I became a psychiatrist in February 2005. The story of one of my first patients has shaped my career.
The patient was a gentleman in his 40’s who had suffered two years of crippling depression. He had no history of childhood maltreatment, nor history of excessive life stress, substance misuse, or physical illness to explain his plight. His local doctor escalated venlafaxine (an antidepressant) to 225mg – the maximum recommend dose. But his depression only partially responded. Earlier trials of other antidepressants failed. Psychological counselling failed. By the time he was referred to me, he had lost his job, his marriage, and had attempted suicide.
Psychiatrists have license to exceed maximum manufacturer recommend doses if - on very careful consideration - such seems clinically appropriate. High dose antidepressants are well described in the literature, assisting a subset of patients – putatively due to their metabolism making it very hard for medication to reach their brain at average doses. I gradually escalated the patient’s venlafaxine to 450mg. He fully remitted – depressive symptoms (including suicidal ideations) completely resolved, and after a few months his confidence had returned. I thought to myself – imagine if his first doctor could have known he needed a high dose to recovery, imagine all the personal and economic losses that could have been saved! I didn’t know it at the time, but that was the start of a 10 year quest.
After my first year in psychiatric practice, it was apparent to me that psychiatric prescribing was entirely trial and error. I wanted to try and change this. I made time to see my local professor. I described the mission I had in mind. He responded “That’s interesting, I just got off the phone to a professor in Melbourne, he’s starting a genetics trial to guide antidepressants, interested?” - I said yes!
When I started research I imagined things happened fast – after all it was medical research and people needed answers ASAP. Boy was I wrong! Ethics approval, funding, team logistics, patient recruitment, data collection, data analysis, publication politics, paper rewrites, a thesis, and so several years passed!
I focussed on trying to unlock the pharmacogenetic keys of the blood-brain-barrier – the genetic ‘combination lock’ to get medications into the brain. A doctoral, post-doctoral, and commercial trial followed. 10 years accounted for!
In healthcare I believe there are three realities: academic reality, clinical reality, and commercial reality. It seems people tend to get siloed into one or the other of these realities. Academics complain about clinicians lacking science backed practice. Clinicians complain about academics being out of touch with clinical reality. Both complain about industry focussing on profits more than people. But our patients (and their loved ones) just want better solutions to their suffering. I believe it is at the intersection of academic, clinical, and commercial reality that there is greatest opportunity to find implementable solutions.
Next week I am launching a company in Silicon Valley. A company born from the real world ‘pain point’ of trial and error antidepressant prescribing. A company based on a decade of peer reviewed research. A company whose intent is to affordably reduce trial and error prescribing. I am a clinician, come researcher, come start-up entrepreneur – all in hopes of better serving patients.
Assoc. Prof. Ajeet B Singh (MBBS MPsych MD FRANZCP) is an Australian Psychiatrist & Pharmacogeneticist, Founder & CEO of cnsdose.com