A cross-sectional look at rural pharmacists’ perceptions on implementing a depression screening service in their pharmacies: A brief report

Abstract

Background:

Rural areas are in desperate need of access to mental healthcare. Rural pharmacists can begin to fill these gaps by offering depression screening services. However, despite evidence suggesting improved patient outcomes and positive reception to pharmacist led depression screening services, implementation has remained low. Research on barriers towards implementing depression screening services and preferred implementation strategies is necessary to increase implementation of this service.

Objective:

Investigate barriers/facilitators and preferred implementation strategies to implementing a depression screening service in rural pharmacies.

Methods:

An exploratory cross-sectional survey was conducted electronically amongst rural pharmacists in Alabama and Mississippi. The survey was developed and pre-tested with a stakeholder panel to identify rural pharmacist confidence, barriers/facilitators, stigma towards patients with mental health conditions, and preferred implementation strategies towards implementing a depression screening service. Likert-type questions from 1 (strongly disagree) to 5 (strongly agree), a rank-choice question, and open-ended questions were used. Quantitative and qualitative data were analyzed descriptively, with qualitative data also analyzed thematically.

Results:

A total of 84 rural pharmacists participated in the study. Confidence towards performing depression screenings and using a depression screening tool (the PHQ-9) was low (2.5 [SD=1.1] and 2.0 [SD=0.9] out of 5, respectively). The most strongly endorsed and highest ranked barrier was lack of time (3.7 [SD=1.1]). Every implementation strategy was scored primarily as “helpful” or “very helpful.” The most cited qualitative theme was financial concerns.

Conclusion:

Pharmacists have low confidence in performing a depression screening service and several structural barriers such as time and financial concerns. Future research should perform cost benefit analyses of implemented depression screening services and assess whether training programs improve confidence towards offering these advanced care services.

Background

Depression is the leading cause of disability in persons over 15 years old,¹ with one in five people in the U.S. affected by a mental health condition.^2,3 In Alabama, suicide is ranked as the 11th cause of death as of 2013.⁴ However, only 33–50% of people seek and receive treatment for their depression leading to large amounts of the population with untreated depressive disorders,^3,5,6 and research has shown under-diagnosis of mental health conditions (including depression) and under-utilization of treatments are common in rural areas.^7–10 Inadequate treatment has sweeping negative effects, including decreased work productivity, school dropouts, and suicide.^3,5,11 Depression alone causes annual losses in productivity that cost the U.S. upwards of $31 billion.¹² To help combat this epidemic, the US Preventive Task Force recommends that everyone over the age of 12 be screened for depression^13,14 as the first step to improving treatment for Major Depressive Disorder (MDD).¹⁵

One reason for the limited mental health treatment in rural areas is the shortage of mental health care providers in rural communities of the U.S.^16–18 Leading health organizations have called on all health professionals to fill these gaps¹⁹ with Walgreens and the National Council for Behavioral Health and American Pharmacists Association offering mental health first aid training to pharmacists.²⁰ Similarly the College of Psychiatric and Neurologic Pharmacists has begun an initiative to decrease stigma towards mental health among pharmacists.²¹

Pharmacists have been consistently shown to be the most accessible health care provider: more accessible than either mental health providers or primary care physicians.^22,23 Pharmacists are accessible both geographically (90% of people live within a 10 or 20 minute drive of a community pharmacy) and financially (patients do not typically pay to receive pharmacist counseling services).^23,24 Additionally, pharmacists have been shown to increase health outcomes when integrated into advanced care services.^25,26 The role of the pharmacist has expanded to include advanced care services, well-positioning them to offer depression screening services, especially in rural communities where limited medical clinics are available.^27,28 Even so, the rate of implementation of depression screening services in pharmacies is low, and further research on rural pharmacist barriers towards and preferences for implementing depression screening services is needed.

Objective

Investigate barriers/facilitators and preferred strategies to implementing a depression screening service in rural pharmacies.

Methods

An exploratory cross-sectional survey was conducted electronically amongst rural pharmacists in Alabama and Mississippi. The protocol for study procedures was approved by the primary author’s institutional review board.

Rural community pharmacists were contacted by mail using the Hayes directory: a directory of U.S. pharmacies and their contact information.²⁹ The directory contained 621 rural pharmacies in Alabama and Mississippi. Individuals were eligible to participate if they were a registered pharmacist employed at a rural community pharmacy. One response per pharmacy was allowed to prevent multiple similar responses from skewing results. Rural-Urban Commuting Area (RUCA)³⁰ categorization 1 codes were used, and codes 4–10 were selected to represent rural areas according to pharmacy zip codes.³¹

A postcard was mailed to each pharmacy with information about the survey and a quick response (QR) code link with instructions for accessing the survey electronically. Postcards were sent out three times: the second postcard two weeks after the first, and the third postcard four weeks after the first. Pharmacists who completed the survey received a $25 monetary incentive.

