Consumer knowledge of mental health conditions, awareness of mental health support services, and perception of community pharmacists’ role in mental health promotion

Abstract

Objective

To explore community pharmacy consumers’ knowledge and attitudes of mental illness, support services, and community pharmacists’ role in supporting people living with mental illness (PLMI).

Methods

This survey was conducted in 15 community pharmacies between June and September 2019. Participants were aged 18 years or older without prior or ongoing history of mental illness and/or with close family members with mental illness. Open-ended responses to the anonymous questionnaire were analysed using content analysis.

Key findings

Majority of the 380 participants were female (57.4%) with a mean age 52.9 years and 33.7% having completed university. Most (70.3%) believed that people with mental illness had a negative image due to poor health literacy providing possible solutions of ‘awareness campaigns’, ‘education and training’, and ‘increased government funding for mental health (MH) support services’. Only 33.7% and 63.7% of participants were aware of Mental Health Week and the R U OK? Campaign, respectively. Whilst 12.4% of participants had participated in MH campaigns, only 3.4% were aware of community pharmacists-led MH educational activities. There were significant differences between adults (<65 years) and older adults (≥65 years old) with the latter reporting a more negative image for mental illness (P < 0.05) and having less exposure and engagement with MH resources (P < 0.001) and campaigns (P < 0.01).

Conclusion

Despite awareness, participants reported low engagement with MH campaigns. Additionally, older adults had lower MH literacy and exposure to resources and campaigns. This study highlighted that the community lacked awareness of what pharmacists can offer to support PLMIs.

Introduction

A recent World Health Organisation report revealed that approximately 1 in 8 people worldwide live with a mental illness, with anxiety and depressive disorders being the most prevalent [1]. Mental illness was found to be the primary cause of years lived with a disability globally, accounting for one in every 6 years [1]. In Australia, mental health (MH)-related expenditures contributed to approximately 7.6% of the total healthcare expenditure in 2019 [2] placing a significant economic strain on the healthcare system [1]. The 2021 national survey estimated that over 43.7% of Australians aged 16–85 years had experienced a mental illness during their lifetime [3]. Therefore, improving support services and health outcomes for people living with mental illness (PLMI) would have significant benefits for society.

Stigma acts as a significant barrier for PLMI who face fear and disdain from the community, resulting in further social isolation and self-stigma [4, 5]. To combat this, increasing the general population’s overall MH literacy and awareness is a potential solution [6–8]. Previous studies have shown that individuals without an educational background in MH exhibit lower MH literacy [9, 10]. Involving primary healthcare practitioners in community outreach programmes to provide information on MH conditions and community-based resources could improve overall MH literacy [11, 12]. Increasing public MH literacy is important, as evidence shows that PLMI are more likely to confide in close friends and family [13, 14].

Community pharmacists are in a valuable position to provide these additional services due to their accessibility [15–17]. Throughout the pandemic, community pharmacies operated face-to-face even when other primary healthcare professions transitioned to telehealth and remote consultations [18, 19]. Australian consumers with mental illness and their families have reported positive perceptions of community pharmacists, appreciating their friendly, sensitive, and non-judgemental approach to service delivery, thereby creating a welcoming and safe MH space [20]. The established trust and rapport between community pharmacists and their consumers make them well-suited to implement MH promotion initiatives [15]. Such initiatives have shown positive impacts on the health-related quality of life within their communities [21].

With additional training and adequate remuneration and policy changes, community pharmacists can play an important role in the MH and wellbeing of their communities [22, 23]. In particular, recent reviews have highlighted how community pharmacists can play a role in screening for undiagnosed depression in adults [23, 24] and monitoring for physical health in PLMI living independently in their communities [22, 23]. International organizations like the International Pharmaceutical Federation [24] and the Pharmaceutical Society of Australia [25] have advocated for expanded roles for pharmacists in mental healthcare, including screening for undiagnosed mental illness, navigating access to support services within health systems and optimizing therapies [23]. However, to the best of our knowledge, there are no published studies investigating the perspectives of Australian community pharmacy consumers on the role of community pharmacists in supporting PLMI.

To address this gap, we sought to explore Australian community pharmacy consumers’ attitudes and beliefs about mental illness, knowledge of MH, and MH support services, and the role that community pharmacists could play in supporting PLMI and educating the community.

