Claire L. O’Reilly

A comprehensive review of the impact of clinical pharmacy services on patient outcomes in mental health.

Background The importance of pharmacists in mental healthcare is starting to be recognised around the world. However few studies have focused on the evidence supporting pharmacist involvement in the inpatient mental healthcare setting. Aim Evaluate types of outcomes achieved and level of evidence supporting clinical pharmacy services in inpatient mental health settings. Methods Medline, PyscINFO and International Pharmaceutical Abstracts databases were searched from January 1990 to March 31 2013. Studies were included if in an inpatient setting, published in English, and reported an intervention provided by a pharmacist or involving a pharmacist with a pivotal role in an intervention team. Data were extracted according to sample population and size, study design and outline, country, role of the pharmacist in the study, and the main results of the study. The level of evidence for each study was assessed using Australia’s National Health and Medical Research Council’s hierarchy of clinical evidence and results were categorised as having economic, clinical and/or humanistic outcomes. Results Eighteen articles met the inclusion criteria. A range of pharmaceutical services provided by pharmacists in inpatient mental healthcare were identified. These services highlight the role of pharmacists as reviewers of medication charts, laboratory results and medication prescribing and as educators of patients and other health care professionals. Six studies included a control or comparison group and had pre and post intervention measures. These comprised of three randomised control trials, one historical control study and two case series post and pre-post tests, corresponding to evidence levels of II, III-3 and IV respectively. Seven studies reported clinical outcomes, two economical and one humanistic outcomes. One study reported both clinical and economical outcomes. Seven studies focused on impact evaluation measures. Conclusions Pharmacists provide a variety of services and play a significant role in inpatient mental healthcare. However, the level of evidence supporting these services is limited and the type of outcomes achieved is narrow.

A scoping review of community pharmacists and patients at risk of suicide

Background: Medications are commonly used in suicide attempts. Pharmacists are inextricably linked to medications and may have roles in helping those at risk of suicide. We conducted a scoping review to characterize the existing literature and make recommendations about future research. Methods: We used a 6-step approach based on an existing scoping review methodological framework, including identifying the research question; identifying relevant studies and other literature; study and literature selection; data charting; collating, summarizing and reporting results; and dissemination of results. We searched electronic databases, various grey literature sources and mobile app stores. Results: Thirty-five articles were included following screening of 1013 database citations. Of 1085 results from grey literature searches, we included 12. Most publications were opinion pieces (n = 22), followed by survey studies (n = 9), primarily assessing pharmacists’ knowledge and attitudes. Themes included education and training to impact knowledge and attitudes, gatekeeping of medication supply, collaboration and integration, and role perception. Public perspectives on pharmacists’ roles were limited. Conclusions: Research regarding pharmacists’ roles in the care of people at risk for suicide is limited. The areas that have dominated the literature include legal liability, especially with respect to gatekeeping medications, ethical decision making and education and training. Research is needed to determine what methods, outcomes and measures are required to best serve in building the evidence base for policy and practice decisions in this area.

Community pharmacists and the assessment and management of suicide risk.

