How pharmacists can transform prescribing safety in psychiatry

Medication-related harm remains a critical challenge in global healthcare settings, with preventable harm affecting about 1 in 20 patients globally, disproportionately affecting patients prescribed mental health medication^​1–7​. The increasing pharmacist prescriber workforce may present an opportunity to reduce harm and represent an important step towards a system-wide approach to improving medication safety for this patient population^{​3,8–12​}.

Evidence increasingly highlights systemic deficiencies, including prescribing errors, inadequate monitoring and hazardous medication use, across both primary and secondary care settings for patients with mental illness^{​3,6,8,9​}. These risks are further amplified by polypharmacy, comorbid physical illnesses, cognitive impairments and systemic challenges, such as fragmented care, communication issues within healthcare, limited clinician knowledge and stigma^{​7–9,13–15​}.

Existing medication safety strategies are largely designed for the general population and are insufficiently tailored to the unique needs of patients with mental illness^​3,8,9​. Unsafe prescribing and medication-related harm arise from multiple factors operating at various levels including individual, organisational and social influences. This highlights the need for a multifaceted approach that pharmacists looking to work in this area should consider^{​3,4,7–9,15​}.

Complexity of psychopharmacology

Psychotropic prescribing is inherently complex because psychiatric conditions — including depression, anxiety, bipolar disorder and schizophrenia — are heterogeneous, and often fluctuate over time, meaning treatment decisions cannot follow a blanket approach and must be tailored to the individual patient’s presentation and needs^​16​. Diagnostic categories in mental health show substantial variability with elements of overlap and clinicians often adjust treatment based on specific symptom profiles rather than uniform protocols, reflecting this complexity in practice^​17,18​. As a result, treatment often involves iterative decision-making, with adjustments over time, and off-label prescribing remains common where evidence is limited or patient responses are variable^​19​. This complexity may be further compounded by variability in clinicians’ knowledge and confidence in psychopharmacology and mental illness, particularly outside specialist settings^​8,9​.

Inappropriate prescribing and polypharmacy

Evidence has highlighted that potentially inappropriate prescribing practices are prevalent among patients, such as older adults with dementia, where psychotropic medications are often prescribed off-label to manage agitation. This is despite limited evidence of effectiveness and an associated increase in mortality risk^{​3,4,20,21​}.

Polypharmacy is prevalent in psychiatric practice and has been linked to an elevated risk of drug interactions, cognitive impairment, falls, metabolic disturbances and reduced treatment adherence^​22,23​.

Despite these well‑recognised risks, structured medication reviews and deprescribing practices remain underutilised in mental healthcare settings^​24​.

How could pharmacist prescribers be part of the solution?

A lack of competence and knowledge among clinicians regarding psychotropics is a contributor to medication errors in mental health, particularly in primary care and community settings, where prescribing and monitoring of psychotropic medications are frequently undertaken by non-specialists^​8,9​. Within this context, pharmacist prescribers represent a strategically valuable workforce. Evidence indicates that pharmacists possess a high level of expertise and confidence in psychopharmacology, and the expansion of pharmacists being prescribers upon graduation from 2026 presents a timely opportunity to use their skillsets and address existing workforce capability gaps^​8,12​. 

Involving patients in their care

Pharmacists’ advanced knowledge of psychopharmacology and medicines optimisation may help them communicate complex medication regimens, provide informed consent and help align treatment decisions with patients’ preferences, values and lived experiences^{​3,8–10,25–27​}. Models of care have historically underestimated the role of patients in decision-making, often positioning them as passive recipients rather than active partners in ensuring safety^​28​. This is particularly consequential in mental healthcare, where individuals may be more susceptible to the adverse effects of psychotropic medications and may also experience power imbalances within therapeutic relationships^​8,9,29​. Limited involvement in decision-making can restrict patients’ understanding of their treatment and diminish opportunities for collaborative engagement. This creates avoidable barriers to safe and effective care, including reduced willingness or ability to adhere to prescribed regimens.

Patients should be recognised as active collaborators in medication safety. The implementation of shared decision-making tools, tailored to the specific needs of this patient population, has the potential to enhance patient empowerment and promote meaningful engagement in treatment processes^​9​. Furthermore, the inclusion of carers and broader support networks strengthens safety mechanisms by providing additional oversight and facilitating more coordinated care delivery^​9​. These principles should extend beyond clinical practice into healthcare research, as actively involving patients and carers can improve the relevance, quality and translational impact of research^{​9,30,31​}. These approaches position patients and their support systems as essential partners in delivering safe, effective and patient-centred management of psychotropic medications. The next important step is to design and rigorously evaluate pharmacist-led interventions in real-world settings that account for these unique needs, to maximise their impact on safety outcomes^​9​.

Communication across care interfaces 

Healthcare for patients with mental illness is frequently delivered by multiple professionals across diverse settings and, in the absence of effective communication and coordinated approaches, can lead to fragmented decision-making, inconsistent or incomplete information sharing, and an increased risk of medication-related errors^​8,9​. Research has highlighted that patients can be discharged into the community with a lack of continuity of care, poor provision of medicines information and variable shared decision-making^​15​. This fragmentation may be compounded when electronic health record systems are not interoperable or when providers lack mechanisms for real-time information sharing^​8,9​.

Interoperable electronic health records that allow all members of a patient’s care team to access, update and coordinate medication plans could help reduce fragmentation, minimise discrepancies and support more informed clinical decision-making^​9​. Pharmacist prescribers are well placed to strengthen continuity and integration of care, both of which are essential for safe psychotropic medication use^​3,9,32​. With expertise in medicines optimisation, they can play a central role in medication reconciliation at transitions of care and ensuring accuracy^{​3,15,33,34​}. Pharmacists can act as a consistent point of contact within multidisciplinary teams by coordinating medication plans across care interfaces and bridging fragmented services.

Professional support

Supporting pharmacist prescribers in mental health requires coordinated investment across education, clinical practice and organisational infrastructure^​27,35​. Enhanced mental health training within undergraduate and prescribing programmes may be needed, particularly in psychiatric assessment and risk management, complemented by structured experiential learning through supervised practice and mentorship to build confidence and competence^​35​. In practice, clear role definition, integration within multidisciplinary teams and consistent access to senior clinical support are essential to facilitate safe decision-making and reduce professional isolation. At a systems level, protected time, sustainable funding and robust governance frameworks are critical to enable pharmacist prescribers to operate effectively and safely. Collectively, these measures support the optimisation of pharmacist prescribing roles and their contribution to high-quality mental healthcare^​27,35​.

Medication safety in mental healthcare remains a multifaceted challenge, shaped by the interplay of clinical, organisational and patient-level factors. Addressing these issues requires a coordinated, system-wide response that moves beyond general safety frameworks towards approaches tailored to the specific needs of individuals with mental illness. Central to this is the strategic integration of pharmacist prescribers, whose expertise in psychopharmacology and medicines optimisation positions them to play a pivotal role in enhancing care for these patients. However, realising this potential depends on wider workforce development and professional support, alongside the robust evaluation of pharmacist-led interventions that incorporate patient and carer involvement. These measures offer a pragmatic pathway towards safer, more effective and person-centred use of psychotropic medications, while reinforcing the value of pharmacist prescribers in evolving models of mental healthcare.