|Home | About | Journals | Submit | Contact Us | Français|
To design and implement an interactive education program to improve the skill and confidence of community pharmacists in providing pharmaceutical services to people with mental illnesses.
A literature review was conducted and key stakeholders were consulted to design a partnership that involved community pharmacists and consumer educators. The partnership was designed so that all participants shared equal status. This facilitated mutual recognition of each others' skills.
Four 2-hour training sessions were conducted over a 2-week period in March 2005. Seven pharmacists, 5 consumer educators, and 1 caregiver educator participated in the partnership. Pharmacists indicated that their participation caused them to reflect on their own medication counseling techniques. Consumer educators reported that speaking about their experiences aided their recovery.
Developing a better understanding and improved communication between community pharmacists and people with mental illnesses is an important aspect of facilitating a concordant approach to patient counseling. Implementing mental health education programs utilizing consumer educators in pharmacy schools is a promising area for further research.
The World Health Organization (WHO) has estimated that as many as 450 million people worldwide suffer from mental disorders, with 1 in 4 families having at least 1 member with a mental illness.1 More than 44 million people in the United States suffer a mental disorder each year, with the annual direct costs of mental illness estimated to be in excess of $69 billion.2 A similar pattern of disease burden is observed in other developed countries. Twenty percent of Canadians will personally experience a mental illness during their lifetime.3 In Australia, mental illness is a national disease priority area, and the leading cause of years lost due to disability.4,5 Improving the quality and accessibility of community care for people with mental illnesses is an aim outlined in the Inquiry Into Mental Health Services in New South Wales.6 Health professionals have identified the management of mental illnesses as among their most challenging therapeutic responsibilties.7
The majority of people with mental illnesses receive treatment from primary care practitioners.8,9 There were over 49 million ambulatory care visits related to mental illnesses in the United States in 1997.2 As primary care health professionals, pharmacists are well placed to contribute to the management of mental illnesses. Pharmacists are key members of the health care workforce responsible for implementing the National Strategy for the Quality Use of Medicines in Australia, and are regarded as among the most trusted professionals.10,11 The development of new community pharmacy services has expanded the opportunities for pharmacists to work collaboratively with general practitioners to provide community mental health care. These services include domiciliary medication management review and community-based multidisciplinary case conference meetings.12 Community pharmacists are frequently consulted for advice about medications used to treat mental illnesses.13-18 Counseling provided by community pharmacists can improve adherence and attitudes to antidepressant medications.19-21 Pharmacists' contributions to community mental health teams may improve adherence to antipsychotic medications and decrease medication-related side-effects.22-25
The provision of information about medications by community pharmacists, however, may be limited by poor communication with people with mental illnesses. Finnish community pharmacists were less likely to provide directions for use of psychotropic medications than for 8 other therapeutic classes of medications studied.26 Pharmacists have reported feeling more uncomfortable counseling on the use of medications used to treat mental illnesses than those used to treat cardiovascular conditions.27 British and Canadian community pharmacists have reported that their ability to provide information about antipsychotic medications is limited by a lack of training to counsel people with severe mental illnesses.27,28 Dutch community pharmacists did not perceive that they have a clear role in the management of schizophrenia.29 In the same study, however, 60% of people with schizophrenia and their caregivers indicated they would like to receive more information about prescribed medications.29 People beginning courses of antidepressant medications in Britain were found to have unmet information needs, and people with mental illnesses in Australia have expressed their dissatisfaction with information about medications provided by their health professionals.30,31
The WHO has recognized the value of consulting with relevant stakeholders, including professional associations, community groups, and advocacy organizations when designing mental health education programs.32 The importance of facilitating consumer involvement in medical education, assessment, and curriculum development has been described.33 An Australian report published in 1999, however, found that consumer and caregiver participation in tertiary mental health education was minimal.34 Institutions offering education to health professionals have typically not been accountable to recipients of health care. The second Australian National Mental Health Plan, released in 1998, recognized consumers, families, and caregivers as key stakeholders who must be adequately financed and resourced to influence decisions relating to service provision.35 Improving the delivery of mental health care services will be facilitated by close collaboration between patient advocacy organizations, organizations responsible for mental health policy and planning, and educational institutions.
