Brittany L. Parmentier, PharmD, MPH, BCPS, BCPP
Michelle L. Blakely, PhD, MEd, NCC
Carolyn O’Donnell, PharmD
This case discusses mental health and suicide and may be a trigger for those who have had someone in their lives attempt or die by suicide. Those individuals are encouraged to prepare emotionally before proceeding.
At the end of this case, students will be able to:
- Identify appropriate screening tools for assessing depression and suicide risk
- Apply the DSM-5 diagnostic criteria for major depressive disorder
- Identify available mental health resources that pharmacists can provide to patients
- Recognize words or phrases that pharmacists may be on alert for in conversations with patients who have depression or are suicidal
- Describe the role that pharmacists can play in the early assessment, intervention, and treatment of mental health disorders in the populations they serve
According to the National Institute of Mental Health (NIMH), approximately 17.3 million or 7.1% of all American adults have experienced at least one major depressive episode in their lifetime with a higher prevalence among adult females compared to males (8.7% vs. 5.3%).1 Depression is the most common mental disorder, and is treatable.2 However, if left untreated, depression can lead to relationship problems, lost work productivity, and personal and/or family suffering, among other effects. Despite the availability of effective treatment options, current depression care is subpar due to a lack of recognition of the condition or underdiagnosis by healthcare professionals.
Depression is often comorbid with other mental health diagnoses, with most chronic medical conditions increasing the risk of depression.3 The overlap of chronic medical conditions with mental health disorders is a significant challenge for healthcare professionals and patients alike. Frequently, depression is the unrecognized and undiagnosed part of the comorbidity because healthcare professionals may not be appropriately trained to recognize and respond to associated symptoms.3 Inadequate recognition, diagnosis, and treatment of depression by healthcare professionals, combined with a stigma toward individuals with depression and poor patient medication adherence, contributes to negative patient outcomes.
Alongside this, suicide is also a major public health concern worldwide. According to the Centers for Disease Control and Prevention (CDC), in 2018, suicide was the tenth leading cause of death overall in the United States, claiming more than 48,000 lives.4 Individuals may seek suicide as a solution to a multitude of issues, including biological, psychological, social, cultural, spiritual, economic, and environmental concerns. Depending on the interactions of these factors, an individual experiencing suicidal thoughts may be discouraged from seeking help. Stigma also contributes to patients’ help seeking behaviors and can often lead to patients not being able to access the care they need.
Healthcare professionals have a responsibility to play a vital role in the identification and management of depression and suicide risk. In fact, the US Preventive Services Task Force (USPSTF) recommends screening for depression with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.5 Depression screenings can be utilized across multiple settings. Since pharmacists are on the front lines of patient care, they are readily available and uniquely positioned to assess risk and implement interventions to support an individual’s safety across the continuum of care. Pharmacists can build long-term relationship with patients and administer self-reported depression and/or suicide screening tools to determine a patient’s current level of risk, as well as connect patients experiencing depression and/or suicidal thoughts with appropriate resources.
CC: “I feel hopeless with all of these new medications I have to take. I don’t have the energy to deal with all of these pills and shots.”
Patient: RJ is a 47-year-old male (72 in, 108 kg) who was recently diagnosed with T2DM and HTN, after seeing a primary care provider for the first time in 10 years.
HPI: RJ is meeting with you today because he is worried about his health, new diagnoses, and the diseases progressing. RJ has never been diagnosed with depression, but he admits to feeling unhappy “for a while now.” He states that his visit with his primary care provider made it worse. Upon asking RJ about his diagnoses, he mentioned that he has not had the desire to leave his home because he feels ashamed and thinks others will judge him for “always letting food get the best of him.” He mentions that he feels like he is always hungry, is sleeping throughout the day, has not been excited about his hobbies, and feels lonely because he is constantly letting others down. After hearing RJ’s story, you ask him to complete a depression screening.
PMH: T2DM (diagnosed one month prior; HTN (diagnosed one month prior); appendectomy (15 years ago)
- Mother decreased (stroke, age 84)
- Father deceased (heart attack, age 78); T2DM
- Brother depression (diagnosed age 50)
- 1-2 alcoholic beverages per night
- Metformin 1000 mg ER tablets once daily
- Liraglutide 1.2 mg subcutaneously once daily
- Simvastatin 20 mg tablet once daily at bedtime
- Amlodipine 5 mg tablet once daily
- Lisinopril 10 mg tablet once daily
- BP 131/80 mmHg
- HR 80 bpm
- RR 16/min
- HgbA1c 8.4%
- Total cholesterol 212 mg/dL
- HDL 45 mg/dL
- Triglycerides 150 mg/dL
- LDL 119 mg/dL
Additional context: The patient does not have prescription medication insurance.
1. What is the DSM-5 diagnostic criteria for a major depressive episode?
2. What are some words or phrases that you might look out for in your conversation with RJ that he might use to describe these symptoms?
3. You decide to complete a depression screening tool during RJ’s visit. What tools are available for depression that might be useful?
