Description of a clinical pharmacist intervention administered to primary care patients with depression

A novel pharmacy liaison program to address health-related social needs at an urban safety-net hospital

PURPOSE

Patients with unmet health-related social needs (HRSNs) often experience poor health outcomes and have high levels of healthcare utilization. We describe a program where dually trained pharmacy liaison-patient navigators (PL-PNs) screen for and address HRSNs while providing medication management services to patients with high levels of acute care utilization in a Medicaid Accountable Care Organization. We are unaware of prior studies that have described this PL-PN role.

METHODS

We analyzed case management spreadsheets for the 2 PL-PNs who staffed the program to identify the HRSNs that patients faced and the ways PL-PNs addressed them. We administered surveys, including an 8-item client satisfaction questionnaire (CSQ-8), to characterize patient perceptions of the program.

RESULTS

Initially, 182 patients (86.6% English speaking, 80.2% from a marginalized racial or ethnic group, and 63.2% with a significant medical comorbidity) were enrolled in the program. Non-English-speaking patients were more likely to receive the minimum intervention dose (completion of an HRSN screener). Case management spreadsheet data (available for 160 patients who engaged with the program) indicated that 71% of participants faced at least one HRSN, most often food insecurity (30%), lack of transportation (21%), difficulty paying for utilities (19%), and housing insecurity (19%). Forty-three participants (27%) completed the survey with an average CSQ-8 score of 27.9, indicating high levels of satisfaction with the program. Survey participants reported receiving medication management services, social needs referrals, health-system navigation assistance, and social support.

CONCLUSION

Integration of pharmacy medication adherence and patient navigation services is a promising approach to streamline the HRSN screening and referral process at an urban safety-net hospital.

Assessment of the current practice of psychiatric pharmacists in the United States

Introduction

A comprehensive review of psychiatric pharmacy practice has never been performed in the United States. As psychiatric pharmacists become more involved in mental illness treatment, determining the current state of practice is important to help advance the specialty. The Professional Affairs Committee of the College of Psychiatric and Neurologic Pharmacists (CPNP) was charged with performing this review to define current psychiatric pharmacy practice.

Methods

An electronic survey was sent to all pharmacist members of CPNP and all nonmember Board Certified Psychiatric Pharmacists (BCPPs) in the United States in late summer 2019. The survey consisted of 36 questions across multiple domains to obtain information about respondents' education and training background, practice setting and type, and information about prescriptive authority and other areas. An initial e-mail invitation was sent along with 2 reminder e-mails over the subsequent 2 weeks.

Results

A total of 334 of 1015 pharmacists completed the survey (32.9%). Responders completed a postgraduate residency 77.8% of the time, and 88.3% were BCPP. Practice settings were split evenly between inpatient and outpatient practices or a combination of the 2. Among respondents, 46.5% reported having prescriptive authority as part of their practice, and 41.3% reported treating nonpsychiatric as well as psychiatric illnesses. Prescriptive authority was more likely in outpatient practices and in those treating nonpsychiatric illnesses.

Discussion

The current practice of psychiatric pharmacy is incredibly varied in terms of practice setting, activities performed, and services provided. Further exploration is needed to help determine the optimal role of psychiatric pharmacists.

The role of relapse prevention for depression in collaborative care: A systematic review

BACKGROUND

Relapse (the re-emergence of depression symptoms before full recovery) is common in depression and relapse prevention strategies are not well researched in primary care settings. Collaborative care is effective for treating acute phase depression but little is known about the use of relapse prevention strategies in collaborative care. We undertook a systematic review to identify and characterise relapse prevention strategies in the context of collaborative care.

METHODS

We searched for Randomised Controlled Trials (RCTs) of collaborative care for depression. In addition to published material, we obtained provider and patient manuals from authors to provide more detail on intervention content. We reported the extent to which collaborative care interventions addressed four relapse prevention components.

RESULTS

93 RCTs were identified. 31 included a formal relapse prevention plan; 42 had proactive monitoring and follow-up after the acute phase; 39 reported strategies for optimising sustained medication adherence; and 20 of the trials reported psychological or psycho-educational treatments persisting beyond the acute phase or focussing on long-term health/relapse prevention. 30 (32.3%) did not report relapse prevention approaches.

LIMITATIONS

We did not receive trial materials for approximately half of the trials, which limited our ability to identify relevant features of intervention content.

CONCLUSION

Relapse is a significant risk amongst people treated for depression and interventions are needed that specifically address and minimise this risk. Given the advantages of collaborative care as a delivery system for depression care, there is scope for more consistency and increased effort to implement and evaluate relapse prevention strategies.

Pharmacy-based management for depression in adults

BACKGROUND

It is common for peoples not to take antidepressant medication as prescribed, with around 50% of people likely to prematurely discontinue taking their medication after six months. Community pharmacists may be well placed to have a role in antidepressant management because of their unique pharmacotherapeutic knowledge and ease of access for people. Pharmacists are in an ideal position to offer proactive interventions to people with depression or depressive symptoms. However, the effectiveness and acceptability of existing pharmacist-based interventions is not yet well understood. The degree to which a pharmacy-based management approach might be beneficial, acceptable to people, and effective as part of the overall management for those with depression is, to date, unclear. A systematic review of randomised controlled trials (RCTs) will help answer these questions and add important knowledge to the currently sparse evidence base.

