Community pharmacists’ recommendations for natural products for stress in Melbourne, Australia: a simulated patient study
Keywords:Complementary Therapies, Nonprescription Drugs, Counseling, Mental Health, Pharmacies, Pharmacists, Patient Simulation, Cluster Analysis, Australia
Background: Community pharmacists are often the first health professional approached to provide treatment for health issues, including the important mental health challenge, stress. Over-the-counter products for stress almost always are complementary and alternative medicines (CAM) and in Australia no protocol exists for their recommendation and sale in community pharmacies.
Objective: To assess the quality and relevance of community pharmacists’ information gathering (questioning), counselling and product selection when interacting with customers requesting a CAM product for stress and consequently determine whether Australian pharmacy practice indicates the need for guidelines similar to those provided for ‘pharmacy only’ (S2) and ‘pharmacist only’ (S3) medicines.
Methods: A covert simulated patient was used to investigate the response of pharmacists to a request for a natural product for stress. The SPs documented the details of the pharmacist-simulated patient interaction immediately on leaving the pharmacy and then re-entered the pharmacy to debrief the pharmacist. The quality of the interaction was scored as a Total CARE (check, assess, respond, explain) Score, based on anticipated questions and counselling advice. The appropriateness of the product was scored as a Product Efficacy Score, based on evidence-based literature.
Results: Data from 100 pharmacies was provided. Information gathering illustrated by the questioning components Check and Assess (C and A) of the total CARE score by pharmacists was poor. The number of questions asked ranged from zero (13 pharmacists) to 7 (four pharmacists), the average being 3.1 (SD 1.9). Provision of advice was generally better (a description of the suggested product was offered by 87 pharmacists) but was lacking in other areas (duration of use and side effects were explained by only 41 and 16 pharmacists respectively). The most common product suggested was B-group vitamins (57 pharmacists) followed by a proprietary flower essence product (19 pharmacists). A two-step cluster analysis revealed two sub-groups of pharmacists: one cluster (74 pharmacists) with a high Total CARE score provided an appropriate product. The other cluster (20 pharmacists) had a low total CARE score and provided an inappropriate product.
Conclusions: The pharmacy visits revealed major shortcomings in questioning, counselling and product recommendation. There is a need to develop guidelines for pharmacists to make evidence-based decisions in recommending complementary and alternative medicine.
Baum A. Stress, intrusive imagery, and chronic distress. Health Psychol. 1990;9(6):653-675. https://doi.org/10.1037//0278-618.104.22.1683
Crum AJ, Salovey P, Achor S. Rethinking stress: The role of mindsets in determining the stress response. J Pers Soc Psychol. 2013;104(4):716-733. https://doi.org/10.1037/a0031201
Hammen C. Stress and Depression. Annu Rev Clin Psychol. 2005;1:293-319. https://doi.org/10.1146/annurev.clinpsy.1.102803.143938
Kivimäki M, Virtanen M, Elovainio M, Kouvonen A, Väänänen A, Vahtera J. Work stress in the etiology of coronary heart disease--a meta-analysis. Scand J Work Environ Health. 2006;32(6):431-442. https://doi.org/10.5271/sjweh.1049
World Health Organization. Disorders specifically associated with stress. Available at: https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/991786158 (accessed Jul 5, 2019).
Patriquin MA, Mathew SJ. The neurobiological mechanisms of generalized anxiety disorder and chronic stress. Chronic Stress (Thousand Oaks). 2017;1. https://doi.org/10.1177%2F2470547017703993
Woody ML, Gibb BE. Integrating NIMH research domain criteria (RDoC) into depression research. Curr Opin Psychol. 2015;4:6-12. https://doi.org/10.1016/j.copsyc.2015.01.004
Kaufman J, Gelernter J, Hudziak JJ, Tyrka AR, Coplan JD. The research domain criteria (RDoC) project and studies of risk and resilience in maltreated children. J Am Acad Child Adolesc Psychiatry. 2015;54(8):617-625. https://doi.org/10.1016/j.jaac.2015.06.001
Hamm AO, Richter J, Pané-Farré C, Westphal D, Wittchen HU, Vossbeck-Elsebusch AN, Gerlach AL, Gloster AT, Ströhle A, Lang T, Kircher T, Gerdes AB, Alpers GW, Reif A, Deckert J. Panic disorder with agoraphobia from a behavioral neuroscience perspective: Applying the research principles formulated by the Research Domain Criteria (RDoC) initiative. Psychophysiology. 2016;53(3):312-322. https://doi.org/10.1111/psyp.12553
Lang PJ, McTeague LM, Bradley MM. RDoC, DSM, and the reflex physiology of fear: A biodimensional analysis of the anxiety disorders spectrum. Psychophysiology. 2016;53(3):336-347. https://doi.org/10.1111/psyp.12462
Lupien SJ, Sasseville M, François N, Giguère CE, Boissonneault J, Plusquellec P, Godbout R, Xiong L, Potvin S, Kouassi E, Lesage A; Signature Consortium. The DSM5/RDoC debate on the future of mental health research: implication for studies on human stress and presentation of the signature bank. Stress. 2017;20(1):95-111. https://doi.org/10.1080/10253890.2017.1286324
Roy Morgan Research. Roy Morgan Image of Professions Survey 2017: Health professionals continue domination with nurses most highly regarded again; followed by doctors and pharmacists. Available at: http://www.roymorgan.com/findings/7244-roy-morgan-image-of-professions-may-2017-201706051543 (accessed Mar 5, 2019).
