Community pharmacists as behavioral health extenders: an effectiveness-implementation hybrid type II feasibility evaluation

Abstract

Background

Availability of mental health services is often limited, with many patients suffering from depression or anxiety either unidentified or unable to access care. Community pharmacists may be well-positioned to serve as behavioral healthcare extenders by offering timely screening, referrals, education, and medication management. However, evidence supporting feasibility and effectiveness of behavioral health (BH) care interventions in community pharmacy settings remains anecdotal. The purpose of this article is to summarize the findings from a feasibility evaluation of a BH intervention in 7 U.S. community pharmacies.

Methods

The BH intervention, delivered over 6–11 months, consisted of a screening and referral program and a 6-session education and medication management program. Participating pharmacies benefited from a multi-faceted implementation strategy (e.g., coaching, toolkits). An effectiveness-implementation hybrid Type II design was used to assess effectiveness of the intervention, while evaluating its implementation. Implementation outcomes involved program adoption rates, levels of program acceptability, appropriateness, and feasibility, intent to sustain, and fidelity rates. Intervention outcomes included: patient referral rates, perceived benefits, and changes in patient knowledge, clinical symptoms, and medication adherence. The data were collected using multiple methods (e.g., surveys, interviews, administrative data) and analyzed accordingly.

Results

Results indicated a 100% adoption rate by the pharmacies with intent to continue past the project period; significant increases in program acceptability, appropriateness, and feasibility; and high levels of program fidelity. All 206 patients were appropriately referred as needed, with patients enrolled in the 6-session program reporting statistically significant changes in knowledge, clinical symptoms, and a nonadherence to medications.

Conclusions

These findings lend support to the role that community pharmacists can play in bridging the mental health care gap and improving population health.

Depression has been identified as one of the leading causes of disability worldwide, with more than 260 million people affected [1]. Similarly, anxiety disorders are one of the most common mental illnesses, impacting approximately 18% of adults each year [2]. The profound impacts that can result from these illnesses include low quality of life, reduced work productivity, poor social connections, physical health issues, and suicide [3].

Both conditions have been further exacerbated by the COVID-19 pandemic, with reported rates four times higher than in 2019 [4]. This sharp increase in prevalence triggered increased demand for mental health services, stressing the healthcare system and creating gaps in care. This new normal, in turn, prompted numerous calls for action to improve access and availability of mental health services. With additional burdens placed on primary care providers and the now strained capacity of mental health professionals [5], it is imperative to identify alternative solutions for those suffering from depression and anxiety.

Community pharmacies have an opportunity to help bridge this access gap and improve population health. As accessible healthcare professionals [6, 7], pharmacists can identify and screen patients at risk or suffering from depression and anxiety, refer patients in need of additional resources, and provide educational counseling and medication management [8]. Although some community pharmacies have started expanding their offerings to include mental health services [8], the evidence supporting feasibility and effectiveness of behavioral health care interventions in community settings remains anecdotal and limited [9–11]. Based on a review of depression screenings by community pharmacists, Miller and colleagues identified the need to more systematically evaluate effectiveness of these interventions through well-designed research studies. These studies should not only involve collection of traditional health outcomes, but also incorporate evaluations of the implementation mechanisms through which pharmacist-led patient care services may lead to these outcomes [12].

Designed to accelerate routine use and impact of interventions in real world settings, implementation science approaches provide a useful lens for both facilitating and evaluating the feasibility and effectiveness of patient care interventions [13, 14]. Not only should implementation research methods be incorporated into the design of traditional outcomes studies, but best practices in implementation practice should be applied to facilitate delivery of the services under investigation.

The Community-based Valued-driven Care Initiative (CVCI), supported by the National Association of Chain Drug Stores (NACDS) Foundation, was designed using an implementation science approach. This initiative aimed to develop, implement, and assess the feasibility of delivering patient care interventions in community pharmacies for three high priority medical conditions, including depression and anxiety. The behavioral health intervention for depression and anxiety developed for this project consisted of two programs, a screening and referral program (BH S&R Program) and a 6-session education and medication management program (Full BH Program). This specific intervention was implemented and tested by 7 pharmacy sites across four community pharmacy organizations in the U.S over a 6 to 11 month period.

