Understanding the provision of a clinical service in mental health and the role of the pharmacist: a qualitative analysis

Pharmacists have important roles in mental health disease; however, their performance in Brazilian Psychosocial Care Centers (CAPS) is unknown. This qualitative study was conducted in a CAPS, Brazil; using interviews and analyzes from the perspective of Bardin, in which categories arising from the perceptions of patients and the health team emerged in relation to the provision of the medication review with follow up (MR) service and the role of the pharmacist in mental health. According to the participants, the MR service is essential and important because it allows professional recognition, beyond the identification of professional attributes of the pharmacists. Moreover, there was a duality in the pharmacist’s role between the logistic and clinical attributes of mental health. Thus, this perception helps to elucidate the pharmacist’s process of work in mental health and supports future strategies of action in this area.


Introduction
There has been an increase within the past decade on the number in mental disorders, mainly for depressive and na anxiety disorder 1,2 . Thus, we are currently living in an era in which mental health is a health global priority 3 .
In Brazil, research carried out by the World Health Organization showed that the country leads the prevalence of anxiety disorders worldwide, being the fifth in diagnoses of depression 2 . Given this scenario, the Brazilian Psychiatric Reform was implemented, contrasting with the model of care centered on internment/reclusion and creating new substitute services as Psychosocial Care Centers (CAPS) 4 . These services form the so-called mental health care network (RAPS) in Brazil, which involves everything from the family health strategy to psychosocial care centers [4][5][6] . Therefore, CAPS is a fundamental substitute service within RAPS, having been designed to respond to the main care needs of patients who suffer from severe and persistent mental disorders 4 .
From 2002, different types of CAPS began to be created in Brazil, with the objective of serving populations with specific needs. Thus, CAPS-I were created into the SUS health network, to provide care to children and adolescents, CAPS II and CAPS-AD, to assist patients with problems related to alcohol use and substance abuse 5 . The CAPS are based on multidisciplinary teams prioritizing the implementation of community-based mental health services and actions 5,6 . These teams have doctors, nurses, psychologists, social workers, occupational therapists, and sometimes other professionals such as pharmacists 6,7 . However, the presence of the pharmacist in the CAPS is not mandatory, being frequent only in the units that have pharmacies that distribute psychotropic drugs 7,8 . It is known that, mainly in the area of mental health and in CAPS that many pharmaceutical services are limited to the distribution and dispensing of medicines 7,8 .
There has been a growing involvement in patient management with mental disorders through the provision of the other professional services 9 . However, there seems to be a lack of patient awareness of pharmacists' full scope of practice, mainly in Brazil 10,11 .
There is positive evidence of the effects of pharmacist integration into healthcare teams through pharmaceutical interventional to people with mental illness [12][13][14][15][16] , include services as medication review with follow up (MR), as well as the provision of advice and training to other health care professionals within the interdisciplinary health teams.
There seems to be a paucity of qualitative studies exploring the perceptions and experiences of patients and health professionals regarding the role of pharmacists in mental health 12,15,[17][18] . Thus, when proposing a new service (MR), in which the pharmacist works collaboratively with the health team to provide mental health care, it was necessary to understand the perception of professionals and patients involved in it.
Therefore, the aim of the study was to develop deeper understanding, from patients' and health professionals' perceptions, about the provision of MR services and the role of the pharmacist in mental health in CAPS.