Xue CCL, Zhang AL, Lin V, Da Costa C, Story DF. Complementary and Alternative Medicine Use in Australia: A National Population-Based Survey. J Altern Complement Med. 2007;13(6):643-650. https://doi.org/10.1089/acm.2006.6355
Xue CC, Lin V, Zhang L, Story DF. The use of complementary and alternative medicine in Australia. Health Issues. 2006(88):12.
Pharmaceutical Society of Australia. Professional Practice Standards, Version 5. Available at: https://www.psa.org.au/wp-content/uploads/2018/08/Professional-Practice-Standards-v5.pdf (accessed Nov 7, 2018).
Watson M, Norris P, Granas A. A systematic review of the use of simulated patients and pharmacy practice research. Int J Pharm Pract. 2020;28(1):13-25. https://doi.org/10.1111/ijpp.12570
Pharmaceutical Society of Australia. Australian pharmaceutical formulary and handbook : the everyday guide to pharmacy practice. Twenty-fourth edition. ed. Deakin West, ACT: Pharmaceutical Society of Australia; 2018.
Braun L. Herbs & natural supplements : an evidence-based guide / Lesley Braun, Marc Cohen. Chatswood, NSW: Elsevier Australia; 2014.
Carroll D, Ring C, Suter M, Willemsen G. The effects of an oral multivitamin combination with calcium, magnesium, and zinc on psychological well-being in healthy young male volunteers: a double-blind placebo-controlled trial. Psychopharmacology (Berl). 2000;150(2):220-225. https://doi.org/10.1007/s002130000406
Schlebusch L, Bosch B, Polglase G, Kleinschmidt I, Pillay B, Cassimjee M. A double-blind, placebo-controlled, double-centre study of the effects of an oral multivitamin-mineral combination on stress. S Afr Med J. 2000;90(12):1216-1223.
Stough C, Scholey A, Lloyd J, Spong J, Myers S, Downey LA. The effect of 90 day administration of a high dose vitamin B-complex on work stress. Hum Psychopharmacol. 2011;26(7):470-476. https://doi.org/10.1002/hup.1229
SPSS Inc. The SPSS Twostep cluster component. Available at: https://www.spss.ch/upload/1122644952_The%20SPSS%20TwoStep%20Cluster%20Component.pdf (accessed Jul 7, 2019).
Australian Government; Department of Health: Therapeutic Goods Association. St John's Wort: Important interactions between St John's Wort (Hypericum perforatum) preparations and prescription medicines. Available at: https://www.tga.gov.au/alert/st-johns-wort-important-interactions-between-st-johns-wort-hypericum-perforatum-preparations-and-prescription-medicines (accessed Jul 20, 2019).
White A, Boon H, Alraek T, Lewith G, Liu JP, Norheim AJ, Steinsbekk A, Yamashita H, Fønnebø V. Reducing the risk of complementary and alternative medicine (CAM): Challenges and priorities. Eur J Integr Med. 2014;6(4):404-408. https://doi.org/10.1016/j.eujim.2013.09.006
Varvogli L, Darviri C. Stress management techniques: evidence-based procedures that reduce stress and promote health. Health Sci J. 2011;5(2):74.
Better Health Channel: Victoria State Government. Stress. Available at: https://www.betterhealth.vic.gov.au/health/healthyliving/stress (accessed Mar 3, 2019).
Richards G, Smith A. Caffeine consumption and self-assessed stress, anxiety, and depression in secondary school children. J Psychopharmacol. 2015;29(12):1236-1247. https://doi.org/10.1177/0269881115612404
Better Health Channel: Victoria State Government. Managing and treating anxiety. Available at: https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/anxiety-treatment-options (accessed Mar 19, 2019).
Ernst E. Bach flower remedies: a systematic review of randomised clinical trials. Swiss Med Wkly. 2010;140:w13079. https://doi.org/10.4414/smw.2010.13079
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