Participating pharmacies benefited from a multi-faceted, systematic implementation strategy (described below in the Methods), including supports from the project team (e.g., coaching, webinars, BH toolkit), designed to facilitate service uptake. Use of active implementation strategies has been found to be critical to ensuring implementation quality, and ultimately improved patient outcomes, assuming a “usable” intervention and a context receptive to this change [13, 15, 16].

The focus of this article is on evaluating the feasibility of having community pharmacists bridge the behavioral healthcare access gap through implementation of a patient care intervention for depression and/or anxiety. Feasibility is defined as the extent to which a particular intervention can be conveniently and successfully carried out in real-world settings [17]. An effectiveness-implementation hybrid type II evaluation was conducted to assess the effectiveness of the BH intervention, while exploring and evaluating its implementation. A hybrid Type II design is a research framework commonly used in implementation science that allows for simultaneous testing of implementation and intervention outcomes [18, 19]. Advancing understanding of innovative delivery models in non-traditional settings to bridge the care gap for those suffering from depression and/or anxiety is critical to increasing access to care and improving population health.

Methods

Description of the behavioral health (BH) patient care intervention

The BH intervention was developed using an adapted version of the Intervention Mapping process [20], that included: an environmental scan of high priority disease states; a targeted literature review; identification of critical program components outlined in a decision tree and logic model; and translation into a user-friendly toolkit for pharmacists and patients. The BH S&R Program was designed to identify patients with untreated or undertreated depression and/or anxiety in need of care. This program involved three main components: screening (based on the Patient Health Questionnaire 9 (PHQ-9 [32]) and the General Anxiety Disorder 7 (GAD-7 [31])), a brief consultation session, and follow-up coordination and referrals as relevant (e.g., local primary care providers, specialists, counselors, other resources).

The goals of the Full BH Program were to increase the patient’s understanding of these conditions and provide them with coping strategies, decrease symptoms of depression and anxiety, and optimize behavioral health medication management. To be eligible for the Full BH Program, patients had to have been diagnosed with depression and/or anxiety or screen “at risk” for depression and/or anxiety through the BH S&R Program (PHQ-9 score greater than or equal to 10, and/or GAD-7 score greater than or equal to 5). Those currently on a depression/anxiety medication were eligible for the full 6-session pharmacist-delivered program consisting of health education and medication management. If the patient was not on a medication, they had the option of completing only the health education components of the program.

The health education sessions each covered a different topic, including nutrition and exercise, stress management, problem-solving skills, reframing, prevention, and a review. They were structured in similar ways (i.e., review of background information, assessment of patient needs, access to or completion of relevant resources, and goal setting). The medication management sessions involved a review of the patient’s relevant records, completion of a medication adherence questionnaire, discussion of therapy goals, and recommended adjustments to medications. Patient visits were designed to be conducted over a 20–30 min period, with detailed guidelines, resources, and tools provided as part of the BH toolkit.

Description of the implementation strategy

The multi-faceted, systematic implementation strategy, informed by implementation science, and visually described in an implementation roadmap [21, 23], consisted of five implementation steps (ranging from ensuring alignment and fit, to identifying champions, to assessing and building readiness for implementation, to implementing, monitoring, and improving program implementation, to sharing data and transitioning) and eight clusters of strategies adapted from Waltz and colleagues [22] for use in pharmacies. These clusters included: evaluative and iterative strategies (e.g., prepare a metrics plan); service integration and tailoring (e.g., development of a BH intervention workflow aligned with the pharmacy workflow); orientation and education (e.g., conduct orientation meetings with the pharmacy organizations); patient and consumer engagement (e.g., making patients aware of the intervention through flyers posted in the pharmacy); implementation infrastructure (e.g., data documentation systems); champions, teams, and stakeholder relationships (e.g., identify site champions); financial and transitioning strategies (e.g., identification of relevant sustainability models); and implementation supports (e.g., coaching). Additional details on the implementation blueprint, strategies, and associated tools are available elsewhere [23].

