On The Cover
Loren Bonner
Most community pharmacists have experienced seeing a patient in distress. In fact, a December 2023 study published in JAPhA found that almost all respondents from a sample of community pharmacists had interacted with someone displaying suicide warning signs. In 161 surveys completed during the study period, pharmacists reported encounters with patients who appeared distressed (96.3%), made concerning statements related to suicide (23.8%), and disclosed suicidal thoughts (8.8%). However, only a minority of pharmacists had asked patients about suicide (21.1%) or referred them to suicide prevention resources (17.4%).
Lead researcher Matthew Witry, PharmD, said this suggests an opportunity to help but also the need for training and support for pharmacists. Only a third of respondents had previous suicide prevention training (37.9%) based on the study findings.
“I think it is important to put some numbers to these issues to acknowledge what pharmacists are experiencing in practice, their potential impact, but also the stress that could accompany these situations,” said Witry, who is an associate professor at the University of Iowa College of Pharmacy.
As one of the most visible and engaged health care providers, more pharmacists are realizing the need for training to help patients in crisis. Witry said they were encouraged that respondents in their study were interested in further training, and he’s in favor of expanding training for pharmacists and pharmacy staff so they are better equipped to handle patients who are in a crisis.
“We saw some evidence of this with the pharmacists with previous suicide prevention training reporting higher levels of confidence and a greater likelihood to engage in intervention behaviors, like asking directly about suicide,” said Witry.
Training programs offering evidence-based strategies for helping people in crisis, including those having thoughts of suicide, exist both in-person and online for pharmacists and staff, said Witry.
According to Jeffrey Gold, PharmD, BCPP, recent data have pointed to the importance of suicide screenings in nonpsychiatric settings.
“That’s why there’s been such a big focus recently on pharmacists and technicians being prepared and knowing how to assess for suicide because those are the settings where people who are suiciding are really seen,” said Gold, a psychiatric pharmacist at the VA Rocky Mountain Regional Medical Center in Denver who spoke about how pharmacists can help people in a crisis during an October 4, 2024, APhA webinar.
Despite what many may think, asking the person in distress about
suicidal thoughts does not increase their likelihood of suicide. In fact, talking about suicidal ideation reduces it, said Gold.
“If you are ever working with a patient, whatever your role is, and you recognize something is off, and follow that path with them and you find they have suicidal thoughts, just you caring is the beginning of the healing process for them,” said Gold. “That is them wanting you to stop them, help them. So never feel like you are saying the wrong thing.”
Witry said research backs this up: Individuals considering suicide or who are in crisis appreciate someone raising the issue and recognizing their distress. “Asking about suicide doesn’t put the idea in anyone’s head; it can be a relief that someone sees them,” said Witry.
The tricky part for most people is knowing what to say and how to say it.
Strategies of crisis intervention
“Anybody at any time can find themselves with a patient in crisis; you don’t have to be a pharmacist,” said Gold. The crisis intervention Gold teaches is technically a form of psychotherapy, but it’s something anybody can do or anyone can be trained to do.
Some key principles of crisis intervention include:
- A focus on the present: Crisis intervention addresses immediate concerns and needs, rather than long-term issues.
- A collaborative approach: Crisis intervention involves working with the individual to identify goals and develop a plan of action.
- A strengths-based perspective: Crisis intervention focuses on an individual’s strengths and resources, rather than their deficits or weaknesses.
Some key strategies of crisis intervention include offering emotional support and understanding; demonstrating coping skills and techniques; providing information and referrals to other resources; and helping the individual access support networks.
Gold said if the pharmacist or technician picks up on something being off with the individual in distress, they should not wait until the end of the conversation to bring up suicide—it should be the first question.
“You always have to ask the question of ‘are you having thoughts of hurting yourself, suicide, any intent or plan to harm yourself or ways to harm yourself?’” said Gold.
He said he’s reminded again and again that people want to live and they want to be stopped from harming themselves.
“Make required suicide screening a standard practice,” said Gold.
When someone is acutely suicidal with intent and plan, acutely homicidal with intent and plan, or is gravely disabled, which is an inability to care for basic needs, then a higher level of care is needed, according to Gold.
“Acute suicidality is when there is expressive intent, and they could immediately act on it. I want to be clear about that distinction,” said Gold.
If there is uncertainty about what to do, it’s really about asking the person directly the question: “Do you have any intent or desire to die or desire to harm anyone?” or “Would you be safe to go home today?”
Gold said the question “Do you feel safe if you were to go home now?” is such a gentle way to ask a hard question. He’s learned to ask that question a lot and prefers it.
“It puts it in patient language,” said Gold. “If they say no, then it may be time to go to the hospital.”
How do you practically manage a patient in crisis?
- Active listening: Give the patient your full attention and allow them to express their thoughts and feelings without interruption or judgment. Repeat back to them what you have heard to ensure understanding.
- Validation: Acknowledge that the patient’s feelings and experiences are valid and understandable given their situation.
- Empathy: Show the patient that you understand and care about what they are going through. Use phrases such as “I can imagine how difficult this must be for you” or “I am here to help you.”
- Language: Keep your tone of voice calm, avoid raising your voice, and use a slow and steady pace of speaking; do not use technical jargon.
Jeffrey Gold, PharmD, “Crisis Intervention: A Pharmacist’s Story”; presented during an APhA webinar on October 4, 2024.
Mental Health First Aid
Mental Health First Aid has grown into one of the more popular training courses in recent years.
