Pharmacists and other health professionals provide a crucial role in supporting people who are struggling with mental illness or at risk of suicide
Lauren* struggled in secret for years with severe anxiety and depression before seeing a doctor about it. (* We have changed Lauren’s name to maintain her privacy.)
“I was too embarrassed to talk to my family or many of my friends about it. I didn’t feel like anybody would understand. When I eventually got the courage to speak to a doctor about what I was feeling, they were quite dismissive, cold and acted quite uncomfortable speaking about it,” she tells the AJP.
“I was referred to see psychologists but despite going to several sessions I did not seem to be getting any better.”
Lauren says at her lowest point, she was struggling with suicidal thoughts and self harm.
“I was eventually put on antidepressants and, honestly, they saved my life. Almost immediately, within a month of starting on them, the extreme feelings of depression and anxiety went away and my emotions became more regulated.”
She ended up taking them for a few years before eventually tapering off them, utilising the ongoing support of a kind psychologist to cope with the change.
Lauren is doing much better now but is still hesitant to share her experience as she is worried about the stigma and judgment that exists around mental illness.
“Pharmacists and other health professionals should approach people who are having mental health issues with compassion and an open mind,” says Lauren.
“From my own experience, I was struggling with very extreme feelings of anxiety and depression due to a variety of reasons, but I desperately wanted to get better. Mostly I just needed compassion, support, and to be provided appropriate treatment in a caring, non-judgmental way.”
Suicide remains the leading cause of death for Australians aged between 15 and 44. Meanwhile one in five (20%) Australians aged 16–85 experience a mental illness in any given year.
In 2017/18, 4.8 million Australians (20.1%) had a mental or behavioural condition, according to the Australian Bureau of Statistics (ABS) National Health Survey.
Depression, anxiety and substance use disorder are the most common mental illnesses across the country.
However 54% of people with mental illness do not access any treatment, and this is worsened by delayed treatment due to serious problems in detection and accurate diagnosis.
Rachel had a history of anxiety and depression starting from 16 years old, seeing many psychologists mostly to receive cognitive behavioural therapy.
“Basically I got diagnosed 12 months ago with ADHD and comorbid autism, it was found out that a lot of the anxiety and depression I felt was actually a result of the ADHD rather than a separate disorder,” she explains.
After getting her diagnosis, she was placed on dexamphetamine which she says has helped her in managing her moods.
“Getting the right diagnosis and the right treatment finally, I am a lot healthier and happier. Now when I have day-to-day anxiety I actually understand where it comes from whereas before I had no idea,” says Rachel, who now advocates publicly for people with ADHD.
“My story isn’t actually unique. There’s a lot of people who are quiet about this, they’re silent, a lot of the mental health issues I had was because I felt like I had to hide so much about myself. I was afraid of the stigma, I was afraid of all the misconceptions around ADHD.”
Rachel and Lauren’s story reveal that mental health is a complex area fraught with misconceptions, stigma and shame.
There are many reasons why a person might be struggling with mental illness at any given time.
This includes traumatic life events, genetics and family history, medical illness, chronic pain, substance use, undiagnosed conditions such as ADHD in Rachel’s case, or a combination of factors.
Anyone, including pharmacists and other health practitioners, can suffer from mental illness.
Bria, a trained pharmacist originally from Brisbane, shared her own experiences with the AJP.
“Mental illness has always been a part of my life. Quite a few of my family members have been diagnosed with mental illness at some point in their lives,” she says.
Bria began exhibiting signs of anxiety at around age 10, but it wasn’t until she was 22 years old that she was diagnosed with severe generalised anxiety disorder (GAD) and severe depression.
“At this stage of my life, everything came to a head. The culmination of my untreated anxiety, the stress of intern year, along with frequent sexual harassment from one of my preceptors, left me in disarray,” she says.
“I was put on strong medication, attended frequent psychologist and psychiatrist appointments and was unable to work for more than 10 months.”
Currently Bria says she is still learning to live with her illness and, for the moment, has stepped away from working in pharmacy.
“I am still taking some medication and working on self improvement. However I have embraced that anxiety will always be a part of who I am.”
Helping people in crisis
With community pharmacy being the first port of call for many presentations, pharmacists are often faced with people who have mental health issues.
According to the ABS, 25% of the Australian population are accessing PBS-subsidised mental health-related prescription medications—for example, antipsychotics, anxiolytics, hypnotics and sedatives, antidepressants and psychostimulants.
“Pharmacists (in particular community pharmacists) come in contact with mental health consumers regularly and are more than capable of providing mental health first aid interventions,” say Hiba Kassir, Heather Eaton, Dr Monika Ferguson and Dr Nicholas Procter in the Journal of Pharmacy Practice and Research.
“While interacting with people, pharmacists are well-placed to observe signs of distress, a change in medication pattern or a change in mood or behaviour.
“The pharmacist can then make an approach to initiate gentle conversation with that person and to link them to further services.
“Through carefully considered engagement, it is possible for pharmacists to engage in sensitive and compassionate conversation.”
Kay Dunkley, executive officer at the Pharmacists’ Support Service (PSS), says pharmacists are “the most accessible health professionals and we also tend to see people on a regular basis when they come in to collect repeat prescriptions and regular medication.
“Some members of the public, who feel very isolated, also come into the pharmacy just to chat. There are people in our community who do not have anyone else besides us to talk to on a regular basis,” she told the AJP.
