Collaborative care model to improve outcomes in major depression

Influential characteristics of physician/pharmacist collaborative relationships

BACKGROUND

A theoretical model of physician/pharmacist collaborative relationships, driven by 3 groups of relationship characteristics termed participant, context, and exchange, has been developed. There are no studies that have examined the types of characteristics which most influence development of collaborative relationships between physicians and pharmacists.

OBJECTIVE

To test the model and determine which drivers most influence physician/pharmacist collaboration.

METHODS

Data on the relationship drivers and collaborative practice were collected via a mailed survey of a random sample of 1000 primary care physicians in Iowa. Participant variables include demographics; context drivers refer to the practice environment and professional interactions between physicians and pharmacists. Exchange characteristics describe the nature of social exchange and were elicited using scores from 3 domains (relationship initiation, trustworthiness, role specification) of the Physician/Pharmacist Collaboration Instrument (PPCI). Five additional questions asked about the physician's collaborative practice with a pharmacist. Hierarchical linear regression analysis was performed with collaborative practice as the dependent variable and measures of participant, context, and exchange drivers as independent variables.

RESULTS

Three hundred forty usable surveys (34%) were returned. Almost 70% of the respondents were male and aged 45.8 +/- 9.9 years (mean +/- SD). The majority were family practice physicians (72.1%) in private practice (67.3%). Regression analyses produced an R2 = 0.804 (p < 0.001). Significant predictors in the model were internal medicine physicians, professional interaction with a pharmacist, and the 3 domains of exchange drivers from the PPCI (p < 0.05).

CONCLUSIONS

Although participant and context factors influenced physician/pharmacist collaborative relationships, exchange characteristics were the most influential relationship drivers. Role specification, trustworthiness, and relationship initiation were positively associated with physician/pharmacist collaborative practice. Recognition of these drivers may help pharmacists who are developing collaborative working relationships with physicians. But, studies are needed to delineate other factors that may influence physician/pharmacist relationships.

Achieving long-term optimal outcomes in geriatric depression and anxiety

Depression and anxiety disorders are very common in the elderly. Data accumulated over the past 2 decades have shown that most older patients can tolerate and respond to acute treatment with serotonergic antidepressants, other psychotropic agents, or manual-based psychotherapy. However, outcomes under usual-care conditions remain poor. This review proposes that clinicians may significantly improve the long-term outcomes of their older patients with depression and anxiety by focusing on four key factors: (1) identification and treatment of comorbid conditions; (2) full remission of acute symptoms; (3) education of patients, families, and professional colleagues about the need for long-term treatment; and (4) prevention and management of medication side-effects.

Evaluating the Impact of Pharmacists in Mental Health: A Systematic Review

Efforts to improve the outcomes of patients with mental illness often have involved incorporating the skills of a variety of health care professionals into collaborative care models. For over 30 years, clinical pharmacists have contributed to these care models in capacities ranging from educator to consultant to provider. This systematic review evaluates the quantity and quality of medical literature examining the impact of pharmacists in mental health from 1972-2003. Although we identified approximately 35 publications describing the roles of clinical pharmacists in this regard, only 16 were of sufficient scientific rigor to permit evaluation and comparison. The 16 studies were divided equally between inpatient and outpatient settings and were conducted in a variety of health care organizations (e.g., Veterans Administration, health maintenance organizations, community mental health clinics, and nursing homes). Nine of the studies examined the role of pharmacists in providing treatment recommendations and patient education, five featured pharmacists as providers (with prescriptive authority), and the remaining two described the impact pharmacists have in delivering education to the psychiatric staff. Six of the 16 studies were prospective, but only three of these incorporated a randomization procedure for patients or facilities. Collectively, the results of the 16 studies were positive, demonstrating improvements in outcomes, prescribing practices, patient satisfaction, and resource use. Unfortunately, most of the investigations were small, and significant limitations in study design limited further comparison. Given the long history and anecdotal success of pharmacists in mental health care settings, additional multicenter cost-effectiveness trials are warranted to further support the role of the psychiatric pharmacist.