A feasibility study of community pharmacists performing depression screening services

doi:10.1016/j.sapharm.2014.08.013

Research in Social and Administrative Pharmacy

Volume 11, Issue 3, May–June 2015, Pages 364-381

https://doi.org/10.1016/j.sapharm.2014.08.013 Get rights and content

Abstract

Background

Depression is one of the largest causes of disease burden globally but can routinely go undetected in primary care. Screening for depression is an effective way to increase early recognition, and there is an opportunity to utilize pharmacists' skills and accessibility to do this.

Objectives

The overall aim of this study was to determine the feasibility of Australian community pharmacists performing screening and risk assessment services for depression. The specific objectives were to: (1) develop a depression screening training program to aid pharmacists in the screening and risk assessment of depression in community pharmacy, (2) assess the feasibility of pharmacists using a screening tool for depression, (3) assess pharmacists' perspectives on the ease of use of different screening tools in the community pharmacy setting and (4) investigate the barriers and facilitators to pharmacists performing screening and risk assessment services for depression in community pharmacy.

Methods

Twenty pharmacists from 12 community pharmacies were recruited. A training program on depression was developed and delivered to the pharmacists, followed by an eight week data collection period during which pharmacists conducted patient screenings for depression. Semi-structured interviews were conducted at the end of the data collection period to gather pharmacists' reflections on the intervention and to explore the barriers and facilitators to depression screening and risk assessment.

Results

Forty-one screening and risk assessments were conducted from 75 consumers who were approached. The majority of consumers screened were female, less than 40 years old and previously known to the pharmacy. More than 70% of consumers were referred on to a GP or psychologist for assessment. Barriers to implementation of the service included time, stigma and a lack of awareness of the pharmacists' role. Facilitators to the service included the accessibility of the pharmacist, having a private consultation area in the pharmacy, awareness campaigns and mental health resources on display.

Conclusions

Pharmacists are capable of performing screening and risk assessment services for depression and making referrals to appropriate health care professionals when required. Pharmacy based depression screening programs have the potential to increase the early detection of depression which may lead to early intervention, and potentially contribute to easing the enormous disease burden associated with depression.

Introduction

Depression is the third leading cause of global disease burden and mental disorders are the leading cause of non-fatal disease burden in the world.1, 2 Depression accounted for more than 40% of all disability-adjusted life years (DALYs) attributed to mental disorders in 2010, increasing by 37.6% since 1990.² In Australia, 1 in 5 people in any given year and 1 in 2 people during their lifetime will experience a common mental disorder with depression one of the most common.³ Depression can have a major impact on emotional and physical well-being as well as social functioning and untreated mental disorders can have an enormous personal and economic burden, with depression estimated to result in over 6 million working days lost each year in Australia.4, 5 A recent study has estimated that treatment rates for mental disorders in Australia is improving in recent years yet more than 50% of the Australian population are still not seeking professional help for their mental health symptoms.⁶ These rates are comparable to the USA and Europe, while in low- and middle-income countries the statistics are even worse.7, 8, 9, 10 Furthermore, while one in 10 GP encounters are for a primary mental health concern, evidence suggests that depression can often remain undetected in primary care.11, 12

Stigma has been shown to have a clear deterrent effect on help seeking behaviors for mental health problems both through treatment stigma (stigma associated with seeking or receiving mental health care) and internalized stigma (personal shame or embarrassment in seeking help).¹³ However, treatment and internalized stigma are not the only barriers to help-seeking in mental health and it is also important to address issues of access, confidentiality concerns, preferences for non-disclosure, structural stigma and recognition of mental health problems.¹³ Another reason for the low rates of help seeking could be related to a lack of recognition from consumers on the availability of mental health care services, which highlights the opportunity for health care professionals to be trained to intervene when mental health symptoms first appear and promote the availability of services.

