If the integrated care management professional is meeting with the individual, he/she should be asked to bring medication bottles to appointments if at all possible. It is a challenge to determine if the individual patient is mixing all their medications in one bottle, not taking the full dosage, or other issues related to non-adherence if the only time for assessment is via the phone.
Individuals may present at the emergency room with depression symptoms, co-occurring illness symptoms or suicide attempts. If this is the case, the emergency room is where the process of assessment of medication knowledge should begin. The assessment process should then transition through the hospital stay. As part of this process, the caregivers of hospitalized individuals should be asked to bring in medications the individual was taking at home if this did not occur in the emergency room. Medication reconciliation and the communication of this process and its outcome must be communicated to the full care management and treatment team. Transition of care along the continuum is critical. If the individual with depression falls through cracks in the system, often they will not be able to recover due to the constant feeling of hopelessness.
When discussing barriers to adherence in individuals with depression, it is critical to include routine, over-the-counter, alternative treatments, recreational drugs, and other medications taken as needed. Much information may be gained, but make sure not to present these questions as a test but as part of the conversation. It may take more than one phone call or interaction because of reduced energy levels and cognitive deficiencies.
The case manager may learn that the individual sometimes takes St. John’s wort with or without discussion with the physician. St. John’s wort has been used for treatment of depression. According to the National Center for Complimentary and Alternative Medicine division of the National Institutes of Health:73
An analysis of the results of 37 clinical trials concluded that St. John’s wort may have only minimal beneficial effects on major depression. However, the analysis also found that St. John’s wort may benefit people with minor depression; these benefits may be similar to those from standard antidepressants. Overall, St. John’s wort appeared to produce fewer side effects than some standard antidepressants.
As the assessment of the medication knowledge continues and the individual indicates taking St. John’s wort, the following may be helpful for further educational discussion and/or physician consultation.
St. John’s wort may interact with antidepressant medications that are used to treat depression or other mood disorders, including tricyclics, SSRIs, and monoamine oxidase inhibitors (MAOIs) such as phenelzine.