Major depression is one of the most common mental health disorders in the United States. It often accompanies other chronic health conditions, and can lead to potentially deadly health consequences for the patient.
About 95 million Americans live in communities that are considered to have a shortage of mental health providers, says Jim Cohn, Director of External Communications for Walgreens. “Medication nonadherence is also considered to be significant among patients with mental illness, and thus we believe there’s an important role our pharmacists can play in that regard,” he says. “The need is great, and there are a lot of opportunities for pharmacists to help jump in as an integral member of the health care team and provide services for depressed patients to lessen the burden on the system,” says Jolene R. Bostwick, PharmD, BCPS, BCPP, a Clinical Pharmacist in Psychiatry at the University of Michigan Health System.
But while there is significant need, there are also obstacles and challenges to improving detection and care for depressed patients. For example, pharmacists in community settings need to find a way to be reimbursed for screening services. And pharmacists in all settings need to develop strategies to encourage medication adherence, work collaboratively with the care team, and provide realistic medication expectations.
According to the National Institute of Mental Health (NIMH), an estimated 16.1 million adults over age 18 in 2015 had at least one major depressive episode within the previous year.
Patients with chronic illnesses or conditions such as diabetes, cancer, chronic pain, or heart disease are at a greater risk for developing depression. Mental Health America, used earlier research by NIMH to find that depression may occur in 40% to 65% of patients who have experienced a heart attack. In addition, the American Cancer Society says that one in four people with cancer has clinical depression.
While there are certain chronic conditions that may make a person more prone to depression, it can develop at any time in any one.
Up next: More on identifying depression and what you can do about it
The U.S. Preventative Services Task Force recommends that screening for depression be done in all adults in the general population, including women who are pregnant or postpartum.
There’s a clear need for these screenings to take place and experts in the industry say pharmacists’ position of trust and accessibility to patients gives them a unique opportunity to provide the screenings—whether it’s in a community pharmacy or a health-system setting.
“I see my patients every month as opposed to once a year. I have the opportunity to develop inroads and relationships and make interventions that really matter,” says John A. Galdo, PharmD, BCPS, BCGP, a pharmacist at FMS Pharmacy in Bessemer, AL.
Community pharmacists usually have tools for patients to screen their blood pressure or blood glucose, so providing avenues to screen other aspects of health—such as mental health—is a logical fit. John Norton, Director of Public Relations for the National Community Pharmacists Association, says health screenings can also provide pharmacies an opportunity to diversify their revenue.
The screening tools for depression are often brief and don’t require specialized skills to conduct. For instance, the patient health questionnaire 2 (PHQ-2) asks just two questions. A more thorough version, the PHQ-9, poses nine to ten questions depending on the patient’s response.
To assess how these screenings can be most effective in the community setting, Jordan Marie Ballou, PharmD, did a small study to examine various delivery methods.
At the time, Ballou was working at Brame Huie Pharmacy in North Wilkesboro, NC, as a PGY1 community pharmacy resident with the University of North Carolina Eshelman School of Pharmacy. She used the PHQ-9 to screen people who came into the pharmacy.
Patients were given the survey one of three ways: either placed into a customer’s bag, given a written version of the questionnaire at the drop-off station to fill out while the customer waited, or were asked the questions by a pharmacist.
Ballou, who works as a Clinical Assistant Professor of Pharmacy Practice at the University of Mississippi School of Pharmacy, found that stuffing the customer’s bag proved to be very ineffective—just 1 out of 50 customers filled out the survey and returned it. But both of the other methods received high participation rates (72% for the group receiving the written test at the drop-off counter and 80% in the group verbally interviewed).
“People were really responsive and I think that speaks highly to the trust patients put into their pharmacists to be able to have those difficult conversations,” she says.
While Walgreens’ pharmacists don’t offer the screenings themselves, the company has partnered with Mental Health America to try to connect more people to available resources in the community. A new portion of Walgreens’ website focuses on mental health and can connect people to free online screenings for multiple conditions, including depression.
One of the obstacles to screening in a community setting is reimbursement. However, Galdo, who is also an Assistant Professor and Residency Director at Samford University in Birmingham, AL, hopes to show that when proper reimbursement is in place, pharmacists can be a valuable resource for identifying undiagnosed depression. He is conducting a grant-funded research project at 10 independent pharmacies to compare screening rates in pharmacies that receive reimbursement for their services with those that don’t. As part of the study, five of the pharmacies will receive $15 in reimbursement for the screenings they complete.
“The goal of this grant is to impact patient care first and foremost. But it is also to show that it is something that a pharmacist can get reimbursed for,” he says.
However, community pharmacists who offer the screenings should have a plan in place about what to do if a customer responds affirmatively to showing signs of depression. Depending on a patient’s test score, the next steps could include referral to a mental health provider, contacting the primary care physician, calling an emergency hotline, or even calling 911.
