Evaluation of a pharmacist intervention on patients initiating pharmacological treatment for depression: a randomized controlled superiority trial

The evolving role of pharmacists in depression care: a scoping review

BACKGROUND

Worldwide, depression is known to contribute significantly to the global burden of disease. Considering pharmacists are among the most approachable healthcare providers, they are well-placed to assist people with depression achieve positive treatment outcomes.

AIM

The primary aim was to examine the evidence regarding pharmacists' roles in interventions, outcomes, and barriers to implementation within depression care globally, with the secondary aim focusing on the Arab region.

METHOD

A scoping review was conducted according to the PRISMA-ScR extension guidelines and the Joanna Briggs Institute framework, using Scopus, Cochrane, ProQuest, and Medline databases for studies worldwide and within the Arab region (22 Arab-league countries). Article selection, along with data extraction, analysis, and narrative synthesis were performed independently by two reviewers. Discrepancies were resolved by consensus.

RESULTS

Forty studies reporting various roles and services provided by pharmacists in depression management were included. Most articles (24) described studies on pharmacist-led specific/single interventions/management strategies, and 16 described studies in which pharmacists provided comprehensive or team-based services. The majority of studies reported positive impact on patient outcomes. In accordance with the secondary aim, only three studies assessed various pharmacists' services for people with depression in the Arab region. Barriers to effective depression-related care included time constraints and training needs.

CONCLUSION

This scoping review supports the expanding role of pharmacists in depression management. The interventions, impact, challenges, and research gaps identified serve as preliminary evidence for advocating for an expanded pharmacists' scope of practice in mental health, both globally and in the Arab region.

Pharmaceutical Care in Mental Health: Pharmacists' Barriers, Collaborations, Attitudes, and Perceptions

Background

Pharmaceutical care is an essential component of mental healthcare.

Objectives

The study assessed pharmacists' collaborations, barriers, perceptions on therapeutic relationships and attitudes toward pharmaceutical care to persons with mental illness.

Methods

A questionnaire-based descriptive cross-sectional survey was conducted among 175 pharmacists in a Nigerian state via purposive sampling. Average mean score of >3 (±SD) was considered positive attitude toward pharmaceutical care, and positive for respondents' perception of pharmacists-patient relationship during consultations. Data were analyzed using SPSS version 25.0 for descriptive statistics.

Results

A total of 140 (80.0%) respondents participated in the study. Access to patients' medical records 90 (64.3%) was the major barrier to the provision of pharmaceutical care to persons with mental illness. Almost half of the study participants 69 (49.3%) desired collaboration with only general practitioners and psychiatrists. Only 44 (31.4%) had full co-operation from their desired collaborators. Average score for respondents' attitude toward provision of pharmaceutical care to the patients, and perception of pharmacist-patient relationship were 4.5 (±0.7) and 3.8 (±0.9) respectively.

Conclusions

Study participants' attitude toward pharmaceutical care, and perception on therapeutic relationship in persons with mental disorder were positive. Lack of access to patients' records mostly hindered provision of pharmaceutical care, and full collaboration with other mental health experts was mostly lacking. Appropriate policies are required to improve these vital components of mental healthcare for desired outcomes.

Beyond satisfaction in person-centered pharmacy services

Patient self-reported satisfaction is commonly used as an assessment of service experience and quality for community pharmacy services. This commentary discusses alternative foundational approaches to evaluating service experience and quality in patient-centered care. It describes historical and recent literature pertaining to the development and use of satisfaction measures for service design and patient experience assessment. It then highlights potential limitations of patient satisfaction as an assessment tool for patient-centeredness and patient experience identified in the pharmacy literature, which include criticisms that use of patient satisfaction may compromise accuracy in measuring quality due to factors such as patients having poor knowledge of and low expectations for quality and having a predisposition toward rating satisfaction highly when experiencing no-cost and/or unfamiliar services. Moreover, satisfaction measurements may change based on service exposure, with patient preferences for service offerings changing with increased service exposure and variation in patient-specific and environmental factors. After discussing limitations and criticism of patient self-reported satisfaction, we introduce alternative assessments methods which may facilitate more accurate assessments of patient experience and patient-centered pharmacy services such as patient-reported outcomes measures (PROMs), patient-reported experience measures (PREMs), and human-centered design techniques such as journey mapping, prototyping, and user testing to design and assess patient-centered pharmacy services. These alternative assessments are rooted in, or related to preferred implementation science approaches to establishing, evaluating, and sustaining pharmacy services.

Association of pharmacist intervention counseling with medication adherence and quality of life: A systematic review and meta-analysis of randomized trials

OBJECTIVE(S)

To assess the association between pharmacist intervention counseling with medication adherence and quality of life. Also, to assess if these associations vary by the focus, structure, training, or robustness of the counseling.

METHODS

The initial search identified 1805 references, of which 62 randomized trials (RCTs) met inclusion criteria for the systematic review. Of the 62 RCTs, 60 (with 62 results) had extractable data for the meta-analysis. Data were pooled using a random-effects model.

RESULTS

Most study patients were older and taking multiple prescription drugs. The pooled results showed a statistically significant increase in the odds of medication adherence with the pharmacist counseling intervention versus no counseling (pooled odds ratio [OR] = 4.41; 95% confidence interval [CI] 2.46-7.91; P < 0.01). The results of a subgroup analysis suggest the primary disease, counseling focus, location, and robustness may modify the effect of pharmacist counseling on medication adherence. There was a statistically significant improvement in the quality of life with pharmacist counseling versus no pharmacist counseling (pooled standardized mean difference [SMD] = 0.69; 95% CI 0.41-0.96; P < 0.01). The results of a subgroup analysis suggest that counseling focus, location, training, robustness, and the measurement method, but not the disease category, may modify the effect of pharmacist counseling on quality of life.

CONCLUSION

The evidence supports pharmacist intervention counseling to increase mediation adherence and quality of life. The counseling location and structure may be significant factors in improving medication adherence. The overall methodological quality of evidence was very low.

Understanding the medication safety challenges for patients with mental illness in primary care: a scoping review

BACKGROUND

Mental illness and medication safety are key priorities for healthcare systems around the world. Despite most patients with mental illness being treated exclusively in primary care, our understanding of medication safety challenges in this setting is fragmented.

METHOD

Six electronic databases were searched between January 2000-January 2023. Google Scholar and reference lists of relevant/included studies were also screened for studies. Included studies reported data on epidemiology, aetiology, or interventions related to medication safety for patients with mental illness in primary care. Medication safety challenges were defined using the drug-related problems (DRPs) categorisation.

RESULTS

Seventy-nine studies were included with 77 (97.5%) reporting on epidemiology, 25 (31.6%) on aetiology, and 18 (22.8%) evaluated an intervention. Studies most commonly (33/79, 41.8%) originated from the United States of America (USA) with the most investigated DRP being non-adherence (62/79, 78.5%). General practice was the most common study setting (31/79, 39.2%) and patients with depression were a common focus (48/79, 60.8%). Aetiological data was presented as either causal (15/25, 60.0%) or as risk factors (10/25, 40.0%). Prescriber-related risk factors/causes were reported in 8/25 (32.0%) studies and patient-related risk factors/causes in 23/25 (92.0%) studies. Interventions to improve adherence rates (11/18, 61.1%) were the most evaluated. Specialist pharmacists provided the majority of interventions (10/18, 55.6%) with eight of these studies involving a medication review/monitoring service. All 18 interventions reported positive improvements on some medication safety outcomes but 6/18 reported little difference between groups for certain medication safety measures.

