Pharmacist–patient communication on use of antidepressants: A simulated patient study in community pharmacy

Research in Social and Administrative Pharmacy 10 (2014) 419–437

Original Research

Pharmacist–patient communication on use of antidepressants: A simulated patient study in community pharmacy Wei Wen Chong, B.Pharm. (Hons.)a,b,*, Parisa Aslani, Ph.D.a, Timothy F. Chen, Ph.D.a a The University of Sydney, NSW 2006, Australia Universiti Kebangsaan Malaysia, Kuala Lumpur 50300, Malaysia

b

Abstract Background: Effective communication between community pharmacists and patients, particularly with a patient-centered approach, is important to address patients’ concerns relating to antidepressant medication use. However, few studies have investigated community pharmacists’ communication behaviors in depression care. Objective: To characterize community pharmacist–patient interactions during consultations involving use of antidepressants. Methods: Twenty community pharmacists received 3 simulated patient visits involving issues related to the use of antidepressants: 1) patient receiving a first-time antidepressant prescription; 2) patient perceiving lack of efficacy of antidepressants after 2 weeks of treatment, and 3) patient intending to discontinue treatment prematurely. All 60 encounters were audio-recorded and analyzed using the Roter Interaction Analysis System (RIAS), a quantitative coding system that characterizes communication behaviors through discrete categories. A patient-centeredness score was calculated for each encounter. Results: The majority of pharmacist communication was biomedical in nature (50.7%), and focused on providing therapeutic information and advice on the antidepressant regimen. In contrast, only 5.4% of pharmacist communication was related to lifestyle/psychosocial exchanges. There were also few instances of emotional rapport-building behaviors (8.6%) or information gathering (6.6%). Patient-centered scores were highest in the scenario involving a first-time antidepressant user, as compared to other scenarios involving issues with continued therapy. Conclusions: Community pharmacists appeared to adopt a “medication-centered” approach when counseling on antidepressant issues. There is scope for improvement in patient-centered communication behaviors, particularly lifestyle/psychosocial discussions, facilitating patient participation, and emotional rapport-building. The RIAS appears suited to characterize brief consultations in community pharmacies and can provide a framework in guiding communication training efforts. Further research is needed to assess the impact of pharmacist communication behaviors on patient care outcomes. Ó 2014 Elsevier Inc. All rights reserved.

* Corresponding author. The University of Sydney, NSW 2006, Australia. Tel.: þ 612 9036 9490; fax: þ 612 93514391. E-mail address: [email protected] (W.W. Chong). 1551-7411/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.sapharm.2013.05.006

420

Chong et al. / Research in Social and Administrative Pharmacy 10 (2014) 419–437

Keywords: Pharmacist–patient communication; Patient-centeredness; Roter Interaction Analysis System; Antidepressant adherence

Introduction Depression is a chronic and relapsing condition, with a lifetime prevalence of 16.2%.1 The burden of depression is substantial in terms of reduced quality of life, loss of productivity and increased healthcare utilization.2,3 Although psychological treatments are available, antidepressant medications remain the mainstay of treatment and are recommended for moderate to severe depression.4,5 However, non-adherence to antidepressant medications remains a major barrier to the effective treatment of depression,6–8 and has been linked to increased risk of relapse and recurrence.9,10 Non-adherence to antidepressant medications has been attributed to multiple factors including stigma associated with depression, side effects of antidepressant medications, healthcare providers’ behavior and healthcare system delivery.6,11–13 Recent literature has also emphasized the importance of patients’ medication beliefs and concerns.14–17 Patients may have misperceptions about antidepressant medications, for example perceiving antidepressants as addictive, that may influence their decision to begin treatment.18 Patients who already have begin treatment also have varying concerns about antidepressant medications that may influence their medicationtaking behavior.19 For example, patients in the acute phase of treatment may have concerns about antidepressant side effects and the perceived lack of efficacy of antidepressants in the first few weeks of treatment.20,21 Patients in the continuation and maintenance phases of treatment may be concerned about long-term effects of antidepressants, and whether antidepressants are necessary once they have achieved symptom improvement.20,22 Effective communication between healthcare providers and patients is important to address these concerns and has been demonstrated to be an important factor influencing patients’ medication beliefs, adherence and treatment outcomes in depression.23,24 As community pharmacists are an important and frequent point of contact in healthcare, they are well-positioned to explore patients’ medication concerns and address issues that may affect the appropriate use of antidepressant medications.25,26

Recent literature has indicated an expansion of pharmacy services beyond traditional medication dispensing for the management of chronic physical diseases such as hypertension and diabetes.27,28 Similarly, community pharmacists can play an important role in the care of patients with mental illnesses such as depression. Findings from pharmacist intervention studies in depression care have demonstrated positive impact in terms of improving antidepressant medication adherence,29,30 patient knowledge31 and treatment satisfaction.30 However, studies have also indicated that there is room for improving pharmacist communication in the mental health area. For example, one study indicated that community pharmacists rarely explored patients’ feelings about taking antidepressants.32 Additionally, lack of an empathetic attitude in pharmacists has been described as a communication barrier by patients starting antidepressant treatment.33 There has been some evidence, which suggests that gaps in pharmacist communication may be in part due to difficulties for pharmacists in making the transition from a “medication-centered” practice to one which focuses on the patient role in the medication-use process.34 Yet, pharmacists’ expanding roles necessitate the shift toward a patientcentered practice. Moreover, patients want to be seen as individuals with unique experiences, circumstances, beliefs and needs regarding medication use.34 A patient-centered approach is therefore essential for community pharmacists in helping patients with their medications; and involves eliciting the patient’s perspectives about treatment and illness, understanding the patient within his or her unique psychosocial context, and partnership building in order to facilitate greater patient involvement in his or her treatment.35,36 Patientcentered communication behaviors may include statements of empathy, support and reassurance, as well as open-ended questions, in order to facilitate patient expression of cues and concerns.37 The importance of patient-centered communication has been demonstrated in terms of improved medication adherence, patient satisfaction and health-related outcomes.38,39 In the context of medication adherence, patient-centered communication is important for providers to identify

Chong et al. / Research in Social and Administrative Pharmacy 10 (2014) 419–437

individual patient circumstances that are barriers to adherence and tailoring care to those needs.40 Patient-centered communication is also consistent with the recovery-oriented movement in mental healthcare that promotes patient empowerment and supports self-management of illness.41 Despite the growing importance of pharmacist– patient interactions in improving medication use and patient outcomes,42 there has been little empirical research exploring the dynamics and processes of pharmacist–patient communication in community settings, particularly within the context of mental healthcare. The development of interaction analysis techniques provides a systematic way to characterize encounters in order to study the content and structure of the interaction. The Roter Interaction Analysis System (RIAS) is one of the most widely used quantitative coding systems for analyzing medical communication.43 This method has demonstrated good reliability and predictive validity, and has been applied to a variety of medical settings and specialties.43–45 In addition, the RIAS has also been widely used to evaluate specific aspects of interactions such as patient-centered communication.44,46 Previous work has recommended the RIAS as a potentially useful tool for assessing pharmaceutical care consultations.47 To the authors’ knowledge, no previous studies have provided a systematic and detailed description of community pharmacists’ communication profiles in depression care. Hence, the aim of this study was to characterize community pharmacist– patient interactions during consultations involving the use of antidepressant medications, specifically adherence-related issues. In this study, the broad aspects of pharmacists’ communication behaviors, including patient-centeredness, were characterized using the RIAS system. The evaluation of the therapeutic or clinical content of the consultations was outside the scope of this study.

