What could UK pharmacy teams learn about suicide prevention from North America?

Introduction

Why suicide prevention research in pharmacy is needed

Mental health is more prominent in the public eye than ever before. In healthcare, “parity of esteem” describes the equal prioritisation of mental and physical health. The UK Health and Social Care Act 2012 embedded this concept in law^[1]
, but while progress is seemingly being made, shortfalls between physical and mental health remain^[2]
. Recently, the pharmacy profession has enhanced their outward-facing commitment to mental health with educational campaigns from the Centre for Pharmacy Postgraduate Education^[3]
and the Royal Pharmaceutical Society (RPS) mental health campaign^[4]
. Ongoing work described in the RPS campaign includes championing the role of pharmacists in mental health across sectors, promoting training at all levels commensurate to those roles and working with stakeholders to support the public health agenda^[4]
.

Perhaps the most devastating consequence of mental health problems is suicide. The Office for National Statistics defines suicide as all deaths from intentional self-harm in persons aged 10 years or over, and deaths where the intent was undetermined in those aged 15 years and over^[5]
. The definition for self-harm differs, in that it is a much broader category covering any deliberate self-injury, and occurs in the presence and absence of suicidal intent^[6]
.

Not everyone who dies by suicide has a diagnosed mental health problem, but almost all mental health problems are associated with an increased risk of suicide. Depending on the specific mental health diagnosis, this risk is between 4 times and 18 times greater than for people without that condition^[7]
. There are many other factors that influence someone’s suicide risk, and often a multitude of factors align and culminate in someone tragically taking their own life. These factors include, but are not limited to, a relationship breakdown and socioeconomic conditions; environmental factors that influence neurodevelopment, such as childhood abuse; and physical illness^[8]
. Proximal to the suicide, access to means of suicide and antidotes influence whether someone will ultimately die^[8]
.

In 2017, there were 5,821 deaths by suicide registered in the UK. The rate for males has decreased but still remains three times higher than that of females (15.5/100,000 vs. 4.9/100,000 population)^[5]
. The enormity of suicide as a public health challenge is shown by the World Health Organization target to reduce the global rate of suicide, currently in excess of 800,000 per year, by 10% by the year 2020^[9]
. The UK government pledged to this in ‘The five year forward view for mental health’ in 2016^[10]
. Subsequently, various policies and guidance have been introduced to coordinate suicide prevention activities, much of which is directed at primary care^{[11],[12],[13],[14]}
. This includes the government’s response to the 2017 Health Select Committee inquiry into suicide, which advocates for all healthcare professionals who may encounter people at risk of suicide to be trained in suicide prevention awareness^[15]
.

With more than 11,000 pharmacies and 1.6 million pharmacy attendees per day in England alone^[16]
, community pharmacies are the most visited, most accessible healthcare providers and are central to primary care, and yet they represent a missed opportunity in suicide prevention activities. There have been occasional specific mentions of pharmacy and pharmacy teams in suicide prevention efforts. In August 2018, NHS pharmacists were one of the listed healthcare professionals in NHS Scotland’s suicide prevention plan, which stated that certain healthcare professionals must undergo mandatory suicide prevention training by May 2019^[17]
. However, this plan does not detail the expected role of pharmacists in suicide prevention or related safeguarding obligations. In October 2018, NHS Health Education England, the National Collaborating Centre for Mental Health and UCL published the ‘Self-harm and suicide prevention competence framework’. There have been three versions published — the ‘Working with children and young people’^[18]
and ‘Working with adults and older adults’^[19]
is aimed at frontline clinical staff, including pharmacy staff; and the ‘Community and public health’ version^[20]
is aimed at nonclinical and other public sector staff and volunteers. It is not expected that all relevant individuals meet all competencies, but certain core competencies should be met if a person is providing an intervention or keeping a person safe^[19]
.

As a researcher of the epidemiology of suicide and a community pharmacist, I sought to further understand and determine the contribution community pharmacy teams could make to suicide prevention efforts. As a recipient of a travel scholarship from the Winston Churchill Memorial Trust (WCMT) (see Box 1), I was able to visit the majority of the few pharmacy–suicide research communities that are mainly based in North America. This article summarises the findings (presented as recommendations and areas for further work) and learnings from this trip which took place in June–July 2018, culminating in attendance at the European Symposium on Suicide and Suicidal Behaviour (ESSSB) conference in Ghent in September 2018.

