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Background: The Bloom Program, which began as a demonstration project, is an ongoing community pharmacy–based mental illness and addictions program funded by the government of Nova Scotia. To be eligible to offer the Bloom Program, interested pharmacists were required to complete a 9-part application on behalf of their pharmacies. A process evaluation was conducted to inform future program implementation changes of program components, including the application process. Methods: Qualitative interviews from 24 pharmacists were inductively analyzed to determine the challenges and opportunities in the program’s application process. Results: Key and impactful components of the application process included training, providing a mental health and addictions resource centre within the pharmacy and completing outreach activities with local mental health and addictions services and support organizations. The training content and format for the program was highly valued. Community outreach to local mental health and addictions resources, and other health care resources in the community, was particularly valuable in supporting patient navigation of the health care system and extending the pharmacists’ networks. Components of the application process were challenging for many pharmacists but were beneficial personally and professionally. Dedicated resources (e.g., time and staffing) are required for the efficient completion of the application process. Conclusion: Pharmacists viewed the Bloom Program application process as intensive yet necessary and relevant for preparing to deliver the Program. The demonstration project process evaluation was essential for elucidating the strengths of the application process and, importantly, identifying areas for improvement. Can Pharm J (Ott) 2021;154:xx-xx.

Background The Bloom Program, a community pharmacy-based mental health and addictions care program, was developed and implemented to optimize pharmacists' care of eligible patients. Characterizing pharmacists' activities in the Bloom Program can facilitate program quality improvement and contribute more broadly to the knowledge base regarding pharmacists’ roles and contributions to patient care. Objectives To characterize the patient care activities of the pharmacists in the Bloom Program. Methods A retrospective analysis of patient charts for participants enrolled in the program for three months or longer was conducted. Using all available documentation, pharmacists’ activities were coded into eight non-mutually exclusive categories: navigation/resource support, urgent triage, medication management, collaboration/communication, education, social support, self-care, and other. Results 2055 activities from 1144 patient care encounters were identified for 126 participants (48 ± 16 years of age, 61% female, 5 regular medications). Medication management was coded most often per encounter (73%). Each of social support, collaboration/communication, and education were coded in 20–25% of encounters. Frequency of navigation/resources, self-care, and urgent triage were 16.6%, 13.5%, and 2.8%, respectively. Non-medication management activities represented 59.4% of all pharmacist patient care services. Conclusions Medication management activities were coded in over 70% of patient encounters for pharmacists delivering a community pharmacy-based mental illness and addictions program. However, this accounted for 40.6% of activities with an average of 1.8 activities per encounter. Other activities were identified frequently (e.g., education, collaboration, social support, navigation and resource support) and help to characterize the nature of pharmacist-patient encounters and facilitates a better understanding of the role of the pharmacist in mental illness and addictions patient care.

Background Benzodiazepine receptor agonist (BZRA) use disorder among older adults is a relatively common and challenging clinical condition. Method The Canadian Coalition for Seniors’ Mental Health, with financial support from Health Canada, has produced evidencebased guidelines on the prevention, identification, assessment, and management of this form of substance use disorder. Results Inappropriate use of BZRAs should be avoided by considering non-pharmacological approaches to the management of late life insomnia, anxiety, and other common indications for the use of BZRA. Older persons should only be prescribed BZRAs after they are fully informed of alternatives, benefits, and risks associated with their use. Clinicians should have a high index of suspicion for the presence of BZRA use disorders. The full version of these guidelines can be accessed at www.ccsmh.ca Conclusions A person-centred, stepped care approach utilizing gradual dose reductions should be used in the management of BZRA use disorder.

The study's objective was to examine Canadian and Australian community pharmacists' experiences with people at risk of suicide.A survey was developed and administered online. Countries were compared by Fisher's exact and t tests. Multivariable logistic-regression analysis was used to identify variables associated with preparedness to help someone in a suicidal crisis.The survey was completed by 235 Canadian and 161 Australian pharmacists. Most (85%) interacted with someone at risk of suicide at least once, and 66% experienced voluntary patient disclosure of suicidal thoughts. More Australians than Canadians had mental health crisis training (p0.001). Preparedness to help in a suicidal crisis was negatively associated with being Canadian, having a patient who died by suicide, lacking training and confidence, and permissive attitudes toward suicide.Several perceived barriers impede pharmacists' abilities to help patients who voluntarily disclose suicidal thoughts. Gatekeeper and related suicide prevention strategy training for community pharmacists is warranted.

Policies have been put in place internationally to reduce the overuse of certain medications that have a high risk of harm, such as sedative-hypnotic drugs for insomnia or opioids for chronic non-cancer pain. We explore and compare the outcomes of policies aimed at deprescribing sedative-hypnotic medication in community-dwelling older adults. Prescription monitoring policies led to the highest rate of discontinuation but triggered inappropriate substitutions. Financial deterrents through insurance scheme delistings increased patient out-of-pocket spending and had minimal impact. Pay-for-performance incentives to prescribers proved ineffective. Rescheduling alprazolam to a controlled substance raised the street drug price of the drug and shifted use to other benzodiazepines, causing similar rates of overdose deaths. Driving safety policies and jurisdiction-wide educational campaigns promoting non-drug alternatives appear most promising for achieving intended outcomes and avoiding unintended harms. Sustainable change should be supported with direct-to-patient education and improved access to non-drug therapy, with an emphasis on evaluating both intended and unintended consequences of any deprescribing-oriented policy.

Background: The Bloom Program was designed to enhance pharmacists’ care of people with lived experience of mental illness and addictions in Nova Scotia. The Program’s demonstration period was from September 2014 to December 2016 and included a qualitative evaluation of the patient experience. Methods: Patients were recruited for individual interviews through Bloom Program pharmacies. Interviews were transcribed verbatim and analyzed following Braun and Clarke’s 6-step approach for thematic analysis. Results: Ten patients were interviewed between May and June 2016. Ten themes were determined through data analysis and included medication management, accessing pharmacists in a new way, providing social support, bridging service gaps, providing interim care, reducing financial barriers, navigation and advocacy, holistic approaches, empowerment through knowledge and awareness and collaboration. Discussion: Pharmacists expectedly provided medication management activities to patients for both physical and mental health concerns in the Bloom Program. Many activities conducted with Bloom Program patients fell outside of dispensing roles and medication management. These activities, such as social support, triage, navigation and increasing access, which were highly valued by patients, are poorly measured and assessed in pharmacy practice research. Conclusion: Participants in the Bloom Program reported the significant contributions of pharmacists and pharmacy teams in their overall health and wellness. Future evaluations of interventions like the Bloom Program should include measurement of constructs valued by patients and also consider impacts on inequalities and inequities. Pharmacy practice researchers can benefit from other research and evaluation being conducted for primary care interventions.

