International Journal of Pharmacy Practice, 2023, XX, 1–10

https://doi.org/10.1093/ijpp/riad091
Advance access publication 23 December 2023
Research Paper

Consumer knowledge of mental health conditions,

awareness of mental health support services, and
perception of community pharmacists’ role in mental

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health promotion
Judith Singleton1, , Julie E. Stevens2,3,4, Raymond Truong3, Adam McCulloch1, Elay Ara1,
Maria B. Cooper3, Britany Hobbs3, Elizabeth Hotham3, Vijayaprakash Suppiah3,5,*,
1
Faculty of Health, School of Clinical Sciences (Pharmacy), Queensland University of Technology, Brisbane, QLD 4000, Australia
2
Pharmacy, School of Health and Biomedical Sciences, RMIT University, Bundoora, VIC 3082, Australia
3
Clinical and Health Sciences, University of South Australia, Adelaide, SA 5000, Australia
4
Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA 5000, Australia
5
Australian Centre for Precision Health, University of South Australia, Adelaide, SA 5000, Australia
Correspondence: Clinical and Health Sciences, University of South Australia, Bradley Building, City West Campus, Adelaide, SA 5000, Australia. E-mail: vijay.
*

[email protected]

Abstract
Objective: To explore community pharmacy consumers’ knowledge and attitudes of mental illness, support services, and community
pharmacists’ role in supporting people living with mental illness (PLMI).
Methods: This survey was conducted in 15 community pharmacies between June and September 2019. Participants were aged 18 years or
older without prior or ongoing history of mental illness and/or with close family members with mental illness. Open-ended responses to the
anonymous questionnaire were analysed using content analysis.
Key findings: Majority of the 380 participants were female (57.4%) with a mean age 52.9 years and 33.7% having completed university. Most
(70.3%) believed that people with mental illness had a negative image due to poor health literacy providing possible solutions of ‘awareness
campaigns’, ‘education and training’, and ‘increased government funding for mental health (MH) support services’. Only 33.7% and 63.7% of
participants were aware of Mental Health Week and the R U OK? Campaign, respectively. Whilst 12.4% of participants had participated in MH
campaigns, only 3.4% were aware of community pharmacists-led MH educational activities. There were significant differences between adults
(<65 years) and older adults (≥65 years old) with the latter reporting a more negative image for mental illness ( P < 0.05) and having less exposure
and engagement with MH resources (P < 0.001) and campaigns (P < 0.01).
Conclusion: Despite awareness, participants reported low engagement with MH campaigns. Additionally, older adults had lower MH literacy
and exposure to resources and campaigns. This study highlighted that the community lacked awareness of what pharmacists can offer to sup-
port PLMIs.
Keywords: mental health support; mental health promotion; community pharmacy; mental health awareness campaigns

Introduction Stigma acts as a significant barrier for PLMI who face fear
A recent World Health Organisation report revealed that ap- and disdain from the community, resulting in further social
proximately 1 in 8 people worldwide live with a mental ill- isolation and self-stigma [4, 5]. To combat this, increasing the
ness, with anxiety and depressive disorders being the most general population’s overall MH literacy and awareness is a
prevalent [1]. Mental illness was found to be the primary potential solution [6–8]. Previous studies have shown that
cause of years lived with a disability globally, accounting for individuals without an educational background in MH ex-
one in every 6 years [1]. In Australia, mental health (MH)- hibit lower MH literacy [9, 10]. Involving primary health-
related expenditures contributed to approximately 7.6% of care practitioners in community outreach programmes to
the total healthcare expenditure in 2019 [2] placing a provide information on MH conditions and community-
signifi- cant economic strain on the healthcare system [1]. based resources could improve overall MH literacy [11, 12].
The 2021 national survey estimated that over 43.7% of Increasing public MH literacy is important, as evidence shows
Australians aged 16–85 years had experienced a mental that PLMI are more likely to confide in close friends and
illness during their lifetime [3]. Therefore, improving family [13, 14].
support services and health outcomes for people living with Community pharmacists are in a valuable position to pro-
mental illness (PLMI) would have significant benefits for vide these additional services due to their accessibility [15–17].
society.