Methods

This study utilized an anonymous questionnaire comprising 16 open-ended questions (Supplementary material). These questions were separated into three sections: (i) demography, (ii) MH (including questions relating to attitudes/stigma/beliefs, the 12 signs and characteristics of depression as listed in the DSM-V Depression Diagnostic Criteria [26], MH support and role of community pharmacists in supporting consumers with mental illness), and (iii) MH resources (awareness of and prior experience with MH resources and role of community pharmacists in MH education). This questionnaire was piloted on a convenience sample of pharmacy academics in the three participating universities for readability and understanding.

A convenience sample of participants was recruited from six South Australian (SA), five Victorian (Vic), and four Queensland (Qld) community pharmacies between June and September 2019. Study data were collected by final-year pharmacy students from three pharmacy schools as part of their final-year research project. Apart from one Victorian pharmacy, all pharmacies were in metropolitan areas. Consumers aged 18 years or older and without prior or ongoing personal history of mental illness and/or with close family members with mental illness were invited to participate in this study. In SA, potential participants’ medication dispensing histories were screened by their community pharmacists to exclude those with existing or a history of mental illness or those caring for an immediate family member with mental illness. Due to privacy laws in Qld, prior screening by community pharmacists was not allowed. Instead, the first question on the questionnaire screened for prior experience with mental illness. Interested participants were then provided with a participant information sheet and those willing to participate signed an informed consent form. In Vic, participants were recruited the same way as in Qld. In SA and Vic, participants completed a hard copy of the anonymous questionnaire in private counselling rooms while in Qld, the anonymous questionnaires were completed on a laptop in a quiet area of the pharmacy. All participants were assigned a unique identifier code for confidentiality and data were recorded against this number.

Content analysis was used to analyse open-ended responses. Demographic data were presented using descriptive statistics. Continuous data were analysed using one-way Anova tests while categorical data were analysed using Pearson’s Chi-squared Test for Independence. Categorical data were further analysed after stratifying for age, dividing respondents into two groups: adults aged 18–64 years and older adults aged 65 years and above. Statistical significance was taken to be P < 0.05. As well as quantitative analysis, data for each question (except demographic data) were coded manually using a three-pass manual coding methodology [27]. Two of the authors undertook the first coding cycle independently. Agreement on final codes and themes was reached through discussion and negotiation. The first coding cycle employed structural coding followed by a second cycle where the original codes were reviewed and revised, if necessary, and allocated into categories. Conceptually similar codes were grouped together under a single category, and some codes that were considered marginal, redundant, or irrelevant were removed from the analysis. This process aimed to develop a more concise list of categories and subcategories [28]. In the third coding cycle, these reorganized categories were synthesized into more general, higher-level themes. Inter-rater reliability was addressed by having a second researcher also analyse samples of the data. Final themes were derived through discussion, negotiation, and agreement between members of the research team.

This study was approved by the three institutions’ Human Research Ethics Committees (HREC Protocols 201419 and 1900000603, SEHAPP 90-18) and permission was obtained from the pharmacy chains, respective owners, and managers of the community pharmacies.

Results

Of the 543 consumers approached (SA = 189, Vic = 224 and Qld = 130), 163 were excluded due to caring for an immediate family member with mental illness, having a mental illness themselves, or not wanting to be involved in the study. Across the 3 states, 380 consumers (SA = 174, Vic = 146, and Qld = 60) completed the questionnaire (Table 1). The cohort comprised slightly more females (57.5%; 218/380) with a mean age of 52.9 years (range 18–98 years). Half had completed high school (50.0%) and one third having completed university (33.7%; 128/380).

Most participants (70.3%, 267/380) believed that PLMI had a negative image in the community. There was a statistically significant difference in responses among the 3 states (73.6%, 65.8%, and 71.7% from SA, Vic, and Qld, respectively, $χdf42$ =19.35, P < 0.001) (Table 2). With age-stratified analysis, the proportion of participants in the younger group who believed that PLMI had a negative image was significantly different from the proportion in the older group (67.0% vs 75.3%, $χdf22=6.18$⁠, P < 0.05) (Table 2).

