Filling a global gap in access to critical mental health services: Engaging pharmacists to enhance the care of individuals with mental health needs and illnesses

It has been estimated that 1 in every 5 individuals, both in the United States and worldwide, lives with a mental health condition and its disabling consequences.^{1 , 2} There are several more millions who do not seek treatment and who would benefit from being diagnosed and properly treated. Among those diagnosed, many children, adolescents, and young adults do not receive mental health services when needed.¹ Suicide is a leading cause of death in the United States and among the top 3 for cause of death of those aged 10-24 years in the United States and across the globe.^{1 , 2} The economic consequences of mental illness have been estimated to cost the United States $193 billion¹ and $1 trillion worldwide.² All of these numbers are staggering and of great concern. Our nation and world continue to struggle with issues of getting more individuals the support they need and to drastically reduce these numbers. Most recently, the American Pharmacists Association (APhA) continues to devote considerable attention to the mental health needs of pharmacists themselves. Pharmacists often report burnout and stress owing to their work environment. This will continue to be a prevailing focus for APhA as they seek to find new ways to understand and reduce such stress and its consequences.

At the time of writing this editorial, our world is faced much significant uncertainty and fear as we struggle with the coronavirus disease pandemic and its impact on the physical, mental, and economic health of our communities around the globe. Pharmacists are at the forefront of the pandemic with many challenges of ensuring optimal medication management support in the context of social distancing and reducing risk of spreading the virus. Pharmacist roles have temporarily expanded across many states to allow pharmacists to help with point-of-care testing, compounding hand sanitizer, and many other additional activities including expansion of telehealth medication management. Pharmacists are administering long-acting injectable antipsychotics, under collaborative practice agreements, to help mental health care teams provide injections so nurses can attend to other functions. This is just one of many examples of how community-based pharmacists can serve as a safety net when other health professionals need to pivot to different tasks. There are many other similar stories across different health care settings and populations.

The importance of pharmacist roles in mental health is not new, and the literature is rich with examples of pharmacist roles in mental health.^{3 , 4} The motivation behind this special issue was to highlight examples of pharmacists providing mental health care and bring forward new exciting ideas and emerging concepts and applications to consider across the intersections of mental health and social science. The 16 articles in this issue represent contributions from around the globe covering a diverse array of topics across 3 key themes.

The first key theme relates to analyses of various perspectives of pharmacist roles in mental health. Articles in this first theme describe the perceptions that various stakeholders have about the different roles that community-based pharmacists and those with a specialization in psychiatric pharmacy can have in providing access to different mental health services, including depression screening in community pharmacies.5, 6, 7, 8 One study in this first thematic area explored patient perspectives on the role of community-based pharmacists as mental health first aid (MHFA) providers.⁸ MHFA is one of a few training programs to support the development of skills on how to help individuals with mental health needs get the support they need to manage and resolve mental health crises.⁹ Pharmacists and pharmacy technicians are seeking such training throughout the country to be more fully prepared to help their patients. Given the current pandemic, it is likely such skills are even more needed because of the greater likelihood of mental health stress owing to social distancing and its negative impact on daily living. The researchers reported that individuals were comfortable in discussing their mental health needs with community-based pharmacists.⁸ A final manuscript related to this first theme described student pharmacists’ attitudes toward their helping individuals with substance use disorders (SUDs) as a result of an elective course on SUD.¹⁰

The second key theme involves the emerging roles of community-based pharmacists being integrated into and collaborating with other professionals in primary care settings. Articles in this area described ways of involving pharmacists in mental health care of those patients seen in primary care settings ranging from expanded pharmacist roles to improve access to pharmacist-led clinics to incorporating psychiatric pharmacy specialists into mental health care delivery.11, 12, 13, 14, 15 Two manuscripts showed how pharmacists improved clinical outcomes for individuals with mental illnesses.^{14 , 15}

The final key theme focuses on the factors associated with medication management processes and outcomes for individuals with mental illness. Articles in this theme demonstrated how pharmacist-led interventions can improve psychotropic medication safety and use^{16 , 17} and support pharmacists’ intentions to engage in antidepressant monitoring as the best predictor of pharmacist systematic antidepressant monitoring behaviors.¹⁸ As suggested by these researchers, intention may be influenced by pharmacists feeling capable to perform the services. Such pharmacist feelings about capabilities, are, in part, evidenced by another study in this thematic area that found stigma, mental health knowledge gaps, and misconceptions among Nigerian pharmacists.¹⁹ Such results found in Nigeria, a developing country, are similar to the stigma, knowledge gaps, and misconceptions found in developed nations. Another manuscript examined the electronic medical records of those with frequent psychiatric readmissions.²⁰ This latter work supports the continued importance of interventions to improve psychotropic medication adherence because of the large extent of psychotropic polypharmacy. Readers learn, from the last study under this third thematic area, that individuals with mental illness (despite being on complex regimens and having 1 or more medication-related problem) are not given a comprehensive medication review.²¹ When considered together, the articles in this theme highlight that individuals with mental illnesses have medication therapy management needs but are not being given the opportunity to access pharmacist support in resolving those needs.

This diverse collection of manuscripts reflects a great need for pharmacists to be involved in filling critical gaps in mental health services often left by overburdened prescribers and health systems. If adequately trained and equipped with private and accessible locations, pharmacists can provide the efficient and time-sensitive access to many valuable services that will increase the (1) detection of mental health problems, (2) provision of critical health and medication education, (3) quality of medication management, and (4) frequency of patient and caregiver experiences involving positive clinical, humanistic, and economic outcomes. Although the pharmacy community needs to build more infrastructure for these opportunities to occur consistently and across an even greater variety of settings than presented in this themed issue, there is a corresponding imperative to create more demand for pharmacist engagement among those with mental health needs and their caregivers and clinical teams. To stimulate such engagement, the pharmacy community should widely promote their interests and expertise to the public and medical communities. This requires relationship building and perseverance. Furthermore, pharmacists need to make it explicit in their communications that they are willing and available to aid in the detection of those needing mental health support and work collaboratively with other professionals to optimize treatment and care. There has never been a time in our world’s history when the need for greater pharmacy involvement in mental health care has been so great.