Elevating the Therapeutic Relationship: The Future of Pharmacists in Outpatient Mental Health Services

Article

Pharmacists working with patients with mental health conditions are able to optimize medication use and improve adherence.

Expanding the Role of Pharmacists

The National Alliance of Mental Illness conducted a 2021 study that found 23% of US adults experienced mental illness, among whom fewer than half are receiving treatment.1

Image credit: Gorodenkoff- stock.adobe.com

Image credit: Gorodenkoff- stock.adobe.com

This statistic may be attributed to the fact that 47% of individuals live in areas demonstrating mental health support shortages between both resources and trained professionals.2 Of these medically underserved areas (MUA), nearly two-thirds are in rural America.

There is a gap that needs to be addressed with professionals who can provide care to individuals facing mental health challenges. The 2023 American Society of Health-System Pharmacists (ASHP) Forecast, a document published annually predicting future trends in pharmacy, sees this as an opportunity for pharmacists to become involved. The ASHP report suggests that there will be an increase in the need for pharmacists in the realm of mental health services.3

This is supported by the fact that among individuals receiving treatment for mental health, 4 out of 5 are prescribed medications.4 This is a significant opportunity for pharmacists to step in and expand our role as indispensable members of the mental health care team.

The Role of the Therapeutic Relationship

The American College of Clinical Pharmacy (ACCP) specifies 6 competencies that are expected of pharmacists for assurance of the success of clinical pharmacy.5 Three of these competencies—direct patient care, system-based care and population health, and communication—overlap in the expectations of maintaining a healthy therapeutic relationship between a patient and provider.

The concept of the client-centered therapeutic relationship, an approach centered around focusing on the present subjective experience and self-perception of the client, was created by Carl Rogers, the father of humanistic psychology. Rogers said that the ability of the therapist to show empathy and unconditional acceptance of the patient was crucial to the patient improving therapeutically.

His success with motivating his patients to achieve their therapeutic goals built a name for him in the field of psychology.6 Pharmacists working with patients with mental health conditions have the ability to mirror this client-centered relationship through their role in optimizing medication use and improving medication adherence.7-9

For example, individuals with severe mental health conditions, such as schizophrenia and bipolar disorder, are more likely to find their medications unnecessary, resulting in higher rates of non-adherence compared to other patients with chronic illness.8 Similarly, another study examining antidepressant use in clinically depressed patients found that 52% were non-adherent to their medication regimen by the 6-month mark.9

These are a couple of missed opportunities for pharmacists to become involved in optimal patient care. The presence of a pharmacist extends beyond influencing the actions of the patient to impacting their perception of their experience and outcomes.

An early demonstration of this traces back to 1978, when clinical pharmacists were given the role of providing case management services within outpatient mental health clinics and given prescriptive authority and autonomy over patient health decisions.10 The authors reported improved satisfaction and clinical outcomes compared to patients treated by other providers in the clinic.10 Pharmacists have been proving themselves as an essential influence on patient health for decades.

Barriers to the Therapeutic Relationship

This longtime demonstration of the importance of the pharmacist role in healthcare begs the question, what is holding us back from having a larger role in mental health services? The feelings of pharmacists come into play here with the feeling of lack of preparedness with counseling on mental health designated medications being prevalent.11

In a survey among pharmacists, 2 out of 5 pharmacists admitted to being more comfortable counseling on cardiac medications compared to counseling for mental health–related medications.11 This was mainly attributed to a lack of exposure and training in their didactic curriculum.

This is supported by the 2023 ASHP Forecast, in which 63% of pharmacists felt some level of unpreparedness at the predicted increase in demand for mental health services.3 Beyond low confidence in the ability to treat mental health conditions, it is sometimes unclear what role pharmacists play in the care of these patients.12

This refers both to the scope of practice as well as the role of transition-of-care throughout the journey after a patient’s admission. Communication with the care team is vital because patients receiving treatment for mental health conditions have a high rate of medication therapy problems and under-documentation of medication use by their physician.7 The complication this presents is a result of our current health care model, a reactive collaboration between pharmacists and other members of the health care team—most commonly physicians—in which pharmacists respond to decisions that have already been made.12

Flaws that present themselves in interprofessional collaboration stem from miscommunication that can result in overprescribing controlled or high alert medications, prescribing medications that the patient is unable to afford, and neglecting to consider proper monitoring requirements and drug interactions. This is further complicated by the current structure of the outpatient and community pharmacy settings, which can often be unconducive to partnerships with other members of the care team.

