Stress test


The stress of COVID has seen a spike in people seeking help with mental health issues, while calls to the Pharmacists’ Support Service (PSS) reveal anxiety levels among pharmacists themselves have been higher than normal too

Even during normal times many people turn to pharmacy for help with common mental health issues but the higher incidence of stress, anxiety, depression and social isolation due to the COVID crisis has seen those people needing support and advice, spike.

Relatively early in the pandemic a Swinburne University survey found people were more stressed, anxious and depressed than they had been before COVID hit. Aussies were reporting three times more negative feelings and emotions in the first days of social isolation, compared to those they reported in a survey from the year before. And people with existing mental health conditions were fairing even worse—and reporting up to five times more negative feelings than they had been before.

While another study analysing what people searched for on the internet found searches for symptoms of stress had skyrocketed by 4500%.

Not surprisingly, a national survey of more than 100 pharmacists reported a rise in the numbers seeking professional advice about issues like managing stress and sleep.

More than 60% of pharmacists saw an increase in demand for help with sleep management and more than half (54%) reported an increase in requests for help to boost mood or manage anxiety.

Priceline said the majority of requests came from people aged 30–40, suggesting that young families were under the most pressure. As many as half of requests for help were related to COVID-social and economic pressures directly, the survey found.

Priceline said the findings accorded with research from The Lab & Nature which showed that a combination of not being able to see friends, economic and job certainty and less social interaction due to COVID had a negative impact on nearly half of all Australians.

This dire picture was underlined by a national survey conducted during the first month of COVID restrictions that found mental health problems were at least twice as prevalent than before the pandemic, especially in populations directly affected by the it. In the first month of restrictions, clinically significant depressive and generalised anxiety symptoms, thoughts of being better off dead or about self-harm and irritability were at least double those in non-COVID affected populations.

The most vulnerable people had lost jobs, lived alone or in poorly resourced areas, or were providing care to dependent family members, were members of marginalised minorities—and women or young. The researchers called for a greater public health response beyond public health messaging, as well as improved clinical interventions.

holding a sign: 'looking for a job'
Those who have lost jobs due to the pandemic are among the most vulnerable to mental health issues

Skills underutilised

Earlier clinical intervention and engaging pharmacists in the delivery of mental healthcare in Australia will lead to improved treatment outcomes and a reduction in medication harms, the PSA pointed out on World Mental Health Day in October.

The PSA said that as the majority of people visit their pharmacists around 14 times a year, pharmacists see a lot of people presenting with mental health issues, as well as providing mental healthcare advice and support.

“Enabling pharmacists to recognise potential signs and symptoms of mental ill health, as well as support patients and refer to GPs or emergency care has the potential to improve health outcomes and potentially save lives,” said PSA acting president Michelle Lynch.

Ms Lynch said there was an opportunity to better use the skills of pharmacists to improve the use of medicines for mental ill health by integrating pharmacists into a multidisciplinary mental healthcare teams, as well as early detection and intervention for a patient in mental health crisis.

She pointed out that the PSA had recently delivered government-funded mental health first aid and training to pharmacists and pharmacy support staff in bushfire affected regions to support the communities affected by the 2019–20 bushfires, with pharmacists often the first port of call for many people suffering mental ill health.

She said feedback indicated that there is a clear need to upskill pharmacists as mental health problems increase in prevalence—as is being seen during the COVID-19 pandemic.

In response to the Productivity Commission’s Draft Report on Mental Health, the PSA made five recommendations which it said have the potential to better use pharmacists’ skills in mental healthcare.

These include:

  • Develop and implement regular review of medicines for people with mental ill health to reduce the time to respond to medication-related problems and to reduce debilitating side effects from medicines which can be preventable.
  • Incorporate pharmacogenomic testing in primary care supported by the medicines expertise of pharmacists for people with mental ill health to personalise medicine therapies to improve the safe and quality use of medicines.
  • Support pharmacists, who are often one of the only frontline healthcare providers in rural and remote regions to incorporate early identification, triage and support for people with mental ill health.
  • Integrate pharmacists in suicide prevention strategies, including supporting pharmacists in their triage role of providing support to people they encounter in mental health crisis situations.

The final report from the Productivity Commission is expected to be released before the end of the year.

The pharmacy frontline

Elise Apolloni, managing partner at award winning Capital Chemist Wanniassa, ACT, has forged a reputation for herself as someone who is really passionate improving the mental health of all Australians.

After losing a colleague and friend to suicide in 2015, she has used skills gained from specialised postgraduate study to inform and shape how pharmacy responds to mental health including: the development of healthier mental health workplace strategies, as well as a raft of innovative patient services in mental health.

Five years on from the loss of her colleague, Ms Apolloni has ensured the team has the tools they need to help deal with a patient with mental health crisis or to talk to someone reaching out about a mental health issue. All staff are required to undergo some form of Mental Health First Aid training as soon as possible—and the store is reaccredited every three years.

“All staff are trained—including our non-pharmacy staff, as the assistants are often the ones triaging. The training really provides staff with a toolkit so they feel more comfortable talking mental health to patients. It can be a difficult topic for a lot of people who worry that they will say the wrong thing. But the training provides the tools to develop the skills to ask questions around things like suicidality, for example.

As pharmacists we are great at asking questions about healthcare problems—that’s part of our professional duty. But I don’t think, generally, when we come out of university we always have the skills for that type of conversation. That’s why Mental First Aid Training can help with the tools to deal with quite complex situations—including when someone may be experiencing psychosis and how to help them in that circumstance,” Ms Apolloni said.

“[As pharmacists] we have become quite aware of a lot of the emotional and the societal issues around people who are experiencing mental health problems and I think it makes us approach things a bit differently and with more sensitivity when we deal with mental health issues in pharmacy. In our store when someone presents with a medication for mental health we take the person for a private consult.

