Mental health is a topic that gets stigmatized too often in our society. It’s a place where conversations can be quite challenging and, in some cases, non-existent. In recent years, mental health has taken a very important stance in healthcare across disciplines and communities, although early screening and follow-up at the primary care level remain crucial.

The Community Pharmacist and Mental Health Care

 As a community pharmacist, I see it all – from patients with bipolar depression to caregivers of those with schizophrenia to severe cases of adults (or parents of teens) with suicidal ideations. Among the most accessible of healthcare professionals, people turn to pharmacists as a trusted source of advice, whether they are picking up a specific prescription, calling about side effects, or stopping into the pharmacy for a one-on-one consult.

In this new column, my goal is to share real patient case scenarios* and how I handled them as an integrative pharmacist. I hope the advice given and the lessons learned may help other community pharmacists – and their cross-disciplinary colleagues – working to address mental health-related questions.

Pharmacy Consult: My Teen Is Not Taking Her Antidepressants

The Scenario at the Pharmacy Counter

“Hi, I’m here to pick up my daughter’s medications. She is not doing so well and I need some advice from the pharmacist. How do I get her to take her medications regularly? She’s 17 and sometimes refuses to take them. She is so depressed and spends all her time in her room and on social media, which is the biggest mistake I allowed her to make. This pandemic has pushed her into a very dark place mentally.”

Upon further inquiry, I learned that the 17-year-old is on escitalopram 20 mg for depression and trazodone 100 mg for insomnia that kicked in after the pandemic.

The mother continued, “She says she feels embarrassed to take her medications. She doesn’t want anyone to know she is having issues.”

In the Consult Room

I invited the mother, Jennifer, and her daughter, Sabrina, to meet with me in the consultation room.* We discussed the following:

  1. Sabrina’s reasons for not wanting to take escitalopram daily
  2. Her reasons for not wanting to take trazodone for sleep
  3. Sabrina had been stable on her medications for a year (starting at age 16, stopping when the COVID-19 pandemic began)
  4. Sabrina was in charge of her own meds since she started them, but when the pandemic began, her mom took over the dispensing, causing major friction between mother and daughter

During our consultation, Sabrina’s mom mentioned that their pediatrician referred them to a pediatric psychiatrist when Sabrina was 15-and-a-half years old – the age when she began having a change in her moods. At the age of 16, her psychiatrist started her on medication. She tried a few different antidepressants in the course of 6 months and found escitalopram to be the most effective.

Further during our conversations, Sabrina disclosed that her medications were discovered by her friends at a recent sleepover party she was hosting. She would regularly take her escitalopram prior to school, and her trazodone an hour before bedtime. When the pandemic began, she felt alone, isolated, and stuck to the four corners of her room – as many teens did during the nationwide lockdown.

As we talked, Sabrina confided that she just didn’t want to take her antidepressant because she felt ashamed after her friends found out. She shared that she stopped taking the meds for a while and when her mom started giving her the medicine, she would just spit it out. She claimed that it was not helping her feel better.

I explained that withdrawal side effects can occur when stopping a medication abruptly. I also explained that it would take a good 4 weeks to achieve something we call “steady state” in pharmacokinetics.

I also allowed my personal journey with mental health to come into the consultation discussion, sharing my own history of loss, grief, and depression. I explained the self-stigma that I placed on myself when I went on medication, despite my clinical training and knowledge of mental health.  I shared that I felt the same “shame” she was describing.

The Wrap-Up: Adherence Strategies

As we wrapped up our 15-minute consultation, I advised Sabrina to let her mom help her with dispensing and handling of her medications, until she felt comfortable. Otherwise, I emphasized again that it would take a good month to feel a difference in her mood.

I shared with Sabrina that she is not alone – that she is at an age where many teens are dealing with emotions, from the pressure of school to the pressure of fitting in. So many teens like her are struggling with mental health. I conveyed with her that this pandemic has been like no other and that, as a pharmacist, I am seeing teen rates of 1 in 4 being prescribed an antidepressant.

Last month, I was able to catch up with Sabrina and her mom when they came to pick up their medications. I was happy to hear that Sabrina is doing well. She joined the soccer team at her high school. She has been stable and compliant with her medications as well as seeing her psychiatrist twice a month.

Professional Takeaways

As clinicians, we know that medication adherence is a big issue in patient care – and this is a common experience at the pharmacy counter with mental health medications In fact, rates of nonadherence in those with serious mental illness is as high as 50% to 75%.2 Some studies have shown that as many as half of individuals treated for chronic diseases may be nonadherent to their medical regimen, and this percentage can climb even higher in those with certain psychiatric disorders.3-5

Often, as is in the presented case, the reason for nonadherence is stigma, whether from the patient’s friends, family, or themselves. It is unfortunate in our society that people may be quick to judge someone on an antidepressant but less so for someone on a drug for, say hypertension or diabetes, or what may be considered a “physical” medical issue.

Educating patients, and caregivers, on how these medications work can reinforce the need to be adherent. We must teach our patients, their family members, and the community at large that, when we look at the psychiatric disorders in the brain, there is an actual chemical imbalance that is happening and medications can specifically target and adjust these imbalances. Taking prescribed medication at the right time and right amount is crucial.

*All patient details have been modified for privacy

Monica Krishnan, PharmD

Monica Krishnan, PharmD

About Dr. Krishnan and the Launch of this Column

My involvement with mental health advocacy came as a desire to be of service, not only as a clinical pharmacist but also as someone who suffered a very profound loss. Ten years ago, I lost my husband to brain cancer. We had two little girls, aged 3 and 5 years at the time. My world turned upside down, I hit rock bottom. I went through many stages of grief, including depression. I approached my journey with the help of both Western and Eastern medicine and, truthfully, I am still trekking. But after a lot of hard work and learning to deal with societal stigma, I realized my story could help others. So, in 2018, I began working as a public speaker around mental health and am currently integrating this work into my day job as a community pharmacist.

Find me on Instagram @drmonicapharmd  My full bio

Last Updated: Oct 12, 2021