The pharmacist's role in suicide prevention
The community chemist is the first port of call for many minor ailments. However, listening to patients and asking the right questions can lead to the awareness and prevention of a more serious issue.
The sad truth is that more than 5,200 people took their own lives in England in 2022. There are opportunities to intervene, however, and community pharmacists play a vital role. More than 80% of people who die by suicide visited health professionals in the year before death, according to one study.
“We are the informal gateway into the NHS,” says Ade Williams, lead pharmacist at Bedminster Pharmacy in Bristol. “This is about holistic care. If I’m helping you with your migraine but not talking about your suicidal thoughts, your anxiety and depression, am I really helping you at all?”
Community pharmacy is “an everyday place that you can go without being embarrassed”, says Dr David Crepaz-Keay, head of research and applied learning at the Mental Health Foundation.
“Friction can develop between people using mental health services and people delivering them. That’s often about medication decisions. A lot of people report that they get much more independent and accurate advice about the pros and cons of medication from pharmacists than from mental health professionals,” he explains.
Dr Hayley Gorton, senior lecturer in pharmacy practice at Huddersfield University, told C+D that her research found pharmacists want training on suicide prevention. “In community pharmacy, you don’t really know what people are going to talk to you about. They [pharmacists] were having conversations about suicide but they were having to think on their feet; they didn’t know what to do.”
The role of pharmacies as community hubs is vital: “They get to know people, often over many years, and can spot changes and see if someone isn’t quite themselves,” says Dr Gorton, who practised as a community pharmacist until 2021.
Shilpa Shah is a volunteer for The Samaritans and chief executive officer of community pharmacy North East London: “We need training. People need to be confident when talking to people at risk of suicide or any mental health condition.”
In 2020/21 more than 72,000 patient-facing staff completed brief online training from the Zero Suicide Alliance under the Community Pharmacy Quality Scheme. Pharmacies were asked to prepare suicide prevention action plans, including advice on how to respond to reports of suicidal thoughts. But it was a one-off.
“The training will support pharmacy staff to help people as they come in and have conversations. It’s really about increasing confidence,” says Dr Gorton. “But it’s difficult to measure the impact of training in suicide prevention. How long does that increase in confidence last? Does it change the way they behave?”
Shah developed a pharmacist suicide prevention plan with the county council’s public health team when she was chief executive of Kent LPC, up to December 2021. She obtained £134,000 funding to pay pharmacists for interventions. But the scheme was not implemented after she moved on to North East London.
“We need the time to be able to do this work and we need to be remunerated for that time," she says. “Everyone should be able to help a patient in immediate need but if the government wants suicide prevention to be a specific part of our workload it needs to fund it.”
One problem is a lack of communication and explanation. When GPs restrict the supply of medicines to patients at risk, they don’t always tell pharmacists the reason. “If the pharmacy team knew that there was a limited supply due to the risk of someone harming themselves, they could be more vigilant,” says Dr Gorton.
Identifying patients at risk
“Anyone can feel suicidal, regardless of diagnosis,” says Dr Gorton. “Between two-thirds and three-quarters of people who die by suicide aren’t in specialist mental health care.”
The Office for National Statistics (ONS) reports that since 2010 men aged 45 to 64 years have had the highest age-specific suicide rates. More broadly, “people might be particularly vulnerable when they are starting treatment or changing treatments,” explains Dr Gorton.
A pilot scheme is testing including depression in the NHS community pharmacy new medicine service. Running until 31 March next year, it emphasises shared decision-making and supporting patients to manage side effects. Eight primary care networks (PCNs) are taking part. It includes a review of training and clinical support needs for the pharmacists involved.
But there are wider factors to consider. Pharmacists know their patients and can see “if something significant is happening in their lives or they’ve been diagnosed with an illness or long-term condition,” says Shah. “If they have lost a loved one, they come in to dispose of old medicines and we can identify if someone is feeling depressed.” Other triggers include relationship breakdowns, money worries and problems at work.
Have the conversation
“People worry that if they talk about suicide, it might put the idea into somebody’s head. With some very narrow exceptions, any conversation about suicide is way more likely to prevent it than encourage it,” says Dr Crepaz-Keay. (One key exception is detailed discussion of means.)
Dr Gorton agrees but warns, “be prepared for the answer to be yes”. Think about what you’d do next – does the person need emergency help? Should you contact any health professionals already involved in their care? Or signpost them to sources of support and advice?”
Don’t overlook non-medical problems. “If you talk to a health professional and say I’m worried about my relationship, I’m worried about my credit card bill and I’m feeling depressed, they latch onto the depression,” says Dr Crepaz-Keay. Helping people to contact organisations such as the Citizens Advice Bureau, food banks or Relate counsellors “shows that you are listening to what they are saying” he adds.
“What changes that suicidal mindset is thinking about the future in a constructive way,” he says. “What you are seeking to do is to help someone build their own suicide prevention plan."
At Bedminster pharmacy, the team has had mental health first aid training. Staff ask people open questions about how they are feeling and listen to the answers. They signpost people to services or sources of help and advice. “A sense of hopelessness and isolation, with nobody to talk to, no connections at all” is a common theme amongst distressed people. “We link people up with activities and support groups,” says Williams. “We are not just offering empathy.”
What do pharmacists need to succeed in this work? “We need read/write access to clinical records. Patients don’t like to keep repeating their stories, especially about mental health with all the stigma that exists,” explains Williams.
Another plea is for training. “Every community pharmacy team should have access to mental health first aid training,” he adds. “We need to understand how to support people.”
Pharmacy has the potential to become “a bastion of hope” he says. Bedminster Pharmacy has a reputation for its interest in mental health. People know “if you're having a mental health crisis, you can come into the pharmacy, you can sit down, we can offer you a cup of water, we can talk to you, we can make a call if you want somebody contacted.”
Pharmacy staff are under pressure as never before. Underfunding, soaring bills at home and for business owners, and the stresses of working in an overstretched NHS are putting people under strain. Anyone dealing with vulnerable patients can be affected by their distress.
Dr Gorton says: “We know workforce wellbeing is at an all-time low, especially in community pharmacy. The tools of suicide prevention can be useful not just for patients but in supporting colleagues too.”
The Samaritans are available day or night, 365 days a year: 116 123
The Pharmacist Support Charity can help with everything from mental and physical health to financial pressures, work and family problems.
Hub of Hope’s resource directory has sources of advice and support in your local area
CPPE Centre for Postgraduate Pharmacy Education suicide prevention video