CONCLUSION

Patients with mental illness are at risk of a variety of DRPs in primary care. However, to date, available research exploring DRPs has focused attention on non-adherence and potential prescribing safety issues in older patients with dementia. Our findings highlight the need for further research on the causes of preventable medication incidents and targeted interventions to improve medication safety for patients with mental illness in primary care.

Global Advancement in Pharmacy Services for Mental Health: A Review for Evidence-Based Practices

The symptoms of psychiatric infirmities have variability, and selected drug regimens for mental illness are comparatively complex and individualized; therefore, pharmacy services vary with respect to patients, diseases, healthcare settings, community structures, and countries. Clinical pharmacy services for mental health (MH) are continuously being upgraded. A structured search of the literature was performed in the Cochrane, PubMed (Medline), PsycINFO, Google scholar, Scopus, Science Direct, and Springer Links databases. The title and abstract of each retrieved article were evaluated for relevance. To remove uncertainty and ambiguity, the full-text articles were retrieved and examined for relevance. The articles were further assessed on the basis of inclusion and exclusion criteria. Narrative synthesis was performed, creating new categories and relevant subcategories and further subsections. The articles and the results were assessed for quality and bias. Pharmacists have a range of expertise in psychiatric care. The services can be classified as conventional, extended, and advanced pharmacy services. Conventional services include the quality use of medicines in healthcare settings and medication support services in communities that ensure medication adherence. Pharmacists perform extended roles in collaborative medication therapy management, multidisciplinary community mental health teams, collaborative care, patient education, home medication review, hospital-to-home transit, and screening services. In the USA, the role of pharmacists was advanced by prescribing as collaborative and interim prescribers. Australia launched an accredited program for psychiatric first-aid pharmacists. Pharmacists can provide mental care to rural populations using health technology. The role of pharmacists in MH is appreciated either independently or as a team member. Patients and healthcare providers rank the services of pharmacists in MH highly. Still, there is a margin for improvement in the training of pharmacists. Pharmacists cannot provide sufficient time to their patients. Public awareness about the role of pharmacists in MH needs more attention. Moreover, the training of psychiatric pharmacists should be standardized around the world.

The Impact of Pharmacist-Led Medication Management Services on the Quality of Life and Adverse Drug Reaction Occurrence

The aim of this research was to assess the impact of comprehensive medication management (CMM) services on patients’ health-related quality of life (HRQoL) and frequency of adverse drug reactions (ADRs) in older patients with cardiovascular diseases (CVDs). A prospective, pre- and post-intervention study with a one-year follow-up was conducted at the Health Care Centre Zagreb—Centre (HCZC). The Euro-Quality of Life Questionnaire 5 Dimensions 5 Levels (EQ-5D-5L) was used to measure the HRQoL at baseline (initial visit at the HCZC) and 12 months following CMM services. The ADRs collected at the initial assessment of the CMM services and throughout follow-up consultations were analyzed according to the occurrence mechanism, seriousness, expectedness and distribution of the Preferred Term according to the System Organ Class. Following the CMM intervention, 65 patients reported significant improvement in dimensions “self-care” (p = 0.011) and “usual activities” (p = 0.003), whereas no significant change was found in the “mobility” (p = 0.203), “pain/discomfort” (p = 0.173) and “anxiety/depression” (p = 0.083) dimensions and the self-rated VAS scale (p = 0.781). A total of 596 suspected ADR reports were found, the majority at patients’ initial assessment (67.3%), with a mean ± SD of 9.2 ± 16.9 per patient. The CMM services significantly reduced the rate of suspected ADRs, namely 2.7 ± 1.7 ADRs per patient at the initial assessment vs. 1.0 ± 1.5 ADRs per patient at the last consultation (p < 0.001). The obtained results indicate that CMM services may improve patients’ HRQoL. Additionally, as CMM services diminished the proportion of ADRs following 1-year patient follow-up, they may serve as a viable solution for safety management.

Impact of Pharmacist Intervention on Medication Adherence and Patient-Reported Outcomes among Depressed Patients in a Private Psychiatric Hospital of Nepal: a randomised controlled trial

Aim: We aimed to evaluate the impact of pharmaceutical service intervention on medication adherence and patient-reported outcomes among patients diagnosed with depression in a private psychiatric hospital in Nepal. Methods: A single-center, open trial with a parallel design was conducted among 18 to 65 years aged patients, diagnosed with depression and under antidepressant medication(s) for ≥2 months. Patients were randomised into either the intervention or control group. The control group (n = 98) received the usual care, while the intervention group (n = 98) received a pharmaceutical service intervention. The two groups were compared using the Mann-Whitney U test, independent t-test, or chi-square test at 2 and 4 months for changes in medication adherence and patient-reported [severity of depression and health-related quality of life (HRQoL)] outcomes. Results: One hundred ninety adult patients were enrolled in the study. At baseline, there were no significant differences in any of the outcome measures between the intervention and control groups. At 2 and 4 months, the intervention group had a significant improvement only in medication adherence (P < .001) compared with the control group [MGL score: 1 (2) vs 2 (2) and 1 (1) vs 2 (1), P < .001, respectively]. Conclusion: Our study suggests that a brief pharmaceutical service intervention in the hospital setting can have a significant impact on patients' adherence to antidepressants but does not improve their severity of depression and HRQoL.

Impact of Pharmacist Activities in Patients With Depression: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Depression is a substantial health burden. Pharmacist activities may help improve health outcomes of patients with depression when comparing to current practice with no pharmacist-involved intervention.

OBJECTIVE

To systematically review and analyze randomized controlled trials assessing the impact of pharmacist services on patients with depression compared to usual care using a meta-analysis approach.

METHODS

Four international and 3 domestic electronic databases were systematically searched. Data from database inception to December 2019 were included. Studies were selected using predefined inclusion criteria, and quality was assessed using the risk-of-bias criteria. Pooled estimation was analyzed to report the relative risk (RR) and standard mean difference (SMD). The meta-analysis used the random-effect model when heterogeneity was observed between studies.

RESULTS

A total of 12 eligible studies with 2133 patients with depression were included in the analysis. The relevant pharmacist interventions included medication therapy management, adherence counseling, and educational advice about depression and antidepressants. Pooled data in the meta-analysis showed a significantly increased number of patients with good adherence (RR = 1.39; 95% CI = 1.11 to 1.75) and improved medication adherence score (SMD = 0.32; 95% CI = 0.07 to 0.56) associated with pharmacist activities compared to usual care. No significant differences were detected in clinical rating scales (SMD = -0.03; 95% CI = -0.16 to 0.10) and quality of life (SMD = 0.10; 95% CI = -0.04 to 0.25).

CONCLUSION AND RELEVANCE

This review suggests that the role of pharmacists in patients with depression has a positive impact on medication adherence.

Development of a primary care pharmacy outcomes framework: An umbrella literature review

BACKGROUND

An aging population and rising multi-morbidity has shifted healthcare provision from secondary to primary care. Pharmacy-led services have been introduced to support this. The development of an outcomes framework for these services would facilitate conclusions to be drawn on their effectiveness.

OBJECTIVES

To identify outcomes used to evaluate pharmacy-led medication therapy and disease management services within primary care settings to develop an outcomes framework for future studies.

METHODS

An umbrella literature review was conducted. MEDLINE, EMBASE, The Cochrane Library and PsycINFO were searched in June 2020 to identify relevant articles. Eligible reviews were those including studies published from 2010 onwards which reported on the outcomes of pharmacy-led medication therapy and disease management services within primary care, excluding community pharmacy settings. Data were extracted and a content analysis, guided by the ECHO model, stratified the outcomes into four areas: economic, clinical, humanistic and service.

