Pharmacy students' experiences in provision of community pharmacy mental health services

Opinions and experiences on the provision of care to people with mental illnesses: a qualitative study with Doctor of Pharmacy graduates after a rotation in psychiatry

BACKGROUND

Pharmacists are vital to optimizing therapy of people with mental illnesses. Limited knowledge, lack of confidence, and mental health-related stigma can lead to pharmacists' reluctance in the provision of pharmaceutical care to this population. Advanced pharmacy practice experiences (APPE) in mental health have been reported as valuable learning opportunities to overcome these challenges.

AIM

This study aimed to explore PharmD graduates' perceived preparedness, attitudes, beliefs, and opinions on influencing factors for the provision of pharmaceutical care to people with mental illnesses after completing an APPE rotation in psychiatry.

METHOD

All PharmD graduates who had completed a rotation in psychiatry were invited to participate in semi-structured interviews. An interview guide was developed based on a literature review. A total of 11 PharmD graduates agreed to participate in the interviews, which were recorded, transcribed, and analysed inductively using thematic analysis and following a phenomenological approach.

RESULTS

Five themes were identified: Prior familiarity to mental health, opinions on the rotation, views on stigma, rotation's areas of improvement, and the positive impact of the rotation on practice. Although participants started the psychiatric rotation with low confidence and a sense of apprehension, they described their experience as unique, eye-opening, and insightful. Familiarity with mental health conditions before the rotation were perceived as a challenge to achieving full confidence in mental health care provision.

CONCLUSION

For the most part, the APPE in psychiatry was viewed as a positive opportunity for enhancing the PharmD graduates' insight, knowledge, and skills for pharmaceutical care provision to people with mental illnesses.

An innovative approach to teaching depression and anxiety medication management: Virtual choose your own adventure, psychiatry edition

Introduction

Rates of depression and anxiety continue to increase in the United States. It's important for pharmacy students to graduate knowledgeable and confident in treating these disorders. The purpose of this study was to evaluate whether a virtual active-learning exercise (choose your own adventure) is helpful in teaching students how to manage medications for depression and anxiety.

Methods

Third-year pharmacy students responded to preactivity questions and then worked on a single patient case in which the presenting problem is worsening depression and anxiety. Students worked in virtual groups of 4 to 5 to select 1 treatment among 5 multiple-choice options and documented the rationale for their choice. Each multiple-choice option led to a different follow-up case. After writing their assessment and plan, the instructor debriefed on therapeutic concepts from each follow-up case. Students then answered postactivity questions and participated in a voluntary survey consisting of 10 retrospective questions.

Results

Of 106 participants, 85 completed the survey (80.2% response rate). Most agreed that their understanding of treatment of depression and anxiety disorders increased following participation (92.9% strongly/somewhat agreed). This was supported by an increase in the percentage of correct responses on the knowledge questions (preactivity: 67.2%, n = 91; postactivity: 83.5%, n = 97; P = .01). Additionally, students reported their confidence in their understanding of depression and anxiety management increased following activity participation (93.0% strongly/somewhat agreed).

Discussion

The virtual active-learning exercise improved student knowledge and confidence in managing depression and anxiety treatments. Educators teaching depression and anxiety pharmacotherapy may consider implementing such activity into their lecture(s).

Pharmacists' experiences with the Bloom Program application process

Background

The Bloom Program, which began as a demonstration project, is an ongoing community pharmacy-based mental illness and addictions program funded by the government of Nova Scotia. To be eligible to offer the Bloom Program, interested pharmacists were required to complete a 9-part application on behalf of their pharmacies. A process evaluation was conducted to inform future program implementation changes of program components, including the application process.

Methods

Qualitative interviews from 24 pharmacists were inductively analyzed to determine the challenges and opportunities in the program's application process.

Results

Key and impactful components of the application process included training, providing a mental health and addictions resource centre within the pharmacy and completing outreach activities with local mental health and addictions services and support organizations. The training content and format for the program was highly valued. Community outreach to local mental health and addictions resources, and other health care resources in the community, was particularly valuable in supporting patient navigation of the health care system and extending the pharmacists' networks. Components of the application process were challenging for many pharmacists but were beneficial personally and professionally. Dedicated resources (e.g., time and staffing) are required for the efficient completion of the application process.

