US Pharm. 2006;11:62-68.

An estimated 15% to 17% of Americans--approximately 35 million people--will experience major depressive disorder (MDD) within their lifetime.1 However, this estimate might be low, since depression is often undiagnosed and untreated for a variety of reasons. Many patients who are diagnosed with depression and receive a prescription for pharmacotherapy are noncompliant with their medication regimen due to concerns or confusion about the diagnosis and treatment. Pharmacists have an opportunity to intervene and improve treatment adherence. This article discusses the role of the pharmacist in the management of depression, with a focus on effective communication.

Depression
MDD is defined as one or more episodes of major depression, without any signs of mania or hypomania.2-5 It affects people of all ages, with women diagnosed two to three times more often than men. MDD can result in decreased quality of life, impaired social skills, low self-esteem, reduced productivity, high health care resource utilization, and increased risk of suicide.5 Depressive symptoms can significantly interfere with a person's day-to-day functioning. Therefore, health care professionals should work diligently to identify and treat depression.

Risk factors for depression include adolescence or young adulthood, history of depression in a first-degree relative, personal history of depression, chronic illness, recent loss/bereavement, sleep disorders, chronic pain, and multiple unexplained somatic complaints.5

If a patient has one or more of these risks factors, he or she should be monitored for depression.5,6 The clinician should ask, "Over the past month, have you felt down, blue, depressed, or hopeless?" or "Over the past month, have you noticed a decreased interest in day-to-day life or a decreased pleasure in your usual activities?"6 These questions are often very sensitive at detecting depression. Also, it is often useful to interview the patient's family members, since the patient might minimize or exaggerate his or her symptoms when speaking with a health care provider. There are several useful questionnaires available that can be used to screen for depression. Many of these tools have an easy literacy level and are short and easy to complete (see Table 1).6,7

An MDD diagnosis is made based on Diagnostic and Statistical Manual of Mental Disorders, 4th edition criteria. To be diagnosed with depression, a patient must exhibit either a depressed mood or a diminished interest and pleasure in daily activities. These symptoms must be present most of the time for two or more weeks. Patients must also exhibit four or more of the following symptoms: pronounced change in appetite, weight loss or gain, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or excessive guilt, inability to think or concentrate; indecisiveness, or thoughts of death, dying, or suicide.2

Substances such as medications and drugs of abuse can cause many of these symptoms, so a complete medical and social history is important to rule out these causes.2,3 For example, hypersomnia, increased appetite, and weight gain are sometimes caused by first-generation antihistamines. Medications known to cause depression are listed in Table 2.4,5 Pharmacists can help identify depression by monitoring patients who are using these therapies for changes in mood and by referring a patient to a physician if depression is suspected.

A thorough interview, physical examination, and laboratory work-up should be conducted to rule out underlying medical disorders such as endocrine diseases, anemia, infection, autoimmune disorders, metabolic problems, cardiovascular diseases, neurological disorders, or malignancies. In addition, psychiatric disorders associated with depression (e.g., alcoholism, eating disorders, anxiety disorders) should be identified.3-5 A diagnosis of MDDcan be established if the symptoms are not secondary to a particular substance, underlying medical disorder, or bereavement.2-5



Depression and Chronic Illness
Many patients with chronic health conditions--such as cancer, heart disease, lung disease, or arthritis--experience depression.5 For instance, patients who have diabetes often become depressed or overwhelmed by their complex schedule of medications, blood glucose monitoring, foot exams, eye appointments, and physician visits. They may become frustrated with trying to eat healthfully, count carbohydrates, and avoid sweets. They may experience pain, sexual dysfunction, and other physical limitations. These frustrations can transition into sadness and despair, increasing the risk of MDD.

Unrecognized and untreated depression in a patient with a chronic condition might lead to loss of interest in optimal management or to poor adherence. Therefore, pharmacists should closely monitor all patients with chronic health conditions for any signs or symptoms of depression. 





