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When I first started working in a mental health hospital, as a rotation during my pharmacy technician training, there was a general perception of people with mental health conditions as being at best confused and amusing or, at worst, as downright dangerous. Newspaper headlines claiming ‘1200 killed by mental health patients’ and using inflammatory terms such as ‘psycho’ and ‘crazies’ certainly have helped to create stigma around these conditions. In reality, serious violence among people with schizophrenia is rare and the annual risk of someone with schizophrenia committing a homicide is 1 in 10,000 or 1 in 150 for being convicted of a violent offence. Put in context, schizophrenia and psychosis are responsible for about 5% of violent crimes in society.1
In fact, 30% of GP appointments are related to mental health issues2 and 1 in 4 people will experience some kind of mental health problem within the course of a year.2 Mental health conditions and issues are common; you might be aware of friends, colleagues or family members who are suffering mental ill health. Unfortunately, ongoing stigma might also be preventing people from telling others about problems they experience.
As prominent people in the public eye have bravely opened up about their own mental health challenges, people have come to realise that anyone can be affected by mental health problems. Exposure to these mental health conditions through cinema and drama has further raised awareness of mental health illness and when to seek help. In turn, this has increased people’s contact with mental health services for themselves or family members.
Eighteen years ago, when I tendered my resignation at my cardiothoracic hospital for a new role in a mental health, I was asked ‘why would you want to do that?’ The advantages include the opportunity to work in a friendly atmosphere with true multidisciplinary collaboration. The work is less pressured as there are long-term patients who you see regularly and have the ability to organise dispensing supplies in advance, which is different to the churn of daily discharges in acute hospitals. The specialism is interesting and wide-reaching, in that people in any hospital of any specialism will have mental health conditions. While working at a large general teaching hospital in London after 13 years at a mental health Trust, it was evident that many of the patients on the ward I was covering (an HIV and infectious diseases ward) had mental health conditions such as bipolar disorder, depression or drug and alcohol misuse. I witnessed a staff member on this ward talking down a patient with alcohol misuse issues who was in a highly aroused and threatening state. The de-escalation and motivational interviewing skills needed here were very much the same as those required in mental health services.
Many of the advanced roles of pharmacy technicians in mental health services are very similar to those in general acute hospitals or other specialist units. These include things such as pharmacy technicians who administer medications as part of their ward-based role, as well as performing medicines reconciliation when patients are admitted to ensure their medication is correctly prescribed, ordering medicines for individual patients, and providing counselling. These also include pharmacy technicians who head specialist areas such as clinical trials, IT, procurement or, like myself, as the operational lead, and those in management roles.
Some innovative roles performed by pharmacy technicians are more specific to mental health services, such as running clozapine clinics for treatment-resistant schizophrenia, where pharmacy technicians are trained in phlebotomy and take and run blood samples to ensure patients can safely continue to take the medication (which can deplete white blood cells). Providing services to community mental health services (such as physical health clinics and medication reviews) are essential, as it is well documented that the physical health needs for patients with mental health problems are often neglected.3
After completing a postgraduate certificate in Psychiatric Therapeutics, and to utilise my enhanced knowledge, I offered to provide fortnightly clinical input to a community mental health team that did not receive a visit from a pharmacist. During this visit, I examined prescription validity, confirmed doses, interactions, contraindications, checked for ECGs and biochemical monitoring, and requested these where necessary. I offered medicines information for nursing and medical staff, updated the patient medicines list on the electronic notes and performed difficult medicines reconciliations.
After a couple of months, I considered how I could further add value to this service and offered to provide a medication clinic for service users, where patients could self-refer or be referred by the medical team or care coordinators. This included providing advice on switching medications, helping patients to make informed treatment choices for both their physical and mental health, giving advice on side effects, and medication reviews. Interactions included enquiries about sexual dysfunction, weight gain and other side effects, and advice on choosing the most effective antipsychotic for the individual.
I also supplied advice via email and phone to an agoraphobic patient who was unable to visit the clinic, thereby providing equity of access to treatment and advice. These clinics were well received by the community team which was able to offer this service to clients for medication-related issues and advice. Patients also came for ongoing support or advice subsequent to life changes for months or years.
Another area specific to mental health in which pharmacy technicians can offer input is in the provision of ‘med-ed’ groups, that is, medication education sessions for patients that cover different topics around medication, varying from medicines used in psychiatry, treatment options for different conditions and side effects (such as sexual dysfunction), or indeed anything medication-related that patients might have an interest in. Interactions might be specific to a particular patient group. When trying to add value, it is vital to understand exactly what patients are trying to achieve (for example, maybe reducing or controlling side effects enough to be able to have a girlfriend, complete a college course or get a job).
Pharmacy technicians add value not only through the skills and knowledge they have but also through their compassion, empathy and the ability to communicate all these things in a way that helps to identify and provide optimal treatment. The benefit is in understanding the importance of kindness to patients coming to a mental health ward for the first time and what it is like for a family member to have their loved one sectioned. An appreciation of what they might have gone through to get to this admission is vital. Emotional intelligence, as well as asking the right questions to obtain the information you need to help, is crucial. During one counselling session, a young woman who was taking a very low dose antipsychotic, asked me, ‘Why am I being prescribed an antipsychotic; I’m not mad?’ After some careful questioning, I discovered that she was taking drugs to induce hallucinations of her father who had recently died, and these visions were a source of comfort to her. How easily this could be missed when we are in the habit of persuading patients to take medication. It is important to remember this is not our only job.
A 16-year-old girl who had cut her wrists was admitted to a ward on a general hospital that a colleague was covering. The girl was manic and would not stay in her room. The medical staff were unsure as to how to handle her and she became destructive.
My colleague introduced herself to the patient and asked if she could help. She explained to the patient that the staff were busy but if she stayed in her room, they would know where she was when they started the ward round. The pharmacy technician asked the girl to come with her, and offered her hand, which the girl took, and she accompanied her back to her room. My colleague asked the girl if she was thirsty, and provided refreshment and offered her reassurance. She told her where she would be if she needed anything else and checked on her periodically.
The patient had been isolated but had not been told why and had not been offered anything to eat or drink. My colleague’s calm intervention made other staff see that the girl was scared rather than ‘scary’. This demonstrates the value that great pharmacy technicians can bring.