1. Introduction

1.1 Mental illness and stigma

Inequalities in health services delivery and utilization for people with mental illness has been widely documented.1 Subsequently this results in poorer outcomes for this population in regard to general health, such as circulatory diseases, mortality from natural causes, and access to interventions .2-4 Several issues have been identified as contributing to these disparities in health service access and delivery, including stigma.5-6Stigma associated with mental illness has been defined as negative attitudes formed on the basis of prejudice or misinformation that are triggered by markers of illness.1-5Illness markers include atypical behaviours, the types of medication prescribed and noticeable medication related adverse effects.5-7These markers allow for the continuation of stigma concerning people with mental illness, but they also allow community pharmacists to identify patients with a broad range of what are often unaddressed health related needs.1 Behavioural and mental disorders are estimated to account for 12% of the global burden of diseases. Mental health related medications account for >10% of all medications prescribed by general medical practitioners8, therefore, it is an inescapable fact that community pharmacists must interact with patients suffering from mental health problems.9 Mental illness is relevant to practising pharmacists who can play vital roles in the treatment of patients with mental illness.10 Throughout the latter half of the previous century, the diagnosis and pharmacological treatment of mental illness improved radically.9 1990-2000 was proclaimed the Decade of the Brain. to promote the study of disorders of the brain, including mental illnesses.11 Despite these advances, the stigma associated with mental illness remains a compelling negative feature in society.10 Unfortunately health care professionals, including pharmacists are not invulnerable to such harmful attitudes.9 Pharmacists attitudes toward mental illness and the mentally ill are extremely important because they can affect their professional interactions and clinical decisions.12-13 In addition, they could ultimately affect the delivery of pharmaceutical care which has been defined as the pharmacist assuming the responsibility for positive patient outcomes.14 Activities like medication counselling and monitoring of therapy have been documented to improve both satisfaction and adherence to drug therapy in patients with mental illness.15 It has been pointed out that pharmacists must become more involved in such activities for patients with mental illness.9

1.2 Optimising the use of medications for mental illness

Community care offers many advantages over institutional care; however, it can place extra demands on family, friends and primary health care practitioners.16 Health professionals have identified people with mental illness as the most challenging patients to manage.8 The quality and accessibility of community care for people with mental illness needs to be improved.17 The appropriate use of medicines plays an imperative role in the effective management of mental illness, nonetheless, there is evidence that psychotropic medicines are often used inappropriately.18-19 Elderly people are especially susceptible to the effects of psychotropic medicines, and may experience adverse effects such as cardio toxicity, confusion and unwanted sedation .8 Contributing factors to the high rates of non-compliance to psychotropic medicines include, psychosocial problems, the emergence of side effects, and the delayed onset of action of anti-depressant medication.20-21 Medical co-morbidity is also common, and polypharmacy increases the risk of medication misuse and drug-drug interactions.22

The World Health Organisation (WHO) has indicated that the inclusion of pharmacists as active members of the health care team can improve psychotropic medication use.23 The benefits of dynamically engaging mental health service users in their own management is supported by both clinical experience and research evidence.24 A systemic review of the role of pharmacists in mental health care, published in 2003, concluded that pharmacists can bring about improvements in the safe and effective use of psychiatric medicines.23 The wide range of pharmaceutical services provided by community pharmacists are potentially well suited to assisting patients and prescribers optimise the use of medications for mental illness.8

2. Method

2.1 Literature search strategy

Pubmed (1965-March 2010), International Pharmaceutical Abstracts (1970-March 2010), Embase (1974-March 2010), Cinahl (1981-March 2010) and Psychinfo (1972-March 2010) were searched using text words and MeSH headings including: community pharmacist.s, pharmacist.s, pharmaceutical care, pharmaceutical services, mental illness, mental disorders, stigma and mental illness, mentally ill persons, depression, schizophrenia, bipolar disorder, psychotic disorders, psychotropic drugs, antidepressive agents, benzodiazepines, anxiety agents and antipsychotic agents. ~550 abstracts were read. Reference lists of retrieved articles were checked for any additional relevant published material. Exclusion criteria included articles not published in English, no service provided by pharmacists, not relevant to mental illness, and studies and surveys that were carried out to evaluate pharmacist.s services in hospital inpatient or acute care settings. The literature search identified 88 papers that reported or discussed community pharmacist.s involvement in the care of patients with mental illness.