OBJECTIVES

To examine the effects of pharmacy-based management interventions compared with active control (e.g. patient information materials or any other active intervention delivered by someone other than the pharmacist or the pharmacy team), waiting list, or treatment as usual (e.g. standard pharmacist advice or antidepressant education, signposting to support available in primary care services, brief medication counselling, and/or (self-)monitoring of medication adherence offered by a healthcare professional outside the pharmacy team) at improving depression outcomes in adults.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMD-CTR) to June 2016; the Cochrane Library (Issue 11, 2018); and Ovid MEDLINE, Embase, and PsycINFO to December 2018. We searched theses and dissertation databases and international trial registers for unpublished/ongoing trials. We applied no restrictions on date, language, or publication status to the searches.  SELECTION CRITERIA: We included all RCTs and cluster-RCTs where a pharmacy-based intervention was compared with treatment as usual, waiting list, or an alternative intervention in the management of depression in adults over 16 years of age. Eligible studies had to report at least one of the following outcomes at any time point: depression symptom change, acceptability of the intervention, diagnosis of depression, non-adherence to medication, frequency of primary care appointments, quality of life, social functioning, or adverse events.  DATA COLLECTION AND ANALYSIS: Two authors independently, and in duplicate, conducted all stages of study selection, data extraction, and quality assessment (including GRADE). We discussed disagreements within the team until we reached consensus. Where data did not allow meta-analyses, we synthesised results narratively.  MAIN RESULTS: Twelve studies (2215 participants) met the inclusion criteria and compared pharmacy-based management with treatment as usual. Two studies (291 participants) also included an active control (both used patient information leaflets providing information about the prescribed antidepressant). Neither of these studies reported depression symptom change. A narrative synthesis of results on acceptability of the intervention was inconclusive, with one study reporting better acceptability of pharmacy-based management and the other better acceptability of the active control. One study reported that participants in the pharmacy-based management group had better medication adherence than the control participants. One study reported adverse events with no difference between groups. The studies reported no other outcomes. Meta-analyses comparing pharmacy-based management with treatment as usual showed no evidence of a difference in the effect of the intervention on depression symptom change (dichotomous data; improvement in symptoms yes/no: risk ratio (RR), 0.95, 95% confidence interval (CI) 0.86 to 1.05; 4 RCTs, 475 participants; moderate-quality evidence; continuous data: standard mean difference (SMD) -0.04, 95% CI -0.19 to 0.10; 5 RCTs, 718 participants; high-certainty evidence), or acceptability of the intervention (RR 1.09, 95% CI 0.81 to 1.45; 12 RCTs, 2072 participants; moderate-certainty evidence). The risk of non-adherence was reduced in participants receiving pharmacy-based management (RR 0.73, 95% CI 0.61 to 0.87; 6 RCTs, 911 participants; high-certainty evidence). We were unable to meta-analyse data on diagnosis of depression, frequency of primary care appointments, quality of life, or social functioning.

AUTHORS' CONCLUSIONS

We found no evidence of a difference between pharmacy-based management for depression in adults compared with treatment as usual in facilitating depression symptom change. Based on numbers of participants leaving the trials early, there may be no difference in acceptability between pharmacy-based management and controls. However, there was uncertainty due to the low-certainty evidence.

A retrospective analysis of patient care activities in a community pharmacy mental illness and addictions program

BACKGROUND

The Bloom Program, a community pharmacy-based mental health and addictions care program, was developed and implemented to optimize pharmacists' care of eligible patients. Characterizing pharmacists' activities in the Bloom Program can facilitate program quality improvement and contribute more broadly to the knowledge base regarding pharmacists' roles and contributions to patient care.

OBJECTIVES

To characterize the patient care activities of the pharmacists in the Bloom Program.

METHODS

A retrospective analysis of patient charts for participants enrolled in the program for three months or longer was conducted. Using all available documentation, pharmacists' activities were coded into eight non-mutually exclusive categories: navigation/resource support, urgent triage, medication management, collaboration/communication, education, social support, self-care, and other.

RESULTS

2055 activities from 1144 patient care encounters were identified for 126 participants (48 ± 16 years of age, 61% female, 5 regular medications). Medication management was coded most often per encounter (73%). Each of social support, collaboration/communication, and education were coded in 20-25% of encounters. Frequency of navigation/resources, self-care, and urgent triage were 16.6%, 13.5%, and 2.8%, respectively. Non-medication management activities represented 59.4% of all pharmacist patient care services.

CONCLUSIONS

Medication management activities were coded in over 70% of patient encounters for pharmacists delivering a community pharmacy-based mental illness and addictions program. However, this accounted for 40.6% of activities with an average of 1.8 activities per encounter. Other activities were identified frequently (e.g., education, collaboration, social support, navigation and resource support) and help to characterize the nature of pharmacist-patient encounters and facilitates a better understanding of the role of the pharmacist in mental illness and addictions patient care.

