Opening the Gate for Student Mental Health Needs

From the September 15, 2023 issue of the Transformational Times

Opening the Gate for Student Mental Health Needs

Kevin Bozymski, PharmD, BCPS, BCPP

Dr. Bozymski, a board-certified psychiatric pharmacist, discusses the mental health stressors faced by health care students, and shares his journey of training future pharmacists to become mental health “gatekeepers” for their peers (and themselves) …

Expanding beyond algorithms

When people ask me what I do for a living, it’s not as straightforward as saying teacher or pharmacist—or even the phrase, mental health pharmacist. It usually involves a back-and-forth dialogue, with me imperfectly describing my winding path as the audience inquires, prompts and clarifies. Upon reflection, the emphasis on one-on-one connections is what got me on my path. 

While healthcare practitioners and researchers value the scientific method (me included), I’ve often found algorithms too restrictive. That’s why psychiatry resonated with me as a student pharmacist, where the right pharmacologic choice cannot be made without considering an individual’s preferences, values, and environment.

It’s also why academia called to me as a resident pharmacist, where a “one-size- fits-all” teaching approach does not meet every learner’s preference, needs, and background. 

Unfortunately, it’s easy to fall into the algorithm trap as a teacher when discussing student mental health, especially when we aren’t taking care of our own mental health. We look back in our own life to how we handled stress as a learner, assuming our experience will translate well to another’s. We worry about finding time to dialogue, looking toward rating scales used in clinic appointments as a model for triaging student concerns. This solutions-first mindset shows in our health care learners, as a recent scoping review of medical student literature found fears of decreased career opportunities, nonconfidentiality and personal stigma as the top individual barriers to care.

Before walking in someone else’s shoes, it’s worth asking about their journey so far and how they find themselves now. 

From stress to burnout to on fire 

As the psychiatric pharmacist on faculty within Medical College of Wisconsin School of Pharmacy, I am invited to give perspective about student mental health on many interdisciplinary councils, committees and workgroups. The most impactful discussions, though, come in one-on-one discussions with my student pharmacist mentees. 

These quarterly meetings have a brief agenda,  and are open-ended for me to actively listen and ask: How is your quarterly session going? What has been a surprise since we last spoke? Where do you want your shoes to take you, and how can I help them do so?

It's no secret that the MCW PharmD curriculum is stressful, with students completing four years of traditional coursework in just three. And while it’s unclear to what extent stress correlates to burnout and mental health concerns, published U.S. student pharmacist surveys identify positive response rates of 19% to 40% for clinical depression (via PHQ-9) and 21% to 41% for clinical anxiety (via GAD-7). (see references 2-5)

Furthermore, the American Academy of Colleges of Pharmacy has released a statement encouraging pharmacy schools to proactively promote overall wellness and stress management techniques.

There’s no easy algorithm to determine who develops clinically significant concerns, but it is near-impossible to do so unless a student is connected enough to their academic community to be asked.

Who’s at the gate for mental health care?

Access and stigma are two driving barriers in psychiatry, and certainly student mental health is no exception. Therefore, gatekeeper training—programs teaching how to identify warning signs of mental crises and connect people to needed services—have been spreading across the globe. Such programs are not just for healthcare practitioners, but for anyone with a desire to improve mental health in their area. Thanks to funding from the Kern Institute, the MCW Pharmacy School, and Advancing a Healthier Wisconsin endowment, I’ve had the honor as a certified Mental Health First Aid instructor of teaching 60 first-year PharmD students (so far) how to open the gate for their peers, their communities, and themselves.

While students over the years have commented on its benefits, one anonymous comment from a course evaluation struck me the most:

“These skills were amazing to learn. It has helped with not only my family and friends but also has been used in practice with my peers. To have the ability to learn about what people go through and how to be able to approach and talk to people about a mental health crisis is something everyone should learn.”

If we cannot break down every systematic gate standing between an individual and mental health resources, we can at least ensure the keepers know how to help passersby. And even if my student pharmacist self from over a decade ago does not fully understand the unique stressors of this generation, I can at least dedicate myself to learning from and conversing with them in a non-algorithmic way - using the information gained to better appreciate, reassure, and connect.

After all, with mental health, an imperfect response is better than no response at all.

Take action:

Interested in becoming trained as a MHFA instructor (or just completing MHFA certification yourself)? Please contact Dr. Kevin Bozymski or Dr. Himanshu Agrawal for more information. 

For further reading:

1. Berliant M et al. Barriers faced by medical students in seeking mental healthcare: a scoping review. MedEdPublish (2016). 2022; 12:70.

