This study identified that only 11.2% of student participants had completed MHFA training of which three-quarters were from a single institution. Of those who had completed MHFA, the majority would recommend pharmacy students to undertake MHFA; and of those who did not, most welcomed the opportunity to participate in MHFA. Generally, students did not deem mental health to be fully integrated across the MPharm. There was evidence of focus on neuropharmacology, with less focus on simulated clinical application or communication. Students gave mixed views of self-reported preparedness relating to mental health, with those students having completed MHFA reporting higher levels of preparedness.
Interpretation
The teaching focus in mental health appears to be towards neuropharmacology or therapeutics, rather than problem solving or communication. This corroborates with a 2013 study of mental health curricula in UK pharmacy schools, where 89% of graduates stated that they did not learn specific communication skills related to mental health in their degree [10]. A small study at a single university reported in 2018 [19] found that 36% of pharmacy graduates were satisfied with university training on mental health. This suggests little progress towards parity of esteem with physical health teaching, in the intervening years. This is likely to result in a disparity in practice. Inadequate coverage of mental health education in curricula for healthcare professionals is an example of structural stigma which needs to be addressed at a leadership level in pharmacy education.
The publication of a Mental Health Competency Framework for Pharmacy Professionals, by Health Education England in 2020, implies that a deficit in mental health exists amongst generalists [20]. Communication is specifically one of the six competency domains described in this Framework. Another domain relates to attitudes and beliefs, thus incorporates stigma. In this study, students indicated a high level of perceived stigma relating to mental health problems, but there was no attempt to measure their personal level of stigma. Perceived stigma is important to understand because it may be a factor in the provision of mental health care by pharmacists even in the presence of positive personal attitudes [21]. Whilst some studies have been quite small, there have been suggestions of a reduction in pharmacy students’ stigma towards mental health owing to MHFA [14], as well as inclusion of a mental health elective [22], and use of contact-based strategies [23, 24]. Integration of MHFA into the pharmacy degree at the University of North Carolina did not influence students’ stigma or attitudes, but did result in increased empathy and self-efficacy, compared to before training [25].
Students who participated in MHFA reported a greater level of preparedness than those who did not, consistent with a recent evaluation of MHFA training involving pharmacists, technicians and students in the USA [26]. In the 12 identified studies of MHFA training of university students of all disciplines, the majority of evaluations were of participants’ self-reported measures [9]. Extensive work in pharmacy students in Sydney has shown that self-reports often overestimated ability to provide MHFA, compared with observed performance [16]. This was especially true in relation to asking about suicide. Furthermore, the value of practising MHFA skills with people with lived experience was identified [27]. These could be important pillars to include in any assessment of the impact of MHFA training, beyond self-reported measures. The initial motivation for roll-out of MHFA in medical and nursing students was a self-care initiative [28]. The potential benefit on self and peers was recognised by students’ qualitative comments in our study, too.
There is a challenge in interpreting the findings, as it is difficult to determine if the benefits for preparedness for practice are attributable to MHFA as an intervention, or the teaching and learning culture that supports the inclusion of MHFA. In one university, for instance, the involvement of patients and carers in curriculum design advocated the inclusion of MHFA in the context of an integrated approach to mental health education. A recent study of medical students indicated that integrating psychiatry in curriculum design decreased stigma and increased understanding of mental health [29]. An integrated model for mental health education in pharmacy was not the most common approach found in the study by Rutter et al., but was seen adopted more in newer schools [10]. These findings suggest that a modular approach is still prevalent. The influence of pharmacists who have previously worked in mental health, or are in patient-facing practice roles, may also have a bearing on curriculum design and the approach to teaching and learning. This was an aspect that Rutter et al. considered and reported that 8 out of 19 Schools of Pharmacy employed pharmacists who had previously worked in mental health [10]. Aspects such as competing priorities and cost considerations likely influence choice to include MHFA, and staff who are strong advocates for mental health may direct choices. Diversity in the culture of mental health education may exist between universities. This will have an impact on the inclusion of MHFA within the context of the overall curricular design and the approach to teaching and learning, and requires further exploration.
The answer to improving mental health education is unlikely to be as simple as to increase content, nor is this practical with busy curricula. Students have identified that the nature of the teaching is important, and that they require more communications training, experiential learning and interprofessional education. The UK Pharmacy regulator [30] requires each of these, but the findings infer that a greater emphasis may be needed, albeit a challenge in the current funding model. Patient involvement in mental health education has been acknowledged to be influential, but has been reported as minimal [10, 31]. All these approaches are likely to be important.
Strengths
This study was conducted by researchers with a shared interest in mental health from across the UK and Ireland, with experience in education and clinical practice. The multi-centre study obtained the views of students from 13 universities (out of a possible 32) and across multiple years of study offering greater generalisability than studies involving single universities. The input from staff helped contextualise the findings. A considerable amount of qualitative data was generated, which was invaluable for interpretation of the quantitative findings.
Limitations
The analyses and interpretation of the data have limitations. The total number of students is unknown, and therefore it is not possible to calculate a response rate. Some students may have intended to participate, but missed out due to the short study window (2 weeks) and no reminder. Responses will be influenced by MPharm level, with 1st year students having only 6 months of study. These students would not be placed to comment on the whole curriculum, and level of preparedness for all aspects of practice would be expected to be low. However, over 70% of participants were in year 3 or above, hence they should have had reasonable experience to draw upon. Skewing of students later in the course could have confounded the observed relationship between MHFA training and increased neuropharmacology teaching, as both may occur later in the course but not a consequence of one another.
The comparisons of students who had completed MHFA versus those who have not should be interpreted carefully for two reasons. Firstly, the MHFA group was small (n = 26) thus affected available comparisons and associated precision. Secondly, this group was homogeneous, with three-quarters attending a single university. This could conflate the value of MHFA with the environmental culture of the undergraduate degree, as previously discussed.
It was the intention to compare student responses relating to MHFA and curriculum to an overview provided by staff at that institution. This is why only one member of staff per institution was invited. This was not completely possible because data from both parties were only provided for nine institutions, with only a few student responses received from many of them. Instead, staff data have served a purpose to contextualise some of the findings. This has been interpreted with the caveat that staff may present a positive slant.