When asked to identify the signs of depression as listed in the DSM-V Depression Diagnostic Criteria (Table 1), less than a third (26.8%, 102/380) identified all 12 symptoms. Only 180 (47.4%) identified unintentional weight loss and 208 (54.7%) decreased appetite as symptoms of depression. Unsurprisingly, 312 (82.1%) identified depressed mood.

Slightly more than half of the participants 51.6% (196/380) reported being aware of MH support resources. There was a statistically significant difference between the proportion of participants aware of resources across the three states (44.3%, 62.3%, and 46.7% for SA, Vic, and Qld, respectively, $χdf22=11.07$⁠, P < 0.01). Age-stratified chi-squared test also showed that the younger group was significantly more aware of support resources than the older group (60.6% vs. 39.2%, $χdf12=16.89$⁠, P < 0.001) (Table 2). The top three resources named by participants were Beyond Blue (43.9%), Black Dog Institute (13.7%), and Lifeline (8.9%) (Table 2). Of these 196 participants, 104 (53%) had used one of the resources, commenting that the information provided by these resources was easy and simple to understand.

There was a significant state-wise difference in the usage of MH resources (SA—43.1%; Vic—13.7%; Qld—15.0%, $χdf22=40.01$⁠, P < 0.001) (Table 2). Even though the younger group was more aware of support resources for mental illness (60.6% vs. older group—39.2%, $χdf22=16.89$⁠, P < 0.001), they were significantly less likely to have used them when compared to the older group (22.2% vs. 34.8%, $χdf12=7.39$⁠, P < 0.01) (Table 2).

With regard to national MH awareness campaigns, 33.7% (128/380) and 63.7% (242/380) of participants were aware of Mental Health Week and the R U OK? Campaign, respectively (Table 2). However, only 12.4% (47/380) had participated in an MH campaign while only 3.4% (6/380) of participants were aware of any MH educational activities that community pharmacists were currently involved in.

Participants were asked why they thought mental illness had a negative image in the community (Table 3). The key theme from content analysis was the belief that PLMI are the ‘out’ group in society—they are perceived as ‘different’ and with this perceived difference comes a negative image. Participants believed this negative image could be lessened through greater awareness with most responding that this could be achieved through encouraging conversations about mental illness, MH awareness campaigns, for example, in the media utilizing celebrities and improving MH literacy by embedding MH content in school and high education curricula. Participants’ beliefs regarding what constitutes important support for PLMI are also depicted in Table 3. When asked what role community pharmacists could play in supporting individuals living with mental illness, content analysis revealed five themes: ‘someone to talk to’, ‘medication supply and counselling’, ‘triage’, ‘education’, and ‘no role’ (Table 4). Participants could not perceive a role for pharmacists apart from medication supply and counselling, being someone to talk to, and being a triage service for other types of professional help. A few participants felt MH was outside pharmacists’ expertise and that there was no expanded MH role for pharmacists.

Discussion

Before this study, there was limited research investigating the knowledge of mental illness and the availability of support services among community pharmacy consumers, as well as their perceptions of the role of community pharmacists in supporting PLMI and educating the public on MH topics. This research highlighted that Australian community pharmacy consumers believed that: (i) PLMI are treated differently by society to those living with other illnesses, and (ii) pharmacists have a limited role in supporting those living with mental illness, apart from medication dispensing (including counselling) and education.

This study has several limitations, including social desirability bias due to direct data gathering from participants that might result in social desirability response bias [29]. The focus on symptoms of depression may not fully reflect participants’ understanding of other mental illnesses. Additionally, factors such as ethnicity, socioeconomic factors, and MH literacy were not explored, which are known to influence attitudes and beliefs, including stigma. The study could have been improved by including a broader range of mental illness types to explore how attitudes and knowledge differ by mental illness type. On reflection, some of the questions could have been written using more open-ended language. Previously validated questionnaires [4, 30, 31] were explored when developing the questionnaire for this study. However, these tended to address mental illness broadly while we specifically wanted to investigate the health literacy of pharmacy consumers regarding their beliefs on mental illness, and the signs and symptoms of depression, considering many people confide in family and close friends for support. Hence, our questionnaire was developed referring to these examples and the structuring of questions but tailored to address the aims of our study.

