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.
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