The community setting isn’t the only outlet where pharmacists can offer the screenings. Kylee Funk, PharmD, BCPS, a Clinical Pharmacist and Assistant Professor in the Department of Pharmaceutical Care and Health Systems at the University of Minnesota College of Pharmacy in Minneapolis, MN, says she offered depression screenings for all patients with diabetes at one of her previous jobs. She then worked closely with physicians to help identify the best antidepressant medications for the patients who were diagnosed with depression.
As medication experts, pharmacists are already armed with the knowledge they need to advise physicians and other members of the care team about what antidepressant medication may be best for an individual patient, as well as the best strategies to taper or titrate off a medication and possible drug interactions to consider.
“There are so many medications for depression that act in different ways and that have different side effects. There are just so many considerations, including the patient’s co-existing medical conditions, medication history, and personal preferences, that go into that selection of a best treatment option for them,” Funk says.
More clinical teams are including pharmacists for their medication expertise and patient counseling abilities.
Clinical pharmacists can also help patients more successfully transition between care settings. For example, Carla Cobb, PharmD, BCPP, a psychiatric pharmacist at RiverStone Health in Billings, MT, works closely with patients recently released from inpatient treatment facilities.
She spends half a day each week working in conjunction with a behavioral health provider to meet with these patients in hour-long appointments. The behavioral health provider does a social history and assesses any current symptoms, while Cobb does a comprehensive medication assessment that includes the patient’s medication history, current medications, and hospitalization records. She also evaluates the effectiveness of their current drug regimen.
In addition to being a screening tool, the PHQ-9 can also be used to evaluate the effectiveness of a particular medication. For instance, if a patient still scores high while taking an antidepressant, he or she may need to make a change. That may mean switching to a different SSRI, switching to a different class of antidepressant, or adding an augmenting agent. “If you are not getting a new response, then you need to do something different,” Cobb says.
Experts say one of the best things pharmacists can do is listen to their patients and not ignore negative side effects or the personal preferences or feelings of an individual patient.
Bostwick, who is also an Associate Chair of the Department of Clinical Pharmacy at the University of Michigan College of Pharmacy in Ann Arbor, MI, regularly evaluates how her patients at the clinic are doing by following up with them one to two weeks after any medication change has been made. During these check-ins, she assesses whether patients are following their plans, how they are tolerating the medications and whether they are experiencing any side effects.
“With the stigma associated with psychiatric illnesses, I think it’s really valuable that patients just know that there’s someone on their side,” she says.
Depressed patients may be prone to non-adherence with their depression medications or other drugs they may be taking for chronic conditions.
Some evidence has shown, however, that when a pharmacist is involved and implements strategies to improve adherence, the rates can improve in this patient population. Genoa, a company that specializes in mental-health pharmacy, provides specialized services to more than 500,000 people with mental illnesses or other chronic conditions each year. The company has long placed an emphasis on improving medication adherence in its patients.
Linda Rowe-Varone, PharmD, BCPP, a Clinical Pharmacist with Genoa who works in a pharmacy at an outpatient mental health facility, says their pharmacists work to improve adherence by using special packaging, regularly following up with patients if they fail to pick up refill prescriptions, coordinating with in-patient treatment centers to make sure medication lists are up-to-date, and notifying members of the care team if a problem is identified.
“I feel as if we really reach out to our clients,” she says.”For example, when it comes to our patients refills, we call them in advance. We inform them that it’s getting to be time for their refill.” The pharmacy then offers patient pick up, delivery, or even mailing the medications based on patient preference.
Pharmacists can also help improve adherence by providing patients with realistic expectations about their medications. Patients need to know that it will take several weeks before they will feel the full effects of their medication.
Removing the Stigma
Unfortunately, a stigma still exists for many suffering from mental health conditions. Pharmacists can help diminish this stigma by having open conversations with patients and doing whatever they can to help a patient meet his or her goals regardless of their health condition.
“I think it’s important for pharmacists in the community or clinic to familiarize themselves with depression and other mental illnesses,” Cobb says. “These should be treated like any other chronic medical conditions, and people need to be treated with respect.”
Patients with depression may be more prone to medication non-adherence.
Linda Rowe-Varone, PharmD, BCPP, a clinical pharmacist with Genoa, says her company has been able to improve patient adherence through these strategies:
Using packaging that is easy and convenient for patients
Working with the medical team to secure prior authorization
Eliminating any barriers for patients to getting their medications, including offering home delivery
Following up with patients through personal phone calls if they fail to pick up refills
Coordinating with in-patient treatment centers to have an accurate medication list
Notifying the patient’s care team if a concern arises