It has been shown that a simple and cost-effective way to increase the early recognition of depression is screening.¹⁴ Depression screening and risk assessment has the potential to increase early identification of signs and symptoms of depression, and prompt a referral to appropriate health care professional if necessary. The effectiveness of depression screening is predominantly dependent on the screening tool used which takes into account its reliability, validity, feasibility and practicality. There is a wide range of depression screening tools available that vary in length, style and presentation. Thus, the effectiveness of a screening tool lies at the balance point between the properties of the tool which includes sensitivity and specificity as well as the length and practicality of the tool. A number of depression screening tools have shown to be reliable and valid in primary care but the feasibility of pharmacists using these different tools have yet to be assessed in practice in Australia.15, 16, 17

Health care professionals, including GPs and pharmacists, play an essential role in improving the detection of depression in primary care. Pharmacists in particular are in a unique position to assist screening for depression in the community setting due to their accessibility and trust in the community.¹⁸ A recent Australian study highlighted that when consumers developed a trusting relationship with their pharmacist they felt the community pharmacy was a safe space to discuss their mental health concerns.¹⁹ Pharmacists also are equipped with the skills and experience to improve quality use of medicines for consumers with mental illness such as depression.20, 21, 22, 23, 24 There has been support for pharmacists to expand their role in the area of primary mental health care through funding initiatives of the Australian government.²⁵ In addition, there are important documents supporting and guiding the role of pharmacists in mental health care in Australia.26, 27, 28 These frameworks and guidelines articulate the activities, knowledge and capabilities expected of pharmacists in mental health care to improve the quality use of medicines and health care outcomes, yet there has been no Australian research to date investigating the feasibility of pharmacists performing some of these professional services such as depression screening.

Pharmacists have been shown to have a high degree of mental health literacy to support their role in the disease state management of depression.²⁹ Screening and risk assessment services for various physical diseases are common and routinely performed in community pharmacy; however, there is currently little evidence for pharmacists performing these services for depression.³⁰ In studies conducted in the US, it has been shown that depression screening and risk assessment by pharmacists is feasible.31, 32, 33 However, no research has been conducted investigating the barriers and facilitators to the uptake of a pharmacy-based depression screening service and in addition there is no data on the style of screening tool most suited to this practice setting.

The overall aim of this study was to test the feasibility of pharmacists offering a screening and risk assessment service for depression in the community pharmacy setting. The specific objectives were to (1) develop a depression screening training program to aid pharmacists in the screening and risk assessment of depression in community pharmacy, (2) assess the feasibility of pharmacists using a screening tool for depression, (3) assess pharmacists' perspectives on the ease of use of different screening tools in the community pharmacy setting and (4) investigate the barriers and facilitators to pharmacists performing screening and risk assessment services for depression in community pharmacy.

Section snippets

Methods

Approval to undertake this study was obtained from The University of Sydney Human Research Ethics Committee in July 2013.

Results

Twelve pharmacies from the 32 pharmacies approached, consented to participate in the study. Twenty pharmacists from these 12 participating pharmacies undertook the training program. The majority of pharmacies were from the greater metropolitan area of Sydney and were independent strip shop pharmacies (Table 1).

Discussion

This study demonstrated that pharmacists are capable of performing screening and risk assessment services for depression in primary care and that depression screening in community pharmacies in Australia is feasible. This included making referrals to appropriate health care professionals when necessary. The interactive training program and the six-step pharmacist screening checklist developed for this study were well received by the pharmacists and enabled them to be prepared and confident in

Conclusion

Pharmacists have shown to be capable of performing screening and risk assessment services for depression and making referrals to appropriate health care professionals. Depression screening and risk assessment services have been demonstrated to be feasible in the community pharmacy setting in Australia. Depression screening has the potential significance to facilitate the early detection of depression which may lead to better management of the condition, and subsequently ease the enormous

Acknowledgments

This study was supported by a research grant from the Pharmacy Research Trust of New South Wales.

