The Pharmaceutical Journal Vol 266 No 7133 p160-61
February 3, 2001

Articles

A training course in mental health care for community pharmacists

By Marilyn A. Ewan, PhD, MRPharmS, and Russell J. Greene, PhD, MRPharmS

The authors describe a training course to develop the role of community pharmacists in mental health care

A three-day training course in mental health was organised in the summer of 1998 for community pharmacists. It aimed to prepare three community pharmacists (study pharmacists) for their role in a mental health research project evaluating the contribution of community pharmacists to the community mental health team (CMHT), a study principally funded by Bexley and Greenwich health authority. Because the training course was felt to be relevant to all community pharmacists with an interest in psychiatry, it was made available to pharmacists not involved in the study free of charge.

The key objectives were:

To provide community pharmacists with up-to-date basic knowledge on anxiety, depression, mania and, particularly, schizophrenia

To inform community pharmacists about the composition and the role of CMHTs

To develop community pharmacists’ communication skills

To promote an understanding, from a patient’s perspective, of the needs of the long-term mentally ill and the role of medicines in their lives

Design and organisation

A brief summary of the course is given in the Panel. (Copies of the full programme are available on request.)

The CRISIS criteria developed by Dunn and Hamilton,¹ which describe how such courses should be devised, were considered in the preparation of the training course. CRISIS is a mnemonic for: Convenient, Relevant, Individual, Self-assessment, Inexpensive, Systematic. According to the CRISIS criteria, a three-day course was appropriate. Evening sessions, although perhaps convenient for community pharmacists since they would not need to book locum cover, might be inconvenient to run. Adequate time was given between training days to allow locum cover to be obtained. The course contents were designed to meet the needs of the participants partly by obtaining opinions from two independent hospital psychiatric pharmacists. The contents were based on the results of a questionnaire posted to 94 community pharmacists (May-August, 1997; 36 respondents), interviews with community pharmacists (October–November, 1997; three interviewees) and two focus groups involving 12 community pharmacists (December, 1997).

A community pharmacist training programme devised for a Liverpool-based mental health project2 also provided some ideas. The training days were systematically constructed (the only exception being day 2, when for unavoidable reasons, drug treatment of depression preceded symptoms, aetiology and prognosis).

Format The course was held at the pharmacy department of King’s College London on three non-consecutive days. Presentations were made by professional speakers, mainly from outside King’s College. They included a psychiatric hospital pharmacist, a representative from the information department at the voluntary self-help organisation Mind (National Association for Mental Health), a mental health social worker who was also a care manager, three community psychiatric nurses, a former patient, a pharmaceutical mental health consultant and a senior lecturer in clinical pharmacy at King’s College London. The social worker and the psychiatric nurses were mental health workers from the CMHT with which we were liaising. The pharmaceutical mental health consultant was a key figure in mental health who had conducted a mental health study in Liverpool between 1991 and 1993 involving community pharmacists liaising with the CMHT.^2-4

Course content and structure

Day 1

Welcome and course introduction (0.75h)

Schizophrenia - aetiology, clinical features, diagnosis (1h)

Schizophrenia - drug treatment (1.5h)

Schizophrenia - case studies (1.25h)

Day 2

Mania - clinical features, treatment (1h)

Depression - drug treatment (1h)

Depression - clinical features (1.25h)

Voluntary organisations and non-drug management (1.25h)

A patient’s perspective (1h)

Communication skills (1h)

Day 3

Community care - National Health Service and Community Care Act, care programme approach, community mental health teams, mental health day centres and depot clinics (1h)

Communication and domiciliary visiting - the role of the community psychiatric nurse (1h)

Anxiety - clinical features, treatment (1.25h)

Community care - social services departments, the Mental Health Act 1983 (1.25h)

Self-assessment and patient-specific care plans (0.5h)

As well as informal presentations with opportunities for participation and feedback, there were case studies and workshops. Anderson et al used “brainstorming” to generate workshop discussion in the training needs analysis for future community pharmacist involvement in extended roles.⁵ The process yielded many ideas, some of which were subsequently rejected. This approach was also used repeatedly by some tutors during this course to stimulate thought and active involvement.

Participants assessed each day using course evaluation forms (copies available on request), which were completed anonymously. These revealed a positive response to the training course. On the final day there was also a self-assessment of knowledge acquired (copies available on request) which provided the participants with the opportunity to identify their own weaknesses. Answer sheets were subsequently distributed.

