Mental Health Disorders in America: Why Pharmacists Are Vital to Improving Care and Outcomes

As statistics suggest, the number of people living in the United States with a mental health disorder has increased but the data also shows pharmacists are in a uniquely beneficial position to interact with and care for these patients. In this online exclusive, Pharmacy Learning Network reviews current rates of diagnosed mental illness across the United States and examines the benefits of pharmacists treating this patient population.

Mental Health Today

The COVID-19 pandemic has been linked to an increase in the number of people experiencing depression, anxiety, and other mental illnesses.¹ However, according to the National Institute of Mental Health, 51.5 million adults in the United States were already diagnosed with a mental illness in 2019.² 

Recent statistics³ suggest that roughly 1 in 4 adults, or 26% of Americans who are aged 18 years and older, receive a diagnoseable mental illness annually. Additionally, patients often manage more than one mental illness at once. Depressive illnesses are known to be linked with substance abuse as well as anxiety disorders.

Women are twice as likely³ to suffer from major depression compared with men, but men and women equally share the risk of developing bipolar disorder. Further, the average age of onset for major depression among adults is in their mid-20s, although some patients can develop the disorder at any age.

Patients who commit suicide often have been diagnosed with a mental illness, such as a depressive disorder or a substance abuse disorder, according to the National Institute of Mental Health Disorders.³ More specifically, there are four times as many men who commit suicide than women even though women attempt suicide more often. It has been reported that Caucasian men who are aged 85 years and older have the highest suicide rates in the United States.

Although prevalence is highest in this older population, suicide is noted to be a leading cause of death among adolescents and adults aged 15 to 24 years. Of important note, the idea of suicide among adults is increasing.⁴ The number of adults who experienced serious thoughts of suicide increased “0.15% from 2016-2017 to 2017-2018—an additional 460,000 people from last year’s dataset,” according to Mental Health America, a community-based nonprofit dedicated to addressing the needs of those living with mental illness.

Although mental health is often recorded and diagnosed among adults, mental health among youth is worsening. Mental Health America reports⁴ that 9.7% of youth in the United States experience severe major depressions—an increase from 9.2% the prior year. They found that younger adults are “struggling most with their mental health.” Their recent report shows young people aged 11 to 17 years have been more likely to experience moderate to severe symptoms of anxiety and depression throughout the COVID-19 pandemic.

According to the Centers for Disease Control and Prevention (CDC), children also experience mental illnesses.⁵ The CDC notes that mental illnesses in children are identified as a serious change in the way children learn, behave, or handle their emotions, causing distress and problems getting through the day. The CDC says that the most common mental health disorders among children can be diagnosed in childhood and include but are not limited to attention deficit/hyperactivity disorder, anxiety, behavioral disorders.

According to the agency, “Early diagnosis and appropriate services for children and their families can make a difference in the lives of children with mental [illnesses].” It is important that parents have access to providers who can offer services such as screenings, referrals, and treatments.

Although treatment and early diagnosis are key for patients with mental health disorders, an unmet need still exists for the treatment of mental health among youth and adults. The Mental Health America report⁴ findings show 60% of youth with major depression did not receive any mental health treatment in 2017-2018, and in states with the greatest access, more than 38% of patients are not receiving the appropriate mental health services.

“Among youth with severe depression, only 27.3% received consistent treatment [and] 23.6% of adults with a mental illness reported an unmet need for treatment in 2017-2018,” Mental Health America highlighted.

According to the data, the number of patients reporting unmet needs for treatment has not declined since 2011.⁴

The Role of the Community Pharmacist

According to Yvette C Terrie, BS Pharm, RPh, consultant pharmacist, “As one of the most accessible health care providers, pharmacists are in a pivotal position to identify patients struggling with mental health issues.”

Ms Terrie elaborated: “Pharmacists can also be instrumental in making clinical recommendations tailored to patient need via screening for potential drug/drug interactions and contraindications especially in those with comorbidities and/or in those who are taking other medications.”

For patients with mental health disorders, 1 in 6 use psychotropic medications.⁶ Psychotropic medications represent roughly 13% of the top 300 most frequently prescribed medications across the country.

As the prevalence of mental illness and number of prescriptions for psychotropic medications rise, the importance of the role of community pharmacists also rises.

“When considering the role of the outpatient community pharmacist in the management of the patient with mental health disorders, it is important to remember that often times they may be the most accessible health care provider for the patient,” says Randolph V Fugit, PharmD, BCPS, internal medicine/infectious diseases clinical specialist, and director of the antimicrobial stewardship program, VA Rocky Mountain Regional Health Care System.

“Community pharmacists are already often seeing these patients with chronic mental health disorders on a monthly basis during medication refills, if not more often, and have likely developed an excellent rapport with their patients,” says Dr Fugit. “It is during these times, that pharmacists are often able to identify acute changes in the patient's mental health status or the patient may even reach out to the pharmacist with questions or concerns regarding worsening of symptoms.”

Improving Medication Adherence

One main challenge that pharmacists face with this patient population is medication adherence. Data⁶ suggests patients who are prescribed antidepressant therapy have a nonadherence rate of 56%. Further, patients with schizophrenia and bipolar disorder have reported nonadherence rates of roughly 61% and 60%, respectively.

Although medication adherence rates are low among these patients, through medication education and side effect monitoring, pharmacists play a vital role.

