Jerry McKee, PharmD, MS, BCPP

Why Is Mental Health First Aid (MHFA) Training Needed?

						Improves understanding of presentation and pervasiveness of mental illness

						Challenges myths and misconceptions regarding engaging individuals who have a mental illness

						Improves general understanding of the spectrum of interventions and support for individuals with mental illness in the community

						Increases comfort and confidence in talking with individuals with mental illness and understanding their unique needs

How Does MHFA Training Help the Pharmacist in Practice?

						Pharmacists will be better able to provide assistance in decreasing the distress related to stressful situations, trauma, and crisis

						Provides pharmacists with the tools to build trusting relationships to help others

						Pharmacists will have an improved comfort level in interacting with individuals with mental illness by knowing appropriate community-based referral options and support systems

						Pharmacists will be enabled to assist in promoting wellness and recovery for those dealing with mental illness

Mental illness affects tens of millions of people in the United States each year. However, overall, only about half of those affected receive treatment.

 For patients with mental illness, there are many barriers to care, including lack of access and of disease state information, limited financial resources, inadequate transportation, and stigma. Patients with mental illness may be stigmatized, even by health care professionals. Such bias can serve as a barrier to patients receiving optimal care, hinder them from realizing their potential, and be detrimental to their sense of well-being.

People suffering from mental illnesses perceive the stigma that exists related to their disorders; the discomfort felt by health care professionals and the general public in interacting with people with mental illness can be an additional barrier to care. It is essential that everyone, including health care professionals, be aware of any biases they might have toward patients with mental illness and make an effort to inform themselves on these conditions with factual information based on research findings.

The College of Psychiatric and Neurologic Pharmacists (CPNP) Foundation, in collaboration with the National Alliance on Mental Illness, conducted an online survey of individuals with mental health conditions (or their family members) about their interactions with their community pharmacists. The 2007 Wilson Rx Pharmacy Customer Satisfaction Survey reports that the average pharmacy customer visits their pharmacy an average 2 to 3 times per month, nearly 12 times their number of primary care doctor visits and 16 times more often than they visit a specialist physician in a year. Therefore, there are multiple opportunities for pharmacists to impact patient care in the community pharmacy setting.

Over 1000 individuals responded to the survey, and 65% of respondents were individuals with a mental health condition. Eighty percent of all respondents reported that they exclusively used a community pharmacy to fill their prescriptions for mental health medications. Responses demonstrate several opportunities for improvement in the community pharmacy setting in the areas of access to pharmacists, privacy, and professional relationship-building, and increased assistance with effectiveness or safety monitoring of mental health medication.

It is clear from the survey that many respondents and their families value their relationship with their pharmacist. Due to accessibility and trust, community pharmacists have a tremendous opportunity to positively impact individuals living with mental illness, their families, and the patient’s health care providers, and to further enhance evidence-based treatments leading to improved outcomes and patient satisfaction. In order to begin to achieve this potential, barriers to pharmacist engagement with individuals with mental illness must be removed as a first step. One aspect of this patient engagement equation is that of stigma, as described above, which is often an aspect of clinical training deficits.

Mental Health First Aid (MHFA) is one potential training tool that can begin a process of bending the curve in terms of minimizing the stigma associated with mental illness. As the CPNP Foundation survey points out, individuals with mental illness typically receive their medications from community pharmacies and many respondents and their families value the relationship with their pharmacist. Beginning with the register clerk, pharmacy technicians, pharmacists, and store managers, all community pharmacy personnel could benefit from this training, which builds mental health literacy and helps participants to better understand the presenting signs of and appropriate response to signs of exacerbation of mental illness.

MHFA is an 8-hour course that gives people the skills to help someone who is developing a mental health problem or experiencing a mental health crisis.

 The evidence behind the program demonstrates that it builds mental health literacy, helping the public identify, understand, and respond to signs of mental illness. MHFA efforts are coordinated by the National Council for Behavioral Health, the Maryland Department of Health and Mental Hygiene, and the Missouri Department of Mental Health to ensure the quality and standardization of the program nationwide, certify instructors to teach MHFA in local communities, and support program growth.

MHFA training, although intended for everyone, may be of particular benefit to individuals who regularly interact with persons with mental illness and their families, such as community pharmacy employees.

