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Community pharmacy services to optimise the use of medications for mental illness: a systematic review

Community pharmacy services to optimise the use of medications for mental illness: a systematic... The objective of this systematic review was to evaluate the impact of pharmacist delivered community-based services to optimise the use of medications for mental illness. Twenty-two controlled (randomised and non-randomised) studies of pharmacists' interventions in community and residential aged care settings identified in international scientific literature were included for review. Papers were assessed for study design, service recipient, country of origin, intervention type, number of participating pharmacists, methodological quality and outcome measurement. Three studies showed that pharmacists' medication counselling and treatment monitoring can improve adherence to antidepressant medications among those commencing treatment when calculated using an intention-to-treat analysis. Four trials demonstrated that pharmacist conducted medication reviews may reduce the number of potentially inappropriate medications prescribed to those at high risk of medication misadventure. The results of this review provide some evidence that pharmacists can contribute to optimising the use of medications for mental illness in the community setting. However, more well designed studies are needed to assess the impact of pharmacists as members of community mental health teams and as providers of comprehensive medicines information to people with schizophrenia and bipolar disorder Introduction tioners in Australia [2]. Although community care offers Mental and behavioural disorders are estimated to many advantages over institutional care, community care account for 12% of the global burden of disease [1]. More can place extra demands on family, friends and primary than 450 million people worldwide suffer from a diagnos- health practitioners [3]. Health professionals have identi- able mental illness, and four of the six leading causes of fied people with mental illness as among their most chal- years lived with disability are due to neuropsychiatric dis- lenging patients to manage [4]. Improving the quality and orders [1]. Much of the burden of mental illness is man- accessibility of community care for people with mental ill- aged in the community setting. In 2003–04 mental health nesses is an aim outlined in the parliamentary report Men- related medications accounted for 10.9% (17.8 million) tal Health Services in New South Wales [5]. of all medications prescribed by general medical practi- Page 1 of 11 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:29 http://www.anzhealthpolicy.com/content/2/1/29 Search terms Databases pharmacy/pharmacists/pharmaceutical Medline (1966-April 2005) services/pharmaceutical care/ Embase (1994-April 2005) mental disorders/mentally ill persons/ PsychInfo (1985-April 2005) depression/schizophrenia/anxiety Cinahl (1982-April 2005) /psychotic disorders/antidepressive International Pharmaceutical Abstracts agents/psychotropic drugs/ (1970-April 2005) benzodiazepines/antipsychotic agents Cochrane Controlled Trials Register (2nd quarter 2005) ~ 4000 abstracts Exclusion criteria • Not published in English  No service provided by pharmacists  Inpatient/hospital acute care setting 59 papers Exclusion criteria  No parallel control group 22 papers Assessment criteria  Study design  Recipient of service  Country  Intervention type  Number of pharmacists  Methodological quality  Outcome measurement Literature search strate Figure 1 gy and review procedure Literature search strategy and review procedure. Page 2 of 11 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:29 http://www.anzhealthpolicy.com/content/2/1/29 nd The appropriate use of medications is central to the effec- and the Cochrane Controlled Trials Register (2 quarter tive management of mental illnesses, however, there is 2005) were searched using text words and MeSH headings evidence that psychotropic medications are often used including: pharmacy, pharmacists, pharmaceutical care, phar- inappropriately [6,7]. Elderly people are especially sensi- maceutical services, mental disorders, mentally ill persons, tive to the effects of psychotropic medications, and may depression, schizophrenia, psychotic disorders, antidepressive be susceptible to adverse reactions including cardiac tox- agents, psychotropic drugs, benzodiazepines, anxiety and antip- icity, confusion and unwanted sedation [8]. Psychosocial sychotic agents. Reference lists of retrieved articles were problems, the emergence of side effects, and the delayed checked for additional studies not identified in the origi- onset of action of anti-depressant medications, may be nal database search. If the abstract clearly indicated that contributing factors in high rates of medication non- the study did not relate to pharmaceutical services pro- adherence [9,10]. Medical co-morbidity is also common, vided by pharmacists to optimise the use of medications and polypharmacy increases the risk of drug-drug interac- for mental illness, or if the study was conducted in an tions and medication misadventure [11]. acute inpatient or hospital setting, then the study was excluded at this stage. The World Health Organization (WHO) has recognised including pharmacists as active members of the health Inclusion criteria and review procedure care team as one approach to improving psychotropic Studies published in English, with a parallel control group medication use [6]. The National Strategy for the Quality (randomised and non-randomised) that reported the pro- Use of Medicines in Australia highlights the importance of vision of services by pharmacists in community and resi- a multidisciplinary approach to improving medication dential aged care settings were considered. This included use [12]. The development of new roles for pharmacists trials specifically conducted for individuals with a mental has expanded the opportunities for pharmacists to pro- illness, or that reported outcomes in terms of changes to vide community-based services to users of psychotropic mental health symptoms, and studies of medication medications. The Third Community Pharmacy Agree- reviews and education initiatives to optimise the use of ment, signed between the Australian Government and medications commonly prescribed for mental illness. Pharmacy Guild of Australia in 2000, provided remuner- Papers that reported pharmacists' activities as part of ation for pharmacists in Australia to conduct medication multidisciplinary teams were included where a pharma- management reviews in the community setting (referred cist or pharmacists provided a service specifically related to as 'Home Medicines Review') and to provide consumer to optimising the use of medications for mental illness. medicine information (CMI) [13]. Residential medication Studies of pharmacists' interventions in residential aged management reviews, initially funded through the Second care facilities were included, because community pharma- Community Pharmacy Agreement in 1995, are available cists frequently provide services to residential aged care to all permanent residents of accredited aged care facilities facilities, but studies evaluating pharmacists' services in in Australia [14]. A systematic review of the role of phar- hospital inpatient or acute care settings were excluded. macists in mental health care, published in 2003, con- Studies without control groups, before and after studies, cluded that pharmacists can bring about improvements in descriptive studies, results of postal surveys and qualita- the safe and efficacious use of psychotropic medications tive interviews were excluded, as were studies to optimise [15]. The review included seven studies conducted for medication use that did not involve a service provided by hospital inpatients and nine studies conducted in residen- pharmacists. Each study meeting the criteria outlined tial aged care or outpatient settings. Since that time phar- above was assessed on the basis of study design, service macists and pharmacy practice researchers have recipient, country of origin, intervention type, number of developed additional community pharmacy services in participating pharmacists, methodological quality and speciality areas. This has corresponded with a significant outcome measurement. An overview of the literature increase in the volume of published research on commu- search strategy and review procedure is presented in Fig- nity-based services provided by pharmacists relating to ure 1. mental health. The objective of this systematic review was to specifically evaluate the impact of pharmacist delivered Results community-based services to optimise the use of medica- The literature search identified 59 papers that reported or tions for mental illness. discussed community pharmacy services to optimise the use of medications for mental illness. Twenty-two papers Methods reported the results of studies that met the inclusion crite- Literature search strategy ria for the review. Studies that met the inclusion criteria Medline (1966-April 2005), Embase (1994-April 2005), were approximately equally divided between services pro- PsychInfo (1985-April 2005), Cinahl (1982-April 2005), vided to consumers (n = 10) (Table 1), and services pro- International Pharmaceutical Abstracts (1970-April 2005) vided to other health care professionals (n = 12) (Table 2). Page 3 of 11 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:29 http://www.anzhealthpolicy.com/content/2/1/29 Table 1: Services provided to consumers Reference Country Design Setting Service No. Ph Sample Main outcome Significant outcomes size measures Brook et al, (2003) NL RCT CP PE 19 64 Int 71 Attitudes to AD Improved attitudes Cont Brook et al, (2003) NL RCT CP PE 19 64 Int 71 Depressive symptoms Improvements in Cont depressive symptoms (significance dependent on treatment of missing data) Brook et al, (2005) NL RCT CP PE 19 64 Int 71 AD adherence, Improved adherence Cont depressive symptoms among those that completed pharmacist intervention. Intention to treat analysis no difference. Finley et al, (2002) USA CT HMO PE/TM 2 91 Int 129 AD adherence, resource Improved adherence, Cont utilisation, higher medication depressive symptoms, switch rates, medication switch rates, decline in patient visits patient satisfaction. to primary care providers, improved patient satisfaction Finely et al, (2003) USA RCT HMO PE/TM 2 75 Int 50 AD adherence, resource Improved adherence, Cont utilisation, improved patient depressive symptoms, satisfaction patient satisfaction, medication costs. Capoccia et al, (2004) USA RCT PCM PE/TM 2 41 Int 33 AD adherence, resource Cont utilisation, depressive symptoms, quality of life, patient satisfaction. Adler et al, (2004) USA RCT PCM PE/TM 5 268 Int 265 AD use rates, Improved AD use rate. Cont depressive symptoms. Rosen et al, (1978) USA CT CMH PE/TM 1 30 Int 152 Patient well-being, Intervention patients' Cont patient satisfaction, had higher personal quantity and adjustment scores, cost of service were 'better since provision. coming to clinic' and less likely to need further help. Razali et al, (1995) Malaysia RCT OP PE 1 85 Int 80 Relapses requiring Fewer relapses requiring Cont hospital readmission. hospitalisation