The evolving role of pharmacists in depression care: a scoping review

Background Worldwide, depression is known to contribute significantly to the global burden of disease. Considering pharmacists are among the most approachable healthcare providers, they are well-placed to assist people with depression achieve positive treatment outcomes. Aim The primary aim was to examine the evidence regarding pharmacists’ roles in interventions, outcomes, and barriers to implementation within depression care globally, with the secondary aim focusing on the Arab region. Method A scoping review was conducted according to the PRISMA-ScR extension guidelines and the Joanna Briggs Institute framework, using Scopus, Cochrane, ProQuest, and Medline databases for studies worldwide and within the Arab region (22 Arab-league countries). Article selection, along with data extraction, analysis, and narrative synthesis were performed independently by two reviewers. Discrepancies were resolved by consensus. Results Forty studies reporting various roles and services provided by pharmacists in depression management were included. Most articles (24) described studies on pharmacist-led specific/single interventions/management strategies, and 16 described studies in which pharmacists provided comprehensive or team-based services. The majority of studies reported positive impact on patient outcomes. In accordance with the secondary aim, only three studies assessed various pharmacists’ services for people with depression in the Arab region. Barriers to effective depression-related care included time constraints and training needs. Conclusion This scoping review supports the expanding role of pharmacists in depression management. The interventions, impact, challenges, and research gaps identified serve as preliminary evidence for advocating for an expanded pharmacists’ scope of practice in mental health, both globally and in the Arab region. Supplementary Information The online version contains supplementary material available at 10.1007/s11096-024-01759-1.


Introduction
Depression is a serious global public health concern with a high prevalence, recurrence, and mortality rate [1].The World Health Organization (WHO) reports that more than 280 million people worldwide experience depression [2].The recent COVID-19 pandemic has been associated with a sharp rise in the number of depressive disorders worldwide [3].A large body of literature indicates that depression places a significant burden on society, both clinical and economic (e.g., direct costs that include resources spent on inpatient and outpatient care and therapies, suicide-related costs, and loss in productivity) [1][2][3][4][5].
The use of effective treatments, both pharmacological and psychotherapy, offers hope for people with depression.However, in a study conducted in 21 countries, results indicated that most people with depression do not receive adequate treatment [6].This finding equated to one in five people in high-income countries, and one in 27 in low-, or low-tomiddle-income countries, highlighting the need to implement fundamental transformations involving community education and outreach, beyond what it is currently being offered in primary and secondary care.
Over time, the role of the pharmacist has expanded to encompass patient-centered clinical services for nearly every type of illness, including mental health disorders.As pharmacists are among the most accessible primary healthcare professionals, they can provide numerous services for people with mental health conditions, such as screening and referral, education, medication counseling, monitoring therapy and supporting treatment adherence [7][8][9].In a recent white paper, the American Pharmacists Association urged community pharmacists to be more actively engaged in managing depression in order to improve patient outcomes and quality of life [10].Similarly, the European Society of Clinical Pharmacy Special Interest Group on Mental Health advocated for enhanced and standardized involvement of clinical pharmacists in depression management [11].
Despite the above reports, there is still a significant gap in the scope of practice among pharmacists when providing care to people with depression.Their function has been reported to be restricted to dispensing medications, the provision of product information, and counseling on the management of antidepressant side effects [12,13].In the Arab region, which is defined as and comprising of 22 nations within the Arab league, this gap is even more significant, with very limited studies reporting on the role of pharmacists in depression care [14,15].Data from the region reports almost 12 million disability-adjusted life years due to mental illness, with depression and anxiety being the most common disorders [16].Given the region's unique cultural, social, and healthcare landscape, a review of such literature can aid in understanding the challenges and opportunities of pharmacists in depression care in countries within the Arab world.This scoping review could serve as a valuable resource for organizations and healthcare professionals through offering insight into the pharmacists' current practice reported in relation to depression care, addressing systemic barriers, and guiding the development of future evidence-based interventions.

Aim
The aim of this scoping review was twofold.It primarily aimed to comprehensively map the literature discussing the role of pharmacists in depression care worldwide, focusing particularly on interventions and management strategies, outcomes assessed, and barriers to effective depression care.As a secondary aim, it also aimed to explore the current landscape of pharmacist-led interventions specifically within the Arab region, comprising the 22 countries belonging to the Arab league (Bahrain, Comoros, Djibouti, Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Mauritania, Morocco, Oman, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, the United Arab Emirates, and Yemen, Algeria).This review will provide a comprehensive understanding of the pharmacist's role in depression care and guide future initiatives in the field in countries within the Arab region and globally.

