Mental Health & the Importance of Medication Adherence

Todd Eury:

Hey there, Pharmacy Podcast nation, Pharmacy Podcast Network. This is Todd Eury, and I'm excited to be here today. Thank you so much to our sponsors, RxSafe. RxSafe does a lot and has worked with Pharmacy Podcast for nearly five years now. And we really like that they bring to the table a lot of subject matter experts on a multitude of things, especially for that community pharmacy provider and owner.

Todd Eury:

But one of the most important things that they're doing is helping us to educate not only our pharmacists, but our other HCPs that we work with physicians, nurse practitioners, specialists about adherence. And today we welcome three very special pharmacists to our panel discussion. This is our mental health and the importance of adherence. And today is the December 17th, 2021.

Todd Eury:

And I'm excited to introduce our panel. I'm going to start off with Tyler Young. He is the lead pharmacist with Hines Prescription Shop, a locally owned pharmacy in Barnesville, Georgia. And Tyler helps hundreds of patients become more compliant with their medications by making it simpler with the RxSafe adherence packaging systems. Welcome Tyler, how are you?

Tyler Young:

I'm doing good. How are you?

Todd Eury:

I'm doing really well. When I get to be surrounded with pharmacist, Tyler, it's a good day for me. So I like being here.

Tyler Young:

Thank you for having me.

Todd Eury:

We also have, returning, Dr. Thomas McDowell, he's no stranger to the Pharmacy Podcast and to RxSafe. He's been working with us for quite some time, was at a live event at the NCPA, 2021, where we talked about adherence. We talked about more of our business strategies, but nonetheless, he's the owner of McDowell's Pharmacy in North Carolina. And Thomas and I, we have discussed things offline as well, and medication adherence in mental health is one of those. And Thomas welcome. I'm looking forward to your insights today.

Thomas McDowell:

Thanks, Todd, appreciate you having me on again.

Todd Eury:

And also Dr. Monica Krishnan, a very special woman to me and the Pharmacy Podcast Network, because of her participation and the launch of the Pharmacist's Focused on Mental Health podcast. I'm so proud to have her here. She's a clinical pharmacist with practice of over 18 years, and she began her career as an inpatient care pharmacist at UCLA medical center. And she started a family and suffered a loss of her husband at a very young age. It's an amazing testimony that, not only as a provider, but someone who really understands the importance of mental health, and being able to really focus on the community pharmacy needs, and the community that she serves. Welcome. Monica, how are you?

Dr. Monica Krishnan:

I'm good, Todd, thank you so much. Thanks for having me.

Todd Eury:

Well, I'm excited that the three of you are here. This is very special today, because it's the holiday season. And I think, as I've read many different findings in research, in 2019, just prior to the COVID-19 pandemic, 19.86% of adults were experiencing some mental illness, and that's equivalent to 50 million Americans. And when we compound that with the pandemic, and when we compound that with the holidays, this can become a very, very stressful time with the millions of lives that are impacted.

Todd Eury:

Because not only the individual, but we're talking about the families and the friends of those individual. And deep depression can take hold, and it's sometimes extremely hard to find the balance between work, life, family, the correct medication, and then staying on medications.

Todd Eury:

As community pharmacy practitioners, I want to start out with Monica, and really focus down on our first question that we'd like the whole panel to take time to answer, but I'm going to start with you, Monica. How can pharmacists be more aware and recognize symptoms associated with mental illness?

Dr. Monica Krishnan:

I think it's all about connection. Being able to connect one- on-one with the actual patient that comes to the pharmacy counter. I know, for me, specifically being a community pharmacist, it's at the consultation counter. And listening, listening is key. And from someone who not only is a clinical pharmacist, but who has been a mental health patient herself, that gives me a little bit more credibility, power to let my patients know that there's no judgment. There's no judgment, because I'm not going to judge you if you're taking Lexapro or Trazodone, because I'm not going to judge someone who's taking metformin for diabetes, or judge someone who's taking albuterol for asthma.

Dr. Monica Krishnan:

It's all about education. Educating and trying to break the stigma, the stigma that's associated with medications. The shame that people put on themselves, the shame that society puts on you, the shame that friends and family put on you, because you are now on an antidepressant, or any mental health medication. I think it's important to understand and reinforce the community, the caregivers, and the patients, that, when you are put on a psychiatric medication, understanding that there is an actual chemical imbalance that's going on. And there's a reason why you're being put on this medication.

Dr. Monica Krishnan:

So we play a huge role, because we are the person they come to, to pick up their medications. We are the ones that spend 10, 15 minutes talking to them about the side effects, how long the medication's going to take to work, what happens if you're not compliant, withdrawal effects, if you don't take it properly. So they spend more time with us about the importance of medication than the actual provider who prescribes it.