in intervention group. Shaw et al, (2000) UK RCT OP PE/CA 1 51 Int 46 Medication knowledge, Cont medication related problems, adherence, hospital readmission. RCT = randomised controlled trial; CT = controlled trial; CP = community pharmacy; HMO = health maintenance organisation; PCM = primary care medical centre; CMH = community mental health centre; OP = outpatients' clinic; NL= The Netherlands; PE = patient education; TM = treatment monitoring; ca = care planning; Ph = pharmacists; Int = intervention group; Cont = control group; AD = antidepressant medication. All but one included study were conducted in developed after interventions or were cohort studies without parallel countries, and 15 of the 22 papers were published in the control groups [38-42]. Six papers reported results of last six years. Thirty-seven papers were excluded from the postal surveys [43-48]. Three papers presented study review for the following reasons. Thirteen papers reported methods only [49-51], and one study was conducted by data from descriptive studies [16-28] and nine papers pharmacy researchers but did not report the outcomes of reported outcomes of qualitative interviews or focus a service provided by pharmacists [52]. groups [29-37]. Five papers reported results of before and Page 4 of 11 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:29 http://www.anzhealthpolicy.com/content/2/1/29 Papers that met the review inclusion criteria reported the responsible for changes in drug attitude, adherence and outcomes of medication counselling by community phar- the symptoms scores observed. macists at the time of dispensing, education and monitor- ing activities conducted at primary care medical centres Services provided at medical centres and health and staff model health maintenance organisations maintenance organisations (HMOs), discharge medication counselling, and medica- Four studies reported patient education and treatment tion monitoring at a community mental health centre. monitoring services for people prescribed antidepressant Pharmacist delivered services provided to other health medications in the United States [56-59]. The patient edu- professionals included medication reviews and outreach cation and treatment monitoring involved the pharma- education activities designed to optimise prescribing. Sev- cists taking a medication history, providing information eral medication review studies reported impacts of phar- about the prescribed antidepressant medications, and macists' interventions in terms of changes in prescribing conducting telephone and face-to-face follow-up. Two of of medications commonly used to treat mental illness the four studies, one controlled [56] and the other ran- and/or changes in mental health symptoms, but were not domised controlled [57], were conducted at a staff model specifically targeted to people with a mental illness. Sev- health maintenance organisation (HMO). Pharmacists' eral small studies of pharmacists' medication review activ- interventions in both studies were associated with signifi- ities specifically conducted for people with a mental cant improvements in adherence to antidepressant medi- illness did not meet the review inclusion criteria cations when calculated at the end of the six-month study [17,18,20,22,41,42]. periods. Medication adherence was calculated by review- ing prescription dispensing data, and reported using an Services provided in community pharmacies intention-to-treat analysis. Both studies also demon- Three papers reported results of community pharmacists' strated that involvement of the pharmacist was associated medication counselling sessions for people commencing with a decrease in the number of visits to other primary non-tricyclic antidepressant therapy in The Netherlands care providers, although statistical significance was only [53-55]. Intervention patients participated in three coun- achieved in one of the studies [56]. The other two studies selling sessions (lasting between 10 and 20 minutes each) were conducted at primary care medical practices. In one and received a take-home video that emphasised the study over 16,000 consecutive patients attending nine importance of medication adherence. The medication practices were screened for depression using a self admin- counselling sessions involved pharmacists informing istered health survey [58]. Patients identified as having patients about the appropriate use of their medication. depression or dysthymia who agreed to participate in the This included providing information about the benefits of study (n = 533) were randomised to intervention or con- taking the medication, informing patients about potential trol groups. Intervention patients were significantly more side-effects, informing patients about the onset of action likely to be taking antidepressants at the six month fol- for antidepressant medications and reinforcing the need low-up. Additionally, patients who were taking their anti- for patients to take their medication on a daily basis. At depressants at the six month follow-up had better three month follow-up the intervention patients had sig- depression symptom scores than those who had discon- nificantly more positive drug attitudes than controls [53], tinued, but the overall symptom scores between interven- and at six months this corresponded with significantly tion and control groups were not significantly different. In greater medication adherence among those patients that the other randomised controlled study, improvements in remained in the study [55]. An intention to treat analysis, antidepressant adherence and depression symptom scores however, showed no significant intervention effect on were similar in both intervention and control groups [59]. medication adherence. Medication adherence was meas- In this study antidepressant adherence was measured by ured using an electronic pill container that recorded the asking patients how many days they took their antidepres- time and frequency that the cover was opened. Analysis of sant medication in the past month. psychological symptoms at the six month follow-up was inconclusive, with apparent improvements in symptom Services provided at community mental health centres and outpatients' clinics scores not replicated using an alternate method of analysis [54]. Randomisation occurred at the patient level, and Three studies investigated the effect of pharmacist deliv- neither pharmacists nor patients were blinded to their ered services to community mental health centres and group allocation. A limitation of this method was that the outpatients' clinics [60-62]. In a controlled trial, patients' same pharmacists provided services to both control and case managed by a pharmacist working at a community intervention patients. As the intervention studied was mental health centre in the United States had significantly multifactorial, it was not clear whether the three face-to- better personal adjustment scores than those receiving face medication counselling sessions conducted by the case management from a nurse, social worker or psychol- pharmacists, or the "take-home" videos, were primarily ogist [60]. They were also significantly less likely to need Page 5 of 11 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:29 http://www.anzhealthpolicy.com/content/2/1/29 help from other providers and rated themselves as more In a randomised controlled study of pharmacist con- healthy. As part of the medication monitoring service pro- ducted domiciliary medication reviews in the United vided, the pharmacist was allowed to adjust medication States there were significant declines in the overall num- doses and dose timing, and prescribe or discontinue med- bers and monthly cost of medications, but no significant ications under supervision. Medication monitoring con- difference in cognitive or affective functioning between ducted by the pharmacist was estimated to cost 40% of the intervention and control groups [64]. This may have equivalent medication monitoring conducted by the been due in part to the relatively short (6 week) follow-up clinic psychiatrists when calculated on a per time basis. period. The authors noted that many patients were unwill- Although the pharmacist performed medication monitor- ing to follow the pharmacist's recommendations to dis- ing for more patients per month than the clinic psychia- continue benzodiazepines and narcotic analgesics. A trists, the pharmacist also spent longer per patient contact. randomised controlled study of a pharmacist-led multi- This offset the overall cost savings of having a pharmacist disciplinary initiative to optimise prescribing in 15 Swed- perform the medication monitoring activities usually per- ish aged care facilities resulted in a significant decline in formed by a psychiatrist. the use of antipsychotics, benzodiazepines and antide- pressants by 19%, 37% and 59% respectively in the inter- In a study of patients discharged home from hospital after vention facilities [65]. The study involved pharmacists admission for relapse of schizophrenia in Malaysia, those participating in multidisciplinary team meetings with identified as having poor medication adherence were allo- nurses, nurses' assistants and physicians at regular inter- cated to receive pharmacist medication counselling or vals throughout the 12-month study period. A follow-up standard care [61]. The importance of medication adher- study of the same intervention and control facilities three ence was also reinforced by the patients' psychiatrists at years later indicated the intervention facilities maintained follow-up visits, although it was not clear whether this significantly higher quality of drug use, with lower pro- applied only to intervention patients or both intervention portions of residents prescribed more than three drugs and control patients. At the 12 month follow-up, patients that could lead to confusion, non-recommended hypnot- who had been exposed to the intervention, and received a ics and combinations of interacting drugs [66]. Neither daily or twice daily medication treatment, had signifi- study reported estimates of cost or clinical outcomes. A cantly fewer relapses that required hospitalisation than cluster randomised controlled study of a multidiscipli- patients in the control group. nary primary care intervention at a HMO in the United States included a quarterly pharmacist medication review A study that evaluated the impact of providing mental to address the potentially inappropriate use of medica- health patients with a pharmacist generated medication tions commonly prescribed for mental illness. The care plan at the time of discharge found that patients with researchers found the intervention had no impact on care plans were less likely to be readmitted to hospital depression scores and the numbers of high risk medica- than those without, however, this result was not statisti- tions prescribed at the 12 week follow-up [67]. cally significant [62]. Information on the medication care plans included lists of discharge medications, a summary Two additional cluster randomised controlled studies of of the patient education that was provided, and the need pharmacists' medication reviews in residential aged care to assess for specific potential adverse reactions. Commu- facilities demonstrated significant reductions in the nity pharmacists who were provided