Recruitment and implementation

Four pharmacy organizations (out of 13 approached) participated in piloting the BH patient care intervention. Potential candidates were identified after completion of a landscape analysis of pharmacy organizations across the country to assess “fit” of the intervention with the organization. Fit was discussed by the project team using a fit checklist developed based on guidance from Blanchard and Livet [24]. The 13 identified organizations were then contacted, with 11 completing an initial interest meeting, and 4 ultimately participating in the project. Reasons for non-participation included concerns over pharmacist time, staffing shortages, and competing priorities. The participating pharmacies were standalone independently owned pharmacies in Iowa (IA), Missouri (MO), and North Carolina (NC). Three of the pharmacy organizations (4 sites) opted to implement the BH S&R Program, while one (3 sites) decided to deliver both the BH S&R and Full BH Program. The sites’ decisions to implement either the BH S&R program or the Full BH Program were based on alignment with organizational priorities and capacity (i.e., time, resources) to deliver the programs.

The first 3 months were dedicated to preparing the participating sites for implementation. During this planning phase, the pharmacies committed to completing a structured and systematic process designed to assess and build their level of readiness for implementing the BH programs. This process (described in detail elsewhere [25, 26]) was facilitated by two trained coaches, and required attendance at a project kickoff webinar and participation in a minimum of four coaching calls. A readiness checklist (e.g., development of a BH program workflow for integration into the pharmacy workflow) was used to assess progress, with sites allowed to start implementation once they achieved 80% of the readiness milestones outlined in the checklist.

Once in implementation (following an implementation kickoff webinar), the sites recruited patients and delivered the programs using the BH patient care intervention toolkits developed for this project over a 6-month period for the BH S&R Program and 11 months for the Full BH Program. In addition to implementing the programs, the pharmacists also participated in monthly coaching calls, collected the necessary data, and completed fidelity checklists to ensure adherence to the programs components. Pharmacies were offered nominal compensation to help offset any administrative burden.

Study design and analysis

To explore the feasibility of implementing the BH intervention in community pharmacies, an effectiveness-implementation hybrid Type II design was used to evaluate both implementation and intervention effectiveness. Implementation outcomes included adoption, acceptability, appropriateness, feasibility, and intent to sustain, as measured by administrative data and surveys. In addition to the fidelity checklists used for continuous quality improvement in both programs, fidelity was assessed for the Full Program. Of note, lessons learned related to use of implementation strategies based on interview data with the participating pharmacists are described elsewhere [23]. Intervention outcomes for both programs included patient referral rates and perceived benefits, based on data collected through patient tracking logs, surveys, and pharmacist interviews. Patient knowledge based on the brief consultation session conducted as part of the BH S&R Program was an added outcome indicator for the BH S&R Program. Likewise, changes in patient knowledge of the disease state, reduction of symptoms, and medication adherence were included as effectiveness indicators for the Full BH Program. Table 1 summarizes the methodology, including data type indicators, data sources, respondent types, and timeline. IRB approval was obtained prior to data collection, with this project deemed non-human subjects research. However, all patients were asked to sign a written consent form prior to participating in the study and receiving treatment. Participation in surveys and interviews was not compensated.

Table 1.