Methods Recruitment of participants An information letter that contained details about this study and an invitation to participate, was mailed to 120 community pharmacies in Sydney, Australia. Community pharmacists were informed that the study involved simulated patient visits over a period of 6 months, and that these visits would be covertly audio-recorded. Pharmacists also were informed that simulated patients would seek medication advice from them,

421

and that the purpose of the study was to learn about the communication process in community pharmacy settings. Pharmacists were not told about the mental health context of the study or that the visits would be about antidepressantrelated issues. Twenty community pharmacists (17% response rate) agreed to participate. Informed consent for conducting and audio-taping the simulated visits were obtained from all participating pharmacists and their pharmacy managers. Upon enrollment, participating pharmacists and pharmacy managers completed background questionnaires detailing pharmacists’ demographics and information about the pharmacy. The study was approved by the institution’s human research ethics committee. Simulated patients Simulated patient methods were used in this study to evaluate community pharmacists’ communication behaviors in their practice settings. The use of simulated patient methods in pharmacy research previously has been described as an effective and reliable way of measuring current practice, and in identifying areas for targeted training.48 Additionally, this method facilitates comparison between pharmacists, as patient variations within standardized scenarios may be reduced. Three simulated patients were recruited, with each assigned to perform a single scenario to ensure consistency. All simulated patients had either previous acting experience or experience as simulated patients. The simulated patients were trained in a 2-h workshop that involved the following: review of case scenarios, delivery of scenarios using standardized scripts, instructions on documentation of findings after each visit and role-playing of scenarios with practicing community pharmacists. Simulated patient scenarios Three case scenarios were developed by the research team based on the literature12,19,20,49 and the researchers’ experiences of common adherence-related issues in community pharmacy practice. These scenarios were developed to reflect patients’ concerns at different phases of antidepressant treatment (see Appendix 1): 1) patients receiving a first-time antidepressant prescription and considering treatment initiation; 2) patients who have started antidepressant treatment for 2 weeks but have not observed any improvement

422

Chong et al. / Research in Social and Administrative Pharmacy 10 (2014) 419–437

in symptoms; and 3) patients who are on a maintenance phase of antidepressant treatment and intending to discontinue treatment, as they feel fine. Data collection Simulated patient visits were conducted between December 2011 and May 2012. Each participating pharmacist received three unannounced visits, with approximately a month’s gap between each visit. The simulated patients were instructed to offer information only when prompted by the pharmacist. The visits were covertly audio-recorded using hidden digital recorders. A researcher (WWC) accompanied the simulated patient to the pharmacy but did not enter the pharmacy during the interaction. On completion of a visit, the researcher listened to the recording and reviewed the visit. The researcher then entered the pharmacy and informed the pharmacist that a simulated patient visit had just taken place. The pharmacist was given the opportunity to reflect and comment on his or her interaction with the simulated patient. The researcher also provided the pharmacist with feedback on the visit. Feedbacks were provided mainly to elicit pharmacists’ perspectives on the interaction and were not intended to change pharmacists’ practice behaviors. Coding of data: Roter Interaction Analysis System (RIAS) The interactions between community pharmacists and simulated patients were coded with the Roter Interaction Analysis System (RIAS). This system assigns each complete thought (the smallest unit of expression referred to as utterance, that may vary in length from a single word to a lengthy sentence) to mutually exclusive and exhaustive categories that represent either task-focused or socio-emotional elements of communication.50 A detailed description regarding the coding system is available elsewhere.43,47 This study used a RIAS coding scheme tailored for depression studies, consisting of 36 pharmacist and 27 patient coding categories. These coding categories were further organized into composite groups representing data gathering (biomedical and lifestyle/psychosocial questions), patient education and counseling (biomedical and lifestyle/ psychosocial topics), rapport-building and partnership building (see Table 1 for RIAS composites, coding categories and examples of quotes). Using both audio-recordings and

transcripts, each consultation was coded by the first author (WWC) (all authors had received RIAS training). Initially, a sample of 10% of the consultations (n ¼ 6) were also double-coded by the second author, and any discrepancies were discussed between the two coders. After agreement had been reached, a random sample of 15% of consultations (n ¼ 9) were then coded independently by the two coders as a means of checking rater reliability.51 Using the intra-class correlation coefficient, the inter-rater reliability for coding categories with a mean count O2 averaged 0.84 over the pharmacist categories (range 0.71–0.98) and 0.85 over the patient categories (range 0.65– 0.95). The duration of each encounter and summary measures that reflect patient-centeredness communication were also examined. These included pharmacist verbal dominance, patient-centeredness communication score, ratio of pharmacist openended questions to all questions and ratio of pharmacist–patient psychosocial statements to biomedical statements. Pharmacist verbal dominance was calculated as a ratio of all pharmacist statements to patient statements, excluding “backchannels” such as “Uh-huh” and “Mm-hmm.” Similar to previous studies,45,52,53 a summary score of patient-centeredness was also calculated for each encounter. This was assessed as the ratio of all codes relating to socio-emotional and psychosocial elements of exchange (all partnership-building, psychosocial information and counseling, and rapport-building statements by pharmacists and patients; all pharmacist open-ended questions; and all patient questions) divided by codes that further the biomedical agenda (the sum of all pharmacist and patient biomedical information and counseling, procedural statements and pharmacist closed-ended questions). Data analysis Descriptive statistics were used to investigate the content of pharmacist and simulated patient communication. The relationship between patientcentered communication score and length of consultation was analyzed using Spearman correlation. Friedman’s ANOVA was conducted to determine if there was a difference in patientcentered scores for individual pharmacists across the scenarios. Mann-Whitney’s U-tests were used to identify differences in patient-centered scores in terms of pharmacist gender, age groups, years since registration, type of pharmacy and number of

Table 1 Roter Interaction Analysis System (RIAS) categories of pharmacist and patient communication RIAS composites Data-gathering (pharmacist)/ Question-askinga (patient)

Patient examples “When you said side-effects, what sort of things?” (Question-therapeutic) “So what happens if you just stop taking it?” (Question-therapeutic)

Lifestyle/ psychosocialc

Asks closed-ended question–lifestyle/ psychosocial Asks open-ended question–lifestyle/ psychosocial

Biomedicalb

Gives information–medical condition Gives information–therapeutic regimen Gives information-other Counsels-medical condition/ therapeutic regimen (Pharmacist only)

“Have you seen a doctor yet about your symptoms?” (Closed-ended question-medical) “What sort of symptoms are you going through at the moment?” (Openended question-medical) “What time of the day do you normally take the medication?” (Closed-ended question-therapeutic) “Are you taking any other medications?” (Open-ended questiontherapeutic) “Do you want to just have a seat?” (Closed-ended question-other) “Whereabouts do you live?” (Closedended question-lifestyle/psychosocial) “Is there any reason why you’re feeling that way?” (Open-ended question– lifestyle/psychosocial) “What is the worst it can get in a particular day?” (Open ended question–lifestyle/psychosocial) “What they found is that people who suffered depression have a lower amount of serotonin in the synapse.” (Gives information– medical) “This Zoloft belongs to a group of medicines called selective serotonin reuptake inhibitors.” (Gives information–therapeutic) “Try to avoid taking it at night time before you go to bed.” (Counsels– medical/therapeutic) “I think it’s best to see your doctor before you stop it.” (Counsels– medical/therapeutic)

“I’ve been feeling quite low. And I’ve been having a lot of trouble concentrating at Uni.” (Gives information-medical) “I had some side-effects when I first went on it.” (Gives informationtherapeutic) “I’m taking one a day in the morning.” (Gives information-therapeutic)

(continued )

423

Pharmacist examples

Asks closed-ended question-medical condition Asks closed-ended questiontherapeutic regimen Asks closed-ended question-other Asks open-ended question–medical condition Asks open-ended question–therapeutic regimen Asks open-ended question-other Bid for repetition