2.2 Inclusion criteria and review procedure

For section 3.1 of the discussion, studies and surveys conducted into the attitudes of community pharmacists toward mental illness and the impact of stigma were considered. The literature review procedure for section 3.2 of the discussion, which deals with optimising the use of medication for mental illness, differed from that of 3.1, as studies without control groups, results of postal surveys and qualitative interviews were excluded. Studies with a parallel control group that reported the provision of services by community pharmacists in community and residential aged care facilities were considered. This included trials specifically conducted for individuals with a mental illness, and studies of medication reviews and education initiatives to optimise the use of medication for mental illness. Papers that reported pharmacist.s interventions in nursing homes were included, because community pharmacists frequently provide services to nursing homes. Studies of pharmacist.s activities as part of multi-disciplinary teams were also included. The literature search identified 57 papers that reported or discussed community pharmacy services to optimise the use of medications for mental illness.

3. Discussion

3.1 Mental illness and stigma

While the views of the public9 and of certain health care professionals25 and health care students26-28 toward mental illness have been well documented over the years, there are limited numbers of investigations accessing community pharmacists and pharmacy student.s attitudes. Crimson et al.12 examined the attitudes of 250 baccalaureate pharmacy students toward mental illness, Phokeo et al.29 studied the outlook of 283 community pharmacists toward users of psychiatric medication, Cates et al.9 detailed the attitudes of community pharmacists toward both mental illness and the provision of pharmaceutical care to patients with mental illness, and Black et al.1 studied the satisfaction that patients with mental illness have with services provided by community pharmacists.

3.1.1 Community pharmacist.s attitudes toward patients with mental illness

In general, pharmacists express positive, unprejudiced attitudes toward mental illness,1, 9, 29, 30 and overall they show encouraging attitudes toward the provision of pharmaceutical care.9 Phokeo et al.29 reported that pharmacists feel uncomfortable inquiring about a patient.s use of psychiatric medication and discussing symptoms of mental illness compared to the medication and symptoms associated with cardiovascular problems. Pharmacists also monitor patients with mental disorders for compliance and adverse effects less frequently than patients with cardiovascular problems. Crimson et al.12 found an association between a personal or family history of mental illness and attitudes of pharmacists toward mental illness. Age and years in practice are also connected with attitudes toward providing pharmaceutical care to patients with mental illness. The older and more experienced pharmacists have more encouraging responses than their counterparts.9Pharmacists are of the opinion, however, that patients with mental illness do not receive adequate information about their medication from their physicians. These patients may also receive less attention from pharmacists compared to medically ill patients, which raises concerns that their drug-related needs are not being met.29

3.1.2 Patient.s attitudes toward community pharmacists

Consumers of mental health services generally have a positive perception of community pharmacists and their services, however, expectations are limited to standard pharmacy services, like providing patients with information about their medication and resolving prescription issues when dispensing medications.29 The majority of patients feel at ease while discussing their psychotropic medication and related illnesses with pharmacists.31 Clinically orientated services like working collaboratively with other health care providers, making dosing or treatment recommendations, monitoring response to treatment, and addressing the individuals physical and mental health needs have been found to be unavailable to patients.32 Patients with mental health problems, expectations of community pharmacists are low, and do not match the services that they can provide.33 Although stigma has been perceived to be similar with other health care professional, Black et al.1 revealed that 25% of patients with mental illness have experienced stigma at community pharmacies.

