US Pharm. 2022;47(5):29-33.
ABSTRACT: Depression is one of the most common mental-health disorders in the United States and globally. Patients often remain untreated, for reasons including lack of or reduced access to mental-health care and concerns about the stigma surrounding depression. Pharmacists’ accessibility enables them to recognize patients at risk for—or exhibiting signs of—depression, and they can encourage patients to talk to their primary healthcare provider. Pharmacists can also educate patients about depression, pharmcologic treatment options (including proper use and potential adverse effects), and nonpharmacologic measures such as psychotherapy and patient-support groups. Providing patients with pertinent information about depression may aid in overcoming worries about stigma and enable them to seek medical evaluation, obtain appropriate therapy, and possibly enhance overall clinical outcomes and health-related quality of life.
In the United States and throughout the world, depression continues to be one of the most common mental-health disorders and the foremost cause of disability.1 It is predicted that by 2030 major depression will be the leading global disease burden.1 The National Alliance on Mental Illness has stated that depression, at its worst, may result in suicidal tendencies or suicide and that suicide is responsible for an estimated 800,000 deaths worldwide each year.1 The use of effective treatments such as psychotherapy, pharmacologic agents, and patient-support groups offers hope for persons with depression. The most important initial steps in treating depression include addressing and reducing the stigma associated with mental illnesses; encouraging individuals struggling with depression to seek and receive help from mental-health professionals; and expanding access to patient-support resources. All of these measures provide patients and their loved ones with the tools they may need to effectively treat and manage depression and potentially improve overall health-related quality of life (HRQOL).
Etiology and Incidence
Although the exact cause of depression remains unknown, research indicates that this complex, multifaceted mental-health disorder may result from genetic, biological, environmental, and psychological factors, singly or in combination.2-4 Persons with a family history of depression are two to three times more likely to develop the disorder compared with the general population, but it is important to be aware that depression can occur in the absence of a family history.4-6 Additionally, depression often coexists with other medical conditions. For example, higher rates of depression have been identified in patients with cardiovascular disease (including cardiomyopathy, ischemic heart disease, and heart failure), diabetes, hypothyroidism, chronic liver disease, irritable bowel syndrome, chronic pain disorders, cancer, and neurologic diseases (including cerebrovascular disease, multiple sclerosis, seizure disorders, Alzheimer’s disease, and Parkinson’s disease).4,7-9 Various life stressors can contribute to or exacerbate depression in some patients, such as traumatic life events (e.g., death of a loved one, divorce/end of a relationship, loss of employment), financial problems, lack of a support system, and chronic stress, to name a few.9,10
According to the National Institute of Mental Health (NIMH), an estimated 21 million adults (8.4% of all U.S. adults) had at least one major depressive episode in 2020.11 The incidence of major depressive episodes was greater among adult females compared with adult males (10.5% vs. 6.2%, respectively), and the age group with the greatest incidence was 18 to 25 years (an estimated 17%).11 The CDC reported that 2.8% of adults experienced severe depressive symptoms, 4.2% experienced moderate symptoms, and 11.5% experienced mild symptoms in 2019.12
Recent studies indicate that the emergence of the COVID-19 pandemic in 2020 also contributed to escalating rates of depression in the U.S. and heightened the persistence of elevated depressive symptoms.13,14 In a comparison of rates of depression before and during the pandemic, the incidence of depressive symptoms was more than three times greater during the pandemic, and examples of contributors to this higher incidence included social isolation resulting from lockdowns and financial struggles due to loss of employment.13 Healthcare workers demonstrated higher rates of depression and anxiety related to extreme stress and inadequate emotional support.15
Classification and Screening
In 2013, the American Psychiatric Association (APA) published the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). The DSM-5 classifies depressive disorders into the following: 1) disruptive mood-dysregulation disorder, 2) major depressive disorder, 3) persistent depressive disorder (dysthymia), 4) premenstrual dysphoric disorder, and 5) depressive disorder due to another medical condition.4,10,16 According to the NIMH, the two most common types are major depressive disorder and persistent depressive disorder.11
Depressive disorders may be further categorized by specifiers including peripartum onset, seasonal pattern, melancholic features, mood-congruent or mood-incongruent psychotic characteristics, anxious distress, and catatonia.16 It is important to be aware that the characteristics common to all of the depressive disorders include feelings of sadness or emptiness, irritable mood, and somatic and cognitive shifts that considerably impact the patient’s ability to function.9,17 However, the presentation, duration, and etiology of depression vary from individual to individual.17
The U.S. Preventive Services Task Force (USPSTF) recommends depression screening in the general population aged 12 years and older, and in pregnant and postpartum women.18 More information is available in the USPSTF’s recommendation statement on depression screening in adults.18 The American Psychological Association notes that the Patient Health Questionnaire–2 (PHQ-2) and PHQ-9 are the preferred screening tools in primary-care and community settings, as they are short, accurate, and simple to administer. These assessment tools are available online.19
The pharmacist’s role goes well beyond the dispensing of medication, and it continues to evolve. As an integral member of the healthcare team, the pharmacist can be instrumental in identifying patients who are at risk for depression or are struggling with it. The pharmacist can also act as a patient educator and advocate, encouraging patients with depression to discuss it with their primary healthcare provider. The pharmacist can assist patients struggling with depression by showing empathy and helping them overcome the stigma associated with depression so that they can seek help and improve overall quality of life (QOL) and clinical outcomes. A collaborative effort between pharmacists, prescribers, and patients and/or caregivers is essential, along with patient education and emphasis on the importance of adherence to the selected therapy in order to effectively manage depression and prevent the adverse consequences of nonadherence. If unrecognized or left untreated, depression can have a profoundly negative impact on the patient’s QOL; complicate other medical conditions; lead to substance abuse; affect productivity as well as personal and professional relationships; and, in some cases, result in suicidal tendencies or suicide.9,10
Identifying and Overcoming Stigma
The stigma associated with depression remains pervasive, and measures to expand awareness of the importance of treating depression and other mental illnesses are of paramount importance. Many people with a mental-health disorder do not seek help or discuss it with their loved ones or healthcare providers because of the stigma attached to mental illness. Many people with depression feel uncomfortable about discussing it with their primary healthcare provider. Various barriers to seeking help and treatment have been identified in persons struggling with depression. In an assessment of survey data, researchers sought to clarify why individuals with depression do not initiate therapy.20 The most common reason cited was inability to pay for treatment (47.7%), and the least common reason was lack of transportation/inaccessibility of treatment (5.8%). Some other reasons given were: therapy not covered by health insurance; not knowing where to seek help; not wanting others to find out; too busy to seek help; didn’t think therapy would help; fear of being forced to take medications; and concerns about confidentiality.20
According to the World Health Organization (WHO), many people with depression postpone or avoid treatment because they are worried about being judged by others.21 Depression is common and can manifest at any stage of life; however, it is greatly underrecognized and frequently undertreated. Therefore, affected individuals and their loved ones should be encouraged to discuss and seek help for depression as well as overcome the associated stigma.21 A health expert from the WHO stated, “Although depression can be treated and prevented, at least 75% of all people suffering from major depression do not receive adequate treatment. However, it is not enough to simply scale up services—it is equally important to raise awareness, build understanding and reduce stigma.”21
Clinical studies have explored the impact of stigma and misconceptions about depression and other mental illnesses. According to the APA, more than 50% of persons with mental illness do not receive therapy for it, and stigma often results from fear, lack of understanding, or misconceptions about mental illness.22 A research review concluded that although much progress has been made in the recognition and treatment of mental illness, more efforts are necessary to encourage and support those who are struggling with these disorders.22 FIGURE 1 presents a classification of the different types of stigma.22,23
A national poll conducted by the APA in 2019 revealed that the stigma associated with mental-health disorders remains a key challenge in the workplace.24 An estimated 50% of workers surveyed were worried about discussing mental-health issues at their place of employment, and more than 33% were concerned about retribution or termination if they sought mental-health care.24 Only about 20% of workers were completely comfortable with discussing their mental health, but millennials were almost twice as likely as baby boomers (62% vs. 32%) to be comfortable with it.24 See reference 24 for more information from this poll.
A recently published study explored trends in mental-illness stigma over the past 2 decades.25 Depression stigmatization lessened significantly, but the stigma associated with other mental-health conditions remained the same or increased. Participants were more aware of recognizing mental illness, and the changes in stigmas associated with mental illness appeared to be principally associated with age and general shifts, with younger people less likely to stigmatize depression.25 However, according to the Mental Health Foundation, approximately nine of every 10 persons with a mental-health disorder says that stigma negatively impacts their lives.26 This stigma can exacerbate symptoms of conditions such as depression or make it more challenging to recover.26
Mental Health America reports that an increasing percentage of young people in the U.S. have major depression. Statistics indicate that 15.08% of youths experienced a major depressive episode in the past year, a 1.24% increase from the previous year. In states with the lowest rates of reported depression, up to 19% of adolescents aged 12 to 17 years experienced major depression.27 Moreover, more than 60% of youths with major depression were receiving no mental-health treatment, and states with the highest rates of access to care reported that 33% of youths were not receiving any treatment.27 Nationwide, fewer than 33% of adolescents with severe depression obtained consistent care.27
Education and Management
Pharmacists can be instrumental in the management of depression. They can provide pharmacovigilance by engaging in medication therapy management, making clinical recommendations tailored to patient need, counseling on the appropriate use of prescribed therapy, screening for contraindications and potential drug-drug interactions, and addressing the patient’s concerns about and understanding of the selected therapy. Pharmacists can also be instrumental in identifying patients who exhibit signs of depression and those at increased risk for depression, including recognizing medical conditions and drugs that carry an increased risk of depression.
Pharmacists can do the following to help patients manage depression and other mental-health disorders:
• Encourage patients to seek help and to discuss their depression or other mental-health issues with their primary healthcare provider.
• Counsel patients about the benefits of therapy, importance of adherence, routine monitoring, and what to expect from therapy, including that once it is initiated it takes time for symptoms to improve.
• Instruct patients about possible therapies, including pharmacologic and nonpharmacologic measures.
• Educate patients about potential adverse effects, how to manage them, and when to contact their primary healthcare provider.
• Identify signs of nonadherence in patients prescribed antidepressants.
• Make recommendations to improve adherence, such as refill reminders.
• Encourage patients to take an active role in their health and provide information about patient-support and cost-savings programs sponsored by pharmaceutical manufacturers, as well as other resources available online (SIDEBAR 1).
• Keep the lines of communication open with both patients and prescribers.
There are multiple effective therapies for depression, including medication, psychotherapy (counseling, cognitive-behavioral therapy), and combinations of these. Combination therapy has been linked to significantly higher rates of improvement of depressive symptoms, enhanced QOL, and better treatment compliance.4 Some commonly prescribed antidepressant classes include selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, and monoamine oxidase inhibitors.
Adherence to therapy is critically important, but some data indicate that one-half of patients prescribed antidepressants discontinue therapy prematurely.28,29 Common reasons for nonadherence to antidepressants include both patient factors (e.g., medication costs, worries about adverse effects, fears of addiction, misconceptions about depression and antidepressants) and clinician factors (e.g., insufficient patient education, poor follow-up). Nonadherence may also be due to poor memory, anxiety, low motivation, or insufficient understanding of/lack of support in managing depression and the selected therapy.28,29 Approximately 33% of patients discontinue antidepressant therapy within the first month, and 44% of patients discontinue by the third month.29
To improve adherence, the treatment plan should be tailored to the individual patient and adjusted as needed. Additionally, patients should be encouraged to take an active role in their health. The overall goals of therapy are to improve symptoms and patient HRQOL while minimizing the incidence of adverse effects from medications. Successful treatment depends on early recognition, management, adherence to selected therapy, and routine monitoring. Patients should be monitored for treatment-resistant depression (TRD), which develops in some individuals; in such cases, the pharmacist can recommend therapies for TRD, such as Spravato (esketamine) CIII nasal spray, a noncompetitive N-methyl-d-aspartate receptor antagonist that may be used adjunctively.30
Pharmacist-provided patient care is often associated with improved clinical outcomes. It has been found that when patients sense that their healthcare provider—including the pharmacist—is comfortable discussing mental-health problems, they in turn feel more comfortable discussing depression. This may enable patients to more readily seek help and receive therapy. For example, one study evaluating the effectiveness of pharmaceutical care services and their influence on patients’ HRQOL demonstrated that the use of pharmacist educational programs and interventions for increasing compliance led to reduced depressive symptoms and enhanced QOL in the study patients.31 Another study concluded that a multidisciplinary approach to treating depression that involved pharmacist intervention resulted in improved QOL, better adherence, and increased therapy effectiveness.32 It has also been found that pharmacists trained in mental-health disorders not only prevent negative outcomes but also enhance positive clinical outcomes by promoting appropriate drug choices and regimen adherence.33
Because pharmacists can be essential in recognizing signs of depression in patients, it is important for them to be comfortable with engaging patients in conversation about mental-health problems when feasible. A recent survey explored pharmacists’ perceptions of their pharmacy training in mental health–related medication issues and how this affected their perceived capability to address these issues with regard to delivery of patient care. Some survey participants stated that their training in this area may have been insufficient. Of the participants, 489 (58.2%) reported that pharmacy-school training adequately prepared them to provide rudimentary pharmaceutical care to patients taking medications for mental-health disorders, and 350 (41.4%) felt less comfortable providing medication counseling for mental health–related medications compared with medications for other health problems, such as cardiovascular disease.34
When counseling patients, it is important to remind patients and their loved ones that depression is a treatable condition and that adherence to therapy is a key component of improving clinical outcomes. Pharmacists can help ensure medication adherence by counseling patients on how to use the medication, the importance of taking the medication consistently, and how to recognize possible adverse effects, with particular attention to the FDA’s black box warnings regarding suicidal thoughts or behaviors in certain patient populations. Patients and loved ones should be reminded to immediately contact their primary healthcare provider if the patient experiences agitation, anxiety, or any suicidal thoughts or behaviors after initiation of an antidepressant. Pharmacists should also advise patients to never abruptly discontinue the medication without consulting the primary healthcare provider and to report any problems with the medication, including adverse drug reactions. Patients who are well informed about their condition and medications are more likely to adhere to therapy.28
As frontline healthcare providers, pharmacists are well poised to educate patients about mental-health disorders and encourage them to seek further medical evaluation from their primary healthcare provider. Pharmacists are instrumental in making clinical recommendations about therapies commonly prescribed for depression, educating patients about the proper use of these agents, counseling them about recommended nonpharmacologic measures for depression, and directing them to reliable patient-education resources.
1. National Alliance on Mental Illness. Let’s talk about depression. www.nami.org/Blogs/NAMI-Blog/January-2018/Let-s-Talk-About-Depression. Accessed February 23, 2022.
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3. CDC. Mental health conditions: depression and anxiety. www.cdc.gov/tobacco/campaign/tips/diseases/depression-anxiety.html. Accessed February 23, 2022.
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18. U.S. Preventive Services Task Force. Depression in adults: screening. www.uspreventiveservicestaskforce.org/uspstf/document/RecommendationStatementFinal/depression-in-adults-screening. Accessed April 5, 2022.
19. Welcome to the Patient Health Questionnaire (PHQ) screeners. www.phqscreeners.com/. Accessed April 5, 2022.
20. Chekroud AM, Foster D, Zheutlin AB, et al. Predicting barriers to treatment for depression in a U.S. national sample: a cross-sectional, proof-of-concept study. Psychiatr Serv. 2018;69:927-934.
21. World Health Organization. 3 out of 4 people suffering from major depression do not receive adequate treatment. www.euro.who.int/en/media-centre/sections/press-releases/2017/3-out-of-4-people-suffering-from-major-depression-do-not-receive-adequate-treatment. Accessed February 23, 2022.
22. American Psychiatric Association. Stigma, prejudice and discrimination against people with mental illness. www.psychiatry.org/patients-families/stigma-and-discrimination. Accessed February 28, 2022.
23. The health crisis of mental health stigma. Lancet. 2016;387:1027.
24. American Psychiatric Association. About half of workers are concerned about discussing mental health issues in the workplace; a third worry about consequences if they seek help. www.psychiatry.org/newsroom/news-releases/about-half-of-workers-are-concerned-about-discussing-mental-health-issues-in-the-workplace-a-third-worry-about-consequences-if-they-seek-help. Accessed February 24, 2022.
25. Pescosolido BA, Halpern-Manners A, Luo L, Perry B. Trends in public stigma of mental illness in the US, 1996-2018. JAMA Netw Open. 2021;4:e2140202.
26. Mental Health Foundation. Stigma and discrimination. www.mentalhealth.org.uk/a-to-z/s/stigma-and-discrimination. Accessed February 23, 2022.
27. Mental Health America. The state of mental health in America. www.mhanational.org/issues/state-mental-health-america. Accessed February 24, 2022.
28. Sansone RA, Sansone LA. Antidepressant adherence: are patients taking their medications? Innov Clin Neurosci. 2012;9:41-46.
29. Alekhya P, Sriharsha M, Priya Darsini T, et al. Treatment and disease related factors affecting non-adherence among patients on long term therapy of antidepressants. J Depress Anxiety. 2015;4:175.
30. Spravato (esketamine) package insert. Titusville, NJ: Janssen Pharmaceuticals, Inc; July 2020.
31. Gomes NC, Abrao PH, Fernandes MR, et al. Effectiveness of pharmaceutical care about the quality of life in patients with depression. SM J Depress Res Treat. 2015;1:1005.
32. Binakaj Z. Pharmaceutical care of the patients suffering from depression. J Pharm Pharmacol. 2016;4:253-260.
33. Bell S, McLachlan AJ, Aslani P, et al. Community pharmacy services to optimise the use of medications for mental illness: a systematic review. Aust New Zealand Health Policy. 2005;2:29.
34. Goodman CS, Smith TJ, LaMotte JM. A survey of pharmacists’ perceptions of the adequacy of their training for addressing mental health–related medication issues. Ment Health Clin. 2017;7:69-73.
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