The recent canadian federal framework for suicide Prevention Act (s.c. 2012, c.30) identifies suicide as a national public health issue that requires federal, provincial, territorial and nongovernmental organization cooperation and action.1,2 The framework sets forth a process intended to fulfill the requirements of the act. This includes numerous directives, of which at least 3 fit well with the work of community pharmacists1,2: Disseminating information about suicide and its prevention Defining best practices for the prevention of suicide Promoting the use of research and evidence-based practices for the prevention of suicide However, the potential contribution of community pharmacists in suicide prevention strategies is not well recognized. Neither the Mental Health Commission of Canada nor the Canadian Society for Suicide Prevention identify a role for community pharmacists in their recent documents pertaining to suicide prevention.3,4 This likely reflects the overall absence of pharmacy-focused research in this area rather than the absence of an active opportunity for community pharmacists in identifying and responding to people at risk of suicide.5,6 Through our combined years of research focused on mental illness and the community pharmacist, our own clinical experience and tacit knowledge and our numerous committee and panel experiences, we know that community pharmacists are regularly directly involved in the care of people at risk of suicide. We are also aware that suicide prevention in the community pharmacy setting has received little professional attention. Suicide is a major public health problem in Canada, and our national mental health strategy identifies suicide prevention in its first of 6 strategic directions.7 The rate of suicide is 3 times higher in men than in women, rising rapidly during adolescence and peaking in both sexes during midlife (see Figure 1).8,9 Self-poisoning is the leading cause of death by suicide in women and is second to hanging in men. In people 40 to 59 years of age, suicide rates by poisoning and hanging are similar. Most sobering is that suicide accounts for 20% to 25% of deaths in adolescence and early adulthood, second only to motor vehicle accidents.10 Physical conditions that compromise quality of life (e.g., heart failure, chronic obstructive pulmonary disease, severe pain, etc.) independently elevate risk of medication overdose deaths in older adults.11 In younger people, a major predictor of suicide, in addition to the presence of mental disorders, is self-injurious behaviours (i.e., nonfatal self-poisoning or self-injury irrespective of suicidal intent).12 The greatest risk of death by suicide occurs in the period following self-injurious behaviours, including overdoses.13 Figure 1 Suicide rates of men and women in Canada, 20118,9 Knowledge of suicide patterns and risk factors is important for community pharmacists in their daily practice, especially when considering that self-poisoning with medication is a leading cause of suicide-related hospitalizations and death.10,14 A recent coroner’s study of overdose deaths in Toronto demonstrates the potential for pharmacists’ interventions. Prescribed medications were implicated in 79% of overdose deaths (62% psychotropics, 17% other medication), suggesting the involvement of a physician and pharmacist in the recent care of the patient, while 21% resulted from overdoses with over-the-counter medications, where a pharmacist may or may not have been involved with the individual’s care.15 These data are consistent with our own community pharmacy mental health research and program development experiences that indicate that prescription and over-the-counter medications are used in suicide attempts and that pharmacists often have concerns about a patient’s self-harm risk in advance of an attempt or may come to realize the missed opportunity for intervention only after the fact. The link between pharmacists and intentional self-poisoning by patients using prescription or nonprescription medications is obvious and thereby provides a clear opportunity for suicide risk assessment and mitigation. Trusted and highly accessible,16,17 pharmacists can be approached in person or via telephone, without the need for an appointment or payment, for advice and support. For these reasons, pharmacists routinely encounter people with risk factors for suicide and people in crisis, irrespective of medication-related needs. The opportunity to take advantage of pharmacists in their accessible positions and with this connection to people in communities has been recognized by the Pharmacy Guild of Australia, which includes staff training in Mental Health First Aid as part of its Community Services Support Pharmacy Practice Incentive program.18 However, the application of pharmacist suicide risk assessment and mitigation training programs needs to be subjected to appropriate third-party scrutiny in Canadian community pharmacy contexts and elsewhere, to determine their appropriateness and whether they achieve the desired goals (i.e., decreasing suicide rates, decreasing incidence of medication-related self-harm and increasing pharmacists’ competencies in suicide risk assessment and management). Some literature is available to support that these programs can have positive outcomes for pharmacy practice,19 but the overall effectiveness of these programs has been questioned in some contexts.20 There are also significant gaps in the health system with respect to transitions in care among services and disciplines, coordination of services and follow-up for people with suicide attempts or self-injurious behaviour. For example, psychosocial assessments, adequate communication back to primary health care providers and follow-up services do not occur for the majority of youth who present to an emergency department (ED) for a self-injurious event, which can include overdose with medication.21-24 A recent Canadian study found that 2 in 3 adolescents who presented to the ED with self-injurious behaviours were discharged directly from the ED.25 Pharmacists may interact with these youth and their families, making recommendations or providing advice, without direct knowledge of the recent ED visit and what has transpired. Patients may be reluctant to disclose information because of concerns of stigma and what they perceive the pharmacist’s role to be with respect to suicide, which currently may be limited in the Canadian context. We are requesting that, as a discipline, we advocate to enhance the education, research and policy agenda for pharmacists with respect to people who are at risk of suicide. We encourage dialogue on suicide risk assessment and ask that appropriate risk management in community pharmacy practice be promoted. Some Canadian pharmacists and students have drawn attention to the issue of suicidal ideation and point to the use of medication reviews as an opportune time to discover these thoughts in patients.6,26 We applaud these pioneering efforts. Looking forward, we think it is timely and necessary to foster collaborative, coordinated and best evidence‒based approaches from policy to practice for suicide risk assessment and management.27 This would also include exploring efficient and effective mechanisms for education, training and mentorship of students and practising pharmacists in assessing and managing suicide risk in people accessing pharmacy services. Pharmacists may require additional education and training to help increase their understanding and competencies in this domain. There is also a need to determine how best to provide postvention support for pharmacists involved in the care of patients who die by suicide, as this need appears underrecognized by researchers, educators and pharmacy employers. Implementation of interventions for pharmacists will also require thoughtful design and planning supported by frameworks that consider changing the behaviours of pharmacists working in the complex environment of community pharmacy practice.28-30 In addition, stigma must be considered, as it can be a pervasive issue with pharmacy staff and patients. Although stigma in the pharmacy context vis-a-vis mental illness has been reasonably well explored, there is little research available regarding stigma in association with those who present in crisis as suicidal or who have a known history of previous suicide attempts. We acknowledge that there needs to be a larger conversation around the integration of pharmacists as members of the primary mental health care team, not just with respect to suicide risk assessment and management. This should include all necessary components that can facilitate this integration, including appropriate mechanisms for communication, triage of patients and information sharing with privacy safeguards among providers, patients and families at various transitions in the health care system. We offer suggestions for action by stakeholders to advance the community pharmacist’s role in suicide risk assessment and management (Table 1). We strongly recommend patient engagement throughout the process from development to implementation. And last, quality assurance and evaluation of the systems in place that allow pharmacists to better serve in this role are imperative. ■ Table 1 Stakeholder actions for advancing the community pharmacist’s role in the assessment and management of people at risk of suicide