copies of the care number and cost of medications prescribed [68-70]. In plans were also more likely to identify medication related one study 10.2% fewer residents were administered psy- problems for the discharged mental health patients than choactive medications and 21.3% fewer hypnotic medica- those pharmacists who were not provided copies of the tions [68]. The impact of medication reviews on mortality care plans. was measured in both studies, and a significant reduction was noted in one [70]. Despite the significant reduction in Medication review in domiciliary and residential aged care mortality, patients in the intervention facilities experi- settings enced a greater deterioration in cognitive function and Components of medication review services provided by behavioural disturbance than those in the control facili- pharmacists include comprehensive medication history ties. taking, patient home interviews, medication regimen review, and patient education [63]. Medication review Educational visiting to general medical practitioners studies described in the review were conducted for resi- In the Netherlands, pharmacotherapy meetings to opti- dents of aged care facilities or for those individuals living mise prescribing are undertaken as part of routine clinical independently in the community identified to be at high practice by groups of local community pharmacists and risk of medication misadventure. general medical practitioners. A cluster randomised con- trolled trial of inter-professional (pharmacotherapy) Page 6 of 11 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:29 http://www.anzhealthpolicy.com/content/2/1/29 Table 2: Services provided to other health professionals Reference Country Design Setting Service No. Sample Main outcome measures Significant Outcomes Ph size Williams et al, USA RCT GP MR 1 63 Int 77 Physical, cognitive and affective Decrease in number and cost (2004) Cont functioning, health status, of medications number and cost of medications. Schmidt et al, Sweden CRCT RAC MR 15 626 Int Incidence and quality of Increase in psychotropic (1998) 1228 Cont psychotropic medication use. medication use and therapeutic duplication in control group. Decrease in antipsychotic and hypnotic use in intervention group, decrease in AD use in intervention and control groups Quality of medication use Previous Improvements in Schmidt et al, Sweden CRCT RAC MR 15 1549 Total (2000) (three-year follow-up). quality of medication use sustained for specific indicators Coleman et al, USA CRCT HMO MR 1 96 Int 73 Depressive symptoms, physical Decrease in urinary (1999) Cont function, service utilisation, incontinence in intervention number of high risk group at 12 months. No medications, satisfaction, differences between urinary incontinence, falls, cost. intervention and control groups at 24 months Roberts et al, Australia CRCT RAC MR ND 905 Int Medication use, medication Decrease in psycholeptic and (2001) 2325 Cont cost, mortality, morbidity and benzodiazepine drug resource utilisation. administration, decrease medication cost Furniss et al, UK CRCT RAC MR 1 158 Int Prescribing patterns, mortality, Decrease in mortality, (2000) 172 Cont mental state, depressive decrease in number of symptoms, and behavioural prescribed medications, disturbance increase in behavioural disturbance Burns et al, UK CRCT RAC MR 1 158 Int Medication costs. Decrease in medication cost (2000) 177 Cont van Eijk et al, NL CRCT GP ED 37 70 Int 1* Prescribing of highly Decrease in high (2001) 52 Int 2* anticholinergic and less anticholinergic AD use in 68 Cont* anticholinergic AD medications intervention group 2. Increase in less anticholinergic AD use in Intervention group 1 Hartlaub et al, USA CT PPGP ED ND 28 Int 1* Benzodiazepine prescribing (1993) 26 Int 2* pattern 37 Cont * de Burgh et al, Australia RCT GP ED 1 142 Int * Benzodiazepine prescribing Overall decline in (1995) 144 Cont pattern benzodiazepine use. * Differences between intervention and control groups not significant Crotty et al, Australia CRCT RACED 1 381 Int Fall rate, psychotropic Increase in 'as required' (2004) 334 Cont medication use, BP, quality of antipsychotic medication use in life the intervention group Avorn et al, USA CRCT RAC ED 1 431 Int Psychotropic mediation use, Decrease in psychotropic (1992) 392 Cont mental status, memory, medication use, decrease in anxiety, depressive symptoms, inappropriateness of drug use, behaviour, sleep less cognitive decline, increase in depression scores. CT = controlled trial; RCT = randomised controlled trial; CRCT = cluster randomised controlled trial; GP = general practice; RAC = residential aged care; PPGP = prepaid group practice; HMO = health maintenance organisation; USA = United States of America; NL = The Netherlands; MR = medication review; ED = prescribing education initiative; ND = not described in paper; Int = intervention group; Cont = control group; AD = antidepressant medication. † Journal article reported overall number of patients (n = 1549) divided between 16 intervention and 18 control residential aged care facilities. ‡ Pharmacists participated in group discussions with physicians, discussions were led by a medical researcher. * Reported sample size based on number of physicians that received pharmacists' educational intervention. Page 7 of 11 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:29 http://www.anzhealthpolicy.com/content/2/1/29 meetings to discuss prescribing of antidepressant medica- excluded from this review, many studies of community tions resulted in a significant reduction in the prescribing pharmacy services to optimise the use of medications for of highly anticholinergic antidepressants to elderly people mental illness have been descriptive, lacked parallel con- by 40% compared to a control group of practitioners that trol groups or have been qualitative in nature. The con- did not receive the prescribing support [71]. In compari- trolled studies included in this review provide some son, educational visiting (academic detailing), reduced evidence of the potential value of including pharmacists prescribing of highly anticholinergic antidepressants by in mental health care across a range of settings and patient 30%. populations. Four additional studies evaluated the impact of pharma- Studies included in the review utilised a range of randomi- cists' educational visits to general medical practitioners to sation techniques, however, the review did not attempt to optimise the prescribing of benzodiazepines and other characterise the quality of the randomisation beyond psychotropic medications commonly prescribed for men- whether randomisation occurred at the patient, practice or tal illness [72-75]. The two papers that reported health residential aged care facility level. The majority of the professional satisfaction indicated that the educational studies involved less than five pharmacists, and 10 out of visits were acceptable and well received [73,74]. In a con- the 22 papers described interventions where just one trolled trial, two types of pharmacists' educational inter- pharmacist was involved. Studies involving small num- ventions (a one-on-one presentation to prescribers with bers of pharmacists may have good internal consistency, individualised feedback and a group presentation to pre- but the results obtained may not be generalisable to out- scribers about the use of benzodiazepines) did not pro- comes of services provided by the wider pharmacy profes- duce significant changes to the prescribing of sion. In several studies the pharmacists' interventions benzodiazepines at a prepaid group practice in the United were components of multidisciplinary team approaches States when compared to a control group that did not to improving mental health care. The challenge of evalu- receive an educational intervention [72]. An Australian ating complex and multi-factorial interventions, which by cluster randomised controlled study of a pharmacist's their nature depend on the context in which the interven- educational visits to general medical practitioners provid- tion takes place, has been described [76]. ing services to residential care facilities detected no signif- icant differences in the use of psychotropic medications Five studies assessed the impact of pharmacists' provision between intervention and control facilities. The only of medicines information and treatment monitoring for exception was a significant increase in the use of "as people commencing antidepressant therapy. Three of the required" antipsychotic medications in the intervention five studies demonstrated that involvement of the phar- facilities [73]. This differed from results of an earlier clus- macist was associated with a significant improvement in ter randomised controlled study in the United States that medication adherence and/or medication use rates when found that educational visits by a pharmacist were associ- measured using an intention to treat analysis. One further ated with a significant decline in prescribing of potentially study demonstrated significant improvements in medica- inappropriate psychotropic medications in intervention tion adherence among patients who received three phar- facilities [75]. Another Australian study of educational vis- macist counselling sessions; however, this was not its to general medical practitioners, conducted by three significant when measured using an intention to treat physicians and one pharmacist, reported a significant analysis. Given the high rates of antidepressant discontin- reduction in the prescribing of benzodiazepines in both uation during the first three months of treatment, phar- intervention and control groups, but the difference macists have a potentially important role in providing between groups was not significant [74]. The authors medicines information and conducting treatment moni- accounted for this overall reduction by a corresponding toring for those patients at high risk of medication non- decline in the rate of diagnoses of anxiety and insomnia, adherence. No studies of pharmacists' treatment monitor- and the possible awareness of prescribing related issues ing for people commencing antidepressant therapy com- generated by asking general medical practitioners to con- pared monitoring provided by pharmacists to monitoring duct a self-audit of their prescribing. conducted by other health professionals. A separate study of antidepressant treatment monitoring conducted by nurses also demonstrated improved medication adher- Discussion Given the extent of mental illness in the community and ence [77]. in aged care, and the fact people with mental illness fre- quently report concerns about their prescribed medica- Despite people with psychotic disorders having reported tions, services directed toward optimising the use of unmet medicines information needs, relatively few con- medications for mental illness fulfil an important public trolled studies assessed community pharmacy services for health need. As evidenced by the large number of papers users of antipsychotic medications. Other studies have Page 8 of 11 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:29 http://www.anzhealthpolicy.com/content/2/1/29 suggested that service provision by pharmacists may be Conclusion limited by not having access to patients' medical histories The review of the international literature