Background:Tardive dyskinesia is a movement disorder characterised by irregular, stereotyped, and choreiform movements associated with the use of antipsychotic medication. We aim to provide recommendations on the treatment of tardive dyskinesia.Methods:We performed a systematic review of studies of the treatment of tardive dyskinesia. Studies were rated for methodological quality using the American Academy of Neurology Risk of Bias Classification system. Overall level of evidence classifications and grades of recommendation were made using the Scottish Intercollegiate Guidelines Network framework.Results:Preventing tardive dyskinesia is of primary importance, and clinicians should follow best practice for prescribing antipsychotic medication, including limiting the prescription for specific indications, using the minimum effective dose, and minimising the duration of therapy. The first-line management of tardive dyskinesia is the withdrawal of antipsychotic medication if clinically feasible. Yet, for many patients with serious mental illness, the discontinuation of antipsychotics is not possible due to disease relapse. Switching from a first-generation to a second-generation antipsychotic with a lower D2 affinity, such as clozapine or quetiapine, may be effective in reducing tardive dyskinesia symptoms. The strongest evidence for a suitable co-intervention to treat tardive dyskinesia comes from tests with the new VMAT inhibitors, deutetrabenazine and valbenazine. These medications have not been approved for use in Canada.Conclusion:Data on tardive dyskinesia treatment are limited, and the best management strategy remains prevention. More long-term safety and efficacy data are needed for deutetrabenazine and valbenazine, and their routine availability to patients outside of the USA remains in question.

Introduction: Community pharmacists are accessible, knowledgeable, and capable of providing mental health promotion and care in communities. This may not be a role that is recognized by the public, and men in particular. Differences between men and women exist in help seeking practices. Headstrong–Taking Things Head-On is a men’s mental health promotion program for community pharmacies that was designed to increase the capacity of community pharmacists in caring for men with lived experience of mental illness and addictions. The program’s core components included signage in pharmacies, education and training for pharmacists, and a website for use with patients. Methods: We applied the Theoretical Framework of Acceptability as the coding scheme to pharmacists’ qualitative interviews to examine the acceptability of Headstrong for pharmacists. Results: Nine pharmacists consented to participate and all chose telephone interviews. With the exceptions of ethicality, affective attitude, and opportunity costs, all components from the TFA were coded in each of the nine transcripts. The most frequently coded constructs were perceived effectiveness of the intervention, burden, and self-efficacy. These were coded at least 20 times. The remaining categories ethicality, intervention coherence, affective attitude, and opportunity costs were coded between 11 to 17 times. Pharmacists’ perceptions of the effectiveness of the program was mixed. The overall burden was perceived to be low, but opportunity costs appear to have limited the participation of some pharmacists in the program. Conclusion: Use of the Theoretical Framework of Acceptability as a coding scheme for qualitative data from community pharmacists in a men’s mental health program was helpful for identifying issues with the program that may require redesign (e.g., signage). Program design should consider how services are advertised in the pharmacy setting, how personal values of pharmacists influence intervention coherence, and whether minimizing the burden of an intervention negates issues related to opportunity costs.

Every year more than 800,000 people die due to suicide, worldwide. Countries with more established suicide prevention plans often advocate for multisector, multidisciplinary, and whole community approaches to suicide prevention. The role of pharmacy teams, particularly community pharmacy teams, within this had rarely been considered but evidence is emerging. This chapter explores what is known about the role of community pharmacy teams in suicide prevention. It presents a narrative review of studies predominately from Canada, Australia, the United Kingdom, and the United States, with a focus on pharmacists’ experiences and attitudes toward suicide prevention. The chapter presents a case study which contains, for the first time, results from a survey of pharmacy staff in England and explores their experiences and perceptions of suicide awareness and prevention.

Objective The objective of this scoping review is to identify, map, and characterize the evidence for assessments that measure driving performance in people taking benzodiazepine receptor agonists. Introduction Benzodiazepines and Z-drugs are widely prescribed for the treatment of anxiety disorders and insomnia even though they are not recommended as an initial treatment for these indications. Benzodiazepine and Z-drug use is associated with an elevated risk of traffic accidents, and guidance documents instruct patients to consult with their health care providers for instructions on how to safely operate a motor vehicle while consuming these medications. However, little is known about the assessments that measure driving performance regarding the extent and length of impairment from the consumption of the individual benzodiazepines and Z-drugs. Inclusion criteria Eligible studies will include participants who are new, intermittent, or chronic users of benzodiazepines and Z-drugs. No exclusions will be applied regarding the health status of participants or whether their benzodiazepine and Z-drug use is for an approved indication as indicated by government agencies (eg, Health Canada) or practice guidelines. Studies that examine the consumption of a benzodiazepine and Z-drug in association with the operation of a motor vehicle (real or simulated) with direct or indirect objective or standard subjective measures or indicators of impairment while operating a motor vehicle will be considered. Methods Embase (Elsevier), MEDLINE (Ovid), and PsycINFO (EBSCO) will be searched as sources of published studies. Only studies published in English will be included, and there will be no limit on dates of publication. After screening the titles and abstracts of identified citations, two independent reviewers will retrieve potentially relevant full-text studies and extract data. Data will be presented in diagrammatic or tabular form accompanied by a narrative summary.

Cannabis use by people receiving mental health services is increasingly common, yet many psychiatrists have limited knowledge about the pharmacology of cannabis or its clinical effects. Though clearly relevant to residency training, there is little information on unmet needs and current teaching practices to guide educators who wish to develop a cannabis curriculum. To address this, the authors interviewed key informants and surveyed Canadian psychiatry program directors and residents about cannabis education seeking to determine appropriate content and approaches to inform curriculum development. The authors conducted semi-structured interviews with 7 experts in addictions and psychiatry education. Findings were then used to develop a needs assessment survey about cannabinoid teaching in residency education. Residents and program directors from psychiatry training programs in Canada were invited to complete the online survey. Key informants believed residents are not adequately prepared to manage substance use disorders and recommended additional training be dedicated to cannabinoid education, including cannabis use disorder. Seven program directors and 27 residents completing the survey made recommendations for curriculum content and design. Pharmacology, neurobiology, and managing cannabis use disorders were identified as the most important topics for inclusion. A majority of respondents rated 5 of 8 proposed learning objectives as not supported by existing curriculum and supported an integration of key topics across training years. Respondents identified an urgent need for programs to offer an integrated cannabis curriculum. As cannabis use increases internationally, these findings may be useful to inform curriculum development in other countries.