The MHFA training program was originally developed in 2001 by professors from the Centre for Mental Health Research at the Australian National University. In 2005, sponsorship of the program moved to the ORYGEN Research Centre at the University of Melbourne in Australia.

 The MHFA training program has been the subject of research trials to evaluate its efficacy and has been shown to increase knowledge related to mental health problems, improve attitudes toward treatment, decrease stigma, and increase the confidence of trainees in reacting to and providing support to people experience symptoms of mental illness.

The success of the program in Australia has led to its dissemination to 18 countries: Australia, Scotland, Canada, the United States, Finland, Singapore, England, Wales, Ireland, Cambodia, Japan, South Africa, Thailand, Hong Kong, Nepal, China, Sweden, and New Zealand. In addition to the original training session that focuses on providing MHFA to adults with mental health disorders, there is a youth MHFA program designed for parents, families, caregivers, teachers, peers, health care professionals, and the general public about caring for and interacting with a young person (aged 12 to 18 years) who is experiencing a mental health or addiction challenge or crisis.

Clinical research studies have focused on the efficacy of MHFA in different populations; some have evaluated the impact of MHFA training on health care professions students. A 2011 study in Australia evaluated the effect of MHFA training on pharmacy students’ mental health literacy, knowledge, attitudes, stigma, and self-reported behavior. All third-year pharmacy students at the University of Sydney (n = 272) were asked to participate in one of two 12-hour MHFA training sessions. Evaluations before and after training included a questionnaire on mental health literacy; the social distance scale, a 7-item scale assessing comfort in interacting with a person with mental illness in specific situations; and a 16-item scale of self-reported behavior. Sixty students participated, with results showing improvement in ability to correctly identify a mental illness, reduction in social distance (ie, the degree that a group is excluded from mainstream activities or marginalized), decreased stigma, and the ability to recognize and have confidence in providing helpful interventions for a person with mental illness.

In addition to the need for training for health care professional students in interactions with patients with mental health disorders, there is recognition that health care professional programs—including pharmacy, medicine, and nursing&mdash;are demanding, and stressors associated with these programs lead to an increased risk of mental health problems in students. An Australian study published in 2015 sought to evaluate the impact of MHFA training on medical and nursing students, either in person or online, on stigma and comfort in providing aid to a person with mental illness, with the goal of improving the ability of the student to support their peers in seeking help for mental health problems. The participating medical and nursing students (n = 434) completed either a face-to-face or online training program, as well as surveys regarding mental health interventions, mental health literacy, confidence in providing help, stigmatizing attitudes, and satisfaction with the MHFA course. The results indicated that both courses improved literacy and confidence while decreasing stigma and social distance from those with mental health disorders.

Although MHFA training is known to be effective for the general public in reducing stigma and improving confidence in interventions with people with mental health disorders, these studies emphasize the growing recognition that additional training in in-person interactions and improvement in confidence is needed in health care professional educational programs. Reducing stigma is an important step in increasing access to care for persons with mental illness. It is clear that MHFA training can be an important addition to educational programs aimed at optimizing patient care and outcomes, as well as increasing the job satisfaction of the community pharmacy health care professional.

Carol A. Ott, PharmD, BCPP, is a clinical associate professor of pharmacy practice at Purdue University College of Pharmacy in Lafayette, Indiana, and clinical pharmacy specialist in psychiatry at Eskenazi Health/Midtown Community Mental Health, in in Indianapolis, Indiana. 

Jerry McKee, PharmD, MS, BCPP, is assistant director of pharmacy operations and payer programs at Community Care of North Carolina in Raleigh, North Carolina.

		Use of mental health services and treatment among adults. National Institute of Mental Health website. www.nimh.nih.gov/health/statistics/prevalence/use-of-mental-health-services-and-treatment-among-adults.shtml. Accessed October 15, 2015

		Caley CF, Stimmel GL. Characterizing the relationship between individuals with mental health conditions and community pharmacists: results from a 2012 survey. College of Psychiatric & Neurologic Pharmacists Foundation website. https://cpnp.org/_docs/foundation/2012/nami-survey-report.pdf. December 2012.

		Mental health first Aid. Mental Health First Aid USA website. www.mentalhealthfirstaid.org/cs/. Accessed October 15, 2015.