Stigma and discrimination experienced by people living with severe and persistent mental illness in assertive community treatment settings

Aims: To describe the perceived experiences of stigma and discrimination among people living with severe and persistent mental illness in assertive community treatment (ACT teams) settings in New South Wales (NSW), Australia. Methods: The Discrimination and Stigma Scale (DISC) was used in this cross-sectional study with people living with severe and persistent mental illness. The DISC is a reliable and valid, quantitative and qualitative instrument used to explore and measure levels of negative, anticipated and positive discrimination. Relevant clinical history and socio-demographic information were also collected. Results: A total of 50 clients participated, with 40 (80%) reporting experienced negative discrimination in at least one life area. Negative discrimination was most commonly experienced in being avoided or shunned (n=25, 50%), by neighbours (n=24, 48%) and family (n=23, 46%). Anticipated discrimination was common, with half of participants (n=25, 50%) feeling the need to conceal their mental health diagnosis. Conclusion: Discrimination was highly prevalent in everyday aspects of life. While healthcare professionals often tend to increase perceived stigma and discrimination, this was only experienced in interactions with general health professionals, while interactions with ACT team members decreased perceived stigma and increased positive discrimination. This indicates that healthcare professionals potentially have a significant role in reducing stigma and discrimination in mental health and that such an effect may be optimised in an ACT team setting.

