Ciara Ni Dhubhlaing, Specialist mental health pharmacist, President of the College of Mental Health Pharmacy
Why did you become a pharmacist?
I have wanted to be a pharmacist since I started thinking about career options at around age 15. I’m not sure what influenced me really, but I enjoyed science and I wanted to be involved in direct patient care. Medicine wasn’t for me – too many negatives with the duration of the study and working hours and too much ‘icky stuff’!
Could you describe your career pathway so far?
I was offered a place on the Pharmacy course at Aston University but deferred it for a year to do first-year Science at Trinity College Dublin. Here I got to learn more about physics (which I hadn’t studied in school) and thoroughly enjoy fresher life without the worry of exams at the end. Studying at Aston ignited my interest in mental health and my preregistration year, split between City Hospital in Birmingham and Murray’s Pharmacies, a small independent chain in Cumbria, cemented it. It is an area in which clinicians have the opportunity to really engage with and think about the patient as an individual and what treatment would suit their needs best rather than which slot they fit into in a guideline. Working in palliative care was plan B for the same reason.
I initially worked as a relief pharmacist in community whilst completing the Aston Certificate in Psychiatric Pharmacy before obtaining a mental health post in Morecambe Bay Primary Care Trust (later Lancashire Care Trust) in 2004. There I was able to work on hospital wards including Acute Assessment Units for Adult, Elderly, and Dementia patients, a PICU, a Forensic Low Secure Unit, an Alcohol Detoxification Unit, and a Tier 4 CAMHS unit. I also worked with Supported Housing, Adult and Elderly CMHTs, CRHT, AOT and EIS Teams. Whilst in Cumbria/Lancashire I attended College of Mental Health Pharmacy (CMHP) Psych 1 and 2, completed my Postgraduate Diploma, and obtained my non-medical prescribing qualification.
On my route back home to Dublin, I took a minor detour into physical health working on a respiratory ward in Derry for nine months. It was a great boost to my confidence to realise my skills as a pharmacist were universal and I could still be useful on a physical health ward. Some people think working in MH is disheartening, but I found it more difficult to deal with the comparatively frequent deaths from lung cancer, pulmonary embolisms, cystic fibrosis, infections etc. that occurred on the respiratory ward. In October of that year I finally returned home to work in St John of Gods and then St Patrick’s University Hospital. Both are private not for profit mental health hospitals which is quite a change from the NHS. It was a big adjustment to leave the NHS and come to a fragmented health service with multiple providers and tiers of service, no defined role for pharmacists within MDTs, and no pharmacist non-medical prescribing. However, a big advantage has been knowing what works in practice and being able to apply that to develop future services.
I obtained full credentialled membership of the CMHP in 2013 which is still my proudest achievement, though presenting my MSc research at the CMHP Conference in 2015 is a close second.
Could you describe a typical working day for you?
In my day job, I am Chief Pharmacist in St Patrick’s University Hospital in Dublin. This is Ireland’s largest, independent, not-for-profit mental health service with just over 300 inpatient beds and several outpatient centres. I manage a total of 18 staff members, including part-time staff and vacant posts, and we have a dispensary on-site.
I typically start the day following up on emails and voicemails and checking what has been prescribed for my patients on our ePrescribing system (RiO) overnight. I have learned that it’s best I have minimal verbal interaction with people first thing in the mornings as I’m definitely an owl not a lark. I may have to rearrange the rota if there is sick-leave and advise clinical pharmacists if there is a change to the wards they are covering. We work in a shared office so communication is straightforward.
Once any urgent medication is ordered, I will then go to the ward(s) I’m covering to see if any additional items are required and I will see new admissions for medicines reconciliation.
I often have a meeting around 11am (e.g. the clinical governance committee, drug and therapeutics committee, or falls committee) and if there is time after that I will try to speak to any patients I didn’t see earlier to complete medicine reconciliation. Occasionally I will take my morning tea-break and catch up with what is happening in my work-colleagues lives.
We close for an hour for lunch and I try to get out for some fresh air if it isn’t raining. That doesn’t happen too often in Ireland though.
After lunch I see what changes have been made to medications, follow up on queries and/or prescribing errors with the doctors, and spend an hour or two working on management tasks, staffing, policies/SOPs etc. Most often, those couple of hours fall from 4.30pm onwards. CMHP work gets done after 5pm too but I don’t mind that as I’m at my most alert in the evenings and it means I miss the traffic going home at rush-hour.
Pilates, meals with friends, and time spent with family help me to relax in the evenings so that I’m ready for the next day at work.
Are you a member of any professional bodies? Which ones and why are you a member?
I joined the College of Mental Health Pharmacy (CMHP) in 2005 and was Co-opted onto the CMHP Council in October 2014. I have since been elected and held the posts of Assistant Registrar, Registrar and Vice- President. I am currently the President. I’m still getting used to that. It’s hard to comprehend as I recall the high esteem with which I held Council members and longstanding CMHP (and formerly UKPPG) members’ knowledge and expertise. Imposter syndrome affects most of us to some degree, but I’m driven to carry on the legacy of those who have done outstanding work before me.
I joined the Executive Committee of the Hospital Pharmacy Association of Ireland (HPAI) in Feb.’16. I wanted to ensure the voices of pharmacists working in mental health were heard, and I wanted to get to know more of my peers in the Republic of Ireland. Working with Chief Pharmacists and colleagues through this Committee has given me the confidence to advance my career and access to experienced colleagues to seek advice from where necessary.