The Patient Interview

When screening for depression, it is important for health care professionals to engage patients in an open dialogue about their emotions. Because many patients are self-conscious and reluctant to discuss their emotions with a health care professional, this dialogue should take place in a safe, private environment. Patients may fear being stigmatized because they have a mental illness. For instance, men who have been trained to hide their emotions and refrain from crying in front of people might downplay their depressive symptoms and avoid medical care. Health care professionals should counsel patients on the pathophysiology and clinical presentation of depression to help patients understand that depression is a "real" illness that requires management. When interviewing the patient, the pharmacist should be respectful, sensitive, and caring. Tissues should be available for the patient in case he or she becomes emotional during the discussion.

It is important to listen closely to the patient. Simple gestures such as maintaining eye contact and pausing often to reflect on what the patient has said indicate that you are interested. By paraphrasing the patient's words, the pharmacist can communicate an understanding of what the patient has described. It is OK to take notes; however, the patient should be informed before the interview that this will occur. Also, the pharmacist should be careful about writing while the patient is talking. If the patient perceives this behavior as a lack of interest or attention, he or she might shut down and stop communicating. Notes should be jotted down during breaks in the conversation.

It is important to show empathy when communicating with the patient. Comments such as "It must be very difficult to function at work when you are not able to sleep at night" are effective. If the pharmacist does not know what to say, repeating the patient's words--for example, "You feel lonely and isolated since you moved to this new town"--can be effective. Do not minimize anything the patient says, and resist the temptation to say, "Don't worry, everything will be OK." Such a statement can make the patient feel alienated. A better response is to convey to the patient that his or her concerns are understood.

Do not make assumptions, but ask probing questions to determine the patient's exact concerns. For instance, if the patient states, "This antidepressant medication just isn't working for me," an inappropriate response would be, "You probably just haven't given it a long enough time to work. It can take up to six to eight weeks to see the full clinical effect." However, the patient might respond to this statement with "I have been taking it for 12 weeks." Therefore, a more appropriate response to the patient's original statement might be, "You are concerned that the medication isn't effective. What are your expectations for this medication? How would you know if it was working? Why do you think it is not working?" This allows the pharmacist to explore the patient's expectations and identify areas that need to be addressed during the education session.

Many patients may not know what to expect from treatment. They may not understand that it can take two to four weeks--and at times, up to eight weeks--to see a clinical effect of the medication.8 As a result, some patients may abandon therapy if they do not experience immediate relief or if they experience a really "bad" day. It is important for patients to understand that if an antidepressant is discontinued too abruptly, rebound symptoms may occur. Furthermore, patients should be aware that they might experience side effects before they begin noting clinical efficacy. If patients are unaware of all these possibilities, they may be less likely to adhere to the medication. Therefore, it is important for patients to receive counseling on these issues when an antidepressant is initiated.

Some patients fear possible adverse effects such as insomnia, weight gain, or sexual dysfunction. A college student might be concerned about excessive somnolence that could interfere with studying. However, the patient's trepidation might be unwarranted if the prescribed medication has a low risk of this adverse effect. Thus, it is important to discuss the possible adverse effects of the specific product that is being dispensed. The patient should understand how to monitor for safety and when to report any unwanted effects to his or her pharmacist or physician. 

Patients in lower socioeconomic brackets might have difficulty accessing treatment. Low health literacy, low income, no health insurance, transportation problems, language barriers, and various other challenges can limit a patient's access to treatment.9 It is important for the pharmacist to be sensitive to these issues when facilitating care.

 

Addressing Adherence: It is important for health care professionals to help improve patient adherence to pharmacotherapy and psychotherapy. It is important to help patients understand the disease state and how a particular medication works. Patients should know how to monitor for efficacy by watching for improvement in the symptoms that they exhibited at the time of diagnosis.

One effective communication strategy that pharmacists can use to improve adherence is the ESFT communication approach. This communication strategy has four domains:9

E is for Explain and Explore. The pharmacist should explore the patient's understanding of depression by asking the patient to describe the nature of the disorder and of his or her symptoms. The following open-ended questions can help guide this discussion: "What did your doctor tell you about your illness? What symptoms of depression are you experiencing? How has this illness impacted your life? What do you think caused your depression? Why do you think you are taking this medication? How long have you experienced these symptoms? How long do you think you will have this condition?"

