This article appears in the current edition of Scottish Pharmacist magazine.

Earlier this year the Scottish Government published its much-anticipated new Mental Health Strategy with an ambition to prevent and treat mental ill-health with the same commitment, passion and drive as physical health problems. Pharmacists have always been closely involved in the care of people with mental illness but, as John Macgill has been finding out, the profession's potential is perhaps only beginning to be seen.

In her introduction to the Mental Health Strategy 2017-2027, Scotland's first Minister for Mental Health, Maureen Watt MSP, sets an ambitious tone:

'We want to see a nation where mental healthcare is person-centred and recognises the life-changing benefits of fast, effective treatment. We want a Scotland where we act on the knowledge that failing to recognise, prioritise and treat mental health problems costs not only our economy, but harms individuals and communities.'

Ms Watt told Scottish Pharmacist: 'Our Mental Health Strategy states that we'll support the development of new multi-disciplinary models of supporting mental health in primary care to ensure that people can 'ask once, get help fast'. Given the role of pharmacists in providing both advice and medicines, there is potential for them to have a role in helping to support this ambition. A wide range of clinical and non-clinical staff, including pharmacists, can provide problem-solving, listening and signposting for physical, mental and social problems and can work with people to optimise their own physical and mental wellbeing.'

One person with a unique perspective as a Member of the Scottish Parliament with a career in psychiatric pharmacy, is Maree Todd MSP. She believes pharmacists play a vital role in supporting people with mental ill health:

'Medication can be the cornerstone of treatment for illnesses like schizophrenia and bipolar affective disorder, but the medicines are not easy to use and it can be hard to find the one that best suits the patient. Even when non-drug treatments are the preferred option, drugs are often still prescribed, like in personality disorders, and a pharmacist's role can be helping to avoid harm from medication in these conditions.

'Some mental illnesses are very common and because treatment is needed during childbearing years, specialist advice on drugs in pregnancy and breastfeeding is essential. For illnesses like depression, where there are non-drug treatment options too, a pharmacist can help weigh up the pros and cons of both options of the individual patient. Those with severe depression will need medication before they will be able to engage with talking therapies. Those with mild depression would be best treated with talking therapies. Pharmacists have a key role to play in choosing the right medicine, minimising and monitoring for side effects, and helping the patient to keep taking the medicine for as long as they need to.'

Maree Todd says it is rewarding to see how good pharmaceutical care makes a real difference to a patient's quality of life.

'The feeling of having made a difference is satisfying. I liked the long-term relationship too. There were people I met early on in my time at the hospital whose care I was still involved in 20 years later when I left. These are often chronic illnesses so you can't cure them but you can make a difference. From an intellectual point of view, there probably isn't a more complex organ system than the brain. A keen pharmacist could spend their whole working life trying to understand it and using that knowledge to improve lives and still have plenty to learn.'

For the majority of people with mental illness, supported outside hospital, community pharmacists have long been central to their care. Indeed, according to Policy and Development Pharmacist with Community Pharmacy Scotland, Adam Osprey, they may be the health professionals who people on medication see most often:

'Generally, people will visit the pharmacy every month or even more frequently depending on their medication schedule. Good relationships are built between pharmacists, pharmacy teams and clients. We get to know them very well. It's a privileged position to be in. People quite often open up to us when things are not going so well and that is where the pharmacist can offer support, and also referrals into other services.

'Even when people do not volunteer the information themselves that things aren't going so well for them, the pharmacy teams will often pick up changes in a person's behaviour, their demeanour perhaps, and pick up clues. We have a professional duty to pick these up, to identify the issue and to help people access the care they need.'

In its Care for People with Long Term Conditions policy document published at the end of last year, the Royal Pharmaceutical Society (RPS) in Scotland cited the work being done with students with depression and anxiety by one campus pharmacy team:

'All patients receiving new medication are offered a one to one private consultation to advise them on how best to use their medication and also discuss any other questions and issues. We advise on key lifestyle factors such as good sleep hygiene, and for patients who are students, we can signpost to various academic support services. We arrange both telephone and face to face follow-ups and once patients are settled on repeat medication, we check how they are progressing with their treatment. For patients we think are at risk of harming themselves, we liaise with our GP colleagues, ensuring they get timely appointments and the regular contact and support they need.'