Received: 6 June 2023 Accepted: 11 December 2023

© The Author(s) 2023. Published by Oxford University Press on behalf of the Royal Pharmaceutical Society.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/),
which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.
 2 Singleton et

Throughout the pandemic, community pharmacies operated

caring for an immediate family member with mental illness.
face-to-face even when other primary healthcare professions
Due to privacy laws in Qld, prior screening by community
transitioned to telehealth and remote consultations [18, 19].
pharmacists was not allowed. Instead, the first question on
Australian consumers with mental illness and their families
the questionnaire screened for prior experience with mental
have reported positive perceptions of community pharmacists,
illness. Interested participants were then provided with a par-
appreciating their friendly, sensitive, and non-judgemental
ticipant information sheet and those willing to participate
approach to service delivery, thereby creating a welcoming
signed an informed consent form. In Vic, participants were
and safe MH space [20]. The established trust and rapport
recruited the same way as in Qld. In SA and Vic, participants
between community pharmacists and their consumers make
completed a hard copy of the anonymous questionnaire
them well-suited to implement MH promotion initiatives
in private counselling rooms while in Qld, the anonymous
[15]. Such initiatives have shown positive impacts on the

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questionnaires were completed on a laptop in a quiet area of
health-related quality of life within their communities [21].
the pharmacy. All participants were assigned a unique iden-
With additional training and adequate remuneration and
tifier code for confidentiality and data were recorded against
policy changes, community pharmacists can play an important
this number.
role in the MH and wellbeing of their communities [22, 23].
Content analysis was used to analyse open-ended responses.
In particular, recent reviews have highlighted how community
Demographic data were presented using descriptive statistics.
pharmacists can play a role in screening for undiagnosed
Continuous data were analysed using one-way Anova tests
depression in adults [23, 24] and monitoring for physical
while categorical data were analysed using Pearson’s Chi-
health in PLMI living independently in their communities
squared Test for Independence. Categorical data were further
[22, 23]. International organizations like the International
analysed after stratifying for age, dividing respondents into
Pharmaceutical Federation [24] and the Pharmaceutical
two groups: adults aged 18–64 years and older adults aged
Society of Australia [25] have advocated for expanded roles
65 years and above. Statistical significance was taken to be
for pharmacists in mental healthcare, including screening
P < 0.05. As well as quantitative analysis, data for each
for undiagnosed mental illness, navigating access to sup-
question (except demographic data) were coded manually
port services within health systems and optimizing therapies
using a three-pass manual coding methodology [27]. Two of
[23]. However, to the best of our knowledge, there are no
the authors undertook the first coding cycle independently.
published studies investigating the perspectives of Australian
Agreement on final codes and themes was reached through
community pharmacy consumers on the role of community
discussion and negotiation. The first coding cycle employed
pharmacists in supporting PLMI.
structural coding followed by a second cycle where the original
To address this gap, we sought to explore Australian com-
codes were reviewed and revised, if necessary, and allocated
munity pharmacy consumers’ attitudes and beliefs about
into categories. Conceptually similar codes were grouped
mental illness, knowledge of MH, and MH support serv-
together under a single category, and some codes that were
ices, and the role that community pharmacists could play in
considered marginal, redundant, or irrelevant were removed
supporting PLMI and educating the community.
from the analysis. This process aimed to develop a more con-
cise list of categories and subcategories [28]. In the third
Methods coding cycle, these reorganized categories were synthesized
into more general, higher-level themes. Inter-rater reliability
This study utilized an anonymous questionnaire comprising was addressed by having a second researcher also analyse
16 open-ended questions (Supplementary material). These samples of the data. Final themes were derived through dis-
questions were separated into three sections: (i) demography, cussion, negotiation, and agreement between members of the
(ii) MH (including questions relating to attitudes/stigma/ research team.
beliefs, the 12 signs and characteristics of depression as listed This study was approved by the three institutions’ Human
in the DSM-V Depression Diagnostic Criteria [26], MH Research Ethics Committees (HREC Protocols 201419 and
support and role of community pharmacists in supporting 1900000603, SEHAPP 90-18) and permission was obtained
consumers with mental illness), and (iii) MH resources from the pharmacy chains, respective owners, and
(awareness of and prior experience with MH resources and managers of the community pharmacies.
role of community pharmacists in MH education). This ques-
tionnaire was piloted on a convenience sample of pharmacy
academics in the three participating universities for reada- Results
bility and understanding.
Of the 543 consumers approached (SA = 189, Vic = 224 and
A convenience sample of participants was recruited from
Qld = 130), 163 were excluded due to caring for an imme-
six South Australian (SA), five Victorian (Vic), and four
diate family member with mental illness, having a mental ill-
Queensland (Qld) community pharmacies between June and
ness themselves, or not wanting to be involved in the study.
September 2019. Study data were collected by final-year phar-
Across the 3 states, 380 consumers (SA = 174, Vic = 146,
macy students from three pharmacy schools as part of their
and Qld = 60) completed the questionnaire (Table 1). The
final-year research project. Apart from one Victorian phar-
cohort comprised slightly more females (57.5%; 218/380)
macy, all pharmacies were in metropolitan areas.
with a mean age of 52.9 years (range 18–98 years). Half
Consumers aged 18 years or older and without prior or
had completed high school (50.0%) and one third having
ongoing personal history of mental illness and/or with close
completed university (33.7%; 128/380).
family members with mental illness were invited to
Most participants (70.3%, 267/380) believed that PLMI had
participate in this study. In SA, potential participants’
a negative image in the community. There was a statistically
medication dispensing histories were screened by their
significant difference in responses among the 3 states (73.6%,
community pharmacists to exclude those with existing or a
65.8%, and 71.7% from SA, Vic, and Qld, respectively, χ2df 4
history of mental illness or those
 Community pharmacists in mental health 3
Table 1. Demographics of study participants and recognition of signs and symptoms of depression.

