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UK Pharmacy Students’ Opinions on Mental Health Conditions

1 Objective : Given the increased emphasis on mental health awareness recently, this study aimed to 2 ascertain future pharmacists’ opinions on mental health conditions (and investigate the influence of 3 gender), since they would soon be advising patients about this in their capacity as healthcare 4 professionals. 5 Methods : Following ethical approval and piloting, all final year Master of Pharmacy students at 6 Queen’s University Belfast were invited to complete a paper-based questionnaire during a compulsory 7 class. Section A was an adapted version of a United Kingdom (UK) public opinion questionnaire on 8 mental health (‘Attitudes to Mental Illness’), largely consisting of rating questions. Section B gathered 9 non-identifiable demographic data. Descriptive statistics were undertaken; Mann-Whitney U test and 10 Chi-square test were used for gender comparisons with significance set at p<0.05. 11 Results: An 89% (97/109) response rate was obtained. Most considered that pharmacological and 12 non-pharmacological measures were beneficial in the management of mental health conditions (89% 13 and 96%, respectively) and that people with mental illness had the same rights to jobs as anyone else 14 (82%). However, only 57% of student respondents felt confident discussing mental health issues with 15 patients and 36% deemed university training to be satisfactory. Males were more likely than females 16 to ‘agree strongly’ or ‘agree slightly’ that they would not want to live next door to someone who has 17 been mentally ill’ (p=0.01). 18 Conclusion: While some positive opinions were evident, more work is needed to prepare these future 19 pharmacists for roles within mental health care teams. 20 21 22 23 24 25 26


INTRODUCTION 1
To the best of the authors' knowledge, there has been limited work in this area involving pharmacy 1 students particularly in the UK and no work specifically conducted in Northern Ireland. This research 2 adds to the existing body of literature by providing useful baseline data from a UK context. Moreover, 3 it is important to ascertain pharmacy students' opinions on mental health conditions, given that they 4 will be advising and counselling patients about this important clinical subject area in their capacity as 5 a healthcare professional (and since the number of people affected by mental health conditions 6 continues to grow 1 ). Importantly, it is anticipated that the findings of this research will inform future 7 teaching of the subject matter. From a pharmacy education standpoint, "developing a clinical 8 knowledge base that culminates in the demonstrated ability of learners to apply knowledge to 9 practice" and preparing students "to provide patient-centered collaborative care" are stipulations in 10 the Accreditation Council for Pharmacy Education (ACPE) Accreditation standards and Key 11 Elements for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree. 23 12 These are also reiterated in the UK Master of Pharmacy (MPharm) accreditation standards. 24  participate in the study. The inclusion criterion was that the study participants had to be currently 18 enrolled Level 4 students. Level 4 students were selected because they had been taught about mental 19 health conditions prior to conducting the research (unlike the other year groups) and also because they 20 were soon to graduate from university and begin their career in pharmacy practice. 21 Data were collected by means of a paper-based self-completed questionnaire. The questionnaire was 22 developed with reference to the wider literature 7-18 and consisted of two sections. Section A was an 23 adapted version of the 'Attitudes to Mental Illness' UK public opinion questionnaire, 8 consisting of 24 many attitudinal statements measured using a five-point Likert scale (Agree strongly/Agree 25 slightly/Neither agree nor disagree/Disagree slightly/Disagree strongly) and, on occasion, a seven-26 point scale (Very uncomfortable to Very comfortable). The Attitudes to Mental Illness questionnaire 27 was developed and funded by the Department of Health and includes items from the 'Community 28 Attitudes toward the Mentally Ill (CAMI)' scale and the 'Opinions about Mental Illness' scale. 8 1 Further statements were included about confidence counselling patients on mental illness and training 2 provision within the degree program. Section B related to demographic information and gathered non-3 identifiable data only. 4