Todd Eury:

And being able to see that follow-up, whether it's week after week, month after month, the community pharmacist has that opportunity to engage and be able to come up with other assessments of your patients. Thomas, you and I, once again, we kind of prefaced this on a side comment and side conversation that we had. And you are running a community pharmacy, you have employees, you have family, you have friends, busy operations. And when I think of that, I think, you sharing ideas with our audience today about being an education resource for your community on mental health awareness, as well as helping to squash stigmas. As a community pharmacy owner, how do you navigate? How do you help your community with mental health?

Thomas McDowell:

Well, first off, we're the most accessible healthcare providers in the community, oftentimes. And so we're seeing our patients 10, 12 times a year, at least, compared to, they may only see their primary care provider or mental health provider a couple of times a year. And so we have the ability to see how the patient is doing on a regular basis. And we want to let them know that we are here to support them, not just with the typical chronic conditions, but with all conditions. And mental health is really important to us.

Thomas McDowell:

And my grandfather, who was pharmacist, really had an inclination to want to help mental health patients. And he served in World War II, and he was at the Naval Hospital in Bethesda, and saw a lot of patients that were suffering from mental health issues. So it's been really near and dear to his heart, my father's heart, and myself as well.

Thomas McDowell:

And so we want to remove all judgment, all stigma, and we want to let them know that, "Hey, you're not alone. You're not the only person dealing with this and it's common, and there is help out there. And we're here to support you. And we want you to be adherent to your medications, but we want you to also know that you can communicate with us, and let us know how you're feeling, and we can be source for you on education, on medications and, and referring if needed to another part of the healthcare team as well."

Todd Eury:

So I think, Tyler, when you are dealing with patients and you know based on sharing, talking with what they might be going through, there may be a death in their family. There may be something, a job loss. They're sharing this with you. Sometimes the pharmacist is the only healthcare provider that your community has access with. So you being keen to, and being aware to recognizing mental health issues, can you elaborate how you manage that as well as being a pharmacy owner?

Tyler Young:

Yeah, so as Monica said, I think one of the most important parts is building that relationship with the patient. Unfortunately, in some retail settings, there's not the staff or the time to make that happen, but I believe every pharmacist and technician wants to have that relationship with their patient. And once those relationships are created, you can begin to recognize if and when something is off about the patient. They may not have any diagnosed mental health condition, but if they're going through a rough patch and all of a sudden they develop a depression or other issues, you can notice when those things are off, if you have that relationship.

Tyler Young:

And more than likely, they're willing to open up, as long as you're able to take them to the side, in one of the consultation rooms or off to the side where nobody can hear them talk about it. And I think they'd be willing to share that. And also in our community, we've got, fortunately, have a lot of mental health clinics and access to mental health care. And so if they're going through a tough time, we can refer them to those counselors or to those providers who can help see them through it with the proper therapy or medication. And then we can work with them when they get prescribed medications.

Todd Eury:

Monica, coming back to what you were saying about the specific psychotropics at times, and how you have to bring a patient up onto a treatment. Sometimes it's not working. Sometimes you have to figure out with the psychiatrist, their primary care what's going on. One in five Americans are currently living with some kind of mental illness or one in six people in the United States are using psychotropic medications for problems that are relating to behavioral health issue. How does stigma play a role in our seemingly increasingly growing mental health crisis? Turn your microphone back on.

Dr. Monica Krishnan:

Oh, sorry. So I feel like the past two years we have, especially being in the largest mental health crisis, not just in our country, but truthfully, globally, as a result of this pandemic. I feel like we are starting to see more conversations with mental health stigma, especially just in my community where I work in Los Angeles. No one really wanted to go to urgent care or ERs or doctors' offices unless they absolutely had to. So they were coming in to pharmacies. And I cannot tell you the amount of conversations I've had with parents, teenagers, adults, who are wanting to have more conversations about their child or themselves going on one of these medications.

Dr. Monica Krishnan:

So I think that we are heading in the direction where conversations and the stigma is starting to break a bit. We're not there a 100%, but I think this pandemic has truthfully opened the doors of addressing the importance of mental health is just as important as physical health. So I think we're working in that direction. I think education is key, understanding why this particular medication, let's say, for example, Lexapro, how does that work in the brain? What is these neurotransmitters in the brain like norepinephrine or serotonin? And how does it work?

Dr. Monica Krishnan:

And, okay, well, if this drug isn't working for you, let's switch it to this one. So I feel like as a community pharmacist, I am seeing more acceptance. I'm seeing more acceptance, especially over the last two years. So we have a lot of work to do in this area of healthcare, but I think we're moving in that direction.

Todd Eury:

Monica, as a mother, as a wife who lost her husband, and what you went through yourself, the extra stress that was placed on you... I'm a father of four daughters, so I'm in the teenage years on both sides. And I think of the stress that it would put on me if one of my children were suffering with something serious depression, because of the volatility, almost feeling like you're on a balance beam as a parent, worrying about how they are and not losing them to even a more serious issue or even a suicide.

Todd Eury:

You wrote a really meaningful article on Psycom Pro that was titled The Integrative Pharmacist in Teen Medication Adherence. And I want you to share with our audience a little bit about that article, and how today we're talking about adherence medication. And how as a pharmacist, you were really helping that specific scenario and that specific family.

