Abstract
Background:
The benefit of generalist pharmacists working within primary care networks (PCNs) and with general practitioners (GPs) is established. We wished to evaluate the contributions and potential benefits of a specialist mental health care prescribing pharmacist within PCNs.
Method:
We prospectively collected data, on clinical and demographic characteristics, referral sources, interventions, outcomes (objective and subjective), and patient feedback, from 466 completed patients, in one PCN by one specialist mental health pharmacist (working 0.5 whole time equivalent), over 15 months.
Results:
Referrals originated from multiple sources, including GPs, other members of the PCN mental health team, and community mental health teams (CMHTs). Two-thirds of treated patients were female; the most frequent age band was 18–30 years; the most common diagnosis was mixed depression and anxiety. Patients with diagnoses of mixed anxiety with depression or personality disorder needed more appointments than those with anxiety or depression. A range of evidence-based treatments were prescribed, including non-formulary medicines, and those medicines are more typically initiated or recommended in secondary care settings. The most frequently started medications were antidepressants (principally fluoxetine and duloxetine), followed by antipsychotics (principally quetiapine and aripiprazole): the most common dosage increases were for sertraline and quetiapine. Common non-medication recommendations were for cognitive behavioral therapy, cognitive behavioral therapy for insomnia, and other psychological therapies. Patient feedback was generally positive.
Discussion:
Developing and implementing a service incorporating a specialist mental health pharmacist within a PCN mental health team is potentially valuable in improving patient care quality, reducing workload for GPs and CMHTs, and enabling faster access to secondary care initiated and recommended medications. This innovative service addressed several national targets, including prevention, early intervention, and access to quality compassionate care.
Plain language summary
Developing and implementing a service incorporating a specialist mental health pharmacist within a PCN mental health team is potentially valuable in improving patient care quality, reducing workload for general practitioners and community mental health teams, and enabling faster access to secondary care initiated and recommended medications. This innovative service addressed several national targets, including prevention, early intervention, and access to quality compassionate care.
Background
Recent decades have witnessed a substantial shift in the location of clinical care delivery for patients, from hospital to community settings. Within the United Kingdom, primary mental health care is delivered mainly by general practices and improving access to psychological therapy services. By contrast, the principal providers of secondary mental health care are predominantly based within community mental health teams (CMHTs): although many ‘third-sector’ and voluntary organizations also support people with mental health problems. General practices and CMHTs sometimes collaborate via shared care arrangements, but the threshold for involvement of CMHTs is often high, leaving primary care practitioners to manage a considerable caseload of varying complexity. General practitioners (GPs) have raised concerns about aspects of cooperation between primary and secondary care, including the need for improved knowledge and competence. Reducing gaps in care pathways for people with mental health problems and challenges arising from neurodiversity is the basis for the ‘No Wrong Door’ approach within the vision for mental health, autism, and learning disability services. 1
Primary care networks (PCNs) were established in England in 2019 to develop more shared provision of services, including pharmacy services and mental health care, across groups of neighboring practices. 2 Community pharmacist-led interventions can contribute to improved treatment adherence and better disease control in many conditions, including hypertension, hypercholesterolemia, chronic obstructive pulmonary disease, and asthma. 3 Generalist pharmacists often undertake work in primary care settings, whereas specialist pharmacists are frequently located in secondary care settings, but are not widely placed in primary care (general practice). PCN pharmacists often review patients with chronic conditions, such as cardiovascular disease, 4 and are often involved in ‘deprescribing’ medicines for residents in care homes. 5 The beneficial contributions of pharmacist-independent prescribers to a range of clinical services for managing long-term conditions have been recognized, both by patients 6 and other healthcare professionals. 7
*Placement of specialist mental health pharmacists within mental health services may enhance clinical care, 8 but the impact of specialist mental health pharmacists in PCNs has not been evaluated widely. A 12-month pilot study in two general practices in remote and rural Scotland (47 patients and a total of 324 consultations) demonstrated that interventions from two specialist mental health pharmacist-independent prescribers were associated with reductions in anxiety and depressive symptom severity, and were generally well received. 9 In a pilot study across five general practice surgeries in northern England, the involvement of a specialist mental health pharmacist and technician contributed to the resolution of a range of issues (in 104 patients), including incomplete medicines reconciliation, adherence concerns, physical health monitoring, and drug errors. 10 In a retrospective evaluation, the introduction of a specialist mental health pharmacist into a PCN in southern England led to 57 consultations for a total of 40 patients, with recommendations regarding psychotropic drug prescribing and physical health monitoring and reduced referrals to CMHTs. 11