Purpose: Despite well-established concerns regarding adverse drug effects, antipsychotics are frequently prescribed for older adults. Our first objective was to identify trends in antipsychotic dispensations to older Nova Scotians. STOPP (Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions) criteria identify antipsychotic use in those with a history of falls as potentially inappropriate. Our second objective was to identify trends, predictors, and adherence with this STOPP criteria by identifying continued antipsychotic dispensations following a fall-related hospitalization. Methods: A descriptive cross-sectional cohort study of Nova Scotia Seniors’ Pharmacare Program (NSSPP) beneficiaries ≥ 66 years with at least one antipsychotic dispensation annually from April 1, 2009 to March 31, 2014 was completed. As well, unique beneficiaries with at least one antipsychotic dispensation in the four-year period between April 1, 2009 and March 31, 2013 were linked to fall-related hospitalizations recorded in the Canadian Institute for Health Information Discharge Abstract Database. The relationship of age, sex, fiscal year, days supply and length-of-stay were studied to identify predictors of continued antipsychotic dispensation post-discharge. Descriptive statistics and multivariate logistic analysis were performed. Odds ratios for the association of risk factors and adherence to STOPP criteria were calculated. Findings: We identified that in each year observed, there were 6% of eligible NSSPP beneficiaries that received at least one antipsychotic dispensation. Approximately 70% of antipsychotic dispensations were for second generation agents, primarily quetiapine and risperidone. Of the unique beneficiaries with at least one antipsychotic dispensation in the four-year period between April 1, 2009 and March 31, 2013 who survived a fall-related hospitalization over 75% were dispensed an antipsychotic in the 100 days following hospital discharge. Logistic regression showed no statistically significant association between potentially inappropriate therapy and potential predictors in multivariate analysis. Implications: In each year from 2009 to 2014, 6% of Nova Scotia Seniors’ Pharmacare beneficiaries were dispensed at least one antipsychotic prescription. Over 75% of the older adults who received an antipsychotic dispensation in the 100 days prior to a fall-related hospitalization, continued the drug class after discharge. This demonstrates that despite the recommendations of quality indicators such as the STOPP criteria, antipsychotics are continued in individuals at a high risk of falling. Future investigations are needed to inform health team, system, and policy interventions to improve concordance with this antipsychotic specific STOPP criterion when appropriate. Classification: Original Research, Geriatric Therapeutics, Keywords: Antipsychotic drugs, STOPP criteria, Health services for the Aged, Geriatric, Pharmacoepidemiology

Background: There is limited information available regarding community pharmacists’ stigma of suicide. Pharmacists regularly interact with people at risk of suicide and stigmatizing attitudes may impact care. Objective: To measure community pharmacists’ stigma of suicide. Method: Pharmacists in Canada and Australia completed an online survey with the Stigma of Suicide Scale–Short Form. Data were analysed descriptively and with univariate and multivariate analyses. Results: Three hundred and ninety-six pharmacists returned completed surveys (Canada n = 235; Australia n = 161; female 70%; mean age = 38.6 ± 12.7 years). The rate of endorsement of stigmatizing terms was low overall. Canadian and Australian pharmacists differed (p Conclusion: Community pharmacists frequently interact with people at risk of suicide and generally have low agreement of stigmatizing terms for people who die by suicide. Research should focus on whether approaches such as contact-based education can minimize existing stigma.

Background:Community pharmacists are accessible health care professionals who are increasingly offering weight management programs. People living with serious mental illness have markedly higher rates of obesity and associated illness outcomes than the general population, providing pharmacists who are interested in offering weight management services with an identifiable patient subgroup with increased health needs. Issues with stigma within obesity and mental illness care are prevalent and can lead to inequities and reduced quality of care.Methods:We conducted a scoping review to map and characterize the available information from published and grey literature sources regarding community pharmacists and weight bias towards obese people with lived experience of mental illness. A staged approach to the scoping review was used.Results:Six articles and 6 websites were abstracted after we removed duplicates and applied our inclusion and exclusion criteria. The published studies that we found indicated that pharmacists and pharmacy students do demonstrate implicit and explicit weight bias.Conclusions:Very limited research is available regarding weight bias in pharmacists and stigma towards people with obesity, and we found no information on these phenomena relating to people with lived experience of mental illness. Investigations are needed to characterize the extent and nature of anti-fat bias and attitudes by pharmacists and the consequences of these attitudes for patient care.

Perinatal depression (PND) screening is encouraged in healthcare settings. We aimed to develop and content validate a basic PND knowledge questionnaire for use among pharmacists and potentially other primary healthcare professionals (HCPs). A six-item questionnaire was developed. Twenty-five perinatal mental health experts were invited to participate in content validation by completing the questionnaire and assessing its content validity. A content validity index (CVI) score above 0.8 was indicative of content validity. Expert comments may inform items' deletion or revision. Between November 2016 and February 2017, ten experts participated. For five out of six items, the CVI score was 0.9 or 1.0. Two experts selected "I think none are correct" for one item regarding the onset of postpartum depression. Comments reflected the lack of consensus in the literature surrounding onset periods and prevalence rates and informed minor modifications to three of six questions and seven of 24 response options. The CVI for the questionnaire was 0.83.Content validation of a questionnaire measuring basic PND knowledge resulted in modifications. Comments about PND onset and prevalence indicated the need for consistency when defining and measuring these constructs. This questionnaire may be used among pharmacists and other HCPs.

Objective The Headstrong program, a pharmacy based men’s mental health promotion program, was designed to enhance pharmacists’ care of men with mental illness and addictions and was focused on six conditions. A simulated patient (SP) encounter on insomnia was used to evaluate pharmacist’s performance as a part of the Headstrong program. Results Six Headstrong pharmacists consented to participate in the SP encounter as part of the evaluation of the Headstrong program. Pharmacists’ mean scores in most categories that were evaluated (e.g., pre-supply/assessment score, sleep score) were lower than expected. In assessing the SP during the encounter, pharmacists’ mean score was 5.7 (SD 2.0) of a possible 13 points. No pharmacists asked about the SP’s age, availability of other supports, allergies, and whether they had an existing relationship with a pharmacist. One pharmacist inquired about medical conditions, and two asked about pre-existing mental health conditions. Three pharmacists inquired about concurrent medications. The Headstrong program was discussed by half of the pharmacists and a resource recommended by the Headstrong program was suggested by one pharmacist. Several pharmacists used self-disclosure as a mechanism to support rapport building. Overall, the SP felt cared for and respected by the pharmacists and had confidence in their knowledge.

Background Men with mental health and addictions problems seek information and help from health service providers and community support less often than women with such problems. Online health resources offer men rapid access to self-care recommendations and resources and anonymity; however, only a few websites are specifically developed for men. Headstrong - Taking Things Head-On was a community pharmacy and online health promotion initiative for men living with mental health and addictions problems. The Headstrong website was developed to offer a curated collection of print and online recommended resources (primarily self-help oriented) for depression, anxiety, insomnia, tobacco and alcohol use problems, and suicide. To increase awareness of the initiative and use of the website’s content and resource recommendations, a Google Ads campaign was developed. Objective This study aimed to compare user acquisition and behavior on the Headstrong website during and after a Google Ads campaign. Methods The Google Ads campaign was launched on December 21, 2017, and run until February 28, 2018. Website analytics (acquisition of new users, behavior in terms of at-website actions and duration, devices used, and conversions [link-outs to recommended resources]) in a 30-day period during the campaign (January 26, 2018 to February 24, 2018) were compared to a similar 30-day period after the campaign (March 23, 2018 to April 21, 2018). A cost analysis of the ad campaign was also performed. Results The ad campaign generated 3011 clicks and 4.5 million impressions in total. In addition, the campaign received 1311 website users during the 30-day period of the ad campaign as compared to 241 users during the 30-day period after the ad campaign (P Conclusions A Google Ads campaign designed to direct men to the Headstrong website increased the number of user visits by more than five-fold. However, engagement by users responding to the ad campaign was substantially lower than that by users who visited the website via other acquisition methods, possibly reflecting the nonspecific online targeting of men by the ad campaign. General targeting of men online to promote men’s mental health appears to have limited value.