A consumer educator in mental health care is a person who has previously received mental health care and works, often on a voluntary basis, to inform and educate professionals, students, and the wider community on mental illness and its effects on individuals, families, and society. Similarly, caregivers undertake this role. The consumer and caregiver educators work through advocacy organizations, including the Schizophrenia Fellowship of New South Wales (SFNSW), from which they receive training and support. The SFNSW is a non-profit community-based organization for people living with mental illnesses and for their caregivers and relatives. Australian government policy has recognized people with mental illnesses as partners in the delivery of mental health care.35
The aim of this initiative was to design and conduct an interactive educational partnership between community pharmacists and consumer educators in mental health care. The specific objective of the partnership was to address the communication skills required for community pharmacists to provide pharmaceutical services to people with mental illnesses.
MEDLINE (1966-2004), International Pharmaceutical Abstracts (1992-2004), Embase (1992-2004), and PsychInfo (1992-2004) were searched using terms including consumer consultant, mental disorders, education, consumer participation, and patient advocacy. Researchers used the outcomes of the literature search and consulted with key stakeholders, including professional organizations representing pharmacists and patient advocacy groups, to inform the design of an interactive training program involving community pharmacists and consumer educators in mental health. The stakeholders involved in the development of the training program are outlined in Table Table11.
The SFNSW recruited the consumers and caregiver educator. The consumer educators employed in the education program had received training as speakers from the SFNSW community pharmacists who had earlier indicated their willingness to participate in a research project being conducted by the Faculty of Pharmacy were invited to participate in the educational partnership. This paper reports the qualitative evaluation of focus groups with the community pharmacists and consumer educators conducted as part of the educational partnership. With the consent of those present, these focus groups were audio taped and the content was analyzed.
Four 2-hour education sessions were conducted during March 2005. Seven community pharmacists, 5 consumers, and 1 caregiver participated in the partnership. An overview of the learning objectives and corresponding educational strategies is presented in Table Table2.2. The sessions included both lecture style presentations and open discussions led by specialist pharmacists, a psychologist, a mental health nurse, and a psychiatrist. In the first and fourth sessions, special emphasis was placed on community pharmacists and consumer educators being able to share their experiences related to the topics presented. An important aspect of the fourth session was the debriefing and focus groups with the consumer educators and community pharmacists.
A key finding from the focus groups was the desire among consumers to receive more information about prescribed medications from their community pharmacist. Consumer educators reported that receiving more information about medications would enable them to make informed decisions regarding their own health care, including the ability to discuss treatment options with their medical doctors. One consumer educator highlighted how it was important for pharmacists to provide medication counseling for the person rather than the diagnosis: “You need to be aware that you are dealing with people. We have lives. People with mental illnesses are treated differently, but mental illness is a physical illness that occurs in the brain, just like other physical illnesses that occur in the heart.” Another consumer educator added, “Individual pharmacists can be very selective who they relate to in their pharmacy practice, who they reach out to… they don't want any scenes in the shop… they rate you according to the drugs that they give you.”
Pharmacists discussed the barriers they perceived to providing pharmaceutical services to people with mental illnesses. Although pharmacists reported having the knowledge and desire to provide information about medications, several reported lacking the confidence and skills necessary to communicate effectively with people with mental illnesses. Many were unaware of the consumers' unmet needs for information about medications. The sessions caused the pharmacists to reflect on their own medication counseling techniques. As one pharmacist commented, “It has changed my perception of how people will react to discussion…I can think of at least eight people [with mental illnesses] that I've never directly discussed their medication with.” Another pharmacist added, “I won't be scared to ask ‘how are you going with your medications?’ It has been surprising how open people have been to share their experiences.”
The consumer educators were enthusiastic about their participation in the partnership, the chance to speak about their experiences, and the format of the sessions. One consumer educator stated, “You are doing a training needs analysis…identifying the gaps between pharmacists and the consumer population.” Another commented, “It's good that you are doing holistic training…workshops are more personal, you can say what you feel from the heart, you can bounce ideas and brainstorm.”
