Effect of pharmacist intervention on improving antidepressant medication adherence and depression symptomology: A systematic review and meta-analysis

Reprint of: Implementation of depression management by ambulatory care pharmacists in the primary care setting

BACKGROUND

In the United States, depression is one of the most common mental health disorders. Ambulatory care pharmacists play a critical role in assisting with medication and dosage selection, identifying and managing drug interactions and adverse effects, and increasing medication adherence. Existing data on depression management by ambulatory care pharmacists trained in primary care is limited and outdated.

OBJECTIVES

This study provides insight into current practices for depression management by primary care pharmacy specialists within an academic health center and how pharmacist interventions may impact functional outcomes of depression.

METHODS

This single-center, retrospective study analyzed 27 patients with a primary care physician within the health system who were seen by an ambulatory care pharmacist for depression. Subjects were excluded if they were under 18 years old, pregnant, or had a diagnosis of bipolar disorder, schizophrenia, schizoaffective disorder, or dementia. The primary outcome was characterization of pharmacist interventions for treatment of depression. Secondary outcomes included change in depressive symptoms, as measured by the patient health questionnaire (PHQ), characterization of adverse effects correlated with medications for depression, and utilization of pharmacogenomics testing and results.

RESULTS

Of 27 patients seen by a pharmacist for depression management, 38 total interventions were made, with an average of 1.77 interventions per patient. The most common intervention was new medication initiation (32%). Average PHQ-9 scores dropped from 14.9 to 7.3 twelve weeks following the initial pharmacist visit. Only 6 patients reported adverse effects to a current antidepressant during their visit with the pharmacist, and only 2 of these cases warranted a change in therapy. Ten patients obtained pharmacogenomic testing with pharmacist facilitation.

CONCLUSION

Pharmacists in the primary care setting are positioned to be an additional resource for depression management and can offer a wide variety of interventions to improve patient health.

Implementation of depression management by ambulatory care pharmacists in the primary care setting

BACKGROUND

In the United States, depression is one of the most common mental health disorders. Ambulatory care pharmacists play a critical role in assisting with medication and dosage selection, identifying and managing drug interactions and adverse effects, and increasing medication adherence. Existing data on depression management by ambulatory care pharmacists trained in primary care is limited and outdated.

OBJECTIVES

This study provides insight into current practices for depression management by primary care pharmacy specialists within an academic health center and how pharmacist interventions may impact functional outcomes of depression.

METHODS

This single-center, retrospective study analyzed 27 patients with a primary care physician within the health system who were seen by an ambulatory care pharmacist for depression. Subjects were excluded if they were under 18 years old, pregnant, or had a diagnosis of bipolar disorder, schizophrenia, schizoaffective disorder, or dementia. The primary outcome was characterization of pharmacist interventions for treatment of depression. Secondary outcomes included change in depressive symptoms, as measured by the patient health questionnaire (PHQ), characterization of adverse effects correlated with medications for depression, and utilization of pharmacogenomics testing and results.

RESULTS

Of 27 patients seen by a pharmacist for depression management, 38 total interventions were made, with an average of 1.77 interventions per patient. The most common intervention was new medication initiation (32%). Average PHQ-9 scores dropped from 14.9 to 7.3 twelve weeks following the initial pharmacist visit. Only 6 patients reported adverse effects to a current antidepressant during their visit with the pharmacist, and only 2 of these cases warranted a change in therapy. Ten patients obtained pharmacogenomic testing with pharmacist facilitation.

CONCLUSION

Pharmacists in the primary care setting are positioned to be an additional resource for depression management and can offer a wide variety of interventions to improve patient health.

Pharmacist roles in the medication use process: Perceptions of patients, physicians, and pharmacists

OBJECTIVES

It is uncertain whether stakeholder perceptions of pharmacist roles in the medication use process (MUP) have evolved alongside pharmacist advanced scope of practice. This study aimed to examine patient, pharmacist, and physician perceptions of pharmacist roles in the MUP.

DESIGN

This IRB-approved study used a cross-sectional design with online panels of patients, pharmacists, and physicians.

SETTING AND PARTICIPANTS

A Qualtrics panel of 1,004 patients, 205 pharmacists, and 200 physicians completed the surveys between August-November 2021.

OUTCOME MEASURES

Using role theory as framework, 12-item surveys were developed to examine perceptions regarding effectiveness of and best choice for improving each MUP step. Data analysis included descriptive statistics, correlations, and comparisons.

RESULTS

Majority of the physician, pharmacist, and patient samples believed that physicians prescribe the best possible medications (93.5%, 83.4%, 89.0% respectively), prescriptions are filled accurately (59.0%, 61.4%, 92.6% respectively) and timely (86.0%, 68.8, 90.2% respectively). Majority of physicians (78.5%) opined prescriptions are generally error free and patients are monitored (71%); fewer pharmacists agreed (42.9%, 51%; p<0.05). Most patients (92.4%) reported taking medications as directed; only 60% professionals agreed (p<0.05). Physicians selected 'pharmacists' as top choice for reducing dispensing errors, providing counseling, and helping patients take medications as directed. Patients wanted pharmacists to help manage their medications (87.0%) and 'someone' to periodically check on their health (100%). All 3 groups agreed physician-pharmacist collaboration was important to improve patient care and outcomes (90.0%-97.1%); however, 24% of physicians were uninterested in collaboration. Both professionals reported lack of time, appropriate setup, and interprofessional communication as challenges to collaboration.

CONCLUSION

Pharmacists believe their roles have evolved to align with expanded opportunities. Patients perceived pharmacists play comprehensive roles in medication management through counseling and monitoring. Physicians recognized pharmacist roles in dispensing and counseling, but not in prescribing or monitoring. Clarity in role expectations amongst these stakeholders is critical to optimizing pharmacist roles and patient outcomes.