RESULTS

Twenty-four reviews covering 52 unique studies were identified. Pharmacy-led services included: medication reviews (n=24, 46.2%), disease and therapy management (n=17, 32.7%), educational services (n=6, 11.5%), medicines reconciliation (n=3, 5.8%), and medication compliance support (n=1, 1.9%). Services were commonly targeted towards endocrine (n=23, 44.2%) or cardiovascular diseases (n=20, 38.5%). Outcomes most commonly explored were clinical (n=38, 73.1%) and service outcomes (n=37, 71.2%), followed by humanistic (n=23, 44.2%) and economic outcomes (n=13, 25.0%). Overall, 17 sub-categories of outcomes were identified; common sub-categories were: disease indicators [clinical]; medication use and healthcare utilisation [service]; adherence to medicines [humanistic]; and healthcare costs [economic].

CONCLUSIONS

The findings informed the development of an outcomes framework to guide the evaluation of medication therapy and disease management services, and facilitate international standardised outcome measures within primary care pharmacy to be developed. This could help offer vital evidence on the effectiveness of these services to ensure the pharmacy workforce is working optimally to support primary care.

Impact of pharmacist intervention on antidepressant medication adherence and disease severity in patients with major depressive disorder in fragile north-east Nigeria

Objectives

Medication adherence is emerging as a major public health challenge particularly in patients with depression. The aim of this study was to explore the usefulness of a pharmacist intervention to improve antidepressant medication adherence and disease severity in patients with major depressive disorder.

Methods

This prospective interventional study was conducted between April 2019 and March 2020 among 101 patients at the Federal Neuro-Psychiatric Hospital, Maiduguri, Nigeria. Consenting patients were randomised into usual care or intervention groups using a computer-generated list. Data were collected at baseline, 3 months and 6 months. Medication adherence and depression severity were assessed using the Medication Adherence Rating Scale and Beck Depression Inventory respectively.

Key findings

At baseline, both the usual care and intervention groups had low mean scores for medication adherence [5.22 (SD = 1.51) versus 5.46 (SD = 1.46)] and high mean scores for depression severity [24.16 (SD = 13.50) versus 27.07 (SD = 16.12)]. At 6 months, there was a significant difference (P &lt; 0.001) between the mean medication adherence scores of 5.22 (SD = 1.90) and 9.15 (SD = 1.62), in the usual care and intervention groups respectively. A significant difference (P = 0.033) was also observed at 6 months between the mean depression severity scores of the usual care and intervention groups [21.40 (SD = 11.52) and 17.34 (SD = 6.96)]. Medication adherence (P &lt; 0.001, Partial eta squared = 0.279) and depression severity (P &lt; 0.001, Partial eta squared = 0.170) positively changed with time in the presence of the intervention.

Conclusions

The intervention significantly improved antidepressant medication adherence and disease severity in patients with major depressive disorder.

A systematic review of community pharmacy initiatives to improve treatment of depression and pain: Focus on types of programs and patient-reported outcomes

INTRODUCTION

Depression and pain are common, disabling, mutually exacerbating conditions. Many patients living with these conditions present to community pharmacies on a regular schedule to purchase both prescribed and over-the-counter medications. Community-pharmacy based programs have been developed to improve depression and pain outcomes.

METHODS

The PRISMA guidelines were utilized to answer the following question: In patients with depression and/or pain, what is the effect of the existing community pharmacy programs on depression and/or pain outcomes. Queried databases included Pubmed, EMBASE, and PsychINFO. DistillerSR was used to organize the screening, abstraction, and review of data. All potential articles were evaluated by two authors, and conflicts were discussed to achieve resolution. In addition to primary outcomes, sources of potential bias and quality indicators were abstracted for every article.

RESULTS

Three thousand nine hundred and twenty articles were reviewed, and 13 studies met eligibility criteria (n = 7 for depression; n = 6 for pain). Most studies demonstrated improvement in measures of depression or pain. However, compared to usual care or other control conditions, most of the depression and pain-specific interventions did not provide additional symptomatic benefit. The community pharmacy-based interventions were superior for other outcomes including medication adherence, reducing stigma, improvement in self-efficacy, and improvement in general management of disease.

CONCLUSION

Community pharmacies may be uniquely positioned to deliver interventions that improve outcomes associated with successful depression and pain treatment outcomes. However, the benefits of published community pharmacy-based treatments for actually improving depression and pain severity has not yet been established. Innovative interventions and additional research may be needed to achieve clinical success for pharmacy interventions for depression and pain.

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.

Community pharmacy interventions for health promotion: effects on professional practice and health outcomes

BACKGROUND

Community pharmacies are an easily accessible and cost-effective platform for delivering health care worldwide, and the range of services provided has undergone rapid expansion in recent years. Thus, in addition to dispensing medication, pharmacy workers within community pharmacies now give advice on a range of health-promoting behaviours that aim to improve health and to optimise the management of long-term conditions. However, it remains uncertain whether these health-promotion interventions can change the professional practice of pharmacy workers, improve health behaviours and outcomes for pharmacy users and have the potential to address health inequalities.

OBJECTIVES

To assess the effectiveness and safety of health-promotion interventions to change community pharmacy workers' professional practice and improve outcomes for users of community pharmacies.

SEARCH METHODS

We searched MEDLINE, Embase, CENTRAL, six other databases and two trials registers to 6 February 2018. We also conducted reference checking, citation searches and contacted study authors to identify any additional studies.

SELECTION CRITERIA

We included randomised trials of health-promotion interventions in community pharmacies targeted at, or delivered by, pharmacy workers that aimed to improve the health-related behaviour of people attending the pharmacy compared to no treatment, or usual treatment received in the community pharmacy. We excluded interventions where there was no interaction between pharmacy workers and pharmacy users, and those that focused on medication use only.

DATA COLLECTION AND ANALYSIS

We used standard procedures recommended by Cochrane and the Effective Practice and Organisation of Care review group for both data collection and analysis. We compared intervention to no intervention or to usual treatment using standardised mean differences (SMD) and 95% confidence intervals (95% CI) (higher scores represent better outcomes for pharmacy user health-related behaviour and quality of life, and lower scores represent better outcomes for clinical outcomes, costs and adverse events). Interpretation of effect sizes (SMD) was in line with Cochrane recommendations.

MAIN RESULTS

We included 57 randomised trials with 16,220 participants, described in 83 reports. Forty-nine studies were conducted in high-income countries, and eight in middle-income countries. We found no studies that had been conducted in low-income countries. Most interventions were educational, or incorporated skills training. Interventions were directed at pharmacy workers (n = 8), pharmacy users (n = 13), or both (n = 36). The clinical areas most frequently studied were diabetes, hypertension, asthma, and modification of cardiovascular risk. Duration of follow-up of interventions was often unclear. Only five studies gave details about the theoretical basis for the intervention, and studies did not provide sufficient data to comment on health inequalities. The most common sources of bias were lack of protection against contamination - mainly in individually randomised studies - and inadequate blinding of participants. The certainty of the evidence for all outcomes was moderate. We downgraded the certainty because of the heterogeneity across studies and evidence of potential publication bias. Professional practice outcomes We conducted a narrative analysis for pharmacy worker behaviour due to high heterogeneity in the results. Health-promotion interventions probably improve pharmacy workers' behaviour (2944 participants; 9 studies; moderate-certainty evidence) when compared to no intervention. These studies typically assessed behaviour using a simulated patient (mystery shopper) methodology. Pharmacy user outcomes Health-promotion interventions probably lead to a slight improvement in health-related behaviours of pharmacy users when compared to usual treatment (SMD 0.43, 95% CI 0.14 to 0.72; I² = 89%; 10 trials; 2138 participants; moderate-certainty evidence). These interventions probably also lead to a slight improvement in intermediate clinical outcomes, such as levels of cholesterol or glycated haemoglobin, for pharmacy users (SMD -0.43, 95% CI -0.65 to -0.21; I² = 90%; 20 trials; 3971 participants; moderate-certainty evidence). We identified no studies that evaluated the impact of health-promotion interventions on event-based clinical outcomes, such as stroke or myocardial infarction, or the psychological well-being of pharmacy users. Health-promotion interventions probably lead to a slight improvement in quality of life for pharmacy users (SMD 0.29, 95% CI 0.08 to 0.50; I²= 82%; 10 trials, 2687 participants; moderate-certainty evidence). Adverse events No studies reported adverse events for either pharmacy workers or pharmacy users. Costs We found that health-promotion interventions are likely to be cost-effective, based on moderate-certainty evidence from five of seven studies that reported an economic evaluation.

