Alan Pollard advises on what to do if you suspect a patient is suffering with a mental health problem

Key learning points

•Depression presents with a variety of symptoms including insomnia, loss of libido and feelings of hopelessness

•Discussions about mental health should always take place in a private consulting room

•Mental health issues can often sit alongside problems with substance misuse

Mary walks into your pharmacy late one afternoon with her repeat prescription. This is unusually late for her and you notice she is not as bright and cheerful as usual. She hands her prescription to your colleague behind the counter with a forced smile, then sits down to wait for it to be dispensed.

You sense something isn’t right with her, but are not sure what to do. You know Mary reasonably well, but haven’t spoken
to her for some time about her medication. Her repeat prescription could be an opportunity to have a chat, but what are you going to say? How will you initiate the conversation?

Recognising depression

Before you have a chat with Mary, it is probably helpful to have an idea of how depression presents. The mnemonic IN SAD CAGES in the box (below) captures some key signs and symptoms.

You may already see some elements of Mary’s presentation fitting into this model and the mnemonic can prompt you to explore other areas as appropriate. A good place to start is asking about any recent changes in appetite, sleep patterns and general energy levels.

Most cases of depression also present with anxiety and stress, but it is important to see beyond this, because any underlying depression needs treating. It may be more comfortable for people to talk about stress rather than depression. In these situations, stress may include worrying thoughts as well as observed evidence of agitated behaviour such as restlessness and avoiding eye contact.

You may feel comfortable in approaching Mary. Indeed, you might already know about her living situation, if she regularly uses your pharmacy. Or her mental health needs may remain hidden and lead to morbidity.

Consider the following questions:

•How do you start the conversation with Mary?

•Where should you talk to her?

•What about consent and confidentiality?

•What if Mary discloses something to you that gives you cause for concern?

•What competencies and training would be helpful?

•What about safeguarding issues?

•What resources should you have available?

•What about the bigger picture?

How do I start the conversation?

A good opening might go something like this.

‘Hello, Mary. I can see you are not looking like your usual self. Could we have a chat about your medicines and how you are getting on more generally? You can come into the consulting area where it’s a bit quieter. Would that be okay?’

Where should you talk to Mary?

Ideally, all conversations about healthcare should take place in your designated consulting area to preserve privacy. It is worth considering whether you should have a chaperone present. This may be more relevant if you are different genders and your customer is seen as especially vulnerable.

The consultation room layout deserves some consideration.

If you sit opposite each other across a table, it may, for Mary, feel like a formal interview. Sitting alongside her with chairs at an acute angle gives her the space she needs without creating a formal barrier.

What about consent and confidentiality?

It is important to seek Mary’s consent if you make notes. Explain that these will be kept secure and confidential. Although the default position is to not disclose any information to third parties without Mary’s permission, some disclosures are prescribed by law or public interest.

The circumstances surrounding these can be found in the General Pharmaceutical Council (GPhC) guidance on patient confidentiality.2 Even with this guidance, where there is any doubt, professional or legal advice should be sought. If Mary has carers and they ask you about her, you will need Mary’s permission to disclose any information.

How do I broach the subject?

When speaking to someone who is depressed, it is important to note that asking about suicide – even in a very direct way – will not put the idea into their head or increase the risk.

In fact, ignoring this important area is likely to do more harm than good. Asking gives the person permission to express such feelings – however desperate.

A good and more comfortable way to approach this topic is to ask what Mary thinks about herself and her future and steer the conversation from this. Suffice to say that if anyone declares evidence of direct intent to harm themselves, this should be disclosed to a third party.

It may be appropriate to ask Mary how she is managing any stress at present. Some people use alcohol to numb some of the distress they are experiencing and in such circumstances it is useful to quantify how much. The recommended safe limits on alcohol consumption have recently been reduced and the current recommendation is 14 units per week maximum in both males and females.3

It is possible that Mary may be self-medicating in other ways, so asking about purchased medicines and the potential use of prescribed, or even illicit, agents should not be forgotten.

What if May discloses something that concerns me?

For yourself, you should have key contacts for any urgent needs you identify – although most often, your first contact will probably be the GP. Safeguarding issues, if urgent, are likely to be dealt with through the county council.

