These insights are published in the latest edition of Scottish Pharmacist magazine http://www.scottishpharmacist.co.uk/magazines/

The View from Secondary Care

Ommar Ahmed, Specialist Clinical Pharmacist in Mental Health, The Royal Edinburgh Hospital, NHS Lothian 

Where I work, in the acute mental health wards, decision processes about choice of medicine vary. If a patient is deemed to have the capacity or the insight, they are involved in the decision making regarding choice of medication. However, if a patient is not in a position to give informed consent because they are acutely unwell, then the decisions are made by the healthcare team supported by evidence-based medicine, keeping the patient’s best interests at heart.

I am quite lucky to be part of a team that is multidisciplinary. We work together to establish patients’ needs and decide on the most suitable medication for each patient at ward rounds or during daily handovers. As a pharmacist, I am mainly involved in providing advice in complex cases because there are not enough pharmacists to be at every consultation. I do provide counselling to patients if patients have asked to discuss their medication with me, but not often. The truth is that the role of the clinical pharmacist in hospitals is not well recognised among patients. Patients don’t see the point in repeating the same information to another person, and they are also sometimes suspicious about people they don’t already know.  However, sometimes patients want to talk to me, or the medical team refer a patient to me to work with that patient, which allows me to help that person understand their treatment and, if required, discuss alternative treatment options. 

I don’t think the resources available giving information on medicines to patients are very good. Quite often the information leaflets are not easy to read, and patients can feel overwhelmed with the information provided in these leaflets. The medicines themselves have hardly changed. For example, clozapine is regarded as the gold standard treatment for the management of schizophrenia. It was introduced to the market in the early 1970s! There has not been another antipsychotic developed since clozapine that works as effectively as clozapine. In fact, I don't think we really understand how clozapine works after almost 50 years because there is little research in this area. Contrast that with the pace of change in our understanding of oncology medicines: the difference is enormous.

The hospital that I work in has recently been moved to a newly purpose build facility, but the number of beds has been cut because of the drive to treat and manage patients in their homes and in community as much as possible. This has caused issues with bed management, primarily due to the fact that the services and resources are not available to accommodate patients in community and primary care who require specialist help. This has a huge impact on them as individuals as they are unable to be discharged to community and, as a consequence, hospital beds are full. 

I would like to see more emphasis on mental health in pharmacists’ training and more courses and seminars organised by the pharmacy profession in Scotland. The more pharmacists there are in mental health, the better the profile of mental health pharmacy will be. This would also help us to run pharmacist-led clinics, not only to look after patient's mental health medication, but also monitor their physical health so that we can try to stop people with some mental illnesses dying 15 to 20 years younger than the general population.

The View from General Practice Pharmacy

Chris Johnson, Specialist Prescribing Support Pharmacist, Primary Care, NHS Greater Glasgow and Clyde Pharmacy and Prescribing Support Unit 

When I set out to be a pharmacist I was interested in clinical pharmacy and that hasn’t changed. Clinical pharmacy is about working with people and most people engage with the health service in primary care, so that’s a good place for me to work. I am interested in the person and how we can best use medicines, where appropriate, to help that person. It doesn’t matter to me whether it is a mental health medicine or a non-mental health medicine, it is a medicine. Our job as pharmacists is to minimise harm and get the best effect for that individual at that point. However, it is important to revisit and review the individual and their medicines after a period to ensure that the medicines are still appropriate and, if not, stop them. 

Part of my work has been reviewing long-term benzodiazepine and z-hypnotic use and enabling GPs to feel competent and comfortable reducing benzo-type drugs, which is important not just from a mental health point of view, but also because of their role in falls and other avoidable drug harms. At the same time, some prescribers may now be using more antipsychotics instead of benzo-type drugs, which have significant cardiometabolic risks. A larger part of my work focuses on supporting the appropriate use of antidepressants. This grew from the antidepressant HEAT target work and provides part of the ongoing framework, as requested by the Scottish Government. A significant part of this work is supporting GPs to review people receiving the same antidepressant long-term (≥2 years); since 2009/10 we have enabled more than 180 practices in NHS Greater Glasgow and Clyde to review over 8000 people, with the work continuing as a prescribing indicator.

There is no health without mental health, therefore a mental health medicines review should be part of a general review. For instance, if I optimise a patient’s COPD medication it may help reduce their anxiety due to shortness of breath. From my point of view, we as pharmacists need to be leading on the complicated and complex polypharmacy work, which I accept is the inverse of how the new GP contract is worded when it comes to pharmacotherapy services. We don't want to de-skilled GPs, but we need to work to our strengths, optimising individualised pharmaceutical care and enabling general practices to be more efficient. 

I realise some pharmacists may be apprehensive about working closely with people with mental illnesses because of all the media stereotypes of people with mental illness being ‘nutters’. That’s such a load of rubbish. Everybody at some stage has had emotional distress or some form of challenge of an emotional nature such that, had they had a diagnosis at that point, they may have been classified as having clinical depression or generalised anxiety disorder. As pharmacists we need to get the medicines right for people who are ill, whatever their illness.

The View from Community Pharmacy

Noel Wicks, Managing Director, Right Medicine Pharmacy 

I think it is inevitable that, as people are taking some responsibility for their own health and people are being signposted to community pharmacy as somewhere to get help easily and quickly, more people will come through our doors with mental as well as physical illnesses. 

I think the challenge for us is how to build the right vehicle in community pharmacy to be able to help these people ourselves and, in turn, to be sure we signpost them to the right places. When people are pointed to community pharmacy as an alternative to their GP, we have tools we can use associated with that, such as the Minor Ailment Service. So, equally, we need to have the right tools to make sure pharmacists and pharmacy staff meet the expectations of people who bring mental health issues to us. 

There are so many factors that can be in play to make someone mentally unwell and, while we have a central role in ensuring their medicines are managed correctly, there are many different other options that also come into play when we consider the person holistically – and we need to know how to help them access these options. If I want someone who has come to the pharmacy to go on to see a doctor, I give the doctor a call there and then and book them an appointment before they leave. I want to be able to make direct referrals in that same way to nonpharmacological therapies, whether it is counselling or support groups or local patient groups. 

Community pharmacists prescribing in mental health is clearly going to be an interesting area in the near future. Potentially, in the same way as we might talk about a rapid start contraceptive pill, perhaps we might need to be able to offer a rapid start mental health intervention for certain conditions. And, if someone is on a medicine, community pharmacy can undertake ongoing monitoring and titration of doses. So, a doctor might do the diagnosing and hand over to the pharmacy for the prescribing, then we’d start off on a particular dose, review its effectiveness and adjust it accordingly. 

There is huge potential for pharmacists to support people in their communities who have mental health problems. A lot of this is not new. In fact, we’ve always done it. We know at first-hand what people suffering from mental ill-health want from their pharmacy in terms of advice, a second opinion, a conversation about different therapy options and answers on how long they should be taking a medicine for, should they come off it and, if so, how? This sort of support goes on continually in the background. We are already playing a not insignificant role. Given the right tools, there is definitely scope for us to do more. 

These interviews conducted by John Macgill at this year’s ‘Mental Health in Scotland: Putting Patients at the Centre of Medicines and Innovation’ conference.