Methods
This was a qualitative study using semi-structured interviews between 2016 and 2018 and content analysis, following the recommendations and applying items of the Consolidated Criteria for Reporting Qualitative Research (COREQ) 19 .
Primary Health Care Services are linked to Psychosocial Care Centers in a Psychosocial Care Network in the context of Brazilian National Health System (SUS) 20 . The setting of this study was a Psychosocial Care Center (CAPS II), in the city of Mossoró-RN, Northeast Region, Brazil. The health team involved in this study consisted of a psychiatrist, two social workers, a nurse, a nursing assistant, a psychologist, a pharmacist, and an occupational therapist. The CAPS II are the main adult outpatient care units for users of mental health services.
The provision of MR, an intervention study, was conducted by the PhD Researcher (a pharmacist). This service was characterized as being an ongoing and structured assessment of the patient's drug therapy aimed at detecting drug-related problems in order to identify, prevent, and solve negative outcomes related to medicines 21, 22 . The pharmaceutical monitoring was carried out using the Dáder Method 21 , which is based on collecting and analyzing information about the patient's health and the pharmacotherapy used. As a result of this analysis, a care plan was established and interventions to improve patient's health start 21 . It is worth mentioning that the MR was not part of the service's work routine before the present research, and the attributions of the pharmacist at the site were still largely linked to technical managerial practices.
The sample consisted of 52 patients, all of whom received the services mentioned above and were followed for four months (one meeting per month). Patients were invited according to these inclusion criteria: Adults (20-60 years old), with diagnosis of depression or some anxiety disorder (ICD-10) [23][24][25] . All the patients included were duly informed about the purpose of the study and signed the Free and Informed Consent Form before any procedure.
The influence of the MR in outcomes as treatment adherence rate, anxiety and depression rates (clinical parameters), and quality of life (humanistic parameters), were assessed through instruments coming from existing studies. For instance, the Morisky Green Levine Test was utilized to measure treatment adherence rates, the Beck Anxiety Scale to anxiety symptoms, Beck Depression Scale to depression symptoms and EQ-5D-3L was utilized to quality of life. In addition, specific forms of the Dáder Method were used in the provision of the MR 21 .
Regarding the health team, the selection was made by convenience. Despite being invited by the eight team members of the team who worked at the CAPS, there was a refusal by the psychologist (lack of time), the doctor (work overload), the pharmacist (absent from the service during the interview period) and the assistant nurse (sick leave during the study period). Thus, four participants accepted our invitation to respond to the questions (one nurse, two social workers, and the director of CAPS), totaling 56 participants of the study.
At the end of follow-up (the fourth and final meeting), participant patients and health professionals were asked just two open-ended questions: 1. "What did you think about the medication review with follow-up service?" 2. "What do you know about the pharmacist's role in mental health?" Given the profile of the patients, were chosen only two short and objective questions in order to be more convenient. The interviews were conducted only at the last provision meeting of the MR, one patient at a time.
Following the recommendations of the COREQ all the answers were recorded by the PhD researcher (36 interviews) or the assistant PhD researcher (20 interviews), in a private room of the CAPS, without the presence of another person 19 .
The audios of the interviews were recorded in digital format and transcribed in full detail and precision by UP SOLUTION® Company. The PhD researcher checked all transcripts to validate the consistency.
Interviews were analyzed using content analysis, in which reports are organized into categories and meaning cores 26 . Cross-validation of the data of the categories, which was done to confirm the interpretation of the themes, was undertaken by two researchers (R1 and R2), who independently analyzed the transcripts. In cases of disagreement, a third investigator was involved (R3), and subsequently a careful review by a senior evaluator (R4) was performed. The transcripts were not returned to the participants for comment and/or correction, and the participants did not provide feedback on the findings. All cores of meaning presented and analyzed in the results and discussion must answer the following research questions: "What is the perception about the medication review service?" and "What is the perception about the role of the pharmacist in mental health at CAPS?" Data analysis was done inductively, and the results emerged from the data. Therefore, the categorization was made using the criteria of pertinence (which answered the research question) and similarity (specific similar themes were grouped). The nuclei of meaning (specific, descriptive, concrete) were then classified, naming the categories (more theoretical, abstract themes that brought meaning there) and regrouped by similarity.

Results and discussion
Interviews comprised a total of 90 minutes of audio for interpretation and posterior cross-validation. The Figures 1 and 2 were made with categories derived from the participants' responses after the analysis. There was a lack of meaning in the categories: "Quality in the interpersonal relationship" in the Health Team, "First contact" and "Professional Recognition" in Patients. This was because these two themes did not generate demands for more specific categorizations, as no data emerged that were specific to the point that there was a need to categorize them in detail.