Background Community pharmacists are autonomous, regulated health care professionals located in urban and rural communities in Canada. The accessibility, knowledge, and skills of community pharmacists can be leveraged to increase mental illness and addictions care in communities. Methods The Bloom Program was designed, developed, and implemented based on the Behaviour Change Wheel and a program of research in community pharmacy mental healthcare capacity building. We evaluated the Bloom Program as a demonstration project using mixed methods. A retrospective chart audit was conducted to examine outcomes and these are reported in this paper. Results We collected 201 patient charts from 23 pharmacies in Nova Scotia with 182 patients having at least one or more follow-up visits. Anxiety (n = 126, 69%), depression (n = 112, 62%), and sleep disorders (n = 64, 35%) were the most frequent mental health problems. Comorbid physical health problems were documented in 57% (n = 104). The average number of prescribed medications was 5.5 (range 0 to 24). Sixty seven percent (n = 122) were taking multiple psychotropics and 71% (n = 130) reported taking more than one medication for physical health problems. Treatment optimization was the leading reason for enrollment with more than 80% seeking improvements in symptom management and daily functioning. There were a total of 1233 patient-care meetings documented, of which the duration was recorded in 1098. The median time for enrolling, assessing, and providing follow-up care by pharmacists was 142 min (mean 176, SD 128) per patient. The median follow-up encounter duration was 15 min. A total of 146 patient care encounters were 60 min or longer, representing 13.3% of all timed encounters. Conclusions Pharmacists work with patients with lived experience of mental illness and addictions to improve medication related outcomes including those related to treatment optimization, reducing polytherapy, and facilitating withdrawal from medications. Pharmacists can offer their services frequently and routinely without the need for an appointment while affording patient confidentiality and privacy. Important roles for pharmacists around the deprescribing of various medications (e.g., benzodiazepines) have previously been supported and should be optimized and more broadly implemented. Further research on the best mechanisms to incentivize pharmacists in mental illness and addiction’s care should be explored.

Background:Akathisia is a common and distressing neuropsychiatric syndrome associated with antipsychotic medication, characterised by subjective and objective psychomotor restlessness. The goal of this guideline is to provide clinicians with recommendations on the assessment and treatment of akathisia.Methods:We performed a systematic review of therapeutic studies assessing the treatment of antipsychotic-induced extrapyramidal symptoms. Forty studies on akathisia and 4 systematic reviews evaluating the adverse effects of antipsychotics were used in the formulation of recommendations. Studies were rated for methodological quality using the American Academy of Neurology Risk of Bias Classification system. The overall level of evidence classifications and grades of recommendation were made using the Scottish Intercollegiate Guidelines Network framework.Results:As a good practice point, clinicians should systematically assess akathisia with a validated scale before starting antipsychotics and during antipsychotic dosage titration. For the management of akathisia, there was adequate evidence to allow recommendations regarding antipsychotic dose reduction, antipsychotic polypharmacy, switching antipsychotic medication, and the use of adjuvant medications including beta-blockers, anticholinergics, 5HT2Aantagonists, benzodiazepines, and vitamin B6.Conclusion:The treatment of antipsychotic-induced akathisia should be personalised, with consideration of antipsychotic dose reduction, cessation of antipsychotic polypharmacy, and switching to an antipsychotic with a perceived lower liability for akathisia, before the use of adjuvant medications. The choice of adjuvant medications should favour the more established treatments, with careful consideration of contraindications and side effects. Limitations in the evidence should be acknowledged and prompt cautious prescribing, particularly with respect to the duration of use of adjuvant medications, is warranted.

To explore Canadian and Australian community pharmacists’ practice experiences in caring for people at risk of suicide. We conducted a thematic analysis of 176 responses to an open-ended extension question in an online survey. Four themes were identified and include referrals and triage, accessibility for confiding, emotional toll, and stigma. Subthemes included gatekeeping the medication supply, sole disclosure, planning for end of life, concerns of support people, assessing the validity of suicidality, gaps in the system, not directly asking, ill-equipped, resources in the pharmacy, relying on others to continue care, and attention seeking. Community pharmacists are caring for patients at risk of suicide frequently, and often with patients seeking the help of pharmacists directly. Pharmacists engage in activities and actions that would be considered outside of the traditional dispensing roles and provide support and intervention to people at risk of suicide through collaboration and other mechanisms. Further research to determine appropriate education and training and postvention supports is required.

There are significant controversies regarding rising antipsychotic prescription trends in children and adolescents. Many pharmacoepidemiology trend studies have been published, and interpretations of these data are helpful in explaining what is happening in prescribing practices, but not why these patterns exist. There is a lack of qualitative data in this area, and the experience of prescribing antipsychotics to children and adolescents has not been adequately researched. We conducted a qualitative study using an interpretive phenomenological analysis of physicians’ experiences of antipsychotic prescribing to children and adolescents. Prescribers participated in individual interviews and a focus group. We used a staged approach for data analysis of transcriptions. In all, 11 physicians including psychiatrists and general practitioners participated in our study. We identified themes related to context, role and identity, and decision-making and filtering. Struggles with health system gaps were significant leading to the use of antipsychotics as substitutes for other treatments. Physicians prescribed antipsychotics to youth for a range of indications and had significant concerns regarding adverse effects. Our results provide knowledge regarding the prescribers’ experience of antipsychotics for children and adolescents. Important gaps exist within the health system that are creating opportunities for the initiation and continued use of these agents.

Background The More Than Meds program was developed to enhance community pharmacy based services for people with mental illness. Objective To evaluate the care of pharmacists who participated in this specific program using a telephone-based simulated patient with insomnia. Methods A trained actor used a simulated patient case scenario and telephoned pharmacists (i.e., intervention group pharmacists) and a control group of pharmacists approximately 6 months following training. Pharmacists were scored on their assessment of the patient and problem, guidance provided on both pharmacological and nonpharmacological care, communications, and overall quality. Results Sixty-three pharmacists (n = 29 intervention, n = 34 controls) were reached. Call duration was longer with intervention versus control group pharmacists [4.93 min (SD 2.3) vs. 4.00 min (SD 1.8)]. Medication recommendations were made by 76 and 100 % of intervention versus control pharmacists (p = 0.002), respectively. Intervention group pharmacists scored significantly higher on most components within communication and overall quality scores. Scores for assessing the patient, the problem, sleep, and medication supply were lower than expected for both groups. Conclusion Intervention group pharmacists performed better than controls on several components of a telephone-based simulated patient scenario for insomnia following More Than Meds training. More research is needed regarding telephone consultations in pharmacy practice.