Aims of the WCMT fellowship

Owing to limitations of the current evidence base, this fellowship aimed to establish what community pharmacy teams can do to raise awareness and help prevent suicide and self-harm. An understanding of the work and research currently being undertaken within this specific topic at the following centres is required: i) the Veteran’s Administration (VA) Center of Excellence for Suicide Prevention in Canandaigua, New York; ii) Dalhousie University, Nova Scotia, Canada; and iii) Washington State Pharmacy Association (WSPA) and Forefront Suicide Prevention, Washington.

The objectives were defined as follows:

1. To understand what and how suicide prevention activities have been implemented into community pharmacy in the United States and Canada, and how the effectiveness of any such activities are measured;
2. To produce a set of recommendations to share with UK suicide prevention, pharmacy and suicide research communities, taking into consideration the parallels and differences between the United States, Canada and the UK;
3. To use learning from exposure to international suicide prevention research to design research questions and methods for grant proposals; and foster research collaborations.

Two broad themes identified during reflection on the fellowship will be discussed in the remainder of this article. The first is: ‘What is, or could be, the social or clinical role of community pharmacy teams in suicide awareness or prevention?’ The second is: ‘Are pharmacy teams involved in suicide and self-harm means restriction activities, or could they be?’ 

What is, or could be, the social or clinical role of community pharmacy teams in suicide awareness or prevention?

Community pharmacy teams offer support to patients on a daily basis. Anecdotally, this often extends beyond clinical advice related to medical conditions and medicine. Through published research, ongoing studies in the UK and experience from New York, Washington and Nova Scotia, the following sections aim to understand how these relationships can be utilised when talking about suicide and the evidence underpinning this.

The Veteran’s Administration Centre for Excellence for Suicide Prevention experience

All staff who work in the VA in the United States are required to undertake Operation S.A.V.E suicide prevention training^[23]
. This is a face-to-face gatekeeper training programme, delivered by trained staff and supplemented with printed information. The programme aims to highlight the importance of suicide prevention (particularly in the veteran population), dispel myths, understand signs and symptoms for suicidal thinking, identify veterans who may be at risk, explain how to ask questions about suicide and know how to refer people for appropriate care^[23]
. In 2012, Lavigne et al. reported the change in skills, knowledge and behaviour of 290 hospital pharmacy staff and 7,431 other VA staff who underwent this training. Following the training, more pharmacy staff (68%) felt that they had adequate knowledge about suicide compared with all VA staff (60%) but the opposite was true regarding preparedness to handle a suicidal veteran (pharmacy: 61%; other VA: 66%) and feeling comfortable talking about suicide (pharmacy: 72%; other VA: 77%)^[24]
. The discrepancy between knowledge and confidence evident for pharmacy staff might be an indication of the perceived scope of the role of pharmacy teams in suicide prevention.

A scoping review by Carpenter et al. sought to establish the state training requirements for pharmacists regarding suicide and identify the currently available educational and training resources for suicide prevention. Across the United States, the authors identified 16 different training programmes that were relevant, with half of them specifically targeting pharmacists or pharmacy students. Training always included statistical and background knowledge of suicide and 88% included tips on communicating about suicide and provided referral resources. In addition to these topics, the authors recommended that training should include information about suicidality as a medicine-related side effect. It is important that they note the lack of evidence regarding long-term implications of this training^[25]
. Washington is the only state where suicide prevention training for pharmacists is mandatory^[25]
.

When information on the current situation in the UK was communicated to suicide researchers at the VA Center for Excellence for Suicide Prevention and the faculty at Stoney Brook University, New York, they were struck by how much community pharmacists interact and speak with the patient in UK practice. In their review, Carpenter et al. suggest that a barrier to suicide prevention interactions in community pharmacy is a lack of privacy^[25]
. This contrasts with our experience in the UK, where the use of a private and confidential consultation room is cited as an enabler [unpublished data]. This could mean one of two things, or a combination of both:

a) People in the United States do not use the pharmacist as a resource for healthcare advice and medicine queries in the same way as people in the UK do;

Or

b) As a pharmacist, my experience of engaging with patients and customers to provide advice and services is biased and I believe this is how all patients interact with pharmacists.