It’s a very natural process as we print out the information leaflet in the consult room as opposed to the main area. It is really important to create a safe space where people feel, if they want to, they can say how they feel or get a bit upset. Sometimes the counselling goes off fine and it’s just a normal interaction.

But we always make sure that people are really comfortable and we make the process as friendly and as smooth as we possibly can,” she said.

“Additionally, make sure people are they’re aware of the extra support available, not just medication, but also talking therapy support groups and other services around us that may not be front of mind when you walk into the pharmacy,” Ms Apolloni said.

During the unusual circumstances of COVID, working collaboratively and with a systematic plan to manage staff, workflow and supply levels was crucial to reducing stress levels in the pharmacy, she said.

“We have all been stressed out and some people can deal with it on their own and some people show it in a very outward way. And when people are frustrated towards our staff, trying remember that it is not directed at them personally can help too. But from our perspective it has mostly been ok but I do know some colleagues in other areas that have had some tough times. But we’re also been quite sure to explain to them that we have a zero-tolerance policy of abusive behaviour towards staff.

On patients stocking piling medications, Elise Apolloni said she believed the behaviour might have been more a case of people trying to get organised.

Elise Apolloni: asking questions and having staff trained are crucial to helping patients 

“It was hard at first until the government stepped in and regulated how much medication could be given away at any one time in volume. It was difficult initially because we wanted to ensure everything would be evenly distributed to all our patients so no one missed out. But I think things are now a lot calmer and people understand that they will get their medication and there is no need to have lots of it at home because it just puts pressure on the supply chain.

We also have contactless delivery and can deliver to someone’s home so they don’t have to stockpile. We’ve seen our home deliveries increase a lot, which has been a good thing for us as it has helped us manage our workflow during busy times.”

Managing workflow was also essential for safety during COVID, she said.

“We changed the workflow and triaged to minimise the number of people potentially touching things on the shelves as they walked through the pharmacy, along with changing protocols around signing scrips.

“In the very early days of the pandemic we operated split shifts to reduce the risk of transmission but that became really quite stressful for our members over time. It’s hard not seeing the whole team. You are not really aware of how much extra benefit you get from working face-to-face with your whole team, even if it’s just for crossover, whether it be for ongoing rapport and connectedness or just hearing what’s happening in their lives. So, it was good to be eventually able to regroup now that things have calmed down.”

Although the stress of COVID continues, Ms Apolloni is very positive about pharmacy’s scorecard.

“What we’ve experienced this year shows that pharmacy again steps up and meets the challenge—no matter how it presents itself. So, if we need to arrange contactless delivery we’ll make that happen; create apps and ways of prepaying so people are not touching cards or cash, we can make that happen too. I feel that pharmacy has definitely tried to evolve to meet all the challenges that have been presented to us so far and we’ve done a pretty good job,” she said.

Doubling the rate of distress

Findings from an ongoing national survey of more than 10,000 healthcare workers has found high levels of anxiety, with 56% reporting being ‘burnt out’ and 29% reporting depression.

Another survey of 255 healthcare industry workers, conducted by Mental Health Australia, had similar findings. Four in five respondents said working during the pandemic increased the amount of stress and pressure they experience in the workplace, even though almost half of the respondents had not sought specific mental health support.

When asked more specifically about the effects of COVID on the mental health and wellbeing, 70% experienced prolonged tiredness and fatigue, 57% now have problems getting to sleep or staying asleep and 42% admitted to mood swings or found themselves over-reacting when faced with minor issues.

But during the past six months, 28% said they had reached out to a trusted friend or family for mental health support and help—with more than half of those saying they believed their family and friends have been extremely supportive.

The Pharmacists’ Support Service has experienced a sharp increase in the number of calls it has received.

From July 2019 to June 2020 it received nearly 400 calls from pharmacists, interns, students or concerned friends, family and colleagues.

PSS executive director Kay Dunkley said during the first wave, overall call numbers to the service were 88% higher than the same time the previous year. Many calls concerned the difficulties associated with the need for pharmacies to make significant changes to the way they operated in a very short time.

“In addition, this change was unprecedented and there was limited guidance available. No-one knew what to expect and there was a lot of concern about the risk of infection as well as panic buying by customers and patients requesting multiple repeats, which was placing a strain on the supply chain,” said Ms Dunkley.

Fortunately, PSS was able to cope with this huge increase in demand as it had trained a new group of volunteers, in addition to its existing team, by the end of 2019.

When the second wave hit in Victoria, Ms Dunkley said she thought by that time the profession had a lot of systems in place, as they didn’t see the same sharp increase in calls for help.

“Overall, our call numbers are slightly higher than the same time last year, and although we are receiving some calls about COVID it is not nearly as many as during the first wave,” she said.

“There is a sense that many callers are feeling worn down and weary as 2020 has been a very hard year for everyone, with bushfires followed so closely by COVID-19. The ongoing stress does put pharmacists and pharmacy staff at risk of burnout and it is important that [they] focus on caring for themselves, which includes taking a break for holidays, even though we cannot travel overseas. We all need to remember that we need to care for ourselves in order to be able to care for others—you can’t pour from an empty cup,” she added.

To assist pharmacists during COVID, PSS has developed a series of webinars with the AJP and other stakeholders. The latest one was undertaken in conjunction with R U OK ambassador, Hockeyroo Rachael Lynch and pharmacists Elise Apolloni and Erin Cooper.

“Our aim was to particularly reach out to early career pharmacists, interns and students with messages about looking after yourself and reducing stigma around mental health issues as pharmacy professionals and in the wider community,” said Ms Dunkley.

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