Depression Rx: involve more pharmacists

Introduction

Pharmacists can help spot depression, improve drug therapy outcomes, lower health care costs, and reduce the risk of suicide among depressed patients.

This was the consensus among speakers at a March 6, 2004 conference in San Francisco sponsored by the UCSF School of Pharmacy Center for Consumer Self Care, in cooperation with the San Francisco-based Iris Alliance Fund.

More than 130 pharmacists, other health care providers, and doctor of pharmacy students attended the day-long event to learn from California's leading psychopharmacologists how they can take more active roles in challenging a disease that is often overlooked and ineffectively treated.

Diagnosis

Untreated depression is common among pharmacy patrons, according to Patrick Finley, PharmD, BCPP, associate professor of clinical pharmacy at the UCSF School of Pharmacy. "At least 10 to 20% of the people who walk into a pharmacy are depressed and not adequately treated, or not treated at all," he said.

The stress of major health problems, and even some medications prescribed for those problems, can bring on clinical depression in vulnerable patients.

Mary Gutierrez, PharmD, BCPP, associate professor at the University of Southern California (USC), believes that pharmacists can play key roles in recognizing cases of depression. At the Veterans' Administration hospital where she works, depressed patients mostly come in about other complaints. "The only patients who will say they are depressed are generally those suffering from a psychosocial stress," she said.

Treatment

Even when depression is diagnosed correctly, it might not be adequately treated. "There is a wide gap between what should be done and what actually occurs" in the treatment of depression, said Glen Stimmel, PharmD, BCPP, professor at the USC School of Pharmacy.

Part of the reason that depression is often inadequately treated is that in recent years the number of medications available for depression has ballooned dramatically:

• Twenty years ago in 1984, the main drugs for treating depression were tricyclic antidepressants and monamine oxidase inhibitors (MOAIs).
• The discovery of selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac), initiated a new era of depression treatments.
• More recent drugs such as venlafaxine (Effexor) and mirtazapine (Remeron), are thought to act on a broader category of neurotransmitter receptors and can sometimes be more effective than the SSRIs.

The increase in drug treatment options means physicians must master growing amounts of information about drug efficacy, side effects, and interactions with other drugs. Knowing the breadth of this kind of information is a primary role of the pharmacist.

"The treatment problem is compounded because most antidepressants are prescribed not by psychiatrists, but by primary care physicians," Stimmel said. "A large body of clinical literature documents the inadequacy of the diagnosis and treatment of major depression in primary care settings. Treatment should be individualized, with patients getting different drugs at different dosages, and then the patient should stay on the drug for at least 6 months if he or she is showing some response."

According to Stimmel, primary care physicians often:

• Prescribe the same dose of the same antidepressant for all patients,
• Do not follow up until 3 months later, if at all, and
• Stop the course of medication when there is some remission.

Patients often:

• Do not take the prescribed dosages, and
• Stop before an effect is seen.

The importance of not stopping too soon was a message reinforced by Finley. "The gold standard now for the treatment of depression is remission, not just a response to drug therapy. Why is it that depression is the only disease for which we think that merely reducing symptoms is enough?"

Like Stimmel, Finley emphasized the importance of picking the right antidepressant and the right dosage for each patient. For instance, SSRIs might be appropriate for patients who tend to feel worried, while bupropion, which has a more activating or stimulating effect, might be more appropriate for patients who are more tired than worried.

When a drug shows some efficacy after the initial 4 to 6 weeks of therapy, the pharmacist and physician should not be afraid to increase the dosage and keep the patient on that dosage for at least 6 months to a year.

Herbals and Supplements

The increasing popularity of non-prescription herbal and supplemental remedies can make prescribing medications for depression even more complex, according to Cathi Dennehy, PharmD, associate clinical professor at the UCSF School of Pharmacy. Some of these are clinically tested substances that can have significant interactions with prescription medications.

St. John's wort (Hypericum perforatum) is one herbal medication that might be useful in alleviating mild to moderate depression but can also have additive effects with other antidepressants.

There have been reports of serotonin syndrome, in which the combined effect of St. John's wort and serotonin reuptake inhibitors boosts serotonin to dangerous levels.

Other herbs and supplements may have other negative side effects or interactions. Those commonly taken for depression include:

• kava-kava,
• S-Adenosyl-L-Methionine (SAMe),
• hihydroepiandronsterone (DHEA),
• omega-3 fatty acids, and
• the serotonin precursor 5-hydroxytryptophan.

Patients might take these compounds without telling their physicians. Or physicians might not know about interactions between these supplements and prescription drugs.

Suicide

The United States Food and Drug Administration recently recommended that physicians who prescribe antidepressants monitor their patients closely for increased risk of suicide, especially when changing medications or dosages.

Gutierrez noted that pharmacists can play an important role in recognizing those at risk of committing suicide or otherwise harming themselves. The risk of suicide actually increases in the first weeks of drug treatment. "In the 3rd or 4th week of treatment, patients are at highest risk for suicide because they have increased energy but are still depressed," she explained.

Pharmacists' Role

Pharmacists can improve outcomes for depressed patients at every step of the patients' treatment. They can:

• Recognize when an antidepressant is indicated,
• Provide patients with realistic expectations,
• Improve antidepressant selection,
• Recognize drug interactions,
• Manage side effects, and
• Recommend alternate treatment options.

"When research shows that only about half of depressed patients are getting any therapy and only about 22% of all depressed patients are adequately treated, there is obviously a huge need that pharmacists can help fill," Finley commented.

Responding to the Challenge

Turning that potential into actual help is a challenge. Most community pharmacists have very little time to spend with individual patients. In general, economic forces have created pressures to spend less time with patients, rather than more.

Some pharmacies have worked to reverse this trend. Wal-Mart reimburses pharmacists to track down patients who are not complying with their prescribed antidepressant regimen. Finley and the UCSF School of Pharmacy department of clinical pharmacy have published two studies in collaboration with Kaiser Permanente. In both, researchers showed that skilled medication management and additional patient education lowered overall disease burden and reduced patient use of medical resources.

"There are a lot of places that don't think they have the time and space to do this sort of counseling," said Finley. "But it's a very rewarding area for pharmacies and pharmacists to pursue, and they should make time for it."