“Mental Health First Aid (MHFA) training is an excellent tool to assist pharmacists and staff identify someone who may be thinking about suicide and it also teaches how to ask questions such as ‘Are you thinking about suicide?’ or ‘Are you considering ending your life?’
“It is important to ask the question directly and use unambiguous words. Terms like ‘harm yourself’ are not direct enough and could refer to cutting or other self-harm behaviours. Asking about suicide will never put the idea into someone’s mind, but will give them the opportunity to talk openly about thoughts of suicide.”
Ms Dunkley says people should be aware of cues that may indicate someone is thinking about suicide.
“For example, words such as ‘my problems will all end soon’ or ‘I won’t have to worry any more’ in the right context can indicate that someone is thinking of ending their life,” she says.
MHFA instructor Jan Decomps says further signs a person may be suicidal include:
- threatening to hurt or kill themselves;
- looking for ways to kill themselves: seeking access to pills, weapons, or other means;
- talking or writing about death, dying or suicide;
- rage, anger, seeking revenge;
- acting recklessly or engaging in risky activities,
- seemingly without thinking;
- feeling trapped, like there’s no way out;
- increasing alcohol and drug use;
- withdrawing from friends, family or society;
- anxiety, agitation, unable to sleep or sleeping all the time;
- dramatic changes in mood; and
- no reason for living, no sense of purpose in life.
“Suicide can be prevented,” said Ms Decomps.
“Most suicidal people do not want to die—they simply do not want to live with the pain. Openly talking about suicidal thoughts and feelings can save a life.”
Ms Dunkley says: “As a pharmacist if we identify someone who is thinking about suicide, it is important to link them up to services which can assist them. If they do not already have links to mental health services, we can support someone by encouraging them to call one of the many telephone helplines. One strategy is to sit them down in the pharmacy and assist them to call the number immediately.”
She suggests the Suicide Call Back Service (1300 659 467) as they offer follow-up contact to those who are thinking about suicide, those who are supporting someone who is suicidal as well as those bereaved by suicide.
“This is a national service which is available 24/7 and is not just a one-off call but can provide ongoing counselling. They also offer online chat, video chat, an app and also assist people to develop a suicide safety plan.”
Some pharmacists have established programs that are helping their patients to achieve positive mental health outcomes.
Canberra pharmacy proprietor Elise Apolloni says her pharmacy, Capital Chemist Wanniassa, has developed a service called ‘Pharmafriend’, which is a pharmacist-led education program for patients experiencing mental health issues.
“Our pharmacists engage with patients and provide in-depth information about mental health issues, treatment options beyond medication and we follow up regularly with our patients,” says Ms Apolloni, who is also a MFHA instructor and a telephone crisis supporter with Lifeline.
She shared the story of a patient whom her staff helped: “Recently Patient X, who is a regular patient, presented to the pharmacy and didn’t seem to have their usual spring in their step. We provided a quiet private place in the pharmacy to sit down and chat with the patient, where they explained some family issues they were having, as well as issues with their health,” she says.
“The pharmacist asked about thoughts of suicide, which the patient agreed was the case.
“A call to the GP to arrange an appointment, discussion of other crisis services available and arranging a friend to spend the rest of the day with the person until the doctor’s appointment led to a positive outcome,” says Ms Apolloni.
“The patient returned a week later to thank us for assisting and connecting them with local services.”
Ms Apolloni encourages pharmacists to design some protocols about how they will help people.
“What resources can you develop? What connections with other services in your community can you make?” she suggests.
“Upskill upskill upskill! While pharmacists are great communicators, there is a lot of specific training that can be done when it comes to having conversations about suicide. Some worth considering include a MHFA qualification and ASIST (Applied Suicide Intervention Skills Training).
“Upskill and empower yourself to have conversations in the pharmacy.”
While the standard MHFA course is 12 hours long and delivered face to face, there is a blended (e-learning and face to face) course specifically designed for pharmacists.
Ms Decomps also suggests MHFA training for pharmacists as they “are widely available and free-to-access healthcare professionals, and of course mental health forms part of the health spectrum.
“With one-in-five Australians experiencing a mental health issue within the previous 12 months, a large number of pharmacy patients are living with a mental illness.
“Added to this, as we know, pharmacy is a stressful profession; so that one-in-five Australians obviously includes pharmacists and pharmacy staff,” she says.
“Learning how to spot the signs and symptoms of a mental health issue, and how to approach the person, and where to recommend they go for professional help are useful tools in the pharmacy environment – but also life in general.”
Ms Dunkley points out that it can also be stressful for pharmacists when helping to support others with mental health issues.
“Dealing with someone who is suicidal can be very stressful and as pharmacists we need to be aware that any encounter with someone who is thinking about suicide can impact on our own wellbeing,” she says.
“After an encounter with someone who is suicidal, allow some time for reflection as soon as possible and consider debriefing with someone if you feel that you need to talk about what has happened. The debriefing does not have to be immediate.
“The PSS is able to provide support and debriefing to any pharmacist, pharmacy intern or student after a stressful incident including supporting someone who is suicidal. The Suicide Call Back Service can also offer support if you have been dealing with someone who is suicidal.
“As pharmacists we need to also practice self-care and prioritise our own wellbeing in order to be able to look after others.”
- Lifeline Australia (Crisis Support and Suicide Prevention): 13 11 14 (24/7) or visit here
- Pharmacists’ Support Service: PSS is available every day of the year between 8am and 11pm EST on 1300 244 910 or here
- Suicide Call Back Service: Call 1300 659 467 (24/7) or go here
- Mental Health First Aid Training: visit their website