Ninety eight percent (98%) of respondents rated their knowledge in psychotropic medicines as either average or poor. This perceived inadequate education is likely to be an important factor limiting their involvement in the management of mental illness (the reason given by 81% of the respondents for their non-involvement). This corroborates with a study conducted in Belgium which showed that lack of training in mental health issues was the most important barrier hindering pharmacists' role in depression [
13]. Although pharmacists are generally experts in drug therapy, offering efficient pharmaceutical care to mentally challenged patients can be quite daunting. Studies have indicated that the provision of information about medications by community pharmacists may be limited by poor communication with people with mental illnesses [
14]. Pharmacists have reported feeling more uncomfortable counseling on the use of medications used to treat mental illnesses than those used to treat cardiovascular conditions [
15]. Hence specific knowledge and skills are required so as to optimise treatments for mentally challenged patients.
All respondents were of the view that regular workshops would help improve their knowledge in mental health care delivery. Pharmaceutical governing bodies, such as the Pharmacy Council of Ghana, could help by organizing these workshops for community pharmacists and psychiatric hospital pharmacists to ensure that they are equipped to perform their expected roles. Topics to be covered could include; communication with mentally challenged patients, pharmacotherapy and other duties expected of the pharmacist as proposed by the community pharmacists. However to adequately organise these workshops, pharmacists and resource persons who are experts in mental health would be needed. Currently Ghana has nine consultant psychiatrists and no specialist psychiatric pharmacist [Personal Communication, office of the Chief Psychiatrist of Ghana]. Hence healthcare personnel, especially psychiatric pharmacists in the developed countries, could assist by volunteering their services so as to upgrade psychiatric pharmacy in Ghana. Furthermore universities offering pharmacy in Ghana could offer postgraduate courses on psychiatric pharmacy. In the United States there are approximately 25 to 30 one-year, post-Pharm. D residencies in psychiatric pharmacy practice, with 17 receiving accreditation by the American Society of Health-System Pharmacists (ASHP) [
16,
17]. Each residency may offer a unique feature such as an ambulatory care focus or teaching skills development; however, the emphasis of residency training is on specialized clinical knowledge and skills development.
Seventy nine percent (79%) of the community pharmacists who responded to the questionnaire had never been consulted by discharged mental patients or their carers for advice on their medication. This could mean one of two things: either mental illness was not a common condition in the community or most people with the condition did not perceive the pharmacy as a place where they could go for consultation on their medication.
Records as at 2002 showed that 4,972 mental patients were discharged from the Ankaful, Pantang and Accra psychiatric hospitals (Ankaful is the 3rd major psychiatric hospital in Ghana) [
2] and in a newspaper report on 8
th of August, 2008, the acting Chief Psychiatrist of the Accra psychiatric hospital stated that about 440,000 Ghanaians suffered a severe form of mental illness[
18]. The second reason, that most people with mental conditions do not perceive the pharmacy as a place where they could go for consultation on their mental health medication, is therefore more plausible and hence it is essential that the mental health law that is being reviewed includes community pharmacists as part of the community mental health teams. This would also address the problem of low encounter with patients cited by 72% as a perceived barrier for hindering their involvement in mental health care delivery. Duties of community psychiatric nurses include awareness creation and mental health promotion, identification of cases and referral of cases to specialist hospitals and management of some cases including counseling [
2]. These duties and more could be performed by community pharmacists working together with community psychiatric nurses to upgrade pharmaceutical care of mentally challenged patients. There is evidence that suggests that pharmacists have a potential role as members of community mental health teams. Pharmacists' participation in community psychiatry clinical team meetings created an opportunity to present medication review findings and recommendations
. Pharmacists were also perceived as a valuable source of unbiased and evidence-based drug information for both mental health team staff and their clients and caregivers [
19]. There is also evidence to the effect that counseling provided by community pharmacists to discharged mental patients significantly contribute to improved medication compliance [
4]. However adequate remuneration should be given through the National Health Insurance Scheme (NHIS) to community pharmacists to enhance their interest in this area since poor remuneration was cited by 56% as a perceived barrier that hinders their involvement in mental healthcare. Community pharmacies are also more accessible to the general population, their opening hours are usually convenient and they provide personalised services [
20]. Therefore their involvement will also aid in decentralization of mental healthcare, resulting in greater accessibility.