Conclusion

Pharmacists viewed the Bloom Program application process as intensive yet necessary and relevant for preparing to deliver the Program. The demonstration project process evaluation was essential for elucidating the strengths of the application process and, importantly, identifying areas for improvement. Can Pharm J (Ott) 2021;154:xx-xx.

Regional variation in primary care improvement strategies and policy: case studies that consider qualitative contextual data for performance measurement in three Canadian provinces

OBJECTIVE

To explore regional primary care improvement strategies that are potentially determinants of primary care performance.

DESIGN

Multiple comparative embedded case study.

SETTING

Three regions in Canada: Fraser East, British Columbia; Eastern Ontario Health Unit, Ontario; Central Zone, Nova Scotia.

DATA SOURCES

(1) In-depth interviews with purposively selected key informants (eg, primary care decision-makers, physician leads, regulatory agencies) and focus groups with patients and clinicians (n=68 participants) and (2) published and grey literature (n=205 documents).

OUTCOME MEASURES

Variations in spread and uptake of primary care improvement strategies across the three study regions. NVivo (V.11) was used to manage data and perform content analysis to identify categories within and across cases. The coding structure was developed by researchers through iterative collaboration, using inductive and deductive processes.

RESULTS

Six overarching primary care improvement strategies, differing in focus and spread, were implemented across the three study regions: interprofessional team-based approaches, provider skill mix expansion, physician groups and networks, information systems, remuneration and performance measurement and reporting infrastructure.

CONCLUSION

The addition of information on regional improvement strategies to primary care performance reports could add important contextual insights into primary care performance results. This could help identify possible drivers of reported performance outcomes and levers for change in practice, regional and system-level settings.

Pharmacists' acceptability of a men's mental health promotion program using the Theoretical Framework of Acceptability

INTRODUCTION

Community pharmacists are accessible, knowledgeable, and capable of providing mental health promotion and care in communities. This may not be a role that is recognized by the public, and men in particular. Differences between men and women exist in help seeking practices. Headstrong-Taking Things Head-On is a men's mental health promotion program for community pharmacies that was designed to increase the capacity of community pharmacists in caring for men with lived experience of mental illness and addictions. The program's core components included signage in pharmacies, education and training for pharmacists, and a website for use with patients.

METHODS

We applied the Theoretical Framework of Acceptability as the coding scheme to pharmacists' qualitative interviews to examine the acceptability of Headstrong for pharmacists.

RESULTS

Nine pharmacists consented to participate and all chose telephone interviews. With the exceptions of ethicality, affective attitude, and opportunity costs, all components from the TFA were coded in each of the nine transcripts. The most frequently coded constructs were perceived effectiveness of the intervention, burden, and self-efficacy. These were coded at least 20 times. The remaining categories ethicality, intervention coherence, affective attitude, and opportunity costs were coded between 11 to 17 times. Pharmacists' perceptions of the effectiveness of the program was mixed. The overall burden was perceived to be low, but opportunity costs appear to have limited the participation of some pharmacists in the program.

CONCLUSION

Use of the Theoretical Framework of Acceptability as a coding scheme for qualitative data from community pharmacists in a men's mental health program was helpful for identifying issues with the program that may require redesign (e.g., signage). Program design should consider how services are advertised in the pharmacy setting, how personal values of pharmacists influence intervention coherence, and whether minimizing the burden of an intervention negates issues related to opportunity costs.

Patient care activities by community pharmacists in a capitation funding model mental health and addictions program

BACKGROUND

Community pharmacists are autonomous, regulated health care professionals located in urban and rural communities in Canada. The accessibility, knowledge, and skills of community pharmacists can be leveraged to increase mental illness and addictions care in communities.