A non-randomized, controlled, interventional study to investigate the effects of community pharmacists' cognitive behavioral therapy-based interventions on medication adherence and relevant indicators in patients with depression

BACKGROUND

The prevalence of depression is increasing in Japan. Pharmacists play an important role in helping patients use medicines effectively. Several studies had investigated the impact of community pharmacists on patient adherence to antidepressant therapy, and their results indicated that further study was warranted.

METHODS

This study was conducted from June 2019 to May 2020 using a cluster non-randomized, open-label, parallel-group design. Four community pharmacy stores in Osaka and Hyogo Prefectures, Japan, participated in the study, and enrolled patients with unipolar depression. In the intervention group (IG), patients received cognitive behavioral therapy (CBT)-based medication support, and their medication adherence and adverse drug reactions were monitored by telephone. In the control group (CG), the pharmacists engaged in routine interactions with the study participants. Before participating in this study, the intervention-group pharmacists attended a 5-hour training session on CBT-based medication support. The primary outcome of this study was medication adherence, assessed using the Drug Attitude Inventory (DAI)-10. Secondary outcomes included the changes from baseline at 6 months in the following variables: the Patient Health Questionnaire (PHQ)-9 total score, the EQ-5D-5 L (Euro-QOL 5 dimensions 5 levels) score, patient satisfaction, and the Pharmacists' Confidence Scale about Medication Consultation for Depressive Patients (PCMCD) score.

RESULTS

Four pharmacies (two in IG and two in CG) completed the intervention period. Results were obtained from 19 patients in the IG and 12 patients in the CG. In the IG, the mean DAI-10 score increased from 4.941 at baseline to 6.105, the mean PHQ-9 score decreased from 9.263 to 8.625, and the mean patient satisfaction score increased from 39.947 to 42.211. In the CG, the mean DAI-10 score decreased from 6.333 to 4.167, the mean PHQ-9 score increased from 9.333 to 12.923, and the mean patient satisfaction score decreased from 38.929 to 38.167.

CONCLUSION

CBT-based medication support provided by community pharmacists may improve patient medication adherence to antidepressant therapy and symptoms. Such support can be expected to facilitate better treatment of depressed patients and may also allow the duration of treatment to be shortened.

TRIAL REGISTRATION

UMIN000037954, Date of first registration: 17/06/2019.

SPUR: A Patient-Reported Medication Adherence Model as a Predictor of Admission and Early Readmission in Patients Living with Type 2 Diabetes

PURPOSE

Poor medication adherence (MA) is linked to an increased likelihood of hospital admission. Early interventions to address MA may reduce this risk and associated health-care costs. This study aimed to evaluate a holistic Patient Reported Outcome Measure (PROM) of MA, known as SPUR, as a predictor of general admission and early readmission in patients living with Type 2 Diabetes.

PATIENTS AND METHODS

An observational study design was used to assess data collected over a 12-month period including 6-month retrospective and 6-month prospective monitoring of the number of admissions and early readmissions (admissions occurring within 30 days of discharge) across the cohort. Patients (n = 200) were recruited from a large South London NHS Trust. Covariates of interest included: age, ethnicity, gender, level of education, income, the number of medicines and medical conditions, and a Covid-19 diagnosis. A Poisson or negative binomial model was employed for count outcomes, with the exponentiated coefficient indicating incident ratios (IR) [95% CI]. For binary outcomes (Coefficient, [95% CI]), a logistic regression model was developed.

RESULTS

Higher SPUR scores (increased adherence) were significantly associated with a lower number of admissions (IR = 0.98, [0.96, 1.00]). The number of medical conditions (IR = 1.07, [1.01, 1.13]), age ≥80 years (IR = 5.18, [1.01, 26.55]), a positive Covid-19 diagnosis during follow-up (IR = 1.83, [1.11, 3.02]) and GCSE education (IR = 2.11, [1.15,3.87]) were factors associated with a greater risk of admission. When modelled as a binary variable, only the SPUR score (-0.051, [-0.094, -0.007]) was significantly predictive of an early readmission, with patients reporting higher SPUR scores being less likely to experience an early readmission.

CONCLUSION

Higher levels of MA, as determined by SPUR, were significantly associated with a lower risk of general admissions and early readmissions among patients living with Type 2 Diabetes.

Pharmacist's interventions in factors contributing to medication errors reduces medication errors in self-management of patients in the rehabilitation ward

BACKGROUND

The number of medications, number of administrations per day, dosing frequency on indicated day, and medication from multiple prescriptions are the medication factors prone to medication errors in self-management that have been previously reported. However, whether pharmacists actually intervene in medication factors that affect medication error occurrences in self-management is unclear. Therefore, we conducted this study to clarify these issues.

METHOD

This study included patients who underwent self-management in the rehabilitation ward of Higashinagoya National Hospital. From April 2019 to March 2020, a one-pharmacist period existed, and from April 2020 to March 2021, a two-pharmacist period existed. The number of patient instructions and interventions were expected to increase with an increase in the number of pharmacists. Considering this to be an environment of differential interventions by pharmacists, a pre-post-test design was conducted with all self-managed patients in both the time periods. The primary and secondary endpoints were the proportion of medication error occurrences and proportion of pharmacist's interventions in medication factors, respectively.

RESULT

The proportions of medication error occurrences during the one-pharmacist and two-pharmacist periods were 41% (71/173) and 28% (51/180) (relative risk 0.690, 95% confidential interval 0.515-0.925), respectively. The proportion of pharmacist's interventions in medication factors in the one-pharmacist period was 13% (22/173) and 22% (40/180) in the two-pharmacist period; there was an increase in the proportion of pharmacist's interventions in medication factors in the two-pharmacist period.

CONCLUSION

The proportion of medication error occurrences was significantly lower in the two-pharmacist period than that in the one-pharmacist period. This can be attributed to the increase in the proportion of pharmacist's interventions in medication factors. Therefore, an environment in which pharmacists could intervene in the medication factors to prevent medication errors in advance is necessary.