What is credentialing and why does it matter?
Credentialing with the CMHP is a huge achievement as it is recognition of your expertise from a panel of your peers. Having held the posts of Assistant Registrar and Registrar for the College, I know what an undertaking the assessments are and how seriously the assessors view them. Putting together a portfolio of evidence of expertise and sitting a viva ensures we have a comprehensive picture of the applicant’s knowledge and skills, so having the honour of using the post-nominals MCMHP is an important validation.
What are the big issues that concern you at the moment in mental health pharmacy?
We talk a lot about stigma in society but an issue I have only become aware of in the last few years is the stigma of mental health amongst healthcare professionals. I have experience of a colleague whose wards were not covered whilst she was on maternity leave as no-one wanted to cover the mental health wards, and I have had a conversation with a highly experienced pharmacist who had no problem seeing a patient for warfarin counselling but was very apprehensive about lithium counselling. Add to this that the most frequent question asked when we do talks to community pharmacists is “how do I talk to someone with mental health problems?” and I do think we have a real problem with awareness and understanding of mental health. (The answer is “just the same as any other one of your patients”, in case you were wondering!)
With more pharmacists moving into primary care, many have identified a need to improve their knowledge in the area of mental health and the CMHP is working with CPPE, MORPh and others to provide opportunities for education, but it would be great if undergraduate training was going further to meet that need sooner.
What are the risks of pharmacists taking on more responsibility in the area of mental health pharmacy?
Pharmacists have significant expertise in assessing risks and benefits of various scenarios. I think the majority will recognise their limitations and the areas in which they can add value. However, there are some people who lack a degree of self-awareness and/or may present themselves as having expertise which may not be valid. Use of non-protected titles such as Consultant Pharmacist should not be encouraged except for those who have followed the recognised pathways to obtain such titles to ensure that only experienced Pharmacists have responsibilities appropriate to their level of expertise.
Are there any particular traits or skills that pharmacists who specialise in mental health need?
Empathy and compassion are essential, although people must also learn self-care and how to protect their own mental health. Flexibility backed up by a knowledge of what the boundaries of guidelines are (and why) usually results in good patient outcomes.
What contribution in caring for people with mental health issues would you expect from a community pharmacist?
Community Pharmacists are tremendously important to patients with mental health issues. I am always delighted when completing medicines reconciliation if my inpatients tell me to ring the pharmacy and ask for their pharmacist by name. There is a lot of trust there in the health professional they often have the most contact with.
Do you think suicide prevention techniques should be taught to community pharmacists?
Yes, definitely.
Mental health first aid should be seen on a par with basic life support courses, and more widespread uptake may also reduce stigma. There is a wonderful suicide prevention taxi service in Ireland (taxiwatch.ie) where drivers learn how to bring up and discuss suicide with passengers whom they may identify as vulnerable – it’s nothing magical, just talking and signposting, but it can be just the right thing at the right time to change someone’s path. Similarly, the Foyle Search and Rescue Services in Derry have set up patrols to make contact with and provide another way for those in distress who may be contemplating suicide. These are not healthcare professionals, but their work is making a big difference. Imagine what a community pharmacist could do with their knowledge and skills!
What has been your proudest moment so far as a pharmacist?
Becoming a Credentialed member of the CMHP!
As a profession how should we reward pharmacists for outstanding practice?
I would like to see more consultant pharmacist posts being funded with clear requirements and a recognised pathway that identifies outstanding practice.
One of the best things about the CMHP is that it is a forum for sharing best practice and therefore improving standards of practice internationally. We celebrate such good practice with our poster and oral presentation awards at our Annual Conference and we are now publishing the award-winning abstracts in the Online Journal of Psychopharmacology for wider dissemination. Recognition of work being done is good for individuals and for the profession as a whole.
Are you optimistic about the future of pharmacy in the UK?
This is difficult to answer as a Europhile. On a day to day level pharmacists will continue to provide skilled care and expert medicines management but there are certainly challenges ahead with medicines shortages due to global drug supply issues and Brexit; the increased power of politicians to change the structure and function of the NHS; and the ever-increasing demands of the health service. I have no doubt, however, that pharmacists will always do the best they can for their patients no matter the circumstances.
What’s next for you?
I’m going to have my hands full for the next few years developing my department as Chief Pharmacist and being President of the CMHP. I have plans to introduce an admissions pharmacist role – something which is new in mental health in Ireland and I will be looking at opportunities to maximise the impact of clinical pharmacists through limited prescribing roles. We will be surveying CMHP members early in the new year and taking direction from them as to the future development of the College so, no doubt, that will generate some interesting and engaging workstreams over the next few years.
What advice would you give to pharmacists who wish to pursue a career in mental health pharmacy?
Go for it!
If you’re interested, you’re more than halfway there. Mental health pharmacy isn’t for everyone. There is ambiguity, legitimate treatments that may be outside the guidelines, and patients’ behaviour may sometimes vary more than with other health conditions. But, if your pedantic pharmacist nature can accommodate that and maintain empathy for your patient whilst keeping their best interest at heart, you will thrive.
Ciara Ni Dhubhlaing MPharm, MSc, MPSI, MCMHP. is Chief I Pharmacist at St. Patrick’s University Hospital, James’ St., Dublin 8. She is also the President of the College of Mental Health Pharmacy (CMHP)