highlights the [46], a lack of specific training to counsel this patient pop- range of pharmaceutical services provided by community ulation [46], and pharmacists' attitudes towards people pharmacists in Australia that are potentially well suited to with mental illness [48]. Further well designed research assisting patients and prescribers optimise the use of med- into community pharmacy services for users of antipsy- ications for mental illness. These data show that medica- chotic medications is needed before conclusions can be tion counselling and treatment monitoring conducted by made about the potential of such services to reduce hospi- pharmacists can improve medication adherence among tal readmission and the cost of health care. people commencing antidepressant therapy. Pharmacist conducted medication reviews and resulting recommen- Pharmacist conducted medication management reviews dations to optimise medication regimens may reduce the appear a valuable strategy to identify potential medication numbers of potentially inappropriate medications for related problems among people taking medications for a mental illness prescribed to elderly people. This review of mental illness. The included studies demonstrated that the available published evidence supports the continued such reviews can reduce the numbers of potentially inap- expansion of pharmaceutical service delivery to people propriate psychotropic medications used for mental ill- with mental illness, but identified the need for further ness prescribed to elderly people in residential aged care well-designed research in specific areas. Future studies are settings. Only one study made the link between a reduc- needed to assess the cost-effectiveness and clinical impli- tion in psychotropic medication use and improved adher- cations of pharmacists working as members of multidisci- ence to national prescribing guidelines [66]. The value of plinary community mental health teams, and as providers pharmacist conducted medication reviews for people with of pharmaceutical services to people with psychotic disor- mental illness may not be limited to optimising the use of ders. mental health medications. Physical health care for peo- ple with mental illnesses is often less than optimal, and Authors' contributions pharmacist conducted medication reviews may be a com- SB conducted the literature search and wrote the manu- prehensive strategy to improve medication use for both script. AJM assisted in the literature search and in the writ- mental and physical illnesses. The tendency among health ing of the manuscript. PA proof read drafts of the professionals to focus solely on the management of the manuscript. PW and TFC participated in the conceptuali- mental illness among people with both mental and phys- sation of the review and assisted in the writing of the man- ical illnesses has been described in the literature [78]. uscript. Educational visiting has been shown to modify prescrib- Acknowledgements This research was funded by the Australian Government Department of ing behaviour [79]. The reviewed studies reported phar- Health and Ageing as part of the Third Community Pharmacy Agreement. macists' interventions that were well received by The authors thank Dr Julija Filipovska for her assistance in compiling the prescribers, but produced differing results as to whether manuscript. such visits were associated with changes in prescribing behaviour. This may have been because efforts to reduce References prescribing of potentially inappropriate medications were 1. Investing in Mental Health. Geneva, The World Health Organi- not accompanied by information about alternate treat- zation; 2003. 2. Mental health services in Australia 2002-03. Canberra, Austral- ments, or because patients were reluctant to discontinue ian Institute of Health and Welfare; 2005. taking benzodiazepine medications. In the Dutch study 3. Meadows GN: Overcoming barriers to reintegration of patients with schizophrenia: developing a best-practice that did produce a significant impact on prescribing pat- model for discharge from specialist care. Medical Journal of Aus- terns, information about the problems associated with tralia 2003, 178:S53-S56. prescribing highly anticholinergic antidepressants was 4. Chang E, Daly J, Bell P, Brown T, Allan J, Hancock K: A continuing educational initiative to develop nurses' mental health accompanied by information about prescribing more knowledge and skills in rural and remote areas. Nursing Educa- appropriate antidepressant medications [71]. Addition- tion Today 2002, 22:542-551. ally, pharmacists' initiatives to improve prescribing may 5. Select Parliamentary Committee on Mental Health: Mental health services in New South Wales: final report. Select Parliamentary be most effective when both the pharmacists and general Committee on Mental Health; 2002. medical practitioners have an opportunity to build rap- 6. Improving access and use of psychotropic medicines. Geneva, World Health Organization; 2004. port. The practitioners involved in the Dutch study were 7. Mort JR, Aparasu RR: Prescribing of psychotropics in the eld- those routinely involved in providing care to the patient erly: Why is it so often inappropriate? CNS Drugs 2002, populations discussed. Data presented on prescribing at 16:99-109. 8. Drug use in the elderly. Prescribing practice review. Sydney, these meetings were relevant and specific to the local area National Prescribing Service Ltd; 2004. in which the meetings took place. 9. 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Garfield S, Smith F, Francis SA: From black clouds to lighter grey: 11. Lambert TJR, Velakoulis D, Pantelis C: Medical comorbidity in how pharmacists can help in depression. Pharmaceutical Journal schizophrenia. Medical Journal of Australia 2003, 178:S67-S70. 2004, 272:576-577. 12. National Strategy for the Quality Use of Medicines. Com- 36. Garfield S, Smith FJ, Francis SA: Pharmacists' roles in the treat- monwealth of Australia; 2002. ment of depression in primary care [abstract]. Pharmaceutical 13. Harvey KJ: The pharmaceutical benefits scheme 2003-2004. Journal 2000, 265:R26. Australia and New Zealand Health Policy 2005, 2:2. 37. Garfield S, Smith FJ, Francis SA: Roles for pharmacists in the 14. Residential medication management review [http:// treatment of depression in primary care [abstract]. Interna- www.health.gov.au/internet/wcms/publishing.nsf/Content/health-epc- tional Journal of Pharmacy Practice 2002, 10:R59. dmmrqa.htm] 38. 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Rees L, Maslen CL, Clarke LE, Redfern PH: Management of 44. Tanskanen P, Airaksinen M, Tanskanen A, Enlund H: Counselling patients with schizophrenia: community pharmacists' inter- patients on psychotropic medication: physicians' opinions on action with patients, carers and health professionals the role of community pharmacists. Pharmacy World and Science [abstract]. Pharmaceutical Journal 1997, 259:R23. 2000, 22:59-61. 22. Ewan MA, Greene RJ: Provision of a community pharmacist- 45. Gardner DM, Murphy AL, Woodman AK, Connelly S: Community run medication advice service at mental health resource pharmacy services for antidepressant users. International Jour- centres. Psychiatric Bulletin 2000, 24:294-297. nal of Pharmacy Practice 2001, 9:217-224. 23. Howard R: Impact of a pharmaceutical care program at a 46. Maslen CL, Rees L, Redfern PH: Role of the community pharma- mental health clinic. Australian Journal of Hospital Pharmacy 1996, cist in the care of patients with chronic schizophrenia in the 26:250-253. community. International Journal of Pharmacy Practice 1996, 24. Stimmel GL: Clinical pharmacy practice in a community men- 4:187-195. tal health center. Journal of the American Pharmaceutical Association 47. Rijcken CAW, Van der Veur H, Knegtering H, De Jong-van den Berg 1975, NS15:400-401, 418. LTW: Schizophrenia care and the Dutch community phar- 25. Bultman DC, Svarstad BL: Effects on pharmacist monitoring on macy: The unmet needs. International Journal of Pharmacy Practice patient satisfaction with antidepressant medication therapy. 2003, 11:97-104. Journal of the American Pharmaceutical Association 2002, 42:36-43. 48. Phokeo V, Sproule B, Raman-Wilms L: Community pharmacists' 26. Schmidt IK, Svarstad BL: Nurse-physician communication and attitudes toward and professional interactions with users of quality of drug use in Swedish nursing homes. Social Science and psychiatric medication. Psychiatric Services 2004, 55:1434-1436. Medicine 2002:1767-1777. 49. Finley PR, Rens HR, Gess S, Louie C: Case management of 27. Schmidt IK, Claesson CB, Westerholm B, Nilsson LG: Physician and depression by clinical pharmacists in a primary care setting. staff assessments of drug interventions and outcomes in Formulary 1999, 34:864-870. Swedish nursing homes. Annals of Pharmacotherapy 1998, 50. Boudreau DM, Capoccia KL, Sullivan SD, Blough DK, Ellsworth AJ, 32:27-31. Clark DL, Katon WJ, Walker EA, Stevens NG: Collaborative care 28. Harris D, Anderson C: Interventions by community pharma- model to improve outcomes in major depression. Annals of cists for older people with mental health problems: are they Pharmacotherapy 2002, 36:585-591. appropriate? [abstract]. International Journal of Pharmacy Practice 51. Bungay KM, Adler DA, Rogers WH, McCoy C, Kaszuba M, Supran S, 2003, 11:R56. Pei Y, Cynn DJ, Wilson IB: Description of a clinical pharmacist 29. Sleath B, Wurst K: Patient receipt of, and preferences for intervention administered to primary care patients with receiving, antidepressant information. International Journal of depression. General Hospital Psychiatry 2004, 26:210-218. Pharmacy Practice 2002, 10:235-241. 52. Smith DH, Christensen DB, Stergachis A, Holmes G: A randomized 30. Sleath B, Wurst K, Lowery T: Drug information sources and controlled trial of a drug use review intervention for sedative antidepressant adherence. Community Mental Health Journal 2003, hypnotic medications. Medical Care 1998, 36:1013-1021. 39:359-368. 53. Brook O, van Hout H, Nieuwenhuyse H, Heerdink E: Impact of 31. MacHaffie S: Health promotion information: Sources and sig- coaching by community pharmacists on drug attitude of nificance for those with serious and persistent mental illness. depressive primary care patients and acceptability to Archives of Psychiatric Nursing 2002, XVI:263-274. patients; a randomized controlled trial. European Neuropsychop- 32. Landers M, Blenkinsopp A, Pollock K, Grime J: Community phar- harmacology 2003, 13:1-9. macists and depression: The pharmacist as intermediary 54. Brook OH, Van Hout HPJ, Nieuwenhuysea H, De Haan M: Effects of between patient and physician. International Journal of Pharmacy coaching by community pharmacists on psychological symp- Practice 2002, 10:253-265. toms of antidepressant users, a randomised controlled trial. 33. Ewan M, Greene R, Anderson C: A qualitative investigation of European Neuropsychopharmacology 2003, 13:347-354. the potential role of the community pharmacist in the care 55. Brook OH, Van Hout HPJ, Stalman W, Nieuwenhuyse H, Bakker B, Heerdink E, De Haan M: A pharmacy based coaching program Page 10 of 11 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:29 http://www.anzhealthpolicy.com/content/2/1/29 to improve adherence to antidepressant treatment among of a program to reduce the use of psychoactive drugs in nurs- primary care patients. Psychiatric Services 2005, 56:487-489. ing homes. New England Journal of Medicine 1992, 327:168-173. 