Improvement in Medication Adherence after Pharmacist Intervention Is Associated with Favorable Clinical Outcomes in Patients with Ulcerative Colitis

Background/Aims

Although pharmacist intervention for patients with chronic diseases has been shown to improve medication adherence, few studies have evaluated its effects on the objective clinical outcomes. We investigated the impact of pharmacist intervention on medication adherence and clinical outcomes in patients with ulcerative colitis (UC).

Methods

Patients with UC and low medication adherence were divided into two groups, based on pharmacist intervention. Their medication possession ratio and nonadherence rate for 6 months before and after the baseline were investigated. The partial Mayo score, flare-up incidence, and factors influencing flare-up events for 1 year after the baseline were analyzed.

Results

Of 99 patients, 33 and 66 were included in the intervention and control groups, respectively. The nonadherence rate significantly declined in the intervention group 6 months after the baseline (60.6% before vs 30.3% after; p=0.013). The groups showed a significant difference regarding time-related partial Mayo scores (p=0.002). Intervention was significantly negatively correlated with time and the partial Mayo score (r2=0.035, p=0.013). A significant difference was observed in the flare-up incidence (33.3% in the intervention group vs 54.6% in the control group; p=0.046). Multivariate logistic regression indicated that pharmacist intervention (adjusted odds ratio, 0.370; 95% confidence interval, 0.145 to 0.945; p=0.038) independently reduced the flareup risk.

Conclusions

Pharmacist intervention significantly decreased the nonadherence rate, improved the partial Mayo score, and reduced the flare-up incidence compared with the control group in a cohort of UC patients identified to have low medication adherence.

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 Pharmaceutical Education on Medication Adherence and Its Clinical Efficacy in Patients with Type 2 Diabetes and Systemic Arterial Hypertension

PURPOSE

To evaluate the impact of pharmaceutical education on medication adherence in patients with Type 2 Diabetes and Systemic Arterial Hypertension.

PATIENTS AND METHODS

This randomized clinical trial enrolled patients with a diagnosis of Type 2 Diabetes Mellitus and Systemic Arterial Hypertension treated in an internal medicine outpatient clinic of a teaching hospital. One hundred and three patients were randomly assigned to the study groups; 51 to the control group and 52 to the intervention group with a 6 months follow-up. Medication adherence was assessed using the Morisky 8-item medication adherence scale. To improve patient adherence to treatment, a wallet card was provided with an up-to-date list of prescribed medications along with recommendations for follow-up care.

RESULTS

One hundred and seventy-nine patients were screened for eligibility, of which 103 (57.5%) participated in the study. The intervention group showed a statistically significant decrease in capillary glucose levels, glycated hemoglobin, systolic and diastolic blood pressure, total cholesterol and triglycerides compared to the control group. The frequencies on medication adherence levels at 3 and 6 months in the control group remained similar to baseline, while in the intervention group the frequency of high adherence increased significantly at 6 months (8.7% to 43.5%).

CONCLUSION

A high percentage of patients are not achieving optimal control of their diabetes. Medication adherence rates were between 45-50% in patients at the baseline of the study, but after receiving education and support from a pharmacist, the intervened group showed a significant increase in their adherence.

Exploring Validated Self-Reported Instruments to Assess Adherence to Medications Used: A Review Comparing Existing Instruments

OBJECTIVE

To provide an overview of instruments that measure adherence to medications to facilitate selection of an instrument and to provide a summary of some published adherence assessment tools tailored to be used by the healthcare team, especially the pharmacists.

DATA SOURCES

Studies were identified via PubMed, Medline, Embase, and Google Scholar using the search terms medication adherence, compliance, persistence, combined with the terms questionnaire, scale, survey, self-report, and instrument.

STUDY SELECTION

Articles written in English, describing questionnaire instruments that were psychometrically evaluated (reporting a good coefficient of internal consistency, reliability assessed through Cronbach's alpha, and had been validated against a subjective or objective measure), and containing 30 or fewer items were included.

DATA SYNTHESIS

Twelve instruments were identified and included in this review. Instruments were reviewed by evaluating specific characteristics (number of items, sample size, reliability, sensitivity, specificity, questionnaire completion time, criterion validity, and component analysis).

CONCLUSION

Various instruments are used to assess patient adherence to medications; however, no single one performs well on all criteria. Every instrument has different advantages and unique properties. A particular instrument can be chosen after considering certain factors, such as the specific requirements, population, the needed time to complete the questionnaire, the sensitivity, and the specificity of the questionnaire. Moreover, there is a recognized need to provide primary care medication adherence services customized to patient's needs. A link for teamwork between healthcare providers such as pharmacists and patients is needed. This link can be a validated instrument to assess patient's adherence to medication.

Cost-Utility Analysis of a Medication Adherence Management Service Alongside a Cluster Randomized Control Trial in Community Pharmacy

BACKGROUND

It is necessary to determine the cost utility of adherence interventions in chronic diseases due to humanistic and economic burden of non-adherence.

PURPOSE

To evaluate, alongside a cluster-randomized controlled trial, the cost-utility of a pharmacist-led medication adherence management service (MAMS) compared with usual care in community pharmacies.

MATERIALS AND METHODS

The trial was conducted over six months. Patients with treatments for hypertension, asthma or chronic obstructive pulmonary disease (COPD) were included. Patients in the intervention group (IG) received a MAMS based on a brief complex intervention, whilst patients in the control group (CG) received usual care. The cost-utility analysis adopted a health system perspective. Costs related to medications, healthcare resources and adherence intervention were included. The effectiveness was estimated as quality-adjusted life years (QALYs), using a multiple imputation missing data model. The incremental cost-utility ratio (ICUR) was calculated on the total sample of patients.