Chong et al. / Research in Social and Administrative Pharmacy 10 (2014) 419–437

Patient education and counseling (pharmacist)/ Information-giving (patient)

RIAS coding categories Biomedicalb

424

Table 1 (continued ) RIAS composites Lifestyle/ psychosocialc

Patient examples

“For some people, it’s a matter of getting through a particular period of time or particular circumstances.” (Gives information-lifestyle/ psychosocial) “Get the help you can from your friends and family.” (Counsels– lifestyle/psychosocial) “Any negative thoughts you get, you’ve got to challenge them before they enter.” (Counsels–lifestyle/ psychosocial) “Do you think you’re perfectly fine because you’re taking this?” (Asks for opinion) “Do you know what I mean?” (Asks for understanding) “Mm-hmm.”/“Hmm.” (Backchannels) “You said you’re not on anything else?” (Check for understanding) “Yeah, that’s right.” (Shows agreement) “That’s a good thing. You’re doing your research and looking at different options.” (Shows approval) “I really understand your concerns.” (Empathy/legitimation) “It makes it very hard if I don’t know what’s happening in the past.” (Shows concern or worry) “So hang in there. It will get better.” (Reassures, encourages or shows optimism) “If there is anything else you need, just feel free to call back and ask.” (Partnership)

“I’m staying with my sister here.” (Gives information-lifestyle/ psychosocial) “It was triggered by a relationship breakup.” (Gives informationlifestyle/psychosocial)

Positive

Laughs, tells jokes Shows approval - direct Gives compliment - general Shows agreement, understanding

Emotional

Empathy/legitimation Shows concern or worry Reassures, encourages or shows optimism Partnership statements (Pharmacist only) Self-disclosure statements (Pharmacist only)

“Are there any particular side-effects I should be especially worried about?” (Asks for reassurance) “Uh-huh.”/”Hmm.”/“Mm-hmm.” (Back-channels) “So just wait it out, is that what you’re saying?” (Check for understanding)

“That’s really helpful. Thank you very much.” (Shows approval) “Okay, I see.” (Shows agreement)

“I heard these have really strong sideeffects and stuff.” (Shows concern or worry) “You know, it’s frustrating because you wanted to be better straightaway.” (Shows concern or worry) “I just feel so much better.” (Reassures, encourages or shows optimism)

Chong et al. / Research in Social and Administrative Pharmacy 10 (2014) 419–437

Pharmacist examples

Gives information–lifestyle/ psychosocial Counsels-lifestyle/psychosocial (Pharmacist only)

Asks for opinion (Pharmacist only) Asks for permission (Pharmacist only) Asks for reassurance Asks for understanding Asks for service (Patient only) Back-channels Paraphrase/check for understanding

Facilitation and patient activation (pharmacist)/ Patient activation and engagement (patient)

Rapport-building

RIAS coding categories

a

Shows disapproval–direct Shows criticism–general

Social

Personal remarks, social conversation

Transition words Gives orientations, instructions

“I just find it hard to believe.” (Shows disapproval) “He didn’t really tell me about sideeffects or anything like that.” (Shows criticism) “How are you?” (Personal remarks, social conversation) “See you.” (Personal remarks, social conversation) “Hold on.”/“Um I was just wondering.” (Transition words) “I just wanted to get some advice from you actually.” (Orientations)

Patients’ questions are categorized by topic but not further distinguished as open vs. closed-ended. Biomedical talk: Categories in this area include questions or statements of fact or opinion focusing on medical condition (i.e., depression symptoms, medical background, personal and family medical histories, diagnosis and prognosis) and therapeutic regimen (i.e., past, current and future medication use, information about medication, ongoing or future treatment plan for depression, future medical appointments, specific referrals to health professionals within the health system or other specific recommendations that imply or require the patient’s accountability to the physician). c Lifestyle/psychosocial talk: Categories in this area include questions or statements of fact or opinion regarding lifestyle (e.g., exercise habits and diet), performance of activities related to daily living, family and home situations, work and employment, psychosocial concerns or problems (including life events and other stressors of depression) and values and beliefs. Counseling statements in this area include proactive or supportive talk and suggestions largely dependent on the patient’s initiative (e.g., joining support groups or referrals to depression websites). d Unintelligible utterance included as a separate RIAS category. b

Chong et al. / Research in Social and Administrative Pharmacy 10 (2014) 419–437

Procedurald

Negative

“I myself went through something like this.” (Self-disclosure) “I don’t think that’s a good idea.” (Shows disapproval) “I think today, doctors are too quick to prescribe antidepressants.” (Shows criticism) “Good morning. How are you doing?” (Personal remarks, social conversation) “Have a good day.” (Personal remarks, social conversation) “All right.”/“So yeah, but look.” (Transition words) “I’ll print out some information for you.” (Orientations)

425

426

Chong et al. / Research in Social and Administrative Pharmacy 10 (2014) 419–437

prescriptions dispensed per day. All data were analyzed using the Statistical Package for Social Sciences (SPSS) version 21.0. The significance value was set to p % 0.05.

Results Twenty community pharmacists from 15 pharmacies participated. Each pharmacist received 3 simulated patient visits, resulting in 60 encounters. Demographic details are summarized in Table 2. Content of consultations The median number of utterances per consultation was 148.5 (inter-quartile range 108–210.8). Overall, pharmacists contributed 5751 utterances (median per consultation ¼ 86, inter-quartile range 59.8–127.5) while simulated patients contributed 4361 utterances (median per consultation ¼ 68.5, inter-quartile range 52–88). Fig. 1 provides a summary of composite communication categories for Table 2 Demographic details of participants Characteristic Pharmacists (n ¼ 20) Gender Male Female Age group 20–29 30–39 40–49 O50 Pharmacy degree BPharm MPharm Number of years since registration

N

%

15 5

75% 25%

14 2 3 1

70% 10% 15% 5%

19 95% 1 5% Mean years: 7.65 SD: 9.11 Median: 5.00 Range: 1–39 years

Pharmacies (n ¼ 15) Type of pharmacies Chain 7 Independent 8 Number of prescriptions dispensed per day 1–50 2 51–100 3 101–200 5 201–300 4 O300 1 Availability of a private counseling area Yes 12 No 3

46.7% 53.3% 13.3% 20.0% 33.3% 26.7% 6.7% 80.0% 20.0%

pharmacist and simulated patient. The majority of pharmacist communication concerned biomedical exchanges (50.7%), while 48% of patient communication was on rapport-building. Lifestyle and psychosocial exchanges were relatively low for both pharmacists (5.4%) and patients (5.3%). The communication behaviors of pharmacists and simulated patients are examined in more detail below. Communication behavior of community pharmacists Table 3 shows the types and frequencies of pharmacists’ communication. The majority of pharmacist talk (45%) was in the category patient education and counseling on biomedical information, specifically on giving therapeutic information (n ¼ 1156, 20.1%) and counseling on the antidepressant regimen (n ¼ 1314, 22.8%). In contrast, 4.5% of pharmacist talk was on lifestyle/ psychosocial information and counseling. Data gathering accounted for 6.6% of pharmacist talk; these tended to be biomedical questions (5.7%) focused on therapeutic regimen rather than lifestyle/psychosocial questions (0.9%). Partnership building accounted for 11.6% of pharmacist talk; this was mainly through the use of back-channels, asking for patients’ understanding and paraphrases. Positive rapport-building accounted for 16.2% of pharmacist talk and consisted mainly of statements showing agreement or understanding. Emotional rapport-building accounted for 8.6% of pharmacist talk, with most of the statements in this area being statements that reassure, encourage or show optimism. Pharmacists rarely engaged in negative rapport-building behavior, and social/personal utterances were restricted to one or two remarks in the opening and closing segments of the visit. Communication behavior of simulated patients Table 4 characterizes the content of simulated patient communication. The most frequent type of utterance from simulated patients was positive rapport-building (37.6%), due mainly to the high amount of ‘agreement’ statements. This was followed by patient activation and engagement (20.2%), consisting mainly of ‘back-channel’ responses as well as statements that check for understanding. Information-giving was focused more on biomedical information, specifically on the therapeutic regimen (13.7%) compared to lifestyle/psychosocial information (5.3%). The level