Dr. Monica Krishnan:

This was a real patient case scenario. Obviously, names are changed due to HIPAA and privacy. So a 17-year-old girl named Sabrina comes into the pharmacy with her mom, and Sabrina was put on antidepressants, Lexapro, and she was put on Trazodone for insomnia. She was 16 when she started seeing a psychiatrist, and 16 as well when she started coming into the pharmacy, along with her mom. So I had built this amazing relationship with her mom and getting to know Sabrina, monthly as she would come in for her refills, and quick consultation.

Dr. Monica Krishnan:

So in the middle of the pandemic, we had a consultation and we found out that she was being noncompliant to both medications, and she was struggling, and the mom herself was struggling and she didn't know what to do. She was very frustrated. So we spent about 20 minutes kind of just really breaking down what the issue was, and what was her cause of nonadherence.

Dr. Monica Krishnan:

So here we are, she's 17 years old. She is feeling the pressure of being a teenager. She's got her school stress, she's in the pandemic, she's feeling isolated. And come to find out in consultation, she had a friend over and her friend discovered, on her nightstand, her medication vials. And her friend picked up her medication vial, and said, "Hey, what's this. I didn't know you're an antidepressant. And I didn't know you were on a sleeping medication." So all of a sudden Sabrina felt extremely ashamed. And she's like, "No, no, no, no, no, it's not mine. It's my mom's."

Dr. Monica Krishnan:

So she just, after that was like, "I don't want to be on these medications, mom." So she comes into the pharmacy and her mom says... Oh, so the reason we found out she was noncompliant is because we do medication adherence protocols, where if someone doesn't come to pick up the refill in a month or two, we reach out to the family, and say, "Hey, Sabrina hasn't been on her medication for a month. Is everything okay? Are you using another pharmacy?"

Dr. Monica Krishnan:

So that's how we found out that she was being nonadherent, because she wasn't coming into the pharmacy. After having a direct conversation with Sabrina, now it was one-on-one, me and Sabrina, and I said, listen, "I have been in your shoes. I know what it's like to feel ashamed. I, myself, as a pharmacist felt ashamed to go on an antidepressant. So I can just imagine you being 17, figuring out just life, that's normal to have these feelings and you're not alone."

Dr. Monica Krishnan:

So I made that connection with her, sharing my own story with her. And she was like, "Really, Dr. Krishnan, you went on an antidepressant." And I kind of told her a little bit about my struggles, what I went through 10 years ago, and how being on this medication really helped me. So then we talked about some strategies of, "Okay, what can we do to help you get back on track to being more compliant?" So we a little bit back and forth, and we found a strategy of letting her mom handle her medications for a month or two, until she felt comfortable to take on the role of dispensing her own medications.

Dr. Monica Krishnan:

So she was okay with that. And then we had a follow-up appointment for, or months later, and she's on steady state. She's compliant. She's back on both medications. And in fact, she was so proud that she is doing some mental health work locally in her high school, with like a group where they talk about mental health. So I was just so proud of her. So, yeah, she's doing well.

Todd Eury:

Thank you for that. That's really digging into how one member of your community was impacted, because you took the time to recognize and dig in to what that patient truly needed. And I think there was a woman to woman thing that was happening as well, which is all part of being a healthcare provider, and being empathetic and getting into the shoes of what the patient is experiencing. That's a beautiful story. Thank you for sharing that.

Todd Eury:

Thomas, when I think of what you've done in your community, I think of what Dr. Krishnan just said about how you could have cascade or domino effects of nonadherence, when you're talking about mental health specifically. What have you experienced with your patients who are suffering with some type of mental health or behavioral health issue, they are on a treatment, but they're also diabetic or they have hypertension or they have something else? And we know that as high as 56% of patients that are on some kind of antidepressant, are more likely to be nonadherent, how do you overcome or help to overcome those challenges for your patients?

Thomas McDowell:

They, a lot of times, might put the mental health medications on the back burner, if they're worried about a diabetes at the moment or hypertension. And a lot of times they don't have time to discuss mental health in detail at their doctor's visits. But we try to make sure we're keeping track of all of the medications they're taking, and make sure all disease states are paid attention to. And our adherence packaging program makes that a lot easier. We have several hundred patients enrolled, where we monitor them monthly. We have an adherence coach that calls them each month, checks in with them, make sure everything's going okay. If they say, "I don't need this, this month." We're going to dig into that a little deeper, "And so what's going on Ms. Smith? And why don't you need that?"

Thomas McDowell:

And, and see if we can figure out a resolution. And it's been a challenging two months for a lot of our patients, a lot of them are elderly and they have felt very lonely, isolated. And so we try to make sure they know that we're here for them, and that they need to make sure they're still staying adherent. And they're not wanting to go to the doctor as much or not wanting to venture out. So we're offering free delivery, whatever we can do to support them and make sure they are not falling back into an issue that they had worked really hard to improve upon with adherence and consultations. And so we really try to treat them holistically, and help however we can and support them however we can.

