Veteran and non-veteran perceptions of community pharmacists as sources of mental health information and referral

Abstract

Background

Given the growing prevalence of mental illness in the U.S. and the number of people receiving psychiatric medications, pharmacists are in a unique position to engage willing participants in mental health care. However, most existing training programs fail to address barriers related to patient acceptability of pharmacists as mental health support professionals.

Objective

We aimed to: (a) determine whether veterans and non-veterans find it acceptable to speak with community pharmacy staff about mental health and suicidal behaviors, and (b) identify barriers that may prevent individuals in either group from engaging in mental health conversations with pharmacy staff.

Methods

A formative qualitative study using semi-structured interviews was conducted to assess the acceptability of discussing mental health and suicidal behaviors with community pharmacists among pharmacy consumers. To capture a cross-section of the community, including individuals with a higher prevalence of mental health conditions, both veterans (n=10) and non-veterans (n=22) were recruited. Results were analyzed using a thematic analysis approach.

Results

Key facilitators to improve patient comfort to discuss mental health with their pharmacists include developing patient-pharmacist relationships, ensuring privacy, improving the physical pharmacy environment, and enhancing pharmacist mental health training. Commonly, participants desired pharmacists to treat them as individuals, remain calm, listen, and provide gentle suggestions without forceful tones. Increasing awareness of pharmacists' roles in mental health through signs, posters, and social media campaigns may result in improved patient interactions. Additionally, participants encouraged pharmacists to build partnerships with mental health providers to integrate pharmacists into the mental health care continuum.

Conclusion

The present study underscores the complex dynamics surrounding mental health conversations between community pharmacists and patients. Among participants in North Carolina, reluctance to engage pharmacists in mental health discussions stemmed largely from limited rapport and unfamiliarity with pharmacists, concerns about privacy, and the perception that pharmacy environments were not always conducive to sensitive conversations. With targeted training, environmental adjustments, and active partnerships with mental health professionals, pharmacists could more confidently address mental health-related concerns, thus becoming more trusted resources in patient care.

Background

In the United States (U.S.), 58.7 million people 18 years and older live with mental illness and 15.6 million people 18 years and older are diagnosed with a severe mental illness.¹ Yet, of those diagnosed with mental illness, less than half (27.1 million) received mental health treatment in 2023.¹ Additionally, in 2023, 41.9 million adults reported taking a prescription psychiatric medication.¹ In the U.S., mental illness costs $282 billion annually, placing a significant strain on the already understaffed healthcare system.² This increased demand for mental health services continues to rapidly outpace the provision of available care, resulting in millions of people being left untreated or with unmet mental healthcare needs.³ Therefore, understanding how healthcare consumers perceive the availability and accessibility of mental health resources could have important implications for healthcare services.

Although mental health concerns are widespread, specific populations, including veterans, are impacted disproportionately. Previous research has found that approximately 43% of veterans experienced mental health issues, including post-traumatic stress disorder (PTSD), depression, or substance use disorders.⁴ Given the rates of diagnosed mental illnesses, many veterans are treated pharmacologically for their mental health conditions. For example, of the veterans diagnosed with PTSD, 80% receive treatment in the form of psychotropic medication.⁵ This puts pharmacists in a position to interact frequently with and refer veterans who may experience an array of mental health symptoms.⁵

In 2020, approximately 90% of the U.S. population lived within 5 miles of a pharmacy, making pharmacists easily accessible healthcare professionals.⁶ They impact mental health outcomes through patient education, recognition of mental status change through observation or brief screening, providing resources and referrals, and evaluating medication lists for drugs that could cause mental status changes.⁷ During the pandemic pharmacists continued face-to-face operations when additional healthcare providers transitioned to telehealth and remote consultations.⁸ Community pharmacists' consistent presence, when coupled with established trust and rapport with patients, makes them well-positioned to implement mental health initiatives, provide referrals, and positively impact health-related quality of life within their communities.⁹

As highly accessible healthcare professionals, pharmacists can play a critical role in expanding access to mental health care and connecting individuals to essential resources.¹⁰ In the U.S., pharmacists complete a four-year doctoral curriculum that includes substantial training in behavioral health. All pharmacy students learn the neuropharmacology, screening, diagnosis, and evidence-based treatment of conditions such as major depressive disorder, bipolar disorder, post-traumatic stress disorder and others. During their training, they develop skills in counseling, monitoring, and optimizing psychiatric pharmacotherapy.^11,12 Training commonly includes video-recorded counseling sessions with standardized patients focused on medication management and referral processes.^13,14 American Association of Psychiatric Pharmacists (AAPP) student chapters, targeted rotations, and postgraduate residencies or fellowships are available for specialized training. Although students gain broad communication skills and experience addressing resistant or distressed patients, most programs provide limited instruction specific to suicide risk recognition, suicide-focused communication, or warm hand-offs to crisis services.^15,16 Furthermore, few studies have examined patient comfort in discussing mental health topics with pharmacists, leaving a clear gap this study aims to address.^9,17,18

Objective

We conducted a formative qualitative study to determine whether veterans and nonveterans find it acceptable to speak with community pharmacy staff about mental health and suicidal behaviors. A second aim was to identify and compare barriers that may prevent individuals in either group from engaging in these conversations.