Chong et al. / Research in Social and Administrative Pharmacy 10 (2014) 419–437

427

Fig. 1. Percentage for composite communication categories in community pharmacist consultations. Percentage of pharmacist and patient statements in Roter Interaction Analysis System (RIAS).

of question-asking was low (2.8%) and was mostly on therapeutic regimen, with almost none on medical and lifestyle/psychosocial aspects. Emotional statements comprised 7.2% of simulated patient talk, with the majority being statements expressing concern or worry. Social and negative statements from simulated patients were rare. Summary measures of pharmacists’ communication behaviors As shown in Table 5, the median duration of interactions was 4.80 min (range 0.75–16.93 min). This was highest in Scenario 1 (median ¼ 5.18 min), with a reduction in length across the three scenarios. Pharmacist verbal dominance was fairly consistent across all 3 scenarios, indicating that pharmacists talk on average about 1.5 times more than patients (median ¼ 1.40, range 0.80– 2.76). The median patient-centeredness score for all encounters was 1.34 (range 0.74–4.41), with the highest being in Scenario 1 (median ¼ 1.44). The ratio of open-ended questions to all questions was consistent across all scenarios, with only about half of all pharmacists’ questions categorized as open-ended. The ratio of lifestyle/ psychosocial exchanges to biomedical exchanges was low in all scenarios (median ¼ 0.07, range 0–1.15). Length of the encounter was significantly related to patient-centered scores across the 60 consultations (rs ¼ 0.27, p ! 0.05). When comparing patient-centered scores for individual pharmacists across the three scenarios, there was

a statistically significant difference, c2(2) ¼ 6.56, p ! 0.05. Subsequent post-hoc analyses with Wilcoxon tests revealed that the scores were statistically significantly lower in Scenario 2 compared to Scenario 1, z ¼ 2.78, p ! 0.01, r ¼ 0.44. Within each scenario, no significant differences in patient-centered scores were found in terms of pharmacist gender, age groups, type of pharmacy and number of prescriptions dispensed per day (data not shown). However, there was a statistically significant difference in patient-centered scores in terms of pharmacists’ years since registration in Scenario 1, with pharmacists registered for !5 years having significantly higher scores compared to pharmacists with R5 years since registration (median ¼ 1.68 vs. 1.26, U ¼ 19.50, z ¼ 2.28, p ! 0.05, r ¼ 0.51). There were no significant differences in scores, in terms of pharmacists’ years since registration, in the other two scenarios. Discussion This study is among the first to examine community pharmacists’ communication behaviors in a mental health context using the RIAS system, specifically when addressing issues and concerns with antidepressant medications. Overall, community pharmacists in this study predominantly employed biomedical communication that focused mainly on providing therapeutic information and counseling on the antidepressant regimen. There were few instances of psychosocial discussions, despite the fact that this was in the context of

Communication category

Scenario 1

Scenario 2

Scenario 3

Total

Number of utterances

Number of utterances

Number of utterances

Number of utterances

119 (5.6%) 22 39 2 19 36 1 0 19 (0.9%) 4 15 884 (41.3%) 76 585 9 214 160 (7.5%) 20 140 236 (11%) 19 0 0 82 95 40 269 (12.6%) 16 8 0 245 250 (11.7%) 11 28

117 (6.3%) 16 52 2 14 33 0 0 22 (1.2%) 7 15 863 (46.7%) 15 323 5 520 67 (3.6%) 4 63 230 (12.4%) 15 3 3 45 105 59 320 (17.3%) 12 16 1 291 123 (6.7%) 23 24

93 (5.3%) 7 41 3 1 41 0 0 11 (0.6%) 3 8 838 (47.6%) 9 248 1 580 31 (1.8%) 15 16 199 (11.3%) 14 0 3 51 78 53 343 (19.5%) 24 24 0 295 119 (6.8%) 4 26

329 (5.7%) 45 132 7 34 110 1 0 52 (0.9%) 14 38 2585 (45%) 100 1156 15 1314 258 (4.5%) 39 219 665 (11.6%) 48 3 6 178 278 152 932 (16.2%) 52 48 1 831 492 (8.6%) 38 78

Range 1–16 0–8 0–8 0–2 0–5 0–5 0–1 0 0–9 0–3 0–6 7–104 0–16 2–80 0–6 1–64 0–61 0–9 0–61 0–32 0–4 0–1 0–2 0–19 0–21 0–14 0–50 0–13 0–5 0–1 0–47 0–31 0–11 0–11

Median (Inter-quartile range) 5 0 2 0 0 1 0 0 0 0 0 39 0 15.5 0 21 0 0 0 9 1 0 0 1.5 3.5 1 13 0 0 0 11 6 0 0

(2–7.75) (0–1) (1–3) (0–0.75) (1–3)

(0–1) (0–1) (28.25–50.75) (0–1) (10–24.75) (11–29.75) (0–4.25) (0–1.5) (5–17) (0–1)

(0–5) (2–6) (1–4) (8–19.75) (0–1) (0–1) (7.25–18) (2–12) (0–1) (0–1.75)

Chong et al. / Research in Social and Administrative Pharmacy 10 (2014) 419–437

Data gathering(biomedical) Asks closed-ended question (medical condition) Asks closed-ended question (therapeutic regimen) Asks closed-ended question (other) Asks open-ended question (medical condition) Asks open-ended question (therapeutic regimen) Asks open-ended question (other) Bid for repetition Data gathering (lifestyle/psychosocial) Asks closed-ended question (lifestyle/psychosocial) Asks open-ended question (lifestyle/psychosocial) Patient education and counseling (biomedical) Gives information (medical condition) Gives information (therapeutic regimen) Gives information (other) Counsels (medical condition/therapeutic regimen) Patient education and counseling (lifestyle/psychosocial) Gives information (lifestyle/psychosocial) Counsels (lifestyle/psychosocial) Facilitation and patient activation Asks for opinion Asks for permission Asks for reassurance Asks for understanding Back-channels Paraphrase/checks for understanding Rapport-building (positive) Laughs/tells jokes Shows approval-direct Gives compliment–general Shows agreement, understanding Rapport-building (emotional) Empathy/legitimation Shows concern or worry

428

Table 3 Pharmacist communication by scenario

(1–2) (1–2) (1–6) (1–4) (0–2) (0–1) (59.75–127.5)

(0–1) (0–1)

Reassures, encourages or shows optimism Partnership statements Self-disclosure statements Rapport-building (negative) Shows disapproval–direct Shows criticism–general Rapport-building (social) Personal remarks, social conversation Procedural Transition words Gives orientation, instructions Unintelligible utterances Total

190 11 10 6 (0.3%) 1 5 44 (2.1%) 44 134 (6.3%) 98 36 20 (0.9%) 2141

68 5 3 16 (0.9%) 8 8 24 (1.3%) 24 63 (3.4%) 50 13 5 (0.3%) 1850

86 3 0 15 (0.9%) 14 1 33 (1.9%) 33 69 (3.9%) 54 15 9 (0.5%) 1760

344 19 13 37 (0.6%) 23 14 101 (1.8%) 101 266 (4.6%) 202 64 34 (0.6%) 5751

0–28 0–3 0–7 0–4 0–3 0–3 0–4 0–4 0–23 0–22 0–5 0–7 17–224

4 0 0 0 0 0 2 2 3 2 0 0 86

(1–8.75) (0–0.75)

