Impact of pharmacists in mental health over the past decade

INTRODUCTION

Psychiatric illness is a highly prevalent problem, and there is a constant search for better treatment options.¹ With the high rate of psychiatrist burnout, there is a great need for changes to be made in the treatment of mental illness.² A multidisciplinary approach to the treatment of mental illness is one proposed solution, which has been implemented in many settings, and could reduce psychiatrist burnout and improve patient care.

Additionally, the movement to an interdisciplinary approach is heralded as a way to improve patient outcomes and maximize therapeutic regimens.

Pharmacists have been directly involved in the care of psychiatric patients as early as the 1970s, in both inpatient and outpatient settings.³⁴ Over the past decade, the role of pharmacists has continued to evolve beyond the traditional dispensing role, and momentum has increased to include pharmacists on the multidisciplinary team. Therefore, the purpose of this article is to elucidate the impact of pharmacists in psychiatry over the last decade.

METHODS

A comprehensive literature search for publications analyzing the effects of pharmacists on the treatment of patients with psychiatric disorders was conducted using the PubMed and CINAHL Plus with Full Text databases. Studies published between January 2002 and December 2011 were included in the search criteria. Search terms consisted of “pharmacy” or “pharmacist” in combination with “psychiatry”, “psychiatric” or “mental illness”. Additional studies were identified by reviewing the reference lists of each study. Inclusion criteria included a study evaluating some form of pharmacist intervention related to psychiatric patients and their care. Case reports and case series were excluded from this review.

RESULTS

While 19 publications were identified, 17 studies met the inclusion criteria for this review (Table 1). Fifteen studies occurred in outpatient settings^5–19 and two occurred in inpatient settings.²⁰²¹ Of the outpatient studies, eight occurred in primary care clinics^{57–911–1316}, two in psychiatric clinics¹⁸¹⁹, four at community pharmacies^6101517, and one within an assertive community treatment (ACT) team.¹⁴ While fifteen studies examined the impact of pharmacist interventions in patients already diagnosed with a psychiatric disorder^{5–1417–21}, two focused on the ability of pharmacists to screen for depression.¹⁵¹⁶ Overall, approximately 50% of the reports focused on depressive disorders.^{569–1315–17} Only seven of the studies included a control group: five studies were randomized, controlled trials^59121718, while two studies were non-randomized controlled trials.¹⁰¹¹ The majority of the studies found a significant improvement of symptoms in both groups^59101217; however, no significant difference existed between the intervention and control groups. Pharmacist interventions most commonly included patient education^{5–1417–20} and pharmacist recommendations to other providers.^{57–911–1419–21} Pharmacist recommendations to other providers commonly involved dose adjustments and changes in medication therapy^{57–911–142021}, and regarded obtaining laboratory work and therapeutic drug levels.²⁰²¹

Table 1. Impact of clinical pharmacists in psychiatric settings: Summary of studies

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Ten studies using various psychiatric inventories assessed clinical outcomes directly resulting from pharmacist interventions.^{57910121317–1921} Of these studies, the uncontrolled trials showed significant improvement in psychiatric symptoms through the course of the study.^7131921 Improvement in symptoms in these studies was measured by various rating scales, including the HAM-A and HAM-D scales⁷, the PHQ-9¹³¹⁹, and the CGI-S.¹⁹²¹ However, the controlled trials found no significant difference in the clinical improvement of patients between the pharmacist intervention and control groups.^5910121718

Economic outcomes resulting from the interventions were explored in four studies.^7121320 The majority found the intervention resulted in economic savings over the study period, when compared to projected costs.⁷¹³²⁰ Estimated savings ranged from $22,380 over 15 months to $125,500 over an 18 month period.⁷²⁰ In the study which estimated cost savings over $120,000 the interventions that saved the most money included: clarification of orders, MAR discrepancy and dose adjustments.²⁰ The only controlled study that assessed economic outcomes found a non-significant increase in institutional drug costs for patients in the intervention group, likely due to increased medication adherence, but this study did not perform a cost-benefit analysis.¹²

Eight studies examined the effect of the interventions on medication adherence.^569–121718 The majority of interventions consisted of increased pharmacist contact with patients for the purposes of following up on medication-related concerns.^568–1217 One study examined the effect of a patient program, which involved medication refill reminders and unit-of-use packaging of all routine medications.¹⁸ Adherence was assessed by pharmacy computerized refill records^11121718, or by self-reported information from the patients.⁵⁶⁹¹⁰ Approximately half of the studies found improved adherence at six months in the intervention groups when compared to control groups.^11121718 Improvement in medication adherence ranged from 19% to 27% higher within intervention groups compared to control groups.¹²¹⁸ Two studies found no significant difference in adherence between intervention and control groups, despite the 95% adherence rate in one of the studies.⁹¹⁰ One uncontrolled study found that 83% of patients reported missing doses, taking additional doses, or stopping their medication during the study.⁶

Six studies assessed patient satisfaction.^6911121518 Patient satisfaction was measured through various follow-up surveys. Two controlled studies found that patients in the intervention groups had higher satisfaction rates in several areas, including the personal nature of care, access to providers, and overall satisfaction with the (health maintenance organization) HMO providing care.¹¹¹² However, the other two controlled studies, despite a satisfaction rate of at least 80%, found no significant difference in patient satisfaction between control and intervention groups.⁹¹⁸ One small uncontrolled study found a patient satisfaction rate of 88% when pharmacists were directly involved in their care via depression screenings.¹⁵

One retrospective study compared clinical outcomes in patients who had high implementation of pharmacist recommendations with those who had lower implementation rates.²¹ This study found a statistically significant correlation between patients with high implementation rates and improvement of symptoms, based on CGI-Severity (CGI-S) scores. The proportion of patients who responded with improved CGI-S scores was greater in the high implementation group when compared with patients who had lower implementation rates (51.9% vs. 31.3%, P=0.036). The same study found that while there was a similar correlation between high implementation and CGI-Improvement (CGI-I) scores, this correlation was not statistically significant.

