Emerging Roles in Mental Health Care for Pharmacists

Nearly 1 in 5 US adults lives with a mental health disorder.¹ Many are currently being treated with medication regimens that benefit from pharmacist oversight.

As the antipsychotic medication landscape evolves, more roles are emerging for pharmacists to fine-tune their patients’ regimens and serve as important access points for individuals experiencing mental health crises.

Psychiatric Pharmacy: A Career Path in Mental Health

For a growing number of pharmacists, an interest in providing mental health care leads to a specialization in psychiatric pharmacy, also known as mental health pharmacy. Currently, there are over 1300 board certified psychiatric pharmacists in the United States and that number is expected to grow, said Charles F. Caley, PharmD, BCPP, chair and professor of pharmacy practice, department of pharmacy practice, at Western New England University College of Pharmacy and Health Sciences in Springfield, Massachusetts.

“The vast majority of psychiatric pharmacists are going to be working in inpatient psychiatric hospitals or in ambulatory or outpatient clinics,” said Caley. “Depending on where you live in the country, they could be state-run facilities or federally run facilities or county-run facilities. For example, in California, the counties govern and dictate and deliver behavioral health care, but in Connecticut that is not the case. It’s the state. So wherever public health care can be delivered, there’s the potential for pharmacists to be involved.”

Medication therapy that is managed by pharmacists has been shown to improve patient adherence while cutting costs for the care provider.

“Many patients are on many, many drugs because it is much easier for someone to add a medication than it is to take one away,” said Stephen R. Saklad, PharmD, BCCP, director of the Psychiatric Pharmacy Program at the University of Texas at Austin College of Pharmacy and a founding member of the College of Psychiatric and Neurologic Pharmacists.“Every time they change providers someone layers on another drug. They may or may not get their prescriptions from the same pharmacies, so many pharmacies may not see the composite picture of what they’re taking. It’s an opportunity for pharmacists to be able to reach in and clean up their meds, make the patient better, and decrease costs. Also, there’s a number of opportunities in giving long-acting antipsychotics or monitoring [patients taking] clozapine. Those are 2 areas where pharmacists have really stepped up.”

To provide and monitor long-acting injectable drugs, such as clozapine, pharmacists must first set up a protocol with the prescriber. They can then monitor treatment and, after getting lab results, adjust doses in collaboration with the prescriber.

“The protocol will differ depending on the state you are in,” said Saklad. “It’s not really very difficult or tedious but requires a few hurdles to jump over depending on [your] state…. There’s a really big opportunity for ambulatory care in community pharmacy and this is being done in a number of states around the country.”

As an associate professor at Pacific University in Forest Grove, Oregon, Bridget Bradley, PharmD, RPh, BCPP, educates future pharmacists about potential roles in mental health care. She also works as a psychiatric pharmacist at Virginia Garcia Memorial Health Center, a federally qualified health center.

“I truly love everything about my job,” said Bradley. “I get to work side by side with physicians, [physician assistants], NPs [nurse practitioners], nurses, [medical assistants], behavioral health providers, mental health providers, and the amazing support staff. In Oregon, pharmacists have the opportunity to practice at the top of their license. I get to provide medication management for patients with depression [and] anxiety, and support providers with managing many different psychiatric medications.”

Choosing psychiatric pharmacy as a career gives pharmacists an opportunity to improve lives and fight the stigma associated with mental health.

“Being knowledgeable about the medications [gives you] the opportunity to connect with a patient and help them with their medication use,” said Bradley. “Psychiatric pharmacists have the opportunity to help patients understand their medications.”

Filling in the Care Gaps

According to Saklad, about a third of all psychiatric patients in the United States are cared for at a family practice. A family practice provider might prescribe a selective serotonin reuptake inhibitor (SSRI) or other antidepressant and schedule a standard 3-month follow-up.

“They might make 1 dose adjustment and if that does not work, send the patient to a psychiatrist,” said Saklad. “Well, there’s not enough psychiatrists. Three months is too long. If you have a psychiatric pharmacist in your practice, patients are sent to them for a more appropriate monitoring adjustment. You have them come back in 1 to 2 weeks to see how they are doing and maybe then make an adjustment.”

Taking advantage of pharmacists’ expertise can do more than ease the burden on family practice physicians and NPs. With the shortage of psychiatrists expected to reach 25% of need by 2025, psychiatric pharmacists will be more essential than ever.²

The medication intervention and management performed by a pharmacist is also valuable during telehealth consultations. A 2020 study followed the pharmacist-led telemental health transitions conducted by a care clinic at a Veterans Affairs medical center. The aim was to improve continuity of psychiatric medication therapy following discharge from an acute psychiatric hospitalization. The study results showed that the pharmacist-led telemental health transitions improved the likelihood of patients adhering to antidepressant medication after their leaving the hospital.³

Getting Trained

Becoming a board certified psychiatric pharmacist requires specialized training. After graduating from a doctor of pharmacy program accredited by the Accreditation Council for Pharmacy Education, pharmacists can specialize in psychiatric pharmacy by acquiring postgraduate residency training, clinical experience, or a combination of the 2.⁴ Although all pharmacy students learn about common mental health conditions and medications, specialization in psychiatric pharmacy involves rotations in a mental health setting.