Methods

Study Design

A formative qualitative study using semi-structured interviews was conducted to assess pharmacy consumers’ acceptability of discussing mental health and suicidal behaviors with community pharmacists.

Recruitment

A total of 37 individuals (25 non-veterans and 12 veterans) were screened for eligibility. Non-veteran participants were recruited through the North Carolina Translational and Clinical Science (NC TraCS) Institute using Research for Me, a centralized resource that connects individuals with research opportunities. Veteran participants were recruited through the Carolina Veteran Resource Center (CVRC) and supplemented by referrals from enrolled veteran participants. A final convenience sample of 22 nonveterans and 10 veterans were recruited from North Carolina.

To capture a cross-section of the community, including individuals with a higher prevalence of mental health conditions, both veterans and non-veterans were recruited. Individuals were eligible if they were 18 years or older, spoke English, had access to the internet or phone, and used pharmacy services in person at least once per month either for themselves or as a caretaker (i.e., for an individual in their direct care). Participants were excluded if they were working as a pharmacist, a pharmacy student, or pharmacy staff; were currently receiving cancer treatment; had a diagnosis of post-partum depression; or were receiving inpatient psychiatric services. Pharmacists, pharmacy students, and pharmacy staff were excluded to prevent professional perspectives from biasing the interpretation of acceptability and barriers. Individuals with postpartum depression, inpatient psychiatric care, or active cancer treatment were excluded because their clinical circumstances could impact mental health status and willingness to discuss mental health with community pharmacists, limiting comparability to the broader population. Although veteran status was the primary determinant for sampling, we also attempted to recruit equal numbers of males and females.

Data Collection

Recruitment and data collection occurred between September 2021 and October 2022. Participation in the study was voluntary, and all participants received a $30 digital incentive card. Interviews were digitally audio-recorded. For uniformity, interviews were conducted by the same interviewer (AS). Before conducting each interview, the interviewer confirmed that the participant was in a private location, free from distraction and away from other individuals who could potentially hear the conversation. The interviewer established rapport with the participant by starting with a brief introduction and then a short description of the study, emphasizing that discussions would be kept confidential and research output would be anonymous. Participants completed semi-structured interviews informed by the PRECEDE-PROCEED model consisting of eight questions and five probes. Interviews ranged from 20 to 90 minutes and were only terminated when the participants indicated they had no additional information to add. Demographic data, including age, sex, number of monthly pharmacy visits, and pharmacy type (i.e., independent, retail chain, or VA-based), was collected during the interview (Table 1). These variables aligned with our objective of understanding pharmacy use patterns and participant context while minimizing the collection of identifiable information. Given our focus on comparing veteran and non-veteran perspectives and the small sample size, we could not meaningfully compare subgroups on other dimensions like race.

Table 1.

Participant characteristics

Characteristic	Total sample (n=32) n (%)	Non-Veteran sample (n=22) n (%)	Veteran sample (n=10) n (%)
Age Range, years (Mean)	18-89 (39.4)	18-64 (28.7)	33-89 (62.8)
Male	14 (43.8)	5 (22.7)	9 (90.0)
Monthly Pharmacy Visits
1-2	19 (59.4)	11 (50.0)	8 (80.0)
3-4	10 (31.3)	9 (40.9)	1 (10.0)
5+	3 (0.1)	2 (0.1)	1 (10.0)
Type of pharmacy
Independent	7 (21.9)	1 (0.04)	6 (60.0)
Chain	22 (68.8)	21 (95.6)	1 (10.0)
VA hospital-based	2 (0.1)	-	2 (20.0)

Data Analysis

Audio recordings were transcribed verbatim by the study's primary investigator. The study team developed a codebook using the PRECEDE-PROCEED Model, providing a theory driven framework to code key factors that impact willingness to discuss mental health with pharmacists (i.e., barriers, facilitators, etc.). Key codes were developed a priori based on the interview guide for thematic analysis.¹⁹ Nine primary codes were defined: opening question, pharmacist relationship, facilitators, facilitators-privacy, barriers, barriers-time, patient comfort, pharmacist response, and mental health role (Appendix 1). These codes guided the thematic analysis, which provided coders with a systematic framework to identify patterns in participant responses.