Assessing Mental Health First Aid Skills Using Simulated Patients

Objective. To evaluate mental health first aid (MHFA) skills using simulated patients and to compare self-reported confidence in providing MHFA with performance during simulated patient roleplays. Methods. Pharmacy students self-evaluated their confidence in providing MHFA post-training. Two mental health vignettes and an assessment rubric based on the MHFA Action Plan were developed to assess students’ observed MHFA skills during audio-recorded simulated patient roleplays. Results. There were 163 students who completed the MHFA training, of which 88% completed self-evaluations. There were 84% to 98% of students who self-reported that they agreed or strongly agreed they were confident providing MHFA. Postnatal depression (PND) and suicide vignettes were randomly assigned to 36 students. More students participating in the PND roleplay took appropriate actions, compared to those participating in the suicide role-play. However, more students participating in the suicide role play assessed alcohol and/or drug use. Ten (71%) participants in the PND roleplay and six (40%) in the suicide roleplay either avoided using suicide-specific terminology completely or used multiple terms rendering their inquiry unclear. Conclusion. Self-evaluated confidence levels in providing MHFA did not always reflect observed performance. Students had difficulty addressing suicide with only half passing the suicide vignette and many avoiding suicide-specific terminology. This indicates that both self-reported and observed behaviors should be used for post-training assessments.

The psychometric properties of depression screening tools in primary healthcare settings: A systematic review.

BACKGROUND Consensus on a tool for depression screening among adults in primary healthcare (PHC) settings is lacking. This systematic review aimed to explore the psychometric properties of depression screening tools. METHODS A systematic literature search composed of four terms (screening AND psychometric AND depression AND primary healthcare) was conducted in PubMed, EMBASE, PsycINFO and MEDLINE, between January 1995 through October 2015. Studies that aimed to psychometrically test a depression screening tool among the general adult population in a PHC setting were included. Studies exploring the diagnostic properties of depression screening tools among specific populations were excluded. RESULTS Sixty publications, evaluating the psychometric properties of 55 tools or adaptations, were included. Studies were conducted in 24 countries and 18 languages on 48234 adults. The Patient Health Questionnaire-9 was the most evaluated tool with 14 studies evaluating its psychometric properties. Fifty-four studies reported on at least one measure of receiver operating characteristics. Sensitivity and specificity values ranged from 28% to 100% and 43% to 100%, respectively. Cronbach alpha values ranged from 0.56 to 0.94. Other forms of reliability and validity testing were less consistently and commonly reported. LIMITATIONS The inclusion of studies regardless of methodological quality or design may have limited generalizability, but allowed for a comprehensive and detailed overview of the current literature. CONCLUSIONS Depression screening tools vary in their psychometric properties. The PHQ-9 was the most extensively psychometrically tested tool. This systematic review may aid PHC professionals in choosing a depression screening tool for universal use as it provides a comprehensive overview of their psychometric properties.

Confidence and attitudes of pharmacy students towards suicidal crises: patient simulation using people with a lived experience

PurposeHealth care professionals, including pharmacists, have the potential to recognise and assist those at risk of suicide. The primary aim of this study was to assess the impact of utilising people with a lived experience of mental illness as simulated patients on final year pharmacy students’ attitudes toward and confidence in caring for people at risk of suicide after first receiving Mental Health First Aid (MHFA) training.MethodsA parallel group repeated measures design was used. People with a lived experience of mental illness enacted patients experiencing a mental health crisis, including possible suicidal ideation. Following MHFA training, the first group directly participated in the simulation, the second group observed, and the final group had no exposure to the simulation. Validated surveys measuring student attitudes and confidence were conducted at three time points; pre and post MHFA, and then at 2–4 weeks follow-up.ResultsFull datasets of survey responses were received from 34/40 direct participants (85%), 104/146 observers (71%) and 50/66 comparison students (76%). Mean confidence scores significantly improved for all groups post MHFA training (p < 0.05). At follow-up, all 8 confidence items for the direct participant and observer group maintained significance from baseline to post intervention (p < 0.05). Mixed results in relation to attitudes towards suicide were evident at each time point and among each participant group.ConclusionsUtilising people with a lived experience of mental illness as simulated patients has a positive effect on sustaining pharmacy student confidence in discussing suicidal behaviour post MHFA training. The inconsistency in attitudes towards suicide suggests that attitudes are complex in nature, involving multiple dynamic influences.