AUTHORS' CONCLUSIONS

Health-promotion interventions in the community pharmacy context probably improve pharmacy workers' behaviour and probably have a slight beneficial effect on health-related behaviour, intermediate clinical outcomes, and quality of life for pharmacy users. Such interventions are likely to be cost-effective and the effects are seen across a range of clinical conditions and health-related behaviours. Nevertheless the magnitude of the effects varies between conditions, and more effective interventions might be developed if greater consideration were given to the theoretical basis of the intervention and mechanisms for effecting behaviour change.

Cost-effectiveness of antidepressants versus active monitoring for mild-to-moderate major depressive disorder: a multisite non-randomized-controlled trial in primary care (INFAP study)

BACKGROUND

The purpose of this study was to evaluate the cost-effectiveness of antidepressants vs active monitoring (AM) for patients with mild-moderate major depressive disorder.

METHODS

This was a 12-month observational prospective controlled trial. Adult patients with a new episode of major depression were invited to participate and assigned to AM or antidepressants according to General Practitioners' clinical judgment and experience. Patients were evaluated at baseline, and 6 and 12-month follow-up. Quality-adjusted life years (QALYs) gained were estimated and used to calculate incremental cost-utility ratios (ICUR) from the healthcare and government perspective. To minimize the bias resulting from non-randomization, a propensity score-based method was used.

RESULTS

At 6 and 12-month follow-up, ICUR was 2549 €/QALY and 6,142 €/QALY, respectively, in favor of antidepressants. At 6 months, for a willingness to pay (WTP) of 25,000 €/QALY, antidepressants had a probability of 0.89 (healthcare perspective) and 0.81 (government perspective) of being more cost-effective than AM. At 12 months, this probability was 0.86 (healthcare perspective) and 0.73 (government perspective).

CONCLUSIONS

Incremental cost-utility ratios favor pharmacological treatment as a first-line approach for patients with mild-moderate major depressive disorder. While our results should be interpreted with caution and further real world research is needed, clinical practice guidelines should consider antidepressant therapy for mild-moderate major depressive patients as an alternative to active monitoring in PC.

General practitioner-pharmacist collaboration in Germany: an explanatory model

Background In Germany, no validated measure and model of pharmacist-physician collaboration existed. Objectives To provide evidence for the factor structure of the previously validated Frequency of Inter-professional Collaboration Instrument and the Attitudes Toward Collaboration Instrument in measuring attitudes toward and frequency of collaboration from the general practitioner's perspective in the context of primary care in Germany; to develop an explanatory model which illustrates factors influencing collaboration. Setting The study was conducted in the primary health care sector in Mecklenburg-Western Pomerania, Germany with a cohort of general practitioners. Method The two measures were translated into German and the survey was administered to 1438 practitioners. Exploratory factor analysis was used to assess the structure of the instruments. Structural equation modelling was used to determine how demographic variables and attitudes influence collaborative behaviour. Main outcome measure Outcome measure comprised frequency of and attitudes toward collaboration among German general practitioners and an explanatory model of practitioner-pharmacist collaboration. Results A response rate of 35.9% was achieved. Exploratory factor analysis revealed one factor for the instrument measuring attitudes and two factors for frequency. The factors were interpreted as 'Communication and Collaboration' and 'Pharmacist medication management'. The significant demographic predictors of collaboration were age, population of the surgery's location, distance to the pharmacy, specialty. Conclusion The results provide evidence for the factor structure of both measures in measuring attitudes toward and frequency of collaboration. A model of collaboration in which behaviour and extent of collaboration are directly influenced by individual and context characteristics is supported.

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.

Role and impact of pharmacists in Spain: a scoping review

Background The role of the pharmacist has evolved greatly over the last decades, expanding to patient-oriented activities, administrative tasks and public health functions. However, considerable differences emerge across regions. Aim of the review To gather evidence in order to describe and highlight the different characteristics of the pharmacists' role and the impact of their activities in Spain. Method A review of the existing literature was conducted. The literature search was undertaken in PubMed between 01/01/2006 and 15/08/2017. Results were screened and reviewed to extract previously established criteria such as author(s), publication year, language, study design, setting, pharmaceutical activity, patient care programs, targeted diseases and intervention description using DEPICT2 tool. Pharmaceutical intervention were classified into eight outcome measures and categorized by types of outcomes reported: descriptive or impact evaluation regarding the effect of the service (positive, neutral or negative). Results The search strategy resulted in 473 articles and 108 articles met the inclusion criteria. The most common design was observational (n = 76, 70%). Most articles were published after 2011 (75%), in English (69%). Studies were conducted in hospitals (60%) and community pharmacies (30%). Of the 24 pharmaceutical activities identified, medication review was the activity most frequently studied (n = 42), followed by patient education (n = 29), risk and prevention (n = 27) and medication reconciliation (n = 19). Only 39 articles (36%) had outcome measures with impact evaluation. Of the 223 impact outcome measures, 48% (107/223) had a positive effect. Conclusion This review shows the substantial scientific production focusing on pharmacy practice in Spain over the last years. The evidence reviewed reflects the pharmacist role at various professional settings, providing a wide variety of activities on diverse targeted diseases and patient care programs, in line with the increasing specialization of clinical pharmacists over the last years.

Pharmacist services for non-hospitalised patients

BACKGROUND

This review focuses on non-dispensing services from pharmacists, i.e. pharmacists in community, primary or ambulatory-care settings, to non-hospitalised patients, and is an update of a previously-published Cochrane Review.

OBJECTIVES

To examine the effect of pharmacists' non-dispensing services on non-hospitalised patient outcomes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, two other databases and two trial registers in March 2015, together with reference checking and contact with study authors to identify additional studies. We included non-English language publications. We ran top-up searches in January 2018 and have added potentially eligible studies to 'Studies awaiting classification'.

SELECTION CRITERIA

Randomised trials of pharmacist services compared with the delivery of usual care or equivalent/similar services with the same objective delivered by other health professionals.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures of Cochrane and the Effective Practice and Organisation of Care Group. Two review authors independently checked studies for inclusion, extracted data and assessed risks of bias. We evaluated the overall certainty of evidence using GRADE.

