Improving Mental Illness Treatment in the Community Pharmacy

Today, many areas in the United States lack sufficient resources to adequately treat the increasing number of patients with mental and behavioral illnesses.

This is a growing concern of equal proportion for patients, providers, and insurers. In addition to concerns pertaining to access, equally important concerns surround their cost. Because of the complexity of standard treatments, mental illnesses are among the most costly conditions to treat, and often become even more costly if they go untreated. In the past 10 years, mental health spending in the United States has been on the rise. According to the Substance Abuse and Mental Health Services Administration, spending on national mental healthcare is predicted to increase from $147 billion in 2009 to $239 billion in 2020.¹

Various regions of the country are handling the growing mental health problems differently; although 30 states experienced an increase in their mental health budget in 2015, 10 states experienced a decrease.² The implementation of the Affordable Care Act further supports the focus on mental and behavioral health by mandating that each insurance plan include mental health and substance abuse services as 1 of 10 essential health benefits.³

National attention and increased funding is being directed toward mental health. Pharmacists should be aware of the changes and opportunities associated with this funding. In an era when dramatic change has the norm, it is vital to remain vigilant to the changes in healthcare that impact our profession. As mental health becomes the focus of national attention, we must remain in contact with mental health professionals, patients, and policymakers. It is through contact and communication that pharmacies will have the opportunity to expand into novel areas.

Assessing Patient Needs and Resource Allocation

Despite a growing national budget for mental health services, each state allocates resources differently, and approaches the lack of mental health services in novel ways. Funding is being channeled to facilities, including community counseling services, state hospitals, and private institutions. These funds have been used to improve and expand services such as home visits, crisis care, or substance abuse rehabilitation programs.

Legislation has focused on improving crisis care in Minnesota and Wisconsin, and suicide prevention in Washington.² The Centers for Medicare & Medicaid Services has been evaluating private institutions in 11 states to determine whether they can improve psychiatric care in adults aged 19 to 64 years. In Illinois, a lack of medical prescribers has led the state legislature to grant psychologists limited prescriptive authority. In Missouri, Medicaid spending for mental health has increased from $1.2 billion in 2012 to $1.6 billion in 2014.^4,5 Missouri’s mental health agencies served approximately 25% of the state’s estimated 223,000 residents with serious mental illnesses in 2010.^6,7

Despite efforts to improve mental health treatment and improve access to care, patients may still not be receiving appropriate care. Pharmacists are in a unique position to be advocates for our patients with mental illness as they are the healthcare professional patients see most often. When the patients we see daily are medically underserved, we have the ability to use our position behind the counter as a bully pulpit. We can contact and persuade those in government to allocate appropriate resources of these growing budgets to benefit those with the various forms of mental illness. We can be a voice for those who need it the most.

Pharmacists and Medication Management

The management of many mental illnesses hinges upon counseling, coupled with appropriate use of medications. Some of the reasons for less-than-appropriate care involve medication management, which can be addressed at the pharmacy. In addition to the clinical management of prescription drugs, medication management addresses insurance formulary issues, adherence, access to medication, and any other factor that interferes with a patient receiving appropriate medication therapy.

In a dialogue with patients and providers, pharmacists can assess and define areas for improvement. If access to medication is an issue, then perhaps formulary issues can be addressed, prior authorization requests sent, or copay issues resolved. If a lack of transportation is preventing medication access, the patient could select a pharmacy that offers delivery services. If medication adherence affects the effectiveness of therapy, the pharmacy may have an adherence program in which the patient can enroll, or offer adherence packaging.

Pharmacists are also readily available to counsel patients on side effects or adverse events associated with medications that may lead to nonadherence to a particular regimen. Moving beyond traditional pharmacy practice, pharmacists are positioned to monitor objective information related to mental health medications (eg, sudden weight gain or a rapid upturn in fasting blood glucose) and report it to medical staff. Sharing this type of information benefits patient care, can improve outcomes, and cements pharmacists into the continuum of care for patients with mental health issues.

In addition, sharing clinical services across the spectrum of providers can bring enhanced efficiencies into the mental health patient care model. These enhanced efficiencies and improved care can make a team-based care approach with pharmacy involvement a very cost-effective model. As mental health budgets expand, improved quality of care and outcomes, coupled with increased efficiencies, may increase the likelihood of future funding for one program over another. This could serve to make pharmacist involvement a vital portion of a clinic’s mental health services.

Addressing Mental Health in Missouri

To seize this opportunity and demonstrate the benefit of future funding, our 3 rural Missouri pharmacies are seeking to expand outpatient care services in mental health. We have initiated a dialogue with a local mental health clinic; this clinic has the opportunity to provide services to >2000 patients in 4 southern Missouri counties.^8-11

Many of these patients seek mental health services on a voluntary basis for a variety of issues.^8-11 This local clinic provides services that include psychiatric counseling, crisis intervention, psychiatric rehabilitation, and in-home nursing services for children and adults. Within the care provided by this counseling center is ample room for direct, positive, pharmacy impact. The clinic’s in-home nursing staff organizes medication weekly for patients. However, preparing weekly medication trays and tracking medications can be a burden for in-home nurses. We have offered adherence counseling and packaging for patients; adherence packaging is seen by the clinic as an important, value-added service.

