Worldwide there are more than 700 000 deaths by suicide every year and the World Health Organization (WHO) aims to reduce this by one third by 2030. Pharmacists and their teams represent a hitherto untapped resource in the multidisciplinary field of suicide prevention. All of the work that’s been done in relation to pharmacy teams and suicide prevention has been focused on community pharmacy. “What’s particularly important about primary care settings is that actually two-thirds to three-quarters of people who die by suicide are not under specialist mental health services, so that means they’re with us in primary care and we have opportunities to intervene”, says Dr Gorton.

Increasingly, community pharmacy teams are being recognised as having a part to play in having conversations with people about self-harm. Some of the work undertaken by Dr Gorton’s team has recently contributed to a new NICE guideline on self-harm.  It is important for pharmacy teams to be aware of the resources available, especially local resources such as Hub of Hope and to avoid the use of stigmatising language.

Antidepressants will be included in the New Medicine Service (NMS) from April 2023 onwards. (The New Medicine Service (NMS) is an Advanced Service in the Community Pharmacy Contractual Framework (CPCF in England). This will provide an opportunity for pharmacist to have in-depth discussions with people who have recently been prescribed anti-depressants.

There is now a worldwide network of pharmacists with an interest in suicide prevention. So far, most of the research has been done in high-income countries but more than three quarters of suicides in the world are in low- and middle-income countries (LMICs) and research is now planned to address this gap.

Read and watch the full series on our website or on YouTube.

Dr Hayley Gorton MPharm, PhD, PGDip (ClinPharm), MRPharmS, FHEA, CF is a senior lecturer in pharmacy practice at the University of Huddersfield. She is also a co-chair of the Association for International Association of Suicide Prevention special interest group on suicide prevention in primary care. At the recent FIP Congress (Seville, 2022) Dr Gorton gave a presentation entitled, Suicide prevention: Are pharmacy teams an overlooked and indispensable asset?

Pharmacists and pharmacy teams that want to find out more about contributing to suicide prevention work should consider using the resources available from Mind and the Samaritans, the Zero Suicide Alliance and Hub of Hope. A suicide awareness video is also available from the Centre for Pharmacy Postgraduate Education in England (CPPE). No matter how much preparation and training is done in advance it will probably “take you by surprise if you find yourself in that situation having to talk to someone [about suicide] so it’s also important to think about how you would look after yourself afterwards”, says Dr Gorton. She suggests having a debriefing plan e.g. a trusted colleague with whom it could be discussed.

Antidepressants will be included in the New Medicine Service (NMS) from April 2023 onwards and this may helpful in this context. Dr Gorton says, “I’m really pleased to see antidepressants included in in the New Medicine Service. Until now there haven’t been any medicines for mental health conditions included in the service and I know the pharmacy world seems to be quite pleased about this. We will therefore have people that we know have a diagnosis of anxiety or depression amongst other things that we have the opportunity to have these in-depth conversations with”.  Having a pre-existing mental health problem increases a person’s risk of suicide, she notes.

The AMPLIPHY study¹ was described as ‘NMS plus’ by many of the pharmacists who were involved, although it was not designed as such. In fact, it was concerned with changes of dose, changes of antidepressant or new antidepressant treatment. However, it provided important information, such as the value of using Hub of Hope as a resource, that will be useful as the new NMS service is implemented.

Dr Gorton sounds a note of caution about the timing of the NMS in relation to antidepressant treatment: “One of the difficulties in mental health epidemiology and looking at medicines and risk is that, actually, by definition, having been prescribed [a new antidepressant], someone’s condition has probably got worse so these people are in a position where they actually might need some extra support. Antidepressants can take up to six weeks to work – I’d like to see the New Medicine Service extended to enable that coverage. You know, actually, if it stays at the four-week mark, what happens to those people that perhaps are not getting the benefit from the medicines but are about to get the benefit from the medicines? and if we follow them up a little bit more intensively would that be helpful?”

Worldwide network

Dr Gorton is not the only pharmacist with an interest in suicide prevention – there is a small network of pharmacists around the world who share her interest and it is open to others who wish to join. She is a co-chair of the International Association of Suicide Prevention special interest group on suicide prevention in primary care. As the recipient of a Churchill Fellowship, she was able to visit a number of colleagues including Andrew Murphy and David Gardner in Canada, Claire O’Reilly in Australia and also some colleagues in the USA where she was hosted by Professor Jill Levine. “We’re all linked now and actually what you can see from the research is that we are coming up with very similar things. But all the research has been done in high income countries yet over three quarters of suicides in the world are in low- and middle-income countries (LMICs) so actually, that’s a really important gap”, she says.  One of her PhD students, Somto Chike-Obuekwe, is now starting to look at this in the Nigerian context, she adds.

Reference

1. Gorton HC, Riste L, Littlewood D, Pickering G, Armitage CJ, Ashcroft DM. Advancing Mental heaLth Provision In PHarmacY (AMPLIPHY): A feasibility study. Res Social Adm Pharm. 2022 Aug;18(8):3414-3424. doi: 10.1016/j.sapharm.2021.11.001. Epub 2021 Nov 9. PMID: 34774424.

Read and watch the full series on our website or on YouTube.

Dr Hayley Gorton MPharm, PhD, PGDip (ClinPharm), MRPharmS, FHEA, CF is a senior lecturer in pharmacy practice at the University of Huddersfield. She is also a co-chair of the Association for International Association of Suicide Prevention special interest group on suicide prevention in primary care. At the recent FIP Congress (Seville, 2022) Dr Gorton gave a presentation entitled, Suicide prevention: Are pharmacy teams an overlooked and indispensable asset?