Content Appropriate and sufficient training is likely to be a prerequisite for carrying out extended roles so it was important to tailor the course to the training needs of community pharmacists. CMHT members were included as presenters because, as shown by the postal survey previously mentioned, 61 per cent of the 36 respondents were ignorant of the CMHT or its composition (eg, 46 per cent believed a community pharmacist was a member and 86 per cent, a general practitioner). The one-to-one interviews had revealed that for community pharmacists to fulfil roles as CMHT members, they believed they needed training in the following key areas:

Types of mental illness

Pharmacology and drug therapy

Counselling skills

Communication skills

The focus groups had indicated a requirement for certain aspects of training (ie, communication skills, clinical knowledge and knowledge about CMHTs, its roles and members). In addition, confusion between the terms “keyworker” and “careworker” was evident throughout.

The course’s communication skills workshop was a role-playing exercise, demanding the community pharmacists’ active participation. Effective communication is essential for achieving a good relationship between patients and health professionals. Ley⁶ asserted that one factor in communicating effectively with any patient was the need to convey information in a comprehensible form. The role-playing exercise helped to illustrate this.

A former patient led one session. As a recovered manic-depressive, he talked about his illness and how community pharmacists could help. The aim was to promote an understanding of what mental illness meant from a patient’s perspective, and the role of medicines in patients’ lives. The representative from Mind was chosen to explain the services this voluntary organisation offered to patients. A hospital psychiatric pharmacist (from the Maudsley hospital, London) was chosen as the most appropriate person to discuss medication review.

The proposed contents were reviewed by the project supervisor, the project steering group and two hospital psychiatric pharmacists. It was confirmed that the commonest severe mental illnesses were being covered, and that the community pharmacists would be given perspectives from both primary and secondary care, which would be expected to enhance their understanding of mental health services.

It is interesting to note that a study to investigate the training priorities of 237 general practitioners in mental health care⁷ revealed training needs different from those of community pharmacists, due in part to different professional responsibilities. The needs of greatest priority in general practice were increased knowledge of psychiatric emergencies (51 per cent), somatisation (48 per cent) and counselling skills (46 per cent). Mental health promotion was the least important (15 per cent).

Accreditation of course To enhance credibility and give the course wider appeal, College of Pharmacy Practice accreditation was obtained. A certificate of course completion was issued to participants.

Sponsorship and publicity The course was sponsored by Zeneca Pharmaceuticals. In order to attract other interested community pharmacists, the researcher initially wrote to two pharmaceutical advisers of two neighbouring health authorities, offering the course for a low fee if the health authorities could cover locum and travel expenses. However, none could be sent. Subsequently, the course fee was waived and participants were found via pharmaceutical advisers and advertisements in The Pharmaceutical Journal and Chemist & Druggist. Twelve community pharmacists telephoned the researcher requesting a place and seven eventually attended (in addition to the three study pharmacists).

Participants

All seven non-study pharmacists attended the first and second training days; six of them attended the third. Four of the pharmacists who attended were male, including two study pharmacists. Two study pharmacists attended all three days; one of them was unable to attend day 1. The then Bexley and Greenwich health authority pharmaceutical adviser attended the morning sessions of all three training days to emphasise the importance of the training course.

Data were collected from six non-study pharmacists on the first day to establish what type of community pharmacists attended and why. Statistical analysis was not appropriate due to the small number; they were also a self-selected group of pharmacists and hence probably did not represent the average community pharmacist. For this reason, general conclusions cannot be inferred from the data. Four of the non-study pharmacists were female and the year of registration ranged from 1977 to 1992. Three worked in large multiples (including one in-store) and three in independent pharmacies. The pharmacists were locums (1), managers (2), both a locum and a manager (1), a pharmacy contractor (1) or another type of pharmacist. Five worked in the same pharmacy each day. They worked between 37.5 and 55 hours per week. Some were preparing for their involvement in providing extended mental health care in various community settings, including residential homes and half-way homes. Some attended the course in preparation for collaborative work with mental health professionals.

Outcome

Positive comments from participants on the course evaluation forms indicated that the objectives of the course were attained. Participants felt that the training days were appropriate. The fact that the course was free may have biased the expectations of the community pharmacists. Had the course not been free, the participants may have had higher expectations and may have been more critical.

