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Adam Todd has paper published in Cochrane Library

 

Pharmacy‐based management for depression in adults

 

Abstract

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

We will examine the effects of pharmacy‐based management interventions compared to an active control, treatment as usual or no intervention/ waiting list, at improving depression outcomes in adults.

Background

Some services provided by pharmacists may have positive effects on patient health, including improved management of blood pressure and physical function (de Barra 2018).  Antidepressant management for depression is usually achieved through general practitioner (GP) contact and monitoring, which typically involves regular appointments (e.g. every two to four weeks within the first three months) in order to assess response and tolerance to treatment (NICE 2018).  Community pharmacists may be well placed to have a role in antidepressant management because of their unique pharmacotherapeutic knowledge and ease of access for patients. In the UK, there have been efforts to raise public awareness about the role that pharmacists can play as part of multidisciplinary team to better support people with managing their health conditions, including mental health problems (Royal Pharmaceutical Society 2018).

In England, an estimated 89.2% of the population have access to a community pharmacy within a 20‐minute walk; in the most deprived areas, this figure increases to 99.8% of the population (Todd 2014).  Therefore, pharmacy teams – working in community, general practice or secondary care – are ideally placed to offer proactive interventions to people with depression or depressive symptoms.  A narrative evidence synthesis by Rubio‐Valera 2014 suggests that pharmacists, specifically, have skills in medication management, provision of drug information, supporting and advising patients about their medicines and facilitating medication adherence strategies in mental health care.  Although pharmacy‐based management interventions can vary in their components, there is scope for these approaches to be used in partnership with other healthcare professionals (for example, as part of a collaborative care approach).  Previous research has suggested that multi‐professional approaches (involving more than one type of health professional, using a structured management plan and scheduled follow‐ups, with enhanced inter‐professional communication) have the potential to improve the management of depression in primary care settings (Archer 2012; Gilbody 2003; Gunn 2006).  However, despite this potential, and the emerging evidence of the role of pharmacy‐based management interventions for depression, the effectiveness and acceptability of these interventions is not yet well understood.

Description of the condition

Depression can be characterised by low mood; markedly diminished interest or pleasure in activities; impaired cognitive function; fatigue or reduced or disturbed sleep; feelings of worthlessness; and significant decrease or increased appetite (APA 2013; Otte 2016).  The aetiology and maintenance of depression is complex and multifactorial, involving environmental and social factors, as well as genetic and biological factors affecting function changes and regions of the brain (Otte 2016).  The condition can be recurrent or long‐term and chronic, and often results in debilitating burden that can interfere with family, home, social and work responsibilities (Marquez 2016).

Depression is a common mental health problem, with more than 300 million people globally estimated to be living with the condition (WHO 2018).  It is the leading cause of disability worldwide and a major contributor to the overall burden of disease (WHO 2018).  In extensive global population research on Global Burden of Disease involving 188 countries between 1990 and 2013, depression was found to be one of the top 10 causes of years lived with disability in every country studied, with higher rates of depression typically found in women (Vos 2015).  The global point prevalence of depression is reported to be 3.2% for men and 5.5% for women (Ferrari 2013a; Ferrari 2013b; Whiteford 2013).  It is estimated that annually 12 billion days of lost productivity (equivalent to 50 million years of work) are attributable to depressive and anxiety disorders (which are often comorbid with each other) combined, with an estimated cost of USD 925 billion, a cost that is anticipated to grow in coming years (Chisholme 2016).

Antidepressants have long been a mainstay of pharmacological treatment for depression (Taylor 2015), and have been reported to be more effective than placebo (Cipriani 2018).  However, it is common for patients not to take antidepressant medication as prescribed, with around 50% of patients likely to prematurely discontinue taking their medication after six months.  Premature discontinuation of antidepressant therapy has been linked to increased healthcare costs, poor treatment outcomes, and increased risk of relapse and recurrence (Chong 2011).

Medication non‐compliance can be broken down into the concepts of 'adherence' and 'persistence'; the former defined as "the extent to which a patient acts in accordance with the prescribed interval, and dose of a dosing regimen", and the latter "the duration of time from initiation to discontinuation of therapy", which can be related to the effects of the medication itself, including any adverse effects (Cramer 2008).  Non‐compliance can impact on the potential for antidepressant medication to improve symptoms of depression and may be related to specific concerns (such as experience of adverse effects, fear of addiction, lack of belief in the role of medication in helping to treat depression) as well as factors associated with medication management (such as insufficient provision of patient information/education, poor post‐prescription follow‐up, or other less explicit reasons) (Anderson 2013; Martin‐Vazquez 2016; Sansone 2012).

