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Abstract
Study objective The aim of this study is to gain knowledge on the opinion of psychiatric patients about the provision of drug information so that the psychiatric hospital pharmacist can consider opportunities to be directly involved in patient care.
Methods Qualitative interviews were performed in a convenience sample of psychiatric patients. The interviews were audio taped, transcribed verbatim and coded. The questions concerned the content and the format of information, the information provider and the possible role of the hospital pharmacist.
Results The sample consisted of 16 patients. Nearly all topics covered by the summary of product characteristics, especially side effects, were considered. Patients were open to a wide variety of drug information formats. They spontaneously named the psychiatrist, general practitioner and nursing staff as the most appropriate people to provide drug information. The hospital pharmacist was not spontaneously mentioned.
Conclusion Psychiatric patients did not identify the hospital pharmacist as being a partner in their treatment. This provides a challenge for the development of clinical psychiatric pharmacy.
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Introduction
The number of patients taking psychotropic medication is steadily increasing. Antidepressants are the most commonly used drugs within the therapeutic class of psychoactive medicines. In 2006, 198 million defined daily doses (DDDs) of antidepressants were prescribed in Belgium (10 million inhabitants), whereas 10 years earlier, in 1997, the number of DDDs was 81.5 million. For neuroleptic drugs the figures were 11.4 million in 2006 and 7.5 million in 1997.1 As far as possible, patients with a mental illness are treated in ambulatory care. When admitted to hospital, patients often need a long stay to recover. Whether treated as an inpatient or as a day case in hospital, the treatment is intensive and requires a profound collaboration between the patient and the hospital staff. However, readmission rates are high; it is estimated that 80% of patients with schizophrenia are readmitted within 2 years.2
When considering the provision of drug information in psychiatric hospitals, the identified experts in the field are mainly medical doctors and nursing staff. It may be asked to what extent hospital pharmacists, more particularly clinical pharmacists, play a role in providing information on drugs. Clinical pharmacy is a health specialty, which describes the activities and services of the clinical pharmacist to develop and promote the rational and appropriate use of medicinal products and devices. The focus has moved from the drug to the single patient or population receiving drugs. Clinical pharmacy includes all the services performed by pharmacists practising in hospitals, community pharmacies, nursing homes, home-based care services, clinics and any other setting where medicines are prescribed and used (http://www.escpweb.org/cms/Clinical_pharmacy). In Belgium clinical pharmacy has systematically been introduced in the hospital setting over the past decade.3 Reports on clinical pharmacists in Belgium being involved in direct patient care have started to appear in the literature.4 The pharmacist could play an even more important role in psychiatric hospitals compared with, for example, surgical wards because interventions in psychiatry are less technical and communication with patients on their medicines may result in a more constructive way of thinking and provide more satisfaction.5
It is believed that drug information may empower patients and help them to recover.6 ,7 To date, research on this topic in population samples with mental illness is limited. A study of 279 psychiatric patients interviewed in a hospital setting demonstrated that there was a negative correlation between the intrinsic desire of information (IDI) and the number of medicines taken and between the IDI and the duration of admission.8 When further investigated, the extent of information desired (EID) was not led by social desirable behaviour, which implies that the opinion of psychiatric patients on information about medicines may be considered reliable.9
A review showed that structured education of mental health consumers can contribute to improvement of knowledge and may enhance compliance, but does not influence relapse.10 A combination of oral and easily understood written information seems to have added value compared with oral information alone and can increase satisfaction. The role of the psychiatric hospital pharmacist remains to be determined.5 ,11
The aim of this study is to gain knowledge on the opinion of psychiatric patients about provision of drug information so that opportunities for the psychiatric hospital pharmacist as a member of the staff communicating with patients can be considered.
Methods
Given our own experience in researching desire for information in psychiatric patients,8 ,9 a qualitative approach using semi-structured interviews in a convenience sample of psychiatric patients was chosen as an appropriate method to investigate the opinion of these patients on the provision of drug information.
The interviews took place in a psychiatric institution affiliated to the university (number of beds for inpatients=365). Patients who were at least 18 years old and took at least one psychotropic drug were eligible for the study. Inclusion of patients in the study was decided by senior ward nurses.