56. Finley PR, Rens HR, Pont JT, Gess SL, Louie C, Bull SA, Bero LA: 76. Campbell M, Fitzpatrick R, Haines A, Kinmonth AL, Sandercock P, Impact of a collaborative pharmacy practice model on the Spiegelhalter D, Tyrer P: Framework for design and evaluation treatment of depression in primary care. American Journal of of complex interventions to improve health. British Medical Health-System Pharmacy 2002, 59:1518-1526. Journal 2000, 321:694-696. 57. Finley PR, Rens HR, Pont JT, Gess SL, Louie C, Bull SA, Lee JY, Bero 77. Aubert RE, Fulop G, Xia F, Thiel M, Maldonato D, Woo C: Evalua- LA: Impact of a collaborative care model on depression in a tion of a depression health management program to primary care setting: a randomized controlled trial. Pharma- improve outcomes in first or recurrent episode depression. cotherapy 2003, 23:1175-1185. American Journal of Managed Care 2003, 9:374-380. 58. Adler DA, Bungay KM, Wilson IB, Pei Y, Supran S, Peckham E, Cynn 78. Hocking B: Reducing mental illness stigma and descrimation - DJ, Rogers WH: The impact of a pharmacist intervention on 6- everybody's business. Medical Journal of Australia 2003, month outcomes in depressed primary care patients. General 178:S47-S48. Hospital Psychiatry 2004, 26:199-209. 79. Thomson O'Brien MA, Oxman AD, Davis DA, Haynes RB, Freeman- 59. Capoccia KL, Boudreau DM, Blough DK, Ellsworth AJ, Clark DR, Ste- tle N, Harvey EL: Educational outreach visits: effects of profes- vens NG, Katon WJ, Sullivan SD: Randomized trial of pharmacist sional practice and health outcomes. Cochrane Database of interventions to improve depression care and outcomes in Systematic Reviews 2005. primary care. American Journal of Health-System Pharmacy 2004, 61:364-372. 60. Rosen CE, Holmes S: Pharmacist's impact on chronic psychiat- ric outpatients in community mental health. American Journal of Hospital Pharmacy 1978, 35:704-708. 61. Razali MS, Yahya H: Compliance with treatment in schizophre- nia: a drug intervention program in a developing country. Acta Psychiatrica Scandinavica 1995, 91:331-335. 62. Shaw H, Mackie CA, Sharkie I: Evaluation of effect of pharmacy discharge planning on medication problems experienced by discharged acute admission mental health patients. Interna- tional Journal of Pharmacy Practice 2000, 8:144-153. 63. Comprehensive medication review. In Professional practice stand- ards Canberra, Pharmaceutical Society of Australia; 2002. 64. Williams ME, Pulliam CC, Hunter R, Johnson TM, Owens JE, Kincaid J, Porter C, Koch G: The short-term effect of interdisciplinary medication review on function and cost in ambulatory eld- erly people. Journal of the American Geriatrics Society 2004, 52:93-98. 65. Schmidt I, Claesson CB, Westerholm B, Nilsson LG, Svarstad BL: The impact of regular multidisciplinary team interventions on psychotropic prescribing in Swedish nursing homes. Journal of the American Geriatrics Society 1998, 46:77-82. 66. Schmidt IK, Fastbom J: Quality of drug use in Swedish nursing homes - A follow up study. Clinical Drug Investigation 2000, 20:433-446. 67. Coleman EA, Grothaus LC, Sandhu N, Wagner EH: Chronic care clinics: a randomized controlled trial of a new model of pri- mary care for frail older adults. Journal of the American Geriatrics Society 1999, 47:775-783. 68. Roberts MS, Stokes JA, King MA, Lynne TA, Purdie DM, Glasziou PP, Wilson DAJ, McCarthy ST, Brooks GE, de Looze FJ, Del Mar CB: Outcomes of a randomized controlled trial of a clinial phar- macy intervention in 52 nursing homes. British Journal of Clinical Pharmacology 2001, 51:257-265. 69. Burns A, Furniss L, Cooke J, Lloyd Craig SK, Scobie S: Pharmacist medication review in nursing homes: a cost analysis. Interna- tional Journal of Geriatric Psychiatry 2000, 2:137-141. 70. Furniss L, Burns A, Craig SKL, Scobie S, Cooke J, Faragher B: Effects of a pharmacist's medication review in nursing homes: Ran- domised controlled trial. British Journal of Psychiatry 2000, 176:563-567. 71. van Eijk MEC, Avorn J, Porsius AJ, de Boer A: Reducing prescribing of highly anticholinergic antidepressants for elderly people: Randomised trial of group versus individual academic detail- Publish with Bio Med Central and every ing. British Medical Journal 2001, 322:654-657. scientist can read your work free of charge 72. Hartlaub PP, Barrett PH, Marine WM, Murphy JR: Evaluation of an intervention to change benzodiazepine-prescribing behavior "BioMed Central will be the most significant development for in a prepaid group practice setting. American Journal of Preventive disseminating the results of biomedical researc h in our lifetime." Medicine 1993, 9:346-352. Sir Paul Nurse, Cancer Research UK 73. Crotty M, Whitehead C, Rowett C, Halbert J, Weller W, Finucane P, Esterman A: An outreach intervention to implement evidence Your research papers will be: based practice in residential care: a randomized controlled available free of charge to the entire biomedical community trial. BMC Health Services Research 2004, 4:6. 74. de Burgh S, Mant A, Mattick RP, Donnelly N, Hall W, Bridges-Webb peer reviewed and published immediately upon acceptance C: A controlled trial of educational visiting to improve ben- cited in PubMed and archived on PubMed Central zodiazepine prescribing in general practice. Australian Journal of Public Health 1995, 19:142-148. yours — you keep the copyright 75. Avorn J, Soumerai SB, Everitt DE, Ross-Degnan D, Beers MH, Sher- BioMedcentral man D, Salem-Schatz SR, Fields D: A randomized controlled trial Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 11 of 11 (page number not for citation purposes) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australia and New Zealand Health Policy Springer Journals

Community pharmacy services to optimise the use of medications for mental illness: a systematic review

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Copyright © 2005 by Bell et al; licensee BioMed Central Ltd.
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Medicine & Public Health; Public Health; Social Policy
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Abstract

The objective of this systematic review was to evaluate the impact of pharmacist delivered community-based services to optimise the use of medications for mental illness. Twenty-two controlled (randomised and non-randomised) studies of pharmacists' interventions in community and residential aged care settings identified in international scientific literature were included for review. Papers were assessed for study design, service recipient, country of origin, intervention type, number of participating pharmacists, methodological quality and outcome measurement. Three studies showed that pharmacists' medication counselling and treatment monitoring can improve adherence to antidepressant medications among those commencing treatment when calculated using an intention-to-treat analysis. Four trials demonstrated that pharmacist conducted medication reviews may reduce the number of potentially inappropriate medications prescribed to those at high risk of medication misadventure. The results of this review provide some evidence that pharmacists can contribute to optimising the use of medications for mental illness in the community setting. However, more well designed studies are needed to assess the impact of pharmacists as members of community mental health teams and as providers of comprehensive medicines information to people with schizophrenia and bipolar disorder Introduction tioners in Australia [2]. Although community care offers Mental and behavioural disorders are estimated to many advantages over institutional care, community care account for 12% of the global burden of disease [1]. More can place extra demands on family, friends and primary than 450 million people worldwide suffer from a diagnos- health practitioners [3]. Health professionals have identi- able mental illness, and four of the six leading causes of fied people with mental illness as among their most chal- years lived with disability are due to neuropsychiatric dis- lenging patients to manage [4]. Improving the quality and orders [1]. Much of the burden of mental illness is man- accessibility of community care for people with mental ill- aged in the community setting. In 2003–04 mental health nesses is an aim outlined in the parliamentary report Men- related medications accounted for 10.9% (17.8 million) tal Health Services in New South Wales [5]. of all medications prescribed by general medical practi- Page 1 of 11 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:29 http://www.anzhealthpolicy.com/content/2/1/29 Search terms Databases pharmacy/pharmacists/pharmaceutical Medline (1966-April 2005) services/pharmaceutical care/ Embase (1994-April 2005) mental disorders/mentally ill persons/ PsychInfo (1985-April 2005) depression/schizophrenia/anxiety Cinahl (1982-April 2005) /psychotic disorders/antidepressive International Pharmaceutical Abstracts agents/psychotropic drugs/ (1970-April 2005) benzodiazepines/antipsychotic agents Cochrane Controlled Trials Register (2nd quarter 2005) ~ 4000 abstracts Exclusion criteria • Not published in English  No service provided by pharmacists  Inpatient/hospital acute care setting 59 papers Exclusion criteria  No parallel control group 22 papers Assessment criteria  Study design  Recipient of service  Country  Intervention type  Number of pharmacists  Methodological quality  Outcome measurement Literature search strate Figure 1 gy and review procedure Literature search strategy and review procedure. Page 2 of 11 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:29 http://www.anzhealthpolicy.com/content/2/1/29 nd The appropriate use of medications is central to the effec- and the Cochrane Controlled Trials Register (2 quarter tive management of mental illnesses, however, there is 2005) were searched using text words and MeSH headings evidence that psychotropic medications are often used including: pharmacy, pharmacists, pharmaceutical care, phar- inappropriately [6,7]. Elderly people are especially sensi- maceutical services, mental disorders, mentally ill persons, tive to the effects of psychotropic medications, and may depression, schizophrenia, psychotic disorders, antidepressive be susceptible to adverse reactions including cardiac tox- agents, psychotropic drugs, benzodiazepines, anxiety and antip- icity, confusion and unwanted sedation [8]. Psychosocial sychotic agents. Reference lists of retrieved articles were problems, the emergence of side effects, and the delayed checked for additional studies not identified in the origi- onset of action of anti-depressant medications, may be nal database search. If the abstract clearly indicated that contributing factors in high rates of medication non- the study did not relate to pharmaceutical services pro- adherence [9,10]. Medical co-morbidity is also common, vided by pharmacists to optimise the use of medications and polypharmacy increases the risk of drug-drug interac- for mental illness, or if the study was conducted in an tions and medication misadventure [11]. acute inpatient or hospital setting, then the study was excluded at this stage. The World Health Organization (WHO) has recognised including pharmacists as active members of the