ADDRESSING MENTAL HEALTH STIGMA IN THE DOCTOR OF PHARMACY CURRICULUM Lisa W. Goldstone, MS, PharmD, BCPS, BCPP Elizabeth Hall-Lipsy, JD, MPH The University of Arizona Department of Pharmacy Practice and Science April 9, 2015

DISCLOSURES • The presenters have no conflicts of interest to disclose

OBJECTIVES • Describe and explain common misconceptions about patients with mental illness • Identify and describe educational interventions to reduce mental illness stigma in health professional students • Identify and implement evaluation processes for educational interventions addressing mental illness stigma

THE FACE OF MENTAL ILLNESS • One out of every five adults (61.5 million) experiences a mental health condition every year • One out of every 17 adults (13.6 million) has a serious mental illness (SMI) • 46% of homeless adults have SMI and/or substance use disorders • ~20% of persons incarcerated in state or local facilities have experienced mental health symptoms in the recent past The National Alliance on Mental Illness. www.nami.org. Accessed on 3/26/15.

LIFE EXPECTANCY • The average life expectancy of a person with SMI is 49-60 years of age. Compare this to the life expectancy of a: – Non-SMI resident of the US: 78.7 years – Resident of Sudan: 58.6 years – Resident of Ethiopia: 52.9 years

• Greater than 90% of all suicides are completed by a person with one or more mental health disorders • However, most people with SMI do not die of suicide or accidents Centers for Disease Control and Prevention. www.cdc.gov. Accessed on 2/10/14. National Institute of Mental Health. www.nimh.nih.gov. Accessed on 2/10/14. The National Alliance on Mental Illness. www.nami.org. Accessed on 3/26/15.

RISK FACTORS • Clinical risk factors – – – –

Obesity Tobacco use Heart disease Diabetes

• Socioeconomic risk factors – Poverty

• Health system factors – Lack of quality health care National Institute of Mental Health. www.nimh.nih.gov. Accessed on 2/10/14. Druss BG et al. Med Care. 2011;49(6):599-604.

THE MOST PUBLIC FACES

• Because up to 60% of mass shootings have been committed by those with paranoia, delusions, and/or depression, this has linked violence and mental illness in the mind of the public Metzi et al. Am J Public Health. 2015;105(2):240-9.

MENTAL HEALTH STIGMA • Healthcare professionals (including pharmacists) have negative attitudes toward patients with mental illness – Pharmacists have more negative attitudes toward patients with schizophrenia than depression – Even mental health providers has some some negative attitudes toward patients with schizophrenia

• Attitudes worsen when patients have been hospitalized for psychiatric reasons Jorm AF et al. Aust N Z J Psychiatr. 2009;43(3):183-200. Rao et al. J Psychiatr Ment Health Nurs. 2009;16(3):279-284. Scheerder G et al. Res Social Admi Pharm. 2009;5(3):242-252. Nordt C. Schizophr Bull. 2006;32(4):709-714. Schulze B. Int Rev Psych. 2007;19(2):137-155. Rickles NM et al. J Am Pharm Assoc. 2010;50:704-713. Stuber et al. Psychiatr Serv. 2014;64(4):490-7.

LACK OF COMFORT • Pharmacists more comfortable and/or willing to provide services to patients with a non-psychiatric illness (e.g. cardiovascular disease, asthma) than a mental illness • High levels of mental health literacy result in more willingness to provide medication education as well as identifying medication-related problems for patients with psychiatric disorders • Mental health, as part of pharmacy education, is often not covered adequately O’Reilly CL et al. Res Social Adm Pharm. 2013;1-9. Rickles NM et al. J Am Pharm Assoc. 2010;50:704-713. Scheerder G et al. Psychiatr Serv. 2008;59(10):1155-1161.

ACPE 2016 STANDARDS • Standard 3: Approach to practice and care – Patient advocacy – Cultural sensitivity – Communication

• Standard 4: Personal and professional development – Self-awareness – Professionalism

EDUCATION MATTERS • A course in psychiatry/mental health can improve the willingness of pharmacy students to engage in relationships with persons with mental illness – – – – –

Assigned readings Class discussions Student presentations Presentations given by patients with mental illness Visits to patients in a variety of hospital psychiatric settings

Dipaula BA et al. Am J Pharm Educ. 2011;75(4):72.

EXPOSURE TO PATIENTS • Programs within a pharmacy school curriculum can help decrease stigma and/or improve attitudes toward providing care to patients with mental illness – – – –

Mental health lectures Supervised community pharmacy practice Educational sessions led by consumer educators Interactive sessions with patients with mental illness

• Shared personal mental health experiences of students as part of the curriculum has been shown to decrease stigma and increase compassion in medical students O’Reilly CL et al. Am J of Pharm Educ. 2010;74(9):167. Patten SB et al. BMC Medical Education. 2012:12:120. Aggarwal AK et al. Acad Psychiatry. 2013;37(6):385-391.