METHODS

The Bloom Program was designed, developed, and implemented based on the Behaviour Change Wheel and a program of research in community pharmacy mental healthcare capacity building. We evaluated the Bloom Program as a demonstration project using mixed methods. A retrospective chart audit was conducted to examine outcomes and these are reported in this paper.

RESULTS

We collected 201 patient charts from 23 pharmacies in Nova Scotia with 182 patients having at least one or more follow-up visits. Anxiety (n = 126, 69%), depression (n = 112, 62%), and sleep disorders (n = 64, 35%) were the most frequent mental health problems. Comorbid physical health problems were documented in 57% (n = 104). The average number of prescribed medications was 5.5 (range 0 to 24). Sixty seven percent (n = 122) were taking multiple psychotropics and 71% (n = 130) reported taking more than one medication for physical health problems. Treatment optimization was the leading reason for enrollment with more than 80% seeking improvements in symptom management and daily functioning. There were a total of 1233 patient-care meetings documented, of which the duration was recorded in 1098. The median time for enrolling, assessing, and providing follow-up care by pharmacists was 142 min (mean 176, SD 128) per patient. The median follow-up encounter duration was 15 min. A total of 146 patient care encounters were 60 min or longer, representing 13.3% of all timed encounters.

CONCLUSIONS

Pharmacists work with patients with lived experience of mental illness and addictions to improve medication related outcomes including those related to treatment optimization, reducing polytherapy, and facilitating withdrawal from medications. Pharmacists can offer their services frequently and routinely without the need for an appointment while affording patient confidentiality and privacy. Important roles for pharmacists around the deprescribing of various medications (e.g., benzodiazepines) have previously been supported and should be optimized and more broadly implemented. Further research on the best mechanisms to incentivize pharmacists in mental illness and addiction's care should be explored.

Perpetuating stigma or reducing risk? Perspectives from naloxone consumers and pharmacists on pharmacy-based naloxone in 2 states

OBJECTIVES

Little is known about attitudes of pharmacists and consumers to pharmacy naloxone. We examined perceptions and experiences of pharmacy naloxone from people with opioid use disorder, patients taking chronic opioids for pain, caregivers of opioid users, and pharmacists from 2 early pharmacy naloxone adopter states: Massachusetts and Rhode Island.

DESIGN

Eight focus groups (4 per state) were held in October to December 2015.

SETTING AND PARTICIPANTS

Participants were recruited from pharmacies, health clinics, and community organizations; pharmacists were recruited from professional organizations and pharmacy colleges.

OUTCOME MEASURES

Focus groups were led by trained qualitative researchers using a topic guide, and recorded and transcribed for analysis. Five analysts developed and applied a coding scheme to transcripts. Thematic analysis involved synthesis of coded data and connections between key themes, with comparisons across the groups.

RESULTS

Sixty-one participants included patients with chronic pain (n = 15), people with opioid use disorders (n = 19), caregivers (n = 16), and pharmacists (n = 11). A majority of pharmacists had dispensed naloxone to patients; a minority of all consumer participants had obtained pharmacy naloxone. Four themes emerged: consumer fear of future consequences if requesting naloxone; pharmacists' concerns about practice logistics related to naloxone; differing perceptions of how opioid safety is addressed in the pharmacy; and solutions to addressing these barriers. Whereas consumer groups differed in awareness of naloxone and availability at pharmacies, all groups expressed support for the pharmacist's role and preferences for a universal offer of naloxone based on clear criteria.

CONCLUSION

Pharmacies complement community naloxone provision to patients and caregivers. To overcome stigma of naloxone receipt, increased public awareness of naloxone and pharmacist training about naloxone and addiction are required. Pharmacists should offer naloxone via universal opt-out strategies-where all patients meeting evidence-based criteria are offered naloxone-rather than targeted or opt-in strategies-where only patients perceived as high risk or patients who request it are offered naloxone.

From personal crisis care to convenience shopping: an interpretive description of the experiences of people with mental illness and addictions in community pharmacies

BACKGROUND

The role of community pharmacists is changing globally with pharmacists engaging in more clinically-oriented roles, including in mental health care. Pharmacists' interventions have been shown to improve mental health related outcomes but various barriers can limit pharmacists in their care of patients. We aimed to explore the experiences of people with lived experience of mental illness and addictions in community pharmacies to generate findings to inform practice improvements.