Characteristic South Australia (n = 174) Victoria (n = 146) Queensland (n = 60) Total (n = 380)
n (%) n (%) n (%) n (%)

Gendera

Female 94 (54.3)b 94 (64.4) 30 (50) 218 (57.5)b

79 (45.7) 52 (35.6) 30 (50) 161 (42.5)
Male 94 (54.3)b 94 (64.4) 30 (50) 218 (57.5)b
79 (45.7) 52 (35.6) 30 (50) 161 (42.5)

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Average agec (range) (years) 69.7 (23– 39.7 36.8 52.9 (18–
98)b (18–89) (18–87) 98)b
Level of education
No formal education 1 (0.6) 1 (0.7) 0 2 (0.5)
Primary school 6 (3.4) 0 0 6 (1.6)
High school/Year 12 103 (59.2) 66 (45.2) 21 (35.0) 190 (50.0)
TAFE 24 (13.8) 19 (13.0) 5 (8.3) 48 (12.6)
University 34 (19.5) 60 (41.1) 34 (56.7) 128 (33.7)
Unknown 6 (3.4) 0 0 6 (1.6)

Signs and symptoms of depression as described by DSM-V

Signs and symptoms South Australia Victoria Queensland Total
(n = 174) n (%) (n = 146) n (%) (n = 60) n (%) (n = 380) n (%)

Depressed mood 133 (76.4) 122 (83.6) 57 (95.0) 312 (82.1)

Observable decrease in interest or pleasure in activities most days 143 (82.2) 115 (78.8) 44 (73.3) 303 (79.7)
Significant weight loss when not intentionally dieting 90 (51.7) 64 (43.8) 26 (43.3) 180 (47.4)
Decreased appetite 89 (51.1) 86 (58.9) 32 (53.3) 208 (54.7)
Insomnia 127 (73.0) 102 (69.9) 43 (71.7) 272 (71.6)
Increased agitation 148 (85.1) 89 (61.0) 40 (66.7) 278 (73.2)
Constant fatigue or loss of energy 132 (75.9) 95 (65.1) 36 (60.0) 263 (69.2)
Constant feeling of worthlessness 146 (83.9) 115 (78.8) 42 (70.0) 304 (80.0)
Excessive or inappropriate level of guilt 123 (70.7) 86 (58.9) 41 (68.3) 250 (65.8)
Diminished ability to think or concentrate 139 (80.0) 84 (57.5) 35 (58.3) 259 (68.2)
Recurrent thoughts of death 123 (70.7) 101 (69.2) 52 (86.7) 276 (72.6)
Recurrent suicidal ideation 122 (70.1) 111 (76.0) 49 (81.7) 283 (74.5)
Number who identified all signs 25 (14.4) 54 (37.0) 23 (39.3) 102 (26.8)
a
Chi squared P value < 0.05.
b
One missing data point.
c
One-way ANOVA between three groups P value < 0.05.

=19.35, P < 0.001) (Table 2). With age-stratified analysis, the

χ2df 1 = 16.89, P < 0.001) (Table 2). The top three resources
proportion of participants in the younger group who believed named by participants were Beyond Blue (43.9%), Black Dog
that PLMI had a negative image was significantly different Institute (13.7%), and Lifeline (8.9%) (Table 2). Of these
from the proportion in the older group (67.0% vs 75.3%, 196 participants, 104 (53%) had used one of the resources,
χ2df 2 = 6.18, P < 0.05) (Table 2). commenting that the information provided by these resources
When asked to identify the signs of depression as listed was easy and simple to understand.
in the DSM-V Depression Diagnostic Criteria (Table 1), less There was a significant state-wise difference in the usage
than a third (26.8%, 102/380) identified all 12 symptoms. of MH resources (SA—43.1%; Vic—13.7%; Qld—15.0%,
Only 180 (47.4%) identified unintentional weight loss and χ2df 2 = 40.01, P < 0.001) (Table 2). Even though the younger
208 (54.7%) decreased appetite as symptoms of depression. group was more aware of support resources for mental illness
Unsurprisingly, 312 (82.1%) identified depressed mood. (60.6% vs. older group—39.2%, χ2df 2= 16.89, P < 0.001),
Slightly more than half of the participants 51.6% (196/380) they were significantly less likely to have used them when
reported being aware of MH support resources. There was compared to the older group (22.2% vs. 34.8%, χ2df 1 = 7.39,
a statistically significant difference between the proportion P < 0.01) (Table 2).
of participants aware of resources across the three states With regard to national MH awareness campaigns, 33.7%
(44.3%, 62.3%, and 46.7% for SA, Vic, and Qld, respectively, (128/380) and 63.7% (242/380) of participants were aware
χ2df 2 = 11.07, P < 0.01). Age-stratified chi-squared test also of Mental Health Week and the R U OK? Campaign, re-
showed that the younger group was significantly more aware spectively (Table 2). However, only 12.4% (47/380) had
of support resources than the older group (60.6% vs. 39.2%, participated in an MH campaign while only 3.4% (6/380)
 4 Singleton et