Raising awareness and knowledge of mental illness within the community is crucial because individuals often rely on family and friends for support when affected [14]. However, fear of stigma is a common barrier to seeking help from loved ones. Therefore, educating the general public can improve the quality of support provided [14]. Recent research indicates that public attitudes towards mental illness have improved over time [32, 33]. However, previous research examining the impact of age, gender, education level, and ethnicity on public stigma towards mental illness has produced conflicting results [32–36]. Our findings align with prior literature demonstrating increased stigma among older individuals [33], although other studies have noted the opposite [32, 35, 36]. This disparity may be explained by the method of age stratification (40 years and older in Bradbury et al.’s study [32] compared with 65 years and older in the present study) and the level of MH literacy, which is reported to be lower in older people [37].

While many participants were aware of at least one national MH awareness campaign, their engagement with these initiatives was considerably low. National MH awareness campaigns aim to reduce stigma and discrimination, improve communities’ MH literacy, enhance communication about MH among friends and family, and increase help-seeking behaviours for PLMI [38]. A review of the R U OK? Campaign demonstrated a significant increase in awareness after their annual campaigns between 2010 and 2014 [13]. Participants reported feeling encouraged to discuss MH issues and inquire about the wellbeing of family and friends, as well as being more willing to seek professional help [13]. Beyond Blue also evaluated their MH-targeted national initiative between 2000 and 2004 [38]. Beyond Blue’s short-term goals of increasing quality information, improving consumer/carer networks and care of depression in primary care settings, and increasing target MH research have been successful [38]. They were also making progress towards their long-term goal of reducing stigma and discrimination. They also reported that Beyond Blue’s efforts have been instrumental in decreasing stigma and discrimination [38]. However, the current study suggests that these public awareness campaigns have yet to achieve their goals. Moreover, there is limited evidence regarding their effectiveness in bringing about behavioural change such as increased uptake of professional services and reduced suicide attempts [17]. Early introduction of MH education in school curricula may provide an effective way to raise awareness and promote participation in MH awareness campaigns.

This study found that the general perception of the pharmacist’s role in MH among the Australian public mainly centres around traditional roles of medication supply and counselling and referral to other healthcare professionals. However, considering their accessibility, pharmacists have the potential to build impactful relationships with their patients. Australians visit their community pharmacies 18 times annually compared to visiting their GPs 5.6 times for the same period [39, 40]. By having repeated consultations with patients with depression, pharmacists can monitor changes in presentation and demeanour contributing to the improvement of the recovery process [15]. The role of pharmacists in MH is expanding rapidly, encompassing professional services such as telepharmacy, interventions to enhance medication adherence, early detection and screening of mental illness, and facilitating access to health services, all of which have demonstrated positive impacts [21, 23]. Public education on the role of pharmacists in community health management is necessary, as currently, even large MH organizations such as Beyond Blue fail to acknowledge pharmacists as a viable support option on their website.

Conclusions

In summary, this study has highlighted that the public can confidently identify the common symptoms of depression. Despite being aware of various national MH awareness campaigns, participants were less actively engaged. This study highlighted that the community lacked awareness of what pharmacists can offer to support people living with MH conditions. Pharmacists also need to be included in national MH awareness campaigns to highlight their role as capable and accessible healthcare professionals, beyond their traditional role of dispensing medications.

Acknowledgements

The authors would like to thank all participants for their valuable contributions and staff and management of the 15 community pharmacies for supporting data collection. The authors would also like to thank the following students for data collection: Miss Myca Alba, Miss Nichole Goh, Miss Runu Hann, Miss Ella Mullins, Mr Biak No Thawng, and Mr Marcus Penev.

Author contributions

Judith Singleton: Formal analysis, writing—review & editing, supervision. Julie E Stevens: writing—review & editing, supervision. Raymond Truong: Formal analysis, investigation, data curation, writing—original draft. Adam McCulloch, Elay Ara and Brittany Hobbs: Formal analysis, investigation, writing—original draft. Maria B Cooper: writing—original draft, writing—review & editing. Elizabeth Hotham and Vijayaprakash Suppiah: Conceptualization, methodology, formal analysis, resources, writing—review & editing; supervision, project administration.

Conflict of interest

None declared.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data access statement

Judith Singleton, Julie E Stevens, Raymond Truong, and Vijayaprakash Suppiah have ongoing access to study data.

Data availability

The data underlying this article will be shared on reasonable request to the corresponding author.

References