Co-creating mental health education with students: a qualitative case study in pharmacy

Abstract

Introduction

Given that medication is often utilised to treat mental health conditions, pharmacists across sectors are well placed to provide enhanced care to patients beyond their knowledge of medicines. However, this requires pharmacists to be appropriately educated about mental health. This study explores the priorities of pharmacy students for learning about mental health.

Aim

This study aimed to explore the ideas and priorities of fourth year pharmacy students for mental health education under the following categories: (1) Content to be included. (2) What knowledge, skills and attitudes students wish to develop. (3) The teaching and learning approaches associated with developing these knowledge, skills and attitudes.

Method

An exploratory case study design was conducted in 2024 within an elective ‘Education and Training’ module for undergraduate pharmacy students in Ireland. Eighteen students participated in the study and engaged in three different focus groups. The study was designed with student partners who supported the facilitation of focus groups and analysis of the data. Data analysis was conducted using thematic analysis on Nvivo software with a student partner. Final themes were agreed with the wider research team.

Results

Four main themes emerged from thematic analysis of focus group transcripts: (1) the pharmacist and pharmacy as a safe space, (2) adaptable communication skills, (3) integration of physical and mental health challenges across curricula, and (4) seeking authenticity in teaching and learning approaches. Students also gave insights into what makes a contact-based learning experience worthwhile for them, and expressed a desire for integration of patient and public involvement into education in order to create a more authentic learning experience.

Conclusion

Pharmacy students find value in authentic learning methods, and appreciate when patients and patient groups are involved in education. Additionally, they see each other as an important learning resource and value small group work. These learning methods have been integrated into our mental health module in the form of patient speakers, simulation practice, and small group work activities.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11096-025-02054-3.

Impact statements

• This study presents transferable findings that may inform the development of mental health education programmes present in other pharmacy education programmes which could impact pharmacy student learning outcomes in mental health

• The methodological approaches described in this study, including patient and public involvement (PPI) and student partnership approaches, are novel and may present a useful model for the development of pharmacy and other health professional undergraduate curricula.

Introduction

Rates of mental health challenges have been increasing since the pandemic [1, 2]. It is estimated that mental illnesses constitute up to 7.4% of the worlds measurable burden of disease [3]. This can be compounded by lack of access to mental health care which is of a global concern [4]. Because of this, there is need for greater cohesion between mental health and primary care teams [2, 5, 6], this means that health care professionals not specialising in mental health, still need to have adequate knowledge and skills in mental health to support this cohesion [5].

Pharmacists are well placed to provide this mental health support. Studies have found that whilst pharmacists are willing and interested in providing mental health support, they do not feel confident doing so [7, 8] and have knowledge gaps [9, 10]. Studies exploring the knowledge and attitudes of undergraduate health profession regarding mental health challenges have suggested considerable deficiencies across pharmacy curricula [10, 11].

For the six years prior to this study, Masters of Pharmacy (MPharm) students enrolled at The Royal College of Surgeons in Ireland (RCSI) have completed Mental Health First Aid (MHFA) training as a mandatory course requirement at RCSI in the third year of the programme. MHFA is a training programme designed to teach trainees to recognise and respond to common mental health crises [12, 13]. It is a 12-h course, typically delivered over 2 days, that equips participants with the skills to offer early intervention for the most common mental health challenges, until the initial crisis resolves or appropriate professional help is received. Since its launch, over 4 million people across 25 countries have received accreditation [12–14].

Research has found that MHFA can support the improvement of mental health literacy, helping behaviours and reducing stigma [13, 15]. Within MHFA training, recovery focused care skills are informed by the knowledge that people can and do recovery from mental distress [16, 17].

Furthermore, as part of a wider curriculum redesign, a mandatory mental health module is set to be introduced in 2026 as part of year four of the MPharm programme along with improving the MHFA for students. This was initiated because of feedback from PPI contributors and stakeholders who advised that there needed to be more focus on mental health within the MPharm curricula. Designed with involvement of patient educators, this module incorporates in-depth content on the most commonly presented mental health condition and their associated medications, and the role of the pharmacist in mental health.