Perception of the Medication Review with Follow-Up Service
The analysis of the perceptions of the health team [HT] about the medication review with a follow-up of patients generated a category of "quality of interpersonal relationships" (Figure 1) "…the question of the patient talking to the pharmacist [who does not speak to other health professionals] shows an excellent rapport" [HT1].
The MR service aroused a category "positive feelings" on the patients who expressed satisfaction, gratitude, a desire to continue the service, motivation, happiness, love, knowledge exchange, and welfare ( Figure 1). Participants highlighted their feelings towards the services: "... very happy, especially because you remembered the times I came to the doctor and made my medication schedules" [P18] (happiness). "…aroused in me the desire to decrease the dosage of drug" [P13] (motivation).
In addition, the "first contact" category came from the fact that many patients did not know of this kind of service and answered that it had been their first experience "...I had never been through this before." [P12]. Another thematic nucleus originated from the patients' perception was the "identification of the characteristics of the service", in which it was identified as having many questions, as well as providing trust and confidentiality. "...I did not have the courage to tell others, but I ended up talking to you..." [P6]. Lastly, the category of professional recognition also emerged through professional and personal praise: "...you (PhD researcher) gave me better assistance than anyone here" [P18].
The "importance of the service" and "identification of the pharmaceutical attributes", emerged through the perception of both (team and patients), (Figure 1). In the perception of the team, the importance is linked to the essentiality of the service. "... it is essential that we have the pharmacist" [HT3].
Furthermore, the team considered the MR important because it was meeting the demand of patients who had difficulty understanding the treatment, helping patients use the correct dose and elucidating the intrinsic responses to the treatment, beyond to helping them with adverse reactions and side effects. One respondent (member of the health team) said: "...sometimes you have a medication, but you doubt if you can replace it or not, but the pharmacist, who is a professional who has been trained to do so, is the one who will give the answer" [HT4] (difficulty understanding).
Regarding the perceptions of patients, the service was believed to be important because it impacted patient outcomes, with self-perceptions of health improvement (clinical and economic), improvement of medication knowledge, and behavioral changes. A patient said: "…I have a good improvement...every time I attend this meeting I feel good" [P14] (self-perception of health improvement [clinical]). "...The generic medicine that I did not buy, I started taking, until that I saved" [P5] (selfperception of health improvement [economic]).
Both groups identified "the attributes of the pharmacist" through the follow-up ( Figure  1). In the perception of the team, these attributes were patient counseling, team support, patient's motivation and follow-up. "… It is extremely important in the institution to support the rest of the team" [HT3] (team support). "…The pharmacist always takes away the patient's doubts about the medication" [HT4] (patient counseling). "…A very good incentive for patients" [HT2] (patient's motivation). "…The patient's pharmacy needs a follow-up like what happened here" [HT4] (follow-up).
For patients, these attributes were patient counseling and medication adherence management. "...She helped me a lot to organize myself, having a scheme ready here, with all the hours, facilitated the right treatment" [P19] (patient counseling.). "...I was very happy because you reminded me of the time to take the medicines" [P18] (medication adherence management).

Perception of the Pharmacist Acting in Mental Health
Through the speech of the health team, the category "non-recognition of the pharmacist's clinical profile" was observed. For them, the pharmacist was defined as a professional who is present only to comply with legislation, who in essence was focused on the logistics of dispensing and managing medications (Figure 2). A member said: "… there is that pharmacist because you have to register that delivery and that's it" [HT1].
Moreover, through some members of the team, the theme "expanding the pharmacist's role in mental health" was generated with a focus on changing from dispensing and managing medications to the patient and expansion of the practice setting. Another health team member said: "...The role of the pharmacist in psychiatry must be directed to the population, one cannot be alone in a pharmacy, has to be in contact with the patients." [HT2].
As for the pharmacist's action on mental health, the following emerged through patients: "different levels of knowledge" and "view on the pharmacist after the service was offered". ( Figure 2). Patients presented different levels of knowledge regarding the pharmacy profession. One patient said: "...I do not know anything" [P1].
The "view on the pharmacist after the service was offered" was recognized as not only being focused on the logistics of dispensing and managing medications, but also as being focused on the patient, the latter perception being built after the offer of the MR "…Only now I am having clarification of the pharmacist's role in the face of these medications, in this CAPS follow-up" [P11].
Both the team members and patients elucidated, through their speeches, the "recognized the duties of the pharmacist". In regard to the team, this recognition was through patient counseling, team support and follow up (Figure 2). A member of multidisciplinary team reported: "...The pharmacist is very important in a pharmacy, especially here in CAPS, because I don't know much about medication" [HT2] (team support).
Patients also recognized the duties of the pharmacists in patient counseling. "... It is that person to accompany us with the medicine ...to know how the medication is, if it is taking the correct" [P33]. However, they recognized the professional also as pharmacy technical manager. "…The contact I have with the pharmacist is just to take this medication, but no talk" [P11].