Mental Health First Aid was originally created in Australia and came to the United States in 2008 with help from the National Council for Mental Wellbeing. According to Tramaine EL-Amin, Mental Health First Aid vice president at the National Council for Mental Wellbeing, they have since trained over 4 million “first aiders” from all 50 states.
“The pharmacists trained in the course can be a first line of help for people who may need support with mental health or substance use challenges,” said EL-Amin.
The baseline of Mental Health First Aid training is understanding the stigma associated with mental illness. Anyone trained in Mental Health First Aid—whether a health professional or not—is given the tools to be able to identify when an individual is experiencing a mental health issue or crisis and to start the intervention process, which includes referring out to help.
Second victim syndrome
A study published online in the American Journal of Health-System Pharmacy on September 28, 2024, found that more than half of pharmacists in a comprehensive cancer center practice setting reported experiencing second victim syndrome at some juncture of their lives.
Based on expert consensus from 2022, a second victim is defined as: “Any health care worker, directly or indirectly involved in an unanticipated adverse patient event, unintentional health care error, or patient injury and who becomes victimized in the sense that they are also negatively impacted.”
Taking this further, second victim syndrome also occurs when a health care worker harbors feelings of personal responsibility for unexpected patient outcomes and feels that they have failed their patient, going so far as to discredit their own personal knowledge and clinical skills.
A medication error is one of the leading causes of second victim syndrome. As defined by the National Coordinating Council for Medication Error Reporting and Prevention, a medication error is “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in control of the health care professional, patient, or consumer.”
Six stages of second victim recovery include:
- Chaos and accident response.
- Intrusive reflections.
- Restoring personal integrity.
- Enduring the inquisition.
- Obtaining emotional support.
- Moving on.
APhA offers resources and support. More can be found here: www.pharmacist.com/Advocacy/Well-Being-and-Resiliency/Second-victim-syndrome. ■
Walgreens worked in collaboration with the National Council for Mental Wellbeing and APhA to develop specialized Mental Health First Aid training for pharmacy staff in mental health literacy, understanding risk factors and warning signs for mental health and substance use concerns, and strategies for how to help someone in both crisis and noncrisis situations.
According to Dan Zlott, PharmD, APhA’s senior vice president of education and business development, Walgreens completed its first phase of Mental Health First Aid training for pharmacists, administered by the National Council for Mental Wellbeing, in 2020. He noted that Walgreens has trained 2,165 pharmacy team members through the Mental Health First Aid program.
Research published in 2020 in Pharmacy Practice suggested that pharmacy professionals who had Mental Health First Aid training felt prepared to engage in it, and many used behaviors such as asking about suicide and making referrals. The analysis was based on 96 responses, and almost all respondents had recommended Mental Health First Aid training to others.
Respondents reported that the training prepared them to address multiple mental health conditions, particularly depression and anxiety. Participants most often reported asking about a distressed mood and listening nonjudgmentally. Almost half of the participants had asked someone if they were considering suicide, and a similar percentage had referred someone considering suicide to appropriate resources.
Many schools of pharmacy are also integrating Mental Health First Aid training into their curriculums or making it available to students at little or no cost.
APhA has actively started marketing the program to schools of pharmacy, state pharmacy associations, as well as community chain pharmacies, independent community pharmacies, health-system pharmacies, and more.
“We have a number of groups that have expressed interest in the program,” Zlott said.
According to a study published in the August 2023 issue of the American Journal of Pharmaceutical Education, Mental Health First Aid training was implemented as a mandatory requirement for all student pharmacists in the didactic portion of a PharmD program. Researchers found that the training led to reduced stigma around mental illness and improved confidence, comfort, and willingness to intervene among student pharmacists—which was 235 student pharmacists in all who completed the all-day required training program. ■
What are the main components of Mental Health First Aid training?
Students of Mental Health First Aid are taught to recognize the signs and symptoms of a mental health or substance use challenge, and it equips people with the tools to respond appropriately in these situations. Topics covered include depression and mood disorders, anxiety disorders, trauma, and substance use disorders.
Mental Health First Aiders are taught the Mental Health First Aid Action Plan (ALGEE), a step-by-step action plan to use when providing support to someone who may be experiencing a distressing situation, just as if the individual were administering first aid for a fall. An important component of the Mental Health First Aid course is the opportunity to practice the intervention strategy rather than to just learn about it.
The five steps, which can be used in any order, are:
- A – Approach. Assess for risk of suicide or harm. Try to find a suitable time or place to start the conversation with the person, keeping their privacy and confidentiality in mind. If the person does not want to confide in you, encourage them to talk to someone they trust.
- L – Listen nonjudgmentally. Many people experiencing a challenge or distress want to be heard first, so let the person share without interrupting them. Try to have empathy for their situation. Get the conversation started by saying something like, “I noticed that …” Try to be accepting, even if you don’t agree with what they are saying.
- G – Give reassurance and information. After someone has shared their experiences and emotions, be ready to provide hope and useful facts.
- E – Encourage appropriate professional help. The earlier someone gets help, the better their chances of recovery. So it’s important to offer to help this person learn more about the options available to them.
- E – Encourage self-help and other support strategies. This includes helping them identify their support network, programs within the community, and creating a personalized emotional and physical self-care plan.
Source: The National Council for Mental Wellbeing.
If you, or someone you know, is struggling or in crisis, please call or text 988, the free Suicide & Crisis Lifeline.