Pharmacogenomics in practice: a case report of personalized inpatient psychiatric care

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From: Pharmacogenomics(Vol. 16, Issue 5)
Publisher: Future Medicine Ltd.
Document Type: Clinical report
Length: 4,291 words
Lexile Measure: 1530L

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Author(s): Alok Madan [*] aff1 aff2 , Cory R Walker aff1 aff2 , Benjamin Weinstein aff1 aff2 , J Christopher Fowler aff1 aff2

Keywords:

inpatient psychiatry; pharmacogenomics; psychosis; psychotropic medications

Case presentation

History of presenting illness

The patient is a 33-year-old single Caucasian male with previous psychiatric diagnosis of attention deficit/hyperactivity disorder, depression and anxiety admitted for comprehensive psychiatric assessment in the context of failed multiple previous medication trials, inpatient treatment and significant disability. He was diagnosed with attention deficit/hyperactivity disorder when he was 12 years old, was first prescribed antidepressants at age 15 and was psychiatrically hospitalized at 16 years for suicidal ideation and self-harm. He reported that at higher doses of stimulants he became psychotic. At admission he was no longer taking stimulants; however, mild psychotic symptoms continued to persist. He had ideas of reference which interfered in his social life and work opportunities due to suspicions that he was being tracked and discerning patterns that led him to believe others were conspiring against him. He experienced anxiety about leaving his home and consequently went grocery shopping at 6 am to avoid seeing other people. He attributed some of his social avoidance to embarrassment associated with his lack of progress in life. However, he also acknowledged finding others annoying.

At admission, his depression was significant including anhedonia, sadness, isolation, guilt, fatigue, hopelessness, intrusive thoughts, ruminations, a recent 20 pound weight gain (which the patient attributed to a recent decrease in physical activity, i.e., staying in bed much of the day) and poor concentration. There was no history of mania. Patient described himself as being anxious and feeling trapped. He denied any history of trauma. He reported intermittently engaging in psychotherapy but nothing intensive. Substance abuse assessment revealed the patient had previous use of marijuana - multiple times daily for several years. He reportedly stopped using marijuana three years prior to the index hospitalization secondary to it 'not working' anymore. The patient met criteria for cannabis dependence in full sustained remission. The patient had a history of binge-type drinking, which included drinking 7-10 beers in one sitting on the weekends. The six months prior to admission, the patient had engaged in drinking 1-2 beers 2-3 times per week. He did meet a criterion for alcohol abuse due to driving after binge episodes.

Past medication trials included: fluoxetine up to 60 mg (discontinued because caused tiredness); duloxetine hcl unknown dose which helped him feel 'great' (discontinued for unknown reasons); risperidone up to 2 mg (discontinued because caused sedation); bupropion (unknown does, unknown effect and unknown reason for discontinuing); sertraline 100 mg may have been potentially helpful (discontinued for unknown reasons); possibly buspirone hcl (unknown dose, unknown effect and unknown reason for discontinuing); and amphetamine/dextroamphetamine 30 mg was helpful but at 60 mg associated with psychotic symptoms. Of note, the treatment team at the study hospital was not responsible for any historical medication trials. This was their first exposure to this patient, and all historical medications and responses were based on patient self-report of...

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Gale Document Number: GALE|A411315290