The recent canadian federal framework for suicide Prevention Act (s.c. 2012, c.30) identifies suicide as a national public health issue that requires federal, provincial, territorial and nongovernmental organization cooperation and action.1,2 The framework sets forth a process intended to fulfill the requirements of the act. This includes numerous directives, of which at least 3 fit well with the work of community pharmacists1,2: Disseminating information about suicide and its prevention Defining best practices for the prevention of suicide Promoting the use of research and evidence-based practices for the prevention of suicide However, the potential contribution of community pharmacists in suicide prevention strategies is not well recognized. Neither the Mental Health Commission of Canada nor the Canadian Society for Suicide Prevention identify a role for community pharmacists in their recent documents pertaining to suicide prevention.3,4 This likely reflects the overall absence of pharmacy-focused research in this area rather than the absence of an active opportunity for community pharmacists in identifying and responding to people at risk of suicide.5,6 Through our combined years of research focused on mental illness and the community pharmacist, our own clinical experience and tacit knowledge and our numerous committee and panel experiences, we know that community pharmacists are regularly directly involved in the care of people at risk of suicide. We are also aware that suicide prevention in the community pharmacy setting has received little professional attention. Suicide is a major public health problem in Canada, and our national mental health strategy identifies suicide prevention in its first of 6 strategic directions.7 The rate of suicide is 3 times higher in men than in women, rising rapidly during adolescence and peaking in both sexes during midlife (see Figure 1).8,9 Self-poisoning is the leading cause of death by suicide in women and is second to hanging in men. In people 40 to 59 years of age, suicide rates by poisoning and hanging are similar. Most sobering is that suicide accounts for 20% to 25% of deaths in adolescence and early adulthood, second only to motor vehicle accidents.10 Physical conditions that compromise quality of life (e.g., heart failure, chronic obstructive pulmonary disease, severe pain, etc.) independently elevate risk of medication overdose deaths in older adults.11 In younger people, a major predictor of suicide, in addition to the presence of mental disorders, is self-injurious behaviours (i.e., nonfatal self-poisoning or self-injury irrespective of suicidal intent).12 The greatest risk of death by suicide occurs in the period following self-injurious behaviours, including overdoses.13 Figure 1 Suicide rates of men and women in Canada, 20118,9 Knowledge of suicide patterns and risk factors is important for community pharmacists in their daily practice, especially when considering that self-poisoning with medication is a leading cause of suicide-related hospitalizations and death.10,14 A recent coroner’s study of overdose deaths in Toronto demonstrates the potential for pharmacists’ interventions. Prescribed medications were implicated in 79% of overdose deaths (62% psychotropics, 17% other medication), suggesting the involvement of a physician and pharmacist in the recent care of the patient, while 21% resulted from overdoses with over-the-counter medications, where a pharmacist may or may not have been involved with the individual’s care.15 These data are consistent with our own community pharmacy mental health research and program development experiences that indicate that prescription and over-the-counter medications are used in suicide attempts and that pharmacists often have concerns about a patient’s self-harm risk in advance of an attempt or may come to realize the missed opportunity for intervention only after the fact. The link between pharmacists and intentional self-poisoning by patients using prescription or nonprescription medications is obvious and thereby provides a clear opportunity for suicide risk assessment and mitigation. Trusted and highly accessible,16,17 pharmacists can be approached in person or via telephone, without the need for an appointment or payment, for advice and support. For these reasons, pharmacists routinely encounter people with risk factors for suicide and people in crisis, irrespective of medication-related needs. The opportunity to take advantage of pharmacists in their accessible positions and with this connection to people in communities has been recognized by the Pharmacy Guild of Australia, which includes staff training in Mental Health First Aid as part of its Community Services Support Pharmacy Practice Incentive program.18 However, the application of pharmacist suicide risk assessment and mitigation training programs needs to be subjected to appropriate third-party scrutiny in Canadian community pharmacy contexts and elsewhere, to determine their appropriateness and whether they achieve the desired goals (i.e., decreasing suicide rates, decreasing incidence of medication-related self-harm and increasing pharmacists’ competencies in suicide risk assessment and management). Some literature is available to support that these programs can have positive outcomes for pharmacy practice,19 but the overall effectiveness of these programs has been questioned in some contexts.20 There are also significant gaps in the health system with respect to transitions in care among services and disciplines, coordination of services and follow-up for people with suicide attempts or self-injurious behaviour. For example, psychosocial assessments, adequate communication back to primary health care providers and follow-up services do not occur for the majority of youth who present to an emergency department (ED) for a self-injurious event, which can include overdose with medication.21-24 A recent Canadian study found that 2 in 3 adolescents who presented to the ED with self-injurious behaviours were discharged directly from the ED.25 Pharmacists may interact with these youth and their families, making recommendations or providing advice, without direct knowledge of the recent ED visit and what has transpired. Patients may be reluctant to disclose information because of concerns of stigma and what they perceive the pharmacist’s role to be with respect to suicide, which currently may be limited in the Canadian context. We are requesting that, as a discipline, we advocate to enhance the education, research and policy agenda for pharmacists with respect to people who are at risk of suicide. We encourage dialogue on suicide risk assessment and ask that appropriate risk management in community pharmacy practice be promoted. Some Canadian pharmacists and students have drawn attention to the issue of suicidal ideation and point to the use of medication reviews as an opportune time to discover these thoughts in patients.6,26 We applaud these pioneering efforts. Looking forward, we think it is timely and necessary to foster collaborative, coordinated and best evidence‒based approaches from policy to practice for suicide risk assessment and management.27 This would also include exploring efficient and effective mechanisms for education, training and mentorship of students and practising pharmacists in assessing and managing suicide risk in people accessing pharmacy services. Pharmacists may require additional education and training to help increase their understanding and competencies in this domain. There is also a need to determine how best to provide postvention support for pharmacists involved in the care of patients who die by suicide, as this need appears underrecognized by researchers, educators and pharmacy employers. Implementation of interventions for pharmacists will also require thoughtful design and planning supported by frameworks that consider changing the behaviours of pharmacists working in the complex environment of community pharmacy practice.28-30 In addition, stigma must be considered, as it can be a pervasive issue with pharmacy staff and patients. Although stigma in the pharmacy context vis-a-vis mental illness has been reasonably well explored, there is little research available regarding stigma in association with those who present in crisis as suicidal or who have a known history of previous suicide attempts. We acknowledge that there needs to be a larger conversation around the integration of pharmacists as members of the primary mental health care team, not just with respect to suicide risk assessment and management. This should include all necessary components that can facilitate this integration, including appropriate mechanisms for communication, triage of patients and information sharing with privacy safeguards among providers, patients and families at various transitions in the health care system. We offer suggestions for action by stakeholders to advance the community pharmacist’s role in suicide risk assessment and management (Table 1). We strongly recommend patient engagement throughout the process from development to implementation. And last, quality assurance and evaluation of the systems in place that allow pharmacists to better serve in this role are imperative. ■ Table 1 Stakeholder actions for advancing the community pharmacist’s role in the assessment and management of people at risk of suicide