Method
A scoping review was undertaken to examine the characteristics of pharmacists' roles in the management and care provision of depression in the literature [17,18].Moreover, the heterogeneity of the evidence concerning this topic calls for an exploration of the landscape of the literature to help guide future research and systematic reviews.
This review used the Joanna Briggs Institute (JBI) methodology for scoping reviews and other related guidelines [19][20][21].This framework was used to provide an expertdeveloped, structured, comprehensive, and transparent approach to this scoping review.A literature search of studies addressing pharmacists' roles in depression care globally was conducted in MEDLINE, SCOPUS, Cochrane Library and ProQuest databases.The scoping review included only full-text English publications from database inception until 31 of December 2022.To determine if there were studies specifically conducted in the Arab region, the following search terms were used: "Arab countries" or "Arab" or "Gulf cooperation countries" or "GCC" or searching by the name of each Arab country.The search was undertaken in English, as English is the predominant language of scientific communication and publication within the Arab region.pertinent publications, a combination of search terms, Boolean operators (OR, AND), and truncations (*) were employed as necessary.Appendix 1 includes specific search strings and filters for each database.

Article selection
One investigator (AS) conducted the database search.The titles of studies identified through the databases were imported into Al Rayyan® software which was used to identify and delete duplicates.Title and abstract screening were independently performed by two reviewers (AS and MZ) in accordance with predetermined eligibility criteria (Table 1).Full text screening for the included studies was similarly performed.In case of discrepancies, consensus was reached through revisiting the eligibility criteria and discussion between the two reviewers, or consulting with a third external reviewer.Furthermore, a supplementary manual search was conducted on all the reference lists and bibliographies of included studies, including those of systematic reviews (SRs) and narrative reviews (NRs), to ensure that no relevant studies were overlooked.Potentially relevant studies were examined individually to see if they met the inclusion criteria for our scoping review.

Data charting process and synthesis
A data collection form was designed using Microsoft Word® software.To facilitate the data analysis, studies were categorized according to the type of pharmacist interventions/ management strategies reported.The following data was extracted, whenever feasible: author(s), year of publication, country, study design, setting, sample size, pharmacist intervention(s), and outcome reported relevant to pharmacist intervention(s).This categorization was informed by an initial screening literature review and was developed to aid examining the evidence in terms of the extent of the pharmacists' role within the reported interventions.The three categories were as follows:  For these studies, the depression-related outcome of the specific pharmacist-led intervention/management strategy (e.g., improvement in symptoms, decrease in severity, adherence, quality of life, patient satisfaction) and the outcome measure utilized (if reported) were also retrieved.Barriers identified in these studies on the pharmacist's role in depression care were analyzed separately.As per the JBI methodology guidance for scoping reviews, no quality assessment was deemed necessary to be performed [20][21][22].

Results
As illustrated in Fig. 1, the initial search in the four databases yielded 191 articles.After removing the duplicates (n = 22), 169 records were initially screened by title and abstract, of which 127 were excluded.Of the remainder 42 records that were fully reviewed, only 19 were eligible for inclusion.A total of 21 articles from the complementary manual search were also eligible for inclusion, yielding a total of 40 articles included in this scoping review.

Pharmacists' collaborative care practices in depression management
As summarized in Table 4, the majority of the studies reporting on pharmacists' collaborative care  Eight of the 15 patients (53%) had face-to-face interviews, and 7 had phone interviews (46%) All who screened positive were informed about clinic services (availability of social workers) and advised to follow up with their GP for further evaluation (number who followed up on any of these recommendations were not reported) Rosser [30] Prospective

Barriers to effective management of depression
The most common barrier to effective depression management reported in the studies was time constraints [32,41,46].The lack of privacy and confidentiality associated with the conventional layout of community pharmacies was another reported reason hindering the pharmacists' ability to provide depression care [32,41,56].Mental health stigma and low patient awareness of the pharmacist's role was reported in some studies as a barrier for patients to seek care from community pharmacists [20,32,56].Some studies reported difficulties in patient followups [20,31,46] and in collaborating with other healthcare providers [31,66].When studies with limited impact were examined, other barriers were identified such as operational constraints [37], insufficient duration of intervention implementation [40], patients' non-adherence to the intervention [42], and lack of intervention documentation [56].