Chong et al. / Research in Social and Administrative Pharmacy 10 (2014) 419–437

429

depression, a condition which can be considered as having strong psychosocial components. Similar to previous work,54 simulated patients’ communication profile (high agreement and back-channel responses, low levels of question-asking) suggests that patients spent most of the consultation listening to the pharmacist rather than more active participation; this interpretation is supported by the verbal dominance of pharmacists in most of the visits. In this study, the use of communication that is considered as patient-centered on the RIAS coding, occurred mainly through pharmacists showing agreement with the patient, back-channel responses, checking for patients’ understanding and paraphrases. These communication behaviors could be seen as important in achieving a shared understanding between pharmacist and patient. Pharmacists also offered some reassurance and provided encouragement to patients with regard to their medication concerns. However, other emotional rapport-building behaviors meant to explore patients’ feelings were used far less frequently, such as expressions of empathy, statements showing concern or partnership statements. Pharmacists also demonstrated few instances of inquiring about the patient’s opinion and open questioning, which are important skills in eliciting patient input and conveying a sense of partnership to the patient. There may thus be scope for improvement in these communication areas. This study’s findings corroborate those of previous pharmacy communication studies. A recent study by Greenhill et al,55 using another communication analytic approach, indicated that pharmacists did not demonstrate information gathering skills and skills aimed at encouraging patient involvement in consultations. There are several possible explanations for these communication patterns based on the pharmacy literature. Community pharmacists face multiple competing demands, and limited time and lack of privacy in community pharmacy settings may have dictated a more directive and controlled form of communication.32,56,57 Pharmacists may also be reticent in approaching patients with questions, especially psychosocial ones, perhaps fearing they were intrusive or could trigger a response in which pharmacists would be uncomfortable dealing with.32 Many pharmacists have reported that a lack of training in mental health issues does not prepare them to communicate on sensitive topics in this area.57,58 However, evidence suggests that rapport-building talk such as empathy has a positive impact on therapeutic alliance,59 which

Communication category

Scenario 1

Scenario 2

Scenario 3

Total

Number of utterances

Number of utterances

Number of utterances

Number of utterances

Range

38 (2.4%) 0 34 3 1 0 0 261 (16.4%) 72 183 6 68 (4.3%) 68

44 (3.5%) 0 41 1 2 1 (0.1%) 1 272 (21.4%) 53 209 10 62 (4.9%) 62

40 (2.7%) 0 40 0 0 0 0 230 (15.4%) 20 207 3 103 (6.9%) 103

122 (2.8%) 0 115 4 3 1 (0.02%) 1 763 (17.5%) 145 599 19 233 (5.3%) 233

0–6 0 0–6 0–2 0–1 0–1 0–1 2–51 0–21 2–29 0–4 0–23 0–23

2 0 2 0 0 0 0 11 0 9.5 0 2 2

282 (17.7%) 0 25 0 196 61 709 (44.5%) 16 110 0 583 76 (4.8%) 0 59 17

170 (13.4%) 1 28 2 56 83 475 (37.3%) 4 45 0 426 131 (10.3%) 0 125 6

427 (28.6%) 0 17 1 351 58 456 (30.5%) 32 48 0 376 106 (7.1%) 0 63 43

879 (20.2%) 1 70 3 603 202 1640 (37.6%) 52 203 0 1385 313 (7.2%) 0 247 66

0–47 0–1 0–4 0–2 0–45 0–12 8–74 0–7 0–11 0 7–62 0–21 0 0–15 0–8

13 0 1 0 6.5 3 25.5 1 3 0 21.5 4.5 0 3 0.5

13 (0.8%) 1 12

1 (0.1%) 1 0

8 (0.5%) 8 0

22 (0.5%) 10 12

0–3 0–3 0–3

Median (Inter-quartile range)

0 0 0

(1–3) (1–3)

(7–17) (0–3) (6–12) (0–5.75) (0–5.75) (7–17) (0–2) (2–12.75) (1–5) (17.25–33) (0–1) (1.25–4) (15–29.75) (2–7) (2–5.75) (0–2)

Chong et al. / Research in Social and Administrative Pharmacy 10 (2014) 419–437

Question asking (biomedical) All questions (medical) All questions (therapeutic regimen) All questions (other) Bid for repetition Question asking (lifestyle/psychosocial) All questions (lifestyle/psychosocial) Information giving (biomedical) Gives information (medical condition) Gives information (therapeutic regimen) Gives information (other) Information giving (lifestyle/psychosocial) Gives information (lifestyle/ psychosocial) Patient activation and engagement Asks for service Asks for reassurance Asks for understanding Back–channels Paraphrase/checks for understanding Rapport-building (positive) Laughs/tells jokes Shows approval-direct Gives compliment-general Shows agreement, understanding Rapport-building (emotional) Empathy/legitimation Shows concern or worry Reassures, encourages or shows optimism Rapport-building (negative) Shows disapproval–direct Shows criticism-general

430

Table 4 Simulated patient communication by scenario

(52–88)

Rapport-building (social) Personal remarks, social conversation Procedural Transition words Gives orientation, instructions Unintelligible utterances TOTAL

57 (3.6%) 57 84 (5.3%) 66 18 7 (0.4%) 1595

28 (2.2%) 28 87 (6.8%) 81 6 2 (0.2%) 1273

32 (2.1%) 32 91 (6.1%) 52 39 0 1493

117 (2.7%) 117 262 (6%) 199 63 9 (0.2%) 4361

0–5 0–5 1–11 0–11 0–4 0–4 21–179

2 2 4 3 1 0 68.5

(1–2.75) (1–2.75) (3–6) (1.25–5) (0–2)

Chong et al. / Research in Social and Administrative Pharmacy 10 (2014) 419–437

431

in turn is positively associated with treatment response and medication adherence in patients with depression.6,60 Future research is needed on the balance that needs to be struck in terms of biomedical (therapeutic) information giving and more patientoriented communication by community pharmacists, and how this relates to patient care outcomes. The average patient-centeredness score for pharmacists in this study is comparable to a previous study involving physicians and using similar RIAS-based scoring methods.45 However, it is somewhat lower than the scores reported by Helitzer et al52 in an intervention study involving primary care providers that included physicians, physician assistants and nursing practitioners (with a mean patient-centered score ¼ 1.96). When comparing to another recent RIAS study conducted within the context of depression care,61 but involving psychiatrists during pharmacotherapy appointments, pharmacists in our study had lower proportions of partnership and rapport-building behaviors (39% vs. 53%) and psychosocial exchanges (5.4% vs. 20%). These findings may reflect differences in communication profiles among the different healthcare professions. Studies involving primary care providers have also reported communication skills training programs to be successful in improving patientcenteredness communication skills;52 such training programs may have the potential to offer similar benefits for community pharmacists. The findings of this study also suggest that there is some variability in the use of patientcentered communication across the different scenarios. Pharmacists’ patient-centeredness scores were highest in the first scenario whereby the patient is requesting information as a first-time antidepressant user, and lowest in the second scenario involving patient’s perceived lack of efficacy of antidepressant after treatment has started, despite the highest level of concern statements from the simulated patient in that scenario. It could be possible that the second scenario, involving a potential lack of therapeutic effectiveness, was more complicated and required some clinical judgment as compared to just provision of information about antidepressant as in the first scenario. This finding supports those of previous studies which indicate that pharmacists are most comfortable when offering advice for patients presenting with first-time prescriptions as compared to dealing with issues pertaining to repeat prescriptions.32,56,62 Previous research has also indicated that most community pharmacists

432

Summary measures Consultation length (min)