Objective: Children with attention-deficit hyperactivity disorder (ADHD) may have oppositional behaviour, conduct problems, and aggression. These symptoms vary in severity, and may be related to a comorbid diagnosis of oppositional defiant disorder (ODD) or conduct disorder (CD). Critical evaluation of the efficacy of ADHD medications may guide the clinician regarding the usefulness of medications for these symptoms. Method: We performed a systematic review and meta-analysis of psychostimulants, alpha-2 agonists, and atomoxetine for oppositional behaviour, conduct problems, and aggression in youth with ADHD, ODD, and CD. The quality of evidence for medications was rated using the Grading of Recommendations Assessment, Development and Evaluation approach. Results: Two systematic reviews and 20 randomized controlled trials were included. There is high-quality evidence that psychostimulants have a moderate-to-large effect on oppositional behaviour, conduct problems, and aggression in youth with ADHD, with and without ODD or CD. There is very-low-quality evidence that clonidine has a small effect on oppositional behaviour and conduct problems in youth with ADHD, with and without ODD or CD. There is moderate-quality evidence that guanfacine has a small-to-moderate effect on oppositional behaviour in youth with ADHD, with and without ODD. There is high-quality evidence that atomoxetine has a small effect on oppositional behaviour in youth with ADHD, with and without ODD or CD. Conclusions: Evidence indicates that psychostimulants, alpha-2 agonists, and atomoxetine can be beneficial for disruptive and aggressive behaviours in addition to core ADHD symptoms; however, psychostimulants generally provide the most benefit.

Objective:To develop evidence-based guidelines on pharmacotherapy for severe disruptive and aggressive behaviour in children and adolescents with attention-deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), or conduct disorder (CD). The guidelines assume that psychosocial interventions have been pursued but did not achieve sufficient improvement.Method:A multidisciplinary consensus group used the Grading of Recommendations Assessment, Development and Evaluation approach for rating evidence quality and for grading recommendations. We conducted a systematic review of medications studied in placebo-controlled trials for treating disruptive and aggressive behaviour in children and adolescents with ADHD, ODD, or CD. We followed consensus procedures to make 1 of 4 recommendations for each medication: strong, in favour (↑↑); conditional, in favour (↑?); conditional, against (↓?); and strong, against (↓↓).Results:For children and adolescents with disruptive or aggressive behaviour associated with ADHD, psychostimulants received a strong recommendation in favour of use, while atomoxetine and alpha-2 agonists received a conditional recommendation in favour of use. If these patients do poorly with ADHD medications, the medication with the most evidence is risperidone. Risperidone also has the most evidence for treating disruptive or aggressive behaviour in the absence of ADHD. However, given risperidone's major adverse effects, it received only a conditional recommendation in favour of use. We recommended against using quetiapine, haloperidol, lithium, or carbamazepine because of the poor quality of evidence and their major adverse effects.Conclusion:When severe disruptive or aggressive behaviour occurs with ADHD, medications for ADHD should be used first. Other medications have major adverse effects and, with the exception of risperidone, very limited evidence to support their use.

Background: Medications are commonly used in suicide attempts. Pharmacists are inextricably linked to medications and may have roles in helping those at risk of suicide. We conducted a scoping review to characterize the existing literature and make recommendations about future research. Methods: We used a 6-step approach based on an existing scoping review methodological framework, including identifying the research question; identifying relevant studies and other literature; study and literature selection; data charting; collating, summarizing and reporting results; and dissemination of results. We searched electronic databases, various grey literature sources and mobile app stores. Results: Thirty-five articles were included following screening of 1013 database citations. Of 1085 results from grey literature searches, we included 12. Most publications were opinion pieces ( n = 22), followed by survey studies ( n = 9), primarily assessing pharmacists’ knowledge and attitudes. Themes included education and training to impact knowledge and attitudes, gatekeeping of medication supply, collaboration and integration, and role perception. Public perspectives on pharmacists’ roles were limited. Conclusions: Research regarding pharmacists’ roles in the care of people at risk for suicide is limited. The areas that have dominated the literature include legal liability, especially with respect to gatekeeping medications, ethical decision making and education and training. Research is needed to determine what methods, outcomes and measures are required to best serve in building the evidence base for policy and practice decisions in this area.

Background: While antipsychotic medications are the mainstay of therapy for individuals with schizophrenia and psychotic disorders, their use is associated with adverse effects on physical health that require the attention and care of prescribers. Methods: We used the ADAPTE process to adapt existing guideline recommendations from the National Institute for Health and Care Excellence (NICE) and Scottish Intercollegiate Guidelines Network (SIGN) guidelines on the dosing of antipsychotics and antipsychotic polypharmacy, screening for adverse effects of antipsychotics, and management of metabolic and extrapyramidal side effects to the Canadian context. Results: Prescribers are encouraged to use the lowest effective dose and to avoid the routine use of multiple antipsychotics. Scheduled monitoring of body mass index, waist circumference, blood pressure, glucose, lipids, prolactin, electrocardiograms, and extrapyramidal symptoms is recommended. Lifestyle interventions are recommended to mitigate antipsychotic-induced weight gain. Prescribers should follow Canadian guidelines on the treatment of obesity, dyslipidemia, and diabetes. Recommendations on antipsychotic drug choice are made for users particularly concerned about extrapyramidal symptoms. Conclusion: Careful monitoring and attention by prescribers may mitigate adverse effects associated with antipsychotic medications.

The objective of this study was to assess men’s acceptability of a men’s mental health promotion program in community pharmacies through pilot testing the theoretical framework of acceptability (TFA) as part of the process evaluation. Five men were interviewed about their experiences with the Headstrong program to learn about the acceptability of the program. The TFA was used as the deductive coding scheme and consists of seven constructs including affective attitude, burden, intervention coherence, ethicality, opportunity costs, perceived effectiveness, and self-efficacy. Three constructs, affective attitude, perceived effectiveness, and intervention coherence, from the TFA were coded in all five transcripts. The most frequently coded constructs were affective attitude and perceived effectiveness, coded 19 and 17 times, respectively. Interviewees all reported good relationships with their pharmacists, which influenced their willingness, attitude, and low burden for participation in Headstrong. Each of the men expressed comments reflecting anticipated effectiveness of the program outside of their own experience and how it could impact other men. Use of the TFA as part of a process evaluation of men’s experiences in a men’s mental health program was useful in identifying men’s perceptions of the program’s acceptability. Further research regarding how the quality of existing relationships with clinicians and patients impacts the TFA constructs of affective attitudes, perceived effectiveness, and burden would be useful.