METHODS

We used interpretive description methodology with analytic procedures of thematic analysis to explore the experiences of people with lived experience of mental illness and addictions with community pharmacy services. Participants were recruited through multiple mechanisms (e.g., paper and online advertisements), offered honorarium for their time, and given the option of a focus group or interview for participation in our study. Data were gathered during July to September of 2012. Interviews and focus groups were audio-recorded, transcribed verbatim, and analyzed by two researchers.

RESULTS

We collected approximately nine hours of audio data from 18 individuals in two focus groups (n = 12) and six individual interviews. Fourteen participants were female and the average age was 41 years (range 24 to 57 years). Expectations, decision-making, and supports were identified as central themes underlying the community pharmacy experiences of people with lived experience of mental illness and addictions. Eight subthemes were identified including: relationships with pharmacy staff; patient's role in the pharmacist-patient relationship; crisis and triage; privacy and confidentiality; time; stigma and judgment; medication-related and other services; and transparency.

CONCLUSIONS

People with lived experience of mental illness and addictions demonstrate a high regard and respect for pharmacist's knowledge and abilities but hold conservative expectations of pharmacy health services shaped by experience, observations, and assumptions. To some extent, expectation management occurs with the recognition of the demands on pharmacists and constraints inherent to community pharmacy practice. Relationships with pharmacy staff are critical to people with lived experience and influence their decision-making. Research in the area of pharmacists' roles in crises and triage, especially in the area of suicide assessment and mitigation, is needed urgently.

A scoping review of weight bias by community pharmacists towards people with obesity and mental illness

BACKGROUND

Community pharmacists are accessible health care professionals who are increasingly offering weight management programs. People living with serious mental illness have markedly higher rates of obesity and associated illness outcomes than the general population, providing pharmacists who are interested in offering weight management services with an identifiable patient subgroup with increased health needs. Issues with stigma within obesity and mental illness care are prevalent and can lead to inequities and reduced quality of care.

METHODS

We conducted a scoping review to map and characterize the available information from published and grey literature sources regarding community pharmacists and weight bias towards obese people with lived experience of mental illness. A staged approach to the scoping review was used.

RESULTS

Six articles and 6 websites were abstracted after we removed duplicates and applied our inclusion and exclusion criteria. The published studies that we found indicated that pharmacists and pharmacy students do demonstrate implicit and explicit weight bias.

CONCLUSIONS

Very limited research is available regarding weight bias in pharmacists and stigma towards people with obesity, and we found no information on these phenomena relating to people with lived experience of mental illness. Investigations are needed to characterize the extent and nature of anti-fat bias and attitudes by pharmacists and the consequences of these attitudes for patient care.

Community pharmacists' experiences in mental illness and addictions care: a qualitative study

Background

Community pharmacists are accessible health care professionals who encounter people with lived experience of mental illness and addictions in daily practice. Although some existing research supports that community pharmacists’ interventions result in improved patient mental health outcomes, gaps in knowledge regarding the pharmacists’ experiences with service provision to this population remain. Improving knowledge regarding the pharmacists’ experiences with mental illness and addictions service provision can facilitate a better understanding of their perspectives and be used to inform the development and implementation of interventions delivered by community pharmacists for people with lived experience of mental illness and addictions in communities.

Methods

We conducted a qualitative study using a directed content analysis and the Theoretical Domains Framework as part of our underlying theory of behaviour change and our analytic framework for theme development. The Theoretical Domains Framework facilitates understanding of behaviours of health care professionals and implementation challenges and opportunities for interventions in health care. Thematic analysis co-occurred throughout the process of the directed content analysis. We recruited community pharmacists, with experience dispensing psychotropics, at a minimum, through multiple mechanisms (e.g., professional associations) in a convenience sampling approach. Potential participants were offered the option of focus groups or interviews.