Whilst there have been studies examining the factors that promote the best outcomes in mental health education [18] it is unknown what the preferences are of pharmacy students. Because of this, it is essential to collaborate with pharmacy students to navigate such curricular adaptations to improve impact for key indicators such as knowledge, attitudes, motivation and confidence to support patients experiencing mental health challenges.

Aim

This study aimed to explore ideas and priorities of fourth year pharmacy students for mental health education under the following categories:

1. Content to be included.

2. What knowledge, skills and attitudes students wish to develop.

3. The teaching and learning approaches associated with developing these knowledge, skills and attitudes.

Method

Study design

The standards for reporting on qualitative research checklist was used to guide the reporting quality within this manuscript [19]. This study employed an exploratory, single site, case study methodology [20]. Case studies focus on experiential knowledge and they are useful when capturing complexity of data within a particular group or community (17). When the approach is applied correctly, it becomes a valuable method for health science research to develop theory, evaluate programs, and develop interventions [21]. This study focuses on year four pharmacy students at RCSI. Data considered in this study includes focus group discussions, documents submitted by the students, patient responses to the data, and researcher observations.

Student partnership methodology

Traditionally, higher education has favoured a hierarchical structure whereby students learn what teachers wish to teach, and this structure continues to dominate today [22]. A recent approach to teaching and learning is the ‘students as partner’s model’. Educators and institutions benefit from this as teaching can be refined based on student perspectives, this can also foster a greater sense of community between students and staff [22].

This study was conducted with two student partners who were responsible for leading and facilitating this research and analysing collected data.

Patient and public involvement

A patient and public involvement (PPI) advisory group have been involved in this study from development to dissemination. They have been involved in developing the study protocol, advising on the analysis and findings and consulting on the development of the mental health module.

Participants

Participants were recruited using a purposive approach. All students registered for the elective ‘education and training’ were eligible to participate. Focus groups were conducted in this module with Year 4 students.

Data collection

Data collection was through conducting focus groups with Mpharm student participants and documentary data collection. Two focus groups were audio recorded, with a researcher observing and taking observational notes with the other two groups.

Two rounds of focus groups were conducted. The first explored students’ views on the pharmacist’s role in mental health, desired knowledge and skills, and preferred learning methods (questions provided in Supplementary File 1). In this focus group, the students discussed among themselves the questions, and agreed on answers. In the second, students designed a mental health module using a blank descriptor form (see Supplementary File 2). This was also a self-facilitated activity among the students and facilitator intervention was minimal. Additional data were gathered through group presentations, where students proposed topics for curricular integration as part of their assessment; all consenting students allowed their presentations to be shared with researchers. Observational notes were also recorded in a spreadsheet.

Analysis

All recordings were transcribed verbatim and identifiers removed. These transcripts were uploaded to Nvivo along with the observational notes to be coded. Reflexive inductive thematic analysis was conducted as described by Braun and Clarke [23]. Analysis of initial codes was done independently by two researchers and coding was conducted inductively. The researchers met to discuss their codes and discussed variances. The analysis was led by the student partners in what codes were most important to be included in line with the student partnership methodology. Once codes were identified and sorted into 4 themes, the lead researcher and student partner met again to discuss the themes and agree on subthemes.

Reflexivity

The first author has lived experience of mental health challenges, which shaped their approach and interpretation of the study while providing valuable insight into the importance of awareness, education, and support. The research team brought diverse perspectives, including student partners with first-hand experience of pharmacy education and existing relationships with participants, an experienced mental health pharmacist, and a pharmacist educator with expertise in curriculum design. These varied backgrounds enabled sensitive handling of themes and fostered productive discussions that built shared understanding throughout the study.

Ethics approval

Ethics approval was obtained in 2023 by RCSI rec number: 202312010. All participants were invited to the study by a gatekeeper who was not a part of the study, two weeks before the education and training module was due to begin. Students were then reminded of the study details at the beginning of the module and informed consent was sought before any focus group activities began. Students who did not consent to be a part of the study were not treated differently to those consenting. Only those who consented to be a part of the study were recorded as part of the study.

