Implications. This study demonstrates the use of automated databases versus randomized clinical trials for comparative effectiveness of clinical specialist versus nonspecialist ICU services. Although subject to the limitations of retrospective studies, these studies are conducted at considerably lower cost, make more efficient use of resources, and can be generalized beyond a single hospital with a single pharmacist.

Valuck and colleagues⁺² reported that depression diagnosing decreases persist, that substitute care did not compensate for declines in antidepressant treatment in pediatric and young adults, and that spillover to adults continues, indicating that unintended effects of policy may be long term, clinically meaningful, and nationwide. The authors studied the consequences of the October 2003 FDA public health advisory on the risk of suicidality for depressed pediatric patients treated with antidepressants and the follow-up warnings in May 2007. The authors performed a time series analysis using a national ambulatory care database of pediatric, young adult, and adult patients with new depression episodes. Changes in pediatric depression care were similar to changes for adults. National diagnosis rates of depression return to pre-1999 levels for pediatric and pre-2004 levels for adult patients. Numbers of prescriptions for anxiolytic and atypical antipsychotic medications were similar to preadvisory levels, and selective serotonin reuptake inhibitor (SSRI) use decreased in all three age groups, although SSRI–norepinephrine inhibitors increased for adults.

Implications. Public health policy often has unintended effects that should be monitored for potential adverse consequences. In this study, the data suggest that psychiatrists may not differentiate between age groups in their prescription for antidepressants. Moreover, psychiatrists may be reticent to diagnose depression in pediatric and adult patients because of the advisories about antidepressant use. They may be reticent because of the potential risk and liability of prescribing an antidepressant, which is first-line treatment for depression.

According to a study from Sweden by Gillespie et al.,⁺³ if implemented on a population basis, the addition of pharmacists to health care teams would lead to major reductions in morbidity and health care costs. Patients 80 years or older are often not included in clinical or interventional trials. This study focused on them to investigate the effectiveness of a ward-based pharmacist service in reducing morbidity and improving outcomes in the hospital. Patients randomized to the control group (n = 186) received standard care and those randomized to the intervention group (n = 182) received medication reconciliation upon admission, received medication review, were educated and monitored throughout their admission about their medications, and received discharge counseling, including changed medications, therapeutic and monitoring goals, and a 2-month follow-up call. Primary outcomes were frequency of emergency department visits and readmissions during the 12-month follow-up. For the intervention group, a 16% reduction occurred in all visits to the hospital, drug-related readmissions were reduced by 80%, and the total cost was lowered by a net of $230 per patient after accounting for intervention costs.

Implications. Pharmacists internationally provide evidence of the value of pharmacy services in all settings. One question that has been posed is whether evidence from countries other than the United States should be used in the health care reform debate.