By Alexis Richardson, PharmD Candidate and Adenike Atanda-Oshikoya, PharmD, BCACP, CDCES
It is estimated that 20% of adults in the United States experience mental health conditions every year, and 46% of adults aged 18 or older with any mental illness (AMI), received inpatient or outpatient mental health services or took prescription medication to treat a mental health condition in the last year.(1) These conditions include anxiety disorders, depression disorders, attention deficit hyperactivity disorder, bipolar disorder, eating disorders, obsessive-compulsive disorder, post-traumatic stress disorder, personality disorders and schizoaffective disorders.(2) Psychiatric pharmacists play a pivotal role in addressing the complex needs of individuals with mental health conditions, which can lead to a reduction in emergency department visits in this population.(3,4,5)
There are currently 1,540 board certified psychiatric pharmacists (BCPP) in the United States who meet the specified board requirements according to the Board of Pharmacy Specialties. These requirements include graduation from an ACPE (Accreditation Council for Pharmacy Education)-accredited pharmacy program, active license to practice in the US, and demonstration of practice experience by either having a 4-year minimum of psychiatric pharmacy practice experience, completion of PGY1 residency (with 2 years of relevant practice experience), or a PGY2 residency in psychiatric pharmacy within the last 7 years.(6) These pharmacy professionals are well-equipped to provide medication management services, engage in collaborative prescribing and support public health initiatives relating to mental health. Unfortunately, despite evidence of impact, there are various barriers that can limit the role of pharmacists in the delivery of psychiatric care.
The first barrier is a limited awareness and practice scope. A qualitative study interviewed nine healthcare providers (psychiatrists, nurses and pharmacists) and three patients regarding collaborative prescribing and the role of pharmacists in mental health.(7) A lack of understanding of the breadth of pharmacy training, healthcare hierarchy, limited collaborative practice agreement scope, practice hesitancy and concerns for adequate renumeration were reported by the participants as potential barriers to collaborative prescribing by pharmacists. Although the study participants recognized that pharmacists enhanced the delivery of care as medication experts, the patients mostly viewed their pharmacist within community practice roles and did not recognize them as members of the health care team providing services for them.(7) As a result, patients and healthcare providers may benefit from targeted education on the training and mental health services provided by pharmacists. Pharmacists can also provide specialty medication services and training on injectable medications to ensure safe and appropriate storage and use.
The second potential barrier is patient mistrust, which is particularly pronounced in this patient population. A qualitative research study in Canada conducted interviews and focus group discussions among six community pharmacists regarding their experiences in mental illness and addictions.(8) Participants reported that limited time, lack of privacy in pharmacy environments and mental health stigmas significantly impaired a pharmacists’ ability to develop trusting relationships with patients and perform to their full scope of practice in mental health and addictions care. Another qualitative research conducted in Boston interviewed 50 adults in inpatient and outpatient psychiatric clinical settings.(9) Select participant comments relating to provider trust included “it’s not that I don’t wanna trust ya, It’s just that I know a lot of people who… just roll over you to get it done” and “You don’t always trust [doctors] enough to tell them certain things. I actually think that most patients want their doctors to explain to them what is going on. Most patients want their doctors to show some interest in them as human beings”.(9) The authors concluded that patients’ trust in mental health providers was derived more from open communication and shared decision making among clinician and patients rather than their professionalism. Pharmacists can provide compassionate communication, ensure enclosed areas for patient counseling as well as provide patient friendly counseling using appropriate terminology to overcome this barrier.
Furthermore, the persistent lack of national recognition of pharmacists as billing healthcare providers can limit a pharmacist’s ability to fully engage in patient care and collaborate with other healthcare professionals. Provider status is defined as “the legal recognition of a healthcare professional eligible for patient care service reimbursement through Medicare Part B.”(10) Reimbursement should be viewed as financial support for essential services and resources required to meet patients’ needs effectively. Psychiatric pharmacists provide evidence-based treatment strategies, ensure appropriate use of pharmacotherapy, and support clinical research efforts and public health initiatives.(3) Without proper recognition as providers on the federal level, psychiatric pharmacists face barriers in sustaining collaborative practice agreements, advocating for cost-effective medications, and navigating insurance coverage hurdles, all of which potentially compromise patient access to essential treatment.