2. Koutsimani P et al. The relationship between burnout, depression, and anxiety: a systematic review and meta-analysis. Front Psychol. 2019; 10:284.

3. Fischbein R et al. Pharmacy and medical students’ mental health symptoms, experiences, attitudes, and help-seeking behaviors. Am J Pharm Educ. 2019;83(10):7558.

4. DeHart RM et al. Prevalence of depression and anxiety among student pharmacists. Int J Med Pharm. 2020;8(2):1-8.

5. Shangraw AM et al. Prevalence of anxiety and depressive symptoms among pharmacy students. Am J Pharm Educ. 2021;85(2):8166.

6. American Colleges of Clinical Pharmacy. AACP Statement on Commitment to Clinician Well-Being and Resilience. Accessed https://www.aacp.org/article/commitment-clinician-well-being-and-resilience on September 5, 2023.

7. Suicide Prevention Resource Center. Choosing A Suicide Prevention Gatekeeper Training Program: A Comparison Table. Accessed https://sprc.org/wp-content/uploads/2022/12/GatekeeperMatrix6-21-18_0.pdf on September 5, 2023.

8. National Council for Mental Wellbeing. About MHFA: What is Mental Health First Aid? Accessed https://www.mentalhealthfirstaid.org/about on September 5, 2023.

Dr. Kevin Bozymski, PharmD, is an Assistant Professor with appointments in the MCW Pharmacy School Department of Clinical Sciences and the School of Medicine Department of Psychiatry & Behavioral Medicine. He is a certified Mental Health First Aid instructor, providing training through an Advancing a Healthier Wisconsin endowment. He also provides clinical services at both the MCW Tosa Health Center and Froedtert Hospital Complex Intervention Unit.

The MCW School of Pharmacy’s COVID-19 Immunization Program

 From the 4/23/2021 newsletter

Some questions for …

 

 George E. MacKinnon III, PhD, MS, RPh - MCW School of Pharmacy

 

 

The MCW School of Pharmacy’s COVID-19 Immunization Program

 

 

In what ways was the MCW School of Pharmacy well-positioned to quickly ramp up a response to the call for COVID-19 immunizers? 

Dr. MacKinnon: The School of Pharmacy ran several influenza clinics on the MCW Milwaukee Campus that well prepared faculty and student pharmacists to respond to the call for immunizers, albeit these were very small operations. In the fall of 2020, under the leadership of Professor Karen, MacKinnon, Director of Outreach in the School of Pharmacy, we expanded the influenza clinics and opened them to more individuals of MCW (all students, staff, and faculty). The intention was that these clinics would serve as the prototype for the COVID-19 Immunization Clinic for MCW. The MCW School of Pharmacy joined with the MCW Office or Research (led by Ann Nattinger, MD, MPH, Associate Provost for Research, Senior Associate Dean for Research, School of Medicine) to jointly lead the creation of a COVID-19 Vaccination Clinic on our Milwaukee Campus to administer the COVID-19 vaccine beginning December 22, 2020.

All eligible MCW student pharmacists are trained early in their education to administer vaccines, including the COVID-19 vaccine. They also receive training in the Doctor of Pharmacy (PharmD) program in point-of-care testing such as nasopharyngeal testing for coronavirus and strep throat testing, and thus were an asset to our clinical partners for COVID testing these past 12 months. Additionally, many of our pharmacy faculty have been trained in immunization administration over the years. Thus, we had a cadre of internal pharmacists and student pharmacist that were able and willing to participate in COVID-19 vaccine administration.

Pharmacists have expertise in planning for vaccine procurement, storage, distribution, preparation, administration, post immunization monitoring, and record keeping. Fortunately, the School of Pharmacy had just jointly hired Kristin Busse, PharmD, BCPS with the Office of Research when the pandemic emerged in early 2020. She came to us with years of experiences in investigational drug services at Froedtert and was an ideal pharmacist to lead the vaccine procurement and preparations (complying with all regulatory issues at federal and state levels for the emergency use authorization (EUA) vaccines that were to be released).

 

How quickly did you decide that you needed to be proactive with the Wisconsin state legislature to change the rules for oversight and delivery of vaccine? What was that process like?

Dr. MacKinnon: When we began to develop our PharmD curriculum in 2015, we identified that we would be unable to include immunization training early on in the program and had to wait until the second year of the program. We did meet with MCW Office of Government Relations but realized that this was a statutory change needing intervention from the state legislature. Over the past four years, we also met with the Pharmacy Society of Wisconsin (PSW) expressing our desire to gather support as we believe that having a state statue dictate the timing of curriculum delivery in a PharmD Program is overly prescriptive, limiting, and antiquated.