3.1.3 Substance misuse

The prevalence of coexisting substance misuse and mental illness (dual diagnosis) has increased over the past decade, and the indications are that it will continue to do so.15 A patient with both a mental illness and a substance misuse problem can face prejudice and stigma from health care professionals, who might question the capacity of dually diagnosed individuals to respond to care.34 A Canadian survey into the attitudes of community pharmacist.s toward mental illness showed that only 55% of respondents agreed that substance misuse is a mental health problem. This finding reflects the perception that addiction represents poor self control or is a self inflicted problem.29 Over recent years, the capacity to intervene pharmacologically in substance misuse has increased greatly, pharmacotherapy is now available for opiate, alcohol and nicotine misuse.19 Some psychiatric patients with comorbid substance abuse achieve stabilisation rapidly, furthermore, severe mental illness does not necessarily predict worse outcomes.35 Socio-economic and emotional aspects are the main challenges to recovery, and case management in the context of integrated community and residential services has been shown to increase medication compliance over time.36 The contribution that community pharmacists have in the management of substance abuse has been well documented.37 Most general psychiatrists are only in the position to give patients 5-10 minutes of brief advise or intervention regarding a substance misuse problem,38 whereas community pharmacist.s are easily accessible to the public and are in a central position to provide specific advice about substance misuse.37 Community pharmacists currently provide dispensing services to drug addicts,38 and they are also the first point of contact for people misusing substances who are not in touch with the substance misuse services.39

3.1.4 Overcoming the barriers created by stigma

Studies have indicated that patients prefer to go to the same pharmacy for their medication and other pharmacy needs and a significant number of patients favour to interact with the same pharmacist, which suggests that the relationship they have with their pharmacist plays an imperative role in their health and well being.1 A lack of privacy from failure to use an available private counselling room in the pharmacy contributes to patients feelings of discomfort regarding talking about their medication and their illness.31 Pharmacists are trained to educate and support patients regarding psychotropic medications, including how a drug works, monitoring for treatment response and adverse effects, and guiding patients through the process of stopping treatment, however, there are inconsistencies in the provision of these services.29 The potential for discrimination and stigma in community pharmacies has been well documented and initiatives to improve exposure of pharmacists to persons with mental illnesses in practice and in training has been suggested.23, 29 Pharmacists experience an increased level of discomfort in this therapeutic area as they receive inadequate undergraduate training in mental health.9 Adequate training in mental health is needed to improve the professional interactions of community pharmacists toward users of psychiatric medication.1

3.2 Optimising the use of medications for mental illness

Community pharmacists are one of the primary health care providers in the community and have the opportunity to influence patient.s perception of their mental illness. Patients are far less likely to adhere to medications for mental health problems outside the hospital setting. Community pharmacists can significantly contribute to optimising medication use in mental illness through counselling, 40-42 patient education and treatment monitoring, 43-36 medication review services, 30, 47-49 pharmacotherapy meetings with general medical practitioners, 50-54 delivering services to community mental health centres and outpatient clinics,55-57 improving the transfer of information between health care settings,58-60 and being active members of community mental health teams.61-63

3.2.1 Counselling services

In the Netherlands, three studies were carried out to highlight the impact of community pharmacist.s medication counselling sessions for people commencing non-tricyclic antidepressant therapy.40, 42 Intervention patients participated in three consecutive counselling sessions which lasted between 10 and 20 minutes each. They also received a take-home video that reiterated the importance of adherence. Throughout the counselling session, pharmacists informed patients about the appropriate use of their medications, which included, providing information about the benefits of taking the medication, informing patients about potential side effects, informing patients about the onset of action for antidepressant medication and explaining the crucial importance of taking their medication on a daily basis. Medication compliance was measured using an electronic pill container that recorded the time and frequency that the cover was opened.41 At the three month follow up the intervention patients had significantly more positive attitudes compared to the controls.40 At six months greater medication compliance was observed with the intervention patients that remained in the study25 55, also apparent improvements in symptoms were noted.41