Todd Eury:

Tyler also with your community in many of your patients suffering with depression, even around the holidays time, nonadherence is a major issue. What have you done with compliance packaging or the simplicity of presenting a way to stay adherent on medications? In comparison to patients having to worry about taking individual vials and remembering when to take their medication and the complexity of what happens when an adherence package isn't in place, specifically to mental health. Can you share us a story of your experience in your community pharmacy?

Tyler Young:

Yeah. I'll try to think of a specific patient, while I kind of talk about this some. But we really focus on, with our packaging system, anybody who is taking more than about three or four medications, it can get really complex. That includes your mental health meds, if they have diabetes or hypertension. So we really try to focus on those patients who are taking multiple medications. We talk about the importance of staying as adherent as possible, especially to their mental health medications, because most of these patients have worked very hard to get on a regimen that works for them. And the last thing we want to see is for them to go a month or so where they're taking it sporadically, or they just completely stopped, because that can really... you took 10 steps for worry, but that may take you 20 steps back doing something like that.

Tyler Young:

So we really educate them on the importance of staying adherent to their medications. And we really stress how simple it is when we are able to package it for them. How they don't have to worry about what time they have to take it. It's going to have it on the package right there for them. They don't have to worry about, have I already taken this once today? If they've torn off that little strip, then they'll know that I've already taken my medications for the morning. I need to worry about the evening next.

Tyler Young:

And we've got one particular patient who was really struggling with her mental health. She had a sister that she was caring for and some things were going on with her family and with a sister. And she ended up having, basically, a breakdown herself and ended up needing counseling and therapy and some medications to work through that. And for a while, she would come in and only pick up one or two. And after discussing what was going on with her, we realized that it was kind of a price issue. So she was picking and choosing which medications that she was going to pick up that time.

Tyler Young:

And what we did with her was we set up an account for, basically, where she could just pay once a month. And we worked with her on her finances with that. And we got everything synced up to one fill day. And then we talked to her about packaging, and she was more than happy to do that. Once all those barriers were removed, she was able to be much more adherent. And now she's doing a lot better. For the first few months there, she was really struggling. But here in, I guess, the last six months she's done way better than she was previously doing.

Todd Eury:

So Thomas said, just to follow-up with what you were saying, the domino effect of nonadherence, the technology that you're using, how do you see the adherence follow-up? And what you're doing with the, I want to say, you have hundreds of patients that you're monitoring with your systems, but how are you seeing the difference between picking up nonadherence with the packaging and the adherence tools that you have versus before you had those tools? What was the noticed difference between the two systems, no packaging versus packaging? Is there a way to quickly see when a patient is not adherent?

Tyler Young:

Yeah. Great question. Before we really increased our volume of adherence packaging, and got a RapidPakRx robot, we were doing it manually. We didn't have a lot of volume. We were much more reactive to situations that were coming up, and it made it a lot more difficult to see those problems happening ahead of time. And we would see them when we're filling medications, hey, they haven't gotten their Zoloft filled, or they haven't gotten their Trazodone. And at that point, we would still try to make a note to speak to the pharmacist at point of sale, and have that conversation, and ask them what's going on. But as we shifted more and more of our volume to adherence packaging and med sync, where either way we're monitoring them monthly, but we're calling them ahead of time, seven days ahead of time.

Tyler Young:

And so we are proactively ensuring that they don't become not adherent. And so we're seeing that we're getting ahead of the problem, because [inaudible 00:28:27] them from becoming not adherent, because we're calling them before it's even time to fill their medications. And if there's an issue, we can go ahead and resolve it right there, during that phone call or bring the pharmacist in. If there is a clinical issue or if there's a side effect, we can with the doctor or talk to the patient about that side effect. And so instead of seeing that they've missed a fill and it's 30, 60, 90 days late, we're talking to them at the time that they're getting their medications refilled or packaged. And it's just a much more proactive approach. And we've seen a huge deal difference in some of these patients being stable on their regimen.

Tyler Young:

We were seeing all kinds of changes before, they weren't picking up certain things. They were missing refills or couldn't get a refill. And so we're calling them, making sure that they're up to date on their appointments with their psychiatrist or their PCP. And so it's been really, really rewarding to see how much it has helped patients, because they know that it's hard enough for them to put their mental health that at the forefront of what's going on in their life, they're trying to manage complex medication regimen. So we're handling all the refills, we're calling the doctor for them, so that they can focus on making sure that they are doing well personally. And so that they know that we're taking care of all the medication complexities. So it's been a game changer for us in our community.

Todd Eury:

Monica, you shared with us a very specific case and thank you, it was very special, with a teenager and how you bonded with them really using a story of your own to lower the guard of that patient. They didn't feel like they were being judged. Then I think of seniors, I think of the depression that they go through around the holidays, for example, maybe not being able to see their family members. I think of that long-term care assisted living center setting, or even the seniors that come in and see you on a weekly or monthly basis. Then I think of our veterans, I think of PTSD and how many veterans who have come back from active duty, are really stressed out and the impact that that has on their family, the impact that has on their communities.