Evaluations in other countries have also suggested that the placement of a specialist mental health pharmacist in primary care can prove beneficial. A retrospective chart review of 50 patients (with a total of 156 consultations) referred to a specialist pharmacist working within a primary care mental health integration (PCMHI) team in Milwaukee, WI, USA found that recommended interventions were associated with reductions in severity of anxiety, depressive, and post-traumatic symptoms. 12 Another retrospective chart review, involving 196 patients attending a Veterans Affairs PCMHI service reviewed by clinical pharmacy specialists in San Antonio, TX, USA generated similar findings, including reductions in symptom severity, improved medication adherence, and reduced numbers of referrals to secondary care mental health services. 13 In Aotearoa New Zealand, community (though not necessarily specialist mental health) pharmacists have been deployed in primary mental healthcare services for some years, although evaluations have been limited: despite this, such pharmacists envisage a range of professional roles, going beyond medicines supply and provision of advice about medicines, toward advocacy roles in health system navigation and broader social support. 14
Method
Our local mental healthcare Trust [Southern Health NHS Foundation Trust (SHFT)], which provides community care and specialist mental health services within Hampshire, did not previously include a specialist pharmacist service within PCNs. We, therefore, set out to evaluate the contributions made to direct patient care by a specialist mental health prescribing pharmacist (RH) working within five general practices in a mixed urban–rural area, Andover (being placed one session per week in each surgery). The scope of practice included all mental health medications within section 4 of the British National Formulary.
RH made treatment recommendations and alterations autonomously based on patient assessment, clinical experience, and patient preference. When there was uncertainty about optimal psychopharmacological treatment decisions for particular patients, this was discussed in a regular forum with clinical supervisor DSB. The service was set up initially with the option of face-to-face or telephone consultations. In the first 3 months, only three patients opted for face to face, so all appointments were moved to remote, either by phone or video link. Virtual appointments permitted some flexibility in appointment times, with patients being offered a morning or afternoon ‘slot’. Information on exact appointment times was not formally collected, but the initial appointment typically lasted between 30 and 60 min, and subsequent follow-up between 5 and 20 min.
Surgery size ranged between 10,370 and 14,669 patients, and the number of patients diagnosed with severe mental health illness (SMI) in each surgery ranged between 80 and 120. Data were gathered prospectively between April 2022 and July 2023, and summarized for all ‘completed patient treatment episodes’ (n = 466). Episodes were considered complete when one of the following occurred: the patient was improved, stopped attending consultations, or was referred to a different service (most often the CMHT). Collected data included referral source, demographic characteristics, primary mental health disorder diagnosis, number of appointments, non-attendances, prescribing interventions, non-pharmacological interventions, and clinical outcomes [assessed through change in depressive Patient Health Questionnaire (PHQ-9) 15 and anxiety Genaralised Anxiety disorder assessment (GAD-7) 16 ] symptom severity, or through patient subjective perception of improvement if the principal symptoms were not anxiety or depression. Treatment decisions relating to prescriptions of non-formulary drugs and to ‘amber’ listed drugs (i.e. medicines that need to be initiated or recommended by secondary care services) were examined in detail. The Andover Primary Care Network Mental Health Team gathered feedback via patient surveys after the intervention/treatment was complete, and medication-specific patient feedback information was also collected. The patients were sent a text with a link to a short survey, with no obligation to complete the survey, we only collected the data that were about the pharmacist and not general comments about the service as a whole.
All referrals were included in the study. However, patients who were under the care of secondary services (CMHT) for medication reviews were not referred to the PCN pharmacist. Any interventions made prior to a transfer of care to the CMHT were accessible to the psychiatrist via the patients’ electronic records. SHFT is not commissioned to provide treatment for patients with a primary diagnosis of substance use disorders or attention deficit hyperactivity disorder (ADHD), so patients with these conditions could not be referred.
Results
Referral source
The most common sources of referral to the specialist prescribing pharmacist were Wellbeing Practitioner/Social Prescriber requests (37%), GP requests (26%), other PCN mental health professional requests (i.e. occupational therapist or mental health nurse) (20%); annual review of patients with severe mental illness (12%); and CMHT (5%) (Table 1). Well-being practitioners support patients to live fulfilling lives through interventions such as problem-solving, graded exposure, and guided self-help, whereas social prescribers connect patients to activities, groups, and support. Practices differed in the origin of referrals (e.g. referrals from wellbeing staff in differing surgeries ranged between 18% and 55%, and referrals from GPs ranged between 9% and 47%), depending upon existing provisions and whether the surgery had a previous educational contribution from the pharmacist. By considering referral processes before and after the pharmacist service was established, it can be estimated that the possible total numbers of ‘redirected’ patients per whole time equivalent per year (not including follow-up appointments) were as follows: GP, 419; CMHT, 210; and possibly GP or CMHT, 142 (Table 2).