THE RELATIONSHIP MATTERS • Healthcare provider interactions with patients – Didactic models a.k.a. the “traditional” approaches to medication education are not as successful in patients with certain mental health disorders – Positive therapeutic relationship related to treatment adherence – Positive affect associated with appointment adherence Valenstein M et al. Schizophr Bull. 2011;37(4):726-737. Barber JP et al. J Consul Clin Psychol. 2001;69:119-124. Meier PS et al. Drug Alcohol Depend. 2006;83:57-64. Cruz M et al. Psychiatr Serv. 2013;64:886-892.

OTHER IMPORTANT POINTS • Remove “ics” (e.g. schizophrenic, anorexic, diabetic, etc) and replace with the word “with: – Patients are people with disorders and/or diagnoses, not diseased people – The disorder and/diagnoses should not define the patient

• Refrain from using slang language to describe patients with mental illness in professional and casual conversation • Describe the behavior not the person • Body language is just as important as spoken language

COURSES EXAMINED • Health Disparities (HD) – Elective course – Mix of students in 1st-3rd year of pharmacy school – Many of the students are involved with the Rural Health Professionals Program/Certificate in Health Disparities

• Advanced Patient Care (APC) – Required capstone course – Third year students in last semester of didactic coursework

DIFFERING APPROACH • Health Disparities (HD) – One hour lecture and large group discussion – Emphasis is on patient, provider, and system factors that result in mental health disparities

• Advanced Patient Care (APC) – Two hour active learning exercise with small group interaction with “patients” with depression and/or anxiety – Emphasis is on effective patient communication

MICA-4 • Mental Illness: Clinicians’ Attitudes Scale • Assesses the attitudes of healthcare professionals toward people with mental illness • 16 items on a six-point Likert-Scale ranging from strongly agree to strongly disagree – Includes a single overall score (scale) is calculated by summing each individual item • Higher score indicates more negative stigmatizing attitudes

• Administered in a pre-post fashion to students attending class

MICA-4 • Previously validated in medical and nursing student populations- in Australia and the UK • No existing scales used in health professions populations that have been examined for reliability and validity across groups

MICA ITEMS • I just learn about mental health when I have to, and would not bother reading additional material about it. • People with severe mental illness can never recover enough to have a good quality of life. • Working in the mental health field is just as respectable as other fields of health care. • If I had a mental illness, I would never admit this to any of my friends because I would fear being treated differently.

MICA ITEMS • People with mental illness are dangerous more often than not. • Health care providers know more about the lives of people treated for mental illness than do family members and friends. • If I had a mental illness, I would never admit this to my colleagues for fear of being treated differently. • Being a health care professional in the area of mental health is not like being a real health care professional.

MICA ITEMS • If a senior colleague instructed me to treat people with mental illness in a disrespectful manner, I would not follow their instructions. • I feel as comfortable talking to a person with mental illness as I do talking to a person with a physical illness. • It is important that any health care professional treating a person with mental illness also ensures that their physical health is assessed. • The public does not need to be protected from people with mental illness.

MICA ITEMS • If a person with a mental illness complained of physical (such as chest pain, shortness of breath, upset stomach etc.) I would be more likely to attribute it to their mental illness. • General health care providers should not be expected to complete a thorough assessment for people with psychiatric symptoms because these patients can be referred to a specialist.

• I have or would use the terms like “crazy”, “nut job”, “psycho” to describe people with mental illness that I have seen on rotations or at my work. • If a colleague told me they had a mental illness, I would still want to work with them.

RESULTS - DEMOGRAPHICS • Response rates: • HD Elective • Pre: 95% • Post: 95% • APC • Pre: 100% • Post: 90%

RESULTS - DEMOGRAPHICS

MENTAL HEALTH INTEREST

STIGMA SCALE: BY CLASS AND PRE/POST

SCALE RELIABILITY • Internal consistency: Cronbach’s ά=0.74 – Tested in nursing students (N=183) ά=0.721

• Item total consistency: item correlations were 0.34 for each item

1.Gabbidon J, Clement S, VAN Nieuwenhuizen A et al. Mental Illness: Clinicians’ Attitudes (MICA) scale psychometric properties of a version for healthcare students and professionals. Psych Res 2013;206(1):81-7

COMPARISON TO MEDICAL/NURSING STUDENTS • Nursing students (UK) n=183 – Stigma scale: 34.55 + 7.11 – Pharmacy students more stigmatized (p