MAIN RESULTS

We included 116 trials comprising 111 trials (39,729 participants) comparing pharmacist interventions with usual care and five trials (2122 participants) comparing pharmacist services with services from other healthcare professionals. Of the 116 trials, 76 were included in meta-analyses. The 40 remaining trials were not included in the meta-analyses because they each reported unique outcome measures which could not be combined. Most trials targeted chronic conditions and were conducted in a range of settings, mostly community pharmacies and hospital outpatient clinics, and were mainly but not exclusively conducted in high-income countries. Most trials had a low risk of reporting bias and about 25%-30% were at high risk of bias for performance, detection, and attrition. Selection bias was unclear for about half of the included studies.Compared with usual care, we are uncertain whether pharmacist services reduce the percentage of patients outside the glycated haemoglobin target range (5 trials, N = 558, odds ratio (OR) 0.29, 95% confidence interval (CI) 0.04 to 2.22; very low-certainty evidence). Pharmacist services may reduce the percentage of patients whose blood pressure is outside the target range (18 trials, N = 4107, OR 0.40, 95% CI 0.29 to 0.55; low-certainty evidence) and probably lead to little or no difference in hospital attendance or admissions (14 trials, N = 3631, OR 0.85, 95% CI 0.65 to 1.11; moderate-certainty evidence). Pharmacist services may make little or no difference to adverse drug effects (3 trials, N = 590, OR 1.65, 95% CI 0.84 to 3.24) and may slightly improve physical functioning (7 trials, N = 1329, mean difference (MD) 5.84, 95% CI 1.21 to 10.48; low-certainty evidence). Pharmacist services may make little or no difference to mortality (9 trials, N = 1980, OR 0.79, 95% CI 0.56 to 1.12, low-certaintly evidence).Of the five studies that compared services delivered by pharmacists with other health professionals, no studies evaluated the impact of the intervention on the percentage of patients outside blood pressure or glycated haemoglobin target range, hospital attendance and admission, adverse drug effects, or physical functioning.

AUTHORS' CONCLUSIONS

The results demonstrate that pharmacist services have varying effects on patient outcomes compared with usual care. We found no studies comparing services delivered by pharmacists with other healthcare professionals that evaluated the impact of the intervention on the six main outcome measures. The results need to be interpreted cautiously because there was major heterogeneity in study populations, types of interventions delivered and reported outcomes.There was considerable heterogeneity within many of the meta-analyses, as well as considerable variation in the risks of bias.

Community pharmacist-led interventions and their impact on patients' medication adherence and other health outcomes: a systematic review

INTRODUCTION

Medication adherence can be defined as the extent to which one's medication-taking behaviour follows that mutually agreed upon by the prescribing physician. Optimal medication adherence is often deemed crucial for the success of a patient's treatment, as suboptimal adherence may lead to treatment failure and unnecessary medical expenditure. Increasing evidence has highlighted the positive contribution community pharmacist-led interventions can have on improving patients' adherence and health outcomes.

OBJECTIVES

To provide an overview of the published literature on community pharmacist-led interventions and their effectiveness in improving patients' adherence and health outcomes.

METHODS

A search strategy was developed, aiming to retrieve published reports of community pharmacy interventions worldwide. Medline, EMBASE, International Pharmaceutical Abstracts, Google Scholar and ProQuest Dissertations and Theses databases were searched. Articles meeting the inclusion criteria were collated, relevant data extracted, and a risk of bias assessment undertaken.

KEY FINDINGS

Twenty-two studies were included in the analysis, and their outcomes were reported in 26 peer-reviewed journal articles. Community pharmacist-led interventions have been shown to improve patients' adherence and contribute to better blood pressure control, cholesterol management, chronic obstructive pulmonary disease and asthma control. Studies in this review, however, did not report statistically significant effects of interventions on diabetes or depression control.

CONCLUSION

Community pharmacist-led interventions have been shown to contribute to improved adherence and better disease control. Future research should attempt to better understand which particular intervention components make the greatest contribution towards improving adherence and health outcomes, for patients with different medical conditions.

Pharmaceutical interventions in mental health: A review of the literature to support evidence-informed policymaking

BACKGROUND

Pharmaceutical interventions may have an impact on different treatment aspects, such as therapy adherence, reducing the number of different medications in use and lowering treatment costs.

OBJECTIVE

Identify pharmaceutical interventions in the mental health field and their possible application in Brazilian public mental health services, considering the evidence-based model to establish implementation options.

METHODS

A structured search of the literature was performed in the Pubmed (Medline), Cochrane, PsycINFO and Lilacs databases to identify the main pharmaceutical intervention studies conducted in the mental health area. The articles selected were evaluated according to the quality of the evidence. The current laws and public database were researched to collect information on services and procedures provided by the Brazilian units, known as CAPS, and the number the pharmacists allocated to them. The proposal to synthesize the results of pharmaceutical interventions in Brazil was based on SUPPORT methodology items to prepare evidence-based policies.

RESULTS

A total of 1442 studies were identified, 18 of which were included. Several interventions are reported in the literature, educational interventions being frequently cited. However, there is a need for further studies with more methodological rigor. The number of pharmacists working in the CAPS is insufficient to cover all the services, since only 26.5% of CAPS employ pharmacists, who work an average of 29 (±11.1) hours a week. Three options were formulated to implement interventions in the Brazilian context that consider including pharmacists on the basic team of CAPS professionals and educational interventions through pharmacist training.

CONCLUSIONS

The present study could support the establishment of health policies, based on a synthesis of the evidence, contextualization of the current situation, given the absence of local evidence, and a discussion of the options available to implement pharmaceutical interventions in the Brazilian health system. Organizational changes in CAPS are needed to broaden pharmacist participation on the multidisciplinary team.

Pharmacist's Demand for Optimal Primary Care Service Delivery in a Community Pharmacy: The OPTiPharm Study

BACKGROUND

The US population continues to expand providing the need for primary health care services. Community pharmacies integrated with medicine may provide greater access while providing high quality care.

OBJECTIVE

To gauge pharmacists' demand for primary health care services delivered through community pharmacies.

METHODS

An online survey was administered to determine community pharmacists' preferences for varying primary care services that could be offered in the community pharmacy setting. A Discrete Choice Experiment was employed to show pharmacists competing scenarios with varied primary care service offerings in the community pharmacy setting. Attributes evaluated were operation hours, service provider, medical records, service logistics, physical examinations, point-of-care diagnostic testing, preventative care, and drug prescribing. Respondents chose the scenario most likely to induce switching employment from base pharmacy to one providing advanced services.

RESULTS

The optimal service delivery model from 291 community pharmacists comprised: inclusion of patient prescriptions and health information into the patient's medical record; provision of point of care testing and vital sign, including blood pressure, heart rate and breathing rate, and blood sugar and cholesterol measurement; and pharmacists prescribing (under physician oversight). Pharmacists were 4 times more likely to switch employment from their current pharmacy to their choice for advanced pharmacy services. Pharmacist demand was highest among those with a PharmD, less experience, working >40 hours per week, and in rural areas.

CONCLUSIONS

This study provides empirical support for the model of pharmacists playing a greater role in the provision of primary care health services through community pharmacy settings.

The impact of a person-centred community pharmacy mental health medication support service on consumer outcomes

BACKGROUND

Mental illness is a worldwide health priority. As medication is commonly used to treat mental illness, community pharmacy staff is well placed to assist consumers.

AIM

To evaluate the effectiveness of a multifaceted, community pharmacy medication support service for mental health consumers.

METHOD

Pharmacists and pharmacy support staff in three Australian states were trained to deliver a flexible, goal-oriented medication support service for adults with mental illness over 3-6 months. Consumer-related outcome measures included perceptions of illness and health-related quality of life, medication beliefs, treatment satisfaction and medication adherence.

RESULTS

Fifty-five of 100 trained pharmacies completed the intervention with 295 of the 418 recruited consumers (70.6% completion rate); 51.2% of consumers received two or more follow-ups. Significant improvements were reported by consumers for overall perceptions of illness (p < 0.001), the mental health domain of quality of life (p < 0.001), concerns about medication (p = 0.001) and global satisfaction with medication (p < 0.001). Consumers also reported an increase in medication adherence (p = 0.005).

CONCLUSIONS

A community pharmacy mental health medication support service that is goal-oriented, flexible and individualised, improved consumer outcomes across various measures. While further research into the cost-effectiveness and sustainability of such a service is warranted, this intervention could easily be adapted to other contexts.