It was clear that weekday training sessions were convenient and appropriate for these community pharmacists and they were given sufficient time to book locum cover. Pharmacists were very much aware that, with the changes in community care legislation, their involvement with the long-term mentally ill is inevitable. For community pharmacists to be equipped for these roles, which may involve advising staff as well as patients, there may be a need for relevant postgraduate training. The innovative mix of tutors and teaching styles possibly made the course particularly attractive to participants. There was also a clear advantage in having full-day sessions, and some pharmacists were fully prepared to commit themselves to that time. Although this course was primarily designed for the study pharmacists, the programme was found to be applicable to all the community pharmacists interested in psychiatry who attended. Such a course could not ensure complete competency, but it was an effective means of improving pharmacists’ knowledge and skills and identifying their weaknesses.

The mental health research project began in December, 1998, and ended in October, 1999. The study pharmacists were sent a questionnaire and asked a closed question to indicate how helpful the training course was. All thought that the course was “very helpful” and informative and that it prepared them for their role in the study.

ACKNOWLEDGMENTS The authors would like to thank the speakers who contributed to the course and the pharmacists who attended. In addition, thanks are due to the three study pharmacists Tony Andrews, Amerjeet Mudan and Jon Wood for their contribution to the main study following their participation in the course. They also thank Bexley and Greenwich health authority for funding the research project and Zeneca Pharmaceuticals for sponsoring the course.

References

1. Dunn WR, Hamilton DD. Determining the continuing education priorities for pharmacists. Pharm J 1986;237:225-8.

2. Donoghue J. Report on a pharmaceutical facilitation project in community mental health services: 1991–93. Liverpool Family Health Services Authority. FHS Development Fund. 1994.

3. Donoghue J. Problems with psychotropic medicines in the community. Pharm J 1993;251:350-2.

4. Aldridge A, Dingwall R, Watson P. Evaluation of two pharmaceutical care programmes for people with mental health problems in the community. Discussion paper No 96/03. Trent Institute for Health Services Research. Universities of Leicester, Nottingham and Sheffield. 1996.

5. Anderson C, Thomson V, Wilson P. Training needs analysis for community pharmacists in north-west Thames region. Pharm J 1993;250: 387-9.

6. Ley P. Communicating with patients. Improving communication, satisfaction and compliance. London: Chapman & Hall; 1988.

7. Kerwick S, Jones R, Mann A, Goldberg D. Mental health care training priorities in general practice. Br J Gen Pract 1997;47:225-7.

At the time of the project, Dr Ewan was a postgraduate research pharmacist at King’s College London, where Dr Greene was head of the Pharmacy Practice Group. Correspondence to Dr Ewan (e-mail malewan@hotmail.com)

A training course in mental health care for community pharmacists
By Marilyn A. Ewan, PhD, MRPharmS, and Russell J. Greene, PhD, MRPharmS
The authors describe a training course to develop the role of community pharmacists in mental health care
A three-day training course in mental health was organised in the summer of 1998 for community pharmacists. It aimed to prepare three community pharmacists (study pharmacists) for their role in a mental health research project evaluating the contribution of community pharmacists to the community mental health team (CMHT), a study principally funded by Bexley and Greenwich health authority. Because the training course was felt to be relevant to all community pharmacists with an interest in psychiatry, it was made available to pharmacists not involved in the study free of charge. The key objectives were: To provide community pharmacists with up-to-date basic knowledge on anxiety, depression, mania and, particularly, schizophrenia To inform community pharmacists about the composition and the role of CMHTs To develop community pharmacists’ communication skills To promote an understanding, from a patient’s perspective, of the needs of the long-term mentally ill and the role of medicines in their lives
Design and organisation A brief summary of the course is given in the Panel. (Copies of the full programme are available on request.) The CRISIS criteria developed by Dunn and Hamilton,¹ which describe how such courses should be devised, were considered in the preparation of the training course. CRISIS is a mnemonic for: Convenient, Relevant, Individual, Self-assessment, Inexpensive, Systematic. According to the CRISIS criteria, a three-day course was appropriate. Evening sessions, although perhaps convenient for community pharmacists since they would not need to book locum cover, might be inconvenient to run. Adequate time was given between training days to allow locum cover to be obtained. The course contents were designed to meet the needs of the participants partly by obtaining opinions from two independent hospital psychiatric pharmacists. The contents were based on the results of a questionnaire posted to 94 community pharmacists (May-August, 1997; 36 respondents), interviews with community pharmacists (October–November, 1997; three interviewees) and two focus groups involving 12 community pharmacists (December, 1997). A community pharmacist training programme devised for a Liverpool-based mental health project2 also provided some ideas. The training days were systematically constructed (the only exception being day 2, when for unavoidable reasons, drug treatment of depression preceded symptoms, aetiology and prognosis). *Format* The course was held at the pharmacy department of King’s College London on three non-consecutive days. Presentations were made by professional speakers, mainly from outside King’s College. They included a psychiatric hospital pharmacist, a representative from the information department at the voluntary self-help organisation Mind (National Association for Mental Health), a mental health social worker who was also a care manager, three community psychiatric nurses, a former patient, a pharmaceutical mental health consultant and a senior lecturer in clinical pharmacy at King’s College London. The social worker and the psychiatric nurses were mental health workers from the CMHT with which we were liaising. The pharmaceutical mental health consultant was a key figure in mental health who had conducted a mental health study in Liverpool between 1991 and 1993 involving community pharmacists liaising with the CMHT.^2-4	Course content and structure *Day 1* Welcome and course introduction (0.75h) Schizophrenia - aetiology, clinical features, diagnosis (1h) Schizophrenia - drug treatment (1.5h) Schizophrenia - case studies (1.25h) *Day 2* Mania - clinical features, treatment (1h) Depression - drug treatment (1h) Depression - clinical features (1.25h) Voluntary organisations and non-drug management (1.25h) A patient’s perspective (1h) Communication skills (1h) *Day 3* Community care - National Health Service and Community Care Act, care programme approach, community mental health teams, mental health day centres and depot clinics (1h) Communication and domiciliary visiting - the role of the community psychiatric nurse (1h) Anxiety - clinical features, treatment (1.25h) Community care - social services departments, the Mental Health Act 1983 (1.25h) Self-assessment and patient-specific care plans (0.5h)