Table 2. Participants understanding of negative image associated with mental illness and support resources.

Do you think PLMI have a negative image in the community?

SA (n = 174) n (%) Vic (n = 146) n (%) Qld (n = 60) n (%) P valuea

No—29 (16.7) No—46 (31.5) No—9 (15.0) <0.001b
Yes—128 (73.6) Yes—96 (65.8) Yes—43 (71.7)
Unsure—12 (6.9) Unsure—3 (2.1) Unsure—8 (13.3)
Unanswered—5 (2.9) Unanswered—1 (0.7) Unanswered—0
Age stratificationc Adults (n = 221)d n (%) Older adults (n = 158)d n (%) P valuea
No—59 (26.7) No—25 (15.8) <0.05b

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Yes—148 (67.0) Yes—119 (75.3)
Unsure—12 (5.4) Unsure—11 (7.0)
Unanswered—2 (0.9) Unanswered—3 (1.9)
Are you aware of any support resources for mental illness?
No—97 (55.7) No—55 (37.7) No—32 (53.3) <0.01
Yes—77 (44.3) Yes—91 (62.3) Yes—28 (46.7)
Age stratificationc Adults (n = 221) n (%) Older adults (n = 158) n (%) P valuea
No—87 (39.4) No—96 (60.8) <0.001
Yes—134 (60.6) Yes—62 (39.2)
What support resources are you aware of for mental health issues?
Resources SA (n = 174) n (%) Vic (n = 146) n (%) Qld (n = 60) n (%)
Lifeline 23 (13.2) 0 11 (18.3)
Beyond Blue 61 (35.1) 87 (59.6) 19 (31.7)
Headspace 9 (5.2) 8 (5.5) 5 (8.3)
This Way Up 0 0 1 (1.7)
GP MH Plans 0 0 1 (1.7)
Mood Gym 0 0 2 (3.3)
SANE 0 2 (1.4) 1 (1.7)
Black Dog Institute 41 (23.6) 8 (5.5) 3 (5.0)
Suicide Hotline 0 2 (1.4) 1(1.7)
Kids Helpline 3 (1.7) 0 1 (1.7)
Mens Line 0 1 (0.7) 1 (1.7)
R U OK? 4 (2.3) 1 (0.7) 1 (1.7)
Salvation Army 1 (0.6) 0 0
Have you ever used a mental health resource yourself?
SA (n = 174) n (%) Vic (n = 146) n (%) Qld (n = 60) n (%) P valuea
No—99 (56.9) No—126 (86.3) No—51 (85.0) <0.001
Yes—75 (43.1) Yes—20 (13.7) Yes—9 (15.0)
Age stratificationc Adults (n = 221) n (%) Older adults (n = 158) n (%) P valuea
No—172 (77.8) No—103 (65.2) <0.01
Yes—49 (22.2) Yes—55 (34.8)
Yes to being aware of Mental Health (MH) week and R U OK?
SA (n = 174) n (%) Vic (n = 146) n (%) Qld (n = 60) n (%) P valuea
MH week—15 (8.6) MH week—87 (59.6) MH week—26 (43.3) <0.001
R U OK? – 95 (54.6) R U OK?—99 (67.8) R U OK?—48 (80.0) <0.001
Age stratificationc Adults (n = 221) n (%) Older adults (n = 158) n (%) P valuea
MH week—103 (46.6) MH week—25 (15.8) <0.001
R U OK?—156 (70.6) R U OK?—86 (54.4) <0.01
Have you taken part in either of these campaigns?
SA (n = 174) n (%) Vic (n = 146) n (%) Qld (n = 60) n (%) P valuea
No—170 (97.7) No—122 (83.6) No—41 (68.3) <0.001
Yes—4 (2.3) Yes—24 (16.4) Yes—19 (31.7)
Age stratificationc Adults (n = 221) n (%) Older adults (n = 158) n (%) P valuea
No—178 (80.5) No—154 (97.5) <0.001
Yes—43 (19.5) Yes—4 (2.5)
a
Chi squared analysis.
b
Comparison of yes, no and unsure.
c
One missing data point.
d
Adults consisted of respondents aged 18–64 years old while older adults consisted of respondents ≥65 years old.
 Community pharmacists in mental health 5
of participants were aware of any MH educational activities
family and friends for support when affected [14]. However,
that community pharmacists were currently involved in.
fear of stigma is a common barrier to seeking help from loved
Participants were asked why they thought mental illness
ones. Therefore, educating the general public can improve the
had a negative image in the community (Table 3). The key
quality of support provided [14]. Recent research indicates
theme from content analysis was the belief that PLMI are
that public attitudes towards mental illness have improved
the ‘out’ group in society—they are perceived as ‘different’
over time [32, 33]. However, previous research examining
and with this perceived difference comes a negative image.
the impact of age, gender, education level, and ethnicity on
Participants believed this negative image could be lessened
public stigma towards mental illness has produced con-
through greater awareness with most responding that this
flicting results [32–36]. Our findings align with prior litera-
could be achieved through encouraging conversations about
ture demonstrating increased stigma among older individuals
mental illness, MH awareness campaigns, for example, in