At the other end of the age spectrum, RPS's Practice and Policy Lead in Scotland, Aileen Bryson, points to the need for continuing pharmaceutical care of the elderly:

'There's a huge amount to be done to reduce the antipsychotic medicines being prescribed to older people, which is one of the reasons that we are calling for pharmacists to have more input into care homes so that we can be sure people are only kept on these drugs for the duration of an episode that warrants them, and not left on them, because they have such a big impact on the risk of heart attack and stroke.

'Where you have a pharmacist working with a GP practice, this too is an ideal opportunity to provide holistic medication reviews. For instance, where somebody is looking for a further supply of antidepressants, which were deliberately not on repeat prescription so that they could be monitored, a pharmacist could do a review and make the judgement in terms of how severely ill the person is, perhaps based on a set of agreed sensible questions to spot any red flags.

While there are fewer independent prescribers active in mental health compared with physical health, Maree Todd suggests some pharmacists in acute settings are leading the way:

'My colleagues in the hospital department I worked in in Inverness are all prescribers now and are taking their specialist skills out into the community, working with Psychiatrists, GPs and community mental health teams. It's quite an innovative pilot and early results are promising. If successful, they will relieve some of the pressure in primary care and provide the continuity which is so essential in mental health care. They are keen to link in with primary care clinical pharmacists and community pharmacists too. One of the areas they are making a big difference in is the physical health of folk with mental ill health.'

So, what are the things that are needed to allow pharmacists to achieve more of their potential in supporting people with mental illness?

For Minister for Mental Health, Maureen Watt MSP it is training:

'The Mental Health Strategy outlines opportunities to provide training in first aid approaches for mental health as well as peer support, digital tools and better use of electronic information which all have the potential for widening access, supporting co-production and self-management. There is potential for pharmacists to undertake mental health first aid training as well as use appropriate technology tools and information to support shared decision making and help people to self-manage their condition.'

Achieving the Mental Health Strategy's ambition of 'ask once, get help fast' will require the professional who is 'asked' to be able to trigger the process of delivering help. And, given that pharmacists are often the first port of call, Adam Osprey of Community Pharmacy Scotland wants to see more structured, digitally-supported referral systems:

'If somebody presents who is in need of a physiotherapist, for instance, then it varies depending on the NHS board as to how you go about referring into that service. Whether it is dieticians, nutritionists or mental health support workers, there are informal local ways of getting people into the services, but they vary.

'Sometimes it does just feel like a referral rather than a full clinical handover to a fellow professional. Often, we don't know what happens to a person who we have referred. We don't even know if they have necessarily gone ahead and accessed the care that we arranged and whether the appointment has been met.'

Community Pharmacy Scotland adds that the need for community pharmacists to have role-based access to clinical records is as great for people with mental health problems as for every other person who seeks their help.

Aileen Bryson says consistent communication within pharmacy is also important:

'There has to be that follow-up, there needs to be that follow-through. The information has to follow people as they move across sectors because too often we see people falling between two stools.'

Maree Todd wonders whether the development of the role of pharmacy in supporting people with mental illness is being matched by the medicines available to treat the patients affected.

'In the 20 years I worked in psychiatry, the main progress I feel we made was learning to use the drugs we had more effectively. I have reflected a lot on the lack of new drugs and progress in treating illnesses like schizophrenia and bipolar affective disorder, we don't even really understand the underlying pathology.

'When you compare that to some of the great strides made in cancer treatment it's disappointing. These illnesses are common, both affecting around 1 in 100 people worldwide, and can have a huge impact on the person's life. From a purely economic perspective, you'd think all the world's best brains would be trying to understand them.'

Interestingly, the medicines makers agree. The Head of Regulatory and Safety Policy at the trade body for the research-based medicines industry, ABPI, is Sunayana Shah:

'Research into mental health and the broader aspect of neurology is a complex area that needs co-operation between industry, academia, clinicians and patients to translate cutting-edge science into treatments that will be useful for patients.

'While our understanding in many therapy areas is expanding very quickly, the rate of change in neurology is slower because the basic science around some conditions is still emerging. Companies do continue to research new treatments, with promising developments for early or mild Alzheimer's disease in the pipeline for example, but we know that we have a very long road ahead.'

Since this article was written, a conference on pharmacy in mental health to be held in November was announced. The Pharmacy Management event will take place at Stirling University on 21 November 2017. More details will be published soon on their website www.pharman.co.uk/events/scotland