Pharmacist-led management of depression in the Arab region
Only 3 studies were found reporting on pharmacists' interventions in the management of depression in Arab countries [23,41,53].Two of these studies reported on "pharmacist-led specific/single depression interventions/ management strategies" (category 1) [23,41] and one on "collaborative care practices in depression management" [53].These studies reported positive outcomes as a result of the pharmacist intervention, such as improvement in depression symptoms [23], improvement in adherence rates [41].In the study conducted in Saudi Arabia [53] collaborative depression care provided by pharmacists using a SDM model of practice resulted in significant improvement in the treatment adherence rate (p < 0.0001), treatment satisfaction (p < 0.0001), and KAB about depression and its treatment (p = 0.021) compared to patients receiving standard care [53].

Statement of key findings
The present scoping review yielded a total of

Interpretation
The studies included in this scoping review provide evidence of the diversity and depth of pharmacists' strategies in depression care.The review also provides information on the impact of these strategies, either pharmacist-led or in collaboration with other members of the healthcare team, on depression treatment outcomes.The majority of the studies included reported on pharmacist-led depression screening and patient education/monitoring strategies, demonstrated a positive effect on the overall management of depression, including referral of patients for more thorough assessments or treatment initiation, an overall improvement in adherence to antidepressants and in patients' KAB about depression and its treatment.These findings are important for supporting a continued expansion of the pharmacist's role in depression care.Despite depression posing a significant burden on society, many people do not seek help for their symptoms and treatment is often not adequate [6].Depression screening by pharmacists is a strategy that has shown positive results and should be a commendable role for pharmacists in depression care.The results of a systematic review on pharmacist-led depression screening services also showed the intervention resulted in positive outcomes, such as early identification and referrals of people at risk of depression to appropriate health services [62].Another important outcome of pharmacists' depression care services reported in the studies included in this scoping review is in relation to improvement in the treatment adherence rates.These results are in line with those from systematic reviews which showed that patient counseling and treatment monitoring conducted by pharmacists can improve adherence to antidepressant medications [63][64][65].Although a previous systematic review reported inconclusive findings in regard to the efficacy of pharmacistbased depression management on improving depression symptoms when compared to usual care [66], considering that non-adherence to antidepressants is high [67,68], by improving treatment adherence through pharmacist's interventions, patients are more likely to experience less symptoms of depression.Adherence to antidepressant treatment is not only essential in achieving remission and restoring the patient's previous levels of functioning, but also in preventing re-occurrence.When dispensing medications, pharmacists are in a suitable position to educate and monitor patients on their medications, but also to collaborate with other healthcare providers to support patients during their treatment, monitor progress and promote the importance of medication adherence.
For the most part, studies classified under category 2 and 3 reported more clinical outcomes such as depression symptom improvement or a decrease in the depression severity using validated psychometric tools, and were evaluated against the outcomes in a comparator group receiving usual care.The majority of these strategies demonstrated a significant difference in decreasing depression severity, reducing troublesome antidepressant side effects, timely detection and management of potential or actual DRPs, and enhancement of patients' quality of life.Despite these positive results, it is important to bear in mind that quality assessment of the included studies was not done, and thus, caution in the interpretation of these results is recommended.Future studies should use more robust study designs, more specific and sensitive evaluation measures and involve longer follow up periods [9,66].
The notable difference in the number of studies undertaken in North America compared to those in other parts of the world, and particularly in the Arab region, is possibly related to the vast differences in the scope of pharmacy practice in these two regions.It is well known that pharmacists in many states in the USA and provinces in Canada are allowed to refill, modify, and even prescribe medications under a protocol or collaborative agreements, which may facilitate a more direct patient care role for pharmacists when monitoring patients on depression treatment [69].Limited public awareness about the community pharmacists' role beyond those related to dispensing medications may also contribute to this paucity in the provision of more advanced or clinically focused community-based services observed in most Middle Eastern countries [70,71].There is also a wide gap in pharmacy practice across the different healthcare settings.Hospital pharmacists in the Middle East often possess an advanced degree and tend to have a higher level of practice compared to that of community pharmacists [72].However, even in the hospital setting, pharmacists are challenged by other mental healthcare providers.In a recent survey to physicians and nurses working in a psychiatric hospital in Qatar, mostly positive perceptions and expectations from clinical pharmacists were reported, although traditional clinical pharmacy services were more favorably viewed than those associated with advanced clinical roles such as prescribing and pharmacist-led medication management clinics [73].As such, it is important that countries within the Arab region set strategies in support of an expanded pharmacist scope of practice, not only to improve their professional image, but also to improve early and sustainable access to depression care.
Barriers for the provision of pharmacist-facilitated depression care reported in the studies included in this scoping review are similar to those in relation to implementation of any new pharmacy service, such as time constraints and training needs [74,75].In addition to that, barriers specifically related to mental health, such as pharmacists' attitudes, stigma and communication skills have been highlighted in these studies.Mental health stigma makes patients and pharmacists afraid to discuss mental health disorders openly [30,46,57,74,76].Some countries are exploring strategies to improve mental health literacy among pharmacists to support them in the provision of mental health services.For instance, in recent studies in Australia where community pharmacists were interviewed and surveyed, participants have emphasized on the significance of mental health training including continuous professional education and the Mental Health First Aid (MHFA) for high-quality late-life and perinatal depression screening [74,75].The MHFA course is an internationally recognized training program that helps front-line healthcare professionals to address how to identify, understand and respond to signs of mental illnesses and substance use disorders [77].This type of training is also becoming increasingly important in pharmacy education [78].Strategies like this can not only decrease mental health stigma, but also help pharmacists to improve their communication skills and gain confidence for engaging in mental health service provision.Furthermore, pharmacists' involvement in mental health awareness campaigns in collaboration with other members of the mental health team, such as the World Mental Health Day organized worldwide by the WHO [79], can increase public awareness not only about mental health overall, but also on the role of the pharmacist.These reported barriers, whether in studies with positive or limited intervention impact, offer insight into the potential challenges and strategies to overcoming them when implementing pharmacist-led interventions as part of depression care.Importantly, lessons learned from identified studies include the importance of intervention integration within operations so as not to disrupt usual practice, implementation of the interventions for a sufficient time before evaluation, and adequate patient education on the intervention to ensure adherence.