Results

There were twenty students who elected to take the module, of these, eighteen gave consent to participate in the study. Students were divided into two groups of four, and two groups of five and all students were of similar age group. The majority of students were female (n = 12). No further demographic information was collected on the students participating.

Four main themes emerged in the data; pharmacists and the pharmacy as a trusted safe space; adaptable communication skills for mental health; and developing a future-focused curricula which integrates physical and mental health problems. Students also discussed the importance of safeguarding students with mental health challenges during mental health education and highlighted the value they place on the involvement on patient educators within module design, teaching and assessment. A full overview of all themes and associated data extracts can be viewed in supplementary file 3 (Figs. 1 and 2).

Fig. 1.

Mpharm students priorities for mental health. Created using Microsoft Word SmartArt

Fig. 2.

Students written answers on Q2 FG1

Pharmacists and the community pharmacy as a trusted, safe space:

Across groups, participants emphasised pharmacists’ pivotal role in supporting people with mental health difficulties due to their accessibility in the community and the public’s trust in them. Beyond dispensing and counselling, pharmacists’ regular contact with patients places them in a unique position to provide early intervention:

“the pharmacist can be the first point of call for a lot of people and we need to be in a position to recognise when something has changed in patient” – Student 1, focus group 3.

“we can be responsible for reducing the stigma around it (mental health). – Student 2, focus group 3.

“And you are seeing someone regularly as well, so you are kind of in a position to recognise when something has changed”- Student 1, focus group 3.

Students also discussed how they would like to have more education on how to navigate daily interactions about mental health. They discussed their own experiences supporting patients who were more comfortable speaking about their mental health than them:

“Patients talk openly about addiction and we are not familiar with openly speaking about this”- Student 2, focus group 2.

“Even to people, especially in hospital, they are so open to talk about their experience” Student 2, focus group 2.

Student’s believed it was vital that pharmacists are confidently practicing mental health support within the pharmacy in order to encompass the Pharmaceutical Society of Ireland’s ‘Core Competency Framework’ [24] with regards to patient-centred care and holistic approaches to medical interventions. Students noted that from an ethical standpoint it would be essential to have developed an understanding of mental health.

“Patient-centred care is at the forefront of pharmacy, and from an ethical standpoint it is essential to learn about mental health in order to deliver holistic care”. -Student 1, focus group 3.

Adaptable communication skills in mental health

Students agreed that the pharmacy was an important space to conduct those initial conversations about mental health with patients. It was noted across focus groups that pharmacists may notice signs in a person that they are not doing well, and a patient may directly approach the pharmacist to speak about mental health. The pharmacist should be prepared to have such conversations, and have the sufficient training to be able to make a well-educated, suitable referral when required:

“There’s been a few anxiety attacks in the pharmacy (that I work in) so knowing how to support someone in a mental health crisis would be important…” -Student 3, Focus group 1.

Additionally, other students mentioned the importance of being aware of ways that people with different mental health conditions such as eating disorders might be using the pharmacy and the importance of the pharmacist to encourage the safe use of OTC medications:

“understanding the safe supply of OTC medications such as laxative abuse” – Student 4, focus group 2.

In addition, whilst MHFA is a mandatory curricular requirement for this cohort of students, some noted that the learning objectives of MHFA does not cover additional training on psychotherapies and other supports. Students suggested that this knowledge is vital to provide the pharmacy students with the contextual knowledge to support people in mental health difficulty:

“I would have little to no knowledge on speaking with a person receiving CBT (cognitive behavioural therapy), education should focus more so on the psychological aspect rather than just the medication treatment of conditions…” – Student 4, focus group 3.

A future-focussed curricula

The content that students prioritised were the conditions they felt are most commonly presented in a pharmacy setting. This included depression, anxiety, sleeping and eating disorders, substance abuse, attention deficit and hyperactivity disorder, and obsessive–compulsive disorder. Students also suggested learning about populations that might be most at risk for developing these conditions.