As well as informal presentations with opportunities for participation and feedback, there were case studies and workshops. Anderson et al used “brainstorming” to generate workshop discussion in the training needs analysis for future community pharmacist involvement in extended roles.⁵ The process yielded many ideas, some of which were subsequently rejected. This approach was also used repeatedly by some tutors during this course to stimulate thought and active involvement. Participants assessed each day using course evaluation forms (copies available on request), which were completed anonymously. These revealed a positive response to the training course. On the final day there was also a self-assessment of knowledge acquired (copies available on request) which provided the participants with the opportunity to identify their own weaknesses. Answer sheets were subsequently distributed. *Content* Appropriate and sufficient training is likely to be a prerequisite for carrying out extended roles so it was important to tailor the course to the training needs of community pharmacists. CMHT members were included as presenters because, as shown by the postal survey previously mentioned, 61 per cent of the 36 respondents were ignorant of the CMHT or its composition (eg, 46 per cent believed a community pharmacist was a member and 86 per cent, a general practitioner). The one-to-one interviews had revealed that for community pharmacists to fulfil roles as CMHT members, they believed they needed training in the following key areas: Types of mental illness Pharmacology and drug therapy Counselling skills Communication skills The focus groups had indicated a requirement for certain aspects of training (ie, communication skills, clinical knowledge and knowledge about CMHTs, its roles and members). In addition, confusion between the terms “keyworker” and “careworker” was evident throughout. The course’s communication skills workshop was a role-playing exercise, demanding the community pharmacists’ active participation. Effective communication is essential for achieving a good relationship between patients and health professionals. Ley⁶ asserted that one factor in communicating effectively with any patient was the need to convey information in a comprehensible form. The role-playing exercise helped to illustrate this. A former patient led one session. As a recovered manic-depressive, he talked about his illness and how community pharmacists could help. The aim was to promote an understanding of what mental illness meant from a patient’s perspective, and the role of medicines in patients’ lives. The representative from Mind was chosen to explain the services this voluntary organisation offered to patients. A hospital psychiatric pharmacist (from the Maudsley hospital, London) was chosen as the most appropriate person to discuss medication review. The proposed contents were reviewed by the project supervisor, the project steering group and two hospital psychiatric pharmacists. It was confirmed that the commonest severe mental illnesses were being covered, and that the community pharmacists would be given perspectives from both primary and secondary care, which would be expected to enhance their understanding of mental health services. It is interesting to note that a study to investigate the training priorities of 237 general practitioners in mental health care⁷ revealed training needs different from those of community pharmacists, due in part to different professional responsibilities. The needs of greatest priority in general practice were increased knowledge of psychiatric emergencies (51 per cent), somatisation (48 per cent) and counselling skills (46 per cent). Mental health promotion was the least important (15 per cent). *Accreditation of course* To enhance credibility and give the course wider appeal, College of Pharmacy Practice accreditation was obtained. A certificate of course completion was issued to participants. *Sponsorship and publicity* The course was sponsored by Zeneca Pharmaceuticals. In order to attract other interested community pharmacists, the researcher initially wrote to two pharmaceutical advisers of two neighbouring health authorities, offering the course for a low fee if the health authorities could cover locum and travel expenses. However, none could be sent. Subsequently, the course fee was waived and participants were found via pharmaceutical advisers and advertisements in The Pharmaceutical Journal and Chemist & Druggist. Twelve community pharmacists telephoned the researcher requesting a place and seven eventually attended (in addition to the three study pharmacists). Participants All seven non-study pharmacists attended the first and second training days; six of them