Pharmacist verbal dominancea

Patient-centeredness scoreb

Ratio of open questions: all questions

Ratio of psychosocial: biomedical exchanges

a

Mean (SD) Median (Inter-quartile Range Mean (SD) Median (Inter-quartile Range Mean (SD) Median (Inter-quartile Range Mean (SD) Median (Inter-quartile Range Mean (SD) Median (Inter-quartile Range

range)

range)

range)

range)

range)

Scenario 1 (n ¼ 20)

Scenario 2 (n ¼ 20)

Scenario 3 (n ¼ 20)

Total encounters (n ¼ 60)

6.30 (3.22) 5.18 (4.34–8.72) 0.75–12.53 1.46 (0.49) 1.42 (1.09–1.60) 0.80–2.76 1.74 (0.91) 1.44 (1.23–1.95) 0.74–4.41 0.50 (0.34) 0.48 (0.29–0.80) 0.00–1.00 0.22 (0.35) 0.06 (0.00–0.20) 0.00–1.15

5.34 (3.56) 4.94 (2.81–6.23) 1.40–16.93 1.45 (0.41) 1.32 (1.18–1.72) 0.90–2.68 1.31 (0.33) 1.24 (1.05–1.58) 0.87–2.25 0.51 (0.24) 0.50 (0.33–0.65) 0.14–1.00 0.10 (0.14) 0.04 (0.01–0.08) 0.00–0.47

4.97 (2.58) 3.97 (3.24–6.38) 2.05–10.80 1.46 (0.36) 1.40 (1.21–1.73) 0.80–2.11 1.49 (0.46) 1.42 (1.09–1.95) 0.80–2.41 0.51 (0.30) 0.45 (0.31–0.74) 0.00–1.00 0.11 (0.11) 0.09 (0.05–0.14) 0.00–0.49

5.54 (3.14) 4.80 (3.25–6.99) 0.75–16.93 1.46 (0.41) 1.40 (1.18–1.72) 0.80–2.76 1.51 (0.64) 1.34 (1.13–1.66) 0.74–4.41 0.51 (0.29) 0.50 (0.32–0.74) 0.00–1.00 0.14 (0.23) 0.07 (0.00–0.15) 0.00–1.15

Pharmacist verbal dominance was calculated as a ratio of all pharmacist statements to patient statements, excluding “back-channels” such as “Uh-huh and “Mm-hmm”. Patient-centeredness score was calculated as the ratio of all codes relating to socio-emotional and psychosocial elements of exchange divided by codes that further the biomedical agenda. b

Chong et al. / Research in Social and Administrative Pharmacy 10 (2014) 419–437

Table 5 Summary measures of pharmacists’ communication behavior

Chong et al. / Research in Social and Administrative Pharmacy 10 (2014) 419–437

did not view monitoring of response to treatment in depression as part of their role.56 As continuous monitoring of treatment is important to ensure quality use of antidepressants, this finding definitely deserves further investigation and consideration when determining pharmacists’ training needs in this area. Pertaining to the influence of pharmacist characteristics on patient-centeredness communication, this study found that pharmacists who have been registered for less than 5 years received higher patient-centered scores compared to pharmacists who have been registered for more than 5 years; however, this was significant only in the first scenario. One possible explanation for this finding is that there could be an increased emphasis on communication skills and patientcentered approaches in recent pharmacy curriculum.34 This study did not find any differences for patient-centered communication in terms of pharmacists’ age, gender, type of pharmacy and number of prescriptions dispensed. This, however, needs to be interpreted with caution owing to the small sample size of this study. Previous research in medical settings has indicated that female physicians adopt more patient-centered communication in comparison to male physicians63; whilst physician personality traits such as openness to feelings are associated with patient-centered communication patterns.64 Further research with larger samples may be needed to investigate the extent that patient-centered communication behaviors are influenced by different pharmacist and patient characteristics within the context of mental healthcare. This study supports the utility of the RIAS in pharmacy communication research. Most utterances by pharmacists and simulated patients in this study were categorized without any difficulties. Previous pharmacy studies that have used RIAS were in the context of structured pharmaceutical care consultations,65 and assessment of pharmacy students’ interview skills.66 In this study, it was found that RIAS was also wellsuited to describe brief consultations taking place at community pharmacy counters, and to assess core elements of patient-centered communication. In line with pharmacists’ expanding roles, the value of effective communication in the practice of pharmacy is becoming increasingly important. The RIAS can provide a useful framework for systematically examining pharmacist–patient interactions in the pharmacy, evaluating key elements of patient-centered communication, and guiding

433

training efforts for pharmacists. However, this method does present potential drawbacks in that it may overlook the multidimensional nature of communication, and may miss some of the depth and complexity of human interactions that are better captured with qualitative techniques.67 In line with this, some authors have suggested the RIAS to be applied in combination with qualitative methods (such as discourse analysis) and sequential analysis in order to provide insight into the dynamic interplay of the communication process.67,68 Limitations In addition to the aforementioned caveats about the use of RIAS, there are other limitations to this study. First, this was exploratory, featuring a relatively small sample size, and further research would be needed to assess the generalizability of the findings. Second, the volunteer rate for participation in this study was low; this is however comparable to other similar simulated patient studies.69 Participating pharmacists may also have been relatively more interested in or positive toward the communication process. Third, the use of simulated patients presents a potentially confounding variable. Although participating pharmacists commented on the realism of the scenarios as resembling consultations they would encounter in routine practice, it is possible that actual depressed patients may have impaired responsiveness to activating communication and may be less likely to request information or express partnership statements.61 There may thus be a possibility that simulated patients in this study are more interactive compared to actual depressed patients. That being said, this further underscores the importance of pharmacists’ patient-centeredness communication in this group of patients to elicit their concerns and facilitate patients’ involvement in treatment. Also, simulated patient visits in this study represent single visits and may not have captured pharmacist communication style with established patients. Fourth, the authors did not assess pharmacists’ non-verbal behaviors, which are also important aspects of communication in the establishment of the pharmacist–patient relationship. For example, empathy conveyed by non-verbal gestures such as facial expressions and postures were not accounted by the RIAS, which may have led to underestimation of empathy. Despite these limitations, this study provides a preliminary foundation for analyzing and

434

Chong et al. / Research in Social and Administrative Pharmacy 10 (2014) 419–437

understanding pharmacist–patient interactions, especially in a mental health context, and identifies some directions for future research and communication training in this area. More research is needed to explore the influence of pharmacist and patient characteristics on pharmacist communication behaviors, and the impact of pharmacist communication behaviors on patient care outcomes including medication adherence and patient satisfaction with pharmacy services. Additionally, the present study has identified potential areas for future training to advance pharmacist–patient interactions, especially in a patient-centered approach. Related to that, communication interventions such as training programs should be evaluated as a mechanism to improve pharmacists’ communication skills in a mental health context.

2.

3.

4.

5.

6.

Conclusion This study demonstrates that it is feasible to use simulated patient methods to identify pharmacist communication behaviors. Additionally, the RIAS appears suited as a tool to code brief consultations between pharmacists and patients. The findings of this study indicate that community pharmacists tend to adopt a “medicationcentered” approach when providing counseling on antidepressant-related issues. There is scope for improvement in pharmacists’ patient-centered behaviors, particularly on lifestyle/psychosocial discussions, facilitating patient’s involvement in treatment and emotional rapport-building. The RIAS can provide a framework to develop communication-training programs to improve patient-centeredness skills, and to assess professional developments in pharmacist communication. Acknowledgments We thank the community pharmacists and simulated patients for their participation in this study. In addition, we also acknowledge Susan Larson and Debra Roter for providing training and advice on the use of RIAS. We also thank Shervin Amirtabar for his assistance during the data collection process. Declaration of interest: The authors report no conflicts of interest.

7.

8.

9.

10.

11.

12.

13.

14.

15.