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Pre and post-training surveys were completed by 136 participants, most of which were pharmacists. Both IG and CG participants had significant reductions in stigma (P < 0.001) post-training. IG participants’ confidence and knowledge regarding metabolic monitoring significantly improved compared to CG (P < 0.001). IG participants were significantly more confident and comfortable in providing medication counseling, compared to CG participants (P < 0.05).
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“There's very little that you can do other than refer them to the doctor if you think they've got postnatal depression”: Scoping the potential for perinatal mental health care by community pharmacists: Community pharmacists and perinatal mental health
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This study demonstrates community pharmacists have a potential role within community mental healthcare in identification of PMH problems and providing appropriate advice and support. Upskilling community pharmacists in mental health should be considered to increase knowledge and confidence while formal referral pathways to other trained healthcare professionals and existing services should be established and made available to pharmacists.
Mental health training programs for community pharmacists, pharmacy staff and students: A systematic review
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Community pharmacists as front-line providers are usually an initial point of contact for people living with mental health disorders, or those at-risk, due to their high accessibility.19 Community pharmacy-based depression screening programs have shown to increase the early detection of depression, leading to early intervention for people who may not otherwise have sought help for their mental health disorders.20 Furthermore, community pharmacists role in mental health care has been shown to enhance patients’ knowledge, beliefs, and sense of treatment progress related to psychotropics (e.g., antidepressants).21
Primary care is often the first point of contact for people living with mental disorders. Community pharmacists, pharmacy staff and students are increasingly being trained to deliver mental health care. However, there is still a gap in the literature exploring the characteristics of all available mental health training programs and their components and their influence on pharmacists, pharmacy staff and students’ outcomes.
To summarize the evidence evaluating mental health training programs completed by community pharmacists, pharmacy staff and students. More specifically, to explore the components of mental health training programs and identify those that facilitate significant improvements in outcomes.
A systematic review was conducted following the Cochrane handbook and reported according to PRISMA guidelines. A search for published literature was conducted in three databases (PubMed, Scopus, and Web of Science) in July 2021. Eligible studies were included if they described and evaluated the impact of mental health training programs delivered to community pharmacists, pharmacy staff and pharmacy students regardless of design or comparator. The methodological quality of included studies was appraised using both the NIH quality assessment, to evaluate studies with an uncontrolled pre-post design, and the Cochrane EPOC risk of bias assessment, to evaluate studies with a controlled (randomized and non-randomized) study design.
Thirty-three studies were included. Most of the identified mental health training programs contained knowledge-based components and active learning activities. Changes in participants' attitudes, stigma, knowledge, confidence and skills were frequently assessed. An extensive range of self-assessment and observational instruments used to evaluate the impact of the training programs were identified. Positive improvements in participants’ attitudes, knowledge and stigma were frequently identified following participation in training programs.
This systematic review highlights the importance of mental health training programs in increasing pharmacists', pharmacy staff and pharmacy students’ skills and confidence to deliver mental health care in community pharmacy. Future research should build upon this basis and further focus on finding the most efficient measures to evaluate these training programs and assess their long-term effectiveness, allowing comparison between programs.
Stakeholders’ Acceptability of Pharmacist-Led Screening in Community Pharmacies: A Systematic Review
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Community pharmacists are among the most accessible healthcare providers. Community pharmacist-led screening may facilitate the early detection of illnesses/medical risk factors, optimizing health outcomes. However, it is important to assess the acceptability of screening services to ensure uptake by key stakeholders. The aim of this review was to explore the acceptability of community pharmacist-led screening by all stakeholders (i.e., patients, pharmacists, and other healthcare professionals) and identify the methods used to evaluate the acceptability of screening.
A systematic search was conducted in Embase, MEDLINE, International Pharmaceutical Abstracts, and Scopus in April 2020 since inception. Studies that explored the acceptability of pharmacist-led screening for any risk factor/medical condition(s) within community pharmacies were included.
A total of 44 studies met the inclusion criteria. A total of 17 studies identified community pharmacies as appropriate screening locations. Seven studies reported that patients were comfortable with participating in pharmacist-led screening. Eight studies explored acceptability from the perspective of medical practitioners and other healthcare professionals, with 6 reporting high recommendation acceptance rates and/or acceptability of pharmacist-led screening. Barriers to pharmacist-led screening included time and privacy constraints, whereas adequate remuneration was considered an important enabler.
Community pharmacist-led screening appears to be acceptable to patients, pharmacists, and other healthcare professionals. However, no uniform psychometrically sound measure of acceptability was used consistently across studies, rendering comparisons difficult and showing the need for future research exploring the psychometric properties of acceptability measures. Findings, including barriers and enablers to pharmacist-led screening, are important to consider when providing screening services in community pharmacies.
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This service evaluation involved a concurrent mixed methods design. Patient characteristics were extracted from consultation notes and descriptive statistics applied. Content analysis was used to summarise consultation foci and comparisons between patients’ priorities with consultation content were made. Pharmacists were interviewed at the start (n = 10) and end (n = 4) of the pilot with themes identified using thematic analysis.
Seventy-six patients participated (63% of recruitment target). The median age was 39 (IQR 28–47) and 62% were female. Seventy percent of patients had one consultation, 26% had two and 4% had three. Prescription for new antidepressant was the most common reason for entry (74%) and sertraline was most prescribed (46%). Consultations commonly focussed on life experience (n = 51), medication (n = 47), health (n = 42), support (n = 36) and patients' expression of their feelings (n = 31). The pharmacists’ experiences were summarised in three themes: i) Motivation, ii) Practicalities and iii) Experience and Outcomes.
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However, studies of high complexity services reported significantly more often the implementation factor lack of staff (5/8 high complexity vs. 0/7 low complexity; p = 0.026), showing a more resource-intense implementation compared to low complexity services. Within the domain inner setting, factors relating to available resources such as time,31–36,38–40,42,43 staff,31,33,34,37,39 and training31,32,39,41 were reported most frequently. Barriers in relative priority, i.e. competing priorities due to engaging in multiple tasks, were frequently reported.34,35,37,39,41
Community pharmacies increasingly offer professional pharmacy services, whose implementation is often influenced by facilitating or obstructive implementation factors. The occurrence and composition of implementation factors vary among different services with discrete characteristics and complexity of the intervention, making it difficult to foresee potential barriers in implementation.
Objective(s): This paper investigates potential associations between intervention complexity and occurring implementation factors.
A systematic literature search on the implementation factors and intervention complexity of professional pharmacy services in the community setting was carried out in electronic databases (PubMed, CINAHL, and PsycINFO) throughout December 2018. Implementation factors were extracted from semi-structured interviews, focus groups, and surveys with community pharmacists and categorized using the Consolidated Framework for Implementation Research (CFIR). The complexity of each service was assessed using the following complexity parameters: (I) number of involved healthcare professions, (II) number of service components such as recruiting of patients, screening intervention, and follow-up, (III) frequency of the service, (IV) expenditure of time per patient (encounter), and (V) workflow distortion, i.e. booking appointments for intervention with the patient. Finally, the association between implementation factors and intervention complexity was analyzed by quantifying implementation factors and by relating them to specific intervention characteristics using Fisher's exact test.
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Key implementation factors and associated complexity parameters seem to be of similar or more importance than the total number of implementation factors with regard to successful implementation. By assessing various complexity parameters of an intervention, potential key barriers could be identified and subsequently addressed prior to implementation.