Research on adherence shows that the patient.s knowledge and beliefs about the benefits of adhering to their medication regime plays a critical role in compliance.64 Non-adherence is not an irrational act but rather a product of poor communication.65 Patient compliance to health care recommendations is more likely when communication is optimal.66 The results of these studies indicated improvements in depressive symptoms,41 more positive attitudes,40 and better compliance to their medication.42 A limitation of this method was that the same pharmacist provided counselling services to both the intervention and the control group. As the intervention studied was multifactorial, it is inconclusive whether the three face-to-face counselling sessions or the take home video were primarily responsible for changes in drug attitude, adherence and the symptom scores.40-42

3.2.2 Patient education and treatment monitoring

Four studies have reported results from pharmacist conducted patient education and treatment monitoring services for people prescribed antidepressant medications in the United States.43-46 These services involved the pharmacist taking a medication history, providing information about the prescribed antidepressant medications, and conducting telephone and face-to-face follow-ups. In two of the investigations, one of which was controled43 and the other randomised controlled, 62 medication adherence was calculated by reviewing prescription dispensing data, and reported using an intention-to-treat analysis. Both studies also demonstrated that involvement of the pharmacist was associated with a decrease in the number of visits to other primary health care providers; however, statistical significance was only achieved in one of the studies. Improved adherence to antidepressant medication was reported in both studies, 43-44 although patient satisfaction was only evident in one.44 The other two studies were randomised controlled.45-46 One of the studies was conducted using a self administered health survey,45 while in the other study antidepressant adherence was measured by asking patients how many times a day they took their medication in the past month. The results obtained from these investigations45-46 showed that patients who were taking their medication at the six month follow-up exhibited better antidepressant compliance and improved symptoms. However, antidepressant adherence and depression symptoms scores were similar for both the intervention and control group.46 Given the high rates of antidepressant discontinuation during the first three months of treatment, pharmacists have a potentially crucial role in providing medicines information and conducting treatment monitoring for those patients at high risk of non-compliance. Studies need to be conducted to compare outcomes of pharmacist.s treatment monitoring of people commencing antidepressant medication and other health professionals monitoring.8 An investigation into the impact of nurses treatment monitoring, also demonstrated improved medication adherence.67

3.2.3 Medication management reviews

Pharmacist conducted medication management reviews are crucial in identifying potential medication related problems among people taking medications for mental illness.8 Medication review services provided by pharmacists comprise of comprehensive medication history taking, patient home interviews, medication regimen reviews, and patient education.68 A randomised controlled study of pharmacist conducted domiciliary medication reviews was carried out in the United States. The patients involved in the study were individuals living independently in the community that were identified to be at high risk of medication misadventure. The results showed a significant decline in the in the overall numbers and monthly costs of medication, however, there was no major difference in cognitive or affective functioning between the intervention and control group. The majority of patients were unwilling to follow the pharmacist.s recommendations to discontinue benzodiazepines and narcotic analgesics.47

The great potential of pharmacist conducted medication reviews for people with mental illness may not be limited to optimising the use of mental health medication.8 Physical health care for people with mental illness is generally less than adequate. This is caused by the tendency among health professionals to focus solely on the management of the mental illness among people with both mental and physical illnesses. Pharmacist conducted medication reviews may be a comprehensive strategy to improve medication use for both mental and physical illness.68

3.2.4 Medication management reviews in nursing homes

Older people who are cared for in nursing homes are arguably the most vulnerable patient group, and the useful contribution that pharmacists can make to the care of these patients has been documented.30 Older people are particularly sensitive to the effects of medication,69 regular use of psychotropic medication is associated with an increased risk of recurrent falls,70 and also long term usage is linked with tardive dyskinesia.71 Psychotropic medication use may also be connected with an increased rate of cognitive decline in dementia.72 The beneficial effects of psychotropic medication must be balanced against extrapyramidal and other side effects.73

In 1995 it was reported that psychotropic drug use in Australian nursing homes was 59%, although this figure has fallen in recent years.74 In Ireland, 19% of older people in nursing homes were reported to be taking phenothiazines,75 however, this figure is lower now following a tightening of the licensing indications of thiordazine. In the England, a study showed that 30% of residents in nursing homes were taking antipsychotics.76 Two studies have looked at the appropriateness of psychotropic medication prescribing in the United Kingdom. In Scotland antipsychotic medication use in nursing homes is 24%, it was found that 88% of these prescriptions were inappropriate if the United States criteria for use were applied. In England, 54% of prescriptions were found to be inappropriate according to the United States criteria.77 A study conducted in Denmark suggested that behavioural problems were a determinant for the use of antipsychotics and benzodiazepines, irrespective of the psychiatric diagnosis of the resident.78