The Dalhousie University experience

As part of this visit to Nova Scotia and Dalhousie University, conversations were held with several psychiatrists and third-party organisations, including the Schizophrenia Society of Nova Scotia and The Canadian Mental Health Association, Nova Scotia Division. These individuals and groups offered a variety of perspectives regarding suicide prevention and their interactions with pharmacies. A recurring theme was the involvement of pharmacists in the so-called ‘circle of care’. By this, colleagues were referring to the health and social care colleagues who can access and share information relating to the patient’s care, in line with appropriate consent. Pharmacists presumed that they were included in this circle of care, but this view was not necessarily held by other health and social care professionals. This is something that we must consider in the UK: are pharmacists and pharmacy teams always privy to the information required to best support our patients?

Perhaps it would be useful for community pharmacy staff to receive a communication if someone was considered to be “at risk” of suicide. It is important to note that the term “at risk” of suicide is used with extreme caution because it is very difficult to predict if someone will die by suicide, as suicide risk assessment scales and tools have poor levels of prediction^[19],[26]
. What is known, however, is that a previous suicide attempt is the biggest risk factor for dying by suicide^[27]
. It was proposed during discussions that it could improve the care pharmacy teams can give to patients if they are included in this circle of care and self-harm or suicide attempts are communicated to them. Essentially, pharmacy teams could be especially vigilant and sensitive to the needs of these patients. It seems that misconceptions about the place of community pharmacy teams in healthcare relationships need to be addressed in order to improve safety and benefits for patients.

Experience of community pharmacy shadowing in the United States

Time spent shadowing in community pharmacies in New York provided opportunities to speak to community pharmacy staff and establish what they knew about suicide prevention. Responses and enthusiasm about the potential role of pharmacy teams in suicide prevention were mixed, but it was unanimously agreed that there is no formal role relating to this. Some pharmacists in the United States described their experience of talking to people about suicidal ideation, including during a visit to a patient in their home and during phone calls to the pharmacy from a patient discussing suicidal ideation. Discussion of suicidality with pharmacy teams over the telephone was identified by Murphy et al. in their qualitative analysis of experiences of pharmacists in Canada and Australia^[28]
. Their thematic analysis of 176 responses to an open-ended question in an online survey distilled four themes to represent the involvement of pharmacists in suicide prevention: referrals and triage; accessibility for confiding; emotional toll; and stigma^[28]
.

It seemed that in the UK perhaps we have even more opportunity to build rapport with patients and support them than was evident in the United States. Pharmacists seemed a little less accessible, behind glass walls both in the store and through drive-through hatches. Both of these environments could be barriers to communication that do not need to be overcome in the UK. While a drive-through could have benefits, for example for patients who are unable to get out of the car, it could be a cause for concern when it comes to discussing sensitive topics, including suicide. Conversely, the drive-through could provide an opportunity for patients to approach pharmacists from the safety of their own environment, which they may not otherwise have done.

The Bloom Program

Canadian pharmacies seemed to be somewhere in between the UK and United States in terms of accessibility. An example of the proactive care offered by some pharmacies in Nova Scotia is the Bloom Program^[29]
. The aim of this scheme is to utilise community pharmacists to improve the health and wellbeing of patients with mental illnesses and/or drug addiction. It provides resources for pharmacists to have regular one-to-one meetings with patients over a six-month period to discuss aspects related to their care, including medicine^[29]
. Patients are able to contact the pharmacist about any issues related to their condition, medicines and circumstances at a suitable time for them, over the telephone or in person.

An initial, formal analysis of the Bloom Program included 1,233 documented meetings with 182 patients from 23 pharmacies. Pharmacists and patients collaborated to optimise treatment and facilitate appropriate withdrawal of medicine and reduction of polypharmacy. The community pharmacist enabled convenient and confidential discussions, without the need for an appointment. Of the 46 patients who completed the discharge questionnaire from the Bloom Program, 78% felt that their identified health and medicine problems were resolved or improved^[29]
. The potential application of the Bloom Program in UK pharmacies could be investigated, in light of the previously mentioned guidance on suicide prevention and the recent National Institute for Health and Care Excellence (NICE) guidance, which recommends that pharmacies should proactively seek opportunities to improve mental and physical health^[30]
.