		Youth mental health first aid. Mental Health First Aid USA website. www.mentalhealthfirstaid.org/cs/take-a-course/course-types/youth/. Accessed September 20, 2015.

		O’Reilly CL, Bell JS, Kelly PJ, Chen TF. Impact of mental health first aid training on pharmacy students’ knowledge, attitudes and self-reported behavior: a controlled trial. 

2011;45(7):549-557. doi: 10.3109/00048674.2011.585454.

		Bond KS, Jorm AF, Kitchener BA, Reavley NJ. Mental health first aid training for Australian medical and nursing students: an evaluation study. 

 2015:3:11. doi 10.1186/s40359-015-0069-0.

Articles

Mental Health First Aid as a Skill Set for Community Pharmacy Personnel

New ways of dealing with patients using evidence-based strategies can lead to greater adherence and job satisfaction.

Effective communication with patients and clinical colleagues is a fundamental aspect of a pharmacist's practice. With the patients I work with, those with severe and persistent mental illnesses, behavioral changes such as tobacco cessation, exercising, proper nutrition, and medication adherence would often bring about profound changes in their well-being—if the patient would simply adopt these changes. Getting to that point is often a significant barrier and a source of frustration, as repeated attempts to engage patients to change end in failure.

Convincing a physician or administrator to make a clinical policy change, a formulary addition, or a practice change can be just as challenging. The day-to-day challenge of being ineffective can lead to long-term frustration, cynicism, and professional burnout.

Our health care training has often led us to believe that physicians, pharmacists, and nurses are at the pinnacle of the health care team. As “all-knowing,” they simply have the task of pointing out to patients what they are doing wrong and what they need to do differently to improve their health and well-being.

It is becoming increasingly clear that dictating directives to patients is a highly ineffective strategy. I like to think of it as “The ‘60s are over and Vince Lombardi is dead!” Commanding patients what to do unilaterally, fear and intimidation tactics (“If you do not lose weight you will develop diabetes, hypertension, joint disease, etc”), and giving pointed advice without permission are strategies that are doomed to fail. Further, it will add to the clinician’s frustration regarding their relative inability to be successful in changing a patient’s behavior and health outcomes.

Motivational interviewing (MI) is an evidence-based strategy that is included in the Substance Abuse and Mental Health Services Administration’ s listing of effective patient care programs. MI incorporates strategies of understanding the patient where they are—via active listening, empathy, respect, and collaboration with the patient on developing and achieving incremental goals. MI is not an intuitive process. On the contrary, it often runs counter to our training as health care providers as being “all-knowing.”

Effective implementation of MI techniques requires basic training and skills development, then repeated practice. Ongoing feedback via trained supervision has been found to best assure that the principles of MI are adhered to over time.

MI uses active listening skills to identify what motivates a patient. The issue becomes one of “What is the patient motivated for?” instead of “Why isn’t the patient motivated?” MI is based on the concept that people are more often “stuck” versus totally opposed to change. As health care providers, pharmacists are in a unique position to positively influence someone’s motivation via applying the techniques of MI.

Quite simply, MI is the effective use of open-ended questions to identify where the patient is in relationship to considering a change in behavior. There are suggested to be 6 stages in the change continuum—pre-contemplation, contemplation, preparation, action, maintenance, and relapse. As the primary experts on themselves, patients are in the unique position of taking action to help themselves. Empowering the patient to see the world from this perspective can help him or her to begin to take action.

The cardinal rule of MI—using the acronym RULE (offered up by Miller, Rollnick, and Butler, 2009)&mdash;is to 

esist the righting reflex (ie, telling the patient what to do or being judgmental), 

Initially, the use of MI may feel cumbersome and may take more time versus the old unilateral advice giving practices. In time, with continued practice and coaching, the skills will become more entrenched. It may always be difficult for some of us to remain neutral and non-judgmental, and to refrain from responding to poor decision making by patients. Transferring the responsibility for success from the provider to the well-informed and change-ready patient can be an effective tool for the pharmacist—and can lead to enhanced professional satisfaction.

Jerry McKee, PharmD, MS, BCCP, is associate director of Behavioral Health Pharmacy Programs Community Care of North Carolina.