A randomised controlled study of pharmacist-led multidisciplinary initiative to optimise prescribing in 15 Swedish nursing homes was carried out. The study involved pharmacists participating in multidisciplinary team meetings with nurses and physicians at regular intervals within a 12 month period. A significant decline in the use of antipsychotics, benzodiazepines and antidepressants by 19%, 37% and 59%, respectively was observed in the intervention facilities.79 A follow-up investigation of the same intervention and control facilities three years later indicated that the intervention facilities maintained a significantly higher quality of drug use, with far fewer residents being prescribed more than three drugs that could lead to confusion, not-recommended hypnotics and combinations of interacting drugs.48 An additional randomised controlled study showed that pharmacist.s medication reviews in residential care facilities demonstrated significant reductions in the number and cost of medications prescribed. 10.2% fewer residents were administered psychoactive medications and 21.3% fewer hypnotic medications. The impact of medication reviews on mortality was also measured and a noteworthy reduction was observed.49 One study indicated that one hour per week of a pharmacist.s time can make a significant contribution to patient care in nursing homes. It was found that this input was well received by nursing staff and prescribers and that general medical practitioners accepted the pharmacist.s advice in 78% of cases.30 Physician.s recognition was 91% in south Manchester, where 55% of interventions resulted in treatment modifications. Community pharmacist.s in Northamptonshire analysed prescriptions of nursing home residents and provided prescribing advice to general medical practitioners. The advice was accepted in 73% of cases and it was estimated that pharmacist involvement could give a 14% reduction in the cost of prescribing.69 A randomised controlled trial in 14 nursing homes in England showed that a brief medication review reduced the quantity of medication overall with no detriment to the mental and physical functioning of the patients.58 A reduction in the use of primary and secondary care resources by pharmacist medication review services has also been shown.80 The recommendations provided by pharmacists included stopping and starting medicines, generic substitution, switching to another medicine, dose modification, changes in administration frequency, formulation change and requests for laboratory tests or nurse monitoring.30 Almost 50% of the recommendations were to stop medication and 66% of these were due to the fact that there was no indication for the drug prescribed. This suggested that medication regimes were not reviewed. Conversely, initiation of a new drug made up 8% of recommendations, which implied that indications were present but not always treated76. Pharmacists have an important part to play in multi-disciplinary health teams and they must be integrated into any proposed models of care. Nursing home residents are a vulnerable group of patients who deserve the same high-quality clinical care as people of any age living at home.30

3.2.4 Pharmacotherapy interventions to optimise prescribing

Pharmacist.s educational visits to general medical practitioners have been shown to modify prescribing behaviour.54 Four studies have evaluated the impact of pharmacists educational visits to general medical practitioners to optimise the prescribing of benzodiazepines and other psychotropic medications prescribed for mental illness,50-53 two of which showed positive results.52-53 A cluster randomised controlled study carried out in the United States found that pharmacists educational visits to general medical practitioners were associated with a significant decline in the prescribing of potentially inappropriate psychotropic medications in intervention facilities.53 An Australian study of educational visits to general medical practitioners, conducted by three physicians and one pharmacist resulted in a noteworthy decline in the prescribing of benzodiazepines.52

In the Netherlands, groups of local pharmacists and general medical practitioners conduct inter-professional meetings to optimise prescribing. These pharmacotherapy meetings are undertaken as part of routine clinical practice. A cluster randomised study of pharmacotherapy meetings to discuss prescribing of antidepressant medications resulted in a 40% reduction in the prescribing of highly anticholinergic antidepressants, compared to a control group of practitioners that did not partake in these meetings39. The possible awareness of prescribing related issues generated by asking general medical practitioners to conduct a self-audit of their prescribing caused this overall reduction.52-53 Additionally, pharmacist.s initiatives to improve prescribing are most effective when both pharmacists and general medical practitioners have an opportunity to build rapport.39

