Impact of a Student Pharmacist Driven Medication Reconciliation and Antidepressant Treatment History Project at a Depression Clinic: A Pilot Study

Abstract

Objectives

To improve treatment of patients with depression, a new pilot service project involving student pharmacists who would conduct medication reconciliation and review of antidepressant treatment history was created and evaluated.

Experimental design

A prospective study conducted at the University of Michigan Depression Center.

Principal observations

From an initial sample of 78 referrals, 41 subjects were reached by phone, with 34 completing medication reconciliation and antidepressant treatment history. Of the 34 patients, 25 (73.5%) had at least one discrepancy identified in their medication list, resulting in 164 medication changes in the electronic medical record (EMR). A total of 105 past antidepressant trials were documented in the 34 individuals, with 34 (32.4%) trials found to be inadequate. Thirteen (38.2%) patients reported failure to respond to two different antidepressants from different classes. All 34 patients participated well in the phone calls and were willing to consult a pharmacist at their upcoming clinic visit.

Conclusions

A student pharmacist pilot was feasible, identified many discrepancies in the medication record, and identified important medication treatment history in patients with depression in advance of the clinic visit. The project provides support for a specialized role for student pharmacists and demonstrates that interprofessional care can contribute to improved treatment of depression.

Medication reconciliation is a key part of medication therapy management that involves evaluating a patient’s medication regimen for medication errors and comparing existing and previous medication regimens.¹ The American Pharmacists Association (APhA) and the American Society of Health-System Pharmacists (ASHP) have established the goal of medication reconciliation as “to obtain and maintain accurate and complete medication information for a patient and use this information within and across the continuum of care to ensure safe and effective medication use.”¹ Medication reconciliation reduces medication errors in prescribing, assures safe medication use by patients, and facilitates appropriate monitoring and adjustment of drug therapy.¹

Several studies that assessed the impact of pharmacy driven medication reconciliation programs in various settings found pharmacy personnel, including technicians, student pharmacists, and pharmacists, were able to identify discrepancies in up to 88% of patients studied.²-⁴ Such discrepancies can be clinically significant, with one study identifying 17.1% of discrepancies as serious or potentially life-threatening.⁴

To the best of our knowledge, a similar study has not been conducted in an outpatient depression clinic setting. In this setting, medication reconciliation is particularly important. The STAR*D trial demonstrated only 36.8% of patients achieved remission after initial treatment for depression, so most patients required many additional medication trials.⁵,⁶ Individuals presenting to depression clinics frequently have histories of multiple medication trials without good documentation, making psychiatric evaluation more challenging. To improve care, interprofessional approaches such as having pharmacists clarify medication treatment history can contribute to effective clinic evaluation and treatment. We report here a pilot study exploring implementation, feasibility, and outcomes of a medication reconciliation and antidepressant treatment history program led by a pharmacy team including student pharmacists in a large, Midwestern academic setting.

Methods

The study received an exempt, not regulated status, from the University of Michigan Institutional Review Board. A team of five student pharmacists and two pharmacist preceptors practicing in psychiatry conducted this pilot over a 12-week period beginning on February 18, 2016 and ending on May 12, 2016. All individuals scheduled for an initial referral at the University of Michigan Depression Clinic were contacted to participate in a pharmacy telephone encounter approximately one week prior to the clinic visit. During the first part of the telephone call, students requested a list of current medications, including: (1) all prescription products, including both psychiatric and non-psychiatric medications, (2) non-prescription products, including over-the-counter medications, vitamins, herbals, and supplements. The second part of the telephone call documented past antidepressant trials as well as adjunctive therapies, with details on dose, duration of therapy, side effects experienced, response to therapy, and reason for discontinuation. Finally, students encouraged patients to share any concerns and also asked whether they would be willing to discuss their medications with a pharmacist if a medication change was made at the clinic visit. The length of telephone calls was recorded.

Students used the duration of therapy information to classify antidepressant trials as adequate (trial length of at least two months) or inadequate, and whether criteria for treatment-resistant depression (TRD) were met (failure to respond to two adequate trials of two different classes of antidepressants).⁷ A drug interaction screen was also performed. Information gathered from the calls were documented in a clinic note in the electronic medical record (EMR).

Results

Data were analyzed using descriptive statistics. Of the 78 patients attempted, 41 (52.6%) were reached by telephone and 34 (43.6%) successfully completed the pharmacy encounter. Of these 34 patients, 24 (70.6%) were women and patients had an average age of 40.7 years (range 17 to 69 years). Seven patients who declined the service cited reasons as inconvenient timing (57.1%, n = 4), clinic appointment cancellation (28.6%, n = 2), and preference for reviewing medications with a clinician (14.3%, n = 1). Call durations for the 34 patients who successfully completed the pharmacy encounter ranged from 5 to 50 minutes, and the average call length was 18.4 minutes.