Data were analyzed using a consensus coding process. This is a collaborative process where each coder independently codes the data, then meets to compare and discuss their interpretations to reach an agreement on final codes. Coding was done after the completion of all interviews. Analysis was performed by three independent coders (AS, SD, KJ) using MAXQDA software version 2022.²⁰ After preliminary coding, the study team reviewed the data, and a secondary analysis was conducted by the primary investigator and two team members (KJ and LV) to identify additional patterns within and across broader code groups.

Ethical Considerations

This study was approved by the University of North Carolina’s Institutional Review Board (Approval #21-2141). All participants agreed to participate after being provided with a study description and informed consent information via Zoom video teleconferencing or over the phone.

Results

Participant Demographics

Thirty-two interviews were analyzed. The non-veteran sample was younger and had more females than the veteran group (Table 1). Across both groups, participants predominantly visited their pharmacy once to twice per month.

We identified six main categories related to patient acceptability of pharmacists as experts in behavioral pharmacology who may be able to connect individuals to mental health resources: (1) pharmacist relationship, (2) patient comfort, (3) facilitators, (4) barriers, (5) pharmacist response, and (6) mental health role (Table 2).

Table 2.

Key themes from interviews and example quotes

Theme	Non-veteran community sample quote	Veterans sample quote
Theme 1: Pharmacist relationship	“My relationship with my pharmacist is essentially that of cashier, they're basically just medicine cashier…”	“Pretty nonexistent…I don't I couldn't tell you if I saw one of them. If they have on a name tag, I probably couldn't tell you their name.”
Theme 2: Patient comfort	“I don't think a pharmacist would be the first person that people would go to, but I think that in the moment … if that's the only resource they have then, I think on a, on a scale of 1 to 10 maybe a six or seven but again I don't like the first person they would go to.” “I think fairly uncomfortable… it's not a developed relationship, it's more of sort of a transactional handoff type of relationship.”	“I think the person in that state, they're not necessarily thinking of a pharmacist for help. But if a pharmacist was to offer help, I think that that you know that might catch somebody off guard and be like, ‘Yeah, I do need help.’ You know? Like help me, and then they can sit there …with them until they can find the proper help to come and help them out. You know, and that's kind of how we were trained in the military, you know.” “The pharmacist doesn't come to my mind when I think someone helping someone in that suicide thoughts.”
Theme 3: Facilitators
Rapport/Building trust	“It starts with every aspect of the experience, like reaching out to folks if they don't have them fill the prescription. Kind of doing the legwork to make it seem like they're working for you, rather than you have to go seek them out.” “I think if pharmacists prioritized knowing their patients. And I guess displaying this by use of like, incorporating their names in conversations or just little things like that can make someone feel closer.”	“I think if they're familiar with the pharmacist that they'll probably be quite open. But I don't see that happening in a large store. Their staff are just too large. But I’ve actually, to tell you truth, I have debated switching to a like a small-town pharmacy. Now they seem to be more in touch with their people than the big ones.” “You know you gotta be a people person in this industry. You gotta build trust. If I don't trust you, then you know I’m not gonna go to you.”
Staffing/Pharmacy organization	“I think if there were, like, least two pharmacists, on a shift at a time. Like definitely having more pharmacy staff would be great. And if, if you can't have more pharmacy staff, having more pharm techs there to do the pickups, the drop-offs, administering flu shots, covid shots, like, all of that stuff, and having the pharmacist, primarily for consultation. Also, if people were able to schedule appointments with their pharmacists, I think that would be nice.” “Maybe like some sort of like signage or something like consultation windows that like let people know that that [speaking to a pharmacist] is an option. Or maybe like how you see like signage just like are you experiencing like these types of symptoms like, talk to your pharmacist.”	“(Providing) kind of like a check-in for the pharmacy where they can have, they can check in and kind of, they can ask you if you're going to need any one-on-one attention with the pharmacist, and then that can put you in a queue, and then you can be brought back to that office, or whatever. “I can't remember if there is a screening when you get to a pharmacy, and when you get like a prescription filled. I think that maybe adding that, like a mental health questionnaire to any prescription or to like, especially any mental health prescription.”
Accessibility	“Pharmacies yes [are accessible], but the pharmacist specifically, I would say, more so no, just because again there's not necessarily specific open space where someone can go to, to speak with the pharmacist unless you make a specific request. And I feel like a lot of people may be uncomfortable, um wanting to do that.”	“If I go to somewhere like CVS or Walgreens, or something like that, their pharmacists seem to be available. So, specifically in my specific scenario [hospital pharmacy], not really easy to get to. When get to her she's great, you know, to communicate with, but at a more public pharmacy, they seem to be more accessible.”