Community pharmacists’ experiences and people at risk of suicide in Canada and Australia: a thematic analysis

PurposeTo explore Canadian and Australian community pharmacists’ practice experiences in caring for people at risk of suicide.MethodsWe conducted a thematic analysis of 176 responses to an open-ended extension question in an online survey.ResultsFour themes were identified and include referrals and triage, accessibility for confiding, emotional toll, and stigma. Subthemes included gatekeeping the medication supply, sole disclosure, planning for end of life, concerns of support people, assessing the validity of suicidality, gaps in the system, not directly asking, ill-equipped, resources in the pharmacy, relying on others to continue care, and attention seeking.ConclusionsCommunity pharmacists are caring for patients at risk of suicide frequently, and often with patients seeking the help of pharmacists directly. Pharmacists engage in activities and actions that would be considered outside of the traditional dispensing roles and provide support and intervention to people at risk of suicide through collaboration and other mechanisms. Further research to determine appropriate education and training and postvention supports is required.

The role of community pharmacists in the identification and ongoing management of women at risk for perinatal depression: A qualitative study

Background: While pharmacists are among the most accessible primary health professionals within a mother’s healthcare team to identify potential cases of perinatal depression (PND), very little in the literature suggests that this role has been explored. Aim: The aim of this study was to explore community pharmacists’ perspectives on their potential roles in perinatal mental health promotion (recognition and health education) and the factors affecting these roles. Methods: In total, 20 semi-structured, in-depth interviews were conducted with community pharmacists. Results: Most pharmacists highlighted their significant roles in recognising PND symptoms and providing medication-related support to perinatal mothers. Barriers to service provision included inter-professional role boundaries, the lack of established referral systems and service remuneration and the lack of adequate training in mental health. Conclusion: Pharmacists could potentially reinforce their involvement in mental health promotion activities.

Community pharmacists’ attitudes and opinions towards supplying clozapine

Background Clozapine is very effective for treatment-resistant schizophrenia, but its use has been limited due to the risk of agranulocytosis. From July 2015, clozapine has been accessible from Australian community pharmacies following regulatory changes, but pharmacists’ attitudes towards these changes remain unknown. Objective To explore pharmacists’ perspectives and experiences in supplying clozapine. Setting Australian community pharmacists. Methods A cross-sectional study with a mixed methods approach involving two phases. An online survey containing Likert-type and open-response questions was distributed to community pharmacists (n = 134) via ClopineCentral™ (clozapine monitoring system). Participants were then invited to participate in semi-structured telephone interviews (n = 12) regarding clozapine supply. Quantitative data were statistically analysed, while qualitative responses were thematically content-analysed. Main outcome measures Pharmacists’ responses to surveys and interviews. Results Community pharmacists were supportive towards supplying clozapine as it increased access for consumers. Better patient-pharmacist relationships and holistic care approach were identified to benefit both consumers and pharmacists. Pharmacists reported to be confident (89.6%), have adequate support (73.1%), knowledge (86.6%) and skills (93.3%) in dispensing clozapine. Training and support received facilitated pharmacists’ roles, whereas administrative issues, especially in obtaining valid haematology results, posed challenges. Educational and technical improvements were suggested to improve service provision. Conclusion Community pharmacists welcomed the regulatory changes positively and were confident in supporting consumers taking clozapine. Despite challenges present, benefits and facilitators identified supported the feasibility of this service in community pharmacies. Future research should explore other aspects of clozapine supply, such as attitudes of other stakeholders, to improve current supply systems.