The role of pharmacists in managing mental health disorders: a review

The role of pharmacists in managing mental health disorders: a review Simeonka Dimitrova1, Gabriela Kehayova1, Mira Siderova2,3 , Stela Dragomanova1 1 Department of Pharmacology, Toxicology and Pharmacotherapy, Faculty of Pharmacy, Medical University “Prof. Dr. Paraskev Stoyanov”, Varna, Bulgaria 2 UMHAT “St. Marina”, Varna, Bulgaria 3 Faculty of Medicine, Medical University “Prof. Paraskev Stoyanov”, Varna, Bulgaria Corresponding author: Stela Dragomanova ([email protected]) Received 17 July 2025♦ Accepted 17 September 2025♦ Published 2 October 2025 Citation: Dimitrova S, Kehayova G, Siderova M, Dragomanova S (2025) The role of pharmacists in managing mental health disorders: a review. Pharmacia 72: 1–14. https://doi.org/10.3897/pharmacia.72.e165494 Abstract Pharmacists are participants in the treatment and management of mental disorders as integral members of multidisciplinary healthcare teams. Their roles extend beyond dispensing medications to providing counseling, promoting adherence, managing drug interactions, assessing treatment outcomes, and supporting symptom management—all while ensuring empathy and confidentiality. They face challenges such as nonadherence, communication barriers, and public stigma. Pharmacists manage complex drug interactions, particularly those between psychiatric medications and nutritional supplements. In hospitals, clinical pharmacists optimize therapy, monitor treatment effectiveness, and train staff in mental health pharmacotherapy. This article emphasizes the need for specialized training for pharmacists to enhance their mental health care competencies. Countries such as the USA, UK, and Australia have successfully implemented such programs, while Bulgaria is integrating mental health care into pharmaceutical practice, expanding the responsibilities of pharmacists and raising public awareness. These achievements highlight the essential contribution of pharmacists to improving mental health outcomes and addressing related challenges. Keywords depression, interdisciplinary collaboration, patient adherence, pharmaceutical counseling, psychotropic drug interactions, substance use disorders Introduction Pharmacists are an integral part of the treatment of patients with mental disorders, with responsibilities extending beyond the dispensing of medications. The classification of mental disorders includes a wide range of conditions that influence mood, cognition, behavior, and perception. This category comprises affective disorders, anxiety disorders, psychotic disorders, eating disorders, obsessive-compulsive disorders, cognitive disorders, as well as substance use disorders and disorders related to stress and trauma. Pharmacists play a crucial role in optimizing pharmacotherapy for patients, ensuring the safe and effective administration of medications for mental health issues such as depression, anxiety, bipolar disorder, and schizophrenia (Chen 2008; Rubio-Valera et al. 2014; Panesar 2016; Karolewicz et al. 2020). They conduct medication reviews to identify and address medication-related issues, manage polypharmacy, and monitor adverse drug reactions (Tai et al. 2014; Soubolsky and Halpape 2022; Khartabil et al. 2024). Copyright Dimitrova S et al. This is an open access article distributed under the terms of the Creative Commons Attribution License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Pharmacia 72: 1–14 DOI 10.3897/pharmacia.72.e165494 Review Article Dimitrova S et al.: Role of pharmacists as partners in the treatment of mental health disorders2 Pharmacists are uniquely positioned to act as the first point of contact for patients in crisis, especially when access to psychiatric services is limited. When identifying worrying indicators, they should provide emergency care guidelines, refer the patient to a doctor, or activate appropriate support networks (Rubio-Valera et al. 2014). Training in areas such as psychological first aid (PFA), de-escalation techniques, and ethics is critical for dealing with such situations. The necessity for motivation and psychological support is paramount in enhancing therapy adherence. Pharmacists employ strategies such as motivational interviewing, which requires specialized training. This approach enables pharmacists to build rapport and empower patients to make informed decisions regarding their treatment. Confidentiality and ethical considerations are of utmost importance, particularly in the context of mental health disorders. Patients often exhibit heightened sensitivity toward their personal information and health status. Therefore, pharmacists must ensure that discussions are held in environments that prioritize discretion and uphold the patient’s right to privacy. Stigma and lack of trust toward healthcare professionals, which can manifest as aggression or hostility, are significant barriers for patients with mental health conditions (Rickles et al. 2010). Such individuals frequently encounter stigma and discrimination, resulting in feelings of distrust and shame during interactions with pharmacists. This environment may inhibit their willingness to disclose pertinent information about their health or adhere to treatment protocols. It is essential that pharmacists are skilled in identifying early signs of mental health deterioration, including symptoms such as social withdrawal, confusion, mood swings, or expressions of hopelessness. This requires specialized knowledge in the field of mental health, as well as developed communication skills to allow for adequate assessment of the condition and the need for medical intervention (O’Reilly et al. 2010). The objective of this research is to examine the complex role of pharmacists in the management and treatment of individuals with mental health disorders, focusing specifically on the principles of pharmaceutical care, effective patient communication, and collaborative efforts across various disciplines. Methods This narrative review synthesizes literature published since 2000, evaluating the role of pharmacists in the treatment and management of mental disorders within multidisciplinary healthcare teams. A document from the World Health Organization, released in 1997, outlines the essential professional duties of pharmacists, which encompass effective communication, education and training, delivery of care, informed decision-making, leadership in transformation, and a commitment to lifelong learning. This