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[33], although other studies have noted the opposite [32, 35,
the media utilizing celebrities and improving MH literacy
36]. This disparity may be explained by the method of age
by embedding MH content in school and high education
stratification (40 years and older in Bradbury et al.’s study
curricula. Participants’ beliefs regarding what constitutes
[32] compared with 65 years and older in the present study)
important support for PLMI are also depicted in Table 3.
and the level of MH literacy, which is reported to be lower in
When asked what role community pharmacists could play
older people [37].
in supporting individuals living with mental illness, content
While many participants were aware of at least one
analysis revealed five themes: ‘someone to talk to’, ‘medica-
national MH awareness campaign, their engagement with
tion supply and counselling’, ‘triage’, ‘education’, and ‘no
these initiatives was considerably low. National MH aware-
role’ (Table 4). Participants could not perceive a role for
ness campaigns aim to reduce stigma and discrimination,
pharmacists apart from medication supply and counselling,
improve communities’ MH literacy, enhance communica-
being someone to talk to, and being a triage service for other
tion about MH among friends and family, and increase help-
types of professional help. A few participants felt MH was
seeking behaviours for PLMI [38]. A review of the R U OK?
outside pharmacists’ expertise and that there was no ex-
Campaign demonstrated a significant increase in awareness
panded MH role for pharmacists.
after their annual campaigns between 2010 and 2014 [13].
Participants reported feeling encouraged to discuss MH issues
Discussion and inquire about the wellbeing of family and friends, as
well as being more willing to seek professional help [13].
Before this study, there was limited research investigating the
Beyond Blue also evaluated their MH-targeted national
knowledge of mental illness and the availability of support
initiative be- tween 2000 and 2004 [38]. Beyond Blue’s
services among community pharmacy consumers, as well as
short-term goals of increasing quality information, improving
their perceptions of the role of community pharmacists in
consumer/carer networks and care of depression in primary
supporting PLMI and educating the public on MH topics.
care settings, and increasing target MH research have been
This research highlighted that Australian community phar-
successful [38]. They were also making progress towards
macy consumers believed that: (i) PLMI are treated differ-
their long-term goal of reducing stigma and discrimination.
ently by society to those living with other illnesses, and (ii)
They also reported that Beyond Blue’s efforts have been
pharmacists have a limited role in supporting those living
instrumental in decreasing stigma and discrimination [38].
with mental illness, apart from medication dispensing (in-
However, the current study suggests that these public
cluding counselling) and education.
awareness campaigns have yet to achieve their goals.
This study has several limitations, including social desira- Moreover, there is limited evidence re- garding their
bility bias due to direct data gathering from participants effectiveness in bringing about behavioural change such as
that might result in social desirability response bias [29]. The increased uptake of professional services and reduced suicide
focus on symptoms of depression may not fully reflect attempts [17]. Early introduction of MH ed- ucation in
participants’ understanding of other mental illnesses. school curricula may provide an effective way to raise
Additionally, factors such as ethnicity, socioeconomic awareness and promote participation in MH awareness
factors, and MH literacy were not explored, which are campaigns.
known to influence attitudes and beliefs, including stigma.
This study found that the general perception of the
The study could have been improved by including a broader
pharmacist’s role in MH among the Australian public mainly
range of mental illness types to explore how attitudes and
centres around traditional roles of medication supply and
knowledge differ by mental ill- ness type. On reflection,
counselling and referral to other healthcare professionals.
some of the questions could have been written using more
However, considering their accessibility, pharmacists have the
open-ended language. Previously validated questionnaires
potential to build impactful relationships with their patients.
[4, 30, 31] were explored when developing the
Australians visit their community pharmacies 18 times an-
questionnaire for this study. However, these tended to
nually compared to visiting their GPs 5.6 times for the
address mental illness broadly while we specifi- cally
same period [39, 40]. By having repeated consultations with
wanted to investigate the health literacy of pharmacy
patients with depression, pharmacists can monitor changes
consumers regarding their beliefs on mental illness, and the
in presentation and demeanour contributing to the improve-
signs and symptoms of depression, considering many people
ment of the recovery process [15]. The role of pharmacists in
confide in family and close friends for support. Hence, our
MH is expanding rapidly, encompassing professional services
questionnaire was developed referring to these examples and
such as telepharmacy, interventions to enhance medication
the structuring of questions but tailored to address the aims
adherence, early detection and screening of mental illness,
of our study.
and facilitating access to health services, all of which have
Raising awareness and knowledge of mental illness within demonstrated positive impacts [21, 23]. Public education on
the community is crucial because individuals often rely on the role of pharmacists in community health management is
 6 Singleton et