Strengths and weaknesses
This scoping review offers synthesized evidence from the literature related to pharmacist-led or and collaborative strategies in depression management, classified by the breadth of the pharmacist intervention.We believe this classification facilitates a more practical analysis of the wide scope of pharmacy practice in depression care across the globe and their associated outcomes.An additional study limitation is that the manual search yielded a greater number of studies compared to the screening search.Nonetheless, the measures to overcome this limitation in fact present a particular strength of this scoping review, as a a thorough review of the references included in previous narrative and systematic reviews on the research topic was conducted as a supplemental manual search.Conference abstracts, protocols, book reviews, opinion pieces, and editorial reviews were not included in this study.As such, it is possible that some studies published in non-peer-reviewed journals or in conference proceedings were not captured.

Further research
Future studies are needed to investigate pharmacists' roles in depression and mental health, especially in the Arab region.Studies can utilize experimental methods to evaluate the efficacy and long-term impact of pharmacist-led interventions on patient quality of life and clinical outcomes.The barriers identified and strategies to overcome them should also be explored to ensure maximum effectiveness of said interventions.Furthermore, it is crucial to study policies and training initiatives employed or needed to support an expanded scope of practice for pharmacists in depression care.

Conclusion
This collection of evidence confirms that pharmacists can play an important role in supporting people experiencing depression and in improving depression treatment outcomes.Pharmacist-led focused interventions such as depression screening, education and treatment monitoring have resulted in early identification, referrals and improved treatment adherence.More comprehensive pharmaceutical care and collaborative depression management interventions have also shown similar positive patient outcomes; however, more robust studies are needed with longer follow-up periods that evaluate their long-term sustainability.Nevertheless, this scoping review can be used as preliminary evidence with stakeholders advocating for an expanded scope of practice for pharmacists in mental health, particularly in countries within the Arab region.