document serves as the basis for defining the timeline starting in 2000 in our pursuit of publications pertaining to the topic. A detailed literature search was conducted across various scientific databases, including PubMed, Web of Science, ScienceDirect, Scopus, and Google Scholar. The search utilized combinations of the following keywords: “pharmacist” and “clinical pharmacist” alongside “mental disorders,” “depression,” “psychiatric conditions,” “substance abuse,” “mental health promotion,” “patient communication,” “psychotropic drug interactions,” “therapy adherence,” “counseling,” and “symptom management,” to ensure a thorough search. To enhance the search further, we manually examined the references of selected articles to uncover additional pertinent studies. We excluded studies where the pharmacist’s role was not directly associated with the themes of this article. The extensive search process yielded a considerable number of studies, which were subsequently reviewed and analyzed based on their relevance to the specific topics of interest. Results Main aspects The main aspects of pharmacists’ roles include counseling and educational services, facilitating adherence to therapy, identifying and managing drug interactions, assessing therapeutic effects, supporting symptom management, and providing confidentiality and empathy. Counseling and education Pharmacists deliver comprehensive counseling aimed at enhancing medication adherence while educating patients regarding their treatment regimens, possible side effects, and the significance of adherence (Tai et al. 2014; Panesar 2016; Shepherd et al. 2022). Additionally, they provide specialized education tailored to the unique needs of individual patients, which can greatly improve therapeutic outcomes (Soubolsky and Halpape 2022; Ashcroft et al. 2024). A key aspect to consider is that pharmacists are vital in the treatment and management of mental health disorders, serving as essential members of multidisciplinary healthcare teams. Within these teams, pharmacists engage in case conferencing, collaborative management of drug therapies, and the formulation of care plans (Rubio-Valera et al. 2014; El-Den et al. 2021). Their cooperation with other healthcare professionals, such as physicians and mental health experts, is crucial for delivering comprehensive patient care. Support for medication adherence A significant obstacle in the management of mental health disorders is the consistent intake of prescribed medications. Pharmacists play a crucial role in emphasizing the necessity of following the prescribed treatment regimen and providing encouragement to patients, particularly when the benefits of the therapy are not immediately apparent. Additionally, they can engage in discussions Pharmacia 72: 1–14 3 regarding effective strategies to enhance adherence, including the use of reminders and the establishment of suitable daily routines for medication administration. A scoping review conducted in 2023 revealed that interventions led by pharmacists—such as educational initiatives, reminders, and follow-up care—substantially enhanced adherence rates among mental health patients across community, hospital, and interdisciplinary environments (Syrnyk and Glass 2023). Detecting and managing drug interactions Pharmacists have the specialized knowledge necessary to recognize and address possible drug interactions, especially those that involve psychiatric medications alongside other medications prescribed at the same time. For instance, some antidepressants may interact with cardiovascular medications or pain relievers, which could require dosage modifications or heightened monitoring. By conducting thorough assessments and providing patient counseling, pharmacists are essential in reducing the risks linked to polypharmacy in mental health treatment (Spina and de Leon 2007). Monitoring the effects of therapy Pharmacists play a crucial role in overseeing the outcomes of therapeutic interventions. They assist patients in identifying both the beneficial and adverse effects of their treatment, thereby facilitating the attainment of the most effective therapeutic results. Additionally, pharmacists can recommend consultations with the prescribing physician for potential dosage modifications or a change of medication if the expected results are not achieved or if severe side effects occur (Soubolsky and Halpape 2022). Support for symptom management Pharmacists are positioned to provide alternative strategies for alleviating certain symptoms associated with mental health disorders and the adverse effects of treatments. This can include recommending supplements or offering lifestyle modifications that may enhance the overall well-being of the patient. Pharmacists frequently serve as the initial point of contact within the community and have the potential to contribute to the early identification of mental health concerns. They are capable of assessing patients and directing them to suitable care providers, thereby enabling prompt interventions (Shepherd et al. 2022; Ashcroft et al. 2024). Assurance of confidentiality and empathy Pharmacists need to maintain confidentiality and cultivate a trusting environment, allowing patients to share their experiences and concerns openly. Pharmacists encounter numerous obstacles, such as the stigma linked to mental health, lack of adequate knowledge, and conflicting priorities (Rubio-Valera et al. 2014; Panesar 2016; Ashcroft et al. 2024). The primary roles that pharmacists undertake when consulting with patients suffering from mental health disorders are shown in Fig. 1. Figure 1. The role of pharmacists in mental health support. Dimitrova S et al.: Role of pharmacists as partners in the treatment of mental health disorders4 Support for medication adherence Addressing the issue of patient non-adherence to prescribed mental health therapies presents a significant challenge for pharmacists. Their responsibilities extend beyond providing access to essential medications; they also play a crucial role in encouraging patients to comply with their treatment regimens by elucidating the significance and advantages of such therapies (Osterberg and Blaschke 2005; Syrnyk and Glass 2023). Effective strategies encompass establishing trust, fostering open communication, detailing the benefits and possible risks associated with the medications prescribed by the therapist, developing reminders and structured plans for consistent medication use, monitoