Patient perspectives on the role of community pharmacists for antidepressant treatment: A qualitative study

Abstract

Objectives:

Patients prescribed antidepressant drug treatment (ADT) for major depression report several needs in relation to their treatment, and a large proportion of these patients will end ADT prematurely. Community pharmacists may play an important role in monitoring ADT and supporting these patients. However, little is known about patient experiences of the services provided in community pharmacies. The objectives of this study were to 1) explore patients’ experiences with the services community pharmacists provide for ADT and 2) identify potential avenues for improvement of pharmacists’ services within the context of ADT.

Methods:

A qualitative descriptive exploratory study was conducted among individuals diagnosed with major depression who had initiated ADT at some point in the 12 months prior to their participation in the study. A total of 14 persons recruited in a local health centre and a community-based organization participated in individual interviews. A thematic analysis of the interview transcripts was conducted.

Results:

Pharmacists tend to concentrate their involvement in treatment at initiation and at the first refill when questions, uncertainties and side effects are major issues. Patients felt that the pharmacists’ contributions consisted of providing information and reassurance; in these respects, their needs were met. Participants had few ideas as to what additional services pharmacists could implement to improve patients’ experience with ADT. Patients’ sole expectations were that pharmacists extend this information role to the whole length of the treatment and enhance the confidentiality of discussions in pharmacy.

Conclusion:

Pharmacists should provide counselling throughout the entire treatment rather than passively waiting for patients to ask their questions. However, facilitation of open discussions may not be achieved unless confidentiality at pharmacies is secured.

Knowledge Into Practice.

• Patients who are prescribed an antidepressant drug treatment perceived that pharmacists are mainly involved at time of treatment initiation and that pharmacists’ support consists mainly of providing information.

• Patients recommended that pharmacists provide more proactive counselling throughout the antidepressant drug treatment rather than passively waiting for patients to ask questions.

• Patients also recommended that the physical layout of pharmacies should better guarantee the confidentiality of discussions.

Mise En Pratique Des Connaissances.

• Les patients à qui l’on avait prescrit un traitement médicamenteux antidépresseur avaient le sentiment que les pharmaciens sont principalement présents à l’instauration du traitement et que le soutien qu’ils offrent se limite principalement à l’apport d’information.

• Les patients ont recommandé que les pharmaciens offrent proactivement des conseils tout au long du traitement antidépresseur plutôt que d’attendre passivement que les patients posent des questions.

• Les patients ont aussi recommandé que l’organisation physique des pharmacies assure la confidentialité des discussions.

Introduction

Depression is a common condition, with a lifetime prevalence around 10% in Canada.¹ Major depression has negative consequences on individuals’ quality of life, physical health, social relationships and employment.² Depression increases the risk of suicide and represents an important economic burden to society.² Antidepressant drug treatment (ADT), alone or in combination with psychotherapy, is recommended by the Canadian Network for Mood and Anxiety Treatments (CANMAT) for a minimum duration of 8 months.^2,3 However, a large proportion of individuals show suboptimal adherence to ADT. In previous studies, 37% to 72%^4-7 ceased treatment within 6 months, with up to 27% to 42%^4,6,7 of patients having ceased their treatment within the first month.

Factors associated with treatment cessation include lack of confidence in ADT efficacy, fear of dependency, side effects at treatment initiation, less severe depressive symptoms at diagnosis, feeling better over time and inadequate support from the prescribing physician.^8-10 Community pharmacists are among the most accessible health professionals and have the potential to play a decisive role in optimizing patients’ use of ADT.^11-13 Over the past 30 years, the role of community pharmacists has shifted from dispensing drugs to engaging in a pharmaceutical care approach that is centred on monitoring patient side effects, drug interactions, adherence and therapeutic objectives.¹⁴

Few qualitative^12,15 or quantitative^16,17 studies have explored the experiences and expectations that ADT patients have with community pharmacists. Our team is currently conducting a series of studies^11,13 to develop a community pharmacist–based intervention aimed at improving patients’ experiences with and adherence to ADT. The objectives of this qualitative study were to 1) explore patients’ experiences with the services that community pharmacists provide for ADT and 2) identify potential avenues for improving pharmacists’ services within the context of ADT.

