15 Pharmacy and Collaborative Practice in Mental Health Care
Learning Objectives
- Describe the role of Pharmacists in Mental Health Care
- Identify medication-related considerations in Mental Health Treatment including common side effects and adherence to treatment
- Examine the challenges and responsibilities of pharmacists in Mental Health Care
- Discuss the relationship between Substance Use, mental Health, and pharmacotherapy
Introduction
This chapter will provide an overview of the role of pharmacists as part of the multidisciplinary team (MDT) within mental health services. Pharmacists play an important role in mental health care. Pharmacotherapy (the use of medicines to treat health conditions) is an important part of mental health treatment and management. Approximately 18% of Australians, or 4.8 million people, filled a prescription related to mental health in the year 2022-2023 (AIHW 2024).
In Australia, pharmacists will work within hospitals, as well as in the community, to support people with accessing and managing medication as well as any medication related problems. This chapter will briefly introduce the role of pharmacy within mental health care as well as some of the medication-related considerations for supporting service users with mental health concerns.
The role of pharmacists in Australian mental health care
Pharmacists are a registered profession, like many others, and are required to meet certain standards regarding knowledge and skills in order to practice in Australia. Within Australia, they also have to maintain transparency about any criminal charges or recorded offences with Australia’s regulatory body (the Australian Health Practitioner’s Regulatory Agency) (AHPRA 2024).
Regulatory Standards and Mandatory Reporting for Pharmacists in Australia
Standards Applying to Pharmacists
Pharmacists in Australia must adhere to professional standards and regulatory requirements set by the Pharmacy Board of Australia. These standards ensure that pharmacists maintain the necessary knowledge, skills, and ethical conduct to provide safe and effective healthcare services.
Key standards include:
- Pharmacy Criminal History Registration Standard (2015)
- Registration Standard: Continuing Professional Development (2015)
- AHPRA Shared Code of Conduct (2022)
For the most up-to-date regulations, refer to the Pharmacy Board of Australia at www.pharmacyboard.gov.au.
Mandatory Reporting Requirements
In some States and Territories, pharmacists are legally required to make mandatory notifications to the appropriate department or agency in cases of suspected harm, abuse, or neglect.
It is essential for both students and practicing professionals to be aware of their specific state or territory’s mandatory reporting obligations. The Australian Institute of Family Studies (AIFS) provides a resource sheet outlining these legal responsibilities.
📌 Further Guidance: AIFS Mandatory Reporting Resource (AIFS, 2024)
Approximately 20,000 registered pharmacists are employed within community pharmacies (The pharmacy guild of Australia, 2024). Due to the high proportion of Australian’s utilising mental health prescriptions, pharmacists hold an important role in supporting the community to manage their mental health.
Pharmacists not only dispense medication, but can also play a role in education, medication management, adherence, and monitoring and management of any medication side-effects (Rubio-Valera et al 2014). When working collaboratively with the wider health care team of a service user, they can greatly enhance the health and wellbeing of someone who is using mental health related medication (Hattingh et al, 2015).
Mental health medication and common adverse side effects
Common side effects of antidepressants
- Decreased alertness
- Headaches
- Changes to sexual function
- Dry mouth (and associated increased risk of tooth decay and oral health issues)
- Increased risk of diabetes (especially for people aged 30 years and over) (MIND 2020a, NIMH 2023)
Challenging side-effects of antipsychotic medications
- Blood disorders – often people on medications known to have this side effect will have frequent blood tests to monitor for any concerns
- Metabolic syndrome – weight gain, high blood sugar levels, development of diabetes, high blood pressure and cholesterol; these symptoms can also increase risk of stroke and heart disease
- Emotional effects – increased feelings of anxiety, agitation, aggression, depression, restlessness (MIND 2020b).
Many mental health medications work by changing the concentration or interaction of chemicals (termed neurotransmitters) in the brain. The response to mental health medications can vary from person to person, and some may be more sensitive to side effects than others.
Generally, most mental health medications take between 4-6 weeks to come into full effect, with initial side effects also subsiding for most people within this time frame. When people first start or change a dose in their medication it is important to clearly communicate this and encourage adherence during this period even if the person is not experiencing the desired impact on their symptoms or health. For some, the first few weeks of starting or changing doses of antidepressant medication can coincide with an increase in suicidal thoughts or behaviour, it is important that people have frequent check-ins from their care team during this time (NIMH, 2023; MIND, 2020a).