Although counseling is a required duty for these pharmacists, an environment built on metrics and other demands competing for time leads to ineffective counseling and limited time with each patient. Atop this time barrier, is the lack of privacy that the outpatient setting presents with.12

Although consistently represented in literature and patient narratives, barriers can be further addressed through awareness and attention to the therapeutic patient-provider relationship; trust and safety play a large role in this opportunity.

Strengthening the Therapeutic Relationship

With the goal of improving patient health outcomes, it is imperative that the patient be made the center of the decision-making process. When Rogers first modified the concept of the therapeutic relationship to be client-centered, he maintained that patient health outcomes depended on the demonstration of unconditional empathy and acceptance from the provider.6 This extends to trusting the patient to involve them in their care plan.

Giving the patient a chance to buy into their care plan is meant to provide them with intrinsic motivation and agency over their health outcomes. In the current era of holistic care, this extends to including the rest of the care team in decisions as well.

Presenting a united front of interprofessional collaboration among the care team members who interact with the patient has a positive effect on their health. Among individuals receiving treatment for depression, collaborative care proved to be more effective in antidepressant adherence and depressive outcomes compared to the standard patient education.13 Medication safety outcomes also improved.7

When strong interprofessional relationships within the community are formed, the access to resources that the patient has also increases and the care they receive expands. In a sampling of various countries, 37% of mental health conditions had comorbid physical chronic illnesses.14

In the United States, 7.6% of adults are diagnosed with a co-occurring substance use disorder and mental health conditions.1 With this level of prevalence, it is important that pharmacists are knowledgeable beyond which resources are available in the community.

Having an intimate familiarity of disease prevention and healthy behavior recommendations can be a useful tool when faced with individuals struggling with their current resource pool. Keeping up with current literature, such as Pharmacist’s Role in Public Health by ASHP, and having quick access to mental health resources, such as Mental Health America Screening Tools, is important in keeping up with the needs of the patient.15,16

Knowledge plays an important role in ensuring a patient feels comfortable trusting a pharmacist with their health. Having additional education and training related to the diseases and disorders present in the community is important to be able to meet the needs of the patient.

There is a higher likelihood of patient satisfaction and level of commitment to the therapeutic relationship when the patient perceives pharmacist expertise and their investment in the relationship.17 Having this breadth of knowledge also increases the likelihood that pharmacists will provide patients with needed resources, such as addiction treatments and care.18

As a long-term initiative, structural improvements need to be made to contribute to the longevity of the therapeutic relationship. Enterprise-wide adjustments can support this, such as advocating for scheduled time and space for patient consults, along with dedicated time in the form of pharmacist overlap to improve counseling services.

It also goes beyond individual corporations to systemic policy improvement. Strong examples of this include increasing prescribing power of the pharmacist and advocating for improved reimbursement structures by moving to a model based on the services provided and the outcome of the patient.19,20 Improving the pharmacist’s dedication to a patient's health and wellbeing at an individual level is important but adjustments to population-level policies have the capability of making a much larger impact.

Our health care system is not built to sustain the mental health crisis that currently exists. We are at a crucial point in determining how this system operates as more attention and resources are dedicated to how to fix it.

The CDC estimates that 8000 practitioners are needed to resolve this barrier to care in health professional shortage areas.4 Pharmacists have the ability to take ownership of the crucial role we play in mental health care for the benefit of the patient.

The base competencies by which our profession subscribes to enable us to build a strong and lasting therapeutic relationship with patients with mental health conditions. This will be a substantial marker in the evolution of elevating the role of the pharmacist.

About the Author

Author: Elise Moore, PharmD candidate, University of Minnesota College of Pharmacy, Class of 2025.

Preceptor: Ashley Sturm, PharmD, BCPS, Clinical Pharmacist, Mayo Clinic Medical Center-St. Mary’s Campus.