In discussions with various pharmacists across Nova Scotia involved in the Bloom Program, individuals highlighted their enthusiasm and commitment to the programme and exemplified the initial research findings. What seemed clear was that these pharmacists felt that they had excellent rapport and professional relationships with patients, and an ability to build such a rapport quickly. This facilitated the success of the Bloom Program discussions and ongoing care. Whether this can be utilised into a gatekeeper role for suicide prevention was a focus of this fellowship. Indications from pharmacists in the United States and Canada, with the exception of those involved in the Bloom program, are that pharmacists are not necessarily trained to discuss suicide.

Before training can be implemented, it is important to understand the evidence base and how the effectiveness of any training for pharmacy teams can be measured. Various training packages are available, both online and face-to-face, but the majority of research focuses on pharmacist’s attitudes and knowledge about talking about suicide^[25]
. The findings of this fellowship show that there is still no clear answer on how we measure how effective training packages are on reducing suicide rates. This is because, although far too common, suicide is still considered a rare event. It would be extremely difficult to measure whether any training undertaken by the pharmacy profession affected suicide rates, especially given the ecological context of other ongoing activities and the UK government’s focus on the reduction of suicide. However, as suicide prevention is largely perceived as a collective responsibility, perhaps any intervention or scheme that contributes any benefit, however small, is helpful.

Talking about suicide

Discussions also highlighted some of the challenges of training people in suicide prevention. First, short training programmes are no substitute for experiential learning and skill development. However, it is unlikely that pharmacy staff will have significant experience in this area, therefore training may help to bridge the gap. Second, conversations reinforced concerns regarding the limited evidence base of training schemes. Kutcher raised concerns about community-based prevention programmes owing to a lack of robust evidence relating to safety or effectiveness^[31]
. In particular, it is important to ensure that these programmes do not have the opposite and adverse event of contributing to increased suicide risk. A recent meta-analysis of studies that evaluated the impact of participating in research about suicide showed no increased risk of suicide and potentially small benefits^[32]
. However, this inference is limited to people who elect to take part in research and therefore may not be applicable to the general population.

In the UK, there are some public campaigns that aim to encourage people to talk about suicide. NICE guidance states that a role of suicide prevention partnerships includes communicating to the public that talking about suicide does not increase the risk of suicide^[14]
. Therefore, pharmacy cannot be left out of public health approaches in the UK, but any interactions that pharmacy professionals have about suicide must be undertaken safely. A third-sector delegate at ESSSB stressed that there is a difference between normalising talking about suicide and normalising suicide. This is an important notion to apply. Community pharmacy teams fit within the remit of the NICE definition of a gatekeeper, defined as “people in groups that have contact, because of their paid or voluntary work, with people at risk of suicide … people in these groups may be trained to identify people at risk of suicide and refer them to treatment or supporting services as appropriate”^[14]
. Gatekeeper training undertaken by the US Air Force and Norwegian army has reduced suicide rates^[31]
.

How are pharmacy teams involved in suicide and self-harm means restriction?

Beyond the potential gatekeeper role of community pharmacy teams from a health and social care aspect, the role of pharmacies as providers of medicines should be considered. Pharmacists might use medicines to identify individuals being treated for a mental health problem. It was clear during pharmacy visits in the United States that the spectrum of awareness and familiarity in helping people with their mental health problems varied. Moreover, pharmacies may provide “access to means” to suicide or self-harm. In other words, they may provide the medicine that may be used for poisoning. In the UK, medicine poisoning is the second most common method of suicide in both women (38.3%) and men (18.2%)^[5]
. Furthermore, intentional self-poisoning was the reported method of self-harm in 82.2% of cases in a UK primary care cohort^[33]
. In 2017–2018, there were 215,735 attendances at accident and emergency departments owing to poisoning, accounting for 1% of all attendances in England^[34]
. Discussions about pharmacies as providers of the medicines that might be used in poisoning deaths are seldom heard to date and it is understood that no papers specifically explore this in terms of suicide prevention.

