US Pharm. 2016;41(11):30-33.
ABSTRACT: Mental health disorders are a major public health problem worldwide. With the increasing use of psychotropic drugs and other advanced therapies, pharmacists form an important part of the multidisciplinary care team for patients with mental illnesses. One of the primary roles of pharmacists in this field is to counsel patients thoroughly in order to improve adherence and patient outcomes related to drug therapy. A range of barriers may deter pharmacists from counseling patients with mental illnesses, including pharmacist, patient, health system, and social or cultural factors. Interventions to improve the management of mental health patients should focus on enhancing communication and education.
Mental health disorders are a major health problem worldwide, with estimates of occurrence as high as 450 million people.1 According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), mental illnesses are a group of disorders that are generally characterized by dysregulation of mood, thought, and/or behavior.2 In the United States, approximately 1 in 5 adults experiences mental illness in a given year.3 Despite such a high prevalence, mental health disorders are often underrecognized and undertreated.4
Multidisciplinary teams employing the skills of psychiatrists, psychologists, nurses, pharmacists, and social workers have been utilized in an attempt to improve the management of mental illnesses. Even though the integration of health specialists has been shown to be beneficial, the right mix is yet to be determined. Psychotropic drugs have played an increasingly important role in the management of mental illness. As the use of more complex drugs grows, there is an increasing need for pharmacists to ensure the safe and effective use of these medications for optimal patient outcomes.5
Pharmacists can assist patients by understanding their condition and their medications better, monitoring adverse effects and drug interactions, facilitating adherence to treatment, and suggesting any changes to therapy to physicians.6 In this way, pharmacists can positively affect the clinical, behavioral, and economic outcomes associated with drug therapy in mental illnesses.7
Various studies have shown that community-based medication counseling interventions have resulted in increased adherence to antidepressants and antipsychotics.8,9 Adherence is crucial for patients to achieve maximal benefits from their therapy.10 However, there is evidence to show that patients with mental illnesses receive less counseling than patients with other conditions. A study conducted in Finland concluded that community pharmacists were less likely to provide directions for the use of psychotropic medications than for eight other therapeutic classes of drugs studied.11 Another study demonstrated decreased willingness on the part of pharmacists to provide pharmaceutical care for people with mental illnesses as compared to physical illnesses (e.g., asthma).6 This article discusses some of the reasons why this may be the case and attempts to offer some suggestions to improve the status quo.
A range of factors that may deter pharmacists from counseling patients with mental illnesses have been identified. These can be broadly divided into pharmacist-related factors, patient-related factors, health system–related factors, and social or cultural factors (TABLE 1).7,12 Some factors seem to have a greater effect than others, and many are interrelated.
Barriers to Counseling
Pharmacist-Related Factors: The most common pharmacist-related factors seem to be the lack of knowledge about the condition as well as having limited information about the patient.13 Studies have shown that pharmacists report the need of training in basic skills in psychosocial communications as well as nonmedical treatment options for mental health disorders. In one study, British and Canadian community pharmacists reported that the lack of training to counsel people with severe mental illnesses limited their ability to provide information about anti-psychotics.14,15 As a result, pharmacists in a Belgian study relating to antidepressants indicated that they feared “saying the wrong thing” and therefore avoided discussions with patients on antidepressants.13 This is probably true for other medications used for the management of mental illnesses. In another study, low levels of mental health stigma combined with high levels of literacy with regard to schizophrenia were associated with a greater willingness on the part of the pharmacists to provide medication counseling and identify drug-related problems for patients with schizophrenia.16
Specifically, pharmacists have indicated the need for further information regarding the causes of mental illnesses and medical treatment options available as well as the symptoms that patients would present with and how to recognize them. Regarding drug therapy, pharmacists have expressed the need for further information on the effects and adverse reactions of agents used in the management of mental illnesses such as depression.13 Unfortunately, there are few mental health education programs for pharmacists designed to overcome this hurdle.14,15
Some pharmacists may be more hesitant to enter into a consultation with a patient that they know little about. To make the situation worse, they might assume that the patient may be ashamed to talk about his or her condition and avoid asking too many questions. Having limited information about the patient’s medication history and background also leads to the uncertainty about counseling the family members or caregivers. In some cases, the pharmacist may feel that the patient’s condition should be kept confidential and only discussed with the patient. In other scenarios, the pharmacist may feel that the patient is not capable of understanding the information provided during a counseling session and therefore may counsel the family members and caregivers only.17
Pharmacists have reported feeling more uncomfortable or uneasy in counseling patients taking medications for mental illnesses than those taking prescription agents for cardiovascular conditions.14 Additionally, it has been found that pharmacists are significantly more willing to provide pharmacy services to patients with asthma than with mental illness.6 These feelings of discomfort may be due in part to the fact that pharmacists lack the knowledge to counsel these patients as discussed earlier.