Todd Eury:

And then of course our teenagers, which you just alluded to and gave us an amazing story about being a pharmacist that was there for the patient. I got to ask you, because you've seen all of these types of patients in your pharmacy, how are you helping these patients in meeting them where they are to understand their medication treatment and the dangers of medication nonadherence?

Dr. Monica Krishnan:

I truthfully feel like it is, and it's like what Thomas said, we are the most accessible healthcare providers, when you compare when patients go to a physician's office or an ER or urgent care, they will see their pharmacist 12 to 15 times a year. So the key thing is, is building that relationship. Getting to know Mr. Jones or Mrs. Smith, and getting to know them. A lot of my patients I've gotten to know them as a first name basis. That's the foundation, is establishing that connection, the relationship, not just a prescription number, but getting to know them individually. And I think it's through conversations and stories is when you really get to know what struggles they're dealing with.

Dr. Monica Krishnan:

My example, where I shared a story about Sabrina, I would have never known that the reason why she was noncompliant is because she felt ashamed due to her friends discovering her prescription bottles. And when you mentioned all the different age groups and mental health, mental health does not discriminate based on age. We're seeing it in teenagers. We're seeing it in adolescence. We're seeing it in adults. We're seeing it in our senior citizens, and we're actually starting to see it, believe it or not, in our under 13 age group. I've seen 10, 11, 12, 13-year-olds being put on antidepressants in this pandemic.

Dr. Monica Krishnan:

And when we talk about mental health, we're not just looking at depression medications, we are looking at everything, including ADHD medications. So we do have a lot of children who are on ADHD medications. And so I think it's finding the reason why they are noncompliant, nonadherent, and finding strategies on having a way to help them. Prescription reminder, reminding them monthly to come pick up their prescriptions. If they're needing help getting assistance, to finding somebody in their family members who could help with dispensing of their medications like we did with this patient Sabrina. Her mom stepped in and started helping her for four months.

Dr. Monica Krishnan:

But, yeah, I think that finding a way to having that conversation and telling them, what are the side effects, if you do not take your medication regularly? These are the withdrawal side effects. You're not going to see an improvement in your mood or whatever you're being you treated with, if you're not taking it for this amount of time. We know that a lot of these medications do take about four to six weeks to get to steady state. So I think it's having these conversations one-on-one, and letting them know that you are there to help them.

Todd Eury:

Thank you for that. Tyler, I just mentioned veterans and in your community, I'm wearing a t-shirt that's brought to us by RxSafe and a myriad of funders. And this is the US Pharmy shirt, because we raise money for veterans. There's a special organization in my community called The Dog Tag Club, and they're actually in 14 different states. And we really want to do all we can to show that pharmacists are there for our veterans. In your specific community, and when I think of adherence, even though that some of these, obviously, the veterans can be taken care of by the VA, but how are veterans specifically in your community, how does me adherence impact those specific patients? And what challenges have you seen as a community pharmacy with your vets?

Tyler Young:

So we do not have a VA clinic close by. They're currently building one, it's under construction right now, in the next town over. But most of the time they have to drive about an hour and a half to another city. That's about the closest VA clinic. So we do have a good bit of military retirees. We have some active duty that are active duty, I guess, with the Reserves. And they have TRICARE and they come by. But specifically with those veterans, most of them will stay adherent as long as they know what the medication is for.

Tyler Young:

I'm not a veteran, but a lot of them seem to be very diligent and they will do exactly as prescribed as long as they know what it's for, why they're doing it. They have to have a purpose it seems. So I have one veteran that I'm thinking of in particular that I sat down with him, went through all of his medications, including some mental health medications. And once he knew what each one was for and how he's supposed to take it, he's like, "Cool. Got it."

Tyler Young:

Some though, especially the old to veterans that are retired military, they have had some trouble just dealing with some medications being mandatory mail order, some medications they have to get specifically through the VA when they go to the clinic. So that's really created a barrier. Thankfully, not so much with mental health medications, but still they're dealing with issues with their hypertension medications or diabetes medications. So we try to be as helpful as we can. If they're waiting on a mail order prescription, we'll call the doctor, try to get a five day supply for them, make sure that there's no discontinuation of therapy for any amount of time. And like I said, I think once they know exactly what the medications are for, the majority of them seem to be very compliant with their medication regimen.

Todd Eury:

Thank you. Thomas, we were talking while at the NCPA and follow-up about some of your adherence reminders and things that you're doing for your patient base. I think of our seniors, and the seniors in your community, who may be suffering with something very serious, like dementia or forgetfulness. And I mean, I forget goodness gracious, and what that can do to create problems. And I know that adherence packaging plays a role in that, however, how are you really helping the senior population in your community remember their medications, especially those that are on some type of behavioral health medication?