In the UK, medicines used in poisoning deaths, both intentional and unintentional, are recorded on the death certificates and on records held by the Office for National Statistics. In 2017 in England and Wales, there were 3,756 deaths related to drug poisoning and the majority (74%) were cases of accidental poisoning^[35]
. Opioids were recorded as being involved in 1,985 of these deaths, while 484 deaths involved antidepressants^[35]
. However, there is little information about where different medicines used in overdose are commonly sourced — while it is assumed that illicit drugs are obtained through illicit channels, it cannot be assumed that all prescribed medicines are prescribed to that individual. It is possible that they are borrowed from someone or obtained from an unapproved supplier. If they were prescribed, it is not known whether they were prescribed in a suitable quantity, for a suitable duration or whether there was potential for stockpiling.

Access to means

In the United States, over-the-counter (OTC) medicines are much more widely available, and few with the equivalent UK ‘P’ status (medicines that can only be sold from a pharmacy under personal control of a Responsible Pharmacist). Moreover, in the United States it is possible to buy medicines in extremely large quantities without consultation with a pharmacist (e.g. 1,000 paracetamol tablets were available to purchase without counsel). In the UK, a legal maximum of 100 paracetamol tablets can be sold from a pharmacy in maximum pack sizes of 32; the maximum pack size from a nonpharmacy outlet is restricted to 16. This law came into force in 1998 in response to rising incidences of paracetamol poisoning. An analysis of the 11 years following this legislation showed a 43% reduction in deaths involving paracetamol^[36]
. The success of this restriction as a suicide prevention strategy is frequently cited in suicide research circles, including at ESSSB in 2018. The availability of medicine in the United States, and to a lesser extent in Canada, seemed excessive. It must be taken into account that the healthcare systems in the United States, Canada and the UK operate differently, and this may influence the availability of OTC medicines; however, this should never compromise safety. In the 2018 NICE guidance ‘Preventing suicide in community and custodial settings’, reducing access to means is a specific aim. This explicitly includes reducing access to painkillers in the community^[14]
— a comment included following the consultation response from the College of Mental Health Pharmacy^[37]
.

Pharmacy teams in the United States seemed alert to medicine poisoning in relation to the so-called ‘opioid crisis’ (the misuse of opioids, both prescription and non prescription, which occurred to such an extent it was declared a public health emergency^[38]
). It was in this context that pharmacy teams considered medicine availability. Some of the pharmacists in the United States were surprised that codeine is available OTC (as co-codamol) in the UK. Pharmacists were well versed in this opioid epidemic and contributed to the public health response primarily through the Prescription Monitoring Program^[39]
. This programme requires pharmacists in New York to access a database to review the prescribing history of opioids to ensure that no other opioids have been prescribed sooner than expected. If prescriptions are issued too soon, the pharmacist refuses to dispense them. The main emphasis seems to be on misuse and accidental overdose, with less focus on intentional drug overdose for self-harm or suicide purposes.

NICE guidance on the long-term treatment of self-harm advises against prescribing medicines that are particularly toxic in overdose, specifically citing tricyclic antidepressants^[40]
. However, in a study conducted using UK primary care records, 8.8% of people who had a previously recorded self-harm event were prescribed a tricyclic antidepressant^[41]
. Currently, there is no formal guidance on restricting quantities of medicine supplied in attempt to mitigate suicide or self-harm. In my own practice, I have observed examples of restricted quantities of supply (e.g. seven days) but whether this is owing to the perceived poisoning risk for that patient is not always communicated with the community pharmacy team. This seems to be a reasonable method to restrict access to medicine; however, further research to understand whether restricted supply could be effective in reducing the risk of self-harm or suicide by poisoning is required. This would include using observational data to understand whether restricted quantities reduce self-harm events. Any scheme that aims to restrict supply would need to be codeveloped with people who have lived experience to mitigate any such scheme on their associated recovery, and any stigma surrounding this (e.g. if people had to go into a pharmacy frequently). The involvement of patients or service users was recommended by Murphy et al. in their review, in which they identified no studies about the role of community pharmacy teams discussing suicide from this perspective^[42]
.