RESULTS

A total of 1186 patients were enrolled (IG: 633; CG: 553). The total intervention cost was estimated to be €27.33 ± 0.43 per patient for six months. There was no statistically significant difference in total cost of medications and healthcare resources per patient between IG and CG. The values of EQ-5D-5L at 6 months were significantly higher in the IG [IG: 0.881 ± 0.005 vs CG: 0.833 ± 0.006; p = 0.000]. In the base case, the service was more expensive and more effective than usual care, resulting in an ICUR of €1,494.82/QALY. In the complete case, the service resulted in an ICUR of €2,086.30/QALY, positioned between the north-east and south-east quadrants of the cost-utility plane. Using a threshold value of €20,000/QALY gained, there is a 99% probability that the intervention is cost-effective.

CONCLUSION

The medication adherence management service resulted in an improvement in the quality of life of the population with chronic disease, with similar costs compared to usual care. The service is cost-effective.

Exploring the effect of perceived organizational support and resilience on Chinese pharmacists' engagement in stressful and competitive pharmaceutical work at hospitals

Background

Currently, pharmacists occupy a non-mainstream position in China's healthcare system, and there has been little research concerning the interaction among pharmacists' psychological status, work engagement, and other aspects of the healthcare system and relationship with their work. Our study examined the basic situation of Chinese pharmacists and investigated the relationship among pharmacists' perceived organizational support, resilience, and engagement when working in a competitive environment.

Objective

To investigate the awareness of perceived organizational support among pharmacists at Chinese hospitals, analyze the correlation between perceived organizational support and short-term resilience and work engagement scale scores after frustration, and examine the effect of various factors on pharmacists' work engagement in a stressful and competitive work environment.

Method

An electronic questionnaire survey was made available to 300 pharmacists at Chinese hospitals, and these pharmacists were engaged in intensely competitive work within their respective hospitals. The questionnaire survey employed the Utrecht Work Engagement Scale (UWES), Brief Resilience Scale (BRS), and Perceived Organizational Support Scale (POS). IBM SPSS Statistics Version 19.0 was used to analyze the collected data.

Results

A total of 295 of the 300 questionnaires were recovered, for a valid questionnaire rate of 98.33% (n = 295). The 3 scales used in this study where scored on 5-point Likert scales; the BRS-6 scale assessed resilience, and a mean value of 3.43 points was obtained; the UWES-9 scale assessed employee engagement, and a mean value of 3.63 points was obtained; and the POS-8 scale assessed perceived organizational support, and a mean value of 3.35 points was obtained. These results indicated that the pharmacists had above average perceived organizational support, short-term resilience, and work engagement. We found that the BRS had a Pearson correlation of 0.553 with the UWES and that the POS had a Pearson correlation of 0.663 (P＜0.01) with the UWES, revealing that there was a significant correlation between the pharmacists' perceived organizational support, short-term resilience, and engagement.

Conclusions

This study found that pharmacists possessing relatively strong short-term resilience and receiving extensive perceived support from their organizations are able to more effectively engage with their everyday work, a result that indicated that the perception of receiving organizational support and the possession of short-term resilience have a significant connection with employees' work engagement.

On-Site Prescription Dispensing Improves Antidepressant Adherence among Uninsured Depressed Patients

The successful treatment of depressive disorders critically depends on adherence to prescribed treatment regimens. Despite increasing rates of antidepressant medication prescription, adherence to the full treatment course remains poor. Rates of antidepressant non-adherence are higher for uninsured patients and members of some marginalized racial and ethnic communities due to factors such as inequities in healthcare and access to insurance. Among patients treated in a free, student-run and faculty-supervised clinic serving uninsured patients in a majority Hispanic community in East Harlem, adherence rates are lower than those observed in patients with private or public New York State health insurance coverage. A prior study of adherence in these patients revealed that difficulty in obtaining medications from an off-site hospital pharmacy was a leading factor that patients cited for non-adherence. To alleviate this barrier to obtaining prescriptions, we tested the effectiveness of on-site, in-clinic medication dispensing for improving antidepressant medication adherence rates among uninsured patients. We found that dispensing medications directly to patients in clinic was associated with increased visits at which patients self-reported proper adherence and increased overall adherence rates. Furthermore, we found evidence that higher rates of antidepressant medication adherence were associated with more favorable treatment outcomes. All patients interviewed reported increased satisfaction with on-site dispensing. Overall, this study provides promising evidence that on-site antidepressant dispensing in a resource-limited setting improves medication adherence rates and leads to more favorable treatment outcomes with enhanced patient satisfaction.

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.

Pharmacist-led interventions to improve medication adherence in older adults: A meta-analysis

BACKGROUND/OBJECTIVE

As pharmacists work to ensure reimbursement for chronic disease management services on the national level, evidence of their impact on important health metrics, such as medication adherence, is needed. However, summative evidence is lacking on the effectiveness of pharmacists to improve medication adherence in older adults. The objective was to assess the effectiveness of pharmacist-led interventions on medication adherence in older adults (65+ years).

DESIGN/SETTING/PARTICIPANTS

Using a systematic review and meta-analytic approach, a comprehensive search of publications in PubMed, Scopus, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Google Scholar was conducted through April 2, 2020 for randomized clinical trials of pharmacist-led interventions to improve medication adherence in older adults. A standardized mean difference effect size (Cohen's d) was calculated for medication adherence in each study. Study effect sizes were pooled using a random-effects model, with effect sizes weighted by inverse of its total variance.

MEASUREMENTS

Medication adherence using any method of measurement.

RESULTS

Among 40 unique randomized trials of pharmacist-led interventions with data from 8822 unique patients (mean age, range: 65-85 years), the mean effect size was 0.57 (k = 40; 95% Confidence Interval [CI]: 0.38-0.76). When two outlier studies were excluded from the analysis, the mean effect size reduced to 0.41 (k = 38; 95% CI: 0.27-0.54). A sensitivity analysis of medication adherence outcome by time point resulted in a mean effect size of 0.64 at 3 months (k = 12; 95% CI: 0.32-0.97), 0.30 at 6 months (k = 13; 95% CI: 0.11-0.48), 0.22 at 12 months (k = 12; 95% CI: 0.08-0.37), and 0.36 for outcome time points beyond 12 months (k = 5; 95% CI: 0.02-0.70).