Make sure you have the details of your local specialist mental health pharmacist. You can also find treatment guidelines for many mental health conditions from the National Institue for Health and Care Excellence (NICE)7 or the Scottish Intercollegiate Guidelines Network (SIGN),8 which identify likely patient treatment pathways.

If you want printed information on mental health conditions and treatments, the Choice and Medication website9 can provide this.

What about safeguarding issues?

When someone is in the midst of a mental health difficulty, they may become vulnerable and open to exploitation by others. Beyond any personal vulnerability from a reduced ability to care for themselves, there may be an impact on those the person is caring for. Mental health difficulties may put children at risk. It is important to have this on your radar.

What about the bigger picture?

Community pharmacy is well placed to promote good mental health, and throughout the year there are specific dates that focus on mental health issues. One is World Mental Health Day,10 around 10 October, which is likely to have activities in your area that you might want to be part of.

It is important to note that many patients present with symptoms in more than one domain. For example, substance misuse often co-exists with mental health conditions. Alcohol is often used as a coping strategy for many aspects of mental discomfort, and can easily become out of control.

Community pharmacies are very accessible and non-threatening; the relationship that you have with some of your regular customers may enable you to spot changes and for them to feel that you are someone they can share some concerns with.

Useful training and competencies

There is a lot of investment in enhancing communication skills of the pharmacy workforce. The College of Pharmacy Practice and Education (CPPE) runs a communication skills workshop4 and in the November 2016 edition of the Pharmaceutical Journal[5] there is an excellent article titled ‘How to build and maintain trust with patients’.

CPPE provides educational packages across a number of different mental health conditions.

The College of Mental Health Pharmacy (CMHP)6 provides an introductory course to the main mental health conditions and their treatment. However, probably your most valuable option is to link in with your local trust-based specialist mental health pharmacist.

[box type="shadow" ]Following the mnemonic IN SAD CAGES – key signs of depression

Insomnia – Typically early morning wakening

Neurotic symptoms – Anxiety/agitation with ruminations

Suicide – Thoughts/plans about self-harm

Appetite decreases – Leading to weight loss

Depressed mood – Tearfulness, feeling low

Concentration decreases – Reading and staying focused, retaining information, concentrating on TV becomes more difficult

Anhedonia – Loss of pleasure in pastimes that are usually rewarding

Feelings of guilt/worthlessness/pessimism about the future – May not believe they are worthy to receive help
Exaggerated negativity around past misdemeanors

Energy decreases – Poor self-care, lack of motivation

Sex – Loss of libido; amenorrhoea[/box]

Alan Pollard is an independent mental health pharmacy consultant and
associate lecturer at Worcester University

References

1 McManus S, Meltzer H, Brugha T et al (eds) 2009. Adult Psychiatric Morbidity in England 2007: results of a household survey. NHS Information Centre for Health and Social Care. Available at http://www.hscic.gov.uk/pubs/psychiatricmorbidity07

2 General Pharmaceutical Council. Guidance on patient confidentiality 2012. Available at http://www.pharmacyregulation.org/sites/default/files/Guidance%20on%20Confidentiality_April%202012.pdf

3 UK Chief Medical Officers’ Low Risk Drinking Guidelines. Department of Health August 2016 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/545937/UK_CMOs__report.pdf

4 Centre for Pharmacy Postgraduate Education (CPPE) https://www.cppe.ac.uk/services/consultation-skills

5 Allinson M, Chaar B. How to build and maintain trust with patients. Pharmaceutical Journal 2016;297: 300-3

6 College of Mental Health Pharmacy http://www.cmhp.org.uk/education/cmhp-psychiatry-1

7 National Institute for Health and Care Excellence (NICE)

8 Scottish Intercollegiate Guidelines Network (SIGN) http://www.sign.ac.uk/guidelines/index.html

9 Choice and medication http://www.choiceandmedication.org/cms/?lang=en

10 No Health without Mental Health. A cross-government mental health outcomes strategy for people of all ages. HM Government Feb. 2011 ref. no.14679 Available at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213761/dh_124058.pdf