Demographic and clinical characteristics.
ADHD, attention deficit hyperactivity disorder.
Prescription recommendations.
Includes benzodiazepines and gabapentinoids.
Includes z-drugs and promethazine (n = 13 starts).
Includes propranolol (n = 3 starts).
Demographic characteristics
Approximately two-thirds of referred patients were women. The most frequent age band in both women and men was 18–30 years (Table 1).
Primary mental health disorder diagnosis
The most common recorded diagnosis seen was depression and anxiety, in both men and women. For women, the second most common diagnosis was emotionally unstable personality disorder; for men, it was psychosis (Table 1).
Number of appointments
Single appointments tended to be for an SMI annual medication review when patients were generally well with no adverse medication effects (principally, for patients with schizophrenia or bipolar affective disorder); by contrast, patients who attended two or three appointments did so following either dosage increase or introduction of a new medication, respectively (and usually as a treatment for depression or anxiety). Patients who attended four or more appointments usually did so following the initiation of two medications for the management of mixed anxiety with depression, or personality disorder diagnoses. Patients with depression were typically seen three times (initial assessment with new prescription; 2-week follow-up to assess tolerability; 4-week follow-up to assess effectiveness), and patients with anxiety disorders were typically seen twice (initial assessment with dosage adjustment; 4-week follow-up to evaluate the efficacy). During the data collection period, there were 29 non-attendances: a non-attendance was recorded when the patient did not answer their phone after at least three attempts on at least two separate days. There was no clear pattern for the non-attendees.
Prescribing interventions
Antidepressant medication was altered in 73% of women and 77% of men in patients with the diagnosis of depression, an anxiety disorder, or mixed anxiety with a depressive disorder. The most frequently initiated antidepressants were fluoxetine, duloxetine, and sertraline, principally for reasons of patient age (fluoxetine, in patients aged 18–30 years), chronic pain or fibromyalgia (duloxetine), and previous response (sertraline). The antidepressants most frequently stopped were sertraline and mirtazapine, principally for non-response (sertraline) and adverse effects, weight gain, or sedation (mirtazapine). Antidepressant dosage increase was most common with sertraline (31 patients). Bupropion was initiated only in women, and agomelatine was initiated mainly in patients older than 60 years. Antipsychotic medication (as a class) was commenced in similar proportions of men and women, although aripiprazole and quetiapine were prescribed proportionately more often in women. Lithium was not started in any patient, but doses were adjusted according to levels.
Medication adherence
This was checked at each appointment by open questioning about what medications the patient was taking and by using the electronic patient record issuing information. Adherence interventions included providing reminder charts, practical suggestions, and conversations around medication risks and benefits.
‘Amber’ and non-formulary medicines
Aripiprazole was primarily started due to reports of weight gain with previous antipsychotics, but some patients also had diabetes or raised levels of HbA1C or cholesterol; other reasons included over-sedation with previous medications, hyperprolactinemia, and previous good response. Lurasidone was started primarily due to weight gain with previous antipsychotics. Patients started on lurasidone had suffered side effects to aripiprazole, aripiprazole was temporarily unavailable, or the patient requested a sedative medication. Flupentixol was started in one patient with the diagnosis of emotionally unstable personality disorder who had previously found it helpful but stopped in two patients (due to weight gain or hyperprolactinemia).
Agomelatine was primarily started due to side effects experienced with other antidepressants, particularly sexual dysfunction and emotional blunting; other reasons include improved sleep without a daytime ‘hangover effect’, a lower propensity to switch to mania, patient choice, concern about potential weight gain, and reduced impact on co-occurring physical health conditions. Bupropion was started due to its reduced incidence of weight gain, sedation, and sweating; typically, patients had previously tried multiple other antidepressants. Duloxetine was primarily started due to co-occurring persistent pain; other reasons include the presence of comorbid ADHD and a lower propensity to cause sweating than venlafaxine. Vortioxetine was mainly prescribed when patients had a poor response to multiple other antidepressants, had marked anhedonia or memory difficulties, or had experienced side effects such as sexual dysfunction.
Non-pharmacological interventions
All patients received a link to the Choice and Medication Patient Information Leaflet for new or recently started medications and general information on taking medications. These efforts were regarded as ‘standard practice’, and so not recorded as an intervention on the data collection form. However, links to reputable sites for sleep improvement with cognitive behavioral therapy (CBT) for insomnia, self-management using CBT (e.g. iTalk), and for chronic pain (local pain group, CBT for chronic pain), or healthy living were provided where relevant. Onward referrals were sometimes made to the CMHT for clarification of diagnosis, to ADHD services for diagnosis and treatment, and to substance use disorder services and perinatal mental health services.
