Hospital Pharmacist
Vol 11 No 2 p74-75
February 2004

My career as ... a specialist mental health pharmacist

By Wendy Davies, MRPharmS, BPharm(Hons), DipClinPharm, MCMHP

Around 400 pharmacists in the UK are thought to work primarily or wholly in the mental health field. Having been a mental health pharmacist for twenty of my thirty years in the profession, I can confidently state that I have always enjoyed my role. It can be humbling when someone explains to you what is going on inside their head, often a painful, private and disturbing experience. It can also be distressing to be the health care professional hearing this information, one of the unique challenges of mental health pharmacy. But mental health pharmacy also offers a great sense of fulfilment, when the knowledge of the pharmacist makes a positive contribution to someone’s care.

This article will describe the role of the specialist psychiatric or mental health pharmacist. However, it is important to remember that mental illness is common: more than one in three adults will suffer a mild to moderate depressive illness at some stage of their life. The incidence of schizophrenia and bipolar affective disorder is one per cent, which is the same as epilepsy. In our general practice as pharmacists we will all face patients with mental illness and we should be aware of the special issues of these patients and their medicines.

Pharmacy services

The pharmaceutical input into the provision of mental health services varies widely across the country. This can range from a sole pharmacist in a district general hospital without specialist training, to a department within a psychiatric hospital, where there can be a number of pharmacists and technicians providing the service.

Our patients will be with us for most of their lives. The journey they take with the mental health services will be lifelong. Pharmacists have an important role to play at the various stages of this journey.

Pharmacists generally meet patients for the first time following an admission to hospital.There are a number of contributions a pharmacist can make at the inpatient stage.

Admission On admission patients should be seen by a pharmacist so that a drug review can be performed and the patient can be given any information that they require. This is becoming more important as the National Institute for Clinical Excellence guidelines state that patients (or carers) should be making informed choices about the medicines that are being prescribed. It is also useful to talk to the patient about any other medicines they may be taking — sometimes patients find it easier to talk to pharmacists than to doctors.

Multidisciplinary team meeting The best opportunity for contributing to patient care is attendance at the multidisciplinary team ward round or meeting which is normally held weekly. This meeting is attended by the consultant, junior medical staff, hospital nursing staff, community psychiatric nurses, social workers, occupational therapists, pharmacists and sometimes psychologists. It is where decisions are made about the patient’s care and it is a place where pharmacists can ensure that the patient is getting the correct treatment. The majority of our input is about mental health drug therapy, but we also have a great deal of expertise in the non-psychiatric medicines that patients may be taking and can offer valuable advice.

Discharge Once the patient’s condition has improved and they are heading towards discharge, it is important for the pharmacist to be involved in the discharge care planning. This can involve talking about concordance and compliance, talking to carers about the medicines and liaising with GPs and community pharmacists in primary care.

Community mental health teams It is important for the pharmacist to be involved with community mental health teams (CMHTs). At Cardiff, two of the CMHTs have a designated pharmacist — this is the same pharmacist who attends the ward round so that patients and staff benefit from the continuity. We plan to extend this to all the CMHTs. We are setting up clozapine and high-dose antipyschotic clinics with the CMHTs with the intention that a pharmacist will spend one day a week there. The plan is that the doctor, nurse and pharmacist will work together. Nursing staff will take physical measurements such as weight, blood pressure, blood glucose, cholesterol, etc. The doctor will assess the patient’s mental state and the pharmacist will be there to assess and advise on medicines and their side-effects. At present this works in different ways in different clinics — in some the pharmacist sees the patient alone after they have been seen by the doctor, in others the doctor and pharmacist see the patient together. Pharmacists are also involved in lithium clinics and depot injection clinics in hospital and community settings.

Medication education group Another important role pharmacists have on the ward and in other settings is the establishment of a medication education group where patients can come together as a group to talk about their drug therapy. This can be a challenging situation, as the pharmacist can often face lengthy complaints about the side-effects of drugs. I think it is important for patients to have this forum to talk about their medicines, and it can lead to better understanding.