Lastly, psychiatric pharmacists may face practice barriers due to drug selection and formulary management conducted by pharmacy benefit manager (PBM). A PBM is an individual or company that manages prescription drug benefits on behalf of health insurers, Medicare Part D drug plans, large employers, and other payers.(11) In the psychiatric patient population, treatment guidelines are not as precise due to the complex nature of the varying disease states and potential for various drug and disease interactions.(9) As a result, patients may have treatment failures and contraindications that require second-line or salvage therapy that are not favored by PBMs due to policies that may favor more precise treatment decision pathways and cost-savings. With their specialized training and expertise, psychiatric pharmacists are well-equipped to conduct comprehensive assessments and review historical data to determine the most suitable and cost effective treatment options for their patients. Therefore, increased involvement of psychiatric pharmacists in PBM formulary and policy decisions could facilitate a balance between cost-effectiveness and patient-centered care in this population.
Psychiatric pharmacists can play multiple roles as clinicians, patient educators, researchers, medication experts and patient advocates within healthcare teams. As mental health care continues to evolve, the necessity for psychiatric pharmacists to directly engage with patients, build their trust and support healthcare teams in navigating the complexities of medication management within this patient population is crucial. Therefore, it will be beneficial for pharmacy organizations to support the training, advocation for provider status and successful integration of pharmacists in the field of psychiatric pharmacy.
Substance Abuse and Mental Health Services Administration. Key Substance Use and Mental Health Indicators in the United States:Results from the 2020 National Survey on Drug Use and Health. October 2021. Accessed April 15, 2024. Available at https://www.samhsa.gov/data/sites/default/files/reports/rpt35325/NSDUHFFRPDFWHTMLFiles2020/2020NSDUHFFR1PDFW102121.pdf.
National Alliance on Mental Health. Mental Health Conditions. Accessed April 15, 2024. Available at https://www.nami.org/About-Mental-Illness/Mental-Health-Conditions.
Goldstone L, DiPaula BA, Werremeyer A, et al. The role of Board-Certified Psychiatric Pharmacists in expanding access to care and improving patient outcomes. Psychiatric Services.2021;72(7):794-801. doi:10.1176/appi.ps.2020.
Werremeyer A, Orr M: Pharmacist-led medication education groups on an inpatient psychiatric unit—impact on readmissions and emergency department visits. J Am Coll Clin Pharm 2019; 2:228–235.
Bell S, Rosen A, Aslani P, et al. Developing the role of pharmacists as members of community mental health teams: perspectives of pharmacists and mental health professionals. Res Social Adm Pharm. 2007 Dec;3(4):392-409. doi: 10.1016/j.sapharm.2006.10.005.
Board of pharmacy specialties. Psychiatric Pharmacy. Accessed April 15, 2024. Available at https://bpsweb.org/psychiatric-pharmacy/.
Wheeler A, Crump K, Lee M, et al. Collaborative prescribing: A qualitative exploration of a role for pharmacists in mental health. Research in Social and Administrative Pharmacy. 2012. 8: 3, 179-192.
Murphy AL, Phelan H, Haslam S et al. Community pharmacists’ experiences in mental illness and addictions care: a qualitative study. Subst Abuse Treat Prev Policy. 2016; 11: 6. doi:10.1186/s13011-016-0050-9.
Vale MD, Good MD. Transcending the Profession: Psychiatric Patients' Experiences of Trust in Clinicians. J Health Soc Behav. 2020;61(2):208-222. doi:10.1177/0022146520918559.
Library of Congress: United States code: social security act, 42 U.S.C. §§ 301-1305 (Suppl. 4 1934). Accessed April 15, 2024. Available at: https://www.loc.gov/item/uscode1934-005042007/.
The Commonwealth Fund. Pharmacy benefit managers and their role in drug spending. April 2019. Accessed April 15, 2024. Available at www.commonwealthfund.org.
Alexis Richardson
PharmD Candidate 2025
University of North Texas
Health Science Center College of Pharmacy Fort Worth, TX
Adenike Atanda-Oshikoya, PharmD, BCACP, CDCES
Assistant Dean of Pharmacy Student Success and Academic Performance - Office of Pharmacy Student Success
Director of Introductory Pharmacy Practice Experiences - Office of Experiential Education
Associate Professor of Pharmacotherapy
University of North Texas
Health Science Center College of Pharmacy
Fort Worth, TX
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