The Pharmaceutical Journal
Vol 272 No 7298 p576-577
8 May 2004

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From black clouds to lighter grey: how pharmacists can help in depression

Sara Garfield, Felicity Smith and Sally-Anne Francis see a role for pharmacists in helping those with mental health problems

The authors are from the University of London School of Pharmacy (correspondence to sara.garfield@ams1.ulsop.ac.uk)

The World Health Organization is predicting that depressive disorder will be the most common cause of disease in the developed region by 2020.¹ Mental health is, for example, a priority area for the UK Government. The National Service Framework for Mental Health² published national standards for the promotion of mental health and treatment of mental illness in 1999. The document identified that community pharmacists are a health care resource to those with mental health problems. Further to its publication, the Royal Pharmaceutical Society³ identified the support of service users and their carers in maintaining adherence to treatment as a role for pharmacists in the care of people with mental health problems.

Over 50 per cent of patients stop taking their antidepressant medicines before the recommended treatment duration. We conducted a study which investigated patients’ views and experiences of antidepressant medication and how they made decisions about whether or not to take their medicines.^4,5 Fifty-one patients who had been prescribed courses of antidepressant medication between the ages of 18 and 65 years were interviewed. From these interviews it became clear that pharmacists could help support patients beginning courses of antidepressant medication, in line with policy objectives. Gaps in the access of information for patients with a diagnosis of depression were identified.

Type of information

Key areas for discussion were identified. They included adverse drug reactions, process of recovery, duration of treatment, dosage in the context of minimum and maximum dosages, dependency and issued surrounding complementary medication.

Information about adverse drug reactions was the most common unmet need. Some respondents were told by health care professionals that they would be unlikely to experience adverse reactions with the medication they had been prescribed. This information affected the decisions they made about their medication if they subsequently experienced adverse reactions. Comments from respondents implied that if medication which was supposed to have few adverse reactions subsequently caused problems, there would be no benefit in changing to a different tablet, and discontinuation would be a better strategy:

When I talked to the pharmacist he said to me that ... they’ve got very very few side effects and I was quite surprised that they were having side effects ... so I just decided that I’m not, um, going to take them [respondent who had changed treatment several times due to adverse drug reactions but who, on this occasion, discontinued treatment completely].
Respondent 04

Recovery from depression was seen by most respondents as a gradual process where fluctuations occurred. Even in the course of time, recovery was not always complete. A recurring theme was that medication on its own was not a cure but could help in conjunction with other factors such as psychological therapy, external support and changes in circumstances. In addition, once medication had begun to take its effect, respondents were able to employ other coping strategies that they had been unable to use when the depression had been at its worst, such as taking more exercise or attending creative classes. The limited but important role of medication in aiding recovery from depression is succinctly captured in the following quote from a study respondent:

There was a cloud, there was a black cloud, a dark cloud, a grey cloud and ... it didn't lift, but now it’s gone, well put it this way, it’s gone a lighter shade of grey now.
Respondent 43

Some respondents had been expecting a miracle cure and were therefore unprepared for the reality of the recovery process. They reported that it would have been beneficial to have understood the process more fully from the beginning.

Pharmacists are a potential source of information about alternative remedies such as St John’s wort. Complementary therapies were an important part of therapy for some of the respondents in the study, with pharmacists being a source of supply. Analysis of interview data suggested that respondents would have benefited from more information regarding side effects and interactions, particularly with the publicity concerning St John’s wort.

Timing of information

Receiving a first prescription for antidepressant medication was a traumatic experience for some people, with the prescribing of medication perceived as labelling the individual as having the condition. The medication information provided at the time of diagnosis at the doctor’s surgery was not always absorbed by respondents. However, the amount of information that patients wanted at this stage was vast.

Pharmacists have an important opportunity to reinforce information. Some respondents in this study identified that the decision to take medication was separate from the decision to having it dispensed. This confirms the importance of medication information at the supply stage. Depression can result in some people having short attention spans. Therefore repeated opportunities for the provision of information could be advantageous. As accessible health professionals, pharmacists can play a valuable role in providing information between doctors’ appointments.

Barriers

Pharmacists’ accessibility and their expertise in the use of medicines mean that they are well placed to provide information to patients beginning courses of antidepressant medication, but strategies to optimise the ability of pharmacists to perform such roles need to be developed.

Although many potential roles for pharmacists were identified from the study findings, the results obtained also suggested that pharmacists do not become hugely involved in the pharmaceutical care of patients with a diagnosis of depression. Few respondents identified pharmacists as a source of information or advice about depression.

The pharmacy environment may be a barrier to enabling interactions to occur. The high level of stigma attached to taking antidepressant medicines resulted in many respondents in the current study wishing to disguise the fact that they were taking it. This finding has implications for pharmacy because the open environment of a community pharmacy may be a barrier to communicating with patients. Having a private room available is a possible way of overcoming difficulties of confidentiality.

Lack of time and remuneration for patient services are also barriers to pharmacists developing further roles. The new pharmacy contract will be an opportunity for pharmacists to receive both local and national remuneration for services provided. “Mental health concordance and advice” has been identified as a service for which remuneration will be provided.⁶ Pharmacists have identified that a lack of access to medical records can impair the extension of the pharmacist’s role. The development of electronic prescribing and the national prescriptions’ service may overcome this constraint.⁶
In addition, factors concerning individual pharmacists may act as barriers to developing their role, eg, lack of confidence, and feelings of discomfort. Incorporating more training about mental health conditions, at both undergraduate and postgraduate level, may help increase confidence in dealing with those with mental health problems.

Conclusion

From our research, we have concluded that pharmacists have an important potential role to play in providing information to patients beginning courses of antidepressant medication. However, current involvement in this area is limited. Addressing barriers to communication between pharmacists and patients with mental health problems will improve the care of this patient group.

References

1. The World Health Report. Geneva: World Health Organization; 2001.
2. Department of Health. National Service Framework for Mental Health: modern standards and service models. London: The Stationery Office; 1999.
3. Royal Pharmaceutical Society. Practice guidance on the care of people with mental health problems. Available here (accessed 4 May 2004).
4. Garfield S, Francis S-A, Smith FJ. Building concordant relationships with patients beginning courses of antidepressant medication. Patient Education and Counseling. In press. Available here (accessed 4 May 2004).
5. Garfield S,. Smith FJ, Francis S-A. The paradoxical role of antidepressant medication — returning to normal functioning while losing the sense of being normal. Journal of Mental Health 2003;12:521–35.
6. Buxton A. The National Health Service pharmacy contract in England. The Pharmaceutical Journal 2003;271:406–8 (PDF 100K)