Effectiveness and cost-effectiveness of a multicomponent intervention to improve medication adherence in people with depressive disorders - MAPDep: a study protocol for a cluster randomized controlled trial

PURPOSE

Depression is a widespread mental disorder which can be treated effectively. However, low adherence to antidepressants is very common. The study of medication adherence in depression (MAPDep study) assesses the effectiveness and cost-effectiveness of a multicomponent strategy to enhance adherence toward medications in patients with depression.

INTERVENTION

The intervention is a multicomponent one consisting of an educational program for psychiatrists and/or a collaborative care program for patients and relatives, plus a reminder system that works through the use of an already available high-quality medication reminder application.

STUDY DESIGN

MAPDep study is an open, multicenter, four-arm cluster randomized controlled trial. The clusters are mental health units where psychiatrists are invited to participate. The clusters are randomly allocated to one of the three interventions or to usual care (control arm). Patients (18-65 years of age) diagnosed with depressive disorder, those taking antidepressant medication for an existing diagnosis of depression, and mobile phone users are selected. In group 1, only patients and relatives receive intervention; in group 2, only psychiatrists receive intervention; and in group 3, patients/relatives and psychiatrists receive intervention. The primary outcome is adherence to the antidepressant drug. The calculated sample size is 400 patients. To examine changes across time, generalized linear mixed model with repeated measures will be used. A cost-effectiveness analysis will be conducted. The effectiveness measure is quality-adjusted life years. Deterministic sensitivity analyses are planned.

CONCLUSION

MAPDep study aims to assess a multicomponent strategy to improve adherence toward medications in patients with depression, based not only on clinical effectiveness but also on cost-effectiveness. This methodology will enhance the transferability of the expected results beyond mental health services (patients and psychiatrists) to health care policy decision making.

CLINICAL TRIAL IDENTIFIER

NCT03668457.

Effectiveness of a tailored training programme in behaviour change counselling for community pharmacists: A pilot study

OBJECTIVE

To undertake a pilot study assessing effectiveness of a tailored training programme in behaviour change counselling (BCC) for community pharmacists on, their competence and confidence in delivering behaviour change consultations, skill retention over time and impact on practice.

METHODS

Community pharmacists (N=87) attending Primary Care Trust training were given study information and invited to take part. Baseline BCC competence of consenting pharmacists (n=17) was assessed using the Behaviour Change Counselling Index (BECCI). Following BCC training, competence was reassessed at 1, 3 and 6 months. Friedman's test was used to compare median BECCI item scores at baseline and after 6 months. Structured interviews were conducted to assess pharmacists' confidence in BCC consultations after training.

RESULTS

Baseline BECCI scores of 0-2 demonstrated pharmacists had not reached competence threshold. Six months after training, BECCI scores improved significantly from baseline (p<0.05). Competence in delivering BCC (scores of 3-4) was achieved at 3 months, but lost at 6 months for some items. After training, pharmacists felt confident in delivering BCC.

CONCLUSION

Training pharmacists enabled them to deliver BCC competently and confidently.

PRACTICE IMPLICATIONS

BCC aligns with pharmacist-patient consultations. It took 3 months to achieve competence. Ongoing support may be needed to maintain competence long-term.

Physician-pharmacist collaborative care model for buprenorphine-maintained opioid-dependent patients

OBJECTIVES

To develop a physician-pharmacist collaborative practice for opioid-dependent patients designed to increase access to treatment, optimize patient care, reduce cost, minimize physician burden, and prevent diversion.

SETTING

Suburban health department.

PRACTICE DESCRIPTION

Physician-pharmacist buprenorphine/naloxone maintenance practice.

PRACTICE INNOVATION

Traditionally, health department buprenorphine/naloxone patients have been referred to community physicians at considerable cost with varying outcomes. In this pilot project, patients were managed using a drug therapy management model. Intake assessments and follow-up appointments were conducted by the pharmacist. The pharmacist debriefed with the physician and documented each interaction, allowing for efficient assessment completion. The physician appended notes, when applicable, and cosigned each patient's record. The pharmacist prevented diversion by gathering data from outside providers, pharmacies, and laboratories.

RESULTS

This health department program improved care by producing structure and expanding treatment options. A total of 12 patients completed full intakes with 135 follow-up appointments equating to an estimated savings of $22,000. The program demonstrated a 91% attendance rate, 100% 6-month retention rate, and 73% 12-month retention rate. Overall, 127 (98%) urine toxicology screens were positive for buprenorphine and 114 (88%) were positive for buprenorphine and negative for opioids.

CONCLUSION

Physician and pharmacist collaboration optimized care of buprenorphine-maintained patients. Data from this pilot were used to develop a permanent physician-pharmacist program and to obtain approval for the first state-approved opioid use disorder drug therapy management protocol.

Interventions for enhancing medication adherence

BACKGROUND

People who are prescribed self administered medications typically take only about half their prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications.

OBJECTIVES

The primary objective of this review is to assess the effects of interventions intended to enhance patient adherence to prescribed medications for medical conditions, on both medication adherence and clinical outcomes.