4. Once a patient is screened for depression, what are the appropriate next steps?
5. RJ answers affirmatively to the question about suicide in the depression screening tool, indicating that he is considering suicide. What screening tools can be used to specifically assess suicide risk?
6. What mental health resources are available to provide to RJ?
7. RJ has expressed worry about his new diagnoses and health. You also note that he is unemployed and does not have prescription insurance coverage. As the ambulatory care pharmacist, you have developed a list of local resources that are available to help patients pay for their medications. What questions could you ask RJ to determine if he needs referral to these resources?
Depression and suicide are significant public health problems in the United States. Healthy People 2030 has 25 objectives related to mental health and mental disorders.6,7 The objectives relevant to this case include: (1) increase the proportion of primary care visits where adolescents and adults are screened for depression, (2) increase the proportion of adults with depression who get treatment, and (3) reduce the suicide rate. The objective to reduce suicide rate is also a leading health indicator, which means that it is a high-priority objective.8 This finding makes addressing these public health objectives even more of a priority in the years to come.
Pharmacists who work in a variety of settings have a unique opportunity to complete mental health screenings and if necessary, make referrals for mental health treatment. A systematic review by Miller and colleagues identified 10 published studies in which pharmacists were involved in screening for depression with a validated tool in the community or outpatient clinic pharmacy setting.9 One of the limitations of currently available studies is that the clinical outcomes of pharmacist-led screening tools have not been studied. Implementation and evaluation of these services would provide an opportunity for pharmacists to expand our role in this area.
Patient Approaches and Opportunities
All pharmacists should have a list of local mental health resources readily available to provide help in emergency situations or to refer patients who need to establish psychiatric care. Pharmacists should be aware of depression and suicide screening tools, including when and how to use them. When talking to patients, listening to the words that patients are using can help determine if the patient may have underlying mental health concerns. Pharmacists should have a strategy in place for managing patients with suicidal ideation with or without a plan. Patients who are not actively suicidal but have a positive depression screening should be referred to a provider for further evaluation and subsequent treatment, if appropriate. Patients with comorbidities that increase their risk for depression should be screened periodically. It is important to develop an open and trusting relationship with the patient to prevent stigmatization and allow the patient to be comfortable to discuss their mental health. Pharmacists can also serve as a great resource for education regarding antidepressant therapy, including efficacy timelines, potential adverse effects, and the potential for multiple medication trials.
In addition to screening and referring to services, pharmacists play a vital role in educating patients about their mental health medications, including antidepressants. Discussing the delayed onset of action of antidepressants and that they may need a trial of multiple antidepressants to find the right one provides the patient with realistic expectations about their medications. In addition, educating patients that depression is a treatable chemical disorder can provide hope for patients who may initially feel discouraged about their antidepressant therapy. Encouraging patients to stick with their antidepressant through transient side effects and trial and error can help patients to stay focused on finding the best treatment for them.
Related chapters of interest:
- Communicating health information: hidden barriers and practical approaches
- Laying the foundation for public health priorities: Healthy People 2030
- Sweetening the deal: improving health outcomes for patients with diabetes mellitus
- Digging deeper: improving health communication with patients
- Tools/instruments (please check permissions prior to use):
- Center for Epidemiologic Studies Depression Scale (CES-D).
- Zung Self-Rating Depression Scale (ZDS).
- Quick Inventory of Depressive Symptomatology (QIDS SR-16).
- Patient Health Questionnaire -9 (PHQ-9).
- Hamilton Depression Rating Scale (HAM-D-21).
- Montgomery-Åsberg Depression Rating Scale (MADRS).
- APA Clinical Practice Guideline for the Treatment of Depression.
- Ask Suicide-Screening Questions Toolkit.
- Columbia Suicide Severity Rating Scale (C-SSRS).
- Substance Abuse and Mental Health Services Administration (SAMHSA) Suicide Assessment Pocket Card.
- Safety Plan Worksheet.
- Ed-SAFE Secondary Screener (ESS-6).
- Patient Safety Screener (PSS-3).
- Suicide Prevention Resource Center. The patient safety screener: a brief tool to detect suicide risk.
- National Institute of Mental Health (NIMH). Major depression. February 2019. . Accessed December 26, 2020.
- American Psychological Association. Depression. . Accessed December 26, 2020.
- Steffen A, Nübel J, Jacobi F, et al. Mental and somatic comorbidity of depression: a comprehensive cross-sectional analysis of 202 diagnosis groups using German nationwide ambulatory claims data. BMC Psychiatry 2020;20(1):142.
- National Institute of Mental Health (NIMH). Suicide. September 2020. . Published September 2020. Accessed December 26, 2020.
- US Preventative Services Task Force. USPSTF home page. . Accessed March 16, 2021.
- US Department of Health and Human Services. Office of Disease Prevention and Health Promotion. About Health People 2030. . Accessed January 13, 2021.
- US Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Mental health and mental disorders. . Accessed January 13, 2021.
- US Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Leading health indicators. . Accessed January 13, 2021.
- Miller P, Newby D, Walkom E, Schneider J, Li SC. Depression screening in adults by pharmacists in the community: a systematic review. Int J Pharm Pract 2020;28(5):428-40.