Perception of the Medication Review with Patient Follow-Up
The health team felt that the service improved quality in interpersonal relationships through dialogue and excellent communication. For the pharmacist, taking a role in the mental health care area demands more than just technical competence. Dialogue and humanization are important factors for the professional to develop an understanding of the use of drugs from the perspective of each patient [27][28][29] . The patient's participation in the decision-making process treatment is fundamental, and imposing decisions of treatment for mental health without a good relationship and patient consent can generate patient resentment, affecting the outcome 30-32. The service of MR aroused positive feelings in patients. The mental health is highly subjective and many patients report prejudices and stigmas from the health professionals themselves or even from themselves in relation to their mental disorders 33 . In fact, mental health stigma can interfere with the professional practice, generating negative feelings and constituting a significant obstacle [33][34][35] . Fortunately, in this study, good relationships were cited as a component of the service by the health team that was essential to establishing a close therapeutic relationship with the patients, which provided a positive perception of the service.
Many patients reported a first contact with the MR. In fact, government agencies and international institutions have supported and encouraged the introduction of pharmacists into multidisciplinary health care teams in mental health 9,36,37 . However, in Brazil the pharmaceutical interventions in the clinical area in CAPS are scarce and mostly unknown by both patients and the health team 16 . There is also a lack of knowledge and clinical skills in mental health 16,38,39 , which may influence the lack of defined work processes of the professional in this area 16, 40 .
The patients recognized that the service was characterized by confidentiality and confidence. One of the themes cited by pharmacists in analyzes of their experiences with people with mental disorders was precisely the "importance of a relationship with their patients based on trust, confidentiality and privacy", which are a necessity on relationships with vulnerable groups 28,41,42 . The provision of follow-up allowed the construction of therapeutic bonds, and in fact, the patients needed to know that this professional was someone they could talk to without being judged 41 .
The health team and the patients acknowledged that follow-up was important. The health team believes that it is essential to have the services of a professional pharmacist in a mental health service. This may reflect the absence of this service previously at CAPS, since the "standard" activities of the local pharmacist were restricted only to technical-managerial issues. Indeed, the essentiality is because the pharmacists are part of a multidisciplinary health care team supporting with their expertise the drug therapy of the patients 16, 17 . In fact, physicians, patients and health leaders perceived the pharmacist as an essential source of expertise to patients using antidepressants 17 .
In regarding patient perceptions, the service was important because it influenced the self-perception of health (clinical and economic improvement). Medication reviews, in a variety of settings, showed positive impacts for patients, which also include economic savings in various specialties and levels of healthcare 22,43,44 . The economic improvement reported by patients is very important, given that their socioeconomic profile shows that 64.3% have low income (1 to 3 minimum wages). In addition, only 15.71% of them were able to purchase their medication for free at CAPS (results from other articles).
It is noteworthy that studies of patients have reported behavioral transformations linked to the importance of the service offered. When there is weakness in the therapeutic bond established between pharmacists and depressed patients, they show resistance in sharing information due to lack of trust 41 . Thus, the confidence factor directly interferes in obtaining better outcomes with consequent self-perceived improvements in treatment.
Components such as identification and resolution of DRPs and improvement of drug knowledge were also identified, respectively, by the health team and patients. Really, several studies show new pharmacists' roles in mental health within multidisciplinary teams, such as the early detection of mental health conditions, development of care plans and pharmacotherapy follow up [45][46][47] . Also, there are studies of patients with mental illness showing that pharmacists contribute to the achievement of therapeutic goals like medication adherence, treatment satisfaction and reduction of depressive and anxiety symptoms [48][49][50][51] .
In both groups, attributes of pharmacists were identified. Patient counseling was an attribute recognized by both patients and the health team. In fact, pharmacists are among the health professionals that are most accessible to patient counseling, with a potential to optimize the outcomes of those using antidepressants and to advise their patients more than doctors do 15,22,52 . The role of the pharmacist can influence the mental health of the actions of pharmacological counseling even when examining aspects not related to the patient's drug therapy, and thus should include active engagement with non-medication responsibilities 42 . It is also worth mentioning that the research participants had a low level of education (37% with elementary education; results from other articles), in which case, the improvement of drug knowledge is essential for obtaining good clinical outcomes.
In fact, educational interventions, in addition to others, are positively related to improved long-term adherence in the treatment of adults under various clinical conditions 22,46,48 . It is important to point out that one of the objectives of the MR with follow-up was the provision of educational interventions (health education). Really, with regard to the number of total medications used daily, there was an expressive prevalence for the practice of polypharmacy among users (data from other articles). Thus, such service components as trust-based, confidential counseling and dialogue (MR characteristics mentioned) were certainly factors that are interconnected in the service provided, and that favored the adherence management as an attribute of the professional.