5
To maximize response rates, the questions were largely in a close-ended question format. 25 The 6 questionnaire was piloted with ten pharmacist postgraduate students at the School in November 2016. 7 As a result, one minor modification was made (wording was amended for one question to clarify that 8 respondents could select as many options as they wished). 9 Questionnaire distribution took place during Semester 1 (in December 2016) in a compulsory class. In 11 January 2017, the responses from the completed questionnaires were coded and entered into a 12 customized database developed on IBM SPSS v22 (SPSS Inc., Chicago, IL) for statistical analysis. 13 Data analysis largely took the form of descriptive statistics. Interpolated median scores were 14 calculated on the rating questions. Comparisons were done between gender responses as previous 15 work revealed differences in opinions. 12,14 Mann-Whitney U test and Chi-square test were used for 16 gender comparisons with significance set at P<0.05 a priori. The Mann-Whitney U test was performed 17 on the data that was ordinal in nature whereas the Chi-square test was performed on the data that was 18 categorical (nominal) in nature. 19 20
Students were asked about the person closest to them who has/had some kind of mental illness. They 1 were instructed to select one option from a list. The results to this question are outlined below, with 2 the top three most popular selections being: a friend, no one known, and immediate family. 'very unlikely'. The interpolated median was 3.7 (5 equated to 'very likely' to 1 for 'very unlikely'). 16 In another hypothetical statement, students were asked to rate how comfortable they would feel talking 18 to a friend or family member about their mental health. For example, telling a friend or family member 19 that they (the student) had a mental health diagnosis and how it affected them. Respondents had to rate 20 their answer from 1 (very uncomfortable) through to 7 (very comfortable). The interpolated median for 21 this statement (n=97 respondents) was 4.4. Similarly (and using the same scale), students had to rate 22 how comfortable they would feel talking to a current or prospective employer about their mental health. 23 The interpolated median for this statement (n=97 respondents) was 2.1.