Basic demographics were collected, followed by four key survey domains: 1) pharmacist confidence 2) barriers and facilitators towards implementing a depression screening service, 3) stigma towards patients with mental health conditions, and 4) preferred implementation strategies. A purposively selected stakeholder panel, consisting of two rural pharmacists, two rural community members, and a mental health provider, was used to pretest the survey and ensure face validity. A modified Delphi method was used via an online questionnaire which generated consensus after two rounds on wording and content of survey items.³² Pharmacist confidence was assessed in two ways: 1) confidence in performing a depression screening and 2) confidence in using the PHQ-9. Both confidence scales were modified from Hastings et al to ask about depression screening services or PHQ-9 usage.³³ Two items from the original scale were removed since they did not pertain to depression screenings and the original 1–7 Likert scale was changed to a 1 (Strongly Disagree) to 5 (Strongly Agree) Likert scale to maintain consistency with the rest of the survey. The Consolidated Framework for Implementation Research (CFIR)³⁴ and Fernandez et al.³⁵ were used to inform survey development in regards to barriers and facilitators which were assessed in two different ways: (1) perceptions regarding barriers/facilitators to implement depression screening services in their pharmacy, measured via a 5-point Likert-type scale from 1 (Strongly Disagree) to 5 (Strongly Agree) and (2) ranking their top three barriers. Pharmacists’ stigma towards patients with mental health conditions was assessed with a modified Perceived Devaluation and Discrimination (PDD) scale which has been validated (α = 0.86–0.88) and tested for reliability with a test-retest reliability of 0.93.^36,37 The PDD was modified to have a 1–5 Likert scale. Preferred implementation strategies were identified from the CFIR,³⁵ Powell et al.,³⁸ and Hohmann et al.³³ and adapted/modified into statements to assess which strategy pharmacists would find the most helpful (e.g. “Establishing procedures to identify patients”). Preferred implementation strategies were assessed with a 1 (least helpful) to 5 (most helpful) Likert-type scale. Open ended questions further explored barriers/facilitators, preferred strategies, preparedness, and general thoughts about implementing a depression screening service.

All domains were analyzed with descriptive statistics using IBM SPSS Statistical Software version 27.³⁹ Items were reverse coded when necessary. Assessment of nonresponse bias was performed by comparing the first 20% of respondents to the last 20% which was not significantly different by demographics, confidence, nor stigma. Reliability was evaluated for each domain with Cronbach’s alpha. Internal consistency was considered high if Cronbach’s α was greater than 0.7. Scores from each domain were averaged with a total average calculated for the confidence and stigma domains. Answers to the rank choice barrier question were weighted with the most important barrier given the highest score of “3”, the second most important barrier given a score of “2”, and the third most important barrier given a score of “1”. The total weighted score was then calculated by summing the scores for each barrier.

Responses to open ended questions were analyzed with qualitative thematic analysis using inductive coding. Qualitative research was performed with a phenomenological approach and an interpretivist research paradigm by the primary investigator (PI). Three rounds of coding were required to generate final codes and themes. Round 1 generated initial codes, round 2 refined codes, and round 3 generated final themes by combining similar and removing irrelevant codes. Member checking occurred with pharmacists from the stakeholder panel reviewing the interpretation of results. The frequency with which the themes were coded across qualitative questions was analyzed.

Researcher characteristics and reflexivity

The primary author is a trained pharmacist with a PhD in Health Outcomes Research and Policy who performed this research for their dissertation. Research in the care and treatment of patients with mental health conditions has always been a passion of theirs, with the stigma towards patients with mental health conditions and access to mental health care becoming a point of focus through their course of study. The PI is researching through the lens of their pharmacist and health outcomes training as well as their passion for increasing access to mental health care.

Results

A total of 84 rural pharmacists participated in the survey with a response rate of 13.7%. Based on a 95% confidence level and the sample size of 84, the margin of error was estimated to be 10%. The majority were white (n=61, 72.6%), non-Hispanic (n=82, 97.6%), and from Mississippi (n=47, 56.0%). Gender was split evenly between male and female (n=42, 50.0%) with most participants being between 25 and 54 years old (n=65, 77.4%). Respondents were primarily pharmacy managers or owners (n=61, 72.6%) and had been in their current role for 1–5 years (n=29, 34.5%) or over 20 years (n=19, 22.6%). Most pharmacists had interacted with patients with mental health conditions (n=81, 96.4%) and patients on psychotropics (n=83, 98.8%). However, the majority did not work in a pharmacy that offered depression screening services (n=79, 94.0%) and had not used the PHQ-9 before (n=76, 90.4%).