Table 3. Content analyses of participants’ beliefs regarding the negative image of mental illness and important supports for PLMI.

Theme Sub-themes Representative quotations

Participants’ beliefs as to why people living with mental illness have a negative image in the community.
People living with MH conditions are ‘Right or wrong they get viewed as being weak.’ [S235];
mental illness are the viewed as a weakness ‘It’s a seen as a sign of weakness to ask for help.’ [M140];
‘Out Group’ ‘Because they are often considered unable to deal with their life situations and environ-
ment.’ [M820];
‘People see MH as a weakness.’ [S520]
Prevailing negative ‘MH is viewed as a taboo topic.’[S530];

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stereotypes—stigma ‘MH conditions have a bad image.’[N194];
‘As it is a long-term condition, stigma is spread by the community.’ [I346];
‘There is increased stigma in the community.’ [F201]; ‘Stigma.’ [K171];
‘There is so much stigma in the world.’ [A180];
‘To some extent mainly due to the medication perceptions.’ [N120];
‘It’s the fault of the media.’ [A223];
‘Media.’ [N164]
Negative image lessening ‘MH is an illness like every other illness,’ [J221];
‘It’s not different to any other medical condition.’ [R222];
‘Very common in today’s society.’ [T180];
‘There are people wo are viewed a lot worse.’ [K144];
‘It’s just another illness, you don’t view someone poorly because they have high blood pres-
sure for example.’ [O115];
‘I don’t view them badly but I don’t know what other people think.’ [E242];
‘An increasing amount of people are experiencing mental health problems or have family
members with mental illness and this increases the understanding about MH and em-
pathy towards them.’ [B142];
‘It is common in the community and well-published.’ [P120]
Community MH literacy ‘People don’t understand mental illness and react the wrong way.’ [M302];
‘It’s probably due to a lack of understanding.’ [L246]; ‘People with mental illness are
misunderstood.’ [N294]; ‘There is a lack of understanding about mental illness from the
public.’ [N231];
‘People use the word ‘depressed’ a lot so no one really knows what it means.’ [F144];
‘There’s a lack of understand of what depression is.’ [B294];
‘Some people still don’t view depression as a serious illness.’ [F121];
‘Because society is not well-informed.’ [A251];
‘Ignorance.’ [R293];
‘People don’t know enough.’ [I144];
‘poor education.’ [B272];
‘Because the community is negative about everything.’[S152]
Support services ‘Not enough government help makes people feel worthless.’ [H042];
‘I don’t think people living with mental illness have enough support and attention as they
are growing up and it gets worse as they get older.’ [F110];
‘Because there has been this new wave of resources it has stopped people guiding them-
selves through it and they constantly rely on other people to solve their problems.’ [E282]
MH conditions viewed ‘People think they are broken.’ [D192];
differently to other ‘It’s a touchy topic.’ [Y043];
medical conditions ‘Right or wrong they are viewed as being damaged, not like any other illness.’ [T240];
‘People think there is something wrong with them.’ [L304];
‘Because other people treat them differently because normal people cannot feel what they
feel.’ [S170];
‘because they are treated unfairly.’ [M303];
‘Mental illness is like any other illness and people with other illnesses do not have a nega-
tive image.’ [K223]
Fear/distrust of MH ‘MH patients can be viewed as dramatic.’ [J153];
patients ‘Seems like today anyone who is different is viewed negatively.’ [C113];
‘Because they act differently.’ [F100];
‘Because they are different.’ [Y820];
‘People view them in a more cautious manner.’ [M113]; ‘They are viewed as having some-
thing wrong with them or being weird I think.’ [N120];
‘They can de deemed as dangerous or insane by the public due to their actions.’ [M221];
‘People are scared of them.’ [L212];
‘They are always associated with ‘craziness’.’ [R121]
Invisibility ‘you’re not sure what is happening in someone else’s mind.’ [J103];
‘Hard to know who is struggling with depression, people are good at hiding their
problems.’ [T113];
‘You don’t know what people are thinking.’ [G105];
‘There may not be any physical manifestations of the disease state.’ [L042]
 Community pharmacists in mental health 7
Table 3. Continued.
Theme Sub-themes Representative quotations
Participants’ beliefs regarding what they believed to be important support for people living with mental illness.
Personal attributes of Personal attributes of ‘Patience would be the main thing.’ [E325];
others others ‘Empathy and understanding.’ [R435];
‘Empathy, respect, caring, trust and big hugs.’ [SA26]; ‘Understanding and empathising with
them.’ [QP221]; ‘Making sure they know they have people who love them.’ [L478];
‘Be there for them—let them talk, laugh and cry.’ [SA162];
‘Be there for them,’ [Vic19];
‘Have someone in their life reminding them of their worth.’ [Vic68];
‘It sound silly but just being supportive.’ [G364];