The attitudes and beliefs of the pharmacist are also a major factor in the way the pharmacist counsels a patient. While some studies have shown that many pharmacists have a positive attitude toward patients with mental illnesses, this is not necessarily reflected in their practice. Other studies demonstrate a negative pharmacist attitude to this patient group. Some examples of negative views include thoughts that the patients are incompetent, unpredictable, and dangerous.6 Furthermore, it has been shown that there are differences in attitudes between the different types of mental illnesses. In one U.S. study, it was evident that community pharmacists had significantly more negative attitudes toward patients with schizophrenia than with depression.6
Pharmacists with less negative attitudes toward individuals with mental illnesses are significantly more willing to provide services to these patients.6 Additionally, pharmacists who value the importance of counseling have been shown to be more likely to provide pharmacy services to patients with mental illness.6,16 Improving the attitude of pharmacists through education is therefore an area that can be addressed to improve service.6
Some pharmacists have reported uncertainty on what is expected of them professionally when it comes to counseling patients with mental health issues. A study conducted on the attitudes of Dutch pharmacists toward patients with schizophrenia found that the pharmacists did not perceive that they had a clear role in the management of schizophrenia. On the other hand, over 60% of patients and caregivers in this study expressed that they would like to receive more information about the prescribed medications.16
A study of counseling activities in community pharmacies found a difference in counseling rates between chain and independent pharmacies, indicating that counseling information is related to practice setting.18 Furthermore, it has been shown that pharmacists are more likely to counsel self-paying and Medicaid patients than capitation individuals, whereby a set fee is paid per patient. This might be linked to the business motives of the pharmacist.11
Other factors reported by pharmacists that may prevent effective counseling of patients with mental health disorders include a poor understanding of the goal of the communication, the pharmacists’ expectations of patient adherence to health advice or patient outcomes, and the fear of legal liability or litigation.12
Patient-Related Factors: It has been found that patients who ask more questions are more likely to be counseled.11 Therefore, this means that patients who are not willing to communicate face the possibility of not being counseled. The patient’s unwillingness to communicate could be due to a number of reasons, including the stigma associated with the condition, or feeling that they might sound illiterate. Some patients may feel that the role of the pharmacist is only to dispense the drug and not give any advice. Others may not have an interest in receiving further information, or may not realize the benefit of discussing the medication with the pharmacist.7 Additionally, some patients may be on long-term medications and therefore may not feel that they need to discuss any issues with the pharmacist when collecting refills. From the perspective of the pharmacist, it has been shown that pharmacists tend to provide less counseling to users of long-term medications as compared with new users.7
Since some mental disorders can impair the cognitive functions of the patient, he or she may not be in a position to understand the information provided. Unless the pharmacist can speak to a family member or caregiver, such patients will not receive all the information required for the correct use of their drug therapy. A similar scenario may occur where the adverse effects of the medication may prevent patients from comprehending the information given to them.7
Health System–Related Factors: The most commonly reported health system–related factors are the lack of privacy for counseling and lack of time.7,14 Other issues include the lack of access to medical histories and thus not having a complete picture of the patient’s medical background. Research has shown that this is often the case. Although pharmacists are acknowledged as dynamic members of the mental healthcare team, they are not always fully embedded into the team.7,13,19 Poor communication between members of the healthcare team (e.g., pharmacists and physicians) or between other members of the healthcare team and the patient may also lead to less than sufficient information being passed on to patients. The high cost of prescription drugs may mean that some patients are not fully adherent to their medication (e.g., they may skip a dose to make their supply last longer). If pharmacists are able to identify such patients, they may be able to assist by suggesting generics, rebates, or other medications of the same class that might be covered on the patient’s health insurance plan.
Social or Cultural Factors: There is a stigma surrounding mental health disorders. This may lead to the pharmacists feeling uncomfortable about discussing the condition with the patient, family members, or caregivers. In addition, patients may be embarrassed to discuss the condition with the pharmacist. One study showed that only about half of all patients who participated in a survey agreed that substance abuse was a mental disorder. This may be due to the fact that the patients believe that the condition is a sign of poor self-control or a self-inflicted problem rather than a medical condition.14
Language barriers have been reported as an obstacle, particularly when it comes to counseling foreign-language patients, as has been shown by a study conducted in Switzerland.20 This may also apply to pharmacists trying to counsel patients from a different cultural background. Some cultures are not accepting of mental disorders and subsequently patients from these cultures are less likely to discuss the condition with the pharmacist. The social and cultural interpretations about the causes and prognosis of mental illnesses will influence the way in which patients approach the pharmacist and the way they interpret the information they are provided with.
The findings described here clearly suggest the need for the interventions to improve the management of patients with mental illnesses by pharmacists. Since the lack of knowledge and skills has been identified by many studies, there is a clear need for targeted training. This may be undertaken in many ways, including with17:
- Continuing education programs;
- Undergraduate modules (one study showed that mental health first aid training for pharmacy students improved their conﬁdence in providing pharmaceutical services to people with mental illness);21
- Training at professional meetings; and
- Small group discussions.
Other suggestions for interventions include the improvement of communication between the healthcare team members and the development of communication tools for foreign-language patients.20
Pharmacists play an important role in the counseling of patients with mental illness by discussing the expected outcomes and adverse effects of therapy as well as identifying potential drug interactions. Furthermore, they can assist in the selection of appropriate medications and dosing and ensure patient adherence. Due to the various barriers identified in this article, pharmacists may not be able to fulfill this role effectively. The implementation of various interventions to overcome these barriers is recommended in order to improve the services that patients with mental illnesses receive from their pharmacists.
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