Example of a patient’s journey.

A 22-year-old college student (male, Asian American) is referred to us for anxiety, trouble sleeping, and occasional panic attacks, one of which landed him in the ED. A parent, who is a physician, has heard about the focus on personalizing treatment at our university-affiliated clinic and brought her son to us for a second opinion. Patient had been seen previously by a community psychiatrist, who prescribed mirtazapine and clonazepam, with minimal benefits and some weight-gain side effects.

Patient reports he has been experiencing academic pressures. He had been attending an Ivy League university, then transferred to a school in his hometown after taking some time off. Patient describes being chronically anxious, going to sleep late, and waking up late. He overeats, is overweight, and lacks motivation. There is a history of marijuana use. No alcohol, no other drugs. In childhood, patient reports seeing his other parent almost die from a medical emergency, which began anxiety symptoms at a young age.

Patient had undergone DNA testing for pharmacokinetic purposes in the past (GeneSight, from Myriad Neurosciences), and brings that report to the appointment. The information from it had not had an impact in his previous care. Patient and parent want to try (novel at that time) blood biomarker testing (MindX One, from MindX Sciences).

Blood biomarker testing indicates a risk for anxiety, stress disorders, and possible bipolar mood disorder. Top medication matches are lithium and fluoxetine. At a follow-up appointment, the results are discussed with patient and parent. Parent expresses mild skepticism about the results and matching to these “old” psychiatric medications, which have a “history” in the field. Patient is scheduled to follow up with his community psychiatrist.

The community psychiatrist and physician parent are reluctant to start lithium, due to concerns about side effects. Fluoxetine is initiated instead of mirtazapine, and titrated to 20 mg po qd, which results in sexual side effects.

Patient is still symptomatic, and returns accompanied by his parent for follow-up at our clinic. They are still reluctant to initiate lithium even at very low prescription dose, but agree to try a nutraceutical version at 15 mg. Fluoxetine is reduced to 10 mg to avoid sexual side effects.

At follow-up six weeks later, patient has improved in terms of anxiety, but still has a disrupted circadian rhythm and low mood. Patient and parent agree to try low-dose lithium 150 mg po qhs in addition to fluoxetine 10 mg po qam. At follow-up three months later, they report improvement in anxiety, stress about exams, and sleep. At a follow-up six months later, patient comes alone, unaccompanied by his parent. He graduated college in an academically successful way, completed his MCAT, lost weight by taking Brazilian jiu-jitsu classes three times a week, and has a full-time job as a medical technician that requires him to get up at 5 a.m.