NHS England is championing the role of primary care providers in tackling mental health issues in the community, but where does pharmacy sit in this challenge?

In the weeks before the drama of the general election, NHS England announced the launch of a new taskforce to develop a five-year national strategy for mental health for people of all ages across England, as signalled in the NHS Five Year Forward View. NHS England CEO Simon Stevens says its aim is to explore the variation in the availability of mental health services across England, look at the outcomes for people who are using services, and identify key priorities for improvement – all of which it will report back on later in the year. Chaired by Paul Farmer, CEO of mental health charity Mind, other members of the taskforce include mental health experts and various Royal Colleges, but there is no representation from pharmacy.

This is despite the original NHS Five Year Forward View promising to help patients get ‘the right care, at the right time, in the right place, making more appropriate use of primary care, community mental health teams, ambulance services and community pharmacies’. With over 1.2 million people visiting their community pharmacy for health-related reasons every day – that’s nearly half a billion opportunities every year to engage with the public about mental health issues – they could be missing a trick.

‘Our collective attitude to mental health problems is shifting and we must build on this momentum to ensure we maximise care for the vulnerable members of our society,’ says Rob Darracott, chief executive of Pharmacy Voice. ‘Embedded in local neighbourhoods, community pharmacies are often part of the daily routine for people with mental health problems, and pharmacists are therefore ideally placed to offer basic advice and signpost people to a specialist or the community mental health team if they are concerned.’

Starting the conversation

So if you want to help, where do you start? The de-stigmatising of mental health issues is by no means complete, so you need to be tactful when it comes to talking about this with your customers. ‘Because you’re a frontliner with regulated professional status, people have a high expectation of professionalism from you, but they also feel less judged or stigmatised by a pharmacist than a GP, which makes you a first port of call for many people with mental health issues,’ says Dr Mark Salter, consultant adult general psychiatrist at East London Foundation Trust.

‘However, often people don’t want the talking, just the answer, and will come into your pharmacy with unrealistically high expectations of a simple chemical solution in the form of tranquilisers, antidepressants and mood stabilisers.’ Dr Salter believes a problem that is often underaddressed by pharmacists is that if someone is hoping that a pill alone will treat the problem, they are going down the wrong route. ‘Start out by saying, “I know we’re talking about a pill here but they are only one part of the solution”,’ he says.

‘You wouldn’t give an asthmatic smoker only amoxicillin, for example, so a holistic approach to every single customer is what’s needed.’ He also stresses that you shouldn’t underestimate how important you are to your customers longitudinally, over time. ‘In my opinion a good pharmacist makes a mental note, or even a physical note, about their customers’ circumstances, so they should be able to spot if someone who is normally happy suddenly seems different, and ask them what has changed.’

However, if you don’t have a patient’s prescription it can be trickier to spot someone who is experiencing depression or anxiety. They could be buying sleep aids, or asking about ‘natural’ treatments such as herbal remedies, or reporting chronic stress headaches or even loss of appetite. ‘Sometimes, just asking a simple ‘How are you feeling at the moment? Are you a bit down or stressed?’ is effective, rather than tip-toeing round the issue,’ says Boots UK pharmacist Angela Chalmers.

‘However, you must be sensitive and make sure that this is a discrete or private conversation. Always offer the consultation room or a quiet area of the pharmacy. I keep a box of tissues around just in case someone gets tearful. As pharmacy is often the first port of call for healthcare for many, this can happen as you may be the first person to actually ask the person how they are feeling.’

And while it is usually easy to identify from a patient’s prescription if they are on a medication for depression or anxiety, Ms Chalmers, adds that it is also important to remember to ask a patient how they are getting on with their medication and if they are finding that their symptoms are being managed. ‘I find this opens up honest conversation and the customer will tell you if things don’t feel quite right. It’s also a good way to find out if someone’s medications aren’t working and need to be reviewed by the GP.’

Our collective attitude to mental health problems is shifting and we must build on this momentum to ensure we maximise care for the vulnerable members of our society

Accessible support

Once someone has been diagnosed as suffering from a mental health illness and presents at the pharmacy with a new prescription for antidepressants, it makes offering support a bit easier – from helping them get the most from their medicines and managing any adverse effects, to encouraging them to seek additional information from their primary care or specialist team. ‘It is really important that the pharmacist is aware of any new prescriptions for antidepressants so that they can speak to the patient individually,’ says Jane Devenish, NHS standards pharmacist at Well. ‘

Check that the patient has a follow-up appointment with the doctor and reiterate the importance of keeping that appointment, even if they don’t feel that their condition is any better. All patients should be told not to stop taking their tablets suddenly, even when they feel well again. The tablets are not addictive, but stopping taking them suddenly can cause side effects as the body adjusts, and can cause a relapse of the condition.

It is normal to continue taking these tablets for at least six months after the patient is fully better again, and for some people it will be much longer than that.’ For Dr Iris Elliott, head of policy and research at the Mental Health Foundation, good practice ‘on the ground’ should also be supported by strategic action, including mental health training for pharmacists within both professional qualifications and CPD.

‘The Royal Pharmaceutical Society has a leadership role to play, for example by confirming that this is a good practice issue, and by working with members and mental health organisations including people with lived experience of mental health problems to develop good practice guidance and resources,’ she says.

Signposting other services

It’s also important to be able to direct customer to other support services in the local network, according to Dr Salter: ‘The pharmacist’s job is to be a network specialist, as much as anyone else, so go out there and talk to people. A clued-up pharmacist will have a folder or noticeboard of local mental health services and know, for example, that there’s a Mind in every borough of the country and they have a record of independent sources of counselling, and that private sector services also often take referrals from pharmacists.

It’s incumbent on every pharmacist to be up to date with what’s going on in their patch.’ As a starting point, pharmacists can prove life saving. ‘I once had a customer who, when I spoke to her in the consultation room, turned out was thinking of suicide,’ says Ms Chalmers. ‘I was able to immediately call her GP (with her permission) who spoke to her on the phone and got her a same-day appointment.

The customer came back after a couple of weeks, thanking me for intervening as she had been in such a bad place; she had received the right acute care and was now feeling much better. This is an extreme example but an important one as until we ask people how they are feeling, we will never know if they need our help.’

Role building

It seems there is plenty of scope for community pharmacy to play a significant role in mental health services and support, despite being left out of some national-level conversations on the topic but, as ever, this takes time and effort. Dr Elliott recommends proactively working with local community mental health services such as residential units in order to understand how to improve service to customers with significant mental health problems and complex needs.

She says the Mental Health Foundation supports the development of initiatives that would help people who experience mental illhealth to self-manage their medication as part of their overall recovery journey, adding, ‘Community pharmacists can play a significant role in supporting people who want to come off medications such as benzodiazepines through tailored clinical support.’ She also thinks it is important to develop a research agenda around mental health and community pharmacy ‘in order to identify how community pharmacy can support this group to live longer healthier lives’.

Involving community pharmacy in long-term research about the outcomes of supporting people with mental health issues might feel like a huge task, but in the meantime the profession has a key role in recognising the signs and symptoms in customers and forming links with local networks around the topic of mental health. Simply asking someone how they feel or even expressing concern that they don’t seem themselves at the moment could be exactly the kind of interaction they need to speak to start getting the help they need.