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Australian Journal of Pharmacy : October 2006
rural report rural pharmacy matters Patrick Ball, Foundation Professor of Rural Pharmacy, Charles Sturt University Depression in rural and remote pharmacy T HE recently published Pharmacy Guild of Australia report, The role of the community pharmacist in the management of depression, describes a Guild-supported project undertaken by Judith Crockett, Sue Taylor, Anita Grabham and Pam Stanford at the University of Sydney (http://beta.guild.org.au/uploaded- files/Rural_Pharmacy/Grants_and_ Scholarships/2003_922%20Final.pdf). It makes valuable reading for rural and remote pharmacists because it clearly highlights what a major issue depression has become in these communities, and what pharmacists can contribute. The report documented the incidence of depression in Australia as around 800,000 patients per year or around 6 per cent of the total population. It notes spe- cific figures for rural and remote Australia are not available, but that death by sui- cide is almost twice as common in male farmers and farm workers than in the gen- eral male population. Similar findings have been reported from the UK,1 USA1 and New Zealand.2 the This has been attributed to stresses arising from the globalisation of trade distorting local mar- ket conditions, and from restructuring and downsizing of the rural workforce with increasing mechanisation.3,4,5 To these are added the irregular nature of agricultural incomes, the need to budget ahead and secure lines of credit in an uncertain financial climate.6,7 This has been seriously exacerbated by recent escalations in fuel costs and interest rates. The inherent problems of geographical and social isolation are being com- pounded by these costs.7 resilient.6,7 There have always been bad years, bad seasons and natural disasters, but extended issues such as the continu- ing drought in many areas has stretched this resilience beyond endurance. In the area of mental illness, there is a common perception that others will see it as weakness. Many rural dwellers, males particularly, are perceived to be reticent about expressing their feelings. They do not seek assistance in the early stages of their illness (when treatment outcomes will generally be better) and the first pre- sentation may be the suicide attempt. It is not surprising, therefore, that a number of studies suggest that psychological stress It is at times such as the collection of the first prescription or ongoing repeats that further advice and reinforcement can be better assimilated In areas where there are no transport alternatives, trad- ing down a large-engine vehicle for a smaller one in the present market would lose thousands of dollars. The only possi- ble saving for many is to cut out every non-essential trip, reducing leisure activi- ties, increasing social isolation and adding to relationship stress. Rural communities have an image of being close-knit, mutually supportive and and depression are some of the most com- mon and costly, yet least acknowledged health issues in rural communities. The report discusses the various strate- gies for the management of depression and notes that psychotherapy and group therapy may be as effective as medication. However, it is observed that facilities for such services in rural areas are limited and the mainstay of therapy is antidepressant medications. No pharmacist needs to be reminded of the long onset time of these agents and the side effects that make them difficult for the patient to persevere with. Yet issues such as the severe weight gain experienced by 30 ? THE AUSTRALIAN JOURNAL OF PHARMACY VOL.87 OCTOBER 2006 some patients on the SSRIs appear to be less well understood by patients and phar- macists. Further, in problematic times when relationships may already be under stress, loss of libido is another side effect that needs to be discussed and managed, but which many may find very difficult to broach and discuss in a small community where everyone knows everyone else’s business. The literature suggests that between 30 per cent and 80 per cent of patients, and probably more than 50 per cent, stop tak- ing their medication prematurely, but that this can be reduced with appropriate information and ongoing support.8,9 This is, again, of special relevance in rural areas where antidepressant medication is likely to be the only therapy the patient will receive, and opportunities for reinforce- ment and support are limited. Horne et al10 found two types of belief to be influential in the adherence of patients to their medication: the extent to which the patient believes in their own need for the medication, and their fears about it. While many GPs try hard to explain these agents when initiating therapy, it is a dif- ficult time for the patient to absorb the advice when they may be confronting the fact that they have a mental illness for the first time. It is at times such as the collection of the first prescription or ongoing repeats that further advice and reinforcement can be better assimilated. The report noted, in particular, the benefits and the value per- ceived by the patient of a follow-up tele- phone call from the pharmacist to see how they were progressing. It is believed that members of the pro- ject group are contemplating further work in this area. In the meantime it is recom- mended that rural pharmacists access and read this report, and consider what they can bring to the amelioration of this com- mon and debilitating condition. References available on request