Normalising the Implementation of Pharmacogenomic (PGx) Testing in Adult Mental Health Settings: A Theory-Based Systematic Review

Abstract

Pharmacogenomic (PGx) testing can help personalise psychiatric prescribing and improve on the currently adopted trial-and-error prescribing approach. However, widespread implementation is yet to occur. Understanding factors influencing implementation is pertinent to the psychiatric PGx field. Normalisation Process Theory (NPT) seeks to understand the work involved during intervention implementation and is used by this review (PROSPERO: CRD42023399926) to explore factors influencing PGx implementation in psychiatry. Four databases were systematically searched for relevant records and assessed for eligibility following PRISMA guidance. The QuADS tool was applied during quality assessment of included records. Using an abductive approach to codebook thematic analysis, barrier and facilitator themes were developed using NPT as a theoretical framework. Twenty-nine records were included in the data synthesis. Key barrier themes included a PGx knowledge gap, a lack of consensus in policy and guidance, and uncertainty towards the use of PGx. Facilitator themes included an interest in PGx use as a new and improved approach to prescribing, a desire for a multidisciplinary approach to PGx implementation, and the importance of fostering a climate for PGx implementation. Using NPT, this novel review systematically summarises the literature in the psychiatric PGx implementation field. The findings highlight a need to develop national policies on using PGx, and an education and training workforce plan for mental health professionals. By understanding factors influencing implementation, the findings help to address the psychiatric PGx implementation gap. This helps move clinical practice closer towards a personalised psychotropic prescribing approach and associated improvements in patient outcomes. Future policy and research should focus on the appraisal of PGx implementation in psychiatry and the role of pharmacists in PGx service design, implementation, and delivery.

Keywords: PGx testing; implementation science; mental health; personalised medicine; personalised prescribing; pharmacogenetics; pharmacogenomics; precision medicine; psychiatry; systematic review.

Figure 1

PRISMA flow chart [52]. Description: pictorial diagram of the process used for identifying and screening relevant records for inclusion, following PRISMA guidance.

Figure 2

Timeline and key characteristics of included studies. Description: A timeline of the included studies showing the study lead author name, study publication year and a brief description of methods used. Those shown in blue are healthcare professional (HCP) only studies, those in red are patient-only studies and those in green are studies including both HCPs and patients. The icons represent whether the study used quantitative, qualitative, or mixed methods approaches. For information about barriers and facilitators extracted from each individual study please refer to Supplementary Material File S2.

Figure 3

Key barrier and facilitator themes with associated NPT sub-constructs. Description: a summary of the main facilitator (left) and barrier (right) themes and associated NPT sub-construct numbers, constructed from the barriers and facilitators presented in Table 5. ‘E + T’ = education and training; ‘EHR’ = electronic health record; ‘PGx’ = pharmacogenomics.