In the patient population (n = 34), a total of 76 psychiatric medications were being taken, with an average of 2.2 medications per patient. The total number of medication changes made in the EMR was 164 (Table 1), with an average of 4.8 changes per patient. A total of 25 (73.5%) patients had at least one discrepancy identified in their medication list. Over the course of the project, 31 potentially clinically significant drug-drug interactions were identified. A total of 18 (52.9%) patients had at least one drug-drug interaction in their current medication list. Patient-reported medication lists included between 0 and 5 drug-drug interactions.

Table 1. Medication Changes Made % (n).

	TOTAL NUMBER OF DELETIONS	TOTAL NUMBER OF ADDITIONS	TOTAL NUMBER OF DOSE CHANGES
Prescription medications (n = 109)	93.1 (27)	57.6 (72)	100.0 (10)
Nonprescription medications (n = 9)	3.4 (1)	6.4 (8)	0.0 (0)
Vitamins/herbals/supplements (n = 46)	3.4 (1)	36.0 (45)	0.0 (0)
Total	100 (29)	100 (125)	100 (10)

Seventeen (50.0%) patients shared the following medication concerns: side effects from current medications (35.3%, n = 6), financial issues (35.3%, n = 6), decreased effectiveness of current medications (35.3%, n = 6), persistent depression symptoms (23.5%, n = 4), and adherence difficulties (11.8%, n = 2). Further, one (5.9%) patient each identified the following: lack of understanding about medications, incorrect diagnosis, and lack of access to psychiatric services.

A total of 105 antidepressant medications were tried by the surveyed population, with an average of 3.1 past medication trials per patient. Nearly one-third (32.4%) of antidepressant medication trials were considered inadequate trials (Table 2). Of the 105 past antidepressant medication trials with documented reasons for discontinuation, the most common reason was attributed to no improvement in mood symptoms (45.7%, n = 48), with the second most common reason being medication side effects (28.6%, n = 30). A total of 13 patients (38.2%) were considered to have TRD.

Table 2. Description of Antidepressant Treatment Histories % (n).

	TOTAL NUMBER OF PATIENTS WHO TRIED EACH CLASS	TOTAL NUMBER OF PATIENTS WITH AN ADEQUATE TRIALa	TOTAL NUMBER OF PATIENTS REPORTING IMPROVED SYMPTOMS	TOTAL NUMBER OF PATIENTS WHO EXPERIENCED SIDE EFFECTS
SSRI	61.8 (21)	85.7 (18)	52.4 (11)	47.6 (10)
SNRI	47.1 (16)	62.5 (10)	12.5 (2)	31.3 (5)
TCA	11.8 (4)	100 (4)	25 (1)	75 (3)
MAOI	8.8 (3)	66.7 (2)	33.3 (1)	100 (3)
Other	47.1 (16)	75 (12)	31.3 (5)	31.3 (5)

Note: ^aDefined as a length of at least 2 months.

Abbreviations: MAOI, monoamine oxidase inhibitor; SNRI, serotonin-norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic antidepressant.

Of the 34 patients who completed the pharmacy encounter, all (100.0%) reported they would be willing to discuss their medications and associated side effects with a pharmacist if a medication change was made at the clinic visit.

Limitations

The students attempted to contact 78 patients and reached only 52.6% of those patients. Additionally, of the seven patients who declined the service, 57.1% cited their reason as inconvenient timing. An additional limitation is the lack of external health records to validate the history of medication use and response.

Conclusions

The student pharmacist driven pilot project proved to be valuable. The pharmacy team identified patient-reported discrepancies in 73.5% of patients reached by telephone. This result is similar to those of previous studies involving student pharmacists.²,³ The record of treatment failure was also a valuable contribution to the patient record and was of assistance to psychiatrists evaluating the patients. These findings highlight the positive impact of a medication reconciliation service in an outpatient depression clinic setting and demonstrates a role for interprofessional care. Further evaluation is necessary to establish the clinical impact of identification of such discrepancies.

In addition, the student pharmacist-patient interactions disclosed patient concerns that may be addressed by pharmacy intervention. For example, of the 17 patients who voiced concerns, 35.3% revealed that they had difficulty paying for their medications. A pharmacy team may refer such patients to patient assistance programs or recommend more cost-effective alternatives to clinicians. Additionally, the findings of the pilot project showed 32.4% of antidepressant medication trials were inadequate, and the most common reason for discontinuing antidepressant medications was no improvement in mood symptoms. These results signify an opportunity for pharmacists to provide patient education, specifically to provide support and reinforce onset of action of antidepressant medications. All patients surveyed were willing to engage with a pharmacist regarding their medications, which suggests that this is an appropriate future direction to explore within the clinic.

The pilot confirmed student pharmacists are well-suited for providing the service. Additional considerations include that this service may be integrated into the required Introductory Pharmacy Practice Experiences (IPPE) after students complete required training. Such training would include an orientation to the EMR system, as well as a review of the telephone call script and mock interactions with a pharmacist preceptor and/or psychiatrist.The results of the pilot project support the need for pharmacy services in an outpatient depression clinic setting. Student pharmacists can lead this type of service with the oversight of pharmacist preceptors.