CONCLUSION

This meta-analysis found a significant improvement in medication adherence among older adults receiving pharmacist-led interventions. Implementation of pharmacist-led interventions supported by Medicare reimbursement could ensure older adults' access to effective medication adherence support.

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.

Pharmacogenomics guided versus standard antidepressant treatment in a community pharmacy setting: A randomized controlled trial

The literature on pharmacogenomics as a tool to support antidepressant precision is burgeoning. Recently, a more active role has been argued for pharmacists in pharmacogenomic testing, with both pharmacists and family physicians perceiving pharmacist‐led testing as a valuable method by which to scale this innovation for depression treatment. In this prospective, single‐blind randomized controlled design, we evaluated the impact of pharmacogenomics guided versus standard antidepressant treatment of depression and anxiety, implemented in three large community pharmacies. Participants were 213 outpatients diagnosed with major depressive disorder and/or generalized anxiety disorder, randomized to receive pharmacogenomics guided (n = 105) or standard antidepressant treatment (n = 108); participants were blinded to the study. Patient reported outcomes of depression, anxiety, disability, and treatment satisfaction were assessed at months 0, 1, 3, and 6. Hypotheses were investigated using mixed effect models on the full data. All clinical outcomes improved significantly. The primary outcome (depression) and two secondary outcomes (generalized anxiety and disability) exhibited significant time by group interactions indicating that they improved for participants who received pharmacogenomics guided treatment more so than they did for participants who received standard treatment. Treatment satisfaction improved similarly for both groups. Results contribute to a growing body of work evaluating the impact of pharmacogenomics testing to inform antidepressant medication treatment for depression and anxiety, and provides important initial evidence for the role of pharmacists in care delivery. Pharmacogenomic testing may be a valuable tool to allow pharmacists to more effectively collaborate in facilitating clinical treatment decisions. ClinicalTrials.gov registration: (NCT03591224).

Interventions to improve medication adherence in mental health: the update of a systematic review of cost-effectiveness

OBJECTIVE

Medication non-adherence in mental health problems has social and economic costs. The objective of the study was to review the cost-effectiveness of interventions to enhance medication adherence in patients with mental health problems.

METHODS

The update of a previous systematic review was performed. Databases were searched in June 2019: MEDLINE, PSYCINFO, EMBASE, CINAHL, CRD, WOS. Cost-effectiveness studies comparing an intervention to improve the medication adherence with other interventions/usual care in adults with mental health problems were included. Data were extracted, methodological quality of the studies was assessed and a narrative synthesis was performed.

RESULTS

Nine studies were included in the review. The interventions that showed medication adherence increase were: a financial incentive when depot injection was taken by patients with psychotic disorders, a value-based benefit design policy including copayment and counselling in a company setting, and a medication treatment decision supported by a pharmacogenetic test. The other studies (coaching by pharmacists; a psychological and educational intervention at health care centres) did not find differences between groups. No study found cost differences between alternatives.

CONCLUSIONS

Interventions to improve medication adherence in adults with mental health problems could be cost-effective, especially those based on financial incentives, although more research is needed. KEYPOINTS There are several types of interventions designed to enhance medication adherence in patients with mental health problems. Few of them have demonstrated cost-effectiveness. Two studies found that a financial incentive per depot injection in patients with psychotic disorders improved the medication adherence. Two other studies found improvement in adherence due to two specific interventions: a value-based benefit design policy in a company setting and a pharmacogenetic test supporting the medication treatment decision. No study found differences in costs between the intervention and the comparator. More research is needed to implement cost-effective interventions.

Reprint of: Psychosocial factors associated with pharmacists' antidepressant drug treatment monitoring

OBJECTIVE

Patients undergoing antidepressant drug treatment (ADT) may face challenges regarding its adverse effects, adherence, and efficacy. Community pharmacists are well positioned to manage ADT-related problems. Little is known about the factors influencing pharmacists' ADT monitoring. This study aimed to identify the psychosocial factors associated with pharmacists' intention to perform systematic ADT monitoring and report on this monitoring.

DESIGN

Cross-sectional study based on the Theory of Planned Behavior (TPB).

SETTING AND PARTICIPANTS

Community pharmacists in the province of Quebec, Canada.

OUTCOME MEASURES

Pharmacists completed a questionnaire on their performance of ADT monitoring, TPB constructs (intention; attitude; subjective norm; perceived behavioral control; and attitudinal, normative, and control beliefs), and professional identity. Systematic ADT monitoring was defined as pharmacists' reporting 4 or more consultations with each patient during the first year of ADT to address adverse effects, adherence, and efficacy. Hierarchical linear regression models were used to identify the factors associated with the intention and reporting of systematic ADT monitoring and Poisson working models to identify the beliefs associated with intention.

RESULTS

A total of 1609 pharmacists completed the questionnaire (participation = 29.6%). Systematic ADT monitoring was not widely reported (mean score = 2.0 out of 5.0), and intention was moderate (mean = 3.2). Pharmacists' intention was the sole psychosocial factor associated with reporting systematic ADT monitoring (P < 0.0001; R² = 0.370). All TPB constructs and professional identity were associated with intention (P < 0.0001; R² = 0.611). Perceived behavioral control had the strongest association.

CONCLUSION

Interventions to promote systematic ADT monitoring should focus on developing a strong intention among pharmacists, which could, in turn, influence their practice. To influence intention, priority should be given to ensuring that pharmacists feel capable of performing this monitoring. The main barriers to overcome were the presence of only 1 pharmacist at work and limited time. Other factors identified offer complementary intervention targets.