Methods

We conducted a qualitative descriptive exploratory study using semi-structured interviews. A convenience sample of participants was recruited in Quebec City between June 2011 and June 2012. Potential participants were identified by family physicians working in a local health centre or by a community-based organization that offers support for people with mental health issues. To be considered eligible, participants had to have received a new diagnosis of depression within the past year, been prescribed ADT for this episode of depression and be without any psychotic symptoms or bipolar disorder. Face-to-face interviews were conducted by a research assistant who was not a pharmacist to reduce social desirability bias (MA in psychology with research experience in mental health). The interview guide is presented in Appendix 1 (available in the online version of the article). Interviews lasted an average of 66 minutes (range, 33-100 minutes). Interviews were recorded and transcribed verbatim by a research assistant. A research team member randomly selected extracts of transcriptions to confirm their accuracy against the audiotapes. A thematic analysis was conducted using qualitative analysis software (QDA Miner, Provalis Research, Canada). We used a mixed inductive and deductive approach to develop codes. Initial codes were based on scientific literature, the objectives of the study, the conceptual framework and the interview guide. Additional codes and modifications emerged from the corpus.^18,19 Since the credibility of analysis increases with intercoder fidelity, 2 members of the research team (A.N., MA student in community health, and L.G., PhD in health education) independently coded 6 interviews until a consensus was obtained on the codebook.²⁰ The remaining interviews were coded by A.N. through ongoing discussions with the research team. The sample size was not set a priori, and recruitment stopped after 14 interviews. This number was deemed sufficient given the overall consistency of the narratives and because no major new ideas had emerged from the last 3 interviews, indicating that data saturation had been achieved.²⁰ This study was approved by the ethics committees of the Centre de santé et des services sociaux de la Ville-Capitale and the CHU de Québec–Université Laval. All participants gave written consent to participate in this study and received $50 compensation.

Results

Participants’ characteristics and experience with ADT

A total of 14 participants were recruited and interviewed (Table 1). Ten participants were recruited in a local health centre while 4 participants were recruited in a community-based organization. Most participants were women (n = 11), were younger than 40 years (n = 9), had obtained a college degree or higher (n = 9) and had a paid job at time of the interview (n = 9). Regarding ADT, 5 participants had received ADT in the past for a previous episode of depression. For the current episode of depression, 9 participants had received their ADT prescription less than 7 months before the interview and 5 participants between 7 and 12 months.

Table 1.

Participant characteristics (n = 14)

Characteristics of participants		Number of participants*
Place of recruitment	Community-based organization	4
	Local health centre	10
Sex	Women	11
	Men	3
Age (years)	20-39	9
	≥40	3
Education	No degree	1
	High school degree	3
	CEGEP† or professional training	3
	University degree	6
Occupation at recruitment	Full-time worker	7
	Part-time worker	2
	At home (e.g., maternity leave)	4
Family situation at recruitment	Couple with children at home	5
	Couple or adults without children at home	3
	Living alone	3
	Single-parent family	2
Annual personal income (CAN$)	<$20,000	2
	$20,000-$40,000	5
	>$50,000	4
Length of treatment (months)	<7	9
	7-12	5
Previous use of ADT for another episode of depression	No	9
	Yes	5

^*Information was missing for some participants.

^†CEGEP (Collège d’enseignement général et professionnel) is a postsecondary, preuniversity college system unique to Quebec. Students generally complete either a 2-year preuniversity or a 3-year technical program.

All participants had initiated their ADT. Most participants reported that they questioned whether to initiate ADT after it was prescribed. They explained how several factors influenced their decision to take ADT, such as their personal evaluation of their health, the extent to which they recognized themselves as clinically depressed, their perceived need for medication and the physician’s level of engagement when listening to their story and providing information. Three participants waited several weeks before starting their ADT, explaining how they needed some time to accept the diagnosis and medication.

At the time of the interviews, all participants were still taking their medication. However, a woman reported that she had prematurely stopped an ADT that had been prescribed for a past episode of depression. Even if participants were adherent to ADT, they periodically debated whether to continue with treatment. The temptation to cease ADT was especially high during the first weeks of treatment when participants were experiencing side effects but had not yet perceived any beneficial effects. Once beneficial effects had set in and the individuals had reengaged in normal activities, participants reported feeling better. These individuals often felt as though they no longer needed medication. Overall, participants took their ADT on a daily basis, but most reported that they sometimes forgot, skipped doses or did not take their ADT at the same time each day because they felt better or there were disruptions to their routine.

Perceptions of community pharmacists’ actual and expected role

During data analysis, the research team identified 2 major dimensions that characterize what patients perceive to be the actual role of community pharmacists within the context of ADT: 1) pharmacists’ support is focused on treatment initiation, primarily the first and second refills, and 2) pharmacists’ support consists mainly of providing information. Interviews also led to the identification of patients’ expectations of community pharmacists.

Pharmacists’ support is focused on treatment initiation and first or second refills

When discussing their first encounter with community pharmacists, participants praised the excellent service that was provided. Participants reported feeling welcomed, reassured, listened to and, above all, not stigmatized for taking ADT. They also felt informed and appreciated that their questions were answered. “She [the pharmacist] took her time with me to be warm, to reassure me, to tell me I was taking an important step . . . it made all the difference to me” (participant 5). Patients often experienced this type of support at the time of treatment initiation (when patients are usually uncertain about ADT) and during the first or second refill (when temptation to stop treatment is highest because of side effects). Unless it was requested, they had no further encounters with pharmacists throughout the remainder of the treatment course. “It’s just like going to buy candies. I get there, I give her my paper, she [the pharmacy technician] says, ‘Thanks, it’ll be ready in 2 minutes’” (participant 11).