Pharmacist demeanor/Characteristics	“I think it depends on the pharmacist and their demeanor and how they're approaching the individual and the words that they use. I mean, I know that layman's terms need used for me and, you know, communicate, empathetically and understand, potentially how this person might be feeling and connect with them.” “I think, body language, and eye contact. For me specifically, being able to have that eye contact is really big for me because I feel like someone has been listening. Just like for me I want to feel like my provider is understanding my concerns, and the issue that I'm having and then trying to help me find a solution.”	“I think that depends largely on the individual that's having the mental health crisis. What their background is. For example, the pharmacist at the pharmacy I go to. In fact, I would think a majority of cases is a woman, and if you are an old codger Vietnam vet like I am, I don't, I'd feel a little, I'd feel a discussion with the woman that I didn't know would be a bit off-putting. It's hard to talk to somebody who's another man about things that are, I won't say intimate in a sexual way but intimate in a psychological way. It would be very difficult to start that conversation with a young woman that you didn't know. I think the 3 pharmacists that I'm familiar with at the VA are all male, and they're all veterans.” “I think their appearance and their attitude is vital, you know. If they come over real rushed, you know. Say, ‘hey, yeah, what do you need?’ You know like they're in a hurry that's not gonna help someone who needs any. So, it's their attitude and their approach and demeanor.”
Privacy	“The pharmacy itself is open to the rest of the store, and maybe if there was like a separate room where you can go in and talk to your pharmacist that would feel more comfortable…[the] pharmacy is like right at the front of the store. So, there's usually a lot of foot traffic.”	“I would think a private setting where there are no distractions, and that person is having a problem knows that they have the full attention of the other person that they're talking to. Maybe, uh, you know the room is painted in some sort of mellow color or something. You know it's just a safe, a safe place for, they feel safe in that room.”
Training/Education	“I think if, if pharmacists had the, the tools … making sure that they have the tools and letting people know that they have the tools to properly respond and guide folks through that.” “If I knew that my specific pharmacist, um, I know there's specialists in pharmacy but if they have like some, I don't know certification of mental health, not like licensing but like something that would show me that they would be, ah good to talk. Just like some sort of like background in mental health so I'd be more comfortable talking to them.”	“Just some knowledge that they have the background to have those conversations right now. When you think about a pharmacist, you think about them in a limited context. That limited context is prescribing med or delivering medication. Not prescribing, not listening, not providing advice or council in a situation where you're looking for assistance.” “A script, right, that says, here you are, as a pharmacist, you're going to be interfacing with this individual, this individual who was in mental distress, and this is what here's your list of dos, here's your list of nos.”
Theme 4: Barriers
Time	“I feel that you know, my five-minute interactions with my pharmacist, maybe like one to two times a year, is not. I wouldn't feel comfortable talking about those topics with someone I kind of consider as like an acquaintance.” “All the pharmacies I've been to are like really understaffed at least in the past like year so um so there's always like a long waiting line, they're always like rushing to get through everyone so honestly like that's not their fault obviously but like, I don't know, understaffing like I feel like makes it really hard to talk to them and like want to like, ask questions because there's always so stressed and busy, that it's like I don't really want to bother them with questions or like trying to talk to them.”	“The reality is pharmacists are busy and they're unlikely, not because they are mean people, but rather they're unlikely to make positive connection with patrons, because that slows down the process.” “If you go to the pharmacy there's a stack of people waiting for their meds, they don't have time to talk. Everybody behind you is gonna be mad because you're taking too much time.”
Judgement/Stigma	“Stigma and judgment. I mean, no one wants to talk but there's, I've never met anyone who's like excited to talk about things that are, that they're struggling with.” “Obviously like being judgmental or, I don't know, having a bad attitude, or just, I guess you can find it by body language. If they're like passive-aggressive anything or I don’t know. I feel like a lot of us with mental illness already know how to put judgment on them. We already have a judgment we put on ourselves. And so, it can be really hard to reach out because you know we're already pretty sensitive we already kind of know what we're going through is pretty extreme, so you know any little bit of, you know, discomfort.”