Washington state pharmacists as gatekeepers

In Washington, pharmacist involvement in suicide prevention encompasses both the health and social care, and medicine access elements. By the end of 2018, all registered pharmacists were required to complete a three-hour mandatory training programme on suicide. This was a result of the 2016 update to the Matt Adler Suicide Assessment, Treatment and Management Act of 2012^[43]
. This law named a wide spectrum of healthcare professionals who are required to have three or six hours of training on suicide prevention. The length of training relates to the perceived role of that group of healthcare professionals, with the three-hour training suitable for professions where only screening and referral elements are relevant^[43]
. Changes to the law were instigated by Jennifer Stuber, director of Forefront Suicide Prevention at the University of Washington. They partnered with Jenny Arnold and colleagues from the Washington State Pharmacy Association (WSPA) to produce three-hour bespoke online and face-to-face training packages to satisfy the aims of the law. Training was mainly centred on understanding and applying the LEARNâ„¢ acronym, which helps with recognising and taking action when someone may be in crisis^[44]
. LEARN is an acronym for the following suggested steps in suicide prevention: Look for signs, Empathise and listen, Ask about suicide, Remove the danger and Next steps^[44]
. Pharmacists who completed the Forefront–WSPA training were asked to complete questionnaires before and after undertaking the training package, but the evaluation of the training has not yet been published.

First-hand anecdotal conversations during the fellowship suggested that pharmacists perceived this suicide prevention training to be important. Not all, however, had completed it because their individual re-registration deadline had not yet approached. One pharmacist described rushing to complete the training the night before their re-registration date. This raised questions about the perceived urgency and importance of the training by pharmacists, who are inundated with other priorities.

Another major theme of the training package is the ‘Safer homes, suicide aware’ campaign. This campaign encourages people to limit access to firearms and medicine in the home by removing them or storing them safely, in order to make lethal means unavailable for a person contemplating suicide to access. Suggestions for medicines included locking medicine in boxes^[45]
. It seems intuitive that such a restriction could work. However, a similar scheme in Sri Lanka that investigated the impact of lockable boxes for pesticides (a major cause of poisoning) did not reduce the incidences of self-poisoning compared with the areas where this intervention was not made^[46]
. It will be essential to understand the impact of these medicine safe boxes on access to medicine and poisoning incidence. Discussions in Washington revealed that it is common for people to keep large quantities of medicines in the home, not least because it was difficult to dispose of them — there were only a few police stations and boxes they could use. This is expected to change after the introduction of the ‘Drug Take-Back Program’ in 2018, which requires all pharmacies to accept and dispose of returned medicine^[47]
. Much of the previous resistance for taking back medicines in pharmacy has seemingly been attributed to funding, and colleagues in the United States were intrigued to find out that it is a requirement of the essential NHS contract in England for pharmacies to accept and safely dispose of medicines returned to them. The purpose of this is to prevent accidental poisoning, mitigate the risk of diversion and reduce environmental damage by waste^[48]
. Interestingly, mitigation of intentional poisoning is not specifically stated. The method in the UK of accepting returned medicines into pharmacy was discussed in the context of being the gold standard disposal method. However, it is noted that it is currently unknown what proportion of unused medicines are actually returned to the pharmacy. This is something that requires further research in the context of means restriction.

Conclusion

This fellowship aimed to understand suicide prevention activities in the United States and Canada, building collaborations within this niche community to produce a set of recommendations relevant to UK practice (see Box 2). These recommendations focus on the potential involvement of community pharmacy in suicide prevention. Further research and development of evidence-based training is required to produce training commensurate to the scope of the role of pharmacy teams.

The UK could learn from the experiences of the mandatory training in Washington. From the broader perspective of supporting people with their mental health problems in community pharmacy, schemes modelled on the Bloom Program could show promise. This fellowship has shown that the UK has more stringent access to OTC medicine than that observed in Canada and the United States, and perhaps the benefits of restricted paracetamol access in the UK can be noted. There are other avenues of access to medicine that require further research to understand whether they can contribute to suicide prevention strategies. It seems that there is an opportunity to involve pharmacy teams in suicide prevention, but this must be done in an evidence-based way and methodically, integrated with other healthcare professionals and suicide prevention strategies.