3.2.5 Community mental health centres and outpatients clinics

Two studies were carried out to investigate the effect of pharmacist delivered services to community mental health centres and outpatient.s clinics.56-57 In a controlled trial, pharmacists managed patient cases in a community mental health centre in the United States. Significantly better personal adjustment scores were observed from patients receiving case management from a pharmacist in comparison to those receiving it from a nurse, social worker or psychologist.56The patients also rated themselves as healthier and were considerably less likely to seek help from other health care providers. The medication service provided allowed the pharmacist to adjust medication doses and dose timing, and prescribe or discontinue medications under supervision. The cost effectiveness of incorporating a pharmacist as part of the health care team was also measured. It was estimated that a 60% cost reduction can be achieved when medication monitoring is conducted by a pharmacists instead of a clinic psychiatrist. The pharmacist also performed more medication monitoring of patients per month than the clinic psychiatrist and had more contact with each individual patient .56

In Malaysia, a study of patients discharged from hospital after admission for relapse of schizophrenia, who were identified as having poor medication adherence were allocated to receive pharmacist medication counselling or standard care.57 The importance of compliance to medication was also reinforced by the patient.s psychiatrists at follow up visits. At the 12 month follow-up, patients receiving counselling from a pharmacist and who were exposed to daily or twice daily medication treatments, had significantly fewer relapses that required hospitalisation than patients receiving standard care.57

3.2.6 Integrated mental health services

The needs of people with recurrent, severe mental illness fluctuate over time and services must be coordinated, and be able to anticipate, prevent and respond to crisis. Integrated mental health services across primary and specialist services should promote early interaction and allow the provision of continuous care to meet patients needs.58 Prescribed medication is an important component in the successful management of mental illness. Accurate information should be transferred seamlessly between primary and secondary sectors to ensure the optimum care of these patients.59

The simple delivery of information to community pharmacists regarding drugs prescribed at discharge enables comparison with general medical practitioners prescriptions and any discrepancies can be followed up and resolved.82 Discrepancies that may occur can be described as any changes observed between supplies of prescribed drugs, including a wide spectrum of observed events.83 These can range from simple changes between supplies of prescribed drugs to more complex errors that might result in adverse reactions.60 This information transfer enables a cost-effective reduction in all unintentional discrepancies, including those judged to have significant adverse effects on patient care.58 An investigation that evaluated the impact of providing mental health patients with a pharmacist generated medication care plan at the time of discharge found that patients with care plans were less likely to be readmitted to hospital than those without. Information contained in the care plan included lists of discharge medications, a summary of the patient education that was provided, and the potential adverse effects that need to be assessed. Community pharmacists who received copies of the care plan were also more likely to identify medication related problems for the discharged mental health patients than those pharmacists who were not provided with copies of the care plan, however, the results from this study are not significantly significant.57Other methods of transferring information such as electronic transfer have the potential to be of value in this patient population.84 People with mental illness have complex needs which are not recognised by organised boundaries.58When discussing discharge and after-care in the community, medication management must be prioritised.85Mentally ill patients are vulnerable and medication is a vital part of their well being. It is therefore essential that an accurate transfer of information between care settings minimises the potentially harmful discrepancies that can occur. Community pharmacist.s interaction in this area could prevent such incidents.58

3.2.7 Community mental health teams

Most people with bipolar mood disorders and psychotic illnesses in the United Kingdom and Australia are managed by interdisciplinary community mental health teams (CMHTs).86 The potential benefits of greater involvement by pharmacists in CMHTs have been documented and debated for over 30 years.87-90 The majority of clinical team meetings conducted by CMHTs do not involve a pharmacist. A review of CMHTs in New South Wales found that just 1 in 5 had a designated pharmacist.91 Pharmaceutical care programs provided by phar