Pharmacists' Knowledge and Practice of Issues Related to Using Psychotropic Medication in Elderly People in Ethiopia: A Prospective Cross-Sectional Study

Purpose

This study is aimed at assessing pharmacists' knowledge and practice of issue related to usage of psychotropic medications in elderly people, in Gondar town Northwest, Ethiopia.

Methods

A cross-sectional study was conducted among pharmacists working in community, health center, and hospital pharmacies in Gondar town from March 1 to May 30, 2020. A total of 73 medication retail outlets (40 pharmacies and 33 drug stores) were included in this study. Pharmacy personnel's knowledge and practice were assessed using self-administered validated questionnaires. Binary and multivariable logistic regression analyses were used to assess the association between different variables. P < 0.05 was used to declare the association.

Result

A total of 144 pharmacists were included in the study; the mean age was 30.13 (SD ±5.87), ranging from 20 to 55years. The mean knowledge score was 7.789 (SD ±2.98), and 75 (52.1%) of them had poor knowledge. The mean practice score was 2.32 ± 0.912 (mean ± SD), and 77 (53.5%) of the respondents had poor practice. All participants had not taken on-the-job training about psychotropic medication. Work experience (P < 0.029) and personal monthly income (P < 0.046) were significantly associated with pharmacists' knowledge. There was a significant association between work experience and practice level (P < 0.043).

Conclusion

The knowledge and practice of pharmacy personnel were low for issues related to the use of psychotropic medication in the elderly. This result indicates the need for training for pharmacists on pharmacotherapy of psychotropic medication.

Psychosocial factors associated with pharmacists' antidepressant drug treatment monitoring

OBJECTIVE

Patients undergoing antidepressant drug treatment (ADT) may face challenges regarding its adverse effects, adherence, and efficacy. Community pharmacists are well positioned to manage ADT-related problems. Little is known about the factors influencing pharmacists' ADT monitoring. This study aimed to identify the psychosocial factors associated with pharmacists' intention to perform systematic ADT monitoring and report on this monitoring.

DESIGN

Cross-sectional study based on the Theory of Planned Behavior (TPB).

SETTING AND PARTICIPANTS

Community pharmacists in the province of Quebec, Canada.

OUTCOME MEASURES

Pharmacists completed a questionnaire on their performance of ADT monitoring, TPB constructs (intention; attitude; subjective norm; perceived behavioral control; and attitudinal, normative, and control beliefs), and professional identity. Systematic ADT monitoring was defined as pharmacists' reporting 4 or more consultations with each patient during the first year of ADT to address adverse effects, adherence, and efficacy. Hierarchical linear regression models were used to identify the factors associated with the intention and reporting of systematic ADT monitoring and Poisson working models to identify the beliefs associated with intention.

RESULTS

A total of 1609 pharmacists completed the questionnaire (participation = 29.6%). Systematic ADT monitoring was not widely reported (mean score = 2.0 out of 5.0), and intention was moderate (mean = 3.2). Pharmacists' intention was the sole psychosocial factor associated with reporting systematic ADT monitoring (P < 0.0001; R² = 0.370). All TPB constructs and professional identity were associated with intention (P < 0.0001; R² = 0.611). Perceived behavioral control had the strongest association.

CONCLUSION

Interventions to promote systematic ADT monitoring should focus on developing a strong intention among pharmacists, which could, in turn, influence their practice. To influence intention, priority should be given to ensuring that pharmacists feel capable of performing this monitoring. The main barriers to overcome were the presence of only 1 pharmacist at work and limited time. Other factors identified offer complementary intervention targets.

Development of a community pharmacy-based intervention to enhance adherence to adjuvant endocrine therapy among breast cancer survivors guided by the Intervention Mapping approach

BACKGROUND

Adjuvant endocrine therapy (AET) is prescribed for 5 or 10 years to women with non-metastatic breast cancer to reduce recurrence and mortality risks. However, AET adherence is suboptimal for many women. The few interventions specifically designed to enhance AET adherence and evaluated to date have provided inconclusive results. None of these interventions was offered in the community pharmacy setting.

OBJECTIVE

To describe the development of the PAcHA program, a community pharmacy-based intervention aiming to enhance AET adherence.

METHODS

The development of the intervention was guided by the six-step Intervention Mapping approach: needs assessment (Step 1); development of objectives matrices (Step 2); selection of theory-based intervention methods and practical applications (Step 3); development of the intervention program (Step 4); development of the adoption and implementation plan (Step 5); and evaluation plan (Step 6). Researchers, pharmacists and women prescribed AET were consulted at key steps.

RESULTS

The logic model was developed based on women's needs identified through a literature review and a qualitative study (Step 1). Optimal use of treatment for each woman with a new AET prescription was considered the behavioral outcome of the intervention. A woman is expected to: acquire knowledge about AET; make an informed decision about AET initiation and persistence; respect administration modalities and cope with side effects (Step 2). Motivational interviewing principles serve to guide the pharmacist intervention (Step 3). The intervention is brief and tailored to AET initiation and follow-up visits. Standardized intervention tools are available as support for pharmacists in their counseling (Step 4). An implementation plan was established, and web-based training was designed to train the pharmacists (Step 5). A cluster-randomized controlled trial was designed to evaluate the intervention (Step 6).

CONCLUSION

The systematic approach used for developing the intervention may increase its potential for being efficiently implemented and effective.

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.

Men's views of antidepressant treatment for depression, and their implications for community pharmacy practice

BACKGROUND

Men with depression can express and navigate their condition differently to women. Understanding this population's needs, and experiences, can help healthcare professionals better support these patients. There is a lack of knowledge in this area, and no studies have explored men's depression in the context of community pharmacy.

OBJECTIVES

Explore views of men around their medication for the treatment of depression and the role of community pharmacy in their treatment.

