Hayley Gorton
THIS is the final in my blog series aimed at raising awareness of suicide as a major public health priority. In this blog, I will offer some possible ways in which pharmacists and pharmacy teams might contribute to suicide prevention activities. These suggestions are my own opinion, plus some from discussion with BPSA students when I spoke at the Pennine Area Conference.
Community pharmacists are the most frequently visited healthcare professional in the UK. Although patients can visit any pharmacy, patients often choose to use a regular pharmacy over many years. Pharmacy teams are well positioned to identify changes in a person’s wellbeing, and may have an understanding of their changing medical, personal and social factors. This might be benefited by long standing service and good local knowledge common in pharmacy support staff, who are often more static than pharmacists. They could flag these patients to the pharmacists or simply ask ‘are you ok?’ There may be opportunities for signposting, to local healthcare providers or national support groups (examples of which are listed below), and there could be cases where safeguarding is appropriate.
Awareness
The whole team can be aware of frequent buyers of over the counter (OTC) medication and intervene if excessive quantities are requested, or frequent requests are made. This could aid prevention of both suicide and accidental poisoning. It is of great concern that in a recent study of paracetamol sales, 58 per cent of non-pharmacy outlets sold more than the legal amount of paracetamol and similar numbers sold multiple paracetamol-containing combination products [1]. We are equipped with the training and knowledge to make simple interventions such as reminding of the maximum daily dose of paracetamol and not to take paracetamol with cold and flu remedies or other pain killers which contain paracetamol.
Pharmacists might identify medicines sometimes implicated in overdose during the clinical check. This could lead to additional counselling of the patient and, where appropriate, discussion with the prescriber. For example, a maximum of two weeks supply of dosulepin is recommended, due to its inherent toxicity [2]. Additionally, pharmacists might be able to identify patients with a high risk of suicide from their prescribed medicines (e.g. those for depression, bipolar disorder etc). They could then counsel patients and explore feelings during Medicine Use Reviews (MUR).
Counselling
Similarly, pharmacists have a role in counselling new users of antidepressant drugs (ADD), and might want to emphasise that it can take up to 4 weeks for these medicines to take full effect. In young people up to the age of 24, it is thought that ADDs can increase risk of suicidality, particularly in this early period [3]. It must be remembered, however, that depression is a major risk factor for suicide hence untreated depression could augment risk. By definition, the introduction of ADDs will correlate with worst symptoms to date.
Recently, a qualitative study of patient’s experiences when starting ADDs concluded that there is a need for more support when people start ADDs and currently there is little done at the pharmacy level but suggest ADDs could be a valuable addition to the New Medicines Service (NMS) [4]. This suggestion follows demonstrated benefits from a pilot in Devon in 2014 [5]. I believe this could really benefit patients but my plea is that pharmacists must be trained in suicide awareness and have clear signposting pathways because if we are going to offer a service specifically to the individuals, who might have a high risk of suicide.
New roles
The evolving roles of pharmacists might put us in positions where we are closer to suicide attempts. For example, pharmacists in A&E might encounter people who have taken overdoses, and be involved in post-discharge care. Often people will need to continue medicines, some of which might have been involved in the overdose. In order to restrict the quantity of medication possessed, the GP may choose to prescribe a daily or weekly prescription. Patients could run into supply problems with daily prescriptions if they have to use a different pharmacy on Sundays, for example. To my knowledge there is no clear guidance on how to manage these patients, perhaps our pharmacists in GP surgeries could have a role. Additionally, pharmacists could recommend medicines with lower toxicity in overdose to people who are being managed for self-harm, in line with NICE guidelines [6].
Public health
Suicide is a major public health problem and currently, it is one which us pharmacists probably have little involvement with in non-specialist settings. Much of the identification and management of patients with mental health problems will always fall to highly trained, specialist practitioners. I do believe, however, that increased awareness, conversations and signposting by pharmacy colleagues, could help to recognise people at risk of suicide and go some way to help prevent them. I am working to raise awareness by introducing suicide to the 4th year curriculum at Manchester Pharmacy School and will speak at the College of Mental Health Pharmacy annual conference in October. I hope this blog series has helped your CPD and please do get in touch if you’ve been able to make a difference as a result.
The views expressed in this are those of the author and not necessarily those of the NHS, the NIHR or the Department of Health.
Support resources (non-exhaustive):
Samaritans: 116 123
Mind: 0300 123 3393
Childline: 0800 1111 (children)
Papyrus: 0800 068 4141 (teenagers and adults)
Hayley Gorton is a community pharmacist and a PhD student at Manchester Pharmacy School involved in suicide, medication safety, and pharmacoepidemiology research.
Follow Hayley @hayley_gorton
References
1. Molloy P, Chambers R, Cork T. How well are national guidelines relating to the general sales of aspirin and paracetamol, adhered to by retail stores: a mystery shopper study. BMJ Open. 2016;6(1).
2. MHRA. Drug Safety Update. 2008.
3. Worsening Depression and Suicidality in Patients Being Treated with Antidepressants [Internet]. Silver Spring: FDA [2004; cited 2014 Dec 08].
4. Anderson C, Kirkpatrick S, Ridge D, Kokanovic R, Tanner C. Starting antidepressant use: a qualitative synthesis of UK and Australian data. BMJ Open. 2015;5(12).
5. Horti S. NMS should include antidepressants, say Devon pharmacists after pilot success. London: Chemist & Druggist; 2014.
6. NICE. Self-harm in over 8s: long-term management [CG133]. Manchester: NICE; 2011.