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Original ResearchA feasibility study of community pharmacists performing depression screening services

Abstract

Background

Objectives

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Results

Discussion

Conclusion

Acknowledgments

Lancet

J Affect Disord

Lancet

J Affect Disord

Psychosomatics

Eur Neuropsychopharmacol

Patient Educ Couns

J Am Pharm Assoc

J Am Pharm Assoc

J Am Pharm Assoc

Lancet

The Global Burden of Disease: 2004 Update

The Mental Health of Australians 2. Report on the 2007 National Survey of Mental Health and Wellbeing

Using the interaction of mental health symptoms and treatment status to estimate lost employee productivity

Aust N Z J Psychiatry

Estimating treatment rates for mental disorders in Australia

Aust Health Rev

Use of mental health services in Europe: results from the European study of the epidemiology of mental disorders (ESEMeD) project

Acta Psychiatr Scand Suppl

Use of mental health services for anxiety, mood and substance disorders in 17 countries in the who world mental health surveys

Lancet

Us prevalence and treatment of mental disorders, 1990 to 2003

N Engl J Med

General Practice Activity in Australia, 2008–09

What is the impact of mental health-related stigma on help-seeking? A systematic review of quantitative and qualitative studies

Psychol Med

Cost-effectiveness of opportunistic screening and minimal contact psychotherapy to prevent depression in primary care patients

PLoS One

Validation of PHQ-2 and PHQ-9 to screen for major depression in the primary care population

Ann Fam Med

Diagnosing ICD-10 depressive episodes: superior criterion validity of the patient health questionnaire

Psychother Psychosom

Images of Professions Survey

Trust and safe spaces: mental health consumers' and carers' relationships with community pharmacy staff

Patient

Original Research
A feasibility study of community pharmacists performing depression screening services