Help Patients Manage Depression

Depression is a leading cause of disability among individuals aged 15 years and older, and evi- dence has shown that early detection and treatment are critical to improve clinical outcomes.¹

The US Preventive Services Task Force rec- ommends screening adults aged 18 years and older for depression, including pregnant and postpartum women.¹

However, according to the results of a recent CDC report survey, 1 in 5 women said that no health care providers asked about depression during pregnancy, and 1 in 8 women said that they were not questioned about depression during postpartum appointments.²

The American Academy of Pediatrics recommends screening teens for depression, as about 3.1 million adolescents aged 12 to 17 years in the United States have experienced at least 1 major depressive episode.³ Because pharmacists are accessible health care professionals, they can play an important role in screening and managing patients with depression through medication therapy management (MTM) services in a variety of settings.

Evidence shows that pharmacists can conduct depression screenings in community settings.⁴ One study compared 3 approaches of administering the Patient Health Questionnaire-9 depression screening tool in an independent pharmacy and found that direct interaction with a pharmacist was the most effective method of participation.⁴ Also, 93% of surveyed participants said they think that screening for depression in a community pharmacy is a valuable service.⁴ Pharmacist and psychiatrist collaborations through MTM services can offer opportunities for a multidisciplinary approach to disease state management and drug therapy.⁵

Pharmacists can also provide mental health MTM services in long-term care facilities.

The results of 1 study showed positive benefits through the collaboration between board-certified psychiatric pharmacists and psychiatrists.⁵ Clinical services included laboratory monitoring, medication counseling, pharmacotherapy management, and specialist referrals.⁵

Pharmacists can also provide mental health MTM services in long-term care (LTC) facilities. The results of another study showed a high completion rate (96%) of comprehensive medi- cation reviews performed by consultant pharmacists in LTC facilities when conducted using a systematic approach.⁶

In an interview, Trang Nguyen, PharmD, BCGP, discussed her role as a pharmacist practicing in a skilled nursing facility in Edmond, Oklahoma.

The most common clinical MTM interventions that her team performs in skilled nursing homes related to mental health and medications are gradual dose reduction, lab monitoring for drug toxicities, and major drug-drug interactions, she said.

“We focus on gradual dose reduction of anti- psychotics, anxiolytics, antidepressants, and hypnotic therapy, especially in the elderly patients,” Nguyen said.

Because patients in nursing homes take multiple medications, geriatric pharmacists are on a mission to solve polypharmacy problems, ensure correct medications for specific conditions, and prevent major drug-drug interactions, she said.

“During the coronavirus disease 2019 (COVID-19) pandemic, we follow guidelines from the American Society of Consultant Pharmacists and the Implementation Guide [for Post-Acute and Long-Term Care] by the Peter Lamy Center [on Drug Therapy and Aging] at the University of Maryland School of Pharmacy,” Nguyen said.

The health care team focuses on deprescribing unnecessary medications and reducing administration times, which can ultimately lower the risk of disease transmissions.

“It also allows nurses to support resident well-being and monitor patients with mental health conditions, especially in some facilities that have positive cases of COVID-19, since their residents have to be self-isolated in their own rooms,” Nguyen said.

CASE STUDY

TN is a 40-year-old woman who was prescribed sertraline (Zoloft) 50 mg once daily for depression about 2 months ago. Based on the refill history documented through the MTM platform, it appears that she has not been adherent to the sertraline, as she is about 2 weeks late picking up the medication. The pharmacist contacts TN through a targeted medication review (TMR) to discuss the identified adherence issue and discovers during the follow-up call that TN stopped taking the sertraline after a week of initiating treatment because her depression symptoms were the same.

WHAT COUNSELING POINTS CAN THE PHARMACIST PROVIDE TN?

Through the TMR, the pharmacist can discuss that selective serotonin reuptake inhibitors, such as sertraline, can take up to 6 weeks before the medication is fully effective.⁷ TN is receiving counseling from a psychologist, but she would like to restart the sertraline for increased benefit. The pharmacist can say that TN can restart the sertraline 50 mg daily and explain that it is important not to stop therapy suddenly due to the risk of discontinuation syndrome.⁷ Withdrawal symptoms may include dizziness, flu-like symptoms, lethargy, and nausea.⁷ Possible adverse effects associated with sertraline may include diarrhea, dizziness, insomnia, nausea, and vomiting, but these should decrease over time as treatment continues. If TN experiences insomnia, she can take the sertraline in the morning. It is also important that TN seek emergency medical care immediately if the depression or suicidal thoughts worsen.⁷ The pharmacist should plan to follow up with TN in 4 to 6 weeks to determine if the sertraline dose should be increased.®

REFERENCES

• Siu Al, Bibbins-Domingo K, Grossman DC, et al; US Preventive Services Task Force (USPSTF). Screening for depression in adults: US Preventive Services Task Force recommendation statement. JAMA. 2016;315(4):380-387. doi:10.1001/ jama.2015.18392
• Bauman BL, Ko JY, Cox S, et al. Vital signs: postpartum depressive symptoms and provider discussions about perinatal depression - United States, 2018. MMWR Morb Mortal Wkly Rep. 2020;69(19):575-581. doi:10.15585/mmwr.mm6919a2
• Adolescent depression screening. American Academy of Pediatrics. Accessed June 2, 2020. https://www.aap.org/en-us/professional-resources/quality-improvement/ Project-RedDE/Pages/Depression.aspx
• Ballou JM, Chapman AR, Roark AM, Huie CH, McKee J, Marciniak MW. Conducting depression screenings in a community pharmacy: a pilot comparison of methods. J Am Coll Clin Pharm. 2019;2(4):366-372. doi:10.1002/jac5.1156
• Tallian KB, Hirsch JD, Kuo GM, et al. Development of a pharmacist-psychi- atrist collaborative medication therapy management clinic. J Am Pharm Assoc. 2012;52(6):e252-e258. doi:10.1331/JAPhA.2012.11215
• O’Shea TE, Zarowitz BJ, Erwin WG. Comprehensive medication reviews in long- term care facilities: history of process implementation and 2015 results. J Manag Care Spec Pharm. 2017;23(1):22-26. doi:10.18553/jmcp.2017.23.1.22
• Selective serotonin reuptake inhibitors (SSRIs). Mayo Clinic. September 17, 2019. Accessed June 3, 2020. https://www.mayoclinic.org/diseases-conditions/depression/ in-depth/ssris/art-20044825