Description of the intervention

Pharmacy‐based management interventions can be delivered by a single pharmacist or the wider pharmacy support team.  In the context of depression, pharmacy‐based management interventions are often delivered in partnership with other healthcare professionals – usually as part of a collaborative care approach – focusing on improving patient adherence and persistence with antidepressant medication.  This can be done in several ways: firstly, by providing patient support, counselling, and education; secondly, by monitoring or following up adverse effects of medications; and, thirdly, under specific protocols, titrating doses of medications according to patient response (Brook 2005; Capoccia 2004; Finley 2003).  These interventions can be provided face‐to‐face, using written support materials or visual information relating to medication, through telephone support, or via more formal 'counselling' strategies (Adler 2004; Al‐Saffar 2005), and they may happen alongside the involvement of care managers, mental health specialists, and primary care physicians (Aljumah 2015; Rickles 2005).

As the intervention can be delivered in multiple ways and, given the number of interacting components involved (including the number and difficulty of behaviours required by those delivering or receiving the intervention, the number and potential variability of outcomes, and the degree of flexibility or tailoring of the intervention permitted) it can be described as a complex intervention (Petticrew 2011).

How the intervention might work

Working alone or as part of a wider collaborative care approach, a goal of pharmacy‐based management is to improve patient adherence and persistence rates with antidepressant medication.  A key aspect of effective collaborative care is 'case management' (Gilbody 2003), which has been described as a 'health worker taking responsibility for proactively following up patients, assessing patient adherence to psychological and pharmacological treatments, monitoring patient progress, taking action when treatment is unsuccessful, and delivering psychological support' (Von Korff 2001).  In addition to improving patient adherence and persistence, pharmacy‐based management interventions might also involve the delivery of direct psychological interventions to patients with depression.  An example of this is behavioural activation (BA) therapy, which uses principles of operant conditioning by encouraging people with depression to reconnect with environmental positive reinforcement (Ekers 2014).  Behavioural activation can be effective when delivered by paraprofessionals (Gilbody 2017), and current research is exploring if it can be delivered by community pharmacies to people with long‐term physical health problems and subthreshold depression (ISRCTN11290592).

Qualitative work has shown that people tend to form different relationships with a pharmacist compared to other healthcare professionals, such as primary care practitioners or general practitioners (GPs), indicating that people might be more likely to see a pharmacist to discuss certain aspects of their health (Lindsey 2016).  Previous research has demonstrated how pharmacist‐based management interventions, including providing patient support, counselling or coaching patients about their medication and what to expect, can improve antidepressant adherence rates (Al‐Saffar 2005; Brook 2005).  It is proposed that pharmacy‐based management interventions, such as engaging patients through face‐to‐face or remote counselling, education and advice (e.g. via teleconferencing, or 'take‐home' audio/visual materials) alongside prescribing and monitoring of antidepressant medication, can also improve depressive symptoms.

Why it is important to do this review

Pharmacists are now engaging with patients in different ways, and it is important to bring together the randomised evidence for pharmacy‐based approaches for depression to determine effectiveness not only on adherence levels, depressive symptoms and adverse effects of prescribed medication, but also on broader patient‐centred outcomes including acceptability, quality of life and levels of social functioning.  Research involving community household surveys from 21 countries showed that only a minority of people received 'minimally adequate treatment' for depression.  This finding equates to 1 in 5 people in high‐income countries, and 1 in 27 in low‐/lower‐middle‐income countries, highlighting the need to implement fundamental transformations involving community education and outreach, beyond that currently being offered in primary and secondary care services (Thornicroft 2017).  Treatment and support for depression clearly extends beyond the pharmacological; however, due to inadequate resources, antidepressants are more often used than treatment alternatives, for example, psychological therapies (Cipriani 2018).

Against this backdrop, there are emerging policy expectations for pharmacies to expand their professional responsibilities beyond retail and dispensing to encompass more patient‐centred services, including counselling and support, education, monitoring adverse events, and advice relating to prescribed medication and medicines optimisation and titration, resulting in a trend for community pharmacy medicine management interventions being introduced globally (including in Australia, Canada, New Zealand, Switzerland, the United States and England) (Latif 2018).  Even with a stronger push for pharmacy‐based interventions, there remains ambivalence amongst pharmacists as to whether the public are willing to engage or would readily accept advice and support (Eades 2011; Rodgers 2016).

Pharmacy‐based management strategies have shown some promising effects in other areas of healthcare (de Barra 2018).  Whilst existing systematic reviews in this area have examined the effects on improving patient adherence to antidepressants in general, for adherence to be clinically important, improvements in symptoms of depression and other person‐centred outcomes are essential.  More evidence is needed on broader, patient‐important outcomes, including depressive symptoms, acceptability of the intervention, healthcare utilisation and quality of life (Hanlon 2004; Holland 2008; Nkansah 2010; Readdean 2018; Royal 2006; Rubio‐Valera 2013; Yaghoubi 2017).  The degree to which a pharmacy‐based management approach might be beneficial, acceptable to patients, effective and cost‐effective as part of the overall management for those with depression is, to date, unclear.  A systematic review of randomised controlled trials will help answer these questions and add important knowledge to the currently sparse evidence base.

 

The full paper can be found here

Dr Adam Todd

published on: 29 May 2019