The Role of the Community Pharmacist in Mental Health

 US Pharm. 2018;43(11):13-20.

ABSTRACT: Millions of Americans suffer from a mental-health condition. Pharmacists are in prime positions to interact with and assist in caring for those with mental health issues. Community pharmacy practitioners can be aware of and recognize symptoms associated with mental illness, assist with triaging patients to the appropriate care provider, closely monitor patient medication adherence, and serve as an education resource for the community.

About one in five Americans are currently living with mental illnesses; one in six people in the United States use psychotropic medications for problems relating to mental illness.^1,2 Psychotropic medications represent approximately 13% of the top 300 most frequently prescribed medications in the U. S.³ Because mental illness is so prevalent and many patients are prescribed psychotropic medications, it is important for community pharmacists, as the most accessible healthcare providers, to be well informed. Some pharmacists may feel uncomfortable owing to social stigma surrounding mental health. However, if pharmacists are aware of the role they can play within mental health, they can be useful resources for these patients and improve their overall care.

Community pharmacists can have an impact on mental-health outcomes by educating patients about psychiatric drugs to improve adherence, recognizing mental illness through observation and screening, providing resources and referrals for patients who may need them, and evaluating medication lists for drugs that may alter patients’ mental status.

Medication Adherence

Patients with mental-health conditions typically have low adherence rates to their psychiatric medications. Reports of patients on antidepressant therapy have shown nonadherence rates as high as 56%; patients with schizophrenia and bipolar disorder have reported nonadherence rates up to 61% and 60%, respectively.⁴ Nonadherence may include patients not filling initial prescriptions, adjusting their own dosing regimens, or stopping their medications completely.⁵ Reasons for these types of nonadherence issues may involve patients’ beliefs regarding the medication, side effects that they may have experienced, or the cost of their medications.

Studies have shown that community pharmacists can improve adherence through medication education and side-effect monitoring.^6,7 Thus, it is important for pharmacists to make these types of interventions each time they receive a new prescription for psychiatric medications.

Providing extensive education about mental-health medications can help reduce certain biases that a patient may have before he or she fills the first prescription. In initial consultations, pharmacists should address what the medication is being used for, how to properly use the medication, and how long it may take to see full therapeutic effects. Pharmacists may also educate patients on the typical side effects or adverse effects that they may experience and guide them on when it may be necessary to contact their physician.⁷

Listening to patients’ concerns, addressing their questions, and setting clear expectations are crucial to ensuring therapy adherence. While these may seem like obvious counseling points to many pharmacists, a 2011 study by Chong and colleagues showed that pharmacists are not always thorough in their counseling techniques.⁶ In this review of 26 randomized clinical trials of over 11,000 patients, 60% of pharmacists counseled patients on the expected time to onset of therapeutic effects, while only 35% counseled on expected treatment duration.⁶ Unfortunately, most pharmacists did not emphasize the importance of patients taking their medications daily, even after initial symptoms resolve.⁶

Furthermore, pharmacists were focusing mostly on patients who were initiating drug therapy, and were rarely having conversations with patients who were on chronic, maintenance drug therapy.⁶ While initial counseling sessions are of great value in improving adherence, it is also necessary to follow-up with patients to monitor their progress, including resolution of symptoms and incidence of side effects. Evidence shows that when pharmacists are providing all of this necessary information to patients regarding their medications, patients are less likely to prematurely discontinue therapy and are more likely to adhere to their regimens.^7,8

Because counseling can make such a direct impact on patient outcomes and adherence, pharmacists should be more intentional with these patient interactions. Currently, the research literature revolves around the impact of pharmacists in depression; further research is needed to fully support the impact of pharmacists on other psychiatric illnesses, such as bipolar disorder or schizophrenia.⁹

Mental Health Screening

According to the 2016 National Survey on Drug Use and Health, depression affects 6.7% of the U.S. adult population, but many people living with depression do not seek treatment due to social stigma.^9,10 Since pharmacists are accessible and generally trusted by the public, they can play a role in screening patients for depression by offering screening tools at their pharmacies. Some validated depression-screening tools that are in use include the Patient Health Questionnaire (PHQ), Well-Being Index, Beck Depression Inventory, and the Hamilton Depression Rating Scale.^10,11 While there is debate about whether these screenings improve outcomes, there are studies that support the benefits.¹² A study by Rosser and colleagues of new and existing patients using the PHQ was conducted at 32 large chain pharmacies in Ohio.¹³ This study demonstrated the feasibility of implementing depression screenings into community pharmacies, and found that screenings were effective in helping diagnose depressed patients and identifying those on antidepressant therapy who were not having adequate symptom control.