Outcomes
PHQ-9 scores were collected at the initial and final appointments for 94 patient episodes: mean scores declined from 18.5 (SD 4.9) to 8.9 (SD 4.8). GAD-7 scores were collected at the initial and final appointments for 49 patient episodes; mean scores were reduced from 15.9 (SD 5.6) to 8.0 (SD 3.8). Subjective improvements were recorded when the target symptoms were not highlighted within the PHQ-9 or GAD-7 scales (e.g. side effect management, poor sleep, emotional instability, and mania): a total of 180 patients described a subjective improvement, 19 patients did either not improve, despite trying several treatments or required referral to another service, primarily the CMHT. A total of 70 of 84 patients attending SMI annual reviews were generally well with no adverse medication effects: as they did not need any intervention, no outcome data were collected. Interventions were made with the 14 patients attending for their SMI annual review. There was also no outcome data when only medication advice or sign-posting was provided.
Patient feedback
Patients could provide free-text comments, but only the minority chose to do so. Submitted comments are as follows: ‘pharmacist listened to me and was very helpful and informative’; ‘found the correct medication and dose’; ‘Rebecca made sure to check in with me and was very proactive in helping me change my medication’; ‘Rebecca was very understanding and knew what sort of advice might help me. She wasn’t patronising or judgemental but was very helpful and friendly’; ‘getting the right medication to make me feel much better and having someone to talk too that is giving you time to explain yourself’; ‘pharmacist was extremely helpful and lovely to speak to’; ‘I missed a few calls from Rebecca and there was no way I could find of contacting her – that was the only frustrating thing. Looked like I was not engaging but actually I have an incredibly knackered phone . . .’.
Discussion
Our findings suggest that developing and implementing a specialist mental health prescribing pharmacist within a PCN mental health team is potentially valuable in improving patient care quality and reducing the workload for GPs and CMHTs. The findings from our prospective evaluation reflect the observations from smaller or retrospective evaluations conducted elsewhere in England, Scotland, and the United States.
The ‘No Wrong Door’ approach to developing new community services has 10 key elements, some addressed by implementing this novel specialist pharmacy service (i.e. prevention, early intervention, access to quality compassionate care, whole-person care). 1 Prevention is addressed by undertaking proactive reviews and identifying potential physical illness in patients with severe mental illness; early intervention is addressed by having a lowered threshold for referral (compared to referral to a CMHT) and through the provision of expert advice on psychotropic drugs at an earlier stage; access to quality compassionate care is addressed through the implementation of a simple ‘single-stop’ referral from the GP to the specialist pharmacist (avoiding the time-consuming hurdles/wrong doors); and whole-person care is addressed by a multidisciplinary PCN mental health team, including psychologists, mental health occupational therapists and mental health nurses and wellbeing practitioners, as well as the specialist mental health prescribing pharmacist.
The most prescribed medications include several medications including duloxetine, agomelatine, vortioxetine, and aripiprazole which are usually initiated or recommended in secondary care. Placing a secondary care specialist within the PCN has arguably enabled more options to be available to more patients in a timely fashion, resulting in improved clinical care. The large number of referrals suggests that the service addressed an important need, and patient feedback suggests patients found this helpful.
Limitations of this evaluation include the fact that the data collection period was when the service was first initiated. It is possible that the number of referrals directly from GPs and CMHTs would increase as the service becomes established: a reaudit would be able to determine whether this is the case. In addition, data were collected by an individual pharmacist working within a single PCN; broadening data collection to other pharmacists within other PCNs would help to establish whether the perceived benefits generalize to other services. In addition, the maximum number of appointments in our evaluation was set at 4+ when the data collection instrument was initiated: however, as this number was higher for some patients, particularly those with personality disorder diagnoses, permitting a higher number to be recorded would be helpful. The estimated impact on CMHT referrals and saved GP time was not determined by a thorough analysis of data within CMHT and GP systems (e.g. through evaluation of referral and waiting time data). Finally, for patients with treatment-resistant depression, although it is common to augment antidepressants, it was not possible to extract this information from the data collected, but this would be a subject for future study.
To summarize, our findings suggest that developing and implementing a specialist mental health independent prescribing pharmacist within a PCN mental health team is potentially valuable in helping to manage and reduce psychological symptoms, improving patient care quality, and in reducing the workload for GPs and CMHTs. Further work should include a broader evaluation over a wider geographic area, with longer follow-up and inclusion of quantitative and qualitative data analysis approaches.