Public awareness of the role played by pharmacists in mental health delivery is essential, as this will increase the level of pharmacists' encounter with mentally-challenged patients. These services would then not seem strange to clients as perceived by pharmacists in this study. Most Ghanaians believe conditions like mental illness, convulsions and epilepsy to be spiritual and hence require spiritual attention [
2]. Thus most carers of patients with such beliefs would rather take discharged patients showing signs of relapse or discomfort due to side effects of psychotropic medications to spiritual healers than seek advice from a pharmacist.
To address perceived barriers of stigmatization of patients and personnel in the field and inadequate funding as cited by 59% and 51% of community pharmacists respectively, relevant policies should be formulated in addition to other policies that avoid controversies over roles within the healthcare team; and regulate traditional healers, prayer camps and other unorthodox institutions. The mental health law of Ghana is being revised to promote the care, and to protect the human rights, of people with mental illness [
21]. In 2006 the Government of Ghana gave approval to the Ministry of Health (MOH) Ghana to revise 19 outmoded health related laws in order to improve health service delivery in the country. The MOH is currently working on seven of these laws, including the Mental Health Law which was last reviewed in 1972. Mental health service decentralization, infrastructure for management and rehabilitation of the mentally ill in the community, condition of service in mental service, mental health awareness and transportation for community health services are being reviewed [
2,
21].
Hospital pharmacists
The study revealed that on admission, the psychiatric hospital pharmacist checks for the appropriateness of any drug prescribed for the patient, whiles dispensing the medicines at the pharmacy. This does not differ widely from what pharmacists in the general hospital setting do. However, it was identified that on admission the pharmacist did not usually see the patient or the carer for a medication review or drug history documentation, and all information about prescribed medication was given to the patient through the nurses. This is not the best approach to optimize pharmaceutical care. Correct documentation of a patient's medication history is an important part of the initial patient assessment after admission to hospital [
22]. Pharmacists, rather than physicians, have been shown to obtain more accurate medication-related information from patients [
23]. Accurate medication history enables the healthcare team to have an idea of all medications, including creams and any herbal preparations the patient had taken, any of which might even be a contributing factor to the presenting illness.
Pharmacists in both hospitals did not usually conduct ward rounds with other members of the healthcare team. Lack of adequate team work between the pharmacist and other members of the healthcare team was also identified as a barrier to their involvement in ward rounds. Ward rounds have been identified as the best opportunity for pharmacists to contribute to patient care. It is where decisions are made about the patient's care and it is therefore the place where pharmacists can ensure that patients are receiving the correct treatment [
12].
The pharmacists in the two hospitals did not normally see the patients when they were discharged. The nurses usually obtained the patient's drugs from the pharmacy and thus all information about the drugs was given to the patient via the nurses. It is, however, important for the pharmacists to be involved in planning the discharge care and to interact with the patient and their carers. This would help solve any issues with medications and foster a good relationship between the pharmacist, patient and carer [
12].
Issues such as poor communication with patients and the fact that most of the patients and their carers attached superstitions to their condition could make the formation of medication education groups difficult. However, the formation of such groups could provide a forum for patients to discuss their therapy and ask questions on their medications. This could improve drug compliance and thus reduce the frequency of relapses.
Policies should be in place detailing the role of the hospital pharmacist in psychiatric hospitals in Ghana so as to enhance pharmaceutical care of patients admitted at the psychiatric hospitals since studies have shown that the presence of the pharmacist on the ward improves accuracy of drug history documentation, reduce prescribing cost and decrease the potential risk of patients in the hospital [
24].