Randomized controlled trials covering pharmaceutical care and medicines management: A systematic review of literature

OBJECTIVE

To review the effects of pharmaceutical care on hospitalizations, mortality and clinical outcomes in patients.

METHODS

Systematic searches were conducted in MEDLINE, EMBASE and International Pharmaceutical Abstracts (IPA) databases to identify studies that were published between 2004 and January 2017. Studies included in this review were randomized controlled trials (RCTs) that spanned across both community and hospital settings. Using strict inclusion/exclusion criteria studies were included if they reported level 1 or 2 outcomes in the hierarchy of outcome measure i.e. clinical and surrogate outcomes (e.g. blood pressure (BP) control, blood glucose level, cholesterol BMI). Each study was assessed for quality using the Jadad scoring system.

RESULTS

Fifty-four RCTs were included in the present review. Forty-six of these studies ranked high quality according to the Jadad scoring system. Studies were categorized into their general condition groups. Interventions in patients with diabetes, depression, respiratory disorders, cardiovascular disorders, epilepsy, osteoporosis, and interventions in older adults were identified. In the majority of studies pharmaceutical care was found to lead to significant improvements in clinical outcomes and/or hospitalizations when compared to the non-intervention group. Some conditions had a large number of RCTs, for example for cardiovascular conditions and in diabetes. Statistically significant improvements were seen in the majority of the studies included for both of these conditions, with studies indicating positive clinical outcomes and/or hospitalizations rates. Within the cardiovascular condition, a subset of studies, focusing on cardiac heart failure and coronary heart disease, had more mixed results. In other conditions the number of RCTs conducted was small and the evidence did not show improvements after pharmaceutical care, i.e. in depression, osteoporosis, and epilepsy. The majority of interventions were face to face interactions with patients, whilst a smaller number were conducted via the telephone and one via a web-based system. Patient education was a key component of most interventions, either verbal and/or written. Longitudinal data, post intervention cessation, was not collected in the majority of cases.

CONCLUSIONS

RCTs conducted to evaluate pharmaceutical care appear to be effective in improving patient short-term outcomes for a number of conditions including diabetes and cardiovascular conditions, however, other conditions such as depression are less well researched. Future research should attempt to evaluate the conditions where there is a lack of data, whether the positive effects of pharmaceutical care persist in patient populations after the interventions cease and what the long-term clinical outcomes would be of continued pharmaceutical care.

Patient preferences for healthcare delivery through community pharmacy settings in the USA: A discrete choice study

WHAT IS KNOWN AND OBJECTIVE

In order to improve public health, it is necessary to facilitate patients' easy access to affordable high-quality primary health care, and one enhanced approach to do so may be to provide primary healthcare services in the community pharmacy setting. Discrete choice experiments to evaluate patient demand for services in pharmacy are relatively limited and have been hampered by a focus on only a few service alternatives, most focusing on changes in more traditional pharmacy services. The study aim was to gauge patient preferences explicitly for primary healthcare services that could be delivered through community pharmacy settings in the USA, using a very large sample to accommodate multiple service delivery options.

METHODS

An online survey was administered to a total of 9202 adult patients from the general population. A subsequent online survey was administered to 50 payer reimbursement decision-makers. The patient survey included a discrete choice experiment (DCE) which showed competing scenarios describing primary care service offerings. The respondents chose which scenario would be most likely to induce them to switch from their current pharmacy, and an optimal patient primary care service model was derived. The likelihood this model would be reimbursed was then determined in the payer survey.

RESULTS AND DISCUSSION

The final optimal service configuration that would maximize patient preference included the pharmacy: offering appointments to see a healthcare provider in the pharmacy, having access to their full medical record, provide point-of-care diagnostic testing, offer health preventive screening, provide limited physical examinations such as measuring vital signs, and drug prescribing in the pharmacy. The optimal model had the pharmacist as the provider; however, little change in demand was evident if the provider was a nurse-practitioner or physician's assistant. The demand for this optimal model was 2-fold higher (25.5%; 95% Bayesian precision interval (BPI) 23.5%-27.0%) than for a base pharmacy offering minimal primary care services (12.6%; 95% BPI 12.2%-13.2%), and was highest among Hispanic (30.6%; 95% BPI: 25.7%-34.3%) and African American patients (30.7%; 95% BPI: 27.1%-35.2%). In the second reimbursement decision-maker survey, the majority (66%) indicated their organization would be likely to reimburse the services described in the optimal patient model if provided in the pharmacy setting.

WHAT IS NEW AND CONCLUSION

This United States national study provides empirical support for a model of providing primary care services through community pharmacy settings that would increase access, with the potential to improve the public health.

Use of pharmacy records to measure treatment adherence: a critical review of the literature

The current frame of reference on adherence to pharmacotherapy includes a set of behaviors experienced by the user, with observation of the detailed and continuous history of the use of each dose of the medication. Indicators based on pharmacy records have been used to measure adherence. The current review aimed to identify and describe indicators based on pharmacy records and to discuss their adequacy and limitations for measuring adherence. An exploratory literature review was conducted in three databases using the terms "adherence", "pharmacy records/administrative data", and "measure" to compose the descriptors for the selection of 81 articles and the elaboration of a chart with the denomination, sources, methods for calculation, description, and interpretation of the operational and referential meaning of 14 indicators. Given the most recent taxonomy for adherence proposed in the literature, we concluded that the indicators can be useful for identifying patients with medication-seeking behavior-related problems and analysis of persistence. The distance between supply-related events and difficulties in treatment follow-up can influence an analysis based exclusively on the use of these indicators.

Review of community pharmacy services: what is being performed, and where are the opportunities for improvement?

Objective

The aim of this review was to assess pharmacist and pharmacy services being provided and identify opportunities to improve patient satisfaction.

Methods

Studies published between January 2006 and July 2016 examining patient satisfaction with pharmacy and pharmacist services, which were written in English, were identified in PubMed. Studies were excluded if they only looked at pharmacy student-provided services.

Key findings

A total of 50 studies were ultimately included in the review. Of these studies, 28 examined services traditionally provided by community pharmacists such as dispensing and counseling, while 16 examined a new in-person service being offered by a pharmacy, and the remaining six involved a new technology-assisted service. While study findings were generally positive for patient satisfaction of pharmacy services, several opportunities were identified for pharmacies to improve.

Conclusion

Overall, patient satisfaction is high across pharmacy services; however, this satisfaction is related to prior patient exposure to services and their level of expectation. Pharmacists have multiple opportunities to improve the services they provide, and there are additional services pharmacists may consider offering to expand their role within the health care system.

Impact of Pharmaceutical Care Interventions on Health-Related Quality-of-Life Outcomes: A Systematic Review and Meta-analysis

OBJECTIVE

To evaluate the impact of pharmaceutical care (PC) interventions on health-related quality of life (HRQoL) and determine sensitivity of HRQoL measures to PC services.

DATA SOURCES

MEDLINE, EMBASE, International Pharmaceutical Abstracts, PubMed, Global Health, PsychINFO, CINAHL, and Web of Science (January 2005 to September 2015) were searched.

STUDY SELECTION AND DATA EXTRACTION

Original English-language articles were included if PC impact on HRQoL was evaluated and reported using validated HRQoL measures.