Patients who consented to participate in the study completed the EID scale to measure the desire for information. The cutoff value for high EID was defined as 19 (EID≤19=low; EID>20=high).8
A standardised semi-structured interview consisting of four open questions was then conducted. The questions covered the following aspects about drug information: what kind of information and why; the format and the source of the information; information providers; and the possible role of the hospital pharmacist. The patients knew that the interviewer was a pharmacist. If questions about the drug regimen were asked, patients were referred to the treating psychiatrists. The interviews were audio taped and transcribed verbatim. Data collection was conducted until no new themes were appearing.
Interviews were analysed according to the five stages of the thematic framework approach described by Pope et al: familiarisation, identifying a thematic framework, indexing, charting, and mapping and interpreting.12 The software QSR NVivo 7 was used in the analysis of the interviews.13
A thematic framework was built on consensus between two readers (SDC and FD). The interviews were coded independently by these two readers (indexing), after which any discrepancies in the findings were discussed until consensus was reached. If needed, a third reader assisted to consent on the codes. Quotes by patients were also selected on consensus.
Results
Our approach resulted in 16 interviews with psychiatric patients (mood disorder, n=3; schizophrenic or psychotic disorder, n=11; personality disorder, n=2; ratio men/women: 10/6; mean age 34 years, age ranged from 18 to 59 years). According to the cutoff value for high and low EID, there were eight patients in each group.
Interviewed on the kind of drug information required, patients spontaneously mentioned the reasons for their desire for information (or the absence of the desire), and the topics to be covered. Asking for drug information was driven by an eagerness to learn about their medicines and by the enhancement of knowledge. The desire to obtain information was also accompanied by the willingness to do something with the knowledge acquired. Information desire was also influenced by previous negative experiences with medicines and feelings of anxiety or concern.
Considering the content of drug information, nearly all topics covered by the summary of product characteristics, especially side effects, were mentioned. However, some other aspects emerged, such as the possible addictive character of psychotropic drugs and the way to taper or stop medication.
Patient 16602 (EID score: high): “Yes I want to know as much as possible. After all, I will have to use this medication the rest of my life, isn't it?”
Patient 6087 (EID score: low): “Yes, because I want to avoid any accident … by taking too much of the medication. I really want to avoid taking too much.”
Patient 36788 (EID score: high): “I want to know about side effects: will you feel sleepy … and if your depression is getting worse while taking antidepressants … Loss of hair is also important to me … Bouts of overeating and stuff like that.”
Patient 16602 (EID score: high): “I suffer already a lot of gaining weight and of impotence. It's difficult already and I want to know as much as possible.”
Patient 36857 (EID score: high): “Why I am suffering of constipation. I need to use macrogol each morning and … a few times a week bisacodyl. Why I am having this? How long will this last? Will it stop in the future? … Also I have a clear appetite increase: I eat quite a lot of chocolate and chocolate spread. Why I am having this and how long will I have this?”
Patients seemed to be open to a wide variety of formats from verbal to written information, video, DVD, and a combination of formats. A number of patients had a clear preference for a particular format. Some of them were willing to read the summary of product characteristics and one appreciated having access to a scientific library to be able to find answers to particular questions. Additionally, common complaints on drug information were given: redundance of information, information too technical to be understood, lack of time during consultation or no contact person permanently available to answer specific questions.
Patient 35247 (EID score: high): “Oral information yes, but also on paper. So I can read it again … they can say important things, and you can have an extra look at it.”
Patient 35755 (EID score: high): “If someone tells you personally it seems like more … like you understand it better and that you can ask questions.”
Patient 36788 (EID score: high): “I prefer to read the formulary of the medical doctors … but I do not have access to it, it is forbidden (in the hospital).” Interviewer: “Why do you want to read it?” Patient: “Because to know more about side effects … the formulary of the doctors contains more information: for each drug it mentions how it works and why it is used for. You can explore more.”
When asked about the most appropriate people to provide information, patients spontaneously cited the treating psychiatrist, their general practitioner and the nursing staff. Some of them preferred taking initiatives themselves to obtain the information desired. Others were open to receive information from any care provider. The professional knowledge of the information providing person was highly scored. Another factor determining the appropriateness of the information provider was the confidence in staff members well aware of the pathological background and the situation of the patient. Independent from the professional background, patients appreciated receiving information in a simple and understandable form.
Patient 35247 (EID score: high): “hmmm … the doctor has studied, I mean he has more experience … it is the same with nursing. They have the most experience and they are sometimes capable to give clear explanation.”
