Patients diagnosed with depression need a team of clinicians to provide support and encouragement. For pharmacists, this translates into a need to provide counseling that addresses a patient’s daily challenges, ability to seek and escalate treatment, and capacity to remain adherent. Many health care providers skip these important assessments or conduct them infrequently. At the 2019 Directions in Pharmacy conference, 1 session addressed this clinical conundrum.

Megan Maroney, PharmD, BCPP, who is a Clinical Associate Professor at the Ernest Mario School of Pharmacy, Rutgers University, in Piscataway, New Jersey, covered major depression and its treatment. She began by discussing the burden of disease, indicating that over a lifetime, approximately 20.6% of American adults experience at least 1 episode of diagnosable depression. Its prevalence in a 12-month period is between 7% and 10%. Interestingly, 4.5% of American adults (or 11 million people) indicated that their depression is so severe it causes impairment and disability. In fact, depression was the second leading cause of disability between 1990 and 2016.

Certain risk factors predispose individuals to depressive episodes. Considered risk factors include childhood trauma, a history of other mental health conditions, substance abuse, any chronic health condition, and family history. Family history is associated with a 2 to 4 times higher risk of depression.

Individuals who develop depression have independent risk factors for ischemic heart disease and cardiovascular mortality. They are also more likely than others to develop arthritis, asthma, back pain, chronic obstructive pulmonary disease, hypertension, and migraine. Sedentary lifestyle, obesity, and cigarette smoking are also common among people who have depression. Of specific note for pharmacists, Dr. Maroney indicated that treatment adherence is very low in this population and is a key area of counseling for patients.

Treatment phases can be divided into acute (typically the first 8 to 12 weeks of treatment) and maintenance (which should last at least 6 months or longer). For acute depression, remission is attained if the patient has no or almost no symptoms and is able to return to normal functioning. The highest risk for relapse or recurrence is within the first 6 months of diagnosis and treatment. During the maintenance phase, it is critical for clinicians to prevent recurrence, help the patient return to full functioning, and improve his or her quality of life. Dr. Maroney said that for clinicians, the 2 questions that are most important are, “How do you get people well?” and “How do you keep them well?”

After briefly discussing nonpharmacologic treatment interventions, Dr. Maroney launched into coverage of available antidepressants, of which there are many. She indicated that current thinking is that treatment should begin with selective serotonin reuptake inhibitors, selective norepinephrine reuptake inhibitors, mirtazapine, bupropion, or vortioxetine. She also described the conditions under which patients may need to augment treatment with an antipsychotic or a benzodiazepine. She covered mixed depression (depression with manic or hypomanic features), which is treated somewhat differently than other types of depression.

A strength of her presentation was her ability to identify the various medications in terms of comparative effectiveness, tolerability, and risk for potential drug interactions. She briefly covered discontinuation syndrome, saying that abrupt discontinuation of paroxetine or venlafaxine is most closely associated with discontinuation syndrome. Patients treated with fluoxetine are least likely to experience the discontinuation syndrome.

Always of great interest to pharmacists, CYP450 pharmacokinetic drug interactions can be significant with many of the antidepressants. Dr. Maroney referred participants to the website crediblemeds.org if they have questions about QTc prolongation or torsades de pointes. She also recommended an article written by Tisdale et al (Tisdale JE, et al. Circ Cardiovasc Qual Outcomes. 2013;6(4):479-487) that covers risk-scoring tools.

Patients who do not respond to traditional antidepressants may need to switch to a different antidepressant, or they may need an additional medication. She said that it appears that adding a second drug may provide a faster response than switching to a different drug, but it does increase the potential for adverse effects and drug interactions.

Numerous drugs have been identified for adjunctive medication strategies. These include the following FDA-approved drugs: aripiprazole, brexpiprazole, quetiapine XR, olanzapine/fluoxetine, and intranasal esketamine. Prescribers also use other drugs off label for this purpose.

Dr. Maroney walked participants through the process of selecting a second-generation antipsychotic. She indicated that patients who lack motivation or have anhedonia (the inability to experience pleasure) are different from those who have anxiety or insomnia and may require different approaches.

Pharmacists have many opportunities to help patients who have depression, starting with screening. Numerous depression screening tools are available and easy to administer, even in community pharmacy settings.

Collaborative medication management is essential to ensure patients achieve their treatment goals. Adherence is a particular concern in this patient population because approximately 40% of patients are nonadherent. Sometimes, adverse effects can be the challenge. In addition, pharmacists need to look for drug interactions and minimize risk of discontinuation syndrome by ensuring that patients taper medication slowly over several weeks.