Two studies assessed the results of a pharmacist-run depression screening program.¹⁵¹⁶ One screening resulted in 33% of the 18 participants being referred to their PCP for follow-up care, after screening with the 10-item Harvard Department of Psychiatry/National Depression Screening Day Scale (HANDS tool).¹⁵ The other study involved screening 45 diabetic patients with the Zung Self-rating Depression Scale (SDS), and showed over half of the patients with diagnoses of depression were either undertreated or not treated at all, while 48% of patients without a major depression diagnosis screened positive.¹⁶ However, clinical outcomes resulting from these screenings were not assessed.

Three controlled studies assessed the effect of pharmacy interventions on the number of patient visits to other healthcare providers. Two of these studies found there was no significant effect on pharmacy interventions and patient visits to other healthcare providers⁹¹², while another study found a greater decrease in number of visits to primary care physicians in the intervention group.¹¹

One study found there was no significant effect of pharmacy interventions and the patients' attitudes towards antidepressant medications.¹⁰ Another study found patients who received pharmacy interventions were more likely to provide feedback about their treatment to the pharmacist, and had improved knowledge and beliefs about antidepressant medications.¹⁷

DISCUSSION

A comprehensive literature search found 17 studies published between January 2002 and December 2011 on the impact of pharmacists on psychiatric patients. These studies varied widely, both in practice setting and in the types of interventions in which pharmacists were involved. Half of the identified publications focused on patients with depression, while the other half involved a variety of psychiatric diagnoses (e.g., anxiety, bipolar disorder). The studies varied greatly in size, study design, and measurement of outcomes. The quality of the studies also widely ranged, with only seven of the 17 studies utilizing a control group.

Overall, 60% of the non-controlled studies demonstrated favorable outcomes^7131519–21, and 30% did not directly measure the outcomes resulting from pharmacist interventions.⁸¹⁴¹⁶ While most studies found high patient satisfaction from pharmacist interventions, one study involving patients filling antidepressant medications at community pharmacies found that only 32% of patients found pharmacists to be helpful in solving medication related problems.⁶ Caution is warranted when interpreting these results since 42% of patients in the study did not state an opinion on whether pharmacist monitoring had been helpful, the pharmacist monitoring styles varied, and many patients did not have further contact with the pharmacist after the medication was dispensed. Therefore, it is difficult to draw definite conclusions from this study.

Each of the uncontrolled studies which evaluated clinical outcomes concluded pharmacist interventions resulted in overall improvement in psychiatric symptoms.^7131921 Despite not having a control group, one of these studies did compare outcomes in patients who had a higher implementation of pharmacist recommendations compared with patients with lower rates of implemented recommendations, and found pharmacist interventions were associated with favorable outcomes.²¹ Another study noted clinical improvements were greater in patients with severe depression, as compared to those with mild to moderate forms of the illness.¹³ The severity of the psychiatric illnesses in most of these studies was not stated. Therefore, if patients were mildly-moderately impaired it may have been difficult to determine significance especially with studies having a small sample size.

Despite clinical outcomes favoring the intervention group in one of the controlled studies⁵, it was interesting to see that none of the controlled studies over the past ten years actually demonstrated any statistically significant difference in clinical outcomes between patients receiving pharmacist interventions and control groups. Several additional reasons may explain why these studies demonstrated a lack of statistical differences. In one study, it was discovered after the intervention period that some of the pharmacists in the control group had provided the same types of services as the intervention pharmacists.¹⁰ In another study, pharmacists in the control group were encouraged to use any available resources to assist in the treatment of their patients, but were not required to document any additional services provided to patients.⁹ As a result, both studies found no significant difference between the intervention and control groups in treatment adherence or improvement of symptoms. A greater standardization of services provided by the control group pharmacists may have resulted in different results, as the control group pharmacists may have been providing many of the same types of interventions as pharmacists in the intervention group. Additionally, the lack of a statistically significant difference in clinical outcomes could also be a function of small sample sizes. Five of the controlled studies involved sample sizes of less than 200 patients.^910121718 It is possible that studies with larger sample sizes would be able to detect a significant difference in clinical outcomes.

The majority of studies assessing economic outcomes found pharmacist interventions resulted in cost savings.⁷¹³²⁰ These findings are especially promising, as there is an ongoing search for ways to reduce health care costs. While these studies did not involve control groups, they compared actual costs with the projected yearly costs, which should give a more accurate estimate of the savings resulting from pharmacist interventions. It may be reasonable to believe the economic savings from some of these studies may have even been greater than estimated. One study concluded only 50–60% of interventions were documented, which may have had a significant impact on the results of the study.²⁰ Although the study did find pharmacy interventions resulted in economic savings for the hospital, the cost savings may have been underestimated due to the voluntary system of tracking interventions.

Future studies should employ larger sample sizes, as well as control groups. There is also a need for more standardization among the rating scales that are used to determine clinical outcomes. The great variation in rating scales used by the studies examined in this review demonstrates the possible need for more consistency.

CONCLUSION

Studies published over the last ten years vary greatly in assessing the value of pharmacists in the treatment of patients with psychiatric illness. Overall, most studies concluded pharmacists provide a valuable role in the treatment of psychiatric patients in both inpatient and outpatient settings on various outcomes (e.g., patient satisfaction, adherence, cost-savings). However, the quality of most of these studies is not ideal, and there is a clear need for additional well-designed, randomized, controlled trials.