S is for Social and Financial Barriers to Adherence. If the patient is concerned about the social stigma of the medication or has any preconceived bias toward treatment, he or she might not be adherent. If the patient has no time for physician follow-up, has transportation challenges, or lacks a support network, he or she might not take the prescribed medication. In addition, if the patient does not have insurance or has limited financial resources, he or she might not be able to afford the prescribed regimen. Therefore, it is important to explore these points with the following probes: "Describe any concerns you have about taking this medication. Are you more concerned about cost or adverse effects? Why? How do you plan to pay for your prescription? Describe any barriers you might have to continued treatment. Are you concerned about what people might think if they learn you are taking a medication for depression? Why?"

F is for Fears. It is important for the pharmacist to explore any concerns or fears that the patient might have about the medication's efficacy or adverse effects. The following questions should be asked: "What do you expect this medication to do for you? How will you monitor efficacy of this medication? What are your concerns about side effects? Describe any concerns that you have about this medication interfering with your day-to-day life. Do you worry about becoming dependent on this medication?"

T is for Therapeutic Contracting and Playback. The pharmacist should assess the patient's commitment to medication adherence and understanding of counseling points that have been covered. If any barriers to adherence are identified at any step of this process, it is important to resolve them by contacting the prescribing clinician and discussing the patient's concerns. The pharmacist might suggest treatment alternatives that might be more successful. The following probes/questions should be asked to ensure the patient's understanding: "Describe how you plan to take this medication. How will you monitor for efficacy? How long will it take for this medication to begin working? What are the possible side effects? When will you contact your physician or pharmacist if you are concerned?"

Patients should be closely monitored when a new antidepressant is initiated or the dose is adjusted.10 The patient and family members should understand the importance of monitoring closely for any worsening of depressive symptoms, increased anxiety, agitation, panic attacks, irritability, insomnia, hostility, or suicidal ideation, because this might indicate an increased risk of suicide.

Conclusion
Depression is a prevalent disorder that impacts millions of Americans of every age, gender, ethnicity, and socioeconomic class. Pharmacists can play an important role in improving patient adherence by communicating sensitively and effectively with their patients to identify and resolve adherence barriers and provide patient counseling.

REFERENCES

1. Kessler RC, Berglund P, Demler O, et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA. 2003;289:3095-3105.

2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders.  4th ed. Washington, D.C.: American Psychiatric Association; 1994.

3. Remick RA. Diagnosis and management of depression in primary care: a clinical update and review. CMAJ. 2002;167:1253-1260.

4. Birrer RB, Vemuri SP. Depression in later life: a diagnostic and therapeutic challenge. Am Fam Physician. 2004;69:2375-2382.

5. Kando JC, Wells BG, Hayes PE. Depressive disorders. In: Dipiro JT, Talbert RL, Yee GC, et al., eds. Pharmacotherapy: A Pathophysiologic Approach. 6th ed. New York: McGraw-Hill; 2005:1235-1255.

6. DISEASEDEX™ Depression Prevention and Screening. [intranet database]. Version 5.1. Greenwood Village, Colo: Thomson Micromedex.

7. Watson LC, Pignone MP.  Screening accuracy for late-life depression in primary care: a systematic review. J Fam Pract. 2003;52:956-964.

8. Fleck MP, Horwath E. Pharmacologic management of difficult-to-treat depression in clinical practice. Psychiatr Serv. 2005;56:1005-1011.

9. Lewis-Fernandez R, Das AK, Alfonso C, et al. Depression in US Hispanics: diagnostic and management considerations in family practice. J Am Board Fam Pract. 2005;18:282-296.

10. DISEASEDEX™ Studies and Alerts. FDA advises changes in warning labels on antidepressants used for treating adults and children. [intranet database]. Version 5.1. Greenwood Village, Colo: Thomson Micromedex.

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