Personalized Medicine (original) (raw)

The Massachusetts General Hospital Guide to Depression

Susan is a 65-year-old married Caucasian woman with a long history of depression, anxiety, type 2 diabetes, and chronic pain due to diabetic neuropathy. She is postmenopausal. She presents for treatment of her depression, which started about 10 years ago after she retired from a busy position as CEO of a small local company. Her depression worsened over the past 2 years once she began to develop complications from her diabetes, in particular a severe neuropathy that limited her ability to be physically active. One of her major complaints is trouble falling asleep and staying asleep, which she attributes to the burning pain in her legs. She also endorses hopelessness that she will ever get better, wishing she were dead, decreased attention, and decreased motivation. Her husband, Bill, notes that Susan is "sensitive to medications" often needing to stop antidepressants because of side effects before reaching a therapeutic dose. Her past medication trials have included multiple selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). She has never been on a tricyclic antidepressant and currently takes only lorazepam 0.5 mg at night for sleep. After a discussion of pharmacological and nonpharmacological treatments for comorbid depression, sleep disorder, and chronic pain, Susan is wary of starting a new medication since she has had such difficulty tolerating antidepressant medications in the past. She is interested in alternative therapies. The provider remembers reading about a study that recommended genotyping for patients over 65 years old starting nortriptyline and recommends a commercial kit offering genotyping of patients starting an antidepressant after failing multiple trials in the past. After discussing the pros and cons of genotyping with Susan, she decides to obtain the kit, which is partially covered by her insurance. While waiting for the results, Susan is referred to a holistic pain clinic where she can begin physical rehabilitation and cognitive behavioral therapy (CBT) for pain and sleep, in the hopes of becoming more active. Her genotype and recommended dosing for nortriptyline come back after a month. She is listed as a "poor metabolizer," which could explain why she has had so many side effects from antidepressants. She is started at a very low dose of nortriptyline. Two months later, Susan returns, with substantial improvement in her depression, better sleep, and less pain. She is also more active after rehabilitation. She is tolerating the nortriptyline well, with only some dry mouth as a side effect.