health Inclusion criteria and review procedure care team as one approach to improving psychotropic Studies published in English, with a parallel control group medication use [6]. The National Strategy for the Quality (randomised and non-randomised) that reported the pro- Use of Medicines in Australia highlights the importance of vision of services by pharmacists in community and resi- a multidisciplinary approach to improving medication dential aged care settings were considered. This included use [12]. The development of new roles for pharmacists trials specifically conducted for individuals with a mental has expanded the opportunities for pharmacists to pro- illness, or that reported outcomes in terms of changes to vide community-based services to users of psychotropic mental health symptoms, and studies of medication medications. The Third Community Pharmacy Agree- reviews and education initiatives to optimise the use of ment, signed between the Australian Government and medications commonly prescribed for mental illness. Pharmacy Guild of Australia in 2000, provided remuner- Papers that reported pharmacists' activities as part of ation for pharmacists in Australia to conduct medication multidisciplinary teams were included where a pharma- management reviews in the community setting (referred cist or pharmacists provided a service specifically related to as 'Home Medicines Review') and to provide consumer to optimising the use of medications for mental illness. medicine information (CMI) [13]. Residential medication Studies of pharmacists' interventions in residential aged management reviews, initially funded through the Second care facilities were included, because community pharma- Community Pharmacy Agreement in 1995, are available cists frequently provide services to residential aged care to all permanent residents of accredited aged care facilities facilities, but studies evaluating pharmacists' services in in Australia [14]. A systematic review of the role of phar- hospital inpatient or acute care settings were excluded. macists in mental health care, published in 2003, con- Studies without control groups, before and after studies, cluded that pharmacists can bring about improvements in descriptive studies, results of postal surveys and qualita- the safe and efficacious use of psychotropic medications tive interviews were excluded, as were studies to optimise [15]. The review included seven studies conducted for medication use that did not involve a service provided by hospital inpatients and nine studies conducted in residen- pharmacists. Each study meeting the criteria outlined tial aged care or outpatient settings. Since that time phar- above was assessed on the basis of study design, service macists and pharmacy practice researchers have recipient, country of origin, intervention type, number of developed additional community pharmacy services in participating pharmacists, methodological quality and speciality areas. This has corresponded with a significant outcome measurement. An overview of the literature increase in the volume of published research on commu- search strategy and review procedure is presented in Fig- nity-based services provided by pharmacists relating to ure 1. mental health. The objective of this systematic review was to specifically evaluate the impact of pharmacist delivered Results community-based services to optimise the use of medica- The literature search identified 59 papers that reported or tions for mental illness. discussed community pharmacy services to optimise the use of medications for mental illness. Twenty-two papers Methods reported the results of studies that met the inclusion crite- Literature search strategy ria for the review. Studies that met the inclusion criteria Medline (1966-April 2005), Embase (1994-April 2005), were approximately equally divided between services pro- PsychInfo (1985-April 2005), Cinahl (1982-April 2005), vided to consumers (n = 10) (Table 1), and services pro- International Pharmaceutical Abstracts (1970-April 2005) vided to other health care professionals (n = 12) (Table 2). Page 3 of 11 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:29 http://www.anzhealthpolicy.com/content/2/1/29 Table 1: Services provided to consumers Reference Country Design Setting Service No. Ph Sample Main outcome Significant outcomes size measures Brook et al, (2003) NL RCT CP PE 19 64 Int 71 Attitudes to AD Improved attitudes Cont Brook et al, (2003) NL RCT CP PE 19 64 Int 71 Depressive symptoms Improvements in Cont depressive symptoms (significance dependent on treatment of missing data) Brook et al, (2005) NL RCT CP PE 19 64 Int 71 AD adherence, Improved adherence Cont depressive symptoms among those that completed pharmacist intervention. Intention to treat analysis no difference. Finley et al, (2002) USA CT HMO PE/TM 2 91 Int 129 AD adherence, resource Improved adherence, Cont utilisation, higher medication depressive symptoms, switch rates, medication switch rates, decline in patient visits patient satisfaction. to primary care providers, improved patient satisfaction Finely et al, (2003) USA RCT HMO PE/TM 2 75 Int 50 AD adherence, resource Improved adherence, Cont utilisation, improved patient depressive symptoms, satisfaction patient satisfaction, medication costs. Capoccia et al, (2004) USA RCT PCM PE/TM 2 41 Int 33 AD adherence, resource Cont utilisation, depressive symptoms, quality of life, patient satisfaction. Adler et al, (2004) USA RCT PCM PE/TM 5 268 Int 265 AD use rates, Improved AD use rate. Cont depressive symptoms. Rosen et al, (1978) USA CT CMH PE/TM 1 30 Int 152 Patient well-being, Intervention patients' Cont patient satisfaction, had higher personal quantity and adjustment scores, cost of service were 'better since provision. coming to clinic' and less likely to need further help. Razali et al, (1995) Malaysia RCT OP PE 1 85 Int 80 Relapses requiring Fewer relapses requiring Cont hospital readmission. hospitalisation in intervention group. Shaw et al, (2000) UK RCT OP PE/CA 1 51 Int 46 Medication knowledge, Cont medication related problems, adherence, hospital readmission. RCT = randomised controlled trial; CT = controlled trial; CP = community pharmacy; HMO = health maintenance organisation; PCM = primary care medical centre; CMH = community mental health centre; OP = outpatients' clinic; NL= The Netherlands; PE = patient education; TM = treatment monitoring; ca = care planning; Ph = pharmacists; Int = intervention group; Cont = control group; AD = antidepressant medication. All but one included study were conducted in developed after interventions or were cohort studies without parallel countries, and 15 of the 22 papers were published in the control groups [38-42]. Six papers reported results of last six years. Thirty-seven papers were excluded from the postal surveys [43-48]. Three papers presented study review for the following reasons. Thirteen papers reported methods only [49-51], and one study was conducted by data from descriptive studies [16-28] and nine papers pharmacy researchers but did not report the outcomes of reported outcomes of qualitative interviews or focus a service provided by pharmacists [52]. groups [29-37]. Five papers reported results of before and Page 4 of 11 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:29 http://www.anzhealthpolicy.com/content/2/1/29 Papers that met the review inclusion criteria reported the responsible for changes in drug attitude, adherence and outcomes of medication counselling by community phar- the symptoms scores observed. macists at the time of dispensing, education and monitor- ing activities conducted at primary care medical centres Services provided at medical centres and health and staff model health maintenance organisations maintenance organisations (HMOs), discharge medication counselling, and medica- Four studies reported patient education and treatment tion monitoring at a community mental health centre. monitoring services for people prescribed antidepressant Pharmacist delivered services provided to other health medications in the United States [56-59]. The patient edu- professionals included medication reviews and outreach cation and treatment monitoring involved the pharma- education activities designed to optimise prescribing. Sev- cists taking a medication history, providing information eral medication review studies reported impacts of phar- about the prescribed antidepressant medications, and macists' interventions in terms of changes in prescribing conducting telephone and face-to-face follow-up. Two of of medications commonly used to treat mental illness the four studies, one controlled [56] and the other ran- and/or changes in mental health symptoms, but were not domised controlled [57], were conducted at a staff model specifically targeted to people with a mental illness. Sev- health maintenance organisation (HMO). Pharmacists' eral small studies of pharmacists' medication review activ- interventions in both studies were associated with signifi- ities specifically conducted for people with a mental cant improvements in adherence to antidepressant medi- illness did not meet the review inclusion criteria cations when calculated at the end of the six-month study [17,18,20,22,41,42]. periods. Medication adherence was calculated by review- ing prescription dispensing data, and reported using an Services provided in community pharmacies intention-to-treat analysis. Both studies also demon- Three papers reported results of community pharmacists' strated that involvement of the pharmacist was associated medication counselling sessions for people commencing with a decrease in the number of visits to other primary non-tricyclic antidepressant therapy in The Netherlands care providers, although statistical significance was only [53-55]. Intervention patients participated in three coun- achieved in one of the studies [56]. The other two studies selling sessions (lasting between 10 and 20 minutes each) were conducted at primary care medical practices. In one and received a take-home video that emphasised the study over 16,000 consecutive patients attending nine importance of medication adherence. The medication practices were screened for depression using a self admin- counselling sessions involved pharmacists informing istered health survey [58]. Patients identified as having patients about the appropriate use of their medication. depression or dysthymia who agreed to participate in the This included providing information about the benefits of study (n = 533) were randomised to intervention or con- taking the medication, informing patients about potential trol groups. Intervention patients were significantly more side-effects, informing patients about the onset of action likely to be taking antidepressants at the six month fol- for antidepressant medications and reinforcing the need low-up. Additionally, patients who were taking their anti- for patients to take their medication on a daily basis. At depressants at the six month follow-up had better three month follow-up the intervention patients had sig- depression symptom scores than those who had discon- nificantly more positive drug attitudes than controls [53], tinued, but the overall symptom scores between interven- and at six months this corresponded with significantly tion and control groups were not significantly different. In greater