Discussion
panic disorder, insomnia, depressed, unipolar depression, depressive symptoms, depression
RECURRENCE, DISEASE, DISORDERS, SECONDARY, REGRESSION
This study suggested the possibility that community pharmacists can help improve the medication adherence of patients with unipolar depression by providing CBT-based medication support. This possibility is probably associated with intervention-induced changes in the patients’ perceptions of medication and health care professionals. This parallel-group study to evaluate the impact of CBT-based medication support on antidepressant adherence was the first of its kind in Japan. The intervention-group patients of our study showed improvements in clinical symptoms, and this positive finding contradicted the results of the systematic meta-analysis that reviewed the effects of pharmacist intervention on antidepressant adherence and symptomatology [Given that CBT-based counseling support can improve medication adherence and symptoms, this approach will provide better healthcare opportunities than information-focused patient education. One of the major challenges for CBT-based medication support is to elicit unspoken (and often biased) assumptions and thoughts from the patients during the contact. Building trust, therefore, is the foundation for the community pharmacist to provide CBT-based medication support to their patients. The intervention-group patients also exhibited increased patient satisfaction. Moreover, the intervention-group pharmacists demonstrated an increase in the self-confidence in interacting with patients with depression. Intervention-group pharmacists commented that their patient assignment helped them build trusting relationships because it allowed them to have a stronger commitment to their study patients. Specifically, the study setting enabled them to gather information on their patients’ background, medical history, and other personal matters. Effective interventions based on these pieces of information contributed to the patients’ satisfaction and the pharmacists’ sense of competence.Several methodological limitations of this study must be pointed out. First, this was not a randomized trial, although the distributions of the demographic and baseline characteristics of the study patients were not significantly biased. The proportion of patients with employment was slightly higher in the intervention group. This probably reflected the differences in the geographic location, with the intervention-group pharmacies being placed in a more urban area than their counterparts. Second, the sample size of this study was small. This warranted a larger study in the future. Third, the primary and secondary endpoints were subjective. However, the instruments used in this study have been thoroughly tested for validity and reliability, and are commonly used in research. Fourth, patient selection bias may have occurred. Fifth, this study included both newly and previously diagnosed patients. As a result, the study patients had varying lengths of disease duration. However, our multiple regression analysis showed a poor correlation between the post-baseline DAI-10 score change and disease duration (Supplemental Table 1), and these results suggested the positive effects of the CBT-based medication support were independent of the time from diagnosis. Patients with depression tend to have negatively biased thinking styles regardless of the duration of disease. CBT can help patients learn effective self-help skills, thereby contributing to preventing the recurrence of depression. Sixth, some control group pharmacists attended the training. The control group was asked not to use CBT-A during the intervention period and to treat patients as usual, but it cannot be denied that this may have been weakened the intervention effect of this study. This study did not collect data on the relapse or recurrence of depressive symptoms. Seventh, the intervention group had telephone follow-up as needed, which may have increased patient contact. It is undeniable that this may have affected medication adherence and patient satisfaction. However, telephone follow-up of patients in intervention trials has been conducted in previous studies [Despite the above limitations, this interventional study demonstrated that CBT-based interventions by community pharmacists improved the medication adherence of patients with depression. This also suggests that it might be possible to shorten the duration of treatment for depressed patients and thus reduce health care costs. We hope that similar initiatives will be pursued in pharmacies in the future for patients with panic disorder, insomnia, addiction, and other disorders.We believe that it would be beneficial to provide basic education on CBT to pharmacy students at universities so that medication support based on CBT can be practiced more widely in the community. It would be also desirable to establish an organization, led by a pharmacist association, to support pharmacists in clinical settings to continue learning about CBT and to monitor the adequacy of the support provided.