SEARCH METHODS

We updated searches of The Cochrane Library, including CENTRAL (via http://onlinelibrary.wiley.com/cochranelibrary/search/), MEDLINE, EMBASE, PsycINFO (all via Ovid), CINAHL (via EBSCO), and Sociological Abstracts (via ProQuest) on 11 January 2013 with no language restriction. We also reviewed bibliographies in articles on patient adherence, and contacted authors of relevant original and review articles.

SELECTION CRITERIA

We included unconfounded RCTs of interventions to improve adherence with prescribed medications, measuring both medication adherence and clinical outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive findings at earlier time points.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted all data and a third author resolved disagreements. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Pooling results according to one of these characteristics still leaves highly heterogeneous groups, and we could not justify meta-analysis. Instead, we conducted a qualitative analysis with a focus on the RCTs with the lowest risk of bias for study design and the primary clinical outcome.

MAIN RESULTS

The present update included 109 new RCTs published since the previous update in January 2007, bringing the total number of RCTs to 182; we found five RCTs from the previous update to be ineligible and excluded them. Studies were heterogeneous for patients, medical problems, treatment regimens, adherence interventions, and adherence and clinical outcome measurements, and most had high risk of bias. The main changes in comparison with the previous update include that we now: 1) report a lack of convincing evidence also specifically among the studies with the lowest risk of bias; 2) do not try to classify studies according to intervention type any more, due to the large heterogeneity; 3) make our database available for collaboration on sub-analyses, in acknowledgement of the need to make collective advancement in this difficult field of research. Of all 182 RCTs, 17 had the lowest risk of bias for study design features and their primary clinical outcome, 11 from the present update and six from the previous update. The RCTs at lowest risk of bias generally involved complex interventions with multiple components, trying to overcome barriers to adherence by means of tailored ongoing support from allied health professionals such as pharmacists, who often delivered intense education, counseling (including motivational interviewing or cognitive behavioral therapy by professionals) or daily treatment support (or both), and sometimes additional support from family or peers. Only five of these RCTs reported improvements in both adherence and clinical outcomes, and no common intervention characteristics were apparent. Even the most effective interventions did not lead to large improvements in adherence or clinical outcomes.

AUTHORS' CONCLUSIONS

Across the body of evidence, effects were inconsistent from study to study, and only a minority of lowest risk of bias RCTs improved both adherence and clinical outcomes. Current methods of improving medication adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. The research in this field needs advances, including improved design of feasible long-term interventions, objective adherence measures, and sufficient study power to detect improvements in patient-important clinical outcomes. By making our comprehensive database available for sharing we hope to contribute to achieving these advances.

Collaborative care for depression and anxiety problems

BACKGROUND

Common mental health problems, such as depression and anxiety, are estimated to affect up to 15% of the UK population at any one time, and health care systems worldwide need to implement interventions to reduce the impact and burden of these conditions. Collaborative care is a complex intervention based on chronic disease management models that may be effective in the management of these common mental health problems.

OBJECTIVES

To assess the effectiveness of collaborative care for patients with depression or anxiety.

SEARCH METHODS

We searched the following databases to February 2012: The Cochrane Collaboration Depression, Anxiety and Neurosis Group (CCDAN) trials registers (CCDANCTR-References and CCDANCTR-Studies) which include relevant randomised controlled trials (RCTs) from MEDLINE (1950 to present), EMBASE (1974 to present), PsycINFO (1967 to present) and the Cochrane Central Register of Controlled Trials (CENTRAL, all years); the World Health Organization (WHO) trials portal (ICTRP); ClinicalTrials.gov; and CINAHL (to November 2010 only). We screened the reference lists of reports of all included studies and published systematic reviews for reports of additional studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of collaborative care for participants of all ages with depression or anxiety.

DATA COLLECTION AND ANALYSIS

Two independent researchers extracted data using a standardised data extraction sheet. Two independent researchers made 'Risk of bias' assessments using criteria from The Cochrane Collaboration. We combined continuous measures of outcome using standardised mean differences (SMDs) with 95% confidence intervals (CIs). We combined dichotomous measures using risk ratios (RRs) with 95% CIs. Sensitivity analyses tested the robustness of the results.

MAIN RESULTS

We included seventy-nine RCTs (including 90 relevant comparisons) involving 24,308 participants in the review. Studies varied in terms of risk of bias.The results of primary analyses demonstrated significantly greater improvement in depression outcomes for adults with depression treated with the collaborative care model in the short-term (SMD -0.34, 95% CI -0.41 to -0.27; RR 1.32, 95% CI 1.22 to 1.43), medium-term (SMD -0.28, 95% CI -0.41 to -0.15; RR 1.31, 95% CI 1.17 to 1.48), and long-term (SMD -0.35, 95% CI -0.46 to -0.24; RR 1.29, 95% CI 1.18 to 1.41). However, these significant benefits were not demonstrated into the very long-term (RR 1.12, 95% CI 0.98 to 1.27).The results also demonstrated significantly greater improvement in anxiety outcomes for adults with anxiety treated with the collaborative care model in the short-term (SMD -0.30, 95% CI -0.44 to -0.17; RR 1.50, 95% CI 1.21 to 1.87), medium-term (SMD -0.33, 95% CI -0.47 to -0.19; RR 1.41, 95% CI 1.18 to 1.69), and long-term (SMD -0.20, 95% CI -0.34 to -0.06; RR 1.26, 95% CI 1.11 to 1.42). No comparisons examined the effects of the intervention on anxiety outcomes in the very long-term.There was evidence of benefit in secondary outcomes including medication use, mental health quality of life, and patient satisfaction, although there was less evidence of benefit in physical quality of life.