Pharmacists’ support consists mainly in providing information

Pharmacists were described as drug experts and a resource for information on taking ADT. This information complemented what had been said by the prescriber. “I feel like I’m getting a second opinion, I feel like the pharmacist knows the drug better” (participant 8). Participants perceived the pharmacists’ role as limited to drug distribution, the provision of information and the management of side effects. “Being reassured about the side effects helped me for sure. But other than that, he’s the guy who gives me my medication” (participant 1). Participants drew clear boundaries between the roles of pharmacists and physicians. Most participants did not share details about their symptoms with pharmacists in the same way that they do with family physicians. Reasons include the fact that pharmacists may vary from one visit to another, a lack of confidentiality and not feeling that it was necessary to discuss this information. “I want to talk to my pharmacist about my medication, not my mental health” (participant 8).

Patients’ expectations from pharmacists

Participants reported 2 main issues where their expectations were not being met. The first concerned the layout of pharmacies. Most patients disliked how discussions on sensitive topics occurred at the pharmacy counter. This layout lacked confidentially and negatively affected participants’ ability to speak freely. None of the participants had ever used a private consulting room. “It should be more discreet . . . everyone can hear. . . . You know, there’s the lady next to you looking for her vitamin D” (participant 4).

The second expectation was that pharmacists would provide proactive counselling throughout the duration of ADT treatment. Patients explained how pharmacists focused their interventions at treatment initiation and during first weeks of treatment. While patients were aware that pharmacists were available throughout the remainder of the treatment course, they did not always know what questions to ask. “Maybe a little follow-up, maybe not each time I’m there, to ask me if it’s going well . . . as patients, we can always ask, but sometimes we forget to or sometimes we don’t know exactly what to ask” (participant 1). Patients recommended that pharmacists assess the situation regularly so that important topics might arise naturally during discussion. “I wasn’t able to ask for help. But if the pharmacist showed an interest in knowing how it was going . . . it would have encouraged me to ask for more services or advice” (participant 9).

Participants discussed other unmet expectations and suggested several services that pharmacists could provide to improve their experience with and adherence to ADT. These include a reminder email before each refill or a small 2-hour group education session. However, nothing was mentioned frequently enough to suggest a consensus. Participants were also unconvinced that the suggested services would result in a real improvement.

Discussion

Participants using ADT expressed a high degree of satisfaction with the services provided by community pharmacists. Pharmacists were described as drug experts and a resource for information that was complementary to what had been provided by prescribers. Participants appreciated pharmacists’ welcoming attitude and their nonjudgmental listening skills. Patients received support from pharmacists at treatment initiation as well as during the first weeks of treatment. These are times when uncertainties are at their highest and managing side effects can be difficult.

Participants recommended that pharmacists offer more consistent support throughout the treatment period, when encounters with health professionals may be infrequent. Although patients reevaluate their decision to take ADT throughout the treatment course, pharmacists focus their efforts on the first encounters. The problem of timing in counselling has also been raised in earlier studies^12,15 and is consistent with concerns that patients may have regarding the long-term side effects of ADT as well as their constant questioning of the need to continue treatment.^21,22 If pharmacists passively wait for patients to ask questions after the second refill, they may miss important opportunities to enhance patient experience with and use of ADT.^23,24 Another unmet expectation of participants was the lack of confidentiality at the pharmacy counter, which hindered their ability to speak freely. Although it has been reported elsewhere that pharmacists are aware of this barrier^16,25,26 and use strategies to overcome it—such as taking consumers to a quiet area of the pharmacy or a counselling room^27,28—the privacy of discussions on ADT remains a major issue for patients and pharmacists.^15,26,29-31 Recommendations for improving the privacy of discussions and increasing the number of encounters offered by pharmacists over the course of treatment are even more important given that stigma associated with depression may cause the patient discomfort and decrease support-seeking behaviours.^22-24,32-34

Many participants had difficulty envisioning what pharmacists could do to improve their experience with ADT. This was, in part, because they perceived pharmacists’ role to be limited to providing information and dispensing drugs. Participants instead relied on physicians to monitor their experience with ADT. These findings are consistent with results of other studies where patients on ADT^12,15-17 or other mental health medications³⁵ perceived the provision of information to be the main contribution of pharmacists, with the difference that patients in the present study did not underline major unmet information needs.^12,15-17 These findings are also in line with our previous study conducted among pharmacists,¹¹ who explained that their practice mainly focused on providing information, verifying drug safety and ensuring tolerability management at the first or second refill. This underscores how the ongoing monitoring of therapeutic objectives and ADT adherence are not yet part of pharmacists’ day-to-day activities.^36,37

Conclusion

This qualitative research should help improve our understanding of ADT patients’ experience with pharmacists and ultimately provide clues for improving the practice of community pharmacists. Our findings have generated hypotheses that could be addressed in future quantitative studies conducted among a larger and more diverse group of patients with ADT. These findings could also be used in the development of questionnaires to assess dimensions of community pharmacy services that are important from the perspective of patients. In addition, they could inform the development of interventions aimed at enhancing patients’ experience with community pharmacists—thus optimizing the use of ADT. Finally, these findings could inform the current debate surrounding pharmacy services and mental health patients as they raise issues on the frequency, timing and content of encounters as well as the physical layout of pharmacies.