Inconsistency/Lack of relationship	“I think it would be hard, unless there was like more of a relationship built. Like for me, I don't, I don't even see the same pharmacist, every time I go, but I think that's like a function of, where I am. It's in like college town, pretty busy area it's like one of three pharmacies that is that's close by. So, usually, the staff is pretty like, they always look frazzled when I go in.” “I feel like I don't really know my pharmacist and they don't really know me. Um, so, when I have had questions like when I was changing medications, but like, have to give all of this background of like my previous medical history to give them like some context about me.”	“Since you only see the pharmacist either casually or with a specific scenario, you don't know them as intimately as you know the techs. So, it'd be sort of like calling EAP blindingly or something, you know? You don't, you don't know them so there's not that comfort back.” “It's hard to get in touch with a pharmacist. You call up there [the pharmacy] and talk to somebody and you don't never know who you're talking to.”
More practical resources exist	“I think one thing is like me, for example, if, if I'm experiencing like depression or suicidal ideation. My first thought is to like, reach out to my, psychiatrist and I don't really think about potentially talking to the pharmacist. So, it might be that like people just don't know that that's an option.”	“If you're having some mental health crisis, you're going to be looking for someone who is in a position to help you, and given the facts, the fact that first pharmacists don't prescribe, you would first think of a doctor, or some type of other counseling, rather than going straight, or straight to a pharmacist for some type of help.”
Pharmacist demeanor	“Like I said it's a personable thing. I think in terms of like doctors and um pretty much any like professional in in a similar field. I think people tend to be a little bit intimidated by and scared because there's this like we put them on a pedestal. Um rather than seeing that oh they're humans like us, you know.” “I think that it's also like, like I said, like a personable thing. Um I feel like they’re not as approachable. And like even when there is a moment of like speaking directly to the pharmacist I feel like it’s like ‘here's your answer now leave’ type of thing.” “I think it's a little bit awkward at times how elevated the pharmacy is in terms of like their actual physical location so like sometimes they're up on a platform. It sort of feels a little bit overpowering at times where it's like they're talking towards me as opposed to talking with me about sort of as someone that's picking up like whatever the medical thing that they are needing, sort of like being talked to as an equal I think is important and sort of coming across like elevated versus lower, I think there's almost like a power dynamic there that's a little bit uncomfortable at times.”	“You have any questions you can ask, [but] you know they're trying to get you out of the doors, rather than keep you in the door.” “But if you're, like, very rushed and you're very just , impersonal, and just not, you know very just blah, you know, then that that to me makes you unapproachable. Especially when it would come down to if you were like, [being] my last resort of like asking for some help before I was like trying to end my life.”
Theme 5: Pharmacists response	“I think, the ideal way is for the pharmacist and the staff to be very calm. To ask about, like, if the person has a plan. If they have access to, like lethal means, ask them about how long they've been feeling that way.” “You don't encourage it. You don't dismiss the individual. You don't… I feel like [there are] obvious things that you, the pharmacist, should not say in a situation like that. Overall, like just don't encourage the behavior like get, get to the root cause if someone doesn't trust you with something so heavy.” “I guess just hear him out. Don't be too like jumpy and like startled by it. You know cause that's a lot other people, if they do bring that up for a, in front of somebody, like they won't ever bring it up again. “	“They shouldn’t be negative and dismissive of the issue. And you know they shouldn't say, “Oh, you're crazy,” something like that.” “They shouldn't give, you know, unsolicited personal advice. Everything should stay on the up and up should be professional demeanor, you know. Even if you have a good relationship with it, when you talk about suicide and things like that, it changes the whole. Everything goes 180. This is, I would expect a pharmacist to become very professional. No humor.”
Theme 6: Mental health role	“…I guess I haven't ever really bothered talking about anything like that because … I suppose they are trained but I had never really crossed my mind that they are trained in that kind of a thing. If they are trained in that kind of thing so I'm not even aware that sort of skill is in their wheelhouse.” “I guess more like an awareness that the pharmacist is somebody you can talk to because I know [a] pharmacist is not probably their first option that you think, I think I need to get help from someone.” “Making sure that pharmacists are connected with, with mental health providers or can connect with mental health providers. I think making that connection closer like they are there are part of the team they're part of the process. They're part of care of the clinical experience.”	“Education, consumer education, You know I mean have signage something that tells you because most people don't know what a pharmacist really does.”

