Jeannette Y. Wick, MBA, RPh, FASCP

Research shows that vaccines prevent disease and save lives.

If that is the case, why have specific vaccines been singled out as different from others, creating discord? One example is the human papillomavirus (HPV) vaccine. The CDC recommends this vaccine for children starting at age 11, indicating that optimal uptake would prevent 13.4 million cervical cancer cases before 2100.

 Yet many parents, even those who have no con- cerns about other vaccines, balk at this one.

The traditional education covers how and why to vaccinate but not how to deal with patient resistance. The key to addressing resistance is to understand the problem’s origins—and that it is not necessarily a science problem but a marketing one.

 In the case of the HPV vaccine, parents have been bombarded with often incorrect information.

 Misunderstanding, unfair attacks, and unsubstantiated information spread at the speed of light.

 Pharmacists can take a lesson from other beneficial products that have struggled with negative publicity.

 The table lists reasons why products develop bad reputations.

Changing the way parents think about the HPV vaccine is like dealing with a negative label applied to an individual. The goal is to help the HPV vaccine fit in with all the other vaccines and to show acceptance benefits in society. In short, it means treating this vaccine exactly as pharmacists treat all other vaccines because their jobs and safety profiles are the same. It also pays to emphasize the positive. The online figure shows best approaches and some facts to remember.

Pharmacy staff members can find additional information on numerous websites to prepare themselves to answer questions. The Shot of Prevention website

 provides a list of reasons that parents sometimes cite when they decline the HPV vaccine. It also offers information to help health care professionals discuss teenage abstinence or lack thereof, prevention versus treatment, and study results. The CDC has prepared a helpful poster that lists parents’ most common questions and best answers.

 It also has a concise web page devoted to vaccine development and testing that is designed to educate parents about the process and build confidence.

Effective HPV vaccines have been available since 2006. The most common concern among parents is safety,

yet clinicians have administered millions of doses of this effective, safe vaccine. Confidence in these products is strong, and pharmacists need to convey this to patients. Pharmacists must stay the course firmly and positively and present all vaccines, not just HPV, as the lifesaving tools that they are. Promote and administer the HPV vaccine in the same way and on the same day as other vaccines that are due.

 is an assistant director of the Office of Pharmacy Professional Development at the University of Connecticut School of Pharmacy in Storrs.

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. Published August 20, 2013. Accessed June 7, 2019.

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Articles

Research shows that vaccines prevent disease and save lives. If that is the case, why have specific vaccines been singled out as different from others, creating discord?

HPV Vaccine, We Have a Marketing Problem

Maternal postpartum depression (PPD), although common, disabling, and sometimes life-threatening, often remains undiagnosed and undertreated. Recent discoveries concerning PPD’s pathophysiology offer tremendous hope to the approximately 400,000 women who develop it annually in the United States.

 Among those women, about 15% will have a disabling, persistent condition, and a small percentage will develop postpartum psychosis.

Subject matter experts indicate that biologic, hormonal, and psychosocial issues are risk factors for postpartum mood disorders (table

 Symptoms can last 1 year or longer, with 25% of women having symptoms at 1 year.

 Sadly, many women do not seek prompt treatment, thinking they are just tired or finding other excuses, such as “it’s just postpartum blues.” In addition, tremendous stigma accompanies this condition.

Postpartum blues—anxiety, fluctuating mood, irritability, and tearfulness&mdash;are real and tend to develop around the fourth or fifth day postpartum in about half of women. Generally, these symptoms spontaneously diminish over 2 weeks. Conversely, PPD is persistent and interferes with the mother’s ability to care for herself and others and may not resolve spontaneously. PPD manifests as anhedonia, appetite disturbance, depressed mood, fatigue, insomnia, recurring thoughts of death, suicidal thoughts, and tearfulness. As with other kinds of depression, symptoms occur along a continuum.

 Affected individuals may also have ambivalent feelings, obsess about the baby, or think about hurting her children or herself.

Early treatment is crucial and starts with nonpharmacologic strategies in women with mild to moderate depressive symptoms. These include group or individual psychotherapy and psychoeducational support groups. Pharmacists should note that some new mothers are breastfeeding and may be hesitant to take medication. For these women, nonpharmacologic strategies are very important.

When the clinician and patient decide that medication is needed, treatment follows a pattern similar to that used in other kinds of depression (figure

 ). Generally, treatment starts with a selective serotonin reuptake inhibitor (SSRI) or a serotonin/norepinephrine reuptake inhibitor administered at the same doses used for others who have depression. Clinicians can consider other antidepressants if first-line antidepressant medications are ineffective or tolerated poorly.

In March 2019, the FDA approved the first drug specifically for PPD. Brexanolone is chemically identical to endogenous allopregnanolone, a hormone that falls after childbirth. In PPD, gamma-aminobutyric acid-A receptors become dysregulated. Brexanolone acts as a positive allosteric modulator at those receptors. Clinical trials identified some serious risks, including excessive sedation or sudden loss of consciousness during administration, so brexanolone has a risk evaluation and mitigation strategy: Patients must receive treatment at a certified health care facility under close monitoring; during the 60-hour infusion, patients must have continuous pulse oximetry; and patients may see their children only under direct supervision. Brexanolone’s most common adverse reactions include dry mouth, flushing, loss of consciousness, and sleepiness.

 Postmarketing trials are under way, and obstetricians look forward to the results.