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‘Show them they can count on you.’ [J227];
‘Provide them with constant reassurance and tell them that things will turn out for the
better.’ [H912];
‘Not telling them to pull themselves together.’ [SA12]; ‘Reach out to them – let them know
you care.’ [SA20];
‘have a non-judgemental approach.’ [E224];
‘Show them compassion,’ [Vic129];
‘Listen without judgement.’ [SA54];
‘Be there for them if they wish to talk about it.’ [SA34]; ‘Listen and be there for them,’ [Vic21];
‘Reassurance and non-judgemental support.’ [Vic147]; ‘Making sure they understand that
mental illness is just like any other illness.’ [T202];
‘Treat them with respect.’ [SA19];
‘Trust and non-judgemental approach.’ [D114];
‘Listen without judgement.’ [K451];
‘Get them involved in music and hobbies.’
Treat MH patients the [Vic113]; ‘Not treating the person any differently,’
same as patients with [L012]; ‘Not changing the way you view them.’
other illnesses [F220]; ‘
Treat with respect ‘Treat them with respect.’ [SA19];
‘Show them respect.’ [C223];
‘Show them respect.’ [E442]
Raise community MH Awareness of signs and ‘Recognise the warning signs.’ [H112];
literacy symptoms of MH ‘Encourage MH patients to reach out for help.’ [SA55]; ‘Community should keep a constant
watch and look out for any unusual behaviours.’ [SA109];
Raise awareness of MH ‘Reduce the “weakness” image of MH (footballers talking about it etc.’ [SA161]
Improve two-way com- Support of family and ‘Being able to talk to someone about it.’
munication channels friends, community [A253]; ‘Have someone to talk to.’ [P133];
and workplaces ‘Sympathetic people to talk to.’ [SA44];
‘Talk to someone.’ [Vic12];
‘Being a friend—listening, not accusing, accepting, don’t tell them to snap out of it.’ [SA172];
‘Independent person to talk to.’ [SA127];
‘Being able to talk to someone in a safe environment.’ [R290];
‘Friends and family need to know how to support the person.’ [SA43];
‘Having a group hobby so they’re around others.’ [SA21];
‘Have a good support network.’
[SA22]; ‘Support of friends and family,’
[Vic38]; ‘Friends and family support.’
[Vic16];
‘Encourage them to talk about it to reduce isolation.’ [Vic122];
Accessible professional Accessible professional ‘Someone to listen to them and provide advice.’ [Vic119]
help and support help and support ‘They need medical care and support, not necessarily just talking to people.’ [O311];
services services ‘Use the services available and talk to counsellors.’ [D103];
‘Therapy and family support.’ [F253];
‘Talk to a medical professional about problems encountered or recommend services avail-
able.’ [SA1];
‘Social workers, GP, psychiatrists.’ [SA4];
‘Medical support and support organisations such as Beyond Blue, helplines etc.’ [SA8];
‘Doctors.’ [SA8];
‘psychiatrists, psychologists, local GP.’ [SA28];
‘Health professional support.’ [Vic77];
‘Professional help such as counselling.’ [Vic133];
‘Support from doctors.’ [Vic146];
‘Workplace support.’ [SA7];
‘Helpline sand easier availability of psychological support.’ [L311];
‘Easy access to support services.’ [SA6];
‘24 hour care and advice.’ [SA15];
‘Employers that are understanding.’ [SA127];
‘More support from the government and more funding for specialists etc and to reduce dis-
crimination in healthcare insurance.’ [SA130];
‘Communicate where they can seek help, how to access it, and who to contact.’ [Vic132]
Educate people living Self-care ‘Think about yourself, take care of yourself.’ [SA128]; ‘Undertake regular exercise.’ [Vic81];
with mental illness to ‘Take time for reflection.’ [Vic106]
self-care
 8 Singleton et

Table 4. Participants’ opinions of the role community pharmacists can play in supporting PLMI.