The act of providing consumer education in a paid and recognized capacity was reported to be a valuable component of the consumer educators' own treatment. The caregiver who participated stated, “It has been wonderful for her [daughter of the caregiver] to go out and share her illnesses. When I saw she was improving so well by being an advocate, I did the carers' advocacy course as well…the advocacy has been a very positive contribution towards her recovery.”
Lack of training to counsel people with mental illnesses about their medications has been cited as a barrier to service delivery, yet few mental health education programs for pharmacists have sought to address this barrier.27,28 The use of consumers as educators has largely been restricted to nursing and medical education, where their contribution has been reported to be well received.36 Other reported advantages of using consumers are improved attitudes and a positive impact on nursing practices.37,38 Although the benefits of pharmacists' membership in mental health advocacy organizations have been presented,39 the research team did not retrieve any published reports of people with mental illnesses being previously employed in the continuing education of community pharmacists. Mental health training programs for community pharmacists have typically focused on the indications and adverse reactions of psychotropic medications, rather than the skills required to communicate this information to consumers. Educational interventions that allow participants to apply desired behaviors have been recognized as more effective than providing theoretical information.40 Role playing (with students or staff acting as consumers) is frequently included in undergraduate pharmacy education; however, role playing the provision of information to people with mental illnesses may be perceived as too artificial to be useful. While promoting interpersonal contact with people with mental illnesses can improve attitudes toward people with mental illnesses,41 one study suggested that pharmacy students' clinical placements at mental health centers may reinforce the “medical model orientation.”42 This may be because students visiting psychiatric facilities observe people receiving treatment, sometimes involuntarily, for acute exacerbations of their illness. Negative attitudes towards people with mental illnesses among health professionals has been identified as a barrier to service delivery.43 The educational partnership with the consumer educators, therefore, represented a new and promising model for mental health education of community pharmacists.
The International Alliance of Patients' Organizations (IAPO) has also recognized the importance of consumers learning the skills required to interact and work together with their health professionals.44 Several consumer educators were unaware that community pharmacists were able to provide comprehensive information about prescribed medications. Barriers to consumer participation include a lack of knowledge about the complexities of the mental health system, the mental health system being perceived as an agency of social control, and a persisting power differential between health professionals and people with mental illnesses.45 Strategies to improve understanding between community pharmacists and people with mental illnesses may be an important first step towards overcoming these barriers and facilitating a “concordant approach” to mental health care.
Several consumer educators reported that speaking about their experiences assisted their recovery. This supported earlier research that suggested the act of providing education to medical students resulted in consumer empowerment, increased self-esteem, development of new insights, and an improved understanding of the doctor-patient relationship.46 The formation of an educational partnership, therefore, may have ongoing benefits for both groups. Although the results of this qualitative research cannot be generalized to all groups of consumers, pharmacists, and pharmacy students, this case study suggests that utilizing consumer educators in pharmacy education is a promising area for future research. An important aspect of the training program involved the consumer educators speaking about their own experiences. A corresponding limitation, however, was that the consumers did not attempt to represent or speak on behalf of all people with mental illnesses. Controlled studies are needed to assess the impact of consumer educators on pharmacists' attitudes toward people with mental illnesses and their willingness to provide pharmaceutical services.
The educational partnership demonstrated the potential value of utilizing consumer educators in the education of community pharmacists. Developing a better understanding and improved communication between community pharmacists and people with mental illnesses is an important step towards improving community care for people with mental illnesses. The outcomes of the training suggest that the use of consumer educators in pharmacy education may improve the confidence of community pharmacists to discuss medication concerns with people with mental illnesses. Employing consumer educators in pharmacy education should be considered as one strategy for improving the confidence and ability of community pharmacists to communicate effectively with people with mental illnesses. The opportunity for consumers to provide education and speak about their experiences may aid their recovery.
This project was funded by the Australian Government Department of Health and Ageing as part of the Third Community Pharmacy Agreement. In recognition of their role as trained educators, all presenters, including the consumer educators, were paid for their time and expertise. The community pharmacists were reimbursed for the costs associated with their participation.