Overview of methodology and data sources

Focus	Data Type	Indicators		Data Source	Respondents	Timeline
Implementation	Administrative Data	Adoption		Project Records (Pharmacy Participation)	Project Team	As needed
				Patient Tracking Logs (screening rates, enrollment rates, session completion rates)	Pharmacies	Monthly throughout implementation
	Surveys	Fidelity		Fidelity CQI checklists (7 items for the BH S&R, and 11 items for the Full BH; dichotomous “yes” or “no” answer; online Qualtrics survey)	Pharmacists	Once a month during first 3 months of implementation
				Adapted fidelity assessment (For Full Program 11 items, 5-point scale, from “Almost Never (0–20% of eligible patients)” to “Almost all of the Time (81–100% of eligible patients”; online Qualtrics survey)[28]	Pharmacists	At the end of implementation
		Acceptability	Acceptability of Program (Pharmacist)	Adapted IOQ [30] (7 retrospective pre-post items; 6-point scale, from “strongly disagree” to “strongly agree”; online Qualtrics survey)	Pharmacists (Store-level and Across Stores)	Retrospective pre-post; At end of implementation
			Pharmacist Satisfaction	Pharmacist Satisfaction Survey[27] (3 items; 6-point scale, from “strongly disagree” to “strongly agree”; online Qualtrics survey)	Pharmacists (Store-level and Across Stores)	At end of implementation
			Patient Satisfaction	Patient Satisfaction Survey (for S&R Program: 11 items; for Full Program: 10 items; 5-point scale, from “strongly disagree” to “strongly agree”, Cronbach’s alpha = 0.97; online Qualtrics survey)	Patients	At end of BH S&R Program and Full Program
		Appropriateness		Adapted IOQ (5 retrospective pre-post items; 5-point scale, from “Not at all” to “Extremely”; online Qualtrics survey)	Pharmacists (Store-level and Across Stores)	Retrospective pre-post; At end of implementation
		Feasibility		Adapted IOQ (8 retrospective pre-post items; 6-point scale, from “strongly disagree” to “strongly agree”; online Qualtrics survey)	Pharmacists (Store-level and Across Stores)	Retrospective pre-post; At end of implementation
		Intent to Sustain		Intent to Continue Use Items adapted from Behavioral Intent to Use Measure (3 retrospective pre-post items; 6-point scale, from “strongly disagree” to “strongly agree”; online Qualtrics survey)[29]	Pharmacists (Store-level and Across Stores)	At end of implementation
Intervention	Interviews	Key insights-barriers, facilitators, and lessons learned (reported elsewhere [23])		Interview Transcripts	Pharmacists (Store-level and Across Stores)	At end of implementation
	Administrative Data (for both programs)	Patient # (e.g., referral rates)		Patient Tracking Logs	Pharmacies	Monthly throughout implementation
	Surveys (for both programs)	Perceived Benefits		Perceived Benefits Items Adapted from the Result Demonstrability Measure[29](4 items; 6-point scale, from “strongly disagree” to “strongly agree”; online Qualtrics survey)	Pharmacists (Store-level and Across Stores)	At end of implementation
				Interview Transcripts	Pharmacists	At end of implementation
		Patient Knowledge of Depression/Anxiety		BH S&R Program Brief Consultation Session Survey (3 items, 5-point scale, from “strongly disagree” to “strongly agree”; either online or hard copy survey) Full BH Program Patient Health Education Session Surveys (5 surveys) (3–4 items per session survey; 5-point scale, from “strongly disagree” to “strongly agree”; either online or hard copy survey)	Patients	Retrospective pre-post; At the end of each of the BH S&R Sessions
	Surveys (for Full BH Program)	Depression/Anxiety Symptoms		PHQ9 [32] (9 items; 4-point scale, from “not at all” to “nearly every day”)/GAD 7 [31] (7 items; 4-point scale, from “not at all” to “nearly every day”; either online or hard copy survey)	Patients	Pre- and post-BH Full Program Completion
		Medication Non-Adherence		Brief Medication Questionnaire (BMQ)[34] (5 items; weekly dose taken based on number of pills per dose/number of times per days/number of days per week (patient); weekly prescribed dose based on number of pills per day/number of days per week (prescriber); either online or hard copy survey)	Patients and Pharmacies	At the end of each session; calculated based on Session 1 and Session 6

The quantitative analysis involved: descriptives and rates for the administrative data (i.e., pharmacy enrollment, patient screening, referrals, and patient enrollment into the Full BH Program); descriptive statistics for the acceptability surveys to measure patient and pharmacist satisfaction [27], the fidelity assessment [28], the intent to sustain survey [29], and the perceived benefits survey [29]; descriptives and paired t-tests for the retrospective pre-post surveys, including the Implementation Outcomes (IOQ) measures assessing acceptability, appropriateness, and feasibility [30] and the patient knowledge of depression and anxiety surveys; descriptives and paired t-tests for the clinical outcomes surveys (i.e., PHQ9, GAD7) [31, 32]; and rate of non-adherence calculated as the percent of missed weekly dosage to prescribed weekly dosage. Missed dosage was the weekly dose taken by patients subtracted from the prescribed weekly dose.

Qualitative data on the perceived impact of the programs generated through interviews with seven pharmacists from the participating sites were analyzed using thematic analysis [33]. Following an initial read of the transcripts, codes were created and clustered into themes during a second read. These codes and themes were then applied systematically to the transcripts. The analysis was conducted by the second author and reviewed by the first to ensure quality and completion, with any disagreements discussed until consensus was reached.