Themes Sub-themes Representative quotations

Someone they Caring, non-judgemental ‘Building relationships—asking if person OK—how they are feeling?’ [SA78]; ‘Not much but
can talk to attitude maybe just show a bit more empathy.’ [T152];
‘Be there for the patient & show empathy & understanding.’ [SA41];
‘Provide a place where patients can safely ask questions & their opinions are respected.’[SA46];
‘Be non-judgemental if someone approaches them for help.’ [Vic128,144]; ‘Help them under-
stand mental health is not their fault.’ [P081]
Good listener ‘Could be someone that you can talk to, if it is part of your daily routine while you are picking
up medications (without being judged).’ [S112]:

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‘Having discussions about meds, picking up signals.’ [SA59];
‘They are pushed for time but could have a chat to them when they pick up their medications.’
[Vic108];
‘Provide them with support throughout their MH journey.’ [Vic143];
‘Have a chat when they pick up their medications.’[Vic112]
Approachable ‘They have good relationships and go out of their way to help where they can.’ [SA77];
‘Presentation to staff (welcoming), personalise counselling to patient, getting to know patient
more.’ [SA37];
‘Being approachable.’ [A132]
Medication ‘Review their medication and provide consultation.’ [F222];
supply and ‘Educating patients on their medication and the use of them to manage their depression.’
counselling [B252];
‘Significant role in describing how to take medications correctly.’ [J203]; ‘Medicines
counselling, issues with medicines.’ [SA4];
‘Medication supply.’[SA24,SA99];
‘Medication management.’ [SA24, SA99]; ‘Medication supply and counselling.’ [Vic10,14,15,16
,18,19,21,22,23,24,26,28,29,31,34,35,40,110,111,118,119,123,127,133,134,141,142,144]
and [SA22,45,67,88]
Referral point Be a safety net or referral ‘Provide information on what services are available.’ [SA46];
point ‘Direct patients to support services.’ [SA22];
‘Tell them about available resources.’ [SA82];
‘Advertise where to get help.’ [Vic121];
‘Be the link between them and the support services.’ [F241];
‘Supporting the doctors and specialists.’ [SA100]
Education & Education & health ‘Be aware of depression and counsel if necessary.’ [K012];
health pro- pro- motion ‘Monitoring potential signs of depression.’ [R033];
motion ‘Recognising signs and offering support.’ [S132];
‘Being able to recognise symptoms when person is in pharmacy.’ [SA35]; ‘Should have an un-
derstanding, someone should be skilled.’ [SA43];
‘Getting to know consumers and asking R u ok?’ [SA98]
No role Unsure ‘No idea how pharmacist can help.’ [SA38,96];
‘Don’t know how a pharmacist can help.’
[SA57]; ‘Not aware of a role.’ [SA73];
‘Unsure.’ [SA16,19;
‘Not sure.’ [W101]
No role ‘They cannot do much apart from supply medication.’
[SA9]; ‘Waste of time for pharmacist to be involved.’
[SA27];
‘Pharmacists don’t have a big role unless background in mental health.’ [SA28];
‘I don’t think it’s their job really.’ [M066];
‘Not the pharmacists role.’ [SA33];
‘Pharmacist won’t be able to do much except provision of medicines.’ [SA39]; ‘Pharmacists are
not qualified.’ [SA88];
‘Hard for Pharmacist to have a role.’
[Vic105]; ‘Can’t fix it with tablets.’ [Vic102]
Never considered ‘Never thought about it. Medication counselling and dispensing?’ [SA2]; ‘Never thought about
pharmacists having a role it.’ [SA5]

necessary, as currently, even large MH organizations such as Despite being aware of various national MH awareness
Beyond Blue fail to acknowledge pharmacists as a viable campaigns, participants were less actively engaged. This
sup- port option on their website. study highlighted that the community lacked awareness of
what pharmacists can offer to support people living with
MH conditions. Pharmacists also need to be included in
Conclusions national MH awareness campaigns to highlight their role as
In summary, this study has highlighted that the public can capable and accessible healthcare professionals, beyond
confidently identify the common symptoms of depression. their tradi- tional role of dispensing medications.
 Community pharmacists in mental health 9
Supplementary data 5. Park NS, Jang Y, Chiriboga DA. Willingness to use mental health
Supplementary data are available at International journal of counseling and antidepressants in older Korean Americans: the
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