Helping at-risk patients

Pharmacists are inextricably linked to medications and may have a role in helping those at risk of suicide, say pharmacy researchers

A scoping review has found some evidence that pharmacists have an impact in the area of suicide prevention – but currently, evidence is limited.

Researchers from the College of Pharmacy and the Department of Pharmacy at Dalhousie University in Canada, in partnership with pharmacist researchers from the University of Sydney, reviewed 35 articles assessing pharmacist roles in relation to suicide.

Examining the role of pharmacists across the articles, they developed several themes including:

  • Education and training as a means to improve the knowledge, attitudes, capabilities and confidence of pharmacists in assessing suicide risk, risk factors and those with intentions of suicide.
  • Gatekeeping of medication supply, with pharmacists seen as managing supply and recognising risk factors so they can adequately decide on appropriateness of the supply.
  • Collaboration and integration, which is is necessary for pharmacists’ participation in suicide risk assessment and mitigation, say the researchers. Specific clinical activities and roles were mentioned, such as pharmacists’ assisting doctors in selecting the most appropriate antidepressants in patients with suicidal ideation.

Despite increased healthcare service utilisation and contact with health providers for medication-related needs prior to suicide-related attempts or death, thoughts and plans related to suicide can often go undetected in clinical practice, say the researchers in their article published in the Canadian Pharmacists Journal.

Suggested roles for pharmacists in managing the quantity of medications include mechanisms such as:

  • managing refill frequency,
  • preventing stockpiling,
  • monitoring the refill rates for adherence to medication in those with experience of mental illness, and
  • maintaining adequate medication history records.

In its mental healthcare framework, PSA says pharmacists may be able to recognise early signs of depression or anxiety in a number of ways, including via verbal or non-verbal cues, direct product requests for analgesics, herbal sleeping aids or through changes in a person’s social or medical history.

Medications management is also important, according to the PSA.

“Staged supply services are another way that pharmacists can support treatment and adherence for mental health consumers,” says the PSA.

“This is a service where a pharmacist will dispense and supply medicines to the consumer in instalments and can be particularly useful for consumers with a mental illness or drug dependency, or homeless people.”

In its 2018-19 federal pre-budget submission released this week, the PSA also proposes a small pilot project to investigate a service model for pharmacists in supporting the wellbeing of people living with mental health conditions and to evaluate the effectiveness of such an intervention.

“Pharmacies can provide a friendly non-confrontational environment that may facilitate and encourage people to seek help about their mental health symptoms,” says the organisation in its framework.

Legal concerns

One theme that did come up in the scoping review is the potential vulnerability of pharmacists in the legal space.

“Several legal liability cases were focused on whether the pharmacists had performed their duties in managing the patients’ supply of medications in either refilling a prescription or the amount given,” say the researchers.

“This was often discussed in the context of the clinical abilities of the pharmacists to recognise whether the underlying conditions (e.g. depression) and medications dispensed should have alerted the pharmacists to assess whether suicide was a risk.

“Refill and prescription records of medication supply could also serve as a method for a proxy for suspected interactions with pharmacy staff in those who had been successful with a suicide attempt.

“In one study, overdose deaths were reviewed from coroners’ reports and examined for the type of prescription and non-prescription medications used.”

Examples of adverse consequences such as patient suicide and litigation against a pharmacist resulted when factors such as good communication were not in place to support collaboration, they say.

Pharmaceutical Defence Limited (PDL), which provides professional liabilities insurance cover for pharmacists, says there are certain limited circumstances where a pharmacist could potentially be liable in this area.

“There could be liability if there is a staged supply arrangement set up by the doctor and pharmacy – where the medicine is typically misused or can be taken in large amounts – if the pharmacist provided more medicines than the doctor has allowed for but didn’t contact the doctor to confirm any changes to the prescription or set doses/intervals,” says PDL Professional Officer Gary West.

“If there’s any doubt regarding a request for supply prior to the stipulated timeframe, it’s always best to go back to the prescriber for confirmation before supplying,” he says.

Real stories

Some pharmacists are making a real impact in the area of mental health support, with many pharmacies offering integrated mental health services.

Just recently, pharmacist Curtis Ruhnau from Western Sydney shared his interaction with a patient in AJP.

Here is an excerpt:

It was on a Thursday in our pharmacy a couple of months ago.

At about 5pm I noticed our intern pharmacist sitting in our private counselling area with a distressed patient. Leanne* is a lady I’ve known for some time, although I know other members of her family better, especially her sister Rebecca* and her mother. Leanne was crying and although Jenny our intern was doing a great job, she wasn’t getting any better.

It was about this time that Leanne motioned to me. I went over and asked how I could help.

“I got bashed last night, by a man that boards with me. I don’t know where to go,” she choked through tears.

I sat down, thanked Jenny for her time and started talking to Leanne. She explained that the boarder was someone distantly related to her and she had taken him in because she couldn’t afford her rent on her own. Now it was going to be dark soon and she didn’t feel safe to go back to her own home.

She said that calling the police wasn’t something she wanted to do; she felt it wouldn’t make any difference. She just didn’t know where to go and it was when she was walking past our pharmacy that she thought she’d come in. She knew us, we treated her with respect and she just didn’t know what else to do.

We had a chat.

Leanne told me that she had lost both of her babies; one was stillborn and the other had died in her arms 10 minutes after being born.

“I just don’t want to be here anymore. I can’t handle it,” she told me.

This worried me. Although I’ve never done any formal mental health training (it’s on my to-do list), I knew she meant that she was thinking of suicide. So I asked her directly if she’d thought about it…..

Read Curtis’ full article here.

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