Category 1: Existing relationship with pharmacists (Pharmacist Relationship)

Both participant groups (veteran and non-veteran) described their interactions with any given pharmacist as infrequent and brief, often interacting more frequently with any number of pharmacy technicians. When probed about whether they could identify the pharmacist visually or by name, pharmacy consumers in both groups indicated that, in most cases, they could not tell the pharmacist from the pharmacy technician. When an interaction occurred with the pharmacist, it was usually brief, and patients had to request to speak with a pharmacist when the specific question was beyond the scope of the pharmacy technician. Patients expressed that they mostly felt their interactions with pharmacists were ‘transactional.’ Both participant groups reported they were more likely to interact with the pharmacist only if they had specific questions.

Category 2: Patient Comfort

Participants reported seeking advice from a family member or trusted friend to discuss mental health issues before speaking with a pharmacist. Most participants associated pharmacists with “medication issues” and would trust a pharmacist to counsel them about side effects related to medications. However, participants did not associate their medications with behavioral or mental health complications or side effects.

Participants acknowledged being comfortable talking about general health issues and medication side effects with pharmacists, but not necessarily mental health. Participants felt that establishing pharmacist credibility in mental health could be accomplished if the pharmacist provided specific recommendations related to mental health services, such as discussing potential medication side effects impacting mental health, and working with patients to identify potential mental status changes and when to seek additional help.

Participants perceived themselves as a burden if they had to ask to speak with a pharmacist. The added stigma and potential judgment of talking about mental health issues increased patient discomfort in speaking with a pharmacist, especially if they felt this topic was not within the scope of the pharmacist’s practice.

The veteran group specifically identified gender as a barrier. Veteran participants indicated that it would be difficult to discuss sensitive topics with a pharmacist of the opposite gender. Veterans also said they would prefer someone with a military background who could relate to what they are going through or who may have similar life experiences.

Category 3: Facilitators

Across both groups, several subthemes related to facilitators emerged: patient-pharmacist relationship development, privacy, environment, training/education, accessibility, and approachability.

Consistently, both veterans and non-veteran community members spoke about how the physical environment of the pharmacy could facilitate conversations. This included having an appropriate private conversation space, positioning pharmacists closer to patients and creating a safe environment. Additionally, participants felt that improving pharmacy logistics could help facilitate discussions. This included keeping patient lines organized and having visual cues, such as identifying pharmacy staff more clearly (i.e., who is on duty board with pictures) and posters that advertise pharmacists are open and willing to talk about mental health.

Participants in both groups were largely unaware that pharmacists had any background knowledge of mental health topics, even as it relates to medications. This includes potential side effects that could impact mental status changes or increase the risk of suicide. Most participants thought that standardized protocols or strategies should be in place for pharmacists when mental health topics come up in patient interactions. Although pharmacists do receive training on mental health topics and can receive additional specialized training, most participants were not familiar with a pharmacist’s training or that these opportunities exist.

Accessibility and approachability of the pharmacist were also discussed as facilitators. Participants generally reported that pharmacists were approachable but not accessible. This was attributed to the perception that most pharmacists “appear busy” and because of patient perception of feeling like a burden when having to specifically ask to speak with a pharmacist. Many participants suggested that including a mechanism where they could schedule a consultation with a pharmacist might encourage more productive discussions between patients and pharmacists.

Category 4: Barriers

A consistent barrier reported by non-veteran community members and veteran participants was a need for a pre-existing rapport with their pharmacists. Interactions with pharmacists are often quick, and participants report that being asked “Do you have any questions?” usually leaves them feeling compelled to answer “no” and move along. Most participants reported that to talk about mental health or feel comfortable talking about mental health topics, it is essential for the pharmacist to build trust.

Participants reported that they often interact with different staff when they visit a pharmacy, which makes it challenging to build relationships. Another important factor related to trust is the staff member’s demeanor. Participants in both groups explained that pharmacists must make eye contact, smile, and treat patients with kindness. Also, pharmacy staff members should be attentive and make the patient feel valued, not just as if the interaction is part of the pharmacist’s job.

Furthermore, when patients interact with a pharmacist, participants reported that the pharmacist's overall demeanor impacts their willingness to ask questions. Most participants perceive pharmacists as too “business-oriented” or demonstrating judgmental body language, making them appear unopen to the conversation. Some participants even indicated that because healthcare professionals, including pharmacists, demonstrate high intelligence, they sometimes lack the necessary social skills, coming off as dismissive which can discourage patients from seeking advice. Likewise, some participants felt that pharmacist attire impacted their comfort in talking with the pharmacist. While some preferred the lab coat's professional appearance, others preferred a casual, less intimidating appearance.

However, the most significant barrier by far is time. Pharmacists already appear busy, combined with participants' perceptions of being rushed while at the pharmacy counter, increasing discomfort when talking with the pharmacist, not only about mental health, but also when asking questions in general. Thus, some participants reported feeling uncomfortable talking to the pharmacist about personal matters or felt that they took up too much time repeating their history to ask additional questions. Additionally, since most patients interact with a pharmacy technician who must call a pharmacist when there is a question, feelings of patient burden are further increased.

In contrast, the veteran group reported some unique experiences. For example, veterans reported that they felt targeted for mental health and suicide interventions because of their veteran status. Further, veterans reported that discussing topics of mental health with a pharmacist would be redundant, especially since they likely already consulted with a doctor. Part of this reluctance stemmed from their access to dedicated mental health and suicide prevention resources from other providers, which they expressed were more accessible and better tailored to their needs.