References 1. Kessler RC, Berglund P, Demler O, et al. The epidemiology of major depressive disorder: results from

16.

the National Comorbidity Survey Replication (NCS-R). JAMA 2003;289:3095–3105. Pyne JM, Patterson TL, Kaplan RM, Gillin JC, Koch WL, Grant I. Assessment of the quality of life of patients with major depression. Psychiatr Serv 1997;48:224–230. Greenberg PE, Kessler RC, Birnbaum HG, et al. The economic burden of depression in the United States: how did it change between 1990 and 2000? J Clin Psychiatry 2003;64:1465–1475. Anderson IM, Ferrier IN, Baldwin RC, et al. Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2000 British Association for Psychopharmacology guidelines. J Psychopharmacol 2008;22:343–396. Depression: The Treatment and Management of Depression in Adults. National Institute for Health and Clinical Excellence, 2009. Available at: http://www. nice.org.uk/CG90. Accessed 28.01.13. Lingam R, Scott J. Treatment non-adherence in affective disorders. Acta Psychiatr Scand 2002;105: 164–172. Pampallona S, Bollini P, Tibaldi G, Kupelnick B, Munizza C. Patient adherence in the treatment of depression. Br J Psychiatry 2002;180:104–109. Chong WW, Aslani P, Chen T. Effectiveness of interventions to improve antidepressant medication adherence: a systematic review. Int J Clin Pract 2011;65:954–975. Melfi CA, Chawla AJ, Croghan TW, Hanna MP, Kennedy S, Sredl K. The effects of adherence to antidepressant treatment guidelines on relapse and recurrence of depression. Arch Gen Psychiatry 1998; 55:1128–1132. Geddes JR, Carney SM, Davies C, et al. Relapse prevention with antidepressant drug treatment in depressive disorders: a systematic review. Lancet 2003;361:653–661. Sirey JA, Bruce ML, Alexopoulos GS, et al. Perceived stigma as a predictor of treatment discontinuation in young and older outpatients with depression. Am J Psychiatry 2001;158:479–481. Demyttenaere K. Risk factors and predictors of compliance in depression. Eur Neuropsychopharmacol 2003;13(Suppl 3):S69–S75. Keller MB, Hirschfeld RM, Demyttenaere K, Baldwin DS. Optimizing outcomes in depression: focus on antidepressant compliance. Int Clin Psychopharmacol 2002;17:265–271. Aikens JE, Nease DE Jr, Klinkman MS. Explaining patients’ beliefs about the necessity and harmfulness of antidepressants. Ann Fam Med 2008;6:23–29. Hunot VM, Horne R, Leese MN, Churchill RC. A cohort study of adherence to antidepressants in primary care: the influence of antidepressant concerns and treatment preferences. Prim Care Companion J Clin Psychiatry 2007;9:91–99. Brown C, Battista DR, Bruehlman R, Sereika SS, Thase ME, Dunbar-Jacob J. Beliefs about

Chong et al. / Research in Social and Administrative Pharmacy 10 (2014) 419–437

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

antidepressant medications in primary care patients: relationship to self-reported adherence. Med Care 2005;43:1203–1207. Anderson C, Roy T. Patient experiences of taking antidepressants for depression: A secondary qualitative analysis. Res Soc Adm Pharm 2012. http:// dx.doi.org/10.1016/j.sapharm.2012.11.002. Givens JL, Datto CJ, Ruckdeschel K, et al. Older patients’ aversion to antidepressants. A qualitative study. J Gen Intern Med 2006;21:146–151. Malpass A, Shaw A, Sharp D, et al. “Medication career” or “moral career”? The two sides of managing antidepressants: a meta-ethnography of patients’ experience of antidepressants. Soc Sci Med 2009; 68:154–168. Grime J, Pollock K. Patients’ ambivalence about taking antidepressants: a qualitative study. Pharm J 2003;271:516–519. van Geffen ECG, Hermsen JHCM, Heerdink ER, Egberts ACG, Verbeek-Heida PM, van Hulten R. The decision to continue or discontinue treatment: experiences and beliefs of users of selective serotoninreuptake inhibitors in the initial months–a qualitative study. Res Soc Adm Pharm 2011;7:134–150. Verbeek-Heida PM, Mathot EF. Better safe than sorry–why patients prefer to stop using selective serotonin reuptake inhibitor (SSRI) antidepressants but are afraid to do so: results of a qualitative study. Chronic Illn 2006;2:133–142. Bultman DC, Svarstad BL. Effects of physician communication style on client medication beliefs and adherence with antidepressant treatment. Patient Educ Couns 2000;40:173–185. Bull SA, Hu XH, Hunkeler EM, et al. Discontinuation of use and switching of antidepressants Influence of patient-physician communication. JAMA 2002;288:1403–1409. Badger F, Kingscote-Davies T, Nolan P. The pharmacist’s role in the medicinal management of depression. Nurs Stand 2002;16:33–40. Bultman DC, Svarstad BL. Effects of pharmacist monitoring on patient satisfaction with antidepressant medication therapy. J Am Pharm Assoc 2002; 42:36–43. Robinson JD, Segal R, Lopez LM, Doty RE. Impact of a pharmaceutical care intervention on blood pressure control in a chain pharmacy practice. Ann Pharmacother 2010;44:88–96. Johnson CL, Nicholas A, Divine H, Perrier DG, Blumenschein K, Steinke DT. Outcomes from DiabetesCARE: a pharmacist-provided diabetes management service. J Am Pharm Assoc 2008;48: 722–730. Adler DA, Bungay KM, Wilson IB, et al. The impact of a pharmacist intervention on 6-month outcomes in depressed primary care patients. Gen Hosp Psychiatry 2004;26:199–209.

435

30. Finley PR, Rens HR, Pont JT, et al. Impact of a collaborative care model on depression in a primary care setting: a randomized controlled trial. Pharmacotherapy 2003;23:1175–1185. 31. Rickles NM, Svarstad BL, Statz-Paynter JL, Taylor LV, Kobak KA. Pharmacist telemonitoring of antidepressant use: effects on pharmacistpatient collaboration. J Am Pharm Assoc 2005; 45:344–353. 32. Landers M, Blenkinsopp A, Pollock K, Grime J. Community pharmacists and depression: the pharmacist as intermediary between patient and physician. Int J Pharm Pract 2002;10:253–265. 33. van Geffen ECG, Kruijtbosch M, Egberts ACG, Heerdink ER, van Hulten R. Patients’ perceptions of information received at the start of selective serotonin-reuptake inhibitor treatment: implications for community pharmacy. Ann Pharmacother 2009;43:642–649. 34. de Oliveira DR, Shoemaker SJ. Achieving patient centeredness in pharmacy practice: openness and the pharmacist’s natural attitude. J Am Pharm Assoc 2006;46:56–66. 35. Epstein RM, Franks P, Fiscella K, et al. Measuring patient-centered communication in PatientPhysician consultations: Theoretical and practical issues. Soc Sci Med 2005;61:1516–1528. 36. Mead N, Bower P. Patient-centredness: a conceptual framework and review of the empirical literature. Soc Sci Med 2000;51:1087–1110. 37. Street RL Jr. Analyzing communication in medical consultations. Do behavioral measures correspond to patients’ perceptions? Med Care 1992; 30:976–988. 38. Stevenson FA, Cox K, Britten N, Dundar Y. A systematic review of the research on communication between patients and health care professionals about medicines: the consequences for concordance. Health Expect 2004;7:235–245. 39. Stewart M, Brown JB, Donner A, et al. The impact of patient-centered care on outcomes. J Fam Pract 2000;49:796–804. 40. Robinson JH, Callister LC, Berry JA, Dearing KA. Patient-centered care and adherence: definitions and applications to improve outcomes. J Am Acad Nurse Pract 2008;20:600–607. 41. Deegan PE, Drake RE. Shared decision making and medication management in the recovery process. Psychiatr Serv 2006;57:1636–1639. 42. Shah B, Chewning B. Conceptualizing and measuring pharmacist–patient communication: a review of published studies. Res Soc Adm Pharm 2006;2: 153–185. 43. Roter D, Larson S. The Roter interaction analysis system (RIAS): utility and flexibility for analysis of medical interactions. Patient Educ Couns 2002; 46:243–251.

