Does a pharmacy degree prepare you for advising suicidal patients?

Peter Kelly

A NUMBER of years ago in a previous job, a young attractive foreign national called into the pharmacy late on a Friday evening asking to speak to the pharmacist. I instantly saw, she was clearly very upset. I brought her into the consultation room. She was very direct and urgent with her query.

“Will taking three full boxes of ibuprofen tablets kill you?”

Instantly I started to think, why do you want to know? Do I need to ring an ambulance? Did you take that many?

She explained that it was her boyfriend. He had taken three packets of ibuprofen tablets and disappeared – she didn’t know where he was now. I checked the British National Formulary (BNF), searched some medical websites and then explained that I wasn’t certain, but I suspected that it would not kill him. However, I told her that if he showed up she should ring an ambulance ASAP.

She thanked me, left the pharmacy and I thought that was the end of the story.

A few weeks later, as soon as we opened on Monday morning there was a queue at the counter. I approached a young man in the line: “Can I help you?” I asked.  His eyes started to well up, so I suggested we talk in the consultation room.

In the consultation room he regained some composure. He handed me a bag of medicines which I dispensed for him the previous Friday. He said he had to give me back the medicines. I looked in the bag and the first thing I saw was a six week course of steroids. Anyone who works in health will know that steroids are never given out for frivolous reasons.

I asked him why he was prescribed the medicine. He told me he had Crohn’s disease and it was to be taken in preparation for surgery.

I told him that it wasn’t a good idea to bring them back, as he needed to take them. He then started crying and went to get up to leave the consultation room. I shouted at him to stop! Sit down! And tell me what is going on!

He then calmly and candidly told me that, he had spent the entire weekend staring at the bag, resisting the urge not to take all the tablets.  Suddenly it clicked, that this was the same guy who had taken all the ibuprofen.

“Have you done this before with ibuprofen?” I asked him.

He confirmed it was him, and it was his girlfriend to whom I had previously spoken.

I told him that it was likely he was depressed and he needed to go to see his GP. He needed to tell his GP, that he was having suicidal thoughts. I got the number for the Samaritans local branch and told him he was not leaving until he spoke to them. He could use my phone and the consultation room to have a private chat. I told him I would hang on to the tablets, but he would call in every day and take the tablets he needed to take for that day until he had surgery. It also meant I could talk to him every day and gauge his mood.

He really believed he was not depressed. He began to tell me how he had been a complete idiot. He and his girlfriend had left their home country hoping to make a better life for themselves. He said things started ok, they both got jobs, then they had an unplanned pregnancy.

From what he said, I believe his girlfriend had post-natal depression, because he kept saying she didn’t care about the baby. I told him, that while I didn’t know how she felt about the baby, I knew she cared about him, as she had come to see me, very worried when he had taken all the ibuprofen. Then on top of that, he got Crohn’s disease and could not work.

Help and advice
I asked him a few basic questions about his lifestyle. He wasn’t sleeping, he wasn’t eating properly or doing any exercise.   I suggested that it was important that he took steps to help get on top of his health: start eating properly, sleeping, exercising and he need to somehow learn to relax. Every day after that when he came in for his daily tablets, I asked how he was progressing. He went to the doctor and started antidepressants, he started going for long walks every day, he started eating properly and sleeping better.

A couple of months after the surgery he called into see me and brought along his mother. He wanted to introduce her to me, which I found a little embarrassing. He told me that the surgery went well, he was back to work, his mother was over helping with the baby and his relationship had improved slightly, but was still not very good.

Over the years I have encountered suicidal patients on numerous occasions working as a pharmacist, but this one always stands out mainly because he was younger than me, he looked good, together they were a great looking couple. It reminded me that depression and suicide can affect anyone. I was more used to talking about suicide with patients who were very old or had major drug and/or alcohol problems.

Further reading
Do I think my pharmacy degree prepared me adequately for dealing with this patient?

To be honest, no. Now, I can’t speak for every school of pharmacy and I can’t speak for my own, with complete certainty (because I did miss some lectures) but I don’t ever remember suicide being spoken about at university.

However, I did feel comfortable and competent dealing with this situation. A few years before I had read a great book on suicide called, Night Falls Fast: Understanding Suicide, by Kay Redfield Jamison.

The book is an absolute masterpiece and essential reading for anyone in health or anyone affected personally or who has a family member or friend by depression.

Kay Redfield Jamison is a Professor of Psychiatry at the Johns Hopkins University School of Medicine and is an Honorary Professor of English at the University of St Andrews. The ambition of the book is huge. Her goal was to gather together all the scientific data on the topic and present it in a readable form – which I believe she achieves. What makes the book more interesting is that suicide and depression run in her family and she has battled it herself her entire life. So she also details her own struggles.

The facts and figures are astonishing as they always are with suicide. In 1998, 2% of all deaths were caused by suicide, that puts it way ahead of war and homicide. Every 17 minutes someone in the United States commits suicide. In 1995 more young people died (again these figures are for the US) of suicide than of AIDS, cancer, stroke, pneumonia, influenza, birth defects and heart disease combined. When you read that last line, it seems incredible that I can’t remember studying suicide at university as I can clearly remember, studying all those other conditions.

The book left me in no doubt that there is a very strong connection between poor mental health and suicide. Here is a passage from the book:

“It is tempting when looking at the life of anyone who has committed suicide to read into the decision to die a vastly complex web of reasons; and, of course, such complexity is warranted. No one illness or event causes suicide; and certainly no one knows all, or perhaps even most, of the motivations behind the killing of the self. But psychopathology is almost always there, and its deadliness is fierce. Love, success, and friendship are not always enough to counter the pain and destructiveness of severe mental illness.”

Action required
The unacceptably high levels of suicide in our societies will remain until we take mental health as serious if not more serious than physical health. Mental health services are notoriously underfunded. Mental health education and discussion attracts a fraction of the time, energy and resources put into physical health education and discussion.

Mental health affects everyone. Your mental health is in constant flux the same way your physical health is. While most people will avoid severe, debilitating mental health illness in their life, everyone will have times in their life when their mental health is at a low ebb. I believe we need to be more honest about that and we need to invest much more resources in mental health services and research.

Peter Kelly is a pharmacist based in London. He recently started a public health campaign, ‘5 Simple Steps to Healthy Living.’ He runs healthy living workshops in London Colleges with his friend and qualified personal trainer Shea Jozana, you can follow their progress on the Facebook page: The friendly pharmacist