AUTHORS' CONCLUSIONS

Collaborative care is associated with significant improvement in depression and anxiety outcomes compared with usual care, and represents a useful addition to clinical pathways for adult patients with depression and anxiety.

Pharmaceutical care to patients treated with antidepressants

Depression is considered one of the ten most disabling conditions on the planet, causing physical, personal and social limitations. Antidepressants are the most commonly used drug treatment for eliminating or controlling the symptoms of depression. A variety of factors can contribute to treatment abandonment, particularly severe side effects. The present article is aimed to provide information and guidelines on the development of a pharmacotherapy follow-up program for patients treated with antidepressant medication. According to this practice, the pharmacist evaluates whether the three following requirements of a proper pharmacotherapy are being observed: need, effectiveness and safety. If one of these requirements is not met, the pharmacist seeks to solve the problem, by intervening in the pharmacotherapy, within the scope of his/her skills. Pharmaceutical care is aimed to improve adherence to treatment and minimize side effects, as well as the occurrence of drug interactions. Thus, the present article presents and discusses the main strategies of pharmaceutical care to achieve the proposed objectives.

Effectiveness of interventions to improve antidepressant medication adherence: a systematic review

Non-adherence to antidepressant medications is a significant barrier to the successful treatment of depression in clinical practice. This review aims to systematically assess the effectiveness of interventions for improving antidepressant medication adherence among patients with unipolar depression, and to evaluate the effect of these interventions on depression clinical outcomes. MEDLINE, PsycINFO and EMBASE databases were searched for English-language randomised controlled trials published between January 1990 and December 2010 on interventions to improve antidepressant adherence. The impact of interventions on antidepressant medication adherence (compliance and persistence) and depression clinical outcomes was evaluated. Data concerning the quality of the included studies were also extracted. Twenty-six studies met the inclusion criteria. Interventions were classified as educational, behavioural and multifaceted interventions. A total of 28 interventions were tested, as two studies investigated two interventions each. Sixteen (57%) of the 28 interventions showed significant effects on antidepressant adherence outcomes, whereas 12 (43%) interventions demonstrated significant effects on both antidepressant adherence and depression outcomes. The interventions which showed significant improvement in outcomes were primarily multifaceted and complex, with proactive care management and involvement of mental health specialists. The most commonly used elements of multifaceted interventions included patient educational strategies, telephone follow-up to monitor patients' progress, as well as providing medication support and feedback to primary care providers. Overall, educational interventions alone were ineffective in improving antidepressant medication adherence. In conclusion, improving adherence to antidepressants requires a complex behavioural change and there is some evidence to support behavioural and multifaceted interventions as the most effective in improving antidepressant medication adherence and depression outcomes. More carefully designed and well-conducted studies are needed to clarify the effect of interventions in different patient populations and treatment settings.

Does integrated care improve treatment for depression? A systematic review

Care management-based interventions promoting integrated care by combining primary care with mental health services in a coordinated and colocated manner are increasingly popular; yet, the benefits of specific approaches are not well established. We conducted a systematic review of integrated care trials in US primary care settings to assess whether the level of integration of provider roles or care process affects clinical outcomes. Although most trials showed positive effects, the degree of integration was not significantly related to depression outcomes. Integrated care appears to improve depression management in primary care patients, but questions remain about its specific form and implementation.

Does integrated care improve treatment for depression? A systematic review

Care management-based interventions promoting integrated care by combining primary care with mental health services in a coordinated and colocated manner are increasingly popular; yet, the benefits of specific approaches are not well established. We conducted a systematic review of integrated care trials in US primary care settings to assess whether the level of integration of provider roles or care process affects clinical outcomes. Although most trials showed positive effects, the degree of integration was not significantly related to depression outcomes. Integrated care appears to improve depression management in primary care patients, but questions remain about its specific form and implementation.

Effectiveness of Pharmacist Care in the Improvement of Adherence to Antidepressants: A Systematic Review and Meta-Analysis

Background

Pharmacists can play a decisive role in the management of ambulatory patients with depression who have poor adherence to antidepressant drugs.

Objective

To systematically evaluate the effectiveness of pharmacist care in improving adherence of depressed outpatients to antidepressants.

Methods

A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted. RCTs were identified through electronic databases (MEDLINE, Cochrane Central Register of Controlled Trials, Institute for Scientific Information Web of Knowledge, and Spanish National Research Council) from inception to April 2010, reference lists were checked, and experts were consulted. RCTs that evaluated the impact of pharmacist interventions on improving adherence to antidepressants in depressed patients in an outpatient setting (community pharmacy or pharmacy service) were included, Methodologic quality was assessed and methodologic details and outcomes were extracted in duplicate.