436

Chong et al. / Research in Social and Administrative Pharmacy 10 (2014) 419–437

44. Roter DL, Stewart M, Putnam SM, Lipkin M Jr, Stiles W, Inui TS. Communication patterns of primary care physicians. JAMA 1997;277:350–356. 45. Cooper LA, Roter DL, Johnson RL, Ford DE, Steinwachs DM, Powe NR. Patient-centered communication, ratings of care, and concordance of patient and physician race. Ann Intern Med 2003;139: 907–915. 46. Mead N, Bower P. Measuring patient-centredness: a comparison of three observation-based instruments. Patient Educ Couns 2000;39:71–80. 47. Cavaco A, Roter D. Pharmaceutical consultations in community pharmacies: utility of the Roter Interaction Analysis System to study pharmacist-patient communication. Int J Pharm Pract 2010;18:141– 148. 48. Watson MC, Norris P, Granas AG. A systematic review of the use of simulated patients and pharmacy practice research. Int J Pharm Pract 2006;14:83–93. 49. Chong WW, Aslani P, Chen TF. Health care providers’ perspectives of medication adherence in the treatment of depression: a qualitative study. Soc Psychiatry Psychiatr Epidemiol 2012. http://dx.doi. org/10.1007/s00127-012-0625-3. 50. Roter D. The Roter Method of Interaction Process Analysis. RIAS Manual. Baltimore; 2012. 51. Gisev N, Bell JS, Chen TF. Interrater agreement and interrater reliability: Key concepts, approaches, and applications. Res Soc Adm Pharm 2013;9: 330–338. 52. Helitzer DL, Lanoue M, Wilson B, de Hernandez BU, Warner T, Roter D. A randomized controlled trial of communication training with primary care providers to improve patient-centeredness and health risk communication. Patient Educ Couns 2011;82:21–29. 53. Pawlikowska T, Zhang W, Griffiths F, van Dalen J, van der Vleuten C. Verbal and non-verbal behavior of doctors and patients in primary care consultations - how this relates to patient enablement. Patient Educ Couns 2012;86:70–76. 54. Vail L, Sandhu H, Fisher J, Cooke H, Dale J, Barnett M. Hospital consultants breaking bad news with simulated patients: an analysis of communication using the Roter Interaction Analysis System. Patient Educ Couns 2011;83:185–194. 55. Greenhill N, Anderson C, Avery A, Pilnick A. Analysis of pharmacist–patient communication using the Calgary-Cambridge guide. Patient Educ Couns 2011;83:423–431. 56. Gardner DM, Murphy AL, Woodman AK, Connelly S. Community pharmacy services for antidepressant users. Int J Pharm Pract 2001;9:217–224. 57. Scheerder G, De Coster I, Van Audenhove C. Pharmacists’ role in depression care: a survey of atti-

58.

59.

60.

61.

62.

63.

64.

65.

66.

67.

68.

69.

tudes, current practices, and barriers. Psychiatr Serv 2008;59:1155–1160. Phokeo V, Sproule B, Raman-Wilms L. Community pharmacists’ attitudes toward and professional interactions with users of psychiatric medication. Psychiatr Serv 2004;55:1434–1436. Epstein RM, Hadee T, Carroll J, Meldrum SC, Lardner J, Shields CG. “Could this be something serious?” Reassurance, uncertainty, and empathy in response to patients’ expressions of worry. J Gen Intern Med 2007;22:1731–1739. Krupnick JL, Sotsky SM, Simmens S, et al. The role of the therapeutic alliance in psychotherapy and pharmacotherapy outcome: findings in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. J Consult Clin Psychol 1996;64:532–539. Cruz M, Roter D, Cruz RF, et al. Psychiatrist– patient verbal and nonverbal communications during split-treatment appointments. Psychiatr Serv 2011;62:1361–1368. van Hulten R, Blom L, Mattheusens J, Wolters M, Bouvy M. Communication with patients who are dispensed a first prescription of chronic medication in the community pharmacy. Patient Educ Couns 2011;83:417–422. Roter DL, Hall JA. Physician gender and patient-centered communication: a critical review of empirical research. Annu Rev Public Health 2004;25:497–519. Chapman BP, Duberstein PR, Epstein RM, Fiscella K, Kravitz RL. Patient-centered communication during primary care visits for depressive symptoms: what is the role of physician personality? Med Care 2008;46:806–812. Cavaco AM, Romano J. Exploring pharmacists’ communication with customers through screening services. Patient Educ Couns 2010;80:377–383. Kubota Y, Yano Y, Seki S, et al. Assessment of pharmacy students’ communication competence using the Roter Interaction Analysis System during objective structured clinical examinations. Am J Pharm Educ 2011;75:43. Chou W-YS, Han P, Pilsner A, Coa K, Greenberg L, Blatt B. Interdisciplinary research on patient-provider communication: a crossmethod comparison. Commun Med 2011;8:29–40. Schouten BC, Meeuwesen L, Harmsen HA. The impact of an intervention in intercultural communication on doctor–patient interaction in The Netherlands. Patient Educ Couns 2005;58:288–295. Weiss MC, Booth A, Jones B, Ramjeet S, Wong E. Use of simulated patients to assess the clinical and communication skills of community pharmacists. Pharm World Sci 2010;32:353–361.

Chong et al. / Research in Social and Administrative Pharmacy 10 (2014) 419–437

Appendix A Simulated patient scenario description Scenario 1: Initiation of antidepressant treatment Simulated patient enters the pharmacy, bringing in a note containing the name of an antidepressant medication (sertraline 50 mg). She asks the pharmacist for information about the medication: “Can you tell me a little more about this medicine?” Upon questioning, she tells the pharmacist that she has been newly diagnosed with depression, and has just been prescribed that antidepressant from a general practitioner. Since this is her first time being on an antidepressant, she wants some information about the antidepressant before deciding whether to begin treatment. She also has some reservations about taking antidepressants, particularly about the sideeffects, and concerns about whether antidepressants are addictive. If the pharmacist inquires about her symptoms, the patient describes feeling low, unable to sleep and having difficulty concentrating. She does not have any other medical conditions and is not on any other medications. Scenario 2: Execution of antidepressant treatment Simulated patient enters the pharmacy, and asks to speak to the pharmacist about St John’s Wort: “My friend told me about this St John’s

437

Wort. Is it really effective in treating depression?” If prompted by the pharmacist, the patient explains that he is interested to try St John’s Wort as the antidepressant (fluoxetine 20 mg) that he has been taking for the past 2 weeks does not appear to be effective. The patient reports still feeling low and having trouble sleeping and focusing on his job. If asked about side-effects, the patient reports experiencing some nausea and dizziness initially but those have been resolved. The patient does not have any other medical conditions and is not on any other medications. Scenario 3: Discontinuation of antidepressant treatment Simulated patient enters the pharmacy with an empty blister pack of escitalopram 20 mg. She asks to speak to the pharmacist about stopping the antidepressant: “I have been on this medication for a while, and am thinking of stopping it. Can I just have some advice on that?” Upon further questioning, the patient says she has been on the antidepressant for about 3 months. She says that she is no longer depressed, and does not see the point of continuing treatment. She is also concerned about the long-term effects of being on an antidepressant medication. She does not have any other medical conditions and is not on any other medications.