The students discussed their preferences for teaching and assessment. In regards to teaching, the students agreed that for content like learning about the chemical basis of drugs, traditional didactic based lectures were the most appropriate form. However, for learning communication skills they agreed that lectures were not appropriate. Student prioritised small group tutorials, Objective Structured Clinical Examinations (OSCEs) and site visits for learning these more practical skills. OSCE’s are designed for students to demonstrate their skills and knowledge throughout a series of stations, each simulating a real life clinical scenario [25].

“OSCE station for sex gender and health module, or post-natal depression”—focus group 2 (group presentation).

“Assessment: communication focused, Patient care lab 1, 2,3 week, Simulation at 4th week, OSCE on 6th week—70% patient graded. “ -focus group 3 (group presentation).

In relation to assessment methods, the students opted for more practice-based assessments where they could focus on building their communication skills rather than exam-based assessment only focusing on knowledge:

“now that I think about it, modules that I may have done well in the written exam, I wouldn’t necessarily think that that translates to how well I would treat patients on those drugs, that knowledge, overtime goes out of your brain a bit, but practical soft skills kind of stay with you” – Student 4, focus group 3.

Students in multiple focus groups discussed their desire to understand the approaches that could support someone in a mental health crisis or challenge beyond how medication can help. Students suggested holistic care, lifestyle adaptations, understanding psychological concepts, healthy eating and smoking cessation as things that pharmacists should have knowledge about and how this could relate to the mental health support a pharmacist could provide:

“…more on the lifestyle stuff as well because I think that is a big thing that pharmacists can help with” – Student 2, focus group 3.

“knowing when to refer a patient to say a psychologist or something…” – Student 1, focus group 3.

“Healthcare is getting more and more complex and you have to take into account the whole person” – Student 2, focus group 3.

Finally, students also considered how Mpharm students might be safeguarded during education about mental health. According to the students involved in this study, safeguarding students throughout any teaching and learning about mental health was paramount. Students suggested in their presentations that this could be done by offering multiple means of engagement with the content, and providing adequate trigger warnings about the material that will be discussed in each class.

“Students will be advised that the material of the module can be sensitive, recordings of lectures will be provided if a student wishes to not attend any session” – Focus group 2 (group presentation).

“trigger warnings will be provided in advance about the module” – Focus group 1 (group presentation).

Seeking authenticity within teaching approaches

Participants noted how many patient-centred care labs focused mostly on general skills such as prescribing of common psychiatric medicines and counselling for prescription of a new medication. It was expressed that navigation of more nuanced and complex issues deserve attention within these labs, such as where a patient may have trouble with side effects of a medication or be misusing an OTC medication. Additionally, participants suggested that pharmacists counselling practices should go beyond the one encounter; counselling patients about medications should also involve checking in with a person regularly if needed, as opposed to just handing out the medication.

Students valued the contributions of patient educators greatly, and all focus groups incorporated a patient educator aspect into their mental health module and integration plans.

“I love a patient contact session…(retracted) were so good too. It changes your perspective…They were just so much more passionate about it”. – Student 1, focus group 1.

“That’s the thing and that is the stuff that sticks with you” – Student 3, focus group 1.

However some students noted that engaging with patient educators in an online format was difficult to fully engage with:

“We also got a talk from (retracted) but like, it’s online, it’s very difficult to engage with it”. – Student 1, focus group 2.

Some students also considered patient educators beyond their contributions to a patient contact session, involving patient educators in the assessment of their communication skills in their presentations:

“We would implement an OSCE at the end of the 6th week that is heavily centered on the patient feedback rather than the assessors i.e. 70% patient graded” – Focus group 1 (group presentation).

Students also discussed the importance of having patient educators which represented different health conditions to speak about the mental health challenges of living with conditions such as asthma:

“With Asthma, I wish it was brought up more about patients for the associated mental health aspect—we had patients for other topics but not this”. Focus group 4 (group presentation).