Results:

Six RCTs were identified. A total of 887 patients with an established diagnosis of depression who were initiating or maintaining pharmacologic treatment with antidepressant drugs and who received pharmacist care (459 patients) or usual care (428 patients) were included in the review. The most commonly reported interventions were patient education and monitoring, monitoring and management of toxicity and adverse effects, adherence promotion, provision of written or visual information, and recommendation or implementation of changes or adjustments in medication. Overall, no statistical heterogeneity or publication bias was detected. The pooled odds ratio, using a random effects model, was 1.64 (95% CI 1.24 to 2.17). Subgroup analysis showed no statistically significant differences in results by type of pharmacist involved, adherence measure, diagnostic tool, or analysis strategy.

Conclusions:

These results suggest that pharmacist intervention is effective in the improvement of patient adherence to antidepressants. However, data are still limited and we would recommend more research in this area, specifically outside of the US.

Quality Patient Care and Pharmacists' Role in Its Continuity—A Systematic Review

Background:

Continuity of care is important for the delivery of quality health care. Despite the abundance of research on this concept in the medical and nursing literature, there is a lack of consensus on its definition. As pharmacists have moved beyond their historical product-centered practice, a source of patient-centered research on continuity of care for practice application is required.

Objective:

To determine the scope of research in which pharmacists were directly involved in patients' continuity of care and to examine how the phrase continuity of care was defined and applied in practice.

Methods:

A working definition of continuity of care and a tool for relevance quality assessment of search articles were developed. MEDLINE, International Pharmaceutical Abstracts, EMBASE, and the Cochrane Collaboration evidence-based medicine reviews and bibliographies were searched (1996–March 2008). Reporting clarity was assessed by the Consolidated Standards of Reporting Trials checklist and outcomes were grouped by economic, clinical, and/or humanistic classification.

Results:

The search yielded 21 clinical and randomized controlled trials, including 11 pharmacist-only and 10 multidisciplinary studies. A broad range of research topics was identified and detailed analysis provided ready reference for considerations of research replication or practice application. Studies revealed a range of research aims, settings, subject characteristics, attrition rates and group sizes, interventions, measurement tools, outcomes, and definitions of continuity of care. Research focused on patients with depression (n = 4), cardiovascular disease {n = 4), diabetes (n = 2), and dyslipidemia (n = 1); specific drugs included non–tricyclic antidepressants, cardiovascular drugs, and benzodiazepines. From the proposed endpoints of economic cost (n = 6) and clinical (n = 14) and humanistic (n = 16) outcomes, 15 studies reported statistically significant results.

Conclusions:

Medication management at primary, secondary, and tertiary levels of care indicated an expanded role and collaboration of pharmacists in continuity of care. However, the exclusion of disadvantaged patients in 19 studies is at odds with continuity of care for these patients, who may have been the most in need for the same reason that they were excluded.

Interventions for enhancing medication adherence

BACKGROUND

People who are prescribed self-administered medications typically take less than half the prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications, but also might increase their adverse effects.

OBJECTIVES

To update a review summarizing the results of randomized controlled trials (RCTs) of interventions to help patients follow prescriptions for medications for medical problems, including mental disorders but not addictions.

SEARCH STRATEGY

We updated searches of The Cochrane Library, MEDLINE, CINAHL, EMBASE, International Pharmaceutical Abstracts (IPA), PsycINFO (all via OVID) and Sociological Abstracts (via CSA) in January 2007 with no language restriction. We also reviewed bibliographies in articles on patient adherence and articles in our personal collections, and contacted authors of relevant original and review articles.

SELECTION CRITERIA

Articles were selected if they reported an unconfounded RCT of an intervention to improve adherence with prescribed medications, measuring both medication adherence and treatment outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive initial findings.

DATA COLLECTION AND ANALYSIS

Study design features, interventions and controls, and results were extracted by one review author and confirmed by at least one other review author. We extracted adherence rates and their measures of variance for all methods of measuring adherence in each study, and all outcome rates and their measures of variance for each study group, as well as levels of statistical significance for differences between study groups, consulting authors and verifying or correcting analyses as needed. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Therefore, we did not feel that quantitative analysis was scientifically justified; rather, we conducted a qualitative analysis.

MAIN RESULTS

For short-term treatments, four of ten interventions reported in nine RCTs showed an effect on both adherence and at least one clinical outcome, while one intervention reported in one RCT significantly improved patient adherence, but did not enhance the clinical outcome. For long-term treatments, 36 of 81 interventions reported in 69 RCTs were associated with improvements in adherence, but only 25 interventions led to improvement in at least one treatment outcome. Almost all of the interventions that were effective for long-term care were complex, including combinations of more convenient care, information, reminders, self-monitoring, reinforcement, counseling, family therapy, psychological therapy, crisis intervention, manual telephone follow-up, and supportive care. Even the most effective interventions did not lead to large improvements in adherence and treatment outcomes.