Results

Implementation outcomes

Of the four organizations and seven sites who initially enrolled, all remained committed to delivering the programs throughout the duration of the project (100% adoption rate). Participating sites are described in Table 2. Intent to continue the programs past the grant period was reported by pharmacists for both programs (N = 9, M = 4.40, SD = 0.90, 6-point Likert scale).

Table 2.

Description of participating pharmacies

Pharmacy Organization	Pharmacy Site	Unique Number of Patients Served (Monthly Average)	Total Number of Pharmacists (FTEs)	Total Number of Pharmacists involved in program implementation	Urbanicity (rural or urban)	Patient Recruitment Methods
Organization 1	Site A	599.08	3.0	2	urban	Self-Identified, Prescription History
	Site B	161.75	2.0	1	urban/rural	Self-Identified, Prescription History
	Site C	302.83	2.0	2	rural	Self-Identified, Prescription History
Organization 2	Site D	Unknown	3.0	1	urban	Self-Identified, Prescription History
Organization 3	Site E	238.75	3.0	2.0	urban	Prescription History
	Site F	539.75	3.0	2.0	urban	Prescription History
Organization 4	Site G	817.50	11.0	2.0	urban	Self-Identified, Prescription History

The information is based on the following time period: January 2022-December 2022

Based on survey results, pharmacists also agreed that both programs were compatible with their context and ways of working, and feasible to implement, with both appropriateness and feasibility increasing significantly over time (appropriateness t(8) = 10.06, p <.05; feasibility t(8) = 24.27, p <.05). Likewise, pharmacists reported high satisfaction with both the BH S&R (N = 9, M = 5.04, SD = 0.48, 6-point Likert scale) and Full Programs (N = 2, M = 5.17, SD = 0.50, 6-point Likert scale). Acceptability was also rated highly by the pharmacists on the IOQ acceptability measure, with significant increases from pre- to post-scores (acceptability t(8) = 2.52, p <.05). Similarly, patients reported the programs to be highly satisfactory, based on patient satisfaction survey scores (i.e., for BH S&R, N = 97, M = 4.69, SD = 0.57, 5-point Likert scale; for BH Full Program, N = 14, M = 4.74, SD = 0.45, 5-point Likert scale).

Finally, the average fidelity score reported by the pharmacists implementing the Full BH Program across the three sites was 4.7 (SD = 0.47) (5-point Likert scale; across the 11 core components of the Program; e.g., review patient’s medication therapy beliefs and goals, provide patients with session-specific health education resources). In other words, pharmacists reported adhering to the Program essential steps for more than 80% of enrolled patients, demonstrating excellent program fidelity.

BH intervention outcomes

Pharmacists reported clear benefits associated with providing the BH S&R program (N = 9, M = 4.97, SD = 0.42, 6-point Likert scale) and Full BH Program (N = 2, M = 5.13, SD = 0.13, 6-point Likert scale). Based on interview data, these benefits included: patients’ increased awareness of the pharmacist’s capabilities beyond dispensing; pharmacists’ feeling empowered and rewarded for practicing at the top of their license; pharmacists’ increased confidence with addressing and managing mental health disease states; strengthened relationships of trust and loyalty between pharmacists and patients; and enhanced motivation to integrate the programs past the project and identify viable reimbursement mechanisms.

BH S&R program

A total of 206 patients were screened through the BH S&R Program, with 72 (35.0%) screening at risk for depression or anxiety. These patients were in majority female (68.9%), white (79.1%), with a mean age of 53 and a previous mental health diagnosis (68.4%). Of those screening at risk, 65 (90.3%) screened positive for anxiety and 49 (68.1%) for depression. Forty-two of those 72 patients (58.3%) screened positive for both conditions. Half of the patients screening at risk (N = 36) were not receiving counseling at the time of screening. Among those not receiving counseling, the majority did not need any further referral (66.7%, 24/36), 25.0% (9/36) had the pharmacist coordinate with their current healthcare professional for medication adjustments or further diagnosis, and 8.3% (3/36) were referred further to a primary care provider, a specialist, or provided suicide prevention resources. Reasons for not needing further referral included the patient already being on a medication for their condition and/or expressing satisfaction with their current regimen (14/24, 58.3%), or the patient opting to follow up with their medical professional on their own (8/24, 33.3%).