Background The role of community pharmacists is changing globally with pharmacists engaging in more clinically-oriented roles, including in mental health care. Pharmacists’ interventions have been shown to improve mental health related outcomes but various barriers can limit pharmacists in their care of patients. We aimed to explore the experiences of people with lived experience of mental illness and addictions in community pharmacies to generate findings to inform practice improvements. Methods We used interpretive description methodology with analytic procedures of thematic analysis to explore the experiences of people with lived experience of mental illness and addictions with community pharmacy services. Participants were recruited through multiple mechanisms (e.g., paper and online advertisements), offered honorarium for their time, and given the option of a focus group or interview for participation in our study. Data were gathered during July to September of 2012. Interviews and focus groups were audio-recorded, transcribed verbatim, and analyzed by two researchers. Results We collected approximately nine hours of audio data from 18 individuals in two focus groups (n = 12) and six individual interviews. Fourteen participants were female and the average age was 41 years (range 24 to 57 years). Expectations, decision-making, and supports were identified as central themes underlying the community pharmacy experiences of people with lived experience of mental illness and addictions. Eight subthemes were identified including: relationships with pharmacy staff; patient’s role in the pharmacist-patient relationship; crisis and triage; privacy and confidentiality; time; stigma and judgment; medication-related and other services; and transparency. Conclusions People with lived experience of mental illness and addictions demonstrate a high regard and respect for pharmacist’s knowledge and abilities but hold conservative expectations of pharmacy health services shaped by experience, observations, and assumptions. To some extent, expectation management occurs with the recognition of the demands on pharmacists and constraints inherent to community pharmacy practice. Relationships with pharmacy staff are critical to people with lived experience and influence their decision-making. Research in the area of pharmacists’ roles in crises and triage, especially in the area of suicide assessment and mitigation, is needed urgently. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1817-4) contains supplementary material, which is available to authorized users.

I read with great interest the recent qualitative investigation of how community pharmacists make decisions by Gregory, Whyte and Austin.1 I read every word, and I can’t remember the last time I did that. It represents exceptional scholarship in the research question, methods, analysis and writing. It advanced my knowledge, stimulated me as a researcher and will influence my teaching and contributions as a member of the undergraduate pharmacy curriculum committee. I’m sure others who read from across the profession also found that it made a strong impression.

Type 2 diabetes mellitus (T2DM) rates are three times higher in patients with bipolar disorder (BD), compared to the general population. This is a major contributing factor to the elevated risk of cardiovascular mortality, the leading cause of death in bipolar patients. There may be shared pathophysiology linking the two disorders, including hypothalamic-pituitary-adrenal and mitochondrial dysfunction, common genetic links, and epigenetic interactions. Life-style, phenomenology of bipolar symptoms, and adverse effects of pharmacotherapy may be contributing factors. Patients with BD and T2DM have a more severe course of illness and are more refractory to treatment. Control of their diabetes is poorer when compared to diabetics without BD, and an existing disparity in medical care may be partly responsible. Glucose abnormalities in bipolar patients need to be screened for and treated. Metformin appears to have the best benefit/risk ratio, and the dipeptidyl peptidase-4 inhibitors and glucagon-like peptide-1 receptor agonists and analogues also appear promising, although these agents have not been specifically studied in populations with mood disorders. Physicians need to be aware of the increased risk for T2DM and cardiovascular disease in bipolar patients, and appropriate prevention, screening, case finding, and treatment is recommended.

ObjectivePotency equivalents for antipsychotic drugs are required to guide clinical dosing and for designing and interpreting research studies. Available dosing guidelines are limited by the methods and data from which they were generated.MethodWith a two-step Delphi method, the authors surveyed a diverse group of international clinical and research experts, seeking consensus regarding antipsychotic dosing. The authors determined median clinical dosing equivalents and recommended starting, target range, and maximum doses for 61 drugs, adjusted for selected clinical circumstances.ResultsParticipants (N=43) from 18 countries provided dosing recommendations regarding treatment of psychotic disorders for 37 oral agents and 14 short-acting and 10 long-acting parenteral agents. With olanzapine 20 mg/day as reference, estimated clinical equivalency ratios of oral agents ranged from 0.025 for sulpiride to 10.0 for trifluperidol. Seventeen patient and treatment characteristics, including age, hepatic and renal fun...

Objective: The aim of this study was to determine patient preferences, satisfaction, and perceived stigma related to community pharmacists. Methods: A total of 79 persons receiving psychotropic medications from community pharmacies were recruited at mental health outpatient clinics in Canada to complete a crosssectional survey. Results: Traditional pharmacy services (providing medication information) were perceived to be of greater importance than some clinical services (such as medication and dosing recommendations). However, perceived importance of service was strongly correlated with its availability. Several gaps in service were identified, including advice on stopping medications, collaborating with other health providers, describing how medications work, addressing side effects, and discussing issues during prescription refills. Inquiries by pharmacists about chronic disease risk factors were uncommon. Perceived stigma was similar to stigma with other types of health providers and lower than that reported with other community members. Conclusions: The perceived value of community pharmacy services appears to be based on their availability. Participants identified some discomfort and stigma associated with community pharmacy services, but experiences were positive overall. (Psychiatric Services 60:1123–1127, 2009)

Much has changed in the past two decades in terms of the pharmacotherapy of psychiatric disorders across the lifespan. It was just over 20 years ago that fluoxetine was first marketed in the United States and shortly thereafter clozapine made its remarkable return to patient care. But at the time these medications received marketing approvals from the FDA, Health Canada, and other nations’ regulatory agencies, we were not to know the impact they would have—on clinical practice, the pharmaceutical industry, psychotropic drug research, drug nomenclature, psychiatric nosology, perceptions of psychiatric patients and care, as well as education in clinical psychopharmacology. Prozac® quickly became a household word, supplanting Valium® as the best known psychotropic (Kramer, 1993). It also emerged as a lightning rod in child and adolescent psychopharmacology (Healy, 2003; Teicher et al., 1990). Prozac® was the first of several very successfully marketed SSRIs, which were found to be particularly effective in pediatric anxiety disorders. However, this therapeutic advance was overshadowed by these SSRIs’ uncertain benefit in adolescent depression and the early indications that they could promote rather than thwart suicidality in young patients (Research Unit on Pediatric Psychopharmacology, 2001; Kutcher & Gardner, 2008). The “awakenings” of chronically psychotic patients treated with clozapine generated hope and renewed interest in psychiatric practice, not unlike the pride described by psychiatrists 30 to 40 years earlier when the benefits of lithium, chlorpromazine, iproniazid, and imipramine were serendipitously uncovered, and heralded the modern psychopharmacologic era (Duckworth et al., 1997; Lambert, 1998). It was much easier to teach (and to learn) about psychotropic drugs when our understanding of the pathophysiological processes of mental illness were simple and the proposed mechanisms of how these drugs worked were uncomplicated. It was also easier to teach about psychotropics when their numbers were limited to a few distinct families with simply described pharmacological actions—dopamine antagonism for schizophreina, dopamine agonistic effects for attention, GABAmimetics for anxiety, and enhancement of serotonin or norepinephrine for depression. For bipolar disorder, we seemed content to have found lithium and other so-called mood stabilizers, even if their mechanisms remained mysterious. Never mind that the above psychotropic drugs were incompletely effective for most patients and completely ineffective for some, the proposed pharmacologic mechanisms meshed well with the pathophysiological proposals (though in many cases this was no coincidence) and this suited us just fine (Teicher, 1988). The neuroscientific basis of psychiatric disorders and investigations into the pharmacological effects of their treatments have exploded in the past 20 years coincident with advances in molecular genetics, molecular and cell biology, molecular pharmacology, pharmacogenomics, and imaging technologies. New findings have revealed the initial biologic theories of psychiatric disorders to be overly simplistic, incomplete, or wrong. However, replacing these aging theories with newer, widely accepted ones has not occurred despite many dramatic advances (Conn & Roth, 2008). Exemplifying the growth in this area and its complexity are the contents of the American College of Neuropsychopharmacology’s exhaustive 2002 reference text Neuropsychopharmacology 5th Generation of Progress. This text has 2,010 pages, written by almost 300 expert contributors, covering 134 chapters (Davis et al., 2002). In contrast to these neuroscience advances, new drug discovery has been slow and disappointing. It is sobering to note that the most commonly prescribed psychotropics share the same mechanism of action discovered many decades earlier. For example, olanzapine, risperidone, and quetiapine are more potent antagonists at 5-HT2 compared to D2, an effect of clozapine which was developed in 1961; venlafaxine’s dual reuptake blockade of serotonin and noradrenaline is a characteristic of the tricyclic antidepressants, and the specificity for serotonin reuptake inhibition was first observed with zimelidine in 1977 but was hardly a new mechanism of antidepressant action even then (Conn & Roth, 2008). Paradoxically, as the research base has expanded there seems to be less emphasis on teaching the neuroscientific basis of psychiatric disorders and their treatments. That is, as the information has become increasingly complex the response has been to de-emphasize its importance.