AUTHORS' CONCLUSIONS

For short-term treatments several quite simple interventions increased adherence and improved patient outcomes, but the effects were inconsistent from study to study with less than half of studies showing benefits. Current methods of improving adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. High priority should be given to fundamental and applied research concerning innovations to assist patients to follow medication prescriptions for long-term medical disorders.

Systematic review of multifaceted interventions to improve depression care

OBJECTIVE

Depression is a prevalent high-impact illness with poor outcomes in primary care settings. We performed a systematic review to determine to what extent multifaceted interventions improve depression outcomes in primary care and to define key elements, patients who are likely to benefit and resources required for these interventions.

METHOD

We searched Medline, HealthSTAR, CINAHL, PsycINFO and a specialized registry of depression trials from 1966 to February 2006; reviewed bibliographies of pertinent articles; and consulted experts. Searches were limited to the English language. We included 28 randomized controlled trials that: (a) involved primary care patients receiving acute-phase treatment; (b) tested a multicomponent intervention involving a patient-directed component; and (c) reported effects on depression severity. Pairs of investigators independently abstracted information regarding (a) setting and subjects, (b) components of the intervention and (c) outcomes.

RESULTS

Twenty of 28 interventions improved depression outcomes over 3-12 months (an 18.4% median absolute increase in patients with 50% improvement in symptoms; range, 8.3-46%). Sustained improvements at 24-57 months were demonstrated in three studies addressing acute-phase and continuation-phase treatments. All interventions involved care management and required additional resources or staff reassignment to implement; interventions were delivered exclusively or predominantly by telephone in 16 studies. The most commonly used intervention features were: patient education and self-management, monitoring of depressive symptoms and treatment adherence, decision support for medication management, a patient registry and mental health supervision of care managers. Other intervention features were highly variable.

CONCLUSION

There is strong evidence supporting the short-term benefits of care management for depression; critical elements for successful programs are emerging.

Collaborative care for depression in primary care. Making sense of a complex intervention: systematic review and meta-regression

BACKGROUND

The management of depression in primary care is a significant issue for health services worldwide. "Collaborative care" interventions are effective, but little is known about which aspects of these complex interventions are essential.

AIMS

To use meta-regression to identify "active ingredients" in collaborative care models for depression in primary care.

METHOD

Studies were identified using systematic searches of electronic databases. The content of collaborative care interventions was coded, together with outcome data on antidepressant use and depressive symptoms. Meta-regression was used to examine relationships between intervention content and outcomes.

RESULTS

There was no significant predictor of the effect of collaborative care on antidepressant use. Key predictors of depressive symptom outcomes included systematic identification of patients, professional background of staff and specialist supervision.

CONCLUSIONS

Meta-regression may be useful in examining "active ingredients" in complex interventions in mental health.

Adherence to treatment in mood disorders

PURPOSE OF REVIEW

Nonadherence to medication is common in mood disorders. Improving adherence should decrease risk of relapse, improve outcome and lessen costs. Here we review recent qualitative and quantitative work in this area.

RECENT FINDINGS

Themes that emerged from qualitative studies for nonadherence are discomfort about psychiatric diagnoses, including denial of the illness, problematic side effects, fears around dependency and the view that medication was unhelpful following resolution of the acute phase. The psycho-educational intervention model alone has shown little improvement in adherence. The collaborative managed care model for improving outcomes in depression in primary care is of limited benefit in increasing adherence or indeed outcomes. Psychological approaches have been most successful when concentrating on the patient-clinician alliance when attitudes and experience are explored, recognizing the importance of the patient's opinion in treatment decisions. Psycho-pharmaceutical interventions such as changing medication preparations have potential efficacy.

SUMMARY

There are difficulties in assessing adherence and developing interventions. The majority of both qualitative and quantitative studies indicate that a collaborative approach when patients are involved in the decision-making process appear to be the most effective. The focus on trial driven, specialty-specific interventions may not be the most helpful way to investigate or improve adherence. This is a fertile area for qualitative work. Interventions that focus on the structure of care alongside increasing patient involvement in treatment have the most potential to improve adherence and hence outcome in mood disorders.

Patient education and treatment strategies implemented at a pharmacist-managed hepatitis C virus clinic

Hepatitis C virus (HCV) infection is a major public health concern. Approximately 4 million people in the United States have been infected with the virus, and up to 85% of them will develop chronic infection. Chronic HCV infection has often been associated with progression of hepatic fibrosis and, in some cases, cirrhosis and end-stage liver disease. The standard of care is combination therapy with pegylated interferon (peginterferon) alfa plus ribavirin. More than 50% of patients with HCV treated with combination therapy achieve a sustained viral response, defined as undetectable hepatitis C viral RNA 6 months after the end of therapy. Effective patient education and drug therapy management are critical in enabling patients to adhere to the treatment regimen, which is either 24 or 48 weeks long, depending on the virus strain. The drug regimen is associated with several possible adverse events as well as weekly subcutaneous administration (of peginterferon alfa). Frequent monitoring of patients and, often, adjustments in the dosage of one or both components of the therapy are necessary during the treatment course. Strategies used by clinical pharmacists at an HCV clinic are discussed that can facilitate a successful treatment outcome for patients with HCV treated with combination therapy, while enabling them to maintain a reasonable quality of life.