Because the clinic has no effective way to monitor patient adherence, our offer of a proven adherence program—with added reporting back to the clinic’s medical staff via facsimile or phone—was seen as a novel service that could dramatically improve patient care.

Beyond adherence counseling and packaging, we offer comprehensive medication reviews, which is a vital clinical service that was not consistently available to patients previously. We have also offered to expand our reporting services to include blood pressure, blood sugar, weight, and waist circumference reports. In addition, there have been discussions about adding Patient Health Questionnaire (PHQ)-9 or PHQ-2 assessments. These tests screen for depression and inquire about episodes of depression and anhedonia,¹² and can be done at the pharmacy to give the clinic’s medical staff additional patient monitoring capabilities outside of the clinic setting.

We have found communication with the clinic to be of utmost importance. It is only through discussion that you can determine what may be considered a valuable service to the clinic and that clinics can learn what can be done at the pharmacy level beyond the typical practice.

Expanding Novel Mental Health Treatment Approaches

These novel, pharmacy-centric approaches to treating mental health issues have the potential to greatly assist patients with these conditions. The type, scope, and availability of a unique pharmacy service hinges on communication. During discussions with mental healthcare providers, pharmacists can determine what services their patient population requires, and what services will benefit the provider.

To better understand and be able to discuss the needs of patients with mental health conditions and providers, our pharmacies have embarked on a mission to have our pharmacists and staff members become more educated on mental illnesses and mental health issues. The more pharmacists become involved in the delivery of services to patients with mental health issues, the more indispensable those services will become to the patient and the provider. The goal nationally is to better serve patients with mental health needs. These are our patients, seen regularly in our pharmacies. To better serve them represents an opportunity for pharmacists to expand their services and further integrate ourselves into the healthcare team providing a variety of mental health services.

Expanding national mental health budgets can mean new opportunities for pharmacists. It benefits not only pharmacists, but the patients we serve. From behind the counter, we can monitor medication therapies and help patients improve outcomes. We can step from behind the counter to provide novel services based on the needs of other providers and our patients. We have but to listen and communicate. If we listen to our patients and other providers and communicate to them how we can help solve their problems, the doors to new opportunities will open. It will be more than the filling of a prescription, it will be expanded patient care for those with mental illness.

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References

1. US Department of Health & Human Services; Substance Abuse and Mental Health Services Administration. Projections of national expenditures for treatment of mental and substance use disorders, 2010–2020. http://store.samhsa.gov/shin/content//SMA14-4883/SMA14-4883.pdf. Published October 2014. Accessed August 31, 2015.
2. National Alliance on Mental Illness (NAMI). State mental health legislation 2014: trends, themes & effective practices. www2.nami.org/Template.cfm?Section=Policy_Reports&Template=/ContentManagement/ContentDisplay.cfm&ContentID=172851. December 2014. Accessed August 31, 2015.
3. Healthcare.gov. Essential health benefits. www.healthcare.gov/glossary/essential-health-benefits/. Accessed September 2, 2015.
4. Missouri Department of Mental Health. FY2012 summary report. http://dmh.mo.gov/about/admin/docs/budgetsummaryreport2012.pdf. September 2011. Accessed September 2, 2015.
5. Missouri Department of Mental Health. FY2014 summary report. http://dmh.mo.gov/about/admin/docs/budgetsummaryreport2014.pdf. September 2013. Accessed September 2, 2015.
6. National Alliance on Mental Illness (NAMI). State statistics: Missouri. www2.nami.org/contentmanagement/contentdisplay.cfm?contentfileid=93504. Accessed August 31, 2015.
7. National Alliance of Mental Illness (NAMI). Election 2010: state-by-state data; How many people with mental illness are being served? Are candidates addressing the facts? www2.nami.org/Template.cfm?Section=press_room&template=/ContentManagement/ContentDisplay.cfm&ContentID=107945. September 28, 2010. Accessed August 31, 2015.
8. Mississippi Department of Mental Health. Mississippi County Division of Behavioral Health: psychiatric services. http://dmh.mo.gov/ada/countylinks/docs/mentaltreatment-mississippi.pdf. Accessed August 31, 2015.
9. Mississippi Department of Mental Health. Stoddard County Division of Behavioral Health: psychiatric services. http://dmh.mo.gov/ada/countylinks/docs/mentaltreatment-stoddardt.pdf. Accessed August 31, 2015.
10. Mississippi Department of Mental Health. Scott County Division of Behavioral Health: psychiatric services. http://dmh.mo.gov/ada/countylinks/docs/mentaltreatment-scott.pdf. Accessed August 31, 2015.
11. Mississippi Department of Mental Health. New Madrid County Division of Behavioral Health: psychiatric services. http://dmh.mo.gov/ada/countylinks/docs/mentaltreatment-newmadrid.pdf. Accessed August 31, 2015.
12. Center for Quality Assessment and Improvement in Mental Health. Stable resource toolkit. www.integration.samhsa.gov/images/res/STABLE_toolkit.pdf. Updated October 27, 2008. Accessed September 1, 2015.