As a result of the BH S&R Program, patients reported being able to identify common symptoms, treatment, and ways to help themselves when feeling anxiety and/or depression (N = 20, post-session M = 4.47, SD = 0.71; N = 31, post-session M = 4.32, SD = 0.85, 5-point Likert scale). The change in knowledge from pre- to post- was significant for anxiety (t(30) = 2.33, p <.05), but not for depression (t(19) = 1.04, p >.05). The lack of significant difference may be due to the high level of patient understanding of depression prior to the screening (pre-session M = 4.32, SD = 0.75).

BH full program

Of the 72 individuals screening at risk across pharmacy sites, 19 were attributed to the one pharmacy organization offering the Full BH Program, with 17 choosing to enroll. Patients selecting to enroll were in majority female (54%), white (100%), with a mean age of 54 years old. Thirteen participated in both medication management and educations sessions, and 4 received the education sessions only (since they were not currently prescribed a medication). As a result of the BH Full Program’s education sessions, patients demonstrated statistically significant increases in their self-reported knowledge of nutrition and exercise, stress management, problem-solving, psychological support, and prevention (Table 3). Additionally, when comparing pre-and post-intervention values, participants experienced improved depression and anxiety levels as demonstrated by a statistically significant reduction in their PHQ-9 and GAD-7 scores (Table 3). Moreover, their nonadherence to medications, as recorded by the pharmacists using the Brief Medication Questionnaire (BMQ) [34], was reduced by 7% (p =.03) (Table 3).

Table 3.

Pre-intervention and post-intervention outcomes BH full program

	Pre-Session Mean (SD)	Post-Session Mean Mean (SD)	T-Test (DF)	P-value
Health Education Sessions Questionnaires
Nutrition and Exercise (N = 16)	2.06 (0.35)	4.08 (0.19)	20.53 (15)	< 0.001
Stress Management (N = 16)	2.50 (0.52)	3.66 (0.60)	10.37 (15)	< 0.001
Problem-solving (N = 14)	2.64 (0.46)	3.67 (0.41)	9.52 (13)	< 0.001
Psych Support (N = 14)	1.90 (0.48)	4.02 (0.21)	15.87 (13)	< 0.001
Prevention (N = 14)	3.46 (0.44)	4.88 (0.16)	12.16 (13)	< 0.001
Depression and Anxiety Screening
PHQ9 Scores (N = 13)	15.54 (3.99)	9.00 (2.71)	4.72 (12)	< 0.001
GAD7 Scores (N = 13)	10.23 (4.27)	7.69 (2.36)	2.75 (12)	0.02
BMQ Questionnaire
Nonadherence (in percentage) (N = 14)	11.07 (8.77)	4.18 (13.89)	2.41 (13)	0.03

Discussion

Availability of mental healthcare services is often limited, with many patients suffering from depression and/or anxiety either unidentified or unable to access the needed care. Timely screening, referrals, education, and medication management are necessary to bridge the care gap, especially in underserved communities. Community pharmacists have an opportunity to serve as care extenders and behavioral health advocates, thereby countering the shortage of mental health professionals and contributing to improving their patients’ well-being. The purpose of this study was to explore the feasibility of a pharmacist-delivered BH intervention in community pharmacy settings using an effectiveness-implementation hybrid Type II design. Based on study findings (e.g., adoption rates, levels of acceptability, appropriateness, and feasibility, perceived benefits), both BH programs were highly beneficial and extremely well-received by pharmacists and patients. The Full BH Program led to significant increases in patients’ knowledge of their disease state, reduction of depression and anxiety symptoms, and enhanced medication adherence. All of the participating pharmacies intended to continue the programs past the project period.

These findings lend data-driven support to the role that community pharmacists can play in bridging the mental healthcare access care gap. Pharmacists’ potential contribution and impact in behavioral health has mostly been anecdotal, often recognized but with limited available evidence [10, 35, 36]. Expanding the evidence base demonstrating community pharmacists’ capabilities beyond traditional dispensing is critical to addressing public health challenges related to provider shortages and access to care.

