The Irish have a hard time opening up when they’re feeling down. Depression is still a difficult subject for people to talk about in this country, with one in five (20%) admitting in a national survey that they are embarrassed to discuss depression with others, including healthcare professionals.

Depression is a common and serious illness but fortunately the majority of sufferers, even those with the most severe depression, can get better with treatment. Medications, psychotherapies, lifestyle modifications and other methods can effectively treat people with depression. However, far too many people with a depressive illness will never ask for help. 

A recent nationwide campaign is encouraging people who are struggling with depression to seek advice and support from their local pharmacists. The Lean on Me Pharmacy initiative – a follow-on from the Lean On Me depression awareness campaign – aims to reinforce the pharmacist as an important point of contact and support for people with depression. 

Research has confirmed that pharmacists can play an integral and multifarious role in tackling depression, such as identifying those suffering from a depressive illness, enhancing management strategies by providing patient education, assisting in monitoring treatment effectiveness, improving medication adherence and identifying and managing side-effects. 

While most people are comfortable talking to pharmacists about physical conditions like colds, headaches and minor injuries, they may not necessarily associate pharmacists as source of support for depression. Only 35% of people surveyed in Ireland are aware that a pharmacist is able to advise about depression. The Lean on Me Pharmacy campaign is the first step in strengthening this association and making the Irish public aware of the availability and accessibility of pharmacists as health experts who can offer help to people with depression.

Qualified to care

“Community pharmacists are healthcare professionals who are just as qualified to support people living with depression as they are to advise on other chronic physical ailments like diabetes and high blood pressure. While research shows a significant number of people do feel they can approach their pharmacist about depression, we want to reach out to everyone who may have depression, which is why the Irish Pharmacy Union (IPU) has joined the Lean on Me campaign,” said Rory O’Donnell, IPU President, at the launch of the campaign in May.

About 500 pharmacists participated in certified training courses around the country, under the Lean on Me Pharmacy initiative. These refresher courses offered pharmacists an overview of medical depression and the benefits of optimising antidepressant therapy, as well as new engagement tools and how they can offer support for customers with depression.

“Many people still have difficulty talking about their depression,” said Ultan Molloy, proprietor pharmacist at HealthWest Community Pharmacy in Ballindine, Co Mayo, who took part in the training course. “Figures from a national survey published at the time of the Lean on Me Pharmacy launch were quite astounding to me. Four in 10 people said they would not want to know if a friend or loved one was suffering from depression, and a similar number said they would be embarrassed to talk about their depression with others, including with a health professional. That’s very unfortunate. I hope community pharmacists can help make a difference and change that situation,” he told Modern Medicine.

Positive relationships

Ultan’s pharmacy in Mayo has earned a widespread reputation for its friendly approach to customer service and last year was a finalist in the national JCI friendly business awards. 

“We’re a community pharmacy in a rural area so our customer care is as much about having the chat as it is about dispensing medicines. Given the stigma that still exists around mental health, if we want people to open up about their depression, trust is key. They need to trust the person they’re talking to and they need to see that you are a competent professional, someone who can in fact guide them,” he said.

“I believe pharmacists in general have very engaging and positive relationships with their patrons. We’re not just a drug delivery system. We’re health professionals and we’re available for long hours at the counter or in our consultation room to have a chat to someone if they need that extra time.

“The more we help people to trust and open up to us, the more we can engage them and ensure that they are getting the most appropriate treatment for their symptoms. It may start off with a bit of a chat, then gradually they can open up and tell us what is going on with them. When they are in that zone of feeling comfortable and feeling cared for, they are more likely to confide in you.”

International primary care surveys show that only 50% of people with depression seek help: of those who do, only half had depression diagnosed and adequately treated. By expanding community pharmacist involvement in the identification of patients with depression and in their care, health authorities hope to maximise the impact health professionals make on the lives of those who suffer from the condition.

For patients with a diagnosis of depression, community pharmacists can help improve outcomes at every step of the patients’ treatment by providing patients with realistic expectations, recognising drug interactions, managing side-effects and recommending alternate treatment options. The importance of not stopping medication too soon is a message that can also be reinforced by a community pharmacist. Non-compliance with antidepressant medication is a serious issue. Patients with depression are three times more likely not to take their medications as compared to the general population.

“The pharmacist is a critical point of contact, really. With the majority of antidepressants that are most popularly prescribed, the patient will only see an initial effect after two to three weeks, and for that interim period the patient may be a little up and down. So it’s important that they have positive expectations and a belief in the benefits and efficacy of the treatment, and that they don’t abandon their medication before it has been given the opportunity to work,” advised Ultan.

The Lean on Me Pharmacy survey confirmed that the majority (65%) of people would accept advice from a pharmacist if advised to continue on antidepressants, which underscores the relationship of trust that already exists between the pharmacist and patient. Community pharmacists are also an important point of information and practical advice, Ultan emphasised. “We can provide educational material around the nature of their illness and encourage people to talk things over with their friends or a self-help group. Some dietary supplements have also been shown to have benefit, such as omega-3 and vitamin B complex, which can be good in terms of reducing stress and has been shown to improve mental functioning.

“A healthy balanced diet and sufficient exercise is also vital; addressing some relatively minor lifestyle changes an have a significant impact on how one functions, day to day.

“In my mind, drug therapy is great and it has a very important role but whatever the issue was at the start of drug therapy, if someone wants to address their mental health issues then they will need to strive to address any underlying issues when they are feeling up to it,” Ultan suggested. “One can externalise and say ‘the medicine will fix me’, but I would be encouraging people to look at how they can address the problem themselves as much possible through lifestyle modification and counselling – basically empowering them to put strategies in place and giving them the opportunity, while they’re on the drug therapy, to tackle the root causes of their depression. There are, of course, unfortunately some cases where patients will need to stay on medication over a long term, and we’re here of course to make ourselves available and support them. Patients can touch base with us and with their GP periodically until we get to an appropriate effective dose.” 

Recognising the symptoms

Community pharmacists also play an important role in recognising cases of undiagnosed depression. Ultan remarked that, in his experience, it is quite common for a person to not even realise that he or she is suffering from depression.

“It has happened countless times; someone will come in looking for something to help them with a minor complaint, such as sleeplessness or they have stomach problems. They may not be aware that the cause is actually that they may be depressed. With experience and engagement you can prompt people to bring the real issue into their consciousness, which can help in terms of acknowledging that there is a problem. Simple things, such as asking ‘do you feel like you’re under pressure at the moment?’ For example, someone comes in with sleeping problems and during our chat I might tease out why they’re not sleeping and maybe identify other symptoms of depression. We can then talk these things through with our patients and refer them on to their GP for diagnosis and prescribed treatment, where appropriate.

“For some people, admitting that they’re feeling depressed can be very difficult, people may see it as a weakness or something they have done wrong or done to themselves. Whereas, the message we need to be getting across is if you have a chest infection you get an antibiotic, if your mental health is off kilter then you get that sorted out as well, it’s just as important, if not more important,” he stressed.

“The main message for pharmacists is that we need to get out from behind the counter and start engaging with patients. We’re not a drug delivery service, we’re healthcare professionals. It’s up to members of the profession to start connecting with customers in a real way, get to know them and see how you can help them, and give them that added value.”