Pharmacogenomic Testing in Psychiatry: Ready for Primetime?

Pharmacogenomic testing in clinical psychiatry has grown at an accelerated pace in the last few years and is poised to grow even further. Despite robust evidence lacking regarding efficacy in clinical use, there continues to be growing interest to use it to make treatment decisions. We intend this article to be a primer for a clinician wishing to understand the biological bases, evidence for benefits, and pitfalls in clinical decision-making.

Quest for timely detection and treatment of women with depression.

Background: Women are at risk for a wide range of depressive and anxiety disorders and particularly for mood disorders associated with their menstrual cycle, with seasonality, and during the menopausal transition.

Objective: To review the presentation of depression, the importance of timely and effective treatment, and some of the research surrounding increased prevalence of depression in women, and the times and conditions--such as the perimenopausal transition, pregnancy, postpartum period, and comorbidities--of this increased risk in women.

Summary: Dynamic interactions of both biological and environmental factors contribute to the development of major depression.

Role of stressful life events and menopausal stage in wellbeing and health.

Stress plays an essential role in the development, continuation and exacerbation of mood problems throughout a woman's life. It exacerbates somatic symptoms of menopause, increasing the risk of recurrence of mood disorders, as well as of a mood disorder de novo throughout the lifespan and specifically in the menopausal transition. Chronic stress affects the hypothalamic-pituitary axis, hypothalamic-pituitary-ovarian axis, the proinflammatory cytokines and cardiovascular risk.

Neurobehavioral impact of menopause on mood.

The menopausal transition is a time of risk for mood change ranging from distress to minor depression to major depressive disorder in a vulnerable subpopulation of women in the menopausal transition. Somatic symptoms have been implicated as a risk factor for mood problems, although these mood problems have also been shown to occur independently of somatic symptoms. Mood problems have been found to increase in those with a history of mood continuum disorders, but can also occur de novo as a consequence of the transition.

Collaborative depression care, screening, diagnosis and specificity of depression treatments in the primary care setting.

The identification, referral and specific treatment of midlife patients in primary care who are distressed by mood, anxiety, sleep and stress-related symptoms, with or without clinically confirmed menopausal symptoms, are confounded by many structural issues in the delivery of women's healthcare. Diagnosis, care delivery, affordability of treatment, time commitment for treatment, treatment specificity for a particular patient's symptoms and patient receptiveness to diagnosis and treatment all play roles in the successful amelioration of symptoms in this patient population. The value of screening for depression in primary care, the limitations of commonly used screening instruments relative to culture and ethnicity, and which clinical care systems make best use of diagnostic screening programs will be discussed in the context of the midlife woman.

Women, anxiety and mood: a review of nomenclature, comorbidity and epidemiology.

Women experience a high prevalence of mood and anxiety disorders, and comorbidity of mood and anxiety disorders is highly prevalent. Both mood and anxiety disorders disturb sleep, attention and, thereby, cognitive function. They result in a variety of somatic complaints.

Nomenclature and endocrinology of menopause and perimenopause.

The early and late perimenopausal transition is characterized by changing cycle length as well as by menopausal symptoms in some women, including increasing hot flashes and night sweats. Breast tenderness decreases as women enter the late transition. This review, as part of the clinical reviews on the menopausal woman with comorbidity, covers the endocrine phenomena of perimenopause, terminology and the observed clinical characteristics of the transition.

Series overview and introduction.

Studies and treatments for the symptomatic menopausal woman have been reviewed elsewhere. The aim of this clinical review series is to examine the evidence for the diagnosis and treatment of the woman who presents with distressing symptoms that she attributes to menopause, whose actual etiology may be a psychiatric disorder, a pre- or co-existing problem such as sleep or cognitive problems, or a dynamic interaction among one of these and a symptomatic menopause. This series of articles will review new research on somatic symptoms of depression, the depression continuum and its impact on morbidity and functioning, treatment issues related to remission of depression, cognitive decline or impairment secondary to a mood disorder, sleep problems in women and their impact on well-being and functioning, and attention and working memory problems in women.

Impact of clinician and patient attitudes on clinical decision making for the symptomatic menopausal woman with or without comorbidity.

Culture, individual health beliefs and distressing symptoms frequently determine women's perceptions of their menopausal transitions. Women's perceptions of mental health problems and the acceptability of different interventions greatly affect if and what a woman is willing to try as a treatment option and whether or not she will accept the possibility that her menopausal symptoms represent a comorbidity with a diagnosis, such as depression or anxiety. These perceptions have a significant impact on women's choices with regard to health practices, as well as on whether or not they will seek out medical care for their distressing symptom(s).