Category 5: Pharmacist Response

There were several ways in which participants wanted a pharmacist to respond if they asked them for advice about mental health. First, the pharmacist must treat the individual in crisis like a “person” and not treat them like a “threat.” Participants in both groups expressed the need for the pharmacist to remain calm, do their best to be proactive, listen, have a personal conversation, avoid technical jargon and use a conversational approach that shows genuine concern. Additionally, participants felt that pharmacists should use gentle suggestions to offer resources and referrals, not make demands or use a forceful tone that makes a person feel rushed or dismissed. Both the community and veteran samples suggested that pharmacists should avoid suggesting hospitalization or solely focusing on medication (i.e., “pill-pushing”) but offer to escort patients to a safe place and to continue the conversation in private. Participants recommended that pharmacists help patients contact mental health services while in the pharmacy and ensure all their questions are answered before they leave. Finally, both groups strongly indicated that pharmacists should not call the police or involve other staff members unless there was an immediate safety threat (i.e., weapons).

Both the veteran and non-veteran community members suggested that pharmacists should provide resources about local mental health professionals for patients who ask about mental health or are in crisis. This includes information for local therapists, psychiatrists, and support groups in the immediate area. Participants also suggested that pharmacists review the pharmacy’s contact information if the patient has any questions or concerns about how their medication impacts their quality of life. Another common suggestion was to create a private or more discreet space in the pharmacy where patients could quietly access printed materials with local resources and tips, especially for those hesitant to ask questions. Finally, some participants suggested offering a phone number or appointment option so patients could have 10–15 minutes with the pharmacist to privately ask questions and discuss their needs in more detail.

Category 6: Mental Health Role

Awareness, initiative, and partnership were identified as subthemes related to making people feel comfortable with pharmacists having a more substantial role in mental health. As previously indicated, most participants do not recognize community pharmacists as mental health care resources or as possessing that expertise. To change this perception, participants suggested increasing awareness of how pharmacists can help with mental health and their role in health promotion and well-being. Some examples provided included adding signs and posters to the pharmacy and social media campaigns that address how pharmacists can support mental health.

Participants also felt that community pharmacists should take the initiative to be involved in the patient’s care. There is a common perception that pharmacists should provide treatment options, and there is a strong “medication only” connection with pharmacists’ professional role. Participants indicated that it would encourage open discussion if pharmacists could become more involved or have more personalized interactions to build patient-provider rapport.

Finally, building partnerships with other mental health providers or initiatives would show that community pharmacists are part of the mental health care continuum. A big reason why participants do not see pharmacists as having a role in mental health care is that they do not understand how or where pharmacists fit into the process. Participants reported that a connection between mental health providers and a pharmacy would show that pharmacies and community pharmacists have a place in mental healthcare.

Discussion

This study provides veteran and non-veteran community members' perspectives on pharmacists as mental health resources. The main finding was that participants did not identify pharmacists as mental health resources. This is the case despite previous research reporting that pharmacists are having increased interactions with people with serious mental health concerns.^21,22 Participants perceived mental health as either not within the scope of pharmacy practice or did not identify mental health outcomes as connected to medication issues. Although both veteran and non-veteran pharmacy consumers generally shared similar experiences when interacting with community pharmacies, veterans overall were slightly more resistant to speaking with a pharmacist about mental health topics. Veterans expressed that they were more likely to be targeted for mental health and suicide interventions in other health spaces.

Participants commonly described their interactions with pharmacists as brief and transactional, with limited familiarity and difficulty distinguishing pharmacists from technicians. Many lacked understanding of pharmacists’ training and scope of practice and typically did not seek consultation unless they had specific questions. Even then, pharmacists were often perceived as unavailable or unqualified to address mental health concerns. These barriers could be mitigated through patient-facing educational materials, structured opportunities for engagement, and collaborative outreach with local mental health organizations to raise awareness of pharmacists’ expertise.²³

Participants expressed general discomfort discussing mental health with pharmacists, preferring to confide in family or friends. This reluctance is not unique to pharmacists and reflects a broader trend extending into primary,²⁴ integrated,²⁵ and emergency care²⁶ settings. Like our findings, privacy concerns^26,27 and need for strong provider relationship²⁶ contribute to patient discomfort, while other studies also identified stigma, unclear communication, and doubts about treatment effectiveness as additional barriers.^25,26 The persistent stigma surrounding mental health underscores the need for all provider types to actively demonstrate their competence and openness to these conversations. For pharmacists, this may involve clearly communicating their mental health expertise and ability to offer referrals or information on available services.