Confidence

The mean score for confidence in being able to perform a depression screening service was 2.5 ([SD]=1.1) on a scale from 1 (Strongly Disagree) to 5 (Strongly Agree). Similarly, confidence using the PHQ-9 was 2.0 ([SD]=0.9) on a scale from 1 (Strongly Disagree) to 5 (Strongly Agree).

Barriers/Facilitators

When asked to rate barriers on a Likert scale from 1 (strongly disagree) to 5 (strongly agree), the barrier that most participants “agreed” or “strongly agreed” with was not having enough time (n=50, 62.5%). The second most “agreed” or “strongly agreed” with barrier was wanting to be reimbursed (n=47, 56.0%), followed by not having the required support staff (n=44, 52.4%). Table 1 provides a further breakdown of responses to each barrier statement.

Table 1:

Individual Scores for Barriers and Implementation Strategy Likert Statements

Barrier (n= # of responses)	Strongly disagree –> Strongly agree
	1	2	3	4	5
The pharmacy I work at does not have a private counseling area	21	22	16	17	7
The physicians I work with are not supportive of pharmacies referring patients from depression screenings	6	15	41	18	4
I do not have the knowledge or skills to deliver a depression screening	8	16	33	21	6
It is difficult to perform a depression screening	4	18	37	21	4
The patients at my pharmacy are not willing to participate in a depression screening service	5	8	48	20	3
Legal liability may be a problem if my pharmacy offers a depression screening service	5	12	37	26	4
The staff at our pharmacy do not have the knowledge and skills to participate in a depression screening service	4	12	29	32	7
I have the support staff necessary to offer a depression screening service**	6	10	24	30	14
I must be reimbursed to offer a depression screening	3	5	29	27	20
I do not have enough time to offer a depression screening service to all of my patients	4	8	22	28	22
Implementation Strategy (n= # of responses)	Not helpful –> Very helpful
	1	2	3	4	5
Adjusting prescription dispensing workflow	3	5	23	26	22
Approaching management, corporate, or owners to gain support	1	8	22	22	26
Arranging staff schedules	2	3	21	31	22
Establishing procedures to identify patients	1	1	26	27	25
Setting a goal or objective	1	3	19	31	25
Preparing an outreach/marketing plan	1	1	24	28	25
Establishing a plan to continuously evaluate and improve services	0	3	23	28	24
Developing a budget	1	1	22	30	24
Establishing procedures to refer patients	1	8	22	22	26
Preparing an action plan	1	1	21	28	28
Establishing staff member roles	1	1	18	35	24
Establishing procedures to follow-up with patients	1	2	15	34	26
Selecting a person who is in charge of service	1	1	15	29	33
Establishing procedures	1	1	14	30	33

^**reverse coded

When weighted, the top two ranked barrier scores were not having enough time (n=106), followed by staff not having the knowledge/skills (n=100). Then, in decreasing order, the pharmacist themselves not having the knowledge/skills (n=73), patients not being willing to participate (n=57), legal liability concerns (n=34), reimbursement concerns (n=25), and the screening service being a financial burden (n=13). Two barriers were not ranked: physicians not being supportive and not having a private counseling area.

Stigma

The mean PDD score was 2.9 (SD= 0.6) on a scale of 1–5 with 1 being higher stigma towards people with mental health conditions and 5 being lower stigma.

Implementation Strategies

All strategies were primarily rated as a 3, 4, or 5 on a 1–5 scale with 1 being “not helpful” and 5 being “very helpful”. The strategies with the highest number of “very helpful” responses were 1) “Selecting a person who is in charge of the service” (n=33, 39.3%) and 2) “Establishing procedures” (n=33, 39.3%). Table 1 shows a breakdown of the responses for each statement.

Qualitative Analysis

The open-ended questions asked pharmacists about their perspectives of implementing a depression screening service and six themes emerged (Table 2): 1) financial concerns, 2) lack of trained staff, 3) lack of time, 4) patient considerations, 5) employer buy-in, and 6) the importance of other healthcare providers.

Table 2:

Overall themes identified with selected quotes

Theme	na	Selected Quotes
Financial concerns	78	“Qualitative and quantitative data [is needed] that shows it is beneficial and worthwhile and can also make profit”
		“If the pharmacy is reimbursed at a fair rate, then lots of services can be implemented and possibly more staff hired. Reimbursement is the main reason most pharmacies cannot offer certain services. We are not reimbursed for services we provide.”
		“Reimbursement”
Trained Staff & Pharmacists	57	“Besides the lack of staff - the lack of available trainers in the pharmacy. My pharmacist manager is not familiar with the screenings.”
		“We would need to be trained on how to administer the depression screening.”
		“Staffing is the main concern, as we are already overburdened with the tight staffing our company enforces.”
Lack of time	37	“The workload is difficult to handle as it is without adding more tasks and less help.”
		“Time is the main barrier.”
		“We already have so many tasks to do each day, it would be very difficult to do.”
Patient considerations	22	“In retail pharmacy we would need to be staffed adequately, and most customers would not take the time to talk to us”
		“… as well as having an environment to make the patient comfortable enough to freely answer assessment questions.”
		“Population study if patients who are on depression meds actually for depression”
Employer buy-in	9	“I think HCPCS codes or proof of billing and reimbursements would help owners to establish depression screening services.”
		“Pharmacists would likely be on board as is. However, financial benefit would need to be demonstrated to get owners/corporate leaders on board.”
		“Not prepared or confident at all due to corporate”
Other Healthcare providers	7	“If tied in to local community prescribers and psychiatric services offered at our local hospital [implementing a depression screening service] could be positive.”
		“We have a mental health facility in town that may frown upon us doing that”
		“The patient would still need an office visit to the physician’s office to obtain appropriate medication prescription”

^afrequency with which the theme was coded across questions

Discussion

This study revealed perceived barriers to the implementation of depression screening services among community pharmacists. The most frequently reported barriers were lack of time, limited knowledge among staff and pharmacists, and lack of reimbursement. Additionally, pharmacists’ confidence in their ability to implement a service was low among respondents.

This study revealed that even though most pharmacists had interacted with patients with mental health conditions (MHC) and who were on psychotropics, very few (only five) pharmacists reported currently offering a depression screening service in their pharmacy. Therefore, it was not surprising that most pharmacists reported having low confidence in performing a depression screening service. This finding echoes the literature that shows pharmacists are less comfortable counseling patients with MHCs than patients with more common conditions like hypertension while also having increased levels of stigma towards patients with MHCs.^40–42 Therefore, including education on mental health stigma in training for pharmacists is necessary.

Lack of time was the highest rated barrier for pharmacists of all demographics. Research has been devoted to categorizing pharmacists time in “time and motion” studies: studies that use pre-defined categories to categorize what a pharmacist is doing every set number of minutes.^43,44 Findings show that a pharmacists’ time is mostly spent on dispensing, supply, and management activities that leave little room for advanced care services. Negaard et al. theorized that there are areas of a pharmacists’ time that could be made more efficient or delegated to a pharmacy technician,⁴⁵ however these changes in structure and workflow still need to be implemented and these implementations would also take time. With time being such an important barrier, it is interesting to note that of the ten studies identified in a systematic literature review of depression screenings in pharmacies, only two studies mentioned “time” as a barrier that needed to be addressed.⁴⁶ This disparity showcases the need for continued and thorough needs assessment research in implementing depression screenings in pharmacies.

Other literature on pharmacist-led screening services for chronic health conditions that are not mental-health related do show that time is a barrier to implementing screenings.^47–49 These studies have also found a way to offset the time barrier by making screening services revenue-generating. Coincidentally, the barrier “I must be reimbursed” was tied with the “I do not have enough time” as the most frequently endorsed statement. Financial concerns, which included reimbursement, was also the theme with the highest frequency of codes. However, pharmacists did not rank reimbursement highly (putting it as the third highest barrier if they ranked it at all). This suggests that while reimbursement is an important barrier that necessitates addressing, other structural barriers, like time and lack of staffing, must be addressed first before pharmacists can begin thinking about more granular steps to implementing a service.

Similarly, pharmacists expressed the need for cost benefit analyses on implementing depression screening services before implementing these services themselves. While to our knowledge no cost effectiveness studies have been performed on depression screenings in pharmacies, screenings for other disease states (e.g., diabetes, cardiovascular disease, asthma) have been shown to be cost effective.^50–53 Future cost effectiveness studies on the implication of depression screenings would be beneficial in convincing pharmacists and pharmacy corporations to implement these services.

Limitations

Since the list of barriers and implementation strategies in the survey was derived from existing literature, it may not fully capture the unique challenges faced by rural pharmacists, potentially omitting some relevant barriers. To mitigate this barrier, a stakeholder panel reviewed the survey prior to launch. Also, as with any self-reported measures, response bias or self-report bias is a limitation in this study. Additionally, with the low response rate, nonresponse error is recognized as a bias; however, a potential non-response bias calculation was performed that showed no significant differences between early and late responders.

Conclusion

Study findings indicate low confidence in performing a depression screening and underscore pharmacist lack of time and staff to implement depression screening services. Findings also indicate an interest in services that are cost-effective. Future research should focus on researcher-pharmacist collaboration to develop effective implementation strategies that will address these barriers as well as assessing the impact of depression screening services in community pharmacies on clinical and economic outcomes.

Key Points.

• What was already known: Community pharmacist-led depression screening services are effective at increasing the number of patients screened and improving medication management

• What this study adds: Pharmacists have low confidence towards performing depression screenings and several structural barriers including lack of time and financial concerns.