Given the extent of mental illness in the community and in aged care, and the fact people with mental illness frequently report concerns about their prescribed medications, services directed toward optimising the use of medications for mental illness fulfil an important public health need. As evidenced by the large number of papers excluded from this review, many studies of community pharmacy services to optimise the use of medications for mental illness have been descriptive, lacked parallel control groups or have been qualitative in nature. The controlled studies included in this review provide some evidence of the potential value of including pharmacists in mental health care across a range of settings and patient populations.
Studies included in the review utilised a range of randomisation techniques, however, the review did not attempt to characterise the quality of the randomisation beyond whether randomisation occurred at the patient, practice or residential aged care facility level. The majority of the studies involved less than five pharmacists, and 10 out of the 22 papers described interventions where just one pharmacist was involved. Studies involving small numbers of pharmacists may have good internal consistency, but the results obtained may not be generalisable to outcomes of services provided by the wider pharmacy profession. In several studies the pharmacists' interventions were components of multidisciplinary team approaches to improving mental health care. The challenge of evaluating complex and multi-factorial interventions, which by their nature depend on the context in which the intervention takes place, has been described [76
Five studies assessed the impact of pharmacists' provision of medicines information and treatment monitoring for people commencing antidepressant therapy. Three of the five studies demonstrated that involvement of the pharmacist was associated with a significant improvement in medication adherence and/or medication use rates when measured using an intention to treat analysis. One further study demonstrated significant improvements in medication adherence among patients who received three pharmacist counselling sessions; however, this was not significant when measured using an intention to treat analysis. Given the high rates of antidepressant discontinuation during the first three months of treatment, pharmacists have a potentially important role in providing medicines information and conducting treatment monitoring for those patients at high risk of medication non-adherence. No studies of pharmacists' treatment monitoring for people commencing antidepressant therapy compared monitoring provided by pharmacists to monitoring conducted by other health professionals. A separate study of antidepressant treatment monitoring conducted by nurses also demonstrated improved medication adherence [77
Despite people with psychotic disorders having reported unmet medicines information needs, relatively few controlled studies assessed community pharmacy services for users of antipsychotic medications. Other studies have suggested that service provision by pharmacists may be limited by not having access to patients' medical histories [46
], a lack of specific training to counsel this patient population [46
], and pharmacists' attitudes towards people with mental illness [48
]. Further well designed research into community pharmacy services for users of antipsychotic medications is needed before conclusions can be made about the potential of such services to reduce hospital readmission and the cost of health care.
Pharmacist conducted medication management reviews appear a valuable strategy to identify potential medication related problems among people taking medications for a mental illness. The included studies demonstrated that such reviews can reduce the numbers of potentially inappropriate psychotropic medications used for mental illness prescribed to elderly people in residential aged care settings. Only one study made the link between a reduction in psychotropic medication use and improved adherence to national prescribing guidelines [66
]. The value of pharmacist conducted medication reviews for people with mental illness may not be limited to optimising the use of mental health medications. Physical health care for people with mental illnesses is often less than optimal, and pharmacist conducted medication reviews may be a comprehensive strategy to improve medication use for both mental and physical illnesses. The tendency among health professionals to focus solely on the management of the mental illness among people with both mental and physical illnesses has been described in the literature [78
Educational visiting has been shown to modify prescribing behaviour [79
]. The reviewed studies reported pharmacists' interventions that were well received by prescribers, but produced differing results as to whether such visits were associated with changes in prescribing behaviour. This may have been because efforts to reduce prescribing of potentially inappropriate medications were not accompanied by information about alternate treatments, or because patients were reluctant to discontinue taking benzodiazepine medications. In the Dutch study that did produce a significant impact on prescribing patterns, information about the problems associated with prescribing highly anticholinergic antidepressants was accompanied by information about prescribing more appropriate antidepressant medications [71
]. Additionally, pharmacists' initiatives to improve prescribing may be most effective when both the pharmacists and general medical practitioners have an opportunity to build rapport. The practitioners involved in the Dutch study were those routinely involved in providing care to the patient populations discussed. Data presented on prescribing at these meetings were relevant and specific to the local area in which the meetings took place.