Outside of comfort, participants described additional factors that may improve or inhibit discussion of mental health with pharmacists. Factors that could facilitate conversations included consistent staffing, accessible private spaces, and increased mental health training for pharmacists. Additionally, participants emphasized the need for pharmacists to display openness and be approachable in ways that convey genuine concern and attentiveness. This is in line with previous research suggesting that patients with mental illness experience several barriers to community pharmacy access.^23,28,29 Previous research supports increased exposure to didactic and experiential educational psychiatric opportunities for pharmacy students and pharmacists, transforming the physical environment of the pharmacy to increase privacy and educate patients on what to expect from community pharmacists.²⁹

Participants suggest several compassionate approaches when pharmacists are called upon to discuss mental health with patients. They emphasized the importance of a non-judgmental, supportive tone, advocating for privacy and using non-forceful language. Both veterans and nonveterans advised against using emergency response services unless necessary, preferring discreet interventions like resource referrals and assistance with connecting to mental health support. Participants recommended that pharmacists raise awareness of their role in mental health support to foster trust and normalize these conversations. Strategies like visible signage, social media messaging, and partnerships with mental health providers could help position pharmacists within the mental healthcare continuum, making patients feel more comfortable discussing mental health in the pharmacy setting.

Lastly, although veterans and non-veterans had similar experiences with pharmacy services overall, veterans stood out in how they approached mental health conversations with pharmacists. Specifically, veterans were more hesitant to talk about mental health with pharmacists. Even when they had a personal relationship with the pharmacist, they felt that pharmacists were not open to discussing mental health issues. Despite valuing professionalism, this perceived lack of openness made veterans less likely to engage. These findings could help inform mental health training programs for community pharmacists by highlighting the need for more patient-centered approaches, especially when working with veterans.

Limitations

While this study offers valuable insights into patient experiences discussing mental health with pharmacists, several limitations should be acknowledged. First, the data were not analyzed by pharmacy type. Most participants in the general community sample reported using chain pharmacies, whereas veterans primarily accessed independent pharmacies. These differences may influence patient experiences due to variations in protocols, training standards, and operational practices across pharmacy settings. Second, data collection was limited to a single U.S. state, which may restrict the generalizability of the findings to broader populations. Finally, the data reflects perceptions from an earlier time period, and attitudes toward mental health and pharmacist engagement may have changed with recent developments. Last, the veteran sample in this study was substantially older than the non-veteran sample, which may explain certain differences in perceptions between groups. Age-related factors, such as generational attitudes towards mental health, exposure to evolving patient-care roles for pharmacists, and differing healthcare experiences, may contribute to participants’ willingness to engage with community pharmacists about mental health. Thus, some variations in perceptions may be attributed to age-related effects rather than veteran status alone.

Conclusion

The present study underscores the complex dynamics surrounding mental health conversations between community pharmacists and patients. While pharmacists are generally perceived as approachable, they are not consistently viewed as accessible or well-informed on mental health topics. Brief, transactional interactions and limited rapport often discourage patients from initiating such discussions. Participants identified several factors that could foster a more supportive environment, including consistent staffing, a welcoming demeanor, privacy, and greater awareness of pharmacists’ roles. Addressing these areas may help position pharmacists as more integral to community mental health support. The findings also suggest broader implications for pharmacy practice: with targeted training, environmental modifications, and collaboration with mental health professionals, pharmacists could more confidently engage in mental health care and become trusted resources for patients. Future research should evaluate rapport building and privacy in high-volume pharmacies as well as test targeted interventions to enhance pharmacists’ confidence and competence in mental health conversations. Additionally, studies with larger, more diverse samples could examine how demographic variables like age and race may shape patient perceptions.

Key Points.

What is already known

• Pharmacists are in a unique position to engage in and provide referrals to mental health care for willing participants.

• Prior research indicates that there is limited information about how pharmacists and pharmacy staff may engage willing individuals who may need additional support for mental health.

• Additionally, most existing training programs fail to address barriers related to patient acceptability of pharmacists as resources for mental health referral or support.

What this study adds

• In this formative qualitative study, we aimed to determine patient acceptability of speaking with community pharmacy staff about mental health, suicidal behaviors, and what barriers exist to having these discussions with their pharmacist.

• Overall, results from this study indicate that participants’ comfort in having mental health discussion is facilitated by supportive relationships, a welcoming environment, and broader public awareness of pharmacists’ backgrounds in mental health and partnerships with mental health providers.

• The present study underscores the complex dynamics surrounding mental health conversations between community pharmacists and patients, which may provide useful information about how to engage patients in mental health conversations and provide referrals for willing participants.