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I have order forms for genetic testing for antidepressant drugs. I've had them for at least three years. In fact, my forms are probably out of date because they update the forms regularly. Have I used one yet?

Nope.

Why not?

With a new patient complaint for depression, what appears on the schedule is "need antidepressant". My shortest visit is 25 minutes. The patient gets weighed, comes in the room and has a seat. I am usually standing, with my laptop on a mayo tray. The mayo tray is my dirt cheap standing desk that I can raise or lower. I often type some as we talk. Patients do not hate this, because at the end of the first one hour visit I printed the comprehensive note and tell them that their homework is to read it and make sure it is correct or tell me if I missed something. Typing may be distracting, but people feel heard when you hand them a two or three page mostly single spaced detailed note.

What is going on in their life? Why do they want an antidepressant?

Most people might be a little embarrassed or shy but are willing to tell the story. Usually they've got something messy going on, family, spouse, work, daughter on drugs, son in jail, family fight where they are not allowed to see the grandchildren. They are APPROPRIATELY in pain and depressed. They are in a situation that sucks, other people are involved, you can't actually fix other people.

About 15-20 minutes into the visit, I return to the topic of "need antidepressant". At that point, about half of people decide they don't need an antidepressant. Why? Their feelings are valid, normal, appropriate and they feel better about their present level of misery. We may discuss approaches to dealing with drug or alcohol addiction in a family member or spouse, or approaches to grief at the loss of a loved one, or grief about mom losing her memory. They may have talked themselves through to an idea about what to do next or about more firm boundaries. Tough love or saying no to unreasonable demands. I offer referral to a counselor, a grief group, a chronic illness group. I also follow up: I want them back in a week or two or four.

If they still want an antidepressant, that means that once they start it, it should not be weaned for six months. Are they on board with that? If there are side effects, we'd change it. They may have been on one before. Or if another family member is on one, well, that's a cheap genetics guess, right? If we are starting an antidepressant in May, I recommend waiting until spring to go off, because the winter here is pretty dark.

I did have a person request the genetic testing recently. I said that I would not do it right then. Why? The person had been tried on multiple antidepressants but was also using an addictive substance. Ok, they were addicted. Alcohol is a depressant and so are benzodiazepines. Want chemical help with withdrawal? Hey, let's work on the problem, not paste an antidepressant on it. There really is a lot of that. Anxiety is the one where I will not prescribe unless the person does a urine drug screen. Too much of the anxiety around here is methamphetamine related. If the person asks for benzodiazepines specifically for anxiety, that is a major red flag for alcohol or benzodiazepine or methamphetamines or polysubstance abuse. It's not that I would refuse an antidepressant to someone on drugs, but there are going to be short prescriptions and regular visits while we attempt to address the addiction problem. And I'm not adding a new addictive drug, that is, no benzodiazepines. I don't like "mother's little helper".