Perception of the Pharmacist Acting in Mental Health
The health team did not recognize the pharmacist's clinical profile in mental health. The team quotes that the professional's focus is only on drug logistics and compliance with legislation that requires him to serve in the pharmacy's CAPS. Really, pharmacists need to work to improve their potential in the area of care, and there are several factors that explain why their actions are limited to the technical-managerial part. Interface (Botucatu) https://doi.org/10.1590/Interface.200788 Pharmacists in interviews with professional colleagues pointed out that the main barriers in implementing MR in establishments are the lack of time related to excessive workloads and an insufficient number of pharmacists and support professionals, leading them to prioritizing non-care activities of the patient 22,40 . In public health units in Brazil, barriers to implementation of the clinical service were related to the health team itself (lack of interaction), to pharmacists themselves (work overload, lack of education for the clinic, lack of previous experience), to service implementation (the short period of service implementation, lack of infrastructure) and to patients (lack of knowledge of the activities of the clinical pharmacist) 16,28,53 .
In CAPS, unfortunately, there is minimal or almost no action by pharmacists in the provision of direct patient care, as well, the subjection of these professionals to political and bureaucratic interests is known 16 . Thus, the fact that the team considered the expansion of pharmaceutical actions in mental health to be necessary is explained. Really, pharmacists are recognized as "passive" and "peripheral" in providing for their patients' mental health 42 .
The patients showed different levels of knowledge about the pharmacist in mental health. The pharmacist does not yet have social recognition in mental health care 16 . The existing idea is that the most important part of the pharmacist's activity is in its technical part, without a wider vision of pharmaceutical care, mainly due to lack of a defined working process, coupled to a doctor-centered health system as the primary care provider 15,16,22,54,55 . Thus, a more proactive role of the pharmacist in outpatient psychiatry becomes urgent.
In addition to the insecurity of many professionals due to the lack of training in the provision of mental health care, many of the pharmacists have negative beliefs in relation to mental disorders, which can result from the lack of knowledge of care in the area 7,56,57 . Thus, it is necessary to rethink the pharmacist's professional training to work in mental health since graduation and to conduct training for pharmacists into the CAPS, in order to increase the quality of services offered.
The collaboration among health professionals is a positive factor in the acquisition of better clinical, economic, and humanistic outcomes and, in the present study, team support was recognized as one of the pharmacist's duties by health team and patients, and as constituting as an attribute of the professional by the health team 22,28 . Despite this, in a research on procedures related to psychosocial care in the SUS, no pharmacist was identified as effectively inserted in the health team 16 , and these professionals do not feel supported in the provision of care services either by the team or by the patients themselves 38 .
Counseling, considered a professional attribute, was also a duty recognized by the health team and patients, and has been associated with improved several outcomes 15,44,58 . However, a review revealed wide variability in the components of pharmacist counseling, for there is no standard definition regarding such counseling, making it necessary to build standardized models 59 .
Finally, the "patient follow-up" also emerged as an attribute and duty considered by the team. Despite the MR being a relatively "new service, it was noticed with the present study a "break" of a traditional model of the pharmaceutical professional established in the CAPS, which was also perceived by the patients after the provision of the MR. In fact, the care practiced by a pharmacist establishes new standards of practice with the patient as the central axis of the philosophy of this practice. This paper has some limitations: 1) The physicians' and pharmacists' perceptions of the CAPS were not analyzed. 2) The pharmacist researcher that offered the service conducted the interviews with some participants, which may have induced them to give predominantly positive responses about the service. 3) The MR service did not remain in the CAPS's organogram, being restricted to the period of study.

Final considerations
By understanding the perceptions of patients and the health team of CAPS, they identified the medication review with follow-up as an important pharmaceutical service in CAPS. In addition to generating professional recognition of the pharmacist and positive feelings in patients, the service allowed the identification of previously unknown professional attributes. Furthermore, for the first time, the components of the MR work process in CAPS were identified. This study allowed us to compare the perceptions of the health team and the patients, as well as to identify the similarities between them. Regarding the role of the pharmacist in mental health, a duality between logistic and clinical pharmacist attributes was noted; however, after the service was offered, patients and the health team began to recognize the clinical attributes of the pharmacist more.
Thus, the perceptions of patients and the health team were essential to understand the components of service and development that are part of a model of the pharmacist's clinical work process in outpatient mental health. These results show that it is possible to develop a model of the pharmacist's clinical work process in mental health and to stimulate pharmacist participation in mental health care on the health team.