Due to the number of patients affected, adolescent mental health issues may be problematic for community pharmacists.
Due to the number of patients affected, adolescent mental health issues may be problematic for community pharmacists. For example, in a cross-sectional study of 10,123 adolescents aged 13 to 18 years in the United States, the incidence of depression or dysthymia was 12%. Higher rates of these mental health issues occurred in an age-dependent manner, and male adolescents were more likely than females to have these conditions.1 Moreover, the annualized crude suicide rate between 2008 and 2010 was 5.22 per 100,000 adolescents aged 13 to 18 years (Figure).2
Greater concerns about adolescent mental health issues arise when discussing how frequently clinicians treat affected adolescents. A study that examined data on 12-month rates of service for adolescent mental health issues found that of those who were given any diagnosis, 45% received treatment, with only about 10% of services received in a primary care setting—even though primary care practitioners may be competent to care for adolescents with mental health issues.3 Richardson et al validated this point through their randomized trial conducted in 9 primary care clinics. Compared with a control group, adolescents with depression who received collaborative care interventions achieved greater reductions on the Child Depression Rating Scale over a 12-month period and improvement in depression symptoms.4
To date, no randomized studies have been conducted to evaluate the impact of integrating adolescent mental health services into community pharmacy practice in the United States. This article reviews the potential barriers and solutions that pharmacists have identified, screening tools for certain mental health conditions in pediatric patients, and recommendations for pharmacologic treatment and patient counseling.
Barriers to Delivering Adolescent Mental Health Services
Community pharmacists have identified barriers as to why they may not properly deliver mental health services to patients. In a survey of 69 community pharmacists in Belgium, regarding delivery of services for depression at their practices, the top 3 barriers to providing care were identified to be lack of mental health education, lack of individual patient time, and limited knowledge of patient history.5 Another survey of 20 Australian community pharmacists identified several barriers to implementing depression screening at their practices, including inadequate compensation for their services, lack of privacy, and a stigma of shame or embarrassment among patients and caregivers (ie, regarding seeking or receiving treatment).6 However, a systematic review in the United Kingdom found that mental-health related stigma has a small to moderate negative effect on seeking help.7
Solutions to Delivering Adolescent Mental Health Services
To overcome the barriers discussed here, community pharmacists have identified solutions to incorporating and delivering mental health services for adolescent patients in their practices. Community pharmacists desire to participate on a multidisciplinary team when they deliver mental health services to adolescent patients and specifically request that general practitioners and caregivers participate.5 The results of a recent Australian study indicated that patients felt their pharmacy was a safe place to discuss mental health issues, as they had developed a trusting relationship with their pharmacist. This shows how important it is for pharmacists to develop a rapport with their patients as they provide mental health services.8 In addition, mental health screening tools may help pharmacists and clinicians properly manage pediatric patients (Table).
In 2015, about 3 million adolescents aged 12 to 17 years (12.5% of the population) had experienced a major depressive episode within the past year. Of those adolescents, 70.7% experienced a major depressive episode with severe impairment, which hindered their ability to do chores at home, excel in academics, and maintain healthy social relationships.9 For clinicians to properly diagnose depression and manage affected adolescents, several organizations have provided their recommendations for screening depression in adolescents. The American Academy of Child and Adolescent Physicians (AACAP) guidelines recommend thorough evaluation if child or adolescent patients show significant signs of depression in screening to determine depressive or other comorbid psychiatric and medical disorders (AACAP Minimal Standard).10 The US Preventive Services Task Force (USPSTF) recommends screening adolescents aged 12 to 18 years for major depressive disorder and ensuring adequate systems are in place for proper diagnosis, treatment, and follow-up (USPSTF Grade B).11 However, the USPSTF has found insufficient evidence to support screening of adolescents for suicide risk.12 Screening tools for detecting pediatric depression include the Beck Depression Inventory. The various screening tools differ in terms of their ages for use, numbers of items, time to complete, sensitivity, and specificity (Table).13-16
Attention-Deficit/Hyperactivity Disorder Screening
The percentage of children given a diagnosis of attention-deficit/hyperactivity disorder (ADHD) increased from 6.9% from 1998 to 2000 to 9% from 2007 to 2009.17 The current evidence lacks support of universal screening in pediatric patients with ADHD, but caregivers and teachers can complete screening tools to aid clinicians in evaluating ADHD symptoms in adolescent patients.18,19 For example, the Conners Rating Scales-Revised tool requires caregivers and teachers to complete a 28-item questionnaire that addresses oppositional problems, cognitive problems, and hyperactivity, and includes an ADHD index; adolescents can fill out the Conners-Wells Adolescent Self-Report Scale.20
The scale that clinicians most commonly use to evaluate ADHD symptoms in pediatric patients is the Vanderbilt ADHD Rating Scale (VARS), which teachers and caregivers can complete.21 Both versions of the VARS assess symptoms and academic performance impairment; the caregiver version also assesses perceptions of school performance and social skills.22 The ADHD Rating Scale-5, recently updated from criteria established by the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders, includes screening forms for teachers and caregivers to complete, separate versions for home and school rating scales, and functional impairment items linked to inattention and hyperactive-impulsive symptoms.23
Effect of Medication Adherence on Adolescent Mental Health
Pharmacologic therapy is a mainstay for depression, ADHD, and other mental health conditions in children and adolescents; however, medication nonadherence continues to hinder therapeutic outcomes. Of the pediatric patients who receive medication(s) for chronic therapy, including mental health conditions, 50% to 88% are nonadherent to their prescribed regimens.24-26 If their nonadherence continues, they are likely to remain nonadherent as adults. One study identified that about 50% of adult patients prematurely discontinue antidepressant therapy due to patient- and clinician-related reasons.27 Therefore, to possibly improve medication adherence in adolescent patients with mental health issues, pharmacists should address medication perceptions among this group of patients.
Positive outcomes have been reported as pharmacists address medication adherence. One study found that long-term adherence to stimulant medications was associated with greater improvement in teacher-reported symptoms after 5 years.28 As pharmacists work together with other health care professionals, caregivers, and adolescents to provide mental health services, adolescents are more likely to be adherent to therapy into adulthood, possibly reducing emergency department visits, hospitalizations, and unnecessary health care spending, as well as improving their quality of life.29,30
Brian J. Catton, PharmD, graduated from the Bernard J. Dunn School of Pharmacy at Shenandoah University in Winchester, Virginia, in 2010. He received the Distinguished Young Pharmacist Award from the New Jersey Pharmacists Association in 2014. He currently is a Pharmacist Communicator at Ashfield Healthcare in Ivyland, Pennsylvania. His areas of interest include pediatrics, immunizations, drug-therapy management, social media, patient counseling, and immuno-oncology.