25
Regarding statements about future relationships, students had to indicate their level of agreement [1 26 ('disagree strongly') to 5 ('agree strongly')]. The interpolated medians for each are: I would be willing to continue a relationship with a friend who developed a mental health problem (4.9), to live 1 with someone with a mental health problem (4.5) and to work with someone with a mental health 2 problem (4.7). respondents knew what advice to give a friend with a mental health problem so that they could get 23 professional help. Moreover, in relation to the statement 'I would not want to live next door to 24 someone who has been mentally ill', males were more likely than females to 'agree strongly' or 25 'agree slightly' [ Lastly, when asked about whether people with mental illness experienced stigma and discrimination 3 nowadays because of mental health problems, 51/97 (53%) selected 'yes, a lot', 46/97 (47%) selected 4 'yes, a little' and no one selected 'no'. 5 6 DISCUSSION 7 Unlike other research, 12,14 gender played a limited role in this current study as there were few 8 significant differences between male and female responses. Only a small percentage (5%) of students 9 reported having a mental illness which is a much lower prevalence than that previously reported in the 10 literature, for example, by Goodwin and colleagues 11 for first year undergraduate university students, 11 Alfaris and colleagues 12 for health professions' university students (and in particular female students) 12 and Payakachat 13 and Panthee 19 and colleagues for pharmacy students. Thankfully the majority of 13 respondents suggested they would be comfortable talking to friends and family about a mental health 14 condition (if applicable), although over 40% appeared reluctant to seek medical help from a doctor. 15 Moreover, the majority of respondents disagreed that most people with mental health problems go to a 16 healthcare professional to get help. In the UK, the doctor is a key medication provider in primary care 17 and a gateway to other mental health services. Similarly, previous work by Reavley and colleagues 26 18 in Australia revealed that 16-24 year olds were less likely to seek help for mental health issues than 19 middle-aged or older adults. Furthermore, Downs and Eisenberg 27 concluded that people who need 20 professional support the most are actually the least likely to source it. Ultimately, pharmacy educators 21 cannot assume that students pursuing healthcare degrees are looking after their own health adequately. 22 We found this previously in relation to alcohol intake: the mean intake of alcohol was 18.3 units per 23 week (exceeding the recommended UK amount) with around 70% of pharmacy students reporting 24 binge drinking on at least one day of the week. 28 In QUB School of Pharmacy, a 'mental health first 25 aid' scheme has just been launched whereby a cohort of students across the year groups are trained to 26 spot warning signs of mental health issues among their peers and signpost them to appropriate sources 27 of help. It would be useful to evaluate the impact of this and conduct further research to ascertain types of professional support that students do, or would consider accessing, in relation to mental 1 health issues, and barriers towards seeking help. 2 In this current study, respondents did not appear particularly comfortable talking about personal 3 mental health issues with employers. The score was much greater in relation to friends and family. It 4 is difficult to draw meaningful conclusions in relation to this as people are probably less likely to talk 5 to employers (than family and friends) about personal issues anyway. However, it could be related to 6 concerns about stigma and discrimination since all students also thought stigma and discrimination 7 associated with mental illness exists today and most considered that we (society) should adopt a far 8 more tolerant attitude toward people with mental illness. Northern Ireland may be slower to adopt 9 appropriate attitudes towards mental health than other countries. For example, a public awareness 10 campaign rolled out across various parts of Europe by Kohls and colleagues 29 gleaned less positive 11 results in Ireland compared with Germany and Portugal. That being said, many of our students' 12 attitudes towards mental health in this current study were positive and appropriate, unlike that 13 previously reported by Bell and colleagues about pharmacy students. 18 The majority of the students in 14 this current study thought that people with mental health problems should have the same rights to a 15 what advice to give a friend with a mental health problem. Only 1 in every 3 respondents considered 24 that the university training was adequate. These findings, among others, suggest that the current 25 training provision (a lecture series) within the School of Pharmacy is potentially not enough to 26 adequately prepare future pharmacists for practice. Similarly, Aaltonen and colleagues 30 investigated perceived barriers among pharmacy students in relation to providing medication counselling for 1 people with mental health disorders (in Australia, Belgium, Estonia, Finland, India and Latvia; n=649 2 respondents) and concluded that more work is needed within pharmacy education programs. 3 Furthermore, in this current study, some misconceptions exist (in relation being able to tell mentally 4 ill patients apart from others). In light of this, the authors consider that QUB teaching should be 5 reviewed and evidence-based interventions explored. 16,17,[31][32][33] The study has several weaknesses. The research was only conducted within one year group at one 8 school of pharmacy and therefore the findings are not generalizable. It is also possible that attitudes 9 could change depending on when the study was conducted in the semester (for example, knowledge 10 of mental health conditions could be better after revising for a clinical examination than beforehand 11 and attitudes might change after working in practice, as has been reported previously for pharmacy 12 students 20 ). 13

CONCLUSION 15
Many of these future pharmacists appeared to have appropriate attitudes towards mental health and 16 people with mental health conditions. Gender seemed to have very limited influence on attitudes. 17 However, there was a lack of confidence around advice provision to friends and patients and level of 18 dissatisfaction with the current training provision. The reluctance to seek medical help if they ever 19 developed a mental illness probably mirrors the view held by many members of the general public, 20 but is perhaps surprising given these students are future healthcare professionals. 21

22
The work adds to the field and provides us with a timely opportunity to reflect on current teaching and 23 make changes to our educational practice. From the findings, it seems that our mental health 24 education is not at an appropriate level to adequately prepare these students for practice. Additionally, 25 this study should provide useful baseline data for other schools of pharmacy in the UK and potentially 26 beyond. Future research should focus on an exploration of whether having personal mental health issues subsequently affects advice provision to patients and also evaluate the impact of introducing 1 specific mental health awareness training into the program. 2 3 ACKNOWLEDGMENTS 4 The authors wish to thank the students who participated in the study (including the pilot). 5 Financial disclosures: none. This research did not receive any specific grant from funding agencies 6 in the public, commercial, or not-for-profit sectors. 7 Conflicts: none.

Interpolated median
There is something about people with mental illness that makes it easy to tell them apart from normal people (n=96)