Prescription: Suicide Prevention

As a pharmacist in a downtown Ottawa neighbourhood where many people struggle with complex mental health issues, substance use, and homelessness, Mark Barnes noticed years ago that his clients often came to him traumatized by disrespect and judgment in the health-care system, which added to their distress.

Along with three partners, he founded a specialized pharmacy for these vulnerable clients called Respect Rx, guided by the idea that pharmacists who practise with compassion and empathy along with their professional expertise could provide benefits for their clients that go beyond just prescriptions. Over the years, Barnes says, he’s worked with people at high risk for suicide “many times.” Crisis can come in many forms — clients may arrive at the pharmacy at all hours amid a psychosis, while experiencing acute substance withdrawal symptoms, or in the immediate aftermath of a sexual assault, eviction, or “a flooded crack house,” for example. “That is my world,” says Barnes.

Respect Rx, which now has five Ottawa branches and one in Cornwall, is built on the idea that a pharmacist should be there to help vulnerable clients by getting to know them, learning about their issues, and addressing them without judgment. It means noticing and asking how they are doing. Initiatives in other provinces, such as Nova Scotia’s Bloom Program, operate on similar principles and the understanding that pharmacists are well placed in the health-care system to have a positive impact on the mental health of their clientele. This includes active partnering with other community supports. For Respect Rx and the Bloom Program, these include rehabilitation centres, housing advocates for women and children, harm reduction sites, and homeless shelters.

Regardless of which neighbourhood they work in, pharmacists will inevitably encounter numerous people contemplating suicide during their careers. According to Statistics Canada, approximately 12 people die by suicide each day, and there are approximately 4,500 deaths by suicide per year. Among young people aged 15-34, suicide is the second-leading cause of death.

Studies show that as many as 45 per cent of people who die by suicide see a primary care provider in the month before their death, and thus prevention has become a top priority in the health-care system. The same studies show that adding suicide screening to primary care visits reduces attempts by 25 per cent.

Any health-care measures that reduce the number of suicides are good news. But millions of people in Canada do not have a primary care physician and therefore cannot benefit from screening measures in the doctor’s office. Could it be that pharmacists are an overlooked resource in preventing suicide? A growing number of voices in the mental health field think so. For many people in Canada, pharmacists may be the most accessible portal to the health-care system. A pharmacist can see things that other health-care professionals do not, through prescription patterns and just getting to know a client over time. A missed antidepressant prescription or, conversely, stockpiling, for example, could alert a pharmacist to ask questions and lead an individual to get help they may need from other professionals, such as a psychiatrist, psychologist, addictions counsellor, or social worker. Another possibility is that pharmacists, like Barnes and his Respect Rx colleagues, may intervene during an acute mental health crisis. “Pharmacists have a high amount of skill, but it’s not just in the operation of a community pharmacy, but also with regard to seeing problems … and doing a lot of work in the community,” says Barnes. That could mean referring clients with complex needs to another resource or interacting with family and other health professionals to alert them that the client is struggling.

“The pharmacy is accessible, more accessible right now than perhaps primary care for a lot of people,” says Nitika Rewari, director of prevention and promotion initiatives at the Mental Health Commission of Canada. “It’s a growing part of the mental health care conversation: How can pharmacists be a part of the solution, and a trusted adviser for people they are seeing regularly?”

More support, conversation, and research are needed, says Rewari, to determine exactly how pharmacists can play a role in suicide prevention, help pick up on warning signs from people thinking about suicide, and then act in a positive and ethical way. “This doesn’t mean, of course, they become mental health providers, but it does mean they are able to hear the concerns people are sharing,” Rewari points out. “Then they can support them within their own scope of practice and point them to the right resources within their communities.”

A 2019 article published by the Ontario College of Pharmacists offers guidance and practical tips for how pharmacists can notice warning signs, assess suicide risk, and act effectively. It can be helpful, for instance, to take a course in mental health first aid. A pilot study evaluated the effects of mental health first aid training on the levels of confidence, attitudes, and knowledge of Manitoba pharmacists and fourth-year pharmacy students regarding the provision of mental health services. This study, which was the first of its kind in Canada, found that participants’ confidence in assessing clients’ risk of suicide and harm rose from 46.7 per cent before the training to 100 per cent after the training.

Other recommendations include asking direct questions if a client exhibits warning signs (such as changes in mood and behaviour). The 2019 Ontario College of Pharmacists article notes that some medications, such as antidepressants, may carry an increased risk of suicidal ideation that should be noted; if a pharmacist knows the client well, they might ask family members of the client for help keeping an eye out for changes in behaviour. The article also advises transparency regarding any interventions; the client should be aware of any actions a pharmacist plans to take to help. Ideally, the pharmacist can help the client navigate toward the resources they need to get beyond a mental health crisis. Partnering with community organizations and other members of the health-care system is key.

With more training and research, it’s clear pharmacists can become an even more valuable part of the whole health-care system and community approach to suicide prevention.

It all comes back to what Barnes calls the human connection. “We have the skill and resources to approach people with dignity, respect, and compassion. When you do that when the person is most vulnerable, you can really make a difference,” Barnes says. “If a pharmacist doesn’t know you by name,” he laughs, “freaking switch!”