As it became apparent that in late 2020 a COVID-19 vaccine would likely be available, we again brought up this topic with PSW and brought the other two schools of pharmacy in the state into the discussion. Our position was simple, during a pandemic, when all appropriately credentialed providers are needed, such arbitrary distinctions would hinder our full deployment of life-saving vaccines now and into the future.

During this process we also requested an additional language change that would allow student pharmacists to be supervised by any health care provider authorized to administer vaccines (e.g., nurses, physicians). As was previously written in statute, a student pharmacist must have been overseen by only a pharmacist in the administration of an immunization. In fact, we used LCME accreditation language to help support our position and draw an analogy to medical education. With the Legislature’s bipartisan bill and the Governors approval, our suggested changes were enacted in late February 2021. Thus, we have been able to support a team-based approach to healthcare in concert at the regulatory and professional levels, at least with respect to immunizations.

 

When the next pandemic arrives (as it likely will!), what will we do differently?

Dr. MacKinnon: Certainly, there were identified process improvements along the way. The clinic, while conceptually the same in December, has grown and matured to an efficient operation. This sentiment was echoed by the many individuals that came to staff the clinic or be immunized. The credit to this goes to the blended teams from the MCW Office of Research (led by Dr. Nattinger) and the School of Pharmacy (led by Dr. MacKinnon) via the MCW COVID-19 Vaccine Program Team Leads as follows:

Vaccine and program logistics:

Leads: Kristin Busse and Lisa Henk

Clinic Supervision and orientation:

Leads:  Karen MacKinnon and Susan Mauermann

Scheduling and planning:

Leads: Jayne Jungmann and AshLeigh Sanchez

Reporting and maintenance of records:

Leads:  Jen Brown and Theresa Dobrowski

Personnel Eligibility and Invitations:

Leads: Katie Kassulke and Ann Nattinger

MCW COVID Administrative Response Team:

Leads: Dan Wickeham and Adrienne Mitchell

As the vaccine goes through the phases of roll-out into our communities, the role of a pharmacist is critical, as pharmacists have specific knowledge about immunization and pharmacists’ accessibility can help address issues surrounding vaccine hesitancy in the public. We need to continue the public health discussion surrounding the value of all immunizations to preventing diseases, disability and death.

 

What reactions did you get from the SOP students, faculty, and staff to the process? 

Dr. MacKinnon: The School of Pharmacy mission is to: Advance the health of our communities through innovative pharmacy education, continuous public and professional service, and diverse scholarly collaborations. So, our desire to contribute to abating the pandemic was right in line with our mission all along.  We were able to get 100% participation from our faculty and staff. With respect to engagement, overall, there were 95 individuals (faculty, staff and students) from the School of Pharmacy that contributed over 4,500 hours in clinic over the 45 days of clinic operations.

 

 

What surprised you most in all of this?

Dr. MacKinnon: Two things in particular stand out, though none as real surprises but rather gratitude.  

First was the initial influx of staffing for the first phase of the COVID-19 Clinic from School of Pharmacy faculty, staff and student pharmacists and staff from the Office of Research over the typical holiday break. Many individuals changed their personal plans to staff the clinic. As time went on many individuals were putting in 12-hour days at the clinic and catching up on their regular responsibilities on weekends, it became apparent that more assistance would be needed. Student pharmacists needed to return to classes and faculty had responsibilities to attend to as well. This is when the entire MCW campus rallied to support the clinic with medical students, having been trained in immunization, joining forces with physicians, nurses, physician assistants, and medical assistants as immunizers. There too was an outpouring of support from the basic sciences as individuals with the requisite technical skillset and experiences were able to prepare the syringes filled with vaccines.  

Next was the outpouring of support that came from all members of the extended MCW Community including Board members and the significant others and family of faculty and staff. Frankly people had been isolated for so long because of the pandemic and they just wanted to do their part to assist in the clinic. We welcomed them with open arms. Everyone’s contributions were essential to so many tasks that needed to be accomplished including the planning, delivery and ongoing operation of the Clinic. 

As the saying goes, culture eats strategic planning every day for lunch. Thus, we can plan and strategize all that we want, but the culture of collegiality and respect that we initiated through the COVID-19 Immunization Clinic is what emerged that allowed us to be successful. This developing culture will have a long-standing impact to MCW in years ahead as it emerges into a health science university. I am certain that the COVID-19 Immunization Clinic will be a defining moment in this transformation internally and externally as others in the community recognize what a resource and gem that MCW is to all.

 

George E. MacKinnon III, PhD, MS, RPh, FASHP, FNAP is the Founding Dean of the School of Pharmacy and Professor of Pharmacy at MCW.