Proposed module

Based on the student’s priorities, a sample mental health module descriptor was developed that incorporated most the students’ priorities. The full module descriptor can be viewed in supplementary file 4, and a breakdown of the content and teaching and learning approaches can be viewed in Table 1.

Table 1.

Overview of student priorities for a mental health module

Content	Teaching approaches	Assessment approaches
Epidemiology of mental health in Ireland	Multimodal and didactic	OSCE based scenarios
Stigma of mental health in Ireland	Student—centred	Critical reflection
Introduction to major mental health challenges	Patient educators	Simulation labs
Medicines related to treatment of depression, anxiety, schizophrenia bipolar disorder, eating disorders, sleep disorders	Simulation labs	70% ranking towards PPI contributors’ assessment of skills and reflection
Holistic care—therapies, lifestyle interventions	Experiential learning through psychiatric hospital site visits

Development of the mental health module

Identified student priorities and preferences informed the creation of the final module descriptor and the initial activity outline for the mental health module scheduled for delivery in 2026 as part of year four of the MPharm programme. The activity list was iteratively developed in collaboration with student partners, lived experience partners and pharmacists practicing in mental health settings. Feedback to the initial draft activity list was incorporated where feasible taking into account resource and time constraints.

Learning activities will be centred on the management of a range of mental health difficulties including formal teaching on supporting patients with eating disorders as pharmacists. The planned module places a strong emphasis on case study-based learning and includes substantial involvement of patient educators, alongside simulation-based learning and assessment activities. Teaching will be primarily delivered using small group social learning approaches, facilitated by a range of professionals with expertise in mental health care. The module integrates full MHFA training, tailored to complement the module learning outcomes. Workshop content exploring self-care and burnout, as well as community-based support referral has been included in response to student priorities regarding holistic care for themselves as professionals and that of patients experiencing mental health difficulties. The module further includes an experiential learning visit facilitated by a partner mental health hospital.

Ongoing engagement with mental health care experts and people with lived experience will ensure the authenticity of teaching materials as they are developed and delivered. All aspects of the module will continue to develop iteratively in response to student and other partner feedback, as well as evolving clinical practice, as it is delivered in successive years.

Discussion

This study has provided important insights into pharmacy student views on their future role as pharmacists and their views about different teaching and learning techniques they have experienced throughout their education. Students clearly recognised the importance of having developed skills in mental health, and identified powerful approaches to this end. Students described how they could learn from each other, from patients and from specialist pharmacists within mental health settings. Students also discussed pharmacist wellbeing and mental health, discussing strategies that could be integrated into the education to support pharmacy students who may have mental health challenges. Although students primarily discussed mental health in relation to a community setting, this may be because many of the students in the focus groups were currently working part time in community pharmacy settings.

Integrated physical and mental health topics Students had a clear sense of how important it would be to integrate mental health education across the curricula and within content on chronic diseases and illnesses. Mental distress is frequent among patients experiencing chronic disease [26, 27] which means that pharmacists are likely to encounter people experiencing mental distress in the pharmacy setting.

Specific training regarding eating disorders and sleep disorders was also noted as absent in the current curricula by students. A lack of training around eating disorders is reported across undergraduate healthcare curricula [28–30] and could impact the stigma and misunderstandings that people with eating disorders face within healthcare settings [31–34]. It has been argued that these negative attitudes could be resolved by providing education to health profession students at the undergraduate stage [34].

Experiential learning and direct contact with patients The students overwhelmingly agreed that developing mental health literacy is integral to their future role as a pharmacist. One educational approach stressed by the students was authentic contact-based education where students could observe and shadow a staff member interacting with patients, and opportunities to practice skills in an authentic environment such as within contact-based opportunities or at the university using simulation or role play. Early longitudinal placements has been explored for pharmacy students which showed that it promotes learning by providing early and repeated patient interactions [35]. In another study of pharmacy students experiential learning visit to a psychiatric hospital, students develop a greater insight and appreciation of their role as a pharmacist for supporting mental health recovery [36].