SETTING

United Kingdom (UK) primary care.

METHOD

Semi-structured in-depth interviews were conducted. Eligible participants were male, aged 18-65 years, and treating depression with antidepressants. Participants were recruited through 5 UK pharmacies (via the pharmacist or poster recruitment) and a UK University (poster recruitment). A thematic approach was used for analysis.

RESULTS

14 men aged 26-61 years, predominantly of white ethnicity were interviewed. Key themes were found. The theme 'Antidepressant's attributions to benefits' highlighted all men noticed benefits when taking antidepressants, but held uncertainty on what extent their antidepressants caused this. The themes 'Views of pharmacist's role influences engagement', and 'Influence of cognitive state upon healthcare interactions' demonstrated men were not inclined to discuss concerns with the community pharmacist. These men didn't see this as the pharmacist's role, nor had these men given cognitive space to evaluate their treatment beliefs or information needs. Yet the theme 'Reflection of support and information needs' shows men did have unmet information and support needs. This also links into the 'Hegemonic Masculinity and taking antidepressants' theme, where taking antidepressants could challenge ones masculinity.

CONCLUSION

Community pharmacists should create opportunities for men to engage in conversations around their antidepressants and wider support. Men, as a requisite for engagement, will need to see such interactions as within the community pharmacists' remit, and as part of a collaborative healthcare system.

PharmActa: Personalized pharmaceutical care eHealth platform for patients and pharmacists

Community pharmacists are critically placed in the patient care chain being an extended frontline within primary healthcare networks across Europe. They are trained to ensure safe and effective medication use, a crucial and responsible role, extending beyond the common misconception limited to just providing timely access to medicines for the population. Technology-wise, eHealth being committed to an effective, networked, patient-centered and accessible healthcare would prove a real asset in this direction by achieving improved therapy adherence with better outcomes and direct contribution to a cost-effective healthcare system. In this work, we present PharmActa, a personalized eHealth platform that addresses key features of pharmaceutical care and enhances communication of pharmacists with patients for optimizing pharmacotherapy. PharmActa empowers patients by providing pharmaceutical care services, such as drug interactions tools, reminders for assisting adhesion and compliance, information regarding adverse drug reactions, as well as pharmacovigilance along with related tools for healthcare management. In addition, it allows the pharmacists to review the medication history in order to provide personalized pharmaceutical care services; thus enhancing their role as healthcare providers. Finally, a mechanism allowing such a system to be interconnected with a developed medical repository following European and International interoperability standards, is also presented. Thus far, the evaluation results presented in this work indicate that PharmActa can be of great benefit to healthcare professionals, especially pharmacists and patients.

Recall of Pharmaceutical Pictograms by Older Adults

BACKGROUND

Low health literacy and high medication burden in the older adult population are contributing factors to the misunderstanding of medication instructions, leading to an increased risk of poor adherence and adverse events in this group of patients.

OBJECTIVE

To evaluate the ability of older adults to recall the meaning of 13 pharmaceutical pictograms 4 weeks after receipt of feedback on pictogram meaning.

METHODS

Older adults (aged 65 or older) were recruited from one community pharmacy in Canada. One-on-one structured interviews were conducted to assess the comprehensibility of 13 pharmaceutical pictograms from the International Pharmaceutical Federation's database of pictograms. Each participant was then told the meaning of each pictogram. Recall was assessed 4 weeks later.

RESULTS

A total of 58 participants met the inclusion criteria and agreed to participate. The number of pictograms meeting the ISO threshold for comprehensibility of symbols increased from 10 at the initial comprehensibility assessment to 13 at the recall assessment. Analysis of demographic data showed no associations between initial comprehensibility of the pictograms and age, sex, education level, or number of medications taken.

CONCLUSIONS

The results of this study indicate that after being informed of the meaning of pharmaceutical pictograms, older adults were able to recall the pictogram meanings for at least 4 weeks.

Knowledge about Disease, Medication Therapy, and Related Medication Adherence Levels among Patients with Hypertension

Background and Objectives: A particular problem in cardiology is poor adherence to pharmacological treatment among patients with hypertension. It is known that approximately half of these patients do not use their medications as prescribed by their doctor. Patients may choose not to follow the doctor's recommendations and regularly do not control their blood pressure, owing to many factors. A convenient method for measuring the level of adherence is the Morisky Medication Adherence Scale, which also provides insight into possible remedies for low adherence. We investigated their therapy, knowledge about the disease and its control, and demographic differences to assess the adherence of patients with hypertension. Materials and Methods: This was a cross-sectional observational study. Data were collected through a survey of 12 pharmacies in Latvia. The study involved 187 participants with hypertension. Results: The prevalence of non-adherence was 46.20% in Latvia. The oldest patients were the most adherent (p = 0.001, β = 0.27). The higher the self-rated extent from 0 to 10, to which the patient takes their antihypertensives exactly as instructed by their physician, the higher the level of adherence (p < 0.0001, β = 0.38), where at "0", the patient does not follow physician instructions at all, and at "10", the patient completely follows the physician's instructions. Non-adherent patients tend to assess their medication-taking behavior more critically than adherent patients. The longer the patient is known to suffer from hypertension, the more adherent he or she is (p = 0.014, β = 0.19). Conclusions: Medication non-adherence among patients with hypertension is high in Latvia. Further investigations are needed to better understand the reasons for this and to establish interventions for improving patient outcomes.

Comparison of Interventions to Improve Long-Term Medication Adherence Across Different Clinical Conditions: A Systematic Review With Network Meta-Analysis

Background: Medication non-adherence has a dynamic, temporal and multifactorial nature with a significant impact on economic and clinical outcomes. Interventions to improve adherence are complex and require adaptation to patients' needs, which may include patient's medical conditions. The aim of this study was to assess the comparative effectiveness of medication adherence interventions per type of clinical condition on adult patients.

