Perception of Community Pharmacists in Malaysia About Mental Healthcare and Barriers to Providing Pharmaceutical Care Services to Patients with Mental Disorders

Strict regulations of record keeping was one of the main reasons for not stocking psychotropics. A report by the International Narcotics Control Board involving 102 countries found that the stocking of such substances were discouraged due to the strict restrictions regarding the dispensing protocol, and the time it consumed (International Narcotics Control Board 2016). Similarly in Saudi Arabia a survey showed that the commonly prescribed psychotropic drugs were unavailable in more than half of the 248 community pharmacies studied due the strict regulations for purchasing and dispensing psychotropics imposed by the government (Al-Ruthia et al. 2017).

The low frequency of prescription requests is another contributing factor, where close to 30% of the respondents revealed that they had never dispensed psychotropics before. This is because the community pharmacy is often regarded as being placed in the primary care setting, with the pharmacist perceived as playing a peripheral as opposed to a central role, in the healthcare system (Crump et al. 2011). In Malaysia the majority of patients seek treatment at government hospitals, which are provided free of charge or at minimal cost, and only purchase psychotropics at community pharmacies when government hospitals are out of stock or do not stock the psychotropics prescribed, similar to that observed in Ghana (Owusu-Daaku et al. 2010). The absence of dispensing separation in Malaysia is also a possible factor for low requests (Shafie et al. 2012), as most medications are dispensed from government and private hospitals and clinics. As a result, most community pharmacies rarely receive prescriptions (Nik et al. 2016; Shafie et al. 2012).

It is encouraging to find out that the majority of respondents agreed that there is a role for CPs in mental health care. This mirrored findings in the United States (US) and Canada, where CPs demonstrated positive attitudes toward treating patients with mental disorders (Guillaumie et al. 2015; Watkins et al. 2017). In a roundtable discussion organized by the Royal Pharmaceutical Society in the United Kingdom (UK) to discuss how pharmacists can support patients with mental health issues, pharmacists expressed excitement in getting more involved in the care of this subset of patients. It was also highlighted that CPs have a significant role to play in the early identification of people with mental disorders, as well as in improving the physical health and adherence rates of these patients (Royal Pharmaceutical Society 2018).

While 60% of respondents reported providing counseling to patients, the majority reported low frequency of providing these services. This could be due to the low frequency of prescription requests. Additionally, less than 20% of respondents reported monitoring for side effects, efficacy, and adherence. As previously mentioned, nonadherence is a significant issue in this population (Higashi et al. 2013; Ho et al. 2015), with side effects cited as a main factor (De Las Cuevas et al. 2014; Hung et al. 2011). There is, however, a misconception on the part of health professionals that the newer generation drugs are void of side effects, thus scant attention is paid to this (Lingam and Scott 2002; Pampallona et al. 2002).

Since Malaysia is a multiracial country, it provided us with the opportunity to look at how different races respond to this issue. Chinese pharmacists had significantly more positive perceptions compared to Malay pharmacists about patients with mental disorders, and about mental illness. It has indeed been found that Malays are more likely to reject mental illness as they believe the condition is caused by supernatural forces (Hanafiah and Van Bortel 2015), making them more predisposed to seeking spiritual and religious therapies (Khan et al. 2010). Subsequently, we found that the majority were quite neutral with regard to their confidence level and responsibility in managing patients with mental disorders. This is not an encouraging trend if PC services to patients with mental disorders are to be provided.

Lack of knowledge about mental disorders was ranked as the main barrier, which corresponds with the findings where close to 60% of the respondents rated their knowledge of mental disorders as ‘fair’ or ‘poor’. This corroborates with studies involving CPs in Australia, Canada, Ghana, Belgium, the UK, and the US, who have cited their low confidence and discomfort due to their lack of training, education, and clinical skills in mental disorders; as barriers to them monitoring patients, identifying drug-related problems, and discussing symptoms of mental disorders as well as drug-related issues with patients (Cates et al. 2005; Liekens et al. 2012a, b; Maslen et al. 1996; O’Reilly et al. 2015; Owusu-Daaku et al. 2010; Phokeo et al. 2004; Watkins et al. 2017).