Thomas McDowell:

And that reminds, we have a patient that does have dementia, and he'll do some traveling sometimes, he's in a incredible physical shape for his age, but does have dementia. And he'll forget his adherence packaging and he'll go to another area and then he'll get his meds filled at a pharmacy there, forgetting, and we'll take him and repackage him when he comes back. And even though we didn't even fill him. And it's been a challenge, but you really need to find a caretaker in the home, in the community, in the family. We do everything we can, but we can't be with them 24/7. And so making sure that they have the support and help they need at home. And so we try to if they're in our adherence packaging program, we want to find that person that is helping them manage their medications in the home, if they are at home and not at an assisted living facility or long-term care.

Thomas McDowell:

And so that we can have that touch point to make sure the patient's being taken care of, and we'll do everything we can to make sure they're adherent, but we're not necessarily able to put the pill in their mouth every time. And so it's not perfect. And those patients are the ones that really, really do need help in the home. And so we try to make sure that somebody's looking out for them, and if we see them getting off track, some of them are really wanting to be independent and maybe they're not advanced to a point where they have somebody living with them or that kind of thing, but we'll try to ask them, "Who's helping you? And can I get their phone number? Can we talk to them and make sure that somebody's keeping an eye out for them?"

Thomas McDowell:

But that population is definitely challenging. And it's really tough to watch at times. And so we really try to go the extra mile for those patients and make sure we're taking care of them, that we're patient with them, that we communicate with them in a kind and patient manner, because they get very frustrated at times. And so we want to make sure we try to help them on understand, and help get them the help they need in the home and give them all the resources they need in the community.

Thomas McDowell:

And so we have a great community, and we have a great small town atmosphere. There's usually always somebody willing to help and a family member or friend, and we all try to look out for other. And, yeah, I see that on a daily basis and it's really rewarding. So we consider it a team approach beyond our four walls here at the pharmacy.

Todd Eury:

Thank you. Monica. I want to talk to you about screening, because you were really digging into a specific pay patient case with the teen that you had mentioned. But let's talk about what ways you are screening patients for comorbidity, where one of those conditions are a mental health condition. Like you're a busy pharmacist, you're putting out 200, 300, 600 prescriptions a day. Talk to us about the screening process.

Dr. Monica Krishnan:

So as far as the screening process, are you asking about like side effects of medications or nonadherence?

Todd Eury:

The initial screening you us to kind of catch, if in fact there's a bigger issue that you're able to kind of assess based on maybe medication nonadherence, maybe looking up on the record and seeing that they haven't been back in a certain amount of time and they show up. But just how you are using the screening process to dig deeper into the patient's condition.

Dr. Monica Krishnan:

So going back to this specific patient case scenario, and I've got so many different patient case scenarios being a community pharmacist, but specifically talking about this one case, I was able to dig deep into it by seeing that she had not been back in about a month, a month and a half to pick up both her medications. So the attempt to call her, she's not responding, so then I called her mother. I was able to call her mother, because she is under the age, she's not 18. So I was able to have a conversation with her mother, which is when I found out that she was struggling at home.

Dr. Monica Krishnan:

And then I invited her mother to come back into the pharmacy and we could have a meeting in our consultation room. And so then I told her to bring her daughter in, and I would love to have a conversation with her daughter, if her daughter felt comfortable. So that was kind of the initial screening process that I did to find out that she was feeling ashamed. She was feeling ashamed. She couldn't make eye contact with me. That was the first red flag.

Dr. Monica Krishnan:

When someone cannot make eye contact with you, they kind of look down. They don't want to look at you, because they feel ashamed. So that is something that I consider a red flag, is the eye connection. And then just letting them talk, opening up the conversation, and keep keeping a safe space, knowing that whatever she is telling me is confidential, establishing that relationship and that trust. And the next thing you know, she spends 20 minutes with me telling me her struggles. And some things that she hasn't even shared with her own mother.

Dr. Monica Krishnan:

So I think the key thing is, is being able to make that eye connection. You will find out within the first five minutes of talking to a patient, what the struggle is. What is the reason that you are not... Is it cost? Can you not afford the medication? Is it because you feel ashamed of taking it? Is it because you don't have that support, like Thomas talked about at home, someone to help you, just because you keep forgetting the medications? So what is it that you need help with?

Dr. Monica Krishnan:

And like Thomas said, there is just so much we can do from a pharmacist standpoint, but what can we do to help you figure out a strategy to get you to be compliant from a home perspective? And so I think that's the key, is having one-on-one... And each patient case is different. Each patient case scenario is different. So it's just that one-on-one, getting to know the case, what can we do as a pharmacist, from a pharmacist standpoint? And then what can we do to help in from a home perspective?

Todd Eury:

Thank you, Monica, that really helps me understand as the non-pharmacist of this group, how you would dig into that. I kind of want to kick it over to Tyler, because there's the aspect of sensitivity that Monica was talking about. There's the stigma that comes with mental health. No one wants to admit it they have an issue. I went through depression in my mid 30s and I didn't tell anybody. The only person that knew was my physician and my pharmacist. And I talked with my pharmacist more than even my physician, and it was almost like I was getting counseling from the pharmacist. And then she asked me to go to a counselor, so that was insightful of her.