medication adherence among those patients that the other randomised controlled study, improvements in remained in the study [55]. An intention to treat analysis, antidepressant adherence and depression symptom scores however, showed no significant intervention effect on were similar in both intervention and control groups [59]. medication adherence. Medication adherence was meas- In this study antidepressant adherence was measured by ured using an electronic pill container that recorded the asking patients how many days they took their antidepres- time and frequency that the cover was opened. Analysis of sant medication in the past month. psychological symptoms at the six month follow-up was inconclusive, with apparent improvements in symptom Services provided at community mental health centres and outpatients' clinics scores not replicated using an alternate method of analysis [54]. Randomisation occurred at the patient level, and Three studies investigated the effect of pharmacist deliv- neither pharmacists nor patients were blinded to their ered services to community mental health centres and group allocation. A limitation of this method was that the outpatients' clinics [60-62]. In a controlled trial, patients' same pharmacists provided services to both control and case managed by a pharmacist working at a community intervention patients. As the intervention studied was mental health centre in the United States had significantly multifactorial, it was not clear whether the three face-to- better personal adjustment scores than those receiving face medication counselling sessions conducted by the case management from a nurse, social worker or psychol- pharmacists, or the "take-home" videos, were primarily ogist [60]. They were also significantly less likely to need Page 5 of 11 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:29 http://www.anzhealthpolicy.com/content/2/1/29 help from other providers and rated themselves as more In a randomised controlled study of pharmacist con- healthy. As part of the medication monitoring service pro- ducted domiciliary medication reviews in the United vided, the pharmacist was allowed to adjust medication States there were significant declines in the overall num- doses and dose timing, and prescribe or discontinue med- bers and monthly cost of medications, but no significant ications under supervision. Medication monitoring con- difference in cognitive or affective functioning between ducted by the pharmacist was estimated to cost 40% of the intervention and control groups [64]. This may have equivalent medication monitoring conducted by the been due in part to the relatively short (6 week) follow-up clinic psychiatrists when calculated on a per time basis. period. The authors noted that many patients were unwill- Although the pharmacist performed medication monitor- ing to follow the pharmacist's recommendations to dis- ing for more patients per month than the clinic psychia- continue benzodiazepines and narcotic analgesics. A trists, the pharmacist also spent longer per patient contact. randomised controlled study of a pharmacist-led multi- This offset the overall cost savings of having a pharmacist disciplinary initiative to optimise prescribing in 15 Swed- perform the medication monitoring activities usually per- ish aged care facilities resulted in a significant decline in formed by a psychiatrist. the use of antipsychotics, benzodiazepines and antide- pressants by 19%, 37% and 59% respectively in the inter- In a study of patients discharged home from hospital after vention facilities [65]. The study involved pharmacists admission for relapse of schizophrenia in Malaysia, those participating in multidisciplinary team meetings with identified as having poor medication adherence were allo- nurses, nurses' assistants and physicians at regular inter- cated to receive pharmacist medication counselling or vals throughout the 12-month study period. A follow-up standard care [61]. The importance of medication adher- study of the same intervention and control facilities three ence was also reinforced by the patients' psychiatrists at years later indicated the intervention facilities maintained follow-up visits, although it was not clear whether this significantly higher quality of drug use, with lower pro- applied only to intervention patients or both intervention portions of residents prescribed more than three drugs and control patients. At the 12 month follow-up, patients that could lead to confusion, non-recommended hypnot- who had been exposed to the intervention, and received a ics and combinations of interacting drugs [66]. Neither daily or twice daily medication treatment, had signifi- study reported estimates of cost or clinical outcomes. A cantly fewer relapses that required hospitalisation than cluster randomised controlled study of a multidiscipli- patients in the control group. nary primary care intervention at a HMO in the United States included a quarterly pharmacist medication review A study that evaluated the impact of providing mental to address the potentially inappropriate use of medica- health patients with a pharmacist generated medication tions commonly prescribed for mental illness. The care plan at the time of discharge found that patients with researchers found the intervention had no impact on care plans were less likely to be readmitted to hospital depression scores and the numbers of high risk medica- than those without, however, this result was not statisti- tions prescribed at the 12 week follow-up [67]. cally significant [62]. Information on the medication care plans included lists of discharge medications, a summary Two additional cluster randomised controlled studies of of the patient education that was provided, and the need pharmacists' medication reviews in residential aged care to assess for specific potential adverse reactions. Commu- facilities demonstrated significant reductions in the nity pharmacists who were provided copies of the care number and cost of medications prescribed [68-70]. In plans were also more likely to identify medication related one study 10.2% fewer residents were administered psy- problems for the discharged mental health patients than choactive medications and 21.3% fewer hypnotic medica- those pharmacists who were not provided copies of the tions [68]. The impact of medication reviews on mortality care plans. was measured in both studies, and a significant reduction was noted in one [70]. Despite the significant reduction in Medication review in domiciliary and residential aged care mortality, patients in the intervention facilities experi- settings enced a greater deterioration in cognitive function and Components of medication review services provided by behavioural disturbance than those in the control facili- pharmacists include comprehensive medication history ties. taking, patient home interviews, medication regimen review, and patient education [63]. Medication review Educational visiting to general medical practitioners studies described in the review were conducted for resi- In the Netherlands, pharmacotherapy meetings to opti- dents of aged care facilities or for those individuals living mise prescribing are undertaken as part of routine clinical independently in the community identified to be at high practice by groups of local community pharmacists and risk of medication misadventure. general medical practitioners. A cluster randomised con- trolled trial of inter-professional (pharmacotherapy) Page 6 of 11 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:29 http://www.anzhealthpolicy.com/content/2/1/29 Table 2: Services provided to other health professionals Reference Country Design Setting Service No. Sample Main outcome measures Significant Outcomes Ph size Williams et al, USA RCT GP MR 1 63 Int 77 Physical, cognitive and affective Decrease in number and cost (2004) Cont functioning, health status, of medications number and cost of medications. Schmidt et al, Sweden CRCT RAC MR 15 626 Int Incidence and quality of Increase in psychotropic (1998) 1228 Cont psychotropic medication use. medication use and therapeutic duplication in control group. Decrease in antipsychotic and hypnotic use in intervention group, decrease in AD use in intervention and control groups Quality of medication use Previous Improvements in Schmidt et al, Sweden CRCT RAC MR 15 1549 Total (2000) (three-year follow-up). quality of medication use sustained for specific indicators Coleman et al, USA CRCT HMO MR 1 96 Int 73 Depressive symptoms, physical Decrease in urinary (1999) Cont function, service utilisation, incontinence in intervention number of high risk group at 12 months. No medications, satisfaction, differences between urinary incontinence, falls, cost. intervention and control groups at 24 months Roberts et al, Australia CRCT RAC MR ND 905 Int Medication use, medication Decrease in psycholeptic and (2001) 2325 Cont cost, mortality, morbidity and benzodiazepine drug resource utilisation. administration, decrease medication cost Furniss et al, UK CRCT RAC MR 1 158 Int Prescribing patterns, mortality, Decrease in mortality, (2000) 172 Cont mental state, depressive decrease in number of symptoms, and behavioural prescribed medications, disturbance increase in behavioural disturbance Burns et al, UK CRCT RAC MR 1 158 Int Medication costs. Decrease in medication cost (2000) 177 Cont van Eijk et al, NL CRCT GP ED 37 70 Int 1* Prescribing of highly Decrease in high (2001) 52 Int 2* anticholinergic and less anticholinergic AD use in 68 Cont* anticholinergic AD medications intervention group 2. Increase in less anticholinergic AD use in Intervention group 1 Hartlaub et al, USA CT PPGP ED ND 28 Int 1* Benzodiazepine prescribing (1993) 26 Int 2* pattern 37 Cont * de Burgh et al, Australia RCT GP ED 1 142 Int * Benzodiazepine prescribing Overall decline in (1995) 144 Cont pattern benzodiazepine use. * Differences between intervention and control groups not significant Crotty et al, Australia CRCT RACED 1 381 Int Fall rate, psychotropic Increase in 'as required' (2004) 334 Cont medication use, BP, quality of antipsychotic medication use in life the intervention group Avorn et al, USA CRCT RAC ED 1 431 Int Psychotropic mediation use, Decrease in psychotropic (1992) 392 Cont mental status, memory, medication use, decrease in anxiety, depressive symptoms, inappropriateness of drug use, behaviour, sleep less cognitive decline, increase in depression scores. CT = controlled trial; RCT = randomised controlled trial; CRCT = cluster randomised controlled trial; GP = general practice; RAC = residential aged care; PPGP = prepaid group practice; HMO = health maintenance organisation; USA = United States of America; NL = The Netherlands; MR = medication review; ED = prescribing education initiative; ND = not described in paper; Int = intervention group; Cont = control group; AD = antidepressant medication. † Journal article reported overall number of patients (n = 1549) divided between 16 intervention and 18 control residential aged care facilities. ‡ Pharmacists participated in group discussions with physicians, discussions were led by a medical researcher. * Reported sample size based on number of physicians that received pharmacists' educational intervention. Page 7 of 11 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:29 http://www.anzhealthpolicy.com/content/2/1/29 