Community pharmacy services to optimise the use of medications for mental illness: a systematic review

The objective of this systematic review was to evaluate the impact of pharmacist delivered community-based services to optimise the use of medications for mental illness. Twenty-two controlled (randomised and non-randomised) studies of pharmacists' interventions in community and residential aged care settings identified in international scientific literature were included for review. Papers were assessed for study design, service recipient, country of origin, intervention type, number of participating pharmacists, methodological quality and outcome measurement. Three studies showed that pharmacists' medication counselling and treatment monitoring can improve adherence to antidepressant medications among those commencing treatment when calculated using an intention-to-treat analysis. Four trials demonstrated that pharmacist conducted medication reviews may reduce the number of potentially inappropriate medications prescribed to those at high risk of medication misadventure. The results of this review provide some evidence that pharmacists can contribute to optimising the use of medications for mental illness in the community setting. However, more well designed studies are needed to assess the impact of pharmacists as members of community mental health teams and as providers of comprehensive medicines information to people with schizophrenia and bipolar disorder

Interventions to enhance medication adherence

BACKGROUND

People who are prescribed self-administered medications typically take less than half the prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications, but also might increase their adverse effects.

OBJECTIVES

To update a review summarizing the results of randomized controlled trials (RCTs) of interventions to help patients follow prescriptions for medications for medical problems, including mental disorders but not addictions.

SEARCH STRATEGY

Computerized searches were updated to September 2004 without language restriction in MEDLINE, EMBASE, CINAHL, The Cochrane Library, International Pharmaceutical Abstracts (IPA), PsycINFO and SOCIOFILE. We also reviewed bibliographies in articles on patient adherence and articles in our personal collections, and contacted authors of original and review articles on the topic.

SELECTION CRITERIA

Articles were selected if they reported an unconfounded RCT of an intervention to improve adherence with prescribed medications, measuring both medication adherence and treatment outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive initial findings.

DATA COLLECTION AND ANALYSIS

Study design features, interventions and controls, and results were extracted by one reviewer and confirmed by at least one other reviewer. We extracted adherence rates and their measures of variance for all methods of measuring adherence in each study, and all outcome rates and their measures of variance for each study group, as well as levels of statistical significance for differences between study groups, consulting authors and verifying or correcting analyses as needed.

MAIN RESULTS

For short-term treatments, four of nine interventions reported in eight RCTs showed an effect on both adherence and at least one clinical outcome, while one intervention reported in one RCT significantly improved patient compliance, but did not enhance the clinical outcome. For long-term treatments, 26 of 58 interventions reported in 49 RCTs were associated with improvements in adherence, but only 18 interventions led to improvement in at least one treatment outcome. Almost all of the interventions that were effective for long-term care were complex, including combinations of more convenient care, information, reminders, self-monitoring, reinforcement, counseling, family therapy, psychological therapy, crisis intervention, manual telephone follow-up, and supportive care. Even the most effective interventions did not lead to large improvements in adherence and treatment outcomes. Six studies showed that telling patients about adverse effects of treatment did not affect their adherence.

AUTHORS' CONCLUSIONS

Improving short-term adherence is relatively successful with a variety of simple interventions. Current methods of improving adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. High priority should be given to fundamental and applied research concerning innovations to assist patients to follow medication prescriptions for long-term medical disorders.

The impact of a pharmacist intervention on 6-month outcomes in depressed primary care patients

The object of the study was to evaluate outcomes of a randomized clinical trial (RCT) of a pharmacist intervention for depressed patients in primary care (PC). We report antidepressant (AD) use and depression severity outcomes at 6-months. The RCT was conducted between 1998 and 2000 in 9 eastern Massachusetts PC practices. We studied 533 patients with major depression and/or dysthymia as determined by a screening test done at the time of a routine PC office visit. The majority of participants had recurrent depressive episodes (63.5% with >/=4 lifetime episodes), and 49.5% were taking AD medications at enrollment. Consultation in person and by telephone was performed by a clinical pharmacist who assisted the primary care practitioner (PCP) and patient in medication choice, dose, and regimen, in accordance with AHCPR depression guidelines. Six-month AD use rates for intervention patients exceeded controls (57.5% vs. 46.2%, P =.03). Furthermore, the intervention was effective in improving AD use rates for patients not on ADs at enrollment (32.3% vs. 10.9%, P =.001). The pharmacist intervention proved equally effective in subgroups traditionally considered difficult to treat: those with chronic depression and dysthymia. Patients taking ADs had better modified Beck Depression Inventory (mBDI) outcomes than patients not taking ADs, (-6.3 points change, vs. -2.8, P =.01) but the outcome differences between intervention and control patients were not statistically significant (17.7 BDI points vs. 19.4 BDI points, P =.16). Pharmacists significantly improved rates of AD use in PC patients, especially for those not on ADs at enrollment, but outcome differences were too small to be statistically significant. Difficult-to-treat subgroups may benefit from pharmacists' care.