Patient 25755 (EID score: high): “I prefer someone who is knowledgeable, like the nursing staff … I am a bit reluctant to (information from) other people … but I like information from the doctor the most as he prescribes and he knows why.”
Patient 30864 (EID score: low): “I think that nurses do not know as good as the doctors. But of course some of them know: like lorazepam has been used for many years, and they know why it is used. For other drugs this is not the case: for example, quetiapine is only for four years on the market. The nurses don't know so much about it. Doctors are better informed.”
Patient 539 (EID score: high): “Because I think he (the doctor) does know what he's prescribing and why … He knows my situation.”
The hospital pharmacist was never spontaneously cited as having a role in the information providing process. When given the hint, some patients were “tolerant” to the hospital pharmacist as a person that could also provide some information about medicines, but this was not the opinion of all patients interviewed.
Patient 36857 (EID score: high): “euh … yes he is also in … he is … he delivers the medicines and he can also … That the one who takes care of medicines and medicines being brought to the patients, that the one doing that should give more information. I can imagine that, but it is not obvious for me. But he may, yes.”
Patient 30864 (EID score: low): “The pharmacist? No, no, not at all. A pharmacist is not the one asking questions to, it is just a shop where you get your pills.”
Patient 26857 (EID score: high): “It might be the pharmacist but he does not have time for this … To be honest, I haven't seen him much.”
Patient 21137 (EID score: low): “I don't see the pharmacist as a real source of information. To my opinion, the doctor is the source of information.”
Patient 9366 (EID score: low): “Because the pharmacist is not prescribing my medicines and because I don't know any pharmacist on the ward.”
Discussion
Psychiatric patients want the same topics to be covered in information on their medicines as patients in a general setting, and have a special interest in information on side effects. According to patient opinion, the way of disseminating information can still be improved. This was also seen in a recent study by Walsh and Boyle.14 Efforts have to be made to tailor information to the needs of the patients. To achieve this, the hospital pharmacist was not considered by the patients interviewed.
There are weaknesses in the approach used in this study. First, we limited our interviews to only one psychiatric hospital. This may affect our conclusions because other psychiatric hospital pharmacists may well be respected members of the team in direct contact with patients. However, we know from informal contacts that in other Flemish psychiatric hospitals the hospital pharmacist is still not systematically involved in providing drug information to patients.
Another limitation may be the patients themselves. Some psychiatric pathological conditions may influence patients' opinions towards the role of the pharmacist. Using the cutoff value as indicated, we recruited an equal number of patients with a low and a high EID. We know that the desire for information in a psychiatric population is not dependent on the diagnosis but correlates negatively with the number of medicines and the duration of treatment.8 There are no data about possible associations between the psychiatric condition of the patient and the possible openness to the hospital pharmacist. Only communicative patients were eligible for interview which was assessed by the senior ward nurses. One could argue that non-communicative patients are non-communicative to all care providers, and would not prefer the hospital pharmacist as the contact person.
Finally, the study was limited to the role of the pharmacist in provision of drug information in this psychiatric hospital. No formal questions on information provision by other members of staff, such as doctors and nurses, were included in the interview guide. However, the patients' responses indicated that information gained from doctors and nurses was reliable and they were valued as trustworthy people.
Considering the opportunities for the psychiatric hospital pharmacist as a member of staff communicating with patients, the people–process–product algorithm may be used. In this case, people represents the patients themselves and their care providers. The process is related to the dialogue on information about drugs in a psychiatric hospital. The product relates to the opinion of patients when reflecting on the drug information process.