“You need experience talking with these folks, talking about the illness, learning how they live and what they struggle with in order to shape how you approach them, so you are of the most benefit to them,” said Caley.

Continuing mental health education, whether that involves focusing on psychiatric pharmacy or taking a mental health first aid course, makes it easier for pharmacists to approach the topic.

“A lot of pharmacists want to be able to do the right thing but they’re not sure what the right thing is,” said Caley. “They also think that talking with someone who has a mental health condition might take too much time, so they don’t. Given how common depression is, you could make the argument that pharmacists should be as well versed in depression as in diabetes, high blood pressure, and other common conditions. If you’re not interested in psychiatry and you don’t do a residency, then it’s up to individual pharmacists to pursue continuing education in areas that are focused on mental illness.”

Opportunities Exist in Community Pharmacy

Pharmacists working in the community setting can also play an important role in mental health care. According to the National Community Pharmacists Association (NCPA), pharmacists are more likely to encounter a patient having a mental health crisis than a patient requiring basic life support or cardiopulmonary resuscitation (CPR). By offering mental health first aid,⁵ a pharmacist can provide essential support during a crisis and then refer the patient to the appropriate medical professional. 

NCPA offers a course for community pharmacists about common mental health disorders and how to deal with a crisis. The training recommends that a pharmacist who notices a patient acting differently—sadder, more anxious, or perhaps more manic—might suggest a simple mental health screening. Such screenings only take a few minutes.

“It really is like CPR—where it stops short of someone providing sutures if you slice a finger,” said Hannah Fish, PharmD, NCPA’s associate director of strategic initiatives. “You’re there to understand. You need to provide some sort of compression to stop the bleeding, but then you call 911 and they’re on their way. It’s the same thing with mental health first aid, where you’re able to figure out what the issue may be or where someone might need some extra support and then extend that support to the person who needs it.”

One way to start the conversation is to post a sign letting patients know that you offer mental health screenings. It’s not unlike putting up a sign that says you offer influenza shots.

“You can say, ‘Hey, how are you doing, are you interested in a screening today?’ We’re here to talk and to help,” said Fish.

The screening is more effective if a patient receives a questionnaire during a 1-on-1 interaction with a pharmacist. A 2019 study⁶ explored whether distributing the standard Patient Health Questionnaire‐9 (PHQ‐9) for depression screening was more effective when added to a prescription pick-up bag or when patients had a 1‐on‐1 conversation with the pharmacist at prescription pick‐up or during a previously scheduled medication therapy management appointment. The highest participation rate occurred during a 1-on-1 interaction between pharmacist and patient, according to the results.

To provide timely referrals, pharmacists need an up-to-date list of accessible mental health professionals, clinics, and services. At Saklad’s Forty Acres Pharmacy in Austin, Texas, that list is updated on a monthly basis.

“Referring someone to a dead end is a bad, potentially lethal thing to do,” said Saklad. “We also check back with all the people we refer in 2 weeks to make sure they made contact and make sure they are okay. If they didn’t make contact we give them another referral and we may basically contact that referral while they are on the phone and get them an appointment. You have to lean in.”

A mental health crisis can happen to anyone—even to those who do not normally suffer from an ongoing mental health disorder.

“A significant portion of adults will go through some kind of mental health crisis at some point in life,” said Fish. “It’s not always permanent. Someone can have a panic attack without having a panic disorder, someone can go through a depressive period and not necessarily be clinically diagnosed with depression.”

Given the isolation prompted by a year of COVID-19 lockdowns, some individuals may be more likely to experience bouts of anxiety and depression.

“There’s a real opportunity for pharmacists to make the outreach, to just do a wellness check with folks and to normalize the mental health conversation,” said Fish.

References

1. Mental illness. National Institute of Mental Health. Updated January 2021. Accessed March 2, 2021. https://www.nimh.nih.gov/health/statistics/mental-illness.shtml#:~:text=Mental%20illnesses%20are%20common%20in,(51.5%20million%20in%202019)
2. Lebovitz L, Eddington ND. Trends in the pharmacist workforce and pharmacy education. Am J Pharm Educ. 2019;83(1):7051. doi:10.5688/ajpe7051
3. Barrett M, Ward S, Colvard M. Pharmacist-led telemental health transitions of care clinic improves antidepressant medication continuity posthospitalization. Ment Health Clin. 2020;10(6):381-384. doi:10.9740/mhc.2020.11.381
4. Becoming a psychiatric pharmacist. College of Psychiatric and Neurologic Pharmacists. Accessed March 19, 2021. https://cpnp.org/career/training
5. Mental health first aid. National Community Pharmacists Association. Accessed March 3, 2021. https://ncpa.org/mental-health-first-aid
6. Ballou JM, Chapman AR, Roark AM, Hule CH, McKee J, Marciniak MW. Conducting depression screenings in a community pharmacy: a pilot comparison of methods. J Am Coll Clin Pharm.2019;2(4):366-372. doi:10.1002/jac5.1156