Fig. 1
Fig. 1 PRISMA diagram reporting the databased used, the number of records screened by title and abstracts, and full-text articles retrieved

Table 1
Eligibility criteria for the scoping review utilizing ECLIPSE* framework *ECLIPSE, Research question framework detailing expectation, client group, location, impact, professionals, and evaluation; MDD, Major Depressive Disorder; GP, General Practitioner; RCT, Randomized Control Trial

Table 2
Characteristics of studies evaluating pharmacist-led specific/single depression interventions/management strategies

Table 3
Patient Health Questionnaire-9; RCT, Randomized controlled Trial; BDI-II, Beck Depression Inventory-II; GDS, Geriatric Depression Scale; PCPs, Primary Care Providers; WHO-5, Five Well-Being Index; HCP, Health Care providers; GP, General practitioner; CES-D, Centre for Epidemiologic Studies-Depression Scale; QOL, quality of life; SF-36, 36 item Short Form Health Survey; TAU, Treatment As Usual; PHQ-2, Patient Health Questionnaire-2; HRQOL, Health-Related Quality Of Life; KAB, Knowledge Attitudes and Beliefs; NNT, Number Needed to Treat; QALYs, Quality Adjusted Life-Years; IG, Intervention Group; DIT, Distress and Impact Thermometer; HANDS, The Harvard Department of Psychiatry National Depression Screening Day Scale; SDS, Zung Self-Rating Depression Scale; SCL-13, self-reported13-item depression subscale; K10, Kessler Psychological Distress Scale; DAI, Drug Attitude Index; PIL, Patient Information Leaflet; OR, Odds Ratio; CI, Confidence Intervals; FPFP, Frequency of Patient Feedback to Pharmacist; SCL-90, The self-rating 90-items (Hopkins) Symptom Checklist Characteristics of studies evaluating pharmacist-led comprehensive depression management strategies

Table 3 (
RCT, Randomized controlled Trial; MTM, Medication Therapy Management; DTP, Drug Therapy Problems; HSCL, Hopkins Symptom Checklist; MVTAS, Modified Version of the Therapeutic Alliance Scale; BMQ, Beliefs about Medicine Questionnaire; EWS, Eat Walk Sleep; PRM, Potential Problems Related to Medicines; PHQ-9, Patient Health Questionnaire; SF-36, 36 item Short Form Health Survey; QOL, quality of life; IG, Intervention group; CG, Control Group; DNOs, Drug-related Negative Clinical Outcomes; DRP, Drug Related Problems; BDI-II, Beck Depression Inventory-II; PC, Pharmaceutical care; ADRS, Adverse Drug Reactions; BRPS, The 18-item Brief Psychiatric Rating Scale; CGI, Clinical Global Impressions scale; HAM-D, 1 Hamilton Psychiatric Rating scores for mood disorder; AIMS, The Abnormal Involuntary Movement scale

Table 4
Characteristics of the studies evaluating pharmacists' collaborative care practices in depression management Usual Care Group; DCM, Depression Care Management; SCL-20, Hopkins Symptom Checklist-20; SF-12, Short Form 12 item Health Survey; MDT, Multidisciplinary team; PHQ-9, Patient Health Questionnaire-9; CI, Confidence Interval; QoL, Quality of life; SDM, Shared decision making; MMAS, Morisky Medication Adherence Scale; TSQM, Treatment Satisfaction Questionnaire for Medication; BMQ, Beliefs About Medicines Questionnaire; MADRS, Montgomery-Åsberg Depression Rating Scale; EQ-5D, European Quality of Life 5 Dimensions 5 Level Version; OPTIONS, Observing Patient Involvement in Decision-Making Scale; HRQOL, Health-Related Quality Of Life; PCPs, Primary care providers; DUSOCS, Duke Social Support and Stress Scale; DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; mBDI, Modified Beck Depression Inventory; DRP, Drugrelated problem; BIDS, Brief Inventory for Depressive Symptoms; WSDS, Work and Social Disability Scale; MPR Medication possession ratio; HMO, Health maintenance organization; CGI, Clinical Global Impression; IDS, Inventory for Depressive Symptomology; SMPA, Swedish Medical Product Agency 40 studies discussing pharmacist role in depression care and management.More than half of the studies focused on pharmacist-led specific/single interventions.Pharmacist interventions included screening, improvement of adherence rate, and education/ monitoring.The studies identified in this review showcased a positive impact on patient outcomes like adherence and satisfaction.Nonetheless, reported barriers to effective management reported included challenges with time constraints, privacy, mental health stigma, follow up, and collaboration with other professionals.Interestingly, only three studies within this review focused on pharmacist-led interventions in the Arab region.This comprehensive overview underscores the diversity, depth, and potential of pharmacist strategies in depression care, emphasizing the imperative need to address barriers to maximize positive outcomes.It also sheds light on the scarcity of such evidence in the Arab region, warranting further research in this area.