Results

Data were collected from one focus group and two interviews involving six pharmacists. Theoretical Domains Framework coding was primarily weighted in two domains: social/professional role and identity and environmental context and resources. We identified five main themes in the experiences of pharmacists in mental illness and addictions care: competing interests, demands, and time; relationships, rapport, and trust; stigma; collaboration and triage; and role expectations and clarity.

Conclusions

Pharmacists are not practicing to their full scope of practice in mental illness and addictions care for several reasons including limitations within the work environment and lack of structures and processes in place to be fully engaged as health care professionals. More research and policy work are needed to examine better integration of pharmacists as members of the mental health care team in communities.

Electronic supplementary material

The online version of this article (doi:10.1186/s13011-016-0050-9) contains supplementary material, which is available to authorized users.

Ensuring rigour and trustworthiness of qualitative research in clinical pharmacy

The use of qualitative research methodology is well established for data generation within healthcare research generally and clinical pharmacy research specifically. In the past, qualitative research methodology has been criticized for lacking rigour, transparency, justification of data collection and analysis methods being used, and hence the integrity of findings. Demonstrating rigour in qualitative studies is essential so that the research findings have the "integrity" to make an impact on practice, policy or both. Unlike other healthcare disciplines, the issue of "quality" of qualitative research has not been discussed much in the clinical pharmacy discipline. The aim of this paper is to highlight the importance of rigour in qualitative research, present different philosophical standpoints on the issue of quality in qualitative research and to discuss briefly strategies to ensure rigour in qualitative research. Finally, a mini review of recent research is presented to illustrate the strategies reported by clinical pharmacy researchers to ensure rigour in their qualitative research studies.

Partnering to enhance mental health care capacity in communities: A qualitative study of the More Than Meds program

BACKGROUND

Community pharmacists care for and support people with lived experience of mental illness in their communities. We developed a program called More Than Meds to facilitate enhancing capacity of community pharmacists' roles in mental health care.

METHODS

We conducted a qualitative study and used a directed content analysis with application of the Theoretical Domains Framework as part of our underlying theory of behaviour change and our analytic framework.

RESULTS

Ten interviews (n = 6 pharmacists, n = 4 community members) were conducted with participants from the More Than Meds program. Three key themes were identified from the experiences of More Than Meds participants: networking and bridging, stigma, and expectations and permissions. The most frequently coded domains in the data from the Theoretical Domains Framework were social/professional role, skills, beliefs about capabilities, knowledge and environmental context and resources.

CONCLUSIONS

The More than Meds Program enabled community pharmacists to increase their capabilities, opportunities and motivation in providing mental health care and support. Involving community pharmacists together with people with lived experience of mental illness was identified as an innovative component of the program.

Pharmacists' performance in a telephone-based simulated patient study after a mental health capacity-building program

BACKGROUND

The More Than Meds program was developed to enhance community pharmacy based services for people with mental illness.

OBJECTIVE

To evaluate the care of pharmacists who participated in this specific program using a telephone-based simulated patient with insomnia.

METHODS

A trained actor used a simulated patient case scenario and telephoned pharmacists (i.e., intervention group pharmacists) and a control group of pharmacists approximately 6 months following training. Pharmacists were scored on their assessment of the patient and problem, guidance provided on both pharmacological and nonpharmacological care, communications, and overall quality.

RESULTS

Sixty-three pharmacists (n = 29 intervention, n = 34 controls) were reached. Call duration was longer with intervention versus control group pharmacists [4.93 min (SD 2.3) vs. 4.00 min (SD 1.8)]. Medication recommendations were made by 76 and 100 % of intervention versus control pharmacists (p = 0.002), respectively. Intervention group pharmacists scored significantly higher on most components within communication and overall quality scores. Scores for assessing the patient, the problem, sleep, and medication supply were lower than expected for both groups.

CONCLUSION

Intervention group pharmacists performed better than controls on several components of a telephone-based simulated patient scenario for insomnia following More Than Meds training. More research is needed regarding telephone consultations in pharmacy practice.