It is important to remember that self-harm is different and distinct from suicide. Self-harm and suicide are on a spectrum of behaviours. “Some people self-harm for different reasons, so for regulation of emotion, because they have suicidal intent, they may be ambivalent or it might be a mixture of all those things – so it’s really quite a complex set of behaviours”, explains Dr Gorton.  Some of the work undertaken by Dr Gorton’s team has recently contributed to a new NICE guideline on self-harm.¹ Increasingly, community pharmacy teams are being recognised as having a part to play in having conversations with people about self-harm.

The expression, ‘to commit suicide’ is no longer thought to be appropriate and is considered to be stigmatising. Until 1961 suicide was illegal in the UK and remains so in some other countries. The phrase ‘to commit suicide’ carries “connotations of crime and that’s not how we want people to feel, so the phrase ‘died by suicide’ is preferred. ……. The key message is that using the word ‘suicide’ is okay. It is okay directly to use the word ‘suicide’ and that is ….encouraged actually by some of the mental health charities”, says Dr Gorton.  During their research it was clear from some of the comments made that pharmacy staff were very conscious of the stigma that might still be attached to suicide and mental health problems, she adds.

Turning to the practical implications for pharmacy teams, Dr Gorton says, “I think the first message is not to be scared – we’re not trying to overwhelm pharmacy teams.  This is about having the conversations actually people are already having with their customers/clients/patients but perhaps in the safest and most effective way. So, it is okay to use the word suicide and ask people about suicide – and there’s some nice resources on both the Mind and Samaritans websites that can help people with those sorts of phrases”. In addition, the Zero Suicide Alliance training is helpful and maybe even practising having the conversations [about suicide] might help to increase confidence, she suggests.

What has emerged from the research is the importance of thinking about triage, referral and signposting to services. “People working in pharmacy do this all the time”, says Dr Gorton.  One useful resource in the UK, that some people may not have heard of, is called Hub of Hope. This is a resource that enables people to search by postcode for relevant services to do with different mental health problems but also some of the wider societal problems or personal difficulties that people might be facing. Dr Gorton is keen to recommend local referral pathways wherever possible. “If you imagine you have someone coming into your pharmacy that’s quite distressed – to start sending them off even two or three miles down the road might be quite difficult for them. So, thinking about what really is in that person’s community but also remembering perhaps online resources for some people might be suitable or remote resources – telephone resources for example”.  She also advises pharmacy teams to explore the local systems including primary care networks and integrated care boards with a view to understanding how they can work across sectors and together.

Reference

1. NICE. Self-harm: assessment, management and preventing recurrence. NICE guideline [NG225] Published: 07 September 2022

Read and watch the full series on our website or on YouTube.

Dr Hayley Gorton MPharm, PhD, PGDip (ClinPharm), MRPharmS, FHEA, CF is a senior lecturer in pharmacy practice at the University of Huddersfield. She is also a co-chair of the Association for International Association of Suicide Prevention special interest group on suicide prevention in primary care. At the recent FIP Congress (Seville, 2022) Dr Gorton gave a presentation entitled, Suicide prevention: Are pharmacy teams an overlooked and indispensable asset?

Dr Gorton’s interest in suicide prevention started with a pharmaco-epidemiology project that involved looking at big data and trends related to suicide and self-harm.

Worldwide there are more than 700 000 deaths by suicide every year this is likely to be an underestimate due to difficulties with data collection. The World Health Organization (WHO) aims to reduce this by one third by 2030. In England and Wales in 2020 there were 5224 suicides. “This was actually lower than the 2019 data, which might be a surprise to some people and is actually hopeful in a sense because people have obviously been concerned about the impact of the pandemic on suicides”, says Dr Gorton. However, we should not be complacent because the potential mental health effects of the pandemic may continue alongside effects arising from the economic situation, which have been known to influence suicide rates in the past.

Pharmacists and their teams represent a hitherto untapped resource in the multidisciplinary field of suicide prevention. Moreover, all of the work that’s been done in relation to pharmacy teams and suicide prevention has been focused on community pharmacy and Dr Gorton believes there are roles for all sectors of the profession. “What’s particularly important about primary care settings is that actually two-thirds to three-quarters of people who die by suicide are not under specialist mental health services, so that means they’re with us in primary care and we have opportunities to intervene”, she says.

Research conducted in in England about the role of pharmacy teams in suicide prevention has identified a social-clinical-holistic role – that is, knowing people and talking to people. “That came through very strongly in our first study which was an interview of pharmacy staff in in England”, says Dr Gorton. Further work has shown that community pharmacy teams often report having conversations with people about suicide.  “In fact, 71% of them had reported knowingly having spoken to someone about suicide at least once and, actually, some work worldwide suggests this is probably higher because people [may be] indicating signs of suicide that perhaps have not been recognised” adds Dr Gorton. Other topics identified were the need for triage and referral, the question of means restriction and the fact that people may use medicines that are obtained from the pharmacy in poisoning. (Poisoning is the second most common method of suicide in the UK).

The Zero Suicide Alliance training was included in the pharmacy quality scheme in England. This is an incentivisation scheme in which pharmacies are remunerated for meeting certain quality standards. “We know that 72,000 of [patient-facing staff] in England have done this training. It’s a 20-minute interactive video and the key message really is about asking directly about suicide and also thinking about aiding triage and referral. That’s freely available training that anyone can access”, explains Dr Gorton.

Read and watch the full series on our website or on YouTube.

Dr Hayley Gorton MPharm, PhD, PGDip (ClinPharm), MRPharmS, FHEA, CF is a senior lecturer in pharmacy practice at the University of Huddersfield. She is also a co-chair of the Association for International Association of Suicide Prevention special interest group on suicide prevention in primary care. At the recent FIP Congress (Seville, 2022) Dr Gorton gave a presentation entitled, Suicide prevention: Are pharmacy teams an overlooked and indispensable asset?