Methods: A systematic review with network meta-analysis was performed (PROSPERO registration number of CRD42018054598). An initial Pubmed search was conducted to select meta-analyses reporting results of interventions aiming to improve medication adherence. Primary studies were selected and those reporting results with a long-term follow up (≥10 months) on adult patients were included for data extraction. Study characteristics, description of interventions and adherence outcomes were extracted. Adherence interventions were classified in four groups: educational, attitudinal, technical, and rewards. Clinical conditions were classified in four groups: circulatory system and metabolic diseases, infectious diseases, musculoskeletal diseases, and mental, behavioral or neurodevelopmental disorders. Network meta-analyses with effect sizes expressed as odds ratio (OR) with a 95% credibility interval (CrI) were built. Ranking probabilities for each measure of adherence were calculated by using surface under the cumulative ranking analysis (SUCRA).

Results: A total of 61 meta-analysis and 149 primary studies were included in the qualitative synthesis and 80 primary studies in the quantitative analysis. The most effective interventions were: educational + technical 79.6% [OR: 0.44 (CrI: 0.26, 0.73)] and 73.3% [OR: 0.56 (0.36, 0.84)] in circulatory system and metabolic diseases and infectious diseases respectively. Attitudinal intervention had the greatest probability for musculoskeletal diseases of 92.3% in SUCRA [OR: 0.30 (0.10, 0.86)]. Finally, educational + attitudinal interventions had the greatest effect (SUCRA 73.8%) for mental, behavioral or neurodevelopmental disorders, although this was not significant according to consistency analysis.

Conclusion: Effectiveness of interventions seems to be related to the clinical condition. Educational and technical interventions resulted in a major effect on long-term management of medication adherence in patients with infectious diseases (HIV) and circulatory system and metabolic diseases whereas attitudinal components presented a higher effect on musculoskeletal and mental, behavioral or neurodevelopmental disorders.

Community pharmacists' experiences and people at risk of suicide in Canada and Australia: a thematic analysis

PURPOSE

To explore Canadian and Australian community pharmacists' practice experiences in caring for people at risk of suicide.

METHODS

We conducted a thematic analysis of 176 responses to an open-ended extension question in an online survey.

RESULTS

Four themes were identified and include referrals and triage, accessibility for confiding, emotional toll, and stigma. Subthemes included gatekeeping the medication supply, sole disclosure, planning for end of life, concerns of support people, assessing the validity of suicidality, gaps in the system, not directly asking, ill-equipped, resources in the pharmacy, relying on others to continue care, and attention seeking.

CONCLUSIONS

Community pharmacists are caring for patients at risk of suicide frequently, and often with patients seeking the help of pharmacists directly. Pharmacists engage in activities and actions that would be considered outside of the traditional dispensing roles and provide support and intervention to people at risk of suicide through collaboration and other mechanisms. Further research to determine appropriate education and training and postvention supports is required.

Clinical Management of Bleeding Risk With Antidepressants

Objective: This nonsystematic review describes risk of bleeding in treatment with serotonin reuptake inhibitors (SRIs) and provide recommendations for the management of patients at risk of bleeding. Data Sources: Articles were identified by English-language MEDLINE search published prior to June 2018 using the terms SRI, serotonin and noradrenaline reuptake inhibitors, OR antidepressive agents, AND hemorrhage OR stroke. Study Selection and Data Extraction: Meta-analyses were utilized to identify information regarding risk of bleeding with antidepressants. Individual studies were included if they had information regarding bleeding risk with specific SRIs, timing of risk, or risk with medications of interest. Data Synthesis: SRIs increase risk of bleeding by 1.16- to 2.36-fold. The risk is synergistic between SRIs and nonsteroidal anti-inflammatory drugs (NSAIDs; odds ratio [OR] range between studies 3.17-10.9). Acid-reducing medications may mitigate risk of gastrointestinal bleeds in chronic NSAIDs and SRI users (OR range between studies 0.98-1.1). Antidepressants with low or no affinity for the serotonin transporter, such as bupropion or mirtazapine, may be appropriate alternatives for patients at risk of bleeding. Relevance to Patient Care and Clinical Practice: This review includes data regarding bleeding risk for specific antidepressants, concomitant medications, and risk related to duration of SRI use. Considerations and evidence-based recommendations are provided for management of SRI users at high bleeding risk. Conclusions: Clinicians must be aware of the risk of bleeding with SRI use, especially for patients taking NSAIDs. Patient education is prudent for those prescribed NSAIDs and SRIs concurrently.

The Development of a Community Pharmacy-Based Intervention to Optimize Patients' Use of and Experience with Antidepressants: A Step-by-Step Demonstration of the Intervention Mapping Process

Objective: To describe the development of a community pharmacy-based intervention aimed at optimizing experience and use of antidepressants (ADs) for patients with mood and anxiety disorders. Methods: Intervention Mapping (IM) was used for conducting needs assessment, formulating intervention objectives, selecting change methods and practical applications, designing the intervention, and planning intervention implementation. IM is based on a qualitative participatory approach and each step of the intervention development process was conducted through consultations with a pharmacists' committee. Results: A needs assessment was informed by qualitative and quantitative studies conducted with leaders, pharmacists, and patients. Intervention objectives and change methods were selected to target factors influencing patients' experience with and use of ADs. The intervention includes four brief consultations between the pharmacist and the patient: (1) provision of information (first AD claim); (2) management of side effects (15 days after first claim); (3) monitoring treatment efficacy (30-day renewal); (4) assessment of treatment persistence (2-month renewal, repeated every 6 months). A detailed implementation plan was also developed. Conclusion: IM provided a systematic and rigorous approach to the development of an intervention directly tied to empirical data on patients' and pharmacists' experiences and recommendations. The thorough description of this intervention may facilitate the development of new pharmacy-based interventions or the adaptation of this intervention to other illnesses and settings.