Pharmacy staff members should note that a form of PPD occurs in fathers. Risk factors appear to be similar to those that mothers experience. A history of depression, financial stressors, and low social support are particularly important in men. When a father and mother both experience depression, they will need increased monitoring and support.

Most antidepressants can be taken during breastfeeding. Paroxetine and sertraline appear to be least likely to pass into breast milk and are preferred as initial therapy. Clinicians should note that all SSRIs pass into breast milk at levels compatible with breastfeeding, and a healthy full-term infant should not be affected. The benefits of breastfeeding outweigh concerns about SSRI exposure in most cases.

 Clinicians and patients can find excellent, evidence-based recommendations about breastfeeding and drugs at LactMed, which is sponsored by the Toxicology Data Network.

With celebrities such as Aarti Sequeira and Chrissy Teigan, going public with their own struggles with PPD, women may be more likely to come forward for help when they have symptoms. Better outcomes will require several things, including appropriate long-term use of medications and therapy, frequent checkin and follow-up from clinicians, and careful reassessment at every opportunity.

, is an assistant director of the Office of Pharmacy Professional Development at the University of Connecticut School of Pharmacy in Storrs.

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Treatment, including appropriate long-term use of medications and therapy, frequent follow-up from clinicians, and careful reassessment, can save lives.

Postpartum Depression Is Not Just Baby Blues

Pharmacists may envision children who act without thinking, have difficulty paying attention, and squirm in their seats when they think about attention-deficit/hyperactivity disorder (ADHD). But ADHD, which affects an estimated 3% to 5% of Americans,

 occurs in individuals of all ages. Characterized by hyperactivity that is impairing and pervasive, inattention, and impulsivity, ADHD creates problems that can interfere with school, social life, and work.

 These problems tend to change over time (online figure). A growing concern is that the use of social media is being linked to increased symptoms in children.

Experts are concerned that health professionals are not identifying and treating individuals with ADHD as aggressively as they could.

 Several recent meta-analyses confirm pharmacological treatment’s short-term efficacy—and long-term efficacy to a lesser extent.

Research into nonpharmacological interventions (table 1

) is less robust. For this reason, experts recommend prescribing behavioral interventions, in combination with medication, as the benefits outweigh the risks.

Researchers think that most ADHD medications work at the catecholamine pathways.

 They appear to increase the availability of synaptic dopamine or norepinephrine (eg, by blocking reuptake). Some study results indicate that individuals with untreated ADHD have dopamine deficits associated with low dopamine transporter (DAT) density. In individuals treated with stimulants, position-emission tomography imaging studies indicate transporter density increases with chronic treatment.

Each medication has a specific mechanism of action

Amoxetine inhibits the norepinephrine transporter 1 and increases norepinephrine neu- rotransmission in the brain and dopamine in the prefrontal cortex. This is important because this area has few DATs.

Amphetamine and methyphenidate inhibit DAT and norepinephrine transporters, functioning as reuptake inhibitors increasing neurotransmission.

Clonidine and guanfacine stimulate alpha-2 nor-adrenaline receptors in the central nervous system. 

Bupropion is converted into 2 potent norepinephrine enhancers: hydroxybupropion and threohydrobupropion.

Tricyclic antidepressants block serotonin and norepinephrine transporters to enhance neurotransmission with little effect on DATs.

Modafinil induces an atypical conformational change in the monoamine transporter DAT.

Most drugs in development for ADHD focus on enhancing dopamine and norepinephrine levels, the traditional approach; enhancing drug delivery; and prolonging drug half-life.

Most guidelines recommend parent behavioral training and social skills training for nonpharmacologic treatment.4-6 These interven- tions are critical in 2 specific populations

Children younger than 6 years, because drugs have been poorly studied in this population.

Individuals with severe ADHD at any age (ie, add cognitive behavioral therapy to the patient’s medication)

Meta-analyses indicate that individuals with ADHD who received nonpharmaccologic treatment had better long-term outcomes than their nontreated counterparts. Combined pharmacologic and non- pharmacologic treatment led to better outcomes than either alone.

Many patients or their parents are reluctant to start or consid- er drug therapy for ADHD.

 Clinicians also can be somewhat reluctant to diagnose ADHD.

 Therefore, pharmacists need to discuss the evidence behind ADHD medications and their potential adverse effects (AEs) in patient-friendly language. They also need to solicit questions. It is critical to stress that evidence now indicates that ADHD is probably a lifelong condition for most.

The main concerns about treatment include the controlled status of stimulants and potential abuse, as well as the need for multiple daily doses. In addition, stimulant abuse problems receive considerable media attention and can be a barrier.

 Parents also worry about their children being labeled or stigmatized.

Parents often think that their children will “grow out of it” or be concerned about AEs, especially growth delays (table 2

Working with clinicians, parents, and teachers to establish a patient’s behavior and sleep baseline before starting medication helps avoid blaming medicine for preexisting problems. If AEs occur, changing the dose, formulation, or medication may provide relief.

Managing ADHD symptoms and encouraging adherence requires discussions among caregivers, clinicians, and patients. Abuse potential, AEs, duration of action, effectiveness, and parental or patient preferences will guide treatment. Routine follow up and monitoring must guide decisions to adjust treatment. 

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It is critical to stress that Attention-Deficit/Hyperactivity Disorder is probably a lifelong condition for most individuals with the condition.