Additionally, students commented that the inclusion of people with lived experience as educators, simulated patients, and assessors was highly beneficial and supported them to develop more positive attitudes towards different mental health challenges and to gain more authentic feedback on their skill development. The value of patient educators has been widely discussed among the literature. For example, Towle presents a ladder of involvement for healthcare education where case based learning is the first step, ending with involvement at the institutional level [37]. Moreover, other authors have stressed the importance of including a wide range of PPI contributors, in a wide range of settings [38] and this was echoed by the students who expressed the importance of hearing from patients with different conditions, and getting the opportunity to meet people with lived experiences in the clinical setting but also in the university setting.

Recovery focused approach to mental health Students also expressed a desire to learn more holistic and diverse approaches to mental health recovery and treatment beyond medicines, such as lifestyle medicine and basic psychology principles and approaches. Previous studies have found that a lifestyle medicine approach is missing from many health profession curricula [39]. This more holistic approach to mental health is also in keeping with national policy which is focused on developing a recovery focused approach to mental health [6].

Challenges in delivering mental health education

Students were aware of the challenges that might be involved for developing mental health education, and tried to problem solve this in their own work. Some students thoughtfully considered the use of trigger warnings for each section of content, or colour coding the timetable to indicate where mental health content may arise, and this created a rich discussion among all students around safeguarding students who might have personal experiences with mental health. Trigger warnings provide caution about potentially distressing material. They are noted to enhance inclusion and empower choice and informed engagement in learning [40]. It has been noted in medical education literature that the use of trigger warnings can support students to prepare themselves for the material, and promote healthy coping strategies [41].

Future work

This study is the first to consider students own priorities for mental health education and provides strong recommendations for student perceptions of learning about mental health topics. This study does have some limitations, for example; student demographics were not collected which could have given us more in-depth insights into how students with different demographic features perceive mental health education. Future studies might look towards assessing students’ experiences learning about mental health alongside PPI advocates to assess the short- and long-term outcomes of this approach. There also lacks research on educators’ experiences teaching mental health to pharmacy students which could be explored.

Conclusion

This study examined pharmacy students’ priorities for mental health education, highlighting the importance of integrating mental health topics across curricula and the need for practical, experiential learning opportunities. Students emphasized the significance of mental health literacy in their future roles as pharmacists and recognized the necessity of developing skills in this area to better support patients with mental health challenges. Furthermore, the inclusion of people with lived experience and the promotion of a recovery-focused approach to mental health were viewed as essential in fostering a more holistic understanding of mental health care. The students’ feedback underscores the need for a more comprehensive approach to mental health education, which not only includes the integration of mental health across their curricula, but also addresses gaps in current curricula, such as the lack of training on eating disorders. By incorporating these findings, a mental health module was developed in collaboration with students and a PPI panel. Through these curricular changes, it is hoped that pharmacy education can better prepare students to meet the evolving demands of healthcare and to play a pivotal role in supporting mental health recovery within their communities.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

ZM: Conceptualisation, methodology, formal analysis, investigation, Writing—Original Draft, Writing—Review & Editing. EO: Methodology, Investigation, Writing—Review & Editing. SR: Formal analysis, Writing—Review & Editing. FFS: Writing—Review & Editing. DK: Supervision, Project administration, Funding acquisition. JS: Supervision, Project administration, Funding acquisition, Writing—Review & Editing.

Funding

Funding for the involvement of student partners was provided by the RCSI Student Partnership and Engagement Fund. Funding for ZM’s PhD is provided by St John of God’s University Hospital Ireland grant number 22359A01.

Data availability

The datasets generated during and/or analysed during the current study are not available.

Declarations

Ethics approval

Ethics approval was obtained in 2023 by RCSI rec number: 202312010. All participants were invited to the study by a gatekeeper who was not a part of the study, two weeks before the education and training module was due to begin. Students were then reminded of the study details at the beginning of the module and informed consent was sought before any focus group activities began. Students who did not consent to be a part of the study were not treated differently to those consenting. Only those who consented to be a part of the study were recorded as part of the study.

Consent to participate

Consent to participate was received from all participants in this study.

Competing interests

The authors declare no competing interests.