The prevalence of major depression is reported as approximately 8% in Canada and 7.5% in Australia, the use of antidepressants is therefore common. However, questions remain about whether depression is under-diagnosed and whether patients are appropriately treated with antidepressants once the disorder is recognized. We compared the use of antidepressant medicines, in Nova Scotia, Canada and Australia, in populations receiving public drug subsidy.The Nova Scotia Pharmacare Program and the Pharmaceutical Benefits Scheme in Australia were used to obtain dispensing data for all publicly subsidized antidepressants. Utilization was compared from 2000-2003, using the World Health Organisation Anatomic Therapeutic Chemical (ATC)/Defined Daily Dose (DDD) system.The use of antidepressants increased in both areas over the study period. However, the use of antidepressants in Nova Scotia increased at a significantly higher rate than Australia. Selective serotonin reuptake inhibitors (SSRIs) were the most commonly prescribed class of drugs in both areas, constituting 60% of all antidepressants prescribed. Eight different antidepressants made up 90% of the antidepressant drug use in Australia, with sertraline the most commonly prescribed. Similarly, nine different antidepressants made up 90% of the antidepressant use in Nova Scotia, with paroxetine most commonly prescribed.This study found differences in the rate but not class of antidepressant prescribing in Nova Scotia and Australia. Antidepressant use increased in both areas over the time period. This may be due to increased exposure to marketing, promotion, education or different prescribing practices in Nova Scotia compared to Australia.

The underlying proposition for any experimental/ therapeutic trial is the uncertainty that the risks of treatment will be outweighed by its benefits. For some therapeutic interventions (e.g., exercise programs, vitamin supplementation), the potential for treatmentemergent adverse events may prima facie be low or negligible, whereas for others (e.g., chemotherapy, invasive surgeries), the potential for treatment-emergent adverse events may be substantial. Because it is both scientifically and ethically necessary to determine efficacy, tolerability, and safety of medical treatments, a number of strategies have been developed to increase the probability that evidence of both effect and harm can be reasonably identified before the intervention passes into general use. One of those strategies is the randomized, placebo-controlled trial (RCT) in the pharmacotherapy of child and adolescent psychiatric disorders. In addition, a variety of structures and procedures have been developed to mitigate the risk to subjects who agree to participate in therapeutic research. These safeguards include but are not limited to study approval from independent institutional review boards, informed consent, and independent third-party audit of data and procedures. One of the structures that has been developed to improve research subject safety in therapeutic research in which risks for harm may either be high or unknown is that of the Data Safety and Monitoring Board (DSMB). A DSMB is an autonomous structure, independent of study sponsors and investigators, and is composed of individuals with expertise in the study subject area as well as in clinical trial methodology (Friedman et al., 1998). Established before study onset, its purpose is to review, analyze, and evaluate data while the study is ongoing. It has the authority to terminate the study if the monitoring identifies an unacceptable harm profile or if the data received before planned study termination are so strongly positive that further exposure to a nonintervention arm (such as a placebo) is not scientifically necessary nor ethically acceptable. DSMBs may also have the capacity to change how a trial is proceeding, such as amending patient assessment, monitoring, and management contingencies. DSMBs were introduced into medical therapeutics research in the 1990s and have become increasingly important in monitoring the safety of subjects participating in clinical trials. Although they have been relatively well established in some medical disciplines such as cancer or HIV/AIDS research, they have generally not been applied to psychopharmacological research in young people. We argue that they should. In this issue of the Journal, Emslie and colleagues publish the results of two RCTs of venlafaxine extended release versus placebo in pediatric depression (Emslie et al., 2007). Although the drug showed no overall efficacy advantage over placebo, the endpoint data analysis showed not only a lack of efficacy but also a clear signal of risk. Is this endpoint finding something that could have been identified while the study was in progress and addressed by an appropriately constituted DSMB? If this finding had been recognized while the study was in progress, could subjects have been spared Accepted October 13, 2006. Drs. Carandang, Carrey, Gardner, and Kutcher are with the Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada; Dr. Santor is with the School of Psychology, University of Ottawa, Ottawa, Ontario, Canada. Reprint requests to Carlo Carandang, M.D., Mood Disorders Group, IWK Health Centre, 5850/5980 University Avenue, P.O. Box 9700, Halifax, NS, Canada B3K 6R8; e-mail: carlo.carandang@iwk.nshealth.ca. 0890-8567/07/4604-0489 2007 by the American Academy of Child and Adolescent Psychiatry. DOI: 10.1097/chi.0b013e31802f5f54 C O M M E N T A R Y

Background: Community pharmacists care for and support people with lived experience of mental illness in their communities. We developed a program called More Than Meds to facilitate enhancing capacity of community pharmacists’ roles in mental health care. Methods: We conducted a qualitative study and used a directed content analysis with application of the Theoretical Domains Framework as part of our underlying theory of behaviour change and our analytic framework. Results: Ten interviews ( n = 6 pharmacists, n = 4 community members) were conducted with participants from the More Than Meds program. Three key themes were identified from the experiences of More Than Meds participants: networking and bridging, stigma, and expectations and permissions. The most frequently coded domains in the data from the Theoretical Domains Framework were social/professional role, skills, beliefs about capabilities, knowledge and environmental context and resources. Conclusions: The More than Meds Program enabled community pharmacists to increase their capabilities, opportunities and motivation in providing mental health care and support. Involving community pharmacists together with people with lived experience of mental illness was identified as an innovative component of the program.