Confronting inequities: A scoping review of the literature on pharmacist practice and health-related disparities

BACKGROUND

An expanding body of literature is exploring the presence and impact of health and health care disparities among marginalized populations. This research challenges policy makers, health professionals, and scholars to examine how unjust and avoidable inequities are created at the societal, institutional, and individual level, and explore strategies for mitigating challenges.

OBJECTIVES

Recognizing the significance of this broader conversation, this scoping review provides an overview of pharmacy-specific research attentive to health-related disparities.

METHODS

Following Arksey and O'Malley's framework, a rigorous screening process yielded 93 peer-reviewed and 23 grey literature articles, each analyzed for core themes.

RESULTS

Lending critical insight to how pharmacy practice researchers are conceptualizing and measuring health inequities, this review highlights three paths of inquiry evident across this literature, including research focused on what pharmacists know about marginalized groups, how pharmacists perceive these groups, and how they provide services. Striving to drive research and practice forward, this review details research gaps and opportunities, including a need to expand the scope of research and integrate knowledge.

CONCLUSIONS

As pharmacists endeavor to provide equitable and impactful patient care, it is essential to understand challenges, and build strong evidence for meaningful action.

A theory-informed approach to mental health care capacity building for pharmacists

Background

Pharmacists are knowledgeable, accessible health care professionals who can provide services that improve outcomes in mental health care. Various challenges and opportunities can exist in pharmacy practice to hinder or support pharmacists’ efforts. We used a theory-informed approach to development and implementation of a capacity-building program to enhance pharmacists’ roles in mental health care.

Methods

Theories and frameworks including the Consolidated Framework for Implementation Research, the Theoretical Domains Framework, and the Behaviour Change Wheel were used to inform the conceptualization, development, and implementation of a capacity-building program to enhance pharmacists’ roles in mental health care.

Results

The More Than Meds program was developed and implemented through an iterative process. The main program components included: an education and training day; use of a train-the-trainer approach from partnerships with pharmacists and people with lived experience of mental illness; development of a community of practice through email communications, a website, and a newsletter; and use of educational outreach delivered by pharmacists. Theories and frameworks used throughout the program’s development and implementation facilitated a means to conceptualize the component parts of the program as well as its overall presence as a whole from inception through evolution in implementation. Using theoretical foundations for the program enabled critical consideration and understanding of issues related to trialability and adaptability of the program.

Conclusions

Theory was essential to the underlying development and implementation of a capacity-building program for enhancing services by pharmacists for people with lived experience of mental illness. Lessons learned from the development and implementation of this program are informing current research and evolution of the program.

New roles for pharmacists in community mental health care: a narrative review

Medicines are a major treatment modality for many mental illnesses, and with the growing burden of mental disorders worldwide pharmacists are ideally positioned to play a greater role in supporting people with a mental illness. This narrative review aims to describe the evidence for pharmacist-delivered services in mental health care and address the barriers and facilitators to increasing the uptake of pharmacist services as part of the broader mental health care team. This narrative review is divided into three main sections: (1) the role of the pharmacist in mental health care in multidisciplinary teams and in supporting early detection of mental illness; (2) the pharmacists' role in supporting quality use of medicines in medication review, strategies to improve medication adherence and antipsychotic polypharmacy, and shared decision making; and (3) barriers and facilitators to the implementation of mental health pharmacy services with a focus on organizational culture and mental health stigma. In the first section, the review presents new roles for pharmacists within multidisciplinary teams, such as in case conferencing or collaborative drug therapy management; and new roles that would benefit from increased pharmacist involvement, such as the early detection of mental health conditions, development of care plans and follow up of people with mental health problems. The second section describes the impact of medication review services and other pharmacist-led interventions designed to reduce inappropriate use of psychotropic medicines and improve medication adherence. Other new potential roles discussed include the management of antipsychotic polypharmacy and involvement in patient-centered care. Finally, barriers related to pharmacists' attitudes, stigma and skills in the care of patients with mental health problems and barriers affecting pharmacist-physician collaboration are described, along with strategies to reduce mental health stigma.