A large number of respondents agreed that patients do not understand the concept of PC, mirroring findings from the Middle-East, Asia, and rural areas in the UK, which found that the majority of consumers have a negative view of CPs, perceiving them to be more business-centric, and declaring that their primary role is to dispense medication (Awad et al. 2017; Merks et al. 2016). Indeed very few are aware of the expanded roles of CPs such as in providing PC services and managing chronic diseases (Hasan et al. 2015; Merks et al. 2016; Erah and Chuks-Eboka 2008; You et al. 2011), and still defer to doctors as the primary expert on drug-related matters (Awad et al. 2017; Hallak 2012). It is postulated that in these countries, similar with Malaysia, consumers are more comfortable with the traditionally-defined roles of healthcare professionals in the healthcare system, where doctors are held in high-esteem on all health-related matters. This then leads them to reject the clinical roles of pharmacists. Additionally, as patients usually receive their prescribed medications from doctors, they are unaware of pharmacists’ roles beyond dispensing medication (You et al. 2011).

The World Health Organization (WHO) has highlighted that CPs should provide PC services to patients (World Health Organization 1994). CPs are the most accessible healthcare professionals due to their proximity to patients, and subsequently the high volume of customers who frequent their pharmacies (Awad et al. 2017; Rubio-Valera et al. 2014; World Health Organization 1994). Pharmacists have also expressed a desire to expand their roles beyond dispensing, and have made the move to engage in more clinically-oriented roles (Luetsch 2017; Murphy et al. 2016a), while patients have expressed that they find pharmacists more approachable and accessible than doctors (Deslandes et al. 2015). CPs are in the perfect position to screen for depression, provide counseling, monitor and encourage adherence, and monitor the outcomes of pharmacotherapy (Rubio-Valera et al. 2014). Findings from this study, however, indicate that there are a few barriers to CPs providing PC services to these patients, such as gaps in knowledge and training, the lack of public knowledge on PC services, and the influence of culture and stigma.

CPs have requested more education and training programs in mental health, such as training in psychosocial communication (Liekens et al. 2012a, b), or regular workshops to educate them on counseling, therapeutics, and signs and symptoms of mental disorders (Owusu-Daaku et al. 2010). It was indeed found that CPs who attended continuing education courses on mental disorders were more confident in interacting with these patients (Maslen et al. 1996), and the quality of pharmacist–patient interactions was improved (Liekens et al. 2014). Additionally, there is a need for mental health education modules to adopt methods which will reduce stigma, instead of solely focusing on the science and therapeutic aspects of the diseases (Murphy et al. 2016b; Rubio-Valera et al. 2014). Incorporating Mental Health First Aid (MHFA) training in pharmacists’ training is also proposed (Kirschbaum et al. 2016).

Approximately 60% of respondents agreed that members of the community are also ignorant about the clinical role of CPs, and one reason for this could be the lack of dispensing separation. This has also led to the lack of prescriptions received, leading to minimal to zero interactions between CPs and patients with mental disorders, curbing their opportunity to learn on the job and enhance their psychosocial communication skills. More importantly, this has denied CPs the chance to provide PC services. Dispensing separation is practiced in many Western countries and has proven to be effective in preventing over-prescribing, minimizing prescription errors or misuse of medication, as well as reducing health-related costs (Salmasi et al. 2016). A strong opposition to this separation was the lack of pharmacists, however it is estimated that Malaysia will soon reach the pharmacist-to-population ratio as recommended by the WHO (Shafie et al. 2012). Patients themselves acknowledge pharmacists as drug experts—viewing them as more suitable to dispense compared to doctors, and willing to pay for their services (Shafie and Hassali 2010). It is thus, time for Malaysia to adopt dispensing separation to ensure the optimum care of these patients in the community.

Our study had a number of limitations such as recall bias especially on questions related to the number and type of patients. Given the low response rate of 36.8%, findings might not be representative of the perceptions of all CPs in Peninsular Malaysia. However, the number of responses was greater than the 88 required. In addition, based on previously conducted nationwide studies of CPs in Malaysia, the demographics of respondents in our survey seem to be a fairly representative sample of CPs in Malaysia, where the majority are Chinese, female, and between 31 and 40 years of age (Chong et al. 2010; Khan et al. 2016; Siang et al. 2008). Other than that, as the question on the stocking of psychotropics was the first question, the majority of CPs might have chosen not to respond to the rest of the questions as they did not stock any psychotropics, assuming the survey was not relevant to them.