References

  1. National Alliance on Mental Illness. Mental health by the numbers. National Alliance on Mental Illness. 2023. https://www.nami.org/mhstats
  2. Health Resources & Services Administration. Health Workforce Shortage Areas Dashboard. Department of Health & Human Services. Accessed June 6, 2023. https://data.hrsa.gov/topics/health-workforce/shortage-areas
  3. DiPiro JT, et al. Pharmacy forecast 2023: strategic planning advice for pharmacy departments in hospitals and health systems. Am J Health-Syst Pharm. 2023;80:10-35.
  4. Terlizzi EP, Norris T. Mental health treatment among adults: United States, 2020. Center for Disease Control and Prevention. 2021. Accessed June 6th, 2023. https://stacks.cdc.gov/view/cdc/110593?__hstc=145536043.4b44870ec4a577029c49e44b73bd3bee.1661731200196.1661731200197.1661731200198.1&__hssc=145536043.2.1661731200199&__hsfp=3632212569&page=20?__hstc=145536043.4b44870ec4a577029c49e44b73bd3bee.1661731200196.1661731200197.1661731200198.1&__hssc=145536043.2.1661731200199&__hsfp=3632212569&page=19
  5. Saseen JJ, Ripley TL, Bondi D, Burke JM, Cohen LJ, McBane S, McConnell KJ, Sackey B, Sanoski C, Simonyan A, Taylor J. ACCP clinical pharmacist competencies. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy. 2017;37(5):630-6.
  6. Horvath AO, Luborsky L. The role of the therapeutic alliance in psychotherapy. Journal of consulting and clinical psychology. 1993 Aug;61(4):561.
  7. Bell S, McLachlan AJ, Aslani P, Whitehead P, Chen TF. Community pharmacy services to optimise the use of medications for mental illness: a systematic review. Aust New Zealand Health Policy. 2005;2:29. Published 2005 Dec 7. doi:10.1186/1743-8462-2-29
  8. Jónsdóttir H, Friis S, Horne R, Pettersen KI, Reikvam A, Andreassen OA. Beliefs about medications: measurement and relationship to adherence in patients with severe mental disorders. Acta Psychiatr Scand. 2009;119(1):78-84.
  9. Sansone RA, Sansone LA. Antidepressant adherence: are patients taking their medications?. Innov Clin Neurosci. 2012;9(5-6):41-46. doi:10.1111/j.1600-0447.2008.01279.x
  10. Rosen CE, Holmes S. Pharmacist's impact on chronic psychiatric outpatients in community mental health. Am J Hosp Pharm. 1978;35(6):704-708.
  11. Goodman CS, Smith TJ, LaMotte JM. A survey of pharmacists' perceptions of the adequacy of their training for addressing mental health-related medication issues. Ment Health Clin. 2018;7(2):69-73. Published 2018 Mar 23. doi:10.9740/mhc.2017.03.069
  12. Murphy AL, Phelan H, Haslam S, Martin-Misener R, Kutcher SP, Gardner DM. Community pharmacists' experiences in mental illness and addictions care: a qualitative study. Subst Abuse Treat Prev Policy. 2016;11:6. Published 2016 Jan 28. doi:10.1186/s13011-016-0050-9
  13. Vergouwen AC, Bakker A, Katon WJ, Verheij TJ, Koerselman F. Improving adherence to antidepressants: a systematic review of interventions. J Clin Psychiatry. 2003;64(12):1415-1420. doi:10.4088/jcp.v64n1203
  14. Daré LO, Bruand PE, Gérard D, et al. Co-morbidities of mental disorders and chronic physical diseases in developing and emerging countries: a meta-analysis. BMC Public Health. 2019;19(1):304. Published 2019 Mar 13. doi:10.1186/s12889-019-6623-6
  15. Cameron G, Chandra RN, Ivey MF, et al. ASHP Statement on the Pharmacist's Role in Public Health. Am J Health Syst Pharm. 2022;79(5):388-399. doi:10.1093/ajhp/zxab338
  16. MHA. Take a Mental Health Test. Mental Health America. 2023. Accessed June 26, 2023. https://screening.mhanational.org/screening-tools/
  17. Alghurair SA, Simpson SH, Guirguis LM. What elements of the patient-pharmacist relationship are associated with patient satisfaction?. Patient Prefer Adherence. 2012;6:663-676. doi:10.2147/PPA.S35688
  18. Hagemeier NE, Alamian A, Murawski MM, Pack RP. Factors associated with provision of addiction treatment information by community pharmacists. J Subst Abuse Treat. 2015;52:67-72. doi:10.1016/j.jsat.2014.11.006.
  19. Poh EW, McArthur A, Stephenson M, Roughead EE. Effects of pharmacist prescribing on patient outcomes in the hospital setting: a systematic review. JBI Database System Rev Implement Rep. 2018;16(9):1823-1873. doi:10.11124/JBISRIR-2017-003697
  20. Doucette WR, DeVolder R, Heggen T. Evaluation of financial outcomes under a value-based payment program for community pharmacies. J Manag Care Spec Pharm. 2021;27(9):1198-1208. doi:10.18553/jmcp.2021.27.9.1198
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