Role of psychiatric comorbidity on cognitive function during and after the menopausal transition.

While cognitive complaints are common during the menopausal transition, measurable cognitive decline occurs infrequently, often due to underlying psychiatric or neurological disease. To clarify the nature, etiology and evidence for cognitive and memory complaints during midlife, at the time of the menopausal transition, we have critically reviewed the evidence for impairments in memory and cognition associated with common comorbid psychiatric conditions, focusing on mood and anxiety disorders, attention-deficit disorder, prolonged stress and decreased quantity or quality of sleep. Both the evidence for a primary effect of menopause on cognitive function and contrarily the effect of cognition on the menopausal transition are examined.

Arthralgias, bodily aches and pains and somatic complaints in midlife women: etiology, pathophysiology and differential diagnosis.

Somatic symptoms characterized by arthralgias, bodily aches and pains, musculoskeletal pain and joint pain have been investigated in a number of menopause and depression studies. Although depression is one of the most common causes of bodily aches and pains, and arthralgias, these same symptoms are also commonly associated with a natural menopause, surgical menopause and menopause induced by chemotherapy in breast cancer treatment. Somatic symptoms in the absence of definitive medical diagnoses result in these patients receiving various diagnoses and labels--'medically unexplained symptoms', 'worried well', as well as various Diagnostic and Statistical Manual of Mental Disorders (4th edition) somatoform diagnoses.

Assessment and treatment for insomnia and fatigue in the symptomatic menopausal woman with psychiatric comorbidity.

Studies and treatments for the symptomatic menopausal woman with sleep complaints have been reviewed elsewhere. This article, as part of the clinical review series on the comorbid symptomatic menopausal woman, aims to examine the evidence for diagnosis and treatment of women who present with distressing sleep symptoms that they attribute to menopause. The etiology of these symptoms may be a psychiatric disorder, a pre- or co-existing problem with sleep, or a dynamic interaction among one of these and/or a symptomatic menopause.

Treatment of vasomotor symptoms in the menopausal transition and postmenopausally: psychiatric comorbidity.

This article aims to educate the nonpsychiatric as well as the psychiatric clinician on the impact of vasomotor symptoms in women with comorbid psychiatric problems and the challenges of treating vasomotor symptoms in these women. The pathophysiology, prevalence and common risk factors associated with disturbing hot flashes in the menopausal transition are reviewed. Hormonal, nonhormonal and behavioral treatment options of vasomotor symptoms for these women are discussed.

A symptomatic approach to understanding women's health experiences: a cross-cultural comparison of women aged 20 to 70 years.

Objectives: To determine patterns of symptoms across age groups, identify symptom groups associated with ovarian hormonal depletion or other variables, and develop a prediction model for each symptom.

Design: This was a cross-sectional survey of 4,517 women ages 20 to 70 years recruited from market research panels in the United States, United Kingdom, Germany, France, and Italy using a self-report questionnaire that included general health information and a checklist of 36 symptoms. Stepwise regression was used to determine for each symptom how prevalence varied with age, indicators of menopausal hormonal changes, and the effects of other explanatory variables, including body mass index, morbidity, and country.

Estrogen and androgen hormone therapy and well-being in surgically postmenopausal women.

Background: Women undergoing surgical menopause experience an abrupt drop in gonadal hormones and are more likely to have symptoms that negatively impact well-being, including hot flashes, sexual dysfunction, psychological problems, and testosterone deficiency. The purpose of this review was to examine the effects of hormone therapies on well-being among surgically menopausal women.

Methods: Studies were retrieved using both Cochrane and PubMed searches.

Practical aspects in the management of vaginal atrophy and sexual dysfunction in perimenopausal and postmenopausal women.

Introduction: The decline in circulating estrogen levels in peri- and postmenopause has a wide range of physiological effects, including atrophy of tissues in the urogenital tract. Vaginal atrophy is an important contributor to postmenopausal sexual dysfunction.

Aim: To provide a framework for clinical evaluation and clinical management of sexual dysfunction secondary to vaginal atrophy.

The effects of postmenopausal hormone therapies on female sexual functioning: a review of double-blind, randomized controlled trials.

Double-blind randomized controlled trials of estrogen and/or testosterone on sexual function among natural or surgical menopause in women are reviewed. Power, validity, hormone levels, and methodological issues were examined. Certain types of estrogen therapy were associated with increased frequency of sexual activity, enjoyment, desire, arousal, fantasies, satisfaction, vaginal lubrication, and feeling physically attractive, and reduced dyspareunia, vaginal dryness, and sexual problems.