The Pharmacist’s Role in Medication Adherence in Mental Health and Beyond
By Matt Phillion
A recent survey has found that individuals living with bipolar I disorder (BD-1) faced the greatest challenges with medication adherence among those living with serious mental health illnesses. This is particularly true at the first-fill stage, and an area where pharmacists can play an important role in supporting initiation and adherence to medications. By providing education on how to start dosing a new medication, what to expect from that medication, and how to manage side effects, pharmacists can offer insights to get patients onboarded and help keep them adherent.
“It’s interesting when we talk about adherence. Historically it doesn’t matter what you’re treating, adherence is always an issue,” says Dr. Alberto Augsten, PharmD, MS, BCPP, DABAT. “We run into it when dealing with medication that’s for, say blood pressure. Unfortunately, for a lot of medications, side effects keep people from staying on them.”
For BD-1, Augsten notes, the side effects of difficulties in waking, weight gain, and sexual dysfunction can be strong deterrents to adherence.
“There are so many changes that can occur that may make someone less likely to adhere to a particular regimen,” he says. “Anything that’s altering how you’re feeling or how you’re functioning can change your perception of that medication.”
This is particularly challenging for BD-1, Augsten explains. With BD-1, he says, there are up moods and down moods, and during those high moods of hypomania, the patient “feels great,” he says.
“There are a lot of high-functioning, successful people in a hypomanic mood and don’t want to lose it,” Augsten says. “The bottom line is nobody wants to feel depressed, but when people are hypomanic, they feel great. Being in the middle can feel blah to them, so treating BD-1 has many challenges not only with side effects, but with those mood changes.”
Barriers to starting medications
There are a number of factors that can enable pharmacists specifically to help patients overcome these adherence challenges. Highly trained, highly educated individuals, they are also embedded in the community and are someone patients have access to readily and frequently, Augsten explains.
“There’s very little delay in talking to people. The pharmacist is someone they deem trustworthy, knowledgeable, and easy to access,” he says.
The role has evolved as well, moving away from the retail setting and into more clinical aspects of care.
“We’re involved in clinical care, hospital care, ICUs, emergency medicine, transplants—these are unique scenarios where we notice not only how the patient is benefiting from the medications but also being counted upon by the are team to do key things like educating patients about medication,” says Augsten.
That level of expertise is more important than ever as the sheer number of medications available grows all the time, adding new classes of medications, new side effects, and new mechanisms for how they work.
“It’s impossible for one profession to keep track of it all unless they are purely focused on it, so pharmacists can be the ones to understand the nuances,” says Augsten.
Another key factor is accessibility, Augsten explains.
“If a provider wants a patient on a particular medication, that’s great. But if you can’t get it to the patient, how does that work? Pharmacists are a key factor in moving from inpatient out outpatient, making sure that patient is able to access that mediation regardless of any hoops they might need to jump through,” he says. “We’re really keen on identifying issues and gaps: Is the patient having an issue because they’re not feeling the way they are supposed to? Did they miss a few doses or are they taking it late? Have they decided to cut the dose in half on their own? A pharmacist is going to get wind of those behaviors.”
An interesting phenomenon Augsten notes is a bias by patients found in various studies toward wanting to make their provider happy.
“If a provider prescribed something, patients want to be good patients. They want their doctor to be happy with them, so they might say it’s working great. But the patient may not be willing to open up and say how they’re really feeling on the medication,” says Augsten. “The pharmacist is an opportunity to hear about this when the patient asks: Is this a normal side effect? We can then investigate. Is that keeping you from taking the medication? And from there we can explain if it’s a temporary side effect or something else.”
He also notes that pharmacists often can simplify instructions in a way the patient will understand and retain.
“A classic response we hear is, ‘Oh, nobody ever told me that.’ And another is, ‘Oh, now I understand why I’m taking this medication and what to expect from it,’” says Augsten.
Part of a pharmacist’s education, Augsten says, is learning how to communicate at a level that’s understandable by the majority of the population.
“One of the things I encounter when we start having discussions on difficult topics is finding not everybody is on the same page,” he says. “So, we need to ask, ‘What is your baseline?’ And whatever that baseline understanding is, that’s where we’re going to meet you at.”
This works both ways, he says. You have patients with very little or no understanding of chemistry or biology and you need to converse with them with that in mind, but you are just as likely to encounter patients who have the training and education who require and benefit from a higher level of conversation.
“One of the benefits of a front-facing experience with patients is learning how they work,” says Augsten.
Building better collaboration
One of the projects Augsten oversees is a clinic that treats patients with bipolar, and schizophrenia treated with an injection form of antipsychotic that lasts one to six months.
“Adherence for this population is always an issue, and one way around that is to inject something that releases slowly and keeps them out of the hospital,” he says. “We do this in collaboration with clinicians in the community to identify patients who are right for this treatment.”
They meet with the patient, educate them on the product, discuss side effects, and administer the medications. They then monitor the patients in collaboration with the clinician, so they know the patient is on the meds, if they’re doing well, if there were any side effects, and if there’s any issues that need to be addressed.
“This kind of collaboration is working well in many areas,” he says.
Similarly, pharmacists can have a collaborative impact on areas like transplant care, reviewing labs, and checking on drug levels and what medications the patient is on to prevent rejection of the new organ.
“That collaboration goes back and forth to make sure the patient is doing well, and we’ve truly changed the dynamic of the interactions between pharmacists and providers,” Augsten says.
The major barrier to taking these collaborations further is often payment, however.
“Pharmacists are not classified as having provider status yet, despite the access to patients and the care we provide,” he explains. “By having provider status pharmacists can get paid for their services. We’re making headway, and hopefully in the near future we’ll see a change at a national level that will allow pharmacists who are working with these patients to bill for their services instead of it being non-billable services. There needs to be a very broad change—and that usually starts at the Medicare and Medicaid level and trickles down to various other insurance coverage.”
Augsten notes that in many ways, pharmacists face a challenge of being stuck in a box, not being able to realize these opportunities.
“It’s our challenge to rise up and figure this out,” he says. “We realize on the front lines that patients love the ability to interact and work with us to advance their well-being. Pharmacists are on the frontlines and uniquely positioned to help patients navigate treatment, making them essential partners in the care continuum.”
Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at matthew.phillion@gmail.com.