Pharmacists Often Uneasy With Psychiatric Patients

Pharmacists have positive attitudes toward patients who fill prescriptions for psychiatric medications but still feel so awkward talking to them that they provide less counseling about symptoms and side effects than to patients with medical diagnoses, says a new Canadian study.

“Pharmacists said they monitored patients with mental illness less frequently than patients with cardiovascular problems,” wrote Beth Sproule, Pharm.D., B.Sc.Phm., an assistant professor in the departments of pharmacy and psychiatry at the University of Toronto. “Apprehension or discomfort during patient interactions may lead to ineffective counseling or the lack of essential medical services.”

A new direction in pharmacy practice calls for providing“ pharmaceutical care” to patients in order to identify and prevent drug-related problems, said Sproule.

Better mental health training and increased privacy while counseling might improve the professional interactions between community pharmacists and patients using psychiatric medications, wrote Sproule in the December Psychiatric Services. She and two colleagues, Vinay Phokeo, M.Sc., B.Sc.Phm., and Lalitha Raman-Wilms, Pharm.D., B.Sc.Phm., surveyed 800 pharmacists in the Toronto area regarding their attitudes toward patients with psychiatric diagnoses, and 283 responded. For comparison, they asked similar questions about patients taking cardiovascular drugs.

They found that 36 percent of the pharmacists felt awkward asking patients why they were taking psychiatric medications. Only 7 percent reacted the same way to patients taking cardiovascular medications. While 93 percent felt comfortable discussing cardiovascular symptoms, only 71 percent had similar reactions to psychiatric symptoms. When asked if patients with mental health problems did not want to talk to pharmacists, they agreed or were neutral almost half of the time (47 percent), compared with 6 percent who gave that response to a question about cardiac symptoms.

That persons working in the heath professions have difficulty talking to patients with mental illness comes as no surprise to some.

“I don't know why pharmacists would be doing any better than the rest of us,” said Boston psychiatrist Ken Duckworth, M.D., medical director for the National Alliance for the Mentally Ill (NAMI). “Stigma is alive and well, and pharmacists are not different from other health professionals.”

“In many disease states, there are always invisible barriers,” agreed Stephen Setter, Pharm.D., an assistant professor of pharmacy at Washington State University in Spokane. “With patients with bipolar disease, dementia, or depression, you have to look beyond the barriers.”

Yet stigma or lack of training aren't the only barriers, said Setter, a spokesperson for the American Pharmacists Association.

The patients are not getting adequate information from the prescribing physicians, said Sproule. “Only 8 percent of pharmacists agreed that patients who use psychiatric medications receive all the necessary drug information from their physician or psychiatrist.”

Lack of compensation often impedes patient counseling too. Some insurance companies now pay pharmacists to counsel patients with diabetes, but the model is still not widely adopted.

“You go to a therapist, you pay, and you get individual attention,” said Setter. “For a pharmacist, there's usually no compensation aside from payment for the prescription.”

A little more education for pharmacists might help as well, added Sproule. Only 24 percent said they had learned enough about mental health during their pharmacy training to help them do their job, compared with 61 percent who claimed an adequate background in cardiovascular issues. When asked about barriers to counseling mental health patients, the pharmacists said they lacked time; information on patient diagnosis, drug indications, or treatment goals; and private counseling areas in the pharmacy. Patient symptoms like hostility, inattentiveness, or irritability created communication difficulties, they said.

Pharmacists could improve their ability to understand and counsel psychiatric patients if undergraduate and continuing education programs included better mental health curricula, said Sproule.

Some pharmacy schools already expose their students to psychiatric patients, noted Setter. Pharmacy education at Washington State now includes a strong psychiatric component, he said. Students first observe interactions with persons simulating depression or Parkinson's disease. Then real patients come in to present and to answer students' questions about their conditions and about which drugs worked and which did not.

“Students learn that not everyone who comes into the pharmacy is happy and healthy,” said Setter. “We're all human, and we all need empathy.”

Some students also take rotations through local psychiatric hospitals. When Setter did such a rotation as a student, he was initially frightened to walk into a psychiatric ward.

“But after six weeks, I felt they were just like other people,” he said. “Not all our students get this chance, but we must find ways to increase their contact with persons with psychiatric diagnoses.”

Part of his work now involves team home visits to geriatric patients. He is impressed by how little patients know about the conditions and medications and the number of questions they ask, even after years of treatment.

Most patients may not need or want the additional counseling a pharmacist can provide, said Setter, but for those who do, the time spent can improve their understanding of their illness and its treatment, make them aware of drug interactions and side effects, increase compliance, and improve the outcome of drug therapy.

The study was supported by the Association of Faculties of Pharmacy of Canada–Apotex Undergraduate Pharmacy Practice Research Award and the Centre for Addiction and Mental Health in Toronto.

The study, “Community Pharmacists' Attitudes Toward and Professional Interactions With Users of Psychiatric Medication,” is posted online at<http://ps.psychiatryonline.org/cgi/content/full/55/12/1434e?>.▪