“Often, one of the most important roles the community pharmacist plays is ensuring medication adherence in the patients they care for,” says Dr Fugit. “This can include reminders to refill medications and counseling patients on expected outcomes and potential adverse events to be aware of.”

“Counseling is one of the most important job functions for a community pharmacist as so many things can be discovered, fixed, and addressed,” says Ashley W Rauchet, PharmD, community pharmacist. “Although one of the biggest barriers to thorough counseling at every encounter is time, community pharmacists can pinpoint situations where counseling may be more necessary and even beneficial for their patients.”

Pharmacists can provide their patients with educational materials about their medications and help reduce biases that a patient may experience while filling their prescriptions.⁶ Pharmacists should address the following in their initial consultations with patients:

• what the medication is and why it is being used;
• how to properly administer the prescribed medication;
• the length of time before a patient will experience full therapeutic effects; and
• typical side effects or adverse effects that a patient may experience.

Although pharmacist counseling is beneficial for patients, older data suggests pharmacists are not always thorough in counseling their patients.⁶

“Most pharmacists are probably not prepared to even address [counseling a patient] because it is more than just dispensing the drug but knowing how to talk and counsel these types of patients [with mental illness],” says Matthew Grissinger, PharmD, director of error reporting, ISMP.

Findings from a clinical trial review⁶ that included more than 11,000 patients showed 60% of pharmacists counseled patients on the expected length of time the patient will experience full therapeutic effects, but only 35% of pharmacists counseled on expected treatment duration. Further, the data shows most pharmacists did not stress the importance of daily medication adherence to their patients even after initial symptoms improved.

“One indicator that a patient may be noncompliant with their psych meds is being on top of their history when they get their medications refilled,” Dr Grissinger explained. For example, Dr Grissenger says, when a patient is adherent to their medications and “feels good” they may decide to stop taking their medications, which could lead to late refills and reduced effectiveness.

He also expressed skepticism regarding some of the larger retail pharmacy chains and adherence, “I know that the chains like CVS and Walgreens have no problem automatically refilling [prescriptions], but I am not convinced they really take a look at the reasons why people are not picking them up.”

Pharmacists should continue their counseling with patients with mental health and psychiatric disorders. The existing evidence shows that providing the necessary information to patients regarding their medications decreases the likelihood that a patient will discontinue their therapy, making them more likely to remain adherent.

“Through effective patient education strategies and in building strong provider/patient relationships, pharmacists can ease patient apprehension and address the stigma often associated with mental health issues,” Ms Terrie says. “As vital members of the health care team, pharmacists can remind patients about the importance of adherence to therapy and in educating patients about the proper use of prescribed medication including when and how to take the medication and potential adverse drug reactions.”

Collaborative Treatment With Psychiatric Pharmacists

Like community pharmacists, board certified psychiatric pharmacists (BCPPs) are also vital assets in the care of patients with mental health disorders.

Research suggests BCPPs work collaboratively to expand access to care, improve mediation-related outcomes, and help reduce health care costs.⁷

A BCPP is a clinically trained pharmacist; however, they also have specialized training and experience in psychiatric pharmacy and patient care. They collaborate with providers as part of team-based care. Multidisciplinary teams optimize pharmacotherapy for this patient population, and BCPPs aim to provide medication management while monitoring for adverse drug reactions. Further, these pharmacists can educate families and patients about medications.

“Mental illness is increasing significantly in the United States and pharmacists can play a very important role in ensuring positive outcomes for patients with a mental health disorder,” stresses Dr Fugit.

BCPPs help improve and provide care in the following areas:

• opioid use disorder;
• antipsychotic use among children;
• long-acting injectable antipsychotics;
• clozapine use; and
• transitions of care and care coordination.

The role of BCPPs continues to grow, and data supports the involvement of these pharmacists in the patient multidisciplinary care team.⁶ Their integration can help optimize and address the overall goal of expanding access, improving outcomes, and minimizing the cost of care.

“Through collaborative efforts with other health care providers, pharmacists can empower patients with pertinent clinical information which will enable them to make informed choices about their health and possibly improve overall outcomes,” says Ms Terrie.

References:

1. Mental Health America. COVID-19 and mental health: A growing crisis. October 20, 2020. Accessed August 13, 2021. https://mhanational.org/research-reports/covid-19-and-mental-health-growing-crisis
2. National Institute of Mental Health. Mental illness. Accessed August 13, 2021. https://www.nimh.nih.gov/health/statistics/mental-illness
3. Johns Hopkins Medicine. Mental health disorder statistics. Accessed August 14, 2021. https://www.hopkinsmedicine.org/health/wellness-and-prevention/mental-health-disorder-statistics
4. Mental Health America. The state of mental health in America. 2021. Accessed August 12, 2021. https://mhanational.org/issues/state-mental-health-america
5. Centers for Disease Control and Prevention. Children’s mental health: data & statistics. Updated March 22, 2021. Accessed August 13, 2021. https://www.cdc.gov/childrensmentalhealth/data.html
6. Moore CH, Powell BD, Kyle JA. The role of the community pharmacist in mental health. US Pharm. 2018;43(11):13-20. https://www.uspharmacist.com/article/the-role-of-the-community-pharmacist-in-mental-health
7. Goldstone LW, DiPaula BA, Werremeyer A, et al. The role of board-certified psychiatric pharmacists in expanding access to care and improving patient outcomes. Psychiatr Serv. 2021;72(7):794-801. doi:10.1176/appi.ps.202000066