In addition to contributing to the emerging literature, results from this evaluation have practical implications for community pharmacy training, implementation practice, and value-based care. Based on the benefits of implementing the BH intervention identified by interviewees, the pharmacist’s level of comfort with mental health and patient care, as well as patients’ awareness of the pharmacist’s expanded role, were important aspects of successful implementation. This is consistent with previous research identifying pharmacists’ discomfort with mental health and uneasiness with patient counseling techniques, as well as a lack of awareness of the pharmacist’s role, as significant barriers to service delivery [36, 37]. To be able to effectively bridge the mental healthcare access gap, community pharmacists need to be appropriately trained in mental health, establish relationships with their patients, and feel confident with patient care-related tasks. These skills should continue to be supported through pharmacy schools curricula and continuing education opportunities.

Second, implementation outcomes data reflected positively on the feasibility of implementing BH interventions in community pharmacy settings. It is worth noting that the participating pharmacies benefited from a robust and systematic implementation approach designed to facilitate service uptake. This strategy was conceptualized and facilitated by the project team, and more specifically by expecting pharmacists to regularly engage with project team members serving as project coaches through a systematic and organized support structure. Effective replication and scaling will require use of implementation science principles and practices, in the form of user-friendly systems, resources, and supports [13]. The implementation strategy package (e.g., roadmap, readiness tools, workflow templates) that was used and refined as a result of this project could serve as an implementation practice model for other similar pharmacist-led initiatives. However, it will be of limited practical utility without being supplemented by both coaching assistance and pharmacists’ basic training in implementation science [38, 39].

Finally, participating pharmacies’ ability to continue the programs were not only driven by their clinical success, but also by availability of health plans support. Integrating patient care BH interventions into community pharmacy care may be facilitated by value-based care models that prioritize improved patient and population health outcomes [40]. It is worth noting that all of the participating organizations were independently-owned pharmacies, with an ability to be nimble and pivot, identify viable sustainability strategies for the programs, and embrace the role of healthcare extenders. Patient care interventions in community pharmacy will only scale successfully with the health plans’ support of this paradigm shift [40, 41].

Of note, while valuable, the findings from this study emerged from a small sample size of pharmacy organizations and patients (especially for the Full Program). Future research is needed to replicate and augment these findings with additional pharmacies, including diverse types of sites (e.g., chains, hospital). Second, the COVID-19 pandemic which occurred during recruitment may have impacted the pharmacy organizations selected to participate in the study. However, results are consistent with previous studies examining patient care interventions in community pharmacies. Finally, the ability to scale the BH programs beyond the current sample will need to be explored. The participating pharmacies received intensive coaching from the project team. The amount of time required to deliver the service and interact with the coaches should be captured in any future studies. Coaching models will also need to be developed and tested for scaling up.

Conclusion

In conclusion, community pharmacies seem to be a viable alternative for screening, referring, and assisting patients with medication management and education related to depression and anxiety. Patients as well as pharmacists benefited from the BH programs, supporting community pharmacies as an often overlooked but accessible healthcare entry point for improving population health.

Authors’ contributions

ML designed the study, managed the study, participated in the data analysis, reviewed and interpreted the analysis, created the implementation blueprint, synthesized the information presented in this article, and wrote the manuscript; AW collected and analyzed the qualitative data, assisted with interpretation of the data, served as the data coordinator for the pharmacies, and contributed to the writing of the manuscript; SP analyzed the quantitative data, assisted with interpretation of the data, and contributed to the writing the manuscript; CH served as one of the pharmacy coaches and facilitated execution of the study; CR served as one of the pharmacy coaches, facilitated execution of the study, and assisted with early study management; JE led efforts to recruit pharmacies, problem-solved as needed, and guided the Project Team through the CVCI project. All authors read and approved the final manuscript.

Funding

Funded by the National Association of Chain Drug Stores (NACDS) Foundation as part of the Community-based Valued-driven Care Initiative (CVCI) grant.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This project was deemed non-human subjects research by the University of North Carolina-Chapel Hill IRB as defined under federal regulations [45 CFR 46.102 (e or l) and 21 CFR 56.102(c)(e)(l)] and did not require IRB approval. However, informed consent to participate was obtained for all patients receiving the intervention. The study followed the ethical principles delineated in the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.