: Value-Based Payment and Behavioral Health
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2798227
MDEdge Clinical Psychiatry News Article: More evidence suicidal thoughts, behaviors are genetically based
New England Journal of Medicine Editorial: Moving the Needle on Alzheimer’s Disease with an Anti-Oligomer Antibody
https://www.nejm.org/doi/full/10.1056/NEJMe2214981
Current Psychiatry Article: Positive psychotherapy: Core principles
https://www.mdedge.com/psychiatry/article/260349/depression/positive-psychotherapy-core-principles
APA Learning Center: Evidence Based Treatment For PTSD: Where Are We and Where Do We Need to Go into the Future—Credits CME: 0.75, Participation: 0.75
https://education.psychiatry.org/diweb/catalog/item?id=6734698
Medscape CME & Education: Clinical Connect: Current Perspectives in Mood Disorders—Credit CME/CE 1.75
https://www.medscape.org/viewarticle/985885
Clinical Psychiatry News Article: Is the FDA serotonin syndrome warning unnecessary?