Medicines information Providing medicines information is also an important role. At Cardiff I have been lucky enough to be able to convert one of the rooms within the department to a dedicated medicines information room. We now have a number of computers with access to the trust’s intranet, Medline, Embase, Ovid, the British National Formulary, Micromedex, UK Medicines Information website, etc, to provide up-to-date information. We are hoping in the future to establish a helpline. There are also plans to use the room for patient counselling with information leaflets, television and video.

Teaching Education is a pivotal role of the psychiatric pharmacist. We should be involved in the teaching of nurses, medical students and pharmacists at undergraduate level where we can talk about both the presentation of psychiatric illness and the pharmacological treatments. It is imperative that students have a basic understanding of how the brain works, what is going wrong in different mental illnesses and how the drugs affect systems resulting in both the therapeutic effects and the side-effects of the drugs. We should also be involved with teaching at ward level and at postgraduate level.

Carer groups and charities One of the most rewarding aspects of the job for me is my involvement with carer groups. Carers seem to be given little information when their friends and relatives are admitted to an acute psychiatric unit. This may be because the information is not available, or they are unable to take it on board at such a distressing time. It is satisfying talking to, for example, the parents of a young man who has just been given a diagnosis of schizophrenia, and to be able to explain what the drugs are for, how they work, what the side-effects are likely to be and how we can minimise them.

It is also rewarding working with the various charitable organisations and voluntary or self-help groups such as Hafal (formerly the National Schizophrenia Fellowship), MIND, Manic Depression Fellowship, Depression Alliance, etc. Again when working with these groups it becomes evident that patients are not given the information they need to make informed choices and a pharmacist is ideally suited to provide this advice. We also spend much of our time correcting misinformation.

Postgraduate study

A good knowledge of psychopharmacology is essential to practice and for teaching psychiatric pharmacy. Having spoken to, and taught, numerous newly qualified pharmacists this seems to be an area that is not as well catered for as it could be on some undergraduate courses. However, for anyone interested in mental health, there are many courses available at postgraduate level to fill this gap. Aston University runs both a certificate in psychiatric therapeutics and a diploma in psychiatric pharmacy which will give the pharmacist all the skills needed to fulfil the role of psychiatric pharmacist.

The British Association of Psychopharmacology (BAP) provide excellent courses in psychopharmacology and also runs a certificate which pharmacists can now enrol on.
www.bap.org.uk

Specialist organisations

United Kingdom Psychiatric Pharmacy Group (UKPPG)

website www.ukppg.co.uk
The UKPPG provides an excellent support network for both pharmacists and technicians with an interest in mental health. This is a group where people can discuss mental health pharmacy issues and it holds a weekend conference annually. Details of what the UKPPG provides can be found on their website. Pharmacy technicians who work in the mental health field are supported by the United Kingdom Mental Health Pharmacy Technicians Network.

College of Mental Health Pharmacists (CMHP)

website more
An exciting development in the last couple of years has been the establishment, by the UKPPG, of the College of Mental Health Pharmacists. To become a member, pharmacists must have spent a number of years working in the field of mental health. A portfolio must be prepared and finally the candidate must pass a viva to obtain membership. This process has filled many psychiatric pharmacists with dread, but 20 mental health pharmacists, myself included, have already been through the process and are glad they did it. Pharmacists who are members of the college have the title specialist mental health pharmacist, and it is hoped this qualification will promote the establishment of consultant pharmacist posts.

Future developments

The most exciting development at the moment is supplementary prescribing. It is hoped that this may ultimately lead to independent prescribing. I think this is an incredible opportunity for all pharmacists, but particularly for those working in the mental health field. We are in the right place to take on this task, and my hope is that one day soon, the doctor will recommend an antipsychotic, and the pharmacist, in consultation with the patient, will decide which antipsychotic to prescribe.

Conclusions

The qualities of a good mental health pharmacist include being caring, understanding and empathic, and this is supported by a knowledge of psychopharmacology. A career as a psychiatric pharmacist is often not seen to be as “sexy” as maybe a renal or an ITU pharmacist, but I hope this article shows how exciting, rewarding and challenging being a specialist mental health pharmacist can be.