meetings to discuss prescribing of antidepressant medica- excluded from this review, many studies of community tions resulted in a significant reduction in the prescribing pharmacy services to optimise the use of medications for of highly anticholinergic antidepressants to elderly people mental illness have been descriptive, lacked parallel con- by 40% compared to a control group of practitioners that trol groups or have been qualitative in nature. The con- did not receive the prescribing support [71]. In compari- trolled studies included in this review provide some son, educational visiting (academic detailing), reduced evidence of the potential value of including pharmacists prescribing of highly anticholinergic antidepressants by in mental health care across a range of settings and patient 30%. populations. Four additional studies evaluated the impact of pharma- Studies included in the review utilised a range of randomi- cists' educational visits to general medical practitioners to sation techniques, however, the review did not attempt to optimise the prescribing of benzodiazepines and other characterise the quality of the randomisation beyond psychotropic medications commonly prescribed for men- whether randomisation occurred at the patient, practice or tal illness [72-75]. The two papers that reported health residential aged care facility level. The majority of the professional satisfaction indicated that the educational studies involved less than five pharmacists, and 10 out of visits were acceptable and well received [73,74]. In a con- the 22 papers described interventions where just one trolled trial, two types of pharmacists' educational inter- pharmacist was involved. Studies involving small num- ventions (a one-on-one presentation to prescribers with bers of pharmacists may have good internal consistency, individualised feedback and a group presentation to pre- but the results obtained may not be generalisable to out- scribers about the use of benzodiazepines) did not pro- comes of services provided by the wider pharmacy profes- duce significant changes to the prescribing of sion. In several studies the pharmacists' interventions benzodiazepines at a prepaid group practice in the United were components of multidisciplinary team approaches States when compared to a control group that did not to improving mental health care. The challenge of evalu- receive an educational intervention [72]. An Australian ating complex and multi-factorial interventions, which by cluster randomised controlled study of a pharmacist's their nature depend on the context in which the interven- educational visits to general medical practitioners provid- tion takes place, has been described [76]. ing services to residential care facilities detected no signif- icant differences in the use of psychotropic medications Five studies assessed the impact of pharmacists' provision between intervention and control facilities. The only of medicines information and treatment monitoring for exception was a significant increase in the use of "as people commencing antidepressant therapy. Three of the required" antipsychotic medications in the intervention five studies demonstrated that involvement of the phar- facilities [73]. This differed from results of an earlier clus- macist was associated with a significant improvement in ter randomised controlled study in the United States that medication adherence and/or medication use rates when found that educational visits by a pharmacist were associ- measured using an intention to treat analysis. One further ated with a significant decline in prescribing of potentially study demonstrated significant improvements in medica- inappropriate psychotropic medications in intervention tion adherence among patients who received three phar- facilities [75]. Another Australian study of educational vis- macist counselling sessions; however, this was not its to general medical practitioners, conducted by three significant when measured using an intention to treat physicians and one pharmacist, reported a significant analysis. Given the high rates of antidepressant discontin- reduction in the prescribing of benzodiazepines in both uation during the first three months of treatment, phar- intervention and control groups, but the difference macists have a potentially important role in providing between groups was not significant [74]. The authors medicines information and conducting treatment moni- accounted for this overall reduction by a corresponding toring for those patients at high risk of medication non- decline in the rate of diagnoses of anxiety and insomnia, adherence. No studies of pharmacists' treatment monitor- and the possible awareness of prescribing related issues ing for people commencing antidepressant therapy com- generated by asking general medical practitioners to con- pared monitoring provided by pharmacists to monitoring duct a self-audit of their prescribing. conducted by other health professionals. A separate study of antidepressant treatment monitoring conducted by nurses also demonstrated improved medication adher- Discussion Given the extent of mental illness in the community and ence [77]. in aged care, and the fact people with mental illness fre- quently report concerns about their prescribed medica- Despite people with psychotic disorders having reported tions, services directed toward optimising the use of unmet medicines information needs, relatively few con- medications for mental illness fulfil an important public trolled studies assessed community pharmacy services for health need. As evidenced by the large number of papers users of antipsychotic medications. Other studies have Page 8 of 11 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:29 http://www.anzhealthpolicy.com/content/2/1/29 suggested that service provision by pharmacists may be Conclusion limited by not having access to patients' medical histories The review of the international literature highlights the [46], a lack of specific training to counsel this patient pop- range of pharmaceutical services provided by community ulation [46], and pharmacists' attitudes towards people pharmacists in Australia that are potentially well suited to with mental illness [48]. Further well designed research assisting patients and prescribers optimise the use of med- into community pharmacy services for users of antipsy- ications for mental illness. These data show that medica- chotic medications is needed before conclusions can be tion counselling and treatment monitoring conducted by made about the potential of such services to reduce hospi- pharmacists can improve medication adherence among tal readmission and the cost of health care. people commencing antidepressant therapy. Pharmacist conducted medication reviews and resulting recommen- Pharmacist conducted medication management reviews dations to optimise medication regimens may reduce the appear a valuable strategy to identify potential medication numbers of potentially inappropriate medications for related problems among people taking medications for a mental illness prescribed to elderly people. This review of mental illness. The included studies demonstrated that the available published evidence supports the continued such reviews can reduce the numbers of potentially inap- expansion of pharmaceutical service delivery to people propriate psychotropic medications used for mental ill- with mental illness, but identified the need for further ness prescribed to elderly people in residential aged care well-designed research in specific areas. Future studies are settings. Only one study made the link between a reduc- needed to assess the cost-effectiveness and clinical impli- tion in psychotropic medication use and improved adher- cations of pharmacists working as members of multidisci- ence to national prescribing guidelines [66]. The value of plinary community mental health teams, and as providers pharmacist conducted medication reviews for people with of pharmaceutical services to people with psychotic disor- mental illness may not be limited to optimising the use of ders. mental health medications. Physical health care for peo- ple with mental illnesses is often less than optimal, and Authors' contributions pharmacist conducted medication reviews may be a com- SB conducted the literature search and wrote the manu- prehensive strategy to improve medication use for both script. AJM assisted in the literature search and in the writ- mental and physical illnesses. The tendency among health ing of the manuscript. PA proof read drafts of the professionals to focus solely on the management of the manuscript. PW and TFC participated in the conceptuali- mental illness among people with both mental and phys- sation of the review and assisted in the writing of the man- ical illnesses has been described in the literature [78]. uscript. Educational visiting has been shown to modify prescrib- Acknowledgements This research was funded by the Australian Government Department of ing behaviour [79]. The reviewed studies reported phar- Health and Ageing as part of the Third Community Pharmacy Agreement. macists' interventions that were well received by The authors thank Dr Julija Filipovska for her assistance in compiling the prescribers, but produced differing results as to whether manuscript. such visits were associated with changes in prescribing behaviour. This may have been because efforts to reduce References prescribing of potentially inappropriate medications were 1. Investing in Mental Health. Geneva, The World Health Organi- not accompanied by information about alternate treat- zation; 2003. 2. Mental health services in Australia 2002-03. Canberra, Austral- ments, or because patients were reluctant to discontinue ian Institute of Health and Welfare; 2005. taking benzodiazepine medications. In the Dutch study 3. 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British Medical Journal 2001, 322:654-657. scientist can read your work free of charge 72. Hartlaub PP, Barrett PH, Marine WM, Murphy JR: Evaluation of an intervention to change benzodiazepine-prescribing behavior "BioMed Central will be the most significant development for in a prepaid group practice setting. American Journal of Preventive disseminating the results of biomedical researc h in our lifetime." Medicine 1993, 9:346-352. Sir Paul Nurse, Cancer Research UK 73. Crotty M, Whitehead C, Rowett C, Halbert J, Weller W, Finucane P, Esterman A: An outreach intervention to implement evidence Your research papers will be: based practice in residential care: a randomized controlled available free of charge to the entire biomedical community trial. BMC Health Services Research 2004, 4:6. 74. de Burgh S, Mant A, Mattick RP, Donnelly N, Hall W, Bridges-Webb peer reviewed and published immediately upon acceptance C: A controlled trial of educational visiting to improve ben- cited in PubMed and archived on PubMed Central zodiazepine prescribing in general practice. Australian Journal of Public Health 1995, 19:142-148. yours — you keep the copyright 75. Avorn J, Soumerai SB, Everitt DE, Ross-Degnan D, Beers MH, Sher- BioMedcentral man D, Salem-Schatz SR, Fields D: A randomized controlled trial Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 11 of 11 (page number not for citation purposes)

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