Because patients visit their pharmacies frequently, pharmacists may be the first healthcare providers who recognize mental illness through simple observation. Besides screening for depression, pharmacists can be pay close attention to mood changes or other signs and symptoms of mental illness exhibited by their patients. Based on their observations and the results of screenings, pharmacists can triage their patients to appropriate healthcare providers.

Resources for Patients

Although community pharmacists are easily accessible—it is estimated that almost 90% of urban patients live within 2 miles of a pharmacy and 70% of rural patients live within 15 miles of a pharmacy—a 2016 qualitative study conducted by Murphy and colleagues found that pharmacists were not practicing to their full scope of practice in mental illness and addiction.^14,15 Greater familiarity and comfort with available mental-health resources may help alleviate some of the barriers that community pharmacists experience concerning mental health pharmacy practice.

For example, if a pharmacy is conducting depression screenings for patients, it could provide a list of local mental-health providers—psychiatrists, psychotherapists, and free clinics offered through hospitals and local health departments—with whom patients can schedule a follow-up appointment. In addition to providing contact information for local practitioners, pharmacists might also provide a list of hotline numbers (Table 1) that could be posted around patient waiting areas for easy access. Patients could also be encouraged to inquire whether their employer offers an employee assistance program, a potential resource some patients may have access to but be unaware of. Employers provide this service at no cost to their employees in order to assist them in resolving personal problems such as marital, family, emotional, or medical problems that might adversely affect the employee’s work performance.

Printed materials about mental health, disease states, and common medications are other types of resources that pharmacists can provide. Patients have varying levels of health literacy, and it has been shown that using written counseling materials can improve outcomes.¹⁶ The National Institute of Health and the American Medical Association recommend that medical information be written at a sixth-grade reading level; however, online resources for mental-health disorders can be more complex.¹⁷ Face-to-face interactions with patients in community pharmacies may help some patients better comprehend mental-health information found online. Pharmacists are able to provide written information on disease states and specific medications as well as talk with the patient to ensure their understanding. Pharmacists are uniquely positioned to use and share these resources with patients in the community setting.¹⁵

Adverse Effects of Common Medications

Over 200 commonly prescribed medications in the U.S. include depression as a potential side effect, including beta-blockers, proton pump inhibitors, analgesics, statins, stimulants, benzodiazepines, anticonvulsants, and many other drug classes. Table 2 lists some commonly prescribed medications that have adverse effects of depression or other mental-health impacts. A 2018 study by Oato and colleagues characterized the use of prescription medications that have depression as a potential adverse effect and assessed associations between their use and concurrent depression. In this cross-sectional, U.S. population–based survey, the more medications having depression as an adverse effect a patient was taking, the higher the likelihood he or she experienced depression.¹⁸ More specifically, when patients were taking three medications with an adverse effect of depression, there was a 15% chance of the patient exhibiting symptoms consistent with depression, compared with 6.9% for one medication and 4.7% for patients not taking any medications with depression-like side effects.¹⁹ It is important to note the study did not show that these medications were causing depression; it simply indicated that these patients were more likely to be depressed.

Community pharmacists can help screen patients’ medication lists for drugs that can potentially exacerbate mental illness. When pharmacists see all the medications a patient is filling, including prescriptions from multiple providers, they are able to observe these trends and make recommendations to control the cumulative side effects. The study findings should motivate pharmacists to be proactive in counseling these patients and providing them with an understanding of what side effects to expect. Pharmacists can help patients evaluate risks and benefits as well as provide recommendations regarding their current medication regimens.

Depression-screening surveys, such as the PHQ, may not be the best tool to identify depression  related to side effects resulting from the start of a new medication.^10,11 It is imperative that patients report to their physician any changes in mood or behavior when taking a medication. Counseling patients on possible side effects and how to respond to them is critical in avoiding potentially serious mental health effects.

Conclusion

Community pharmacists are in a position to have a direct impact on patient care as it relates to mental illness. Through education and screening, providing valuable resources, and evaluating any medication-related problems, community pharmacists can improve patient outcomes. If community pharmacists recognize the beneficial impact they can have and work to improve their practice when approaching mental illness, they can provide a unique and meaningful aspect of care for these patients.

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