People
When psychiatric patients express a positive desire for information about the drugs they have to take, a learning component can be identified. As patients want to do something with the knowledge they obtain, a structural partner in the acquiring and using of knowledge is needed. This partner should also play an important role in the dialogue with the patients when negative feelings or experiences keep them from intellectually participating in the therapeutic process. Medical doctors and nursing staff were seen as the most appropriate people to provide drug information. Apparently patients made the link between diagnosis and insight into the pathological condition and the preferential contact person when drug information was provided. Nevertheless there existed some openness to other healthcare providers. The reason why hospital pharmacists were not mentioned could be related to their (in)visibility in the caring process and to former experiences in ambulatory care. However, the literature shows that the pharmacist may have a positive influence on treatment outcomes in psychiatric patients, in a hospital and an outpatient setting. Pharmacists have been reported to efficiently monitor the drugs prescribed, with patients functioning as well as or even better than other patients monitored only by psychiatrists.15
Process
A wide variety of information processes were cited by patients as appropriate means of providing drug information. Among these, one patient wanted access to the scientific library so that he could study his medicines. Given the diversity of sources and the fact that the information is often too technical to be understood, patients complained about not being able to retrieve the information wanted. The need for a contact person permanently available to answer specific questions was expressed. The role of a specially trained pharmacist as a resource in psychopharmacology and a provider of direct patient care has been highlighted in rural community mental health centres, with patients indicating that they were at least as satisfied with their care as patients who received care from other mental health professionals.16 ,17
Initial models of collaborative care in psychiatry were based on collaboration between family physicians, psychiatrists and nurses. Nowadays collaborative care has been expanded to patients' psychologists, social workers, occupational therapists and finally also pharmacists.18 Based on our interviews, this large scope is not univocally welcomed by patients as far as drug information is concerned. Therefore, we think that the role of the pharmacist in collaborative care should be carefully discussed by the staff caring for the patient and with the patient before implementation. Preferentially, counselling on the drug regimen should start when requested by the patient or his/her relatives. If there is no request from the patient, carefully initiating the counselling process might still be an option. ‘Unilateral’ counselling by the pharmacist, however, should be avoided, especially as most of the patients interviewed did not identify the pharmacist as belonging to the hospital staff, or the caring team. If initiated by the pharmacist, a presequence during which a full counselling session is offered should enable patients to give their consent. In a second session the pharmacist can offer well defined counselling to the patient, who can again be compliant or refuse to participate. The pharmacist's behaviour has to be respectful to the patient throughout the counselling process. They should regularly ask: “Do you want me to just explain?”19
Product
Patients considered the professional knowledge of the information provider as an important factor determining their consent to receive information. Independent from the provider's professional background, the patients appreciated receiving information in a simple and understandable format. When the competences of all the caring professions are taken into consideration, hospital pharmacists have the most extensive drug knowledge. Therefore, they should be able to use this knowledge in caring for patients, either directly or through hospital staff. There have been reports of education programmes on psychopharmacology run by hospital pharmacists, resulting in well educated clinical staff in hospitals.20 What is possible for psychiatric healthcare professionals is also possible for patients, as long as the pharmacist is skilled in communication techniques. More particularly, pharmacists could contribute to the humanistic approach to patients when psychiatry is tending too much to the medical model of caring instead of the educational or self-empowerment model. Therefore, the language used must sustain the personal growth of an active patient if possible.21 Finally, the pharmacist must be well aware of the limits of enhancing knowledge and the relation between knowledge and behaviour.22 It is our opinion that, when these conditions are fulfilled, a counselling session with the hospital pharmacist may achieve a positive outcome regarding the patient's knowledge and treatment adherence, and if possible, a self-supporting patient.
Key messages
Psychiatric patients did not identify the hospital pharmacist as a partner in their treatment.
Finally, recent literature on clinical pharmacy interventions in mental health suggests that adherence and even clinical outcomes can be improved. Pharmacist-conducted medication reviews and recommendations to optimise medication use may reduce the complexity of the medication regimen.23 These results tend to support the continued expansion of the pharmacist's role in this setting. Pharmacists were reported to be willing to take up such an extended role.24 However, the hospital studied in this paper did not provide any clinical pharmacy services at the time of the study.
Conclusion
The psychiatric patients interviewed in this hospital setting did not identify the hospital pharmacist as a partner in their treatment. Nevertheless the literature suggests there is potential for hospital pharmacists to actively support psychiatric patients in their pharmacotherapy. However, according to our results, there still seems a long way to go before the clinical psychiatric pharmacist is actively involved in supporting patients.
Acknowledgments
The authors are indebted to all patients who participated in the study and to Reverend Sister Clara and Reverend Sister Stefana of the University Hospital Kortenberg who logistically facilitated the study
References
Footnotes
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Funding A non-restrictive grant was obtained from Janssen-Cilag via the Belgian Hospital Pharmacist Society.
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Competing interests None.
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Patient consent Obtained.
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Provenance and peer review Not commissioned; externally peer reviewed.
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Data sharing statement The interviews were tape recorded and verbatim transcribed. They are kept securely and are only accessible to the authors of this article. Citations were selected from the texts and the remainder have not been published.