You’re working in the pharmacy when regular patient John Goode comes in to pick up a prescription. You see it is his first prescription for citalopram. What do you do?

1. Hand him the bag – after all, it’s too difficult to approach patients with mental health issues in a pharmacy
2. Tell him to take it at night
3. Tell him that it may take up to six weeks to work
4. Ask him if he has any questions
5. Do a new medicine service (NMS) consultation, even though you know you won’t be paid for it

Unsure of what to do? It’s not surprising. Patients commonly experience side effects and difficulty adhering to antidepressants, but these medicines are not included in the NMS. This means that, despite the clear need for support, pharmacists won’t be paid for helping these patients.

But this could and should change. A pilot in Devon demonstrated that running NMS consultations for patients on antidepressants yields positive results. Support for making this a nationwide service is growing. The all-party pharmacy group has just this week called for the NMS to include antidepressants. The MPs have the backing of mental health expert Allan Young, a professor at the King's College Institute of Psychiatry, who branded it an “innovative way” of improving compliance among patients prescribed antidepressants. So why is this such an important issue for community pharmacy?

 

The data

Firstly, let’s look at the data behind depression. People on antidepressants are likely to be treated by their GP and community pharmacist – 90 per cent of people with depression are treated in primary care, and up to a third of primary care consultations have a significant mental health component, according to Royal College of General Practitioners data from 2006.

The importance of this is only compounded by the exponential rise in antidepressant consumption. In England, there was a 165 per cent increase in prescriptions for antidepressants between 1998 and 2012 – equating to more than 7 per cent a year – and, in 2013, more than 53 million prescriptions for antidepressants were dispensed in the UK at a cost of over £280 million to the NHS. It is not clear what has prompted this increase – a Quality Watch report in 2014 attributed it to a complex interaction of factors occurring at an individual level, general practice level and across broader society. But what is clear is that, given the prevalence of depression and costs involved, patients taking antidepressants should receive adequate support.

 

The patient experience

This is often where the system falls down. Receiving a prescription for antidepressants for the first time is a significant and frequently worrying time for patients, who feel they have little support.

During consultations that lead to an antidepressant prescription, patients may feel distressed and therefore experience difficulty taking in the information they are given. They may also hold preconceptions about the treatment based on their past experiences with medicines, the quality of their relationship with their healthcare provider, and their own and other people’s attitudes about addiction and dependence.These obstacles may lead to a delay in taking their medicine.

We interviewed 36 people with experience of taking antidepressants and found it often took them a while to get treatment. Firstly, they would suffer from the symptoms of depression for some time before going to the doctor. After receiving a prescription for antidepressants, they were often hesitant over taking the medication. They would leave the box on the shelf, read and re-read the information leaflet, as well as turning to the internet to look for support and information about how others have coped. People struggled with the idea of taking medicines 'for the mind' rather than for a physical condition, which adds an extra dimension to the problem.

Side effects and doubts

Once these patients actually started taking the antidepressants, new problems reared their head. In our research, people told us they had experienced side effects before perceiving any benefits. Patients often had to try a number of antidepressants before they found the one that suited them and made a difference. The medication often left them feeling numb, distant or detached. Some took time off work in order to cope. Others found ways of minimising the effects – varying the time of administering the dose can help with sleep-related problems or make other side effects more bearable.

Crucially, people often feel very alone when dealing with the initial effects of the antidepressants. This feeling of isolation combined with side effects can make it difficult for patients to adhere to their medication – especially if there are other factors at play. Unwillingness to view depression as a medical illness and the associated lack of belief about the need for antidepressants, as well as concerns about addiction, are thought to influence adherence - or lack of it.

 

The role of healthcare professionals

All of the above makes it important for healthcare professionals to talk to patients. Research in the Netherlands in 2014 supports this view. The extent to which patients accepted their diagnosis and prescription of antidepressants in early consultations with health professionals was critical to their ongoing adherence to medication, it found.

It seems support is often lacking in this area. The involvement of pharmacy was notable by its absence in our interviews with patients on antidepressants. Few interviewees mentioned having any support when their first or subsequent prescriptions were dispensed.  Only one said they had received support from a pharmacist when commencing treatment, and a number of people said they had just been handed the bag with the antidepressant in it. Others perceived that the pharmacist was uncomfortable and felt the environment was not conducive to such a conversation.

 

Pharmacist training

Considering the potential impact of pharmacist interventions, we can’t let this continue. This is why it is so important to include antidepressants in the NMS. Offering these consultations needn’t involve extensive training. A Belgian randomised controlled trial showed that, with just one day of training, pharmacists could provide increased support to people on antidepressants. Intervention group pharmacists conducted significantly longer consultations with these patients, consisting of more education and counselling statements about lifestyle and psychosocial concerns. Intervention group pharmacists also asked more questions about the medical condition and therapeutic regimen, as well as socio-emotional concerns.

There are also online resources that can help you give advice in this area – healthtalk.org provides information on a range of illnesses including depression that has been gathered by seeing and hearing real-life experiences. Pharmacists can refer patient to relevant parts of the site during consultations or when counselling them about their prescriptions.

The NMS has been shown to be effective in helping patients to adhere to new medicines. Our data shows that the additional support that this service brings may be very helpful to people being prescribed antidepressants. So next time someone like John Goode hands you a prescription, please consider how difficult it is to commence treatment with antidepressants - and try to offer some support and not just hand out a bag of medicine.

Claire Anderson is a professor of social pharmacy at the University of Nottingham’s School of Pharmacy and a member of the Royal Pharmaceutical Society English Pharmacy Board. Susan Kirkpatrick is a senior researcher at the Health Experiences Research Group, University of Oxford. The study mentioned in this article was funded by National Institute for Health Research’s School for Primary Care Research. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.