Todd Eury:

But, Tyler, how are you handling this stigma? How are you digging into, there's a lot of pride that people have. They might not be able to afford their medication. They may have issues at home. They are stressed out because of something that's had happening at work. Regardless, how do you overcome stigma?

Tyler Young:

One thing that we try to do with all of our mental health patients is let them know that they're not alone with their situation. There are people that may not be going through exactly what they're going through, but there are people that are struggling as well. So they're not out there trying to do this completely alone. Thankfully, in our community, we've got some resources where we can try to send them and get some professional counseling therapy. There's all kinds of apps that they can use now. But one thing we do particularly in the pharmacy, when we're consulting with these patients, [inaudible 00:47:13] as possible, thankfully, at our pharmacy here, we've got plenty of space.

Tyler Young:

We have a couple different consultation rooms, where we can take them in and have a conversation away from everybody completely. You have some patients that don't necessarily care, they'll talk about whatever in front of whoever. But we do try to give them that space to be private, and talk to us one on one. And just, we let them know that they're not alone, and that seems to go a long way.

Todd Eury:

I wanted to jump back to Thomas as well and kind of ask the same question, how you're handling that? How you're handling the possibility of sensing that there may be a stigma with admitting that there's a behavior health or mental health problem?

Thomas McDowell:

We really try to remove that as quickly as possible. And it definitely goes back to building that relationship, like Monica and Tyler said it, that you're going to have a hard time getting patients to open up to you, until they trust you, because they are often ashamed and uncomfortable. And so we try to proactively counsel patients, and at a lot of pharmacies, besides the independents, they might not have time to counsel and educate patients, but we really try to make the time. And at point of sale, we'll put a note on the bag, and instead of simply just asking the patient, if they want counseling, we'll rephrase it, if it's a new medication, and especially a mental health medication, because the initial startup is so important for helping them understand why they're using it.

Thomas McDowell:

And like Tyler said, they need to know what it's doing, what it's for, and like Monica said, the mechanism behind it. A lot of people are interested in that and it makes sense, and it takes the stigma away from it, when you get into the science a little bit behind how it's working, and that it's something you're helping. It's not just throwing a pill down, and hoping that you'll feel better.

Thomas McDowell:

So we actually tell the patient, "Hey, the pharmacist wanted to speak to you about this since it's new, would that be okay with you?" And so we're flipping that question around, and usually they say, "Yes." But if you say, "Do you want to speak to the pharmacist?" They will usually say, "No," because they're uncomfortable, and they don't want to take that first step forward, and opening up to the clerk that they may have just met, if they just got put on an antidepressant for the first time.

Thomas McDowell:

So that's the way that we've gotten our foot in the door to develop that relationship. We'll take them off to the side, into a consultation area privately, and say, "Hey did the doctor tell you about this medication? And what did they talk to you about?" And so sometimes the doctor was able to get into a lot of detail. Sometimes they were not, and so we know what their education level is on that medication. And so we can tell them, "Hey, with this antidepressant, you're going to need to take it every day. It's not an as needed kind of thing. You're going to need to let it be in your system for a couple of weeks. You might have these side effects at first. You usually start tolerating it better after a couple of weeks."

Thomas McDowell:

And giving them that insight, and they really do appreciate it. And you would think that they'd be uncomfortable, but they really open up. And then you've developed that relationship. And you're the one they're calling if they're having an issue about that medication or an issue about anything. So that gets our foot in the door and that's really helped us break through that stigma, and let them know that, that they have somebody they can trust and talk to about it.

Todd Eury:

That's gold Thomas, you're building trust through education. And I wanted to go back to Monica real quick, and the element of trust, and the element of trust that I admire you, Monica, is that not only have you built trust with your patients, which is primary, but you've also built trust with your primary care physicians. And the reason why I mentioned that is, is if you make a call to a physician that knows you, that trusts you, that you're looking out for the best interest, you're going to get a much different response, if you make a suggestion to change something or ask for even a PGX test, because this psychotropics not working as intended. Whatever it might be, trust is so critical.

Todd Eury:

I want you to share with the listeners how you've built trust with physicians. And you are an Instagram star where you actually have your grow and glow sessions, where you have a physician with you, and you guys are actually discussing mental health cases together, which I think is really special. But talk to us about the element of trust with other HCPs.

Dr. Monica Krishnan:

Being a community pharmacist, and, obviously, we deal with mental health, so we have a really good relationship with our local psychiatrists here in Los Angeles, where they send their patient's prescriptions directly to our team. Which is nice, because sometimes, let's say, somebody is going on vacation, it's the holidays. Well, we want to make sure that they have a 60 day fill or 90 day fill, so there's no gap of them not getting their refill.

Dr. Monica Krishnan:

So a lot of the times the prescriptions are sent in for 30 days, but because we take that extra step in saying, "Hey Sabrina's going on vacation for a month. We want to make sure that she doesn't miss out on her me medication for a week. So can we get that 60 day?" So we'll take that extra step.