attended the third. Four of the pharmacists who attended were male, including two study pharmacists. Two study pharmacists attended all three days; one of them was unable to attend day 1. The then Bexley and Greenwich health authority pharmaceutical adviser attended the morning sessions of all three training days to emphasise the importance of the training course. Data were collected from six non-study pharmacists on the first day to establish what type of community pharmacists attended and why. Statistical analysis was not appropriate due to the small number; they were also a self-selected group of pharmacists and hence probably did not represent the average community pharmacist. For this reason, general conclusions cannot be inferred from the data. Four of the non-study pharmacists were female and the year of registration ranged from 1977 to 1992. Three worked in large multiples (including one in-store) and three in independent pharmacies. The pharmacists were locums (1), managers (2), both a locum and a manager (1), a pharmacy contractor (1) or another type of pharmacist. Five worked in the same pharmacy each day. They worked between 37.5 and 55 hours per week. Some were preparing for their involvement in providing extended mental health care in various community settings, including residential homes and half-way homes. Some attended the course in preparation for collaborative work with mental health professionals. Outcome Positive comments from participants on the course evaluation forms indicated that the objectives of the course were attained. Participants felt that the training days were appropriate. The fact that the course was free may have biased the expectations of the community pharmacists. Had the course not been free, the participants may have had higher expectations and may have been more critical. It was clear that weekday training sessions were convenient and appropriate for these community pharmacists and they were given sufficient time to book locum cover. Pharmacists were very much aware that, with the changes in community care legislation, their involvement with the long-term mentally ill is inevitable. For community pharmacists to be equipped for these roles, which may involve advising staff as well as patients, there may be a need for relevant postgraduate training. The innovative mix of tutors and teaching styles possibly made the course particularly attractive to participants. There was also a clear advantage in having full-day sessions, and some pharmacists were fully prepared to commit themselves to that time. Although this course was primarily designed for the study pharmacists, the programme was found to be applicable to all the community pharmacists interested in psychiatry who attended. Such a course could not ensure complete competency, but it was an effective means of improving pharmacists’ knowledge and skills and identifying their weaknesses. The mental health research project began in December, 1998, and ended in October, 1999. The study pharmacists were sent a questionnaire and asked a closed question to indicate how helpful the training course was. All thought that the course was “very helpful” and informative and that it prepared them for their role in the study. ACKNOWLEDGMENTS The authors would like to thank the speakers who contributed to the course and the pharmacists who attended. In addition, thanks are due to the three study pharmacists Tony Andrews, Amerjeet Mudan and Jon Wood for their contribution to the main study following their participation in the course. They also thank Bexley and Greenwich health authority for funding the research project and Zeneca Pharmaceuticals for sponsoring the course.

1.	Dunn WR, Hamilton DD. Determining the continuing education priorities for pharmacists. Pharm J 1986;237:225-8.
2.	Donoghue J. Report on a pharmaceutical facilitation project in community mental health services: 1991–93. Liverpool Family Health Services Authority. FHS Development Fund. 1994.
3.	Donoghue J. Problems with psychotropic medicines in the community. Pharm J 1993;251:350-2.
4.	Aldridge A, Dingwall R, Watson P. Evaluation of two pharmaceutical care programmes for people with mental health problems in the community. Discussion paper No 96/03. Trent Institute for Health Services Research. Universities of Leicester, Nottingham and Sheffield. 1996.
5.	Anderson C, Thomson V, Wilson P. Training needs analysis for community pharmacists in north-west Thames region. Pharm J 1993;250: 387-9.
6.	Ley P. Communicating with patients. Improving communication, satisfaction and compliance. London: Chapman & Hall; 1988.
7.	Kerwick S, Jones R, Mann A, Goldberg D. Mental health care training priorities in general practice. Br J Gen Pract 1997;47:225-7.