There are a wide range of antipsychotic medications. Over time, newer antipsychotic medications have been developed that have fewer challenging side effects, these are often called 2nd generation antipsychotics. The type of antipsychotic drug someone is prescribed will depend on a range of factors, including their sensitivity to side-effects, and the method of intake (e.g. via oral pill, or via depot injection).
Supporting safe and effective use of medication
For many reasons, a person using medication to address mental health concerns may face challenges in managing their prescribed medication regime.
For some severe and enduring mental health conditions, people may experience challenges with cognition, including memory impairments, and problems with planning, problem solving, judgement, and insight (Brown, 2019).
Cognitive Deficits and Medication Use
Memory: may forget to take their medications at the same time each day, support to implement reminders and cues to improve their adherence may be beneficial. Pharmacists may provide medications in a webster pack and prompt consumers to place the packet in a visible location.
Planning: may not plan to attend the pharmacy before medications run out, or not successfully make appointments with their GP when a repeat prescription is needed. Pharmacists aware of a consumers’ concerns with planning may prompt the consumer when they provide the last repeat, or gain consent to notify the GP to make an appointment.
Problem Solving: if medication gets lost or runs out, consumers may struggle to problem solve how to get an emergency supply. Pharmacists who have a good relationship and are aware of the history of the consumer may be able to prescribe an emergency dose off-script and arrange to have the prescribing medical officer send through an urgent prescription.
Judgement: Consumers with impaired judgement may not fully appreciate the likely challenges associated with not taking medication supportive of their mental health. They may consider challenging side effects to be a reason for ceasing medication even though when unmedicated they risk significant mental health and social concerns. Pharmacists can assist in education, as well as regular monitoring and sharing with the wider health care team if concerns about ceasing medication arise.
Insight: Consumers with impaired insight may not realise that while they are not experiencing on medication, ceasing medication can lead to increased symptoms. Pharmacists can be involved in continuing to educate and remind consumers of other negative side effects of suddenly ceasing medication for mental health conditions.
Note: for consumers who have identified concerns with judgement and insight, they may be under treatment orders, or other legislative orders, which give power health care providers to administer medication to prevent safety risks to the person and the community. For further information on involuntary treatment in Australia, see: AIHW – Involuntary treatment.
As pharmacists are in a unique position to monitor frequency of collecting medications, they may be able to alert the wider health care team if a persons’ routines around collection of their medication changes, or if the person begins to report changes in side effects or function while picking up medication.
Substance use, mental health, and pharmacotherapy
Co-occurring use of Alcohol and/or Other Drugs (AoD) is a common concern for people with mental health conditions (Ketcherside, Matthews & Filby, 2013). Using Alcohol or recreational drugs, such as cannabis and methamphetamines, can have implications for people with mental health conditions, this includes if they are not taking medication to support their condition.
Regular alcohol use can impact on the brain functions and contribute to feeling low, or depressed mood, when not drinking. Alcohol can increase sedative effects of many medications used to treat depression and psychotic disorders (MIND, 2022).
There are a range of illicit drugs that can trigger psychosis, including psychotic symptoms that last beyond the period of time in which drugs are active within a persons’ system (NHS, 2023). After prolonged substance use, a withdrawal from alcohol or other drugs can also trigger psychotic symptoms.
Substance use disorders, including addiction and dependence, are most often treated with a combination of psychotherapy, social support, and pharmacotherapy. Pharmacists will play a role in supporting those with substance use disorders to reduce and cease their use of substances. They might work within specialist treatment centres, such as substance withdrawal programs, or in the community providing medication to treat the impact of reduction and withdrawal from substances as well as providing the medication to support reduction and cessation of substance use.
Due to this frequent contact, Pharmacists can play an important role within a persons’ care team, being able to regularly monitor their presentation, behaviour, and use of supporting medication, and collaborating with other health professionals that might be involved to provide increased support and care where needed.
Opioid Therapy Substitution Programs
Within Australia, most states have a program to provide medication assisted opioid therapy for people who have experienced dependence on opioids.
As per SA Health (2022); “In general, treatment of opioid dependence via the MATOD (Medication Assisted Treatment for Opioid Dependence) program is based on daily supervised dosing at a pharmacy or clinic. Supervised daily supply of methadone or buprenorphine (+/- naloxone) by a pharmacist or nurse allows patients to be assessed before dosing to maximise their safety and that of the community, and to minimise the risk of drug overdose, abuse and diversion.”
