Mental illness is common throughout the United States, affecting tens of millions of people each year, and overall, only about half of those affected receive treatment1. For those with mental illness, there are many barriers to accessing optimal care, including lack of access to care, lack of accurate disease state information, limited financial resources, inadequate transportation, and stigma. In this context, stigma refers to daily challenges, including social stereotypes and prejudices that result from widespread misconceptions of mental illness throughout society. In fact, people with mental illness so frequently bear this stigma that they often accept such notions and misconceptions as facts. It is well known that people with mental illness are treated differently than those without these disorders, even by healthcare professionals. This in turn prevent patients from receiving optimal care, realizing their potential, and detrimentally affects their sense of well-being. Ultimately it is essential that everyone, including healthcare professionals, acknowledge their own biases and address any preconceived notions that do not align with clinical evidence and recommendations.
The College of Psychiatric and Neurologic Pharmacists (CPNP) Foundation, in collaboration with the National Alliance on Mental Illness (NAMI), conducted an online survey of individuals (or family members) with mental health conditions to assess interactions with their community pharmacists. Eighty percent of respondents reported that they exclusively used a community pharmacy to fill their prescriptions for mental health medications. Responses suggest several opportunities, including access to, and relationship development with pharmacists, privacy, and increased assistance with effectiveness or safety monitoring of mental health medication2. It is clear from the survey that many respondents and their families value the relationship with their pharmacist. Due to accessibility and trust, community pharmacists in particular have a tremendous opportunity to positively impact individuals living with mental illness, their families, and the patient’s healthcare providers, to further enhance evidence-based treatments leading to improved outcomes and patient satisfaction. However, in a survey of North Carolina community pharmacists designed to assess perceptions towards working with persons with severe and persistent mental illness (SPMI), researchers determined that lack of time and confidence in managing and monitoring medications used to treat SPMI are key barriers identified in preventing community pharmacists from providing optimal care and services to this population.3 How do we begin to bridge this gap in comfort and confidence?
Specifically, how can we as board certified pharmacists begin to bend this curve and minimize stigma, with the goal of improving access to care for persons with mental illness? One potential area is to promote increased psychiatric clinical training opportunities in pharmacy education. Very few schools of pharmacy require an advanced practice clinical experience in psychiatry and/or have limited access to psychiatric clinical training sites in general. Studies have found that pharmacy students who had in-person clinical exposure/experience with persons with mental illness had far less stigma regarding those with mental illness than those students without this experience. Promotion of increased student access to clinical educational experiences in psychiatry by serving as clinical preceptors (required or elective APPEs, internships, shadowing, etc.) by board certified psychiatric pharmacists should be a priority. As one example, I had no specific interest in psychiatric practice until I had a summer internship experience in a psychiatric inpatient facility. By the end of the first week, I knew this was my calling… and without the internship experience (made possible by a pharmacist being a willing mentor), I may never have made this discovery. Lastly, as pharmacists are increasingly involved in ambulatory care practice, and most patients receive their treatment for depression and anxiety from their primary care provider, there are opportunities in this practice arena for students to learn about dealing effectively with patients who have a mental illness. Board certified ambulatory care pharmacists are therefore in a position to model effective behaviors when dealing with persons with mental illness as well. The key concept is that trainees benefit from the opportunity to interact with persons with mental illness to improve their clinical comfort and confidence in doing so.
How can we take proactive steps to overcome our biases? My friend and colleague Carla Cobb Pharm.D. BCPP who practices at Riverstone Health, an FQHC in Billings Montana, has suggested that “a beginning step is to be curious, not critical, about your own beliefs. Keep an open mind and educate yourself and others about the truth surrounding these illnesses, their causes, and manifestations. Reach out to patients to learn their stories of personal experiences living with these illnesses. Work with students, residents, and other healthcare professionals to expose them to patients with these disorders, to reduce their discomfort or fear when they encounter these patients in their future practice settings.” Doing so may be a great beginning towards improving the social isolation and poor access to care and proper treatment that patients with mental illness often experience, and these interactions can be an incredible professionally rewarding experience for the pharmacist.
I challenge each of us to reflect on our own biases regarding mental illness. Do you use pejorative terms to describe these persons or treat them differently? Do you use person first language? Are your beliefs regarding the biological basis of mental illness consistent with the evidence and consistent with your beliefs regarding persons with diabetes? Do you believe that persons with mental illness are beyond hope or help? Do you allow them to participate in treatment decision making or go with your own preferences?
In closing, stigma borne by people with mental illness is unique, associated with individual and societal impact (including emotional, physical, and financial costs), and should be evaluated in the context of professional practice and development. There are tremendous opportunities to align the access that community-based pharmacists provide to patients with the content expertise clinical specialists (in psychiatry and ambulatory care in particular) provide in clinics, hospitals, or other institutional settings. Pharmacist to pharmacist (i.e. “pharm to pharm”) collaboration and communication between community-based pharmacists and clinical specialists is critical for the betterment of patient care and improved healthcare outcomes for the population dealing with mental illness.
- National Institute of Mental Health. http://www.nimh.nih.gov/health/statistics/prevalence/any-mental-illness-ami-among-adults.shtml. Accessed September 20, 2015.
- Characterizing the Relationship between Individuals with Mental Health Conditions and Community Pharmacists-Results from a 2012 Survey. College of Psychiatric and Neurologic Pharmacists Foundation. https://cpnp.org/_docs/foundation/2012/nami-survey-report.pdf
- Watkins A, McKee J, Hughes C, Pfeiffenberger T. Community pharmacists’ attitudes toward providing care and services to patients with severe and persistent mental illness. JAPhA 2017. (57): S217-224.
- Program History. Mental Health First Aid Canada. Available at www.mentalhealthfirstaid.ca/EN/about/Pages/ProgramHistory.aspx. Accessed September 20, 2015.
- Youth Mental Health First Aid. USA Mental Health First Aid. Available at www.mentalhealthfirstaid.org/cs/take-a-course/course-types/youth/. Accessed September 20, 2015.
- O’Reilly CL, Bell JS, Kelly PJ, Chen TF. Impact of mental health first aid training on pharmacy students’ knowledge, attitudes and self-reported behavior: a controlled trial. Aust N Z J Psychiatry 2011;45:549-557.
- Bond KS, Jorm AF, Kitchener BA, Reavley NJ. Mental health first aid training for Australian medical and nursing students: an evaluation study. BMC Psychology 2015:3:11. doi 10.1186/s40359-015-0069-0.