Dr. Monica Krishnan:

So our relationship that we're building with our physicians, I see it as a team effort, they are doing what they need to do. We are doing what we need to do, at the end result of taking care of this patient. So, yeah, it's this beautiful relationship that we have established.

Dr. Monica Krishnan:

And just another example is we are at the forefront of COVID vaccines. So these physicians that we have built an amazing relationship with, they will send their patients directly to, let's say, Dr. Monica. "Can you go to Dr. Monica for your vaccine? Can you go to Dr. Monica here at this pharmacy for your initial prescriptions?" Because they know that I genuinely care about this patient. I'm going to take that extra 10 minutes, even though I don't have that 10 minutes, because I am bombarded with all these things, I am going to find a way to make that extra 10 minutes or 15 minutes to talk to this patient.

Dr. Monica Krishnan:

So it's something that I've been to doing now for close to 19 years, and I have been in this community where I work for the last 10 years. So I have gotten to know, not only private practice physicians, but ER physicians, who actually do call us up at like nine o'clock at night saying, "Hey, I'm discharging a patient, do you have this?" And so it's kind of like a two-way thing. They rely on us, we rely on them for the end result of patient care.

Todd Eury:

Thomas, you were telling me about how you inform your local physicians about what you're doing with adherence packaging. How does that play into adherence? How does that play into mental health and in keeping patients on their medications, the trust that you've built with those local physicians?

Thomas McDowell:

Well, it really loops them into what we're doing. And it's amazing, in general, just in pharmacy, how often physicians don't know what you're doing, if you're not in same clinic with them, unless you tell them. And they really do appreciate what we're doing, and so we try to let them know that we offer these services such as adherence packaging, so that they know that we're looking out for their patient long after leave their office visit. And so that's really helped strengthen that trust even further, we've been in our community for 120 years. And so we have always tried to work closely with the providers. We're a small town. And so they can call us and say, "Hey, has Ms. Smith been taking this medication?"

Thomas McDowell:

Because the patient will go to the doctor and if they don't bring their meds and the doctors they're asking, "Are you taking your medication?" "Yeah. Yeah. I'm taking it." And so, "Well, your blood pressure's high, so we're going to add another blood pressure pill," Or, "You seem like you're feeling down, should we go up on your Zoloft?" And if they're not taking it to begin with it's, you don't need to increase the dose or add a new drug. And so they know that they can get that information really quickly and timely from us. And they'll refer patients to us that are struggling, and bringing in a grocery bag full of bottles from different pharmacies, and we can clean that up, and they can focus on treating the patient and diagnosing and counseling the patient, and let us handle the medication complexities. And so we really do partner and value that relationship. And it's been eyeopening, I think, for us to be able to show that value that we can offer to their patients.

Todd Eury:

Tyler, your relationship with your physician, how are you communicating with them about adherence packaging as well as about specific cases? How are you building trust between you and your providers?

Tyler Young:

Kind of like Thomas said, we've been able to build good relationships with our local providers. One thing we do specifically with the adherence packaging is we've taken every office a sample box, what that looks like. And most of them are willing to sit that out on the little counter with all the magazines, when you're in the waiting room. We had somebody develop like a little tri-fold pamphlet about our packaging and how it works. And they're more than happy to leave those out on the waiting room area as well.

Tyler Young:

And then one thing we've really focused on is telling them, if you see a patient who is struggling or you see a patient who's on four or five plus medications, usually more than that, talk to them about, are they taking it properly? And if not, we're more than happy to help get that cleaned up. As Thomas said, it's our job to focus on their medications, make sure they're doing it properly, avoiding any side effects, avoiding those unneeded additional medications, when simply taking it properly, would've solved the problem.

Tyler Young:

And a lot of the providers are, like everybody has said, willing to call us up, say, "Hey, is this person taking their medications right?" Or they'll call us and say, "Hey, we're sending you a new person. They use the pharmacy down the road. Can y'all please package them and help get their medications in line?" And we're more than happy to help. And that usually leads to new referrals every single week, we see multiple ones. And it's been great building those relationships with providers and really focusing on the entire picture for the patients. Instead of just the medication part, we look at everything.

Todd Eury:

Thomas, Monica, Tyler, this has been packed full of great ideas around mental health, helping patients, being open, being honest, being trustworthy as the most accessible provider in your community as the community pharmacist. This is such an important topic to keep in the minds and keep talking about it. So if there's other things that you'd like to talk with us about, please send it our way before we do more of these on mental health.

Todd Eury:

If you're listening, if you're a pharmacist and you know of other services, other resources, please reach out to the Pharmacy Podcast or the RxSafe team. RxSafe is doing an absolute, amazing job supporting community pharmacy with their adherence packaging technology. I want to give a shout out to Bill Holmes and the team at RxSafe, thank you so much for sponsoring this mental health and adherence session. And I want to give a special thank you to Monica, Thomas, and Tyler for participating today. Thank you.

Dr. Monica Krishnan:

Thank you.

Tyler Young:

Thank you for having me.

Thomas McDowell:

Thanks, Todd.