DATA SYNTHESIS

A total of 31 randomized controlled trials, 9 nonrandomized studies with comparison groups, and 8 before-after studies were included. PC interventions resulted in significant improvement in 1 domain and ≥3 domains of HRQoL measures in 66.7% and 27.1% of the studies, respectively. There was a significant improvement in at least 1 domain in 18 of 32 studies using generic and 16 of 21 studies using disease-specific measures. When the Short Form 36 Items Health Survey (SF-36) measure was used, PC interventions had a moderate impact on social functioning (standardized mean difference [SMD] = 0.59; 95% CI = 0.14, 1.04), general health (SMD = 0.36; 95% CI = 0.12, 0.59), and physical functioning (SMD = 0.30; 95% CI = 0.11, 0.48). The pooled data on heart failure-specific (SMD = -0.17; 95% CI = -0.43, 0.09), asthma-specific (SMD = 0.17; 95% CI = -0.03, 0.36), and chronic obstructive pulmonary disease-specific (SMD = -0.09; 95% CI = -0.37, 0.19) measures indicated no significant impact of PC on HRQoL.

CONCLUSIONS

PC interventions can significantly improve at least 1 domain of HRQoL. Existing measures may have minimal to moderate sensitivity to PC interventions, with evidence pointing more toward social functioning, general health, and physical functioning of the SF-36 measure. However, evidence generated from current non-PC-specific HRQoL measures is insufficient to judge the impact of PC interventions on HRQoL. The development of a suitable HRQoL measure for PC interventions may help generate better evidence for the contribution of pharmacist services to improving HRQoL.

Exploring an increased role for Australian community pharmacy in mental health professional service delivery: evaluation of the literature. J Ment Health 2015;25:550-559. [PMID: 26607639 DOI: 10.3109/09638237.2015.1101418]

BACKGROUND

Australian general practitioners primarily treat mental health problems by prescribing medication dispensed by community pharmacists. Pharmacists therefore have regular interactions with mental health consumers and carers.

AIMS

This narrative review explored the potential role of community pharmacy in mental health services.

METHOD

Medline, CINAHL, ProQuest, Emerald, PsycINFO, Science Direct, PubMed, Web of Knowledge and IPA were utilised. The Cochrane Library as well as grey literature and "lay" search engines such as GoogleScholar were also searched.

RESULTS

Four systematic reviews and ten community pharmacy randomised controlled trials were identified. Various relevant reviews outlining the impact of community pharmacy based disease state or medicines management services were also identified.

CONCLUSION

International studies involving professional service interventions for mental health consumers could be contextualised for the Australian setting. Australian studies of pharmacy professional services for chronic physical health conditions provided further guidance for the expansion of community pharmacy mental health professional services.

Community pharmacists' support improves antidepressant adherence in the community

The treatment goal of major depressive disorder (MDD) is achieving and maintaining remission. One of the major obstacles in attaining remission is poor adherence to the medication regimen. Community pharmacists (CPs) are accessible to primary care patients and are in a unique position to help improve adherence. The aim was to compare the effectiveness of pharmacist intervention with standard care for patients with MDD. This was an exploratory controlled trial conducted in 17 general pharmacies with clinical pharmacists in Israel. Participants were patients with MDD prescribed escitalopram by their general practitioner. CP medication review was initiated at enrollment, with face-to-face pharmacist adherence support at treatment initiation and every month throughout the study. Treatment as usual (TAU) was derived from computerized medical charts for the same pharmacies during the same time period. Comparison with published 'historical' controls was also carried out. No blinding was possible. Continuous antidepressant treatment at 6 months as reflected in computerized pharmacy records was the primary outcome. Within a 1-year period, 173 patients were enrolled. There were 49 men (28%) and 124 women (72%) in the CP group, mean age 53.9 ± 18.9 years. There were 4079 men (32%) and 8667 women (68%) in the TAU group, mean age 50.4 ± 17.8 years. Ninety-six patients (55%) completed 6 months of antidepressant treatment. At 1 month, the adherence rate was 71% in the CP arm and at 6 months, the rates were 55% versus published norms of 42% (P=0.004). At 1 month, the adherence rate was 57% (N=7256) in the TAU arm and at 6 months, the rate was 15.2% (N=1934) (compared with CP rates: P<0.0001). There were no differences between sites in adherence rates. CPs participating in this study reported higher levels of confidence in supporting MDD patients at the end of the study. This is the first trial of pharmacist adherence support in Israel, and shows benefits for patients in the community with MDD.

Mapping the terrain: A conceptual schema for a mental health medication support service in community pharmacy

OBJECTIVE

Mental health-related problems pose a serious issue for primary care, and community pharmacy could make a significant contribution, but there is a dearth of information.

METHODS

This article reports synthesis of the literature on mental health interventions across a range of pharmacy models, and pharmacy services in contexts beyond mental health. To best inform the design of a community pharmacy medication support intervention for mental health consumers, the literature was reported as a conceptual schema and subsequent recommendations for development, implementation and evaluation of the service. A broad conceptualisation was taken in this review. In addition to mental health and community pharmacy literature, policy/initiatives, organisational culture and change management principles, and evaluative processes were reviewed. Key words were selected and literature reviews undertaken using EMBASE, PubMed, CINAHL and Web of Science.

RESULTS

Recommendations were made around: medication support intervention design, consumer recruitment, implementation in community pharmacy and evaluation. Surprisingly, there is a scarce literature relating to mental health interventions in community pharmacy. Even so, findings from other pharmacy models and broader medicines management for chronic illness can inform development of a medication support service for mental health consumers. Key learnings include the need to expand medicines management beyond adherence with respect to both intervention design and evaluation.

CONCLUSION

The conceptual framework is grounded in the need for programmes to be embedded within pharmacies that are part of the health system as a whole.

[Impact of pharmaceutical intervention in preventing relapses in depression in Primary Care]

OBJECTIVE

To evaluate the long-term impact of a brief pharmacist intervention (PI) compared with usual care (UC) on prevention of depression relapse.

DESIGN

randomised controlled clinical trial

SETTING

Primary Care

PARTICIPANTS

Of the 179 depressed patients initiating antidepressants, the 113 whose clinical symptoms had remitted (main definition) at 6 months assessment were selected for this secondary study (PI=58; UC=55).

INTERVENTION

PI was an interview to promote medication adherence when patients get antidepressants from pharmacy.

MAIN MEASUREMENTS

Baseline, 3 months, and six-months follow-up assessments were made. The severity of depressive symptoms was evaluated with PHQ9. Patients presenting a remission of symptoms were selected. The patient medical records were reviewed to identify a relapse in the following 12 months by using 4 indicators.

RESULTS

There was a lower proportion of patients that relapsed in the PI group than in the UC group 18 months after initiation of treatment, but the difference was not statistically significant either in the intent-to-treat analysis (OR=0.734 [95%CI; 0.273-1.975]) or the per-protocol analysis (OR=0.615 [95%CI; 0.183 -2.060]). All the sensitivity analyses showed consistent results. The sample size and adherence to the protocol in the intervention group were low.

CONCLUSION

PI group showed a non-statistically significant tendency towards presenting fewer relapses. This could be related to the improvement in adherence among patients that received the intervention.

Depression screening and advisory service provided by community pharmacist for depressive students in university

Background

Depressive symptom among adolescent is prevalent but advisory service for this symptom is limited, particularly in university.

Objectives

(1) To identify depressive students in health science faculties, (2) To evaluate the consequence of depression advisory service by community pharmacist, compared between a group counseling and an individual one.

Methods

A two-phase study was designed—a cross-sectional study followed by an experimental study. Health science students were screened by CES-D questionnaire. The prevalence and predictors of depressed mood were determined. Depressive students were then invited to the experimental study. Participants were assigned into 2 groups, by stratified random sampling, and followed up for 16 weeks. Group 1 received a group counselling, group 2 received an individual counselling from a trained pharmacist. Outcomes measured were the CES-D score and quality of life.