Most states have additional prescribing regulations, meaning pharmacists will have to meet certain requirements in order to provide services under the various opioid treatment programs:
South Australia – MATOD
Queensland – QOTP (Queensland Opioid Treatment Program)
Victoria – Opioid Replacement Therapy
Western Australia – Community Program for Opioid Pharmacotherapy
New South Wales – NSW OTP
Northern Territory – Opioid Substitution Treatment is run through local AoD Services
Tasmania – Opioid Pharmacotherapy Program
Australian Capital Territory – Opioid Treatment Service
Summary
Pharmacists can play an important role in collaborative care of service users who are using medication to manage symptoms and mental health conditions. Community pharmacists are accessible and have frequent contact with service users, allowing them to be active in monitoring medication use, effectiveness, and any medication-related problems. Within a collaborative care environment the role of pharmacists can also extend to supporting monitoring of mental health conditions and symptoms, communicating with other health professionals about the need for further input or review as symptoms or conditions fluctuate.
Reflective Activities
- How can pharmacists play a proactive role in supporting individuals with mental health conditions beyond dispensing medication?Consider the ways pharmacists contribute to education, adherence, side effect management, and collaboration with other healthcare professionals.
- What are some of the challenges pharmacists may face when supporting individuals with mental health conditions, and how can they address these challenges? Reflect on issues such as medication non-adherence, cognitive deficits, stigma, and legal responsibilities (e.g., mandatory reporting, involuntary treatment).
- How does substance use impact mental health treatment, and what role can pharmacists play in addressing substance use concerns in individuals taking psychotropic medications?Think about interactions between alcohol/drugs and mental health medications, opioid substitution programs, and pharmacist-led interventions.
References
Australian Health Practitioner Regulation Agency. (2024). Pharmacy Registration. https://www.pharmacyboard.gov.au/Registration.aspx
Australian Institute of Health and Welfare. (2024). Mental health related prescriptions. https://www.aihw.gov.au/mental-health/topic-areas/mental-health-prescriptions#Patient-characteristics
Brown, C. (2019). Schizophrenia and Schizoaffective Disorder. In Brown, C., Soffel, V., Munoz, J. (Eds.). Occupational Therapy in Mental Health: A Vision for Participation (2nd ed., p. 231). F.A. Davis.
Hattingh, H. L., Scahill, S., Fowler, J. L., & Wheeler, A. J. (2015). Exploring an increased role for Australian community pharmacy in mental health professional service delivery: evaluation of the literature. Journal of Mental Health, 25(6), 550–559. https://doi.org/10.3109/09638237.2015.1101418
Ketcherside, A., Matthews, I., & Filbey, F. (2013). The Serotonin Link between Alcohol Use and Affective Disorders. Journal of addiction & prevention, 1(2), 3.
MIND. (2020a). Antidepressants. https://www.mind.org.uk/information-support/drugs-and-treatments/antidepressants/side-effects-of-antidepressants/
MIND. (2020b). Antipsychotics. https://www.mind.org.uk/information-support/drugs-and-treatments/antipsychotics/side-effects/
MIND. (2022). Interactions between recreational drugs and psychiatric medication. https://www.mind.org.uk/information-support/types-of-mental-health-problems/recreational-drugs-alcohol-and-addiction/interactions-between-recreational-drugs-and-psychiatric-medication/
National Institute of Mental Health. (2023). Mental health medications. https://www.nimh.nih.gov/health/topics/mental-health-medications
NHS. (2023). Psychosis. https://www.nhs.uk/mental-health/conditions/psychosis/causes/
The Pharmacy Guild of Australia. (2024). About Us. https://www.guild.org.au/about-us
Rubio-Valera, M., Chen, T., O’Reilly, C. (2014). New Roles for Pharmacists in Community Mental Health Care: A Narrative Review. Int. J. Environ. Res. Public Health. 11. https://doi.org/10.3390/ijerph111010967
SA Health. (2022). Medication Assisted Treatment for Opioid Dependence (MATOD) – Regulatory information and resources. https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/clinical+resources/clinical+programs+and+practice+guidelines/medicines+and+drugs/programs+for+the+prescribing+and+supply+of+medicines/matod