Results

The prevalence of depressed mood students was 13.7 % (195/1421). Students in year 2nd and year 3rd, nursing and medicine students, and GPA were strongly associated with the CES-D score (P < 0.05). Sixty-eight depressive students were assigned into the experiment. The CES-D scores of both groups were significantly reduced from the baseline (P < 0.001). The post-test score of group 2 was lower than group 1 (17.7 ± 4.5 vs 20.1 ± 4.6, P = 0.038). At week 16, both counselling types significantly increased mean score of physical health (P < 0.001) whereas score of mental health was increased significantly only by the individual counselling, from 37.9 ± 9.9 to 43.1 ± 8.4 (P = 0.036).

Conclusions

Depressive symptom among health science students is considerably high. Year of study, faculty and GPA are significant predictors of this disorder. Trained community pharmacists can effectively screen and provide advisory service. Individual counseling is more effective than using group advice.

Cost-effectiveness of active monitoring versus antidepressants for major depression in primary health care: a 12-month non-randomized controlled trial (INFAP study)

BACKGROUND

Clinical practice guidelines for the treatment of major depressive disorder (MDD) recommend antidepressants for patients with moderate-severe depression and active monitoring for patients with mild-moderate symptoms. The feasibility and efficiency of active monitoring has not been proven conclusively. The aim of this study is to evaluate the cost-effectiveness of active monitoring in comparison to antidepressants for primary care patients with mild-moderate MDD.

METHODS/DESIGN

This is a 12-month follow-up multicenter observational prospective controlled trial. Patients are enrolled in 12 primary care centers in Barcelona (Spain). Eligible patients are adults (≥18 years-old) with a new episode of MDD that sign a written consent to participate. This is a naturalistic study in which general practitioners (GPs) use their professional judgment to allocate patients into active monitoring or antidepressants groups. GPs treat the patients following their clinical criteria. At baseline, GPs complete a questionnaire (sociodemographic/job characteristics, training, attitude towards depression, interest on mental health and participation in communication groups). Patients' measurements take place at baseline and after six and 12 months. Main outcome measures include severity of depression (PHQ-9), health-related quality of life (EuroQol-5D) and use of healthcare and social care services (Client Service Receipt Inventory). Secondary outcomes include diagnosis of MDD according to DSM-IV diagnostic criteria (SCID-I), disability (WHO-DAS), anxiety (BAI), comorbidities, medication side-effects and beliefs about medicines (BMQ). The analysis will be done according to the intention to treat analysis. Missing data will be imputed using multiple imputation by chained equations. To minimize the bias resulting from the lack of randomization, a propensity score will be used. Incremental effects and costs between groups will be modelled in each of the imputed databases using multivariate generalized linear models and then combined as per Rubin's rules. Propensity scores will be used to adjust the models. Incremental cost-effectiveness ratios will be calculated by dividing the difference in costs between groups by the difference in effects. To deal with the uncertainty, resampling techniques with bootstrapping will be used and cost-effectiveness planes and cost-effectiveness acceptability curves will be constructed. A series of sensitivity analyses will be performed.

DISCUSSION

Given the high burden and costs generated by depressive disorder, it is important that general practitioners treat major depression efficiently. Recent evidence has suggested that antidepressants have low benefits for patients with mild to moderate major depression. For such cases of depression, active monitoring exists as a treatment option, but it is not without difficulties for implementation and its effectiveness and efficiency have not been demonstrated conclusively. The results of the study will provide information on which is the most efficient approach to treat patients with mild to moderate major depression in primary care.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02245373.

New roles for pharmacists in community mental health care: a narrative review

Medicines are a major treatment modality for many mental illnesses, and with the growing burden of mental disorders worldwide pharmacists are ideally positioned to play a greater role in supporting people with a mental illness. This narrative review aims to describe the evidence for pharmacist-delivered services in mental health care and address the barriers and facilitators to increasing the uptake of pharmacist services as part of the broader mental health care team. This narrative review is divided into three main sections: (1) the role of the pharmacist in mental health care in multidisciplinary teams and in supporting early detection of mental illness; (2) the pharmacists' role in supporting quality use of medicines in medication review, strategies to improve medication adherence and antipsychotic polypharmacy, and shared decision making; and (3) barriers and facilitators to the implementation of mental health pharmacy services with a focus on organizational culture and mental health stigma. In the first section, the review presents new roles for pharmacists within multidisciplinary teams, such as in case conferencing or collaborative drug therapy management; and new roles that would benefit from increased pharmacist involvement, such as the early detection of mental health conditions, development of care plans and follow up of people with mental health problems. The second section describes the impact of medication review services and other pharmacist-led interventions designed to reduce inappropriate use of psychotropic medicines and improve medication adherence. Other new potential roles discussed include the management of antipsychotic polypharmacy and involvement in patient-centered care. Finally, barriers related to pharmacists' attitudes, stigma and skills in the care of patients with mental health problems and barriers affecting pharmacist-physician collaboration are described, along with strategies to reduce mental health stigma.

Perspective of community pharmacists on their practice with patients who have an antidepressant drug treatment: findings from a focus group study

BACKGROUND

Around 2/3 of patients with major depression discontinue their antidepressant drug treatment (ADT) prematurely. Community pharmacists can rely on their regular contacts with patients to identify and support those experiencing difficulties with their ADT.

OBJECTIVE

The aim of this study is to describe pharmacists' perceptions with respect to their practices related to patients having an ADT.

METHODS

A qualitative study was conducted based on 6 focus groups involving 43 community pharmacists in 5 regions of Quebec province, Canada. Verbatim transcripts of focus groups were analyzed using computer-assisted thematic analysis.

RESULTS

The discussions revealed three major aspects of the participants' pharmacy practice: convincing patients to initiate ADT, dealing with side effects in the first weeks of the treatment, and taking a reactive approach to managing the treatment for the remainder of the follow-up. Discussions also enabled participants to identify the challenges they face concerning their practice with patients who have an ADT, and voice their recommendations for improving pharmacy practice and ultimately patient adherence to ADT.

CONCLUSIONS

Pharmacists wishing to help their patients to adequately manage their ADT face important barriers. Potential solutions include tools designed to help pharmacists better detect and intervene in ADT-related problems. Study findings will guide the on-going development of training and tools to support pharmacists' practice in this context.

Utility Values for Adults with Unipolar Depression: Systematic Review and Meta-Analysis

BACKGROUND

Unipolar depression is a mental illness with a substantial health-related and economic burden. Health interventions for depression predominately focus on improving sufferers' health-related quality of life (HRQoL). Utility is a measure of HRQoL that is required for use in model-based cost-utility analyses to assess the added value of health interventions. This review aimed to identify, summarize, and where feasible, synthesize published utilities for unipolar depression.

METHODS

A structured electronic search combining common terms for unipolar depression and utility was conducted in MEDLINE, EMBASE, and PsycINFO. Utility values identified were summarized, and the study designs were appraised in terms of the patient population and valuation method used to generate utilities. Random-effect meta-analyses were applied to pool mean utilities identified for 3 depressive health states (mild, moderate, and severe) elicited from direct and indirect valuation methods separately.

RESULTS

Thirty-five studies were identified that reported utilities for various levels of depression severity. The most commonly used direct valuation method for eliciting utilities was standard gamble (SG) (n = 5), and the most commonly used indirect valuation method was EQ-5D (n = 20). The pooled mean (standard deviation) utilities from studies using SG as a direct valuation method were mild = 0.69 (0.14), moderate = 0.52 (0.28), and severe = 0.27 (0.26). The pooled utilities from studies using EQ-5D as an indirect valuation method were mild = 0.56 (0.16), moderate = 0.45 (0.18), and severe = 0.25 (0.15).

CONCLUSIONS

This systematic review is a useful resource for decision analysts who need health-related utility values to populate model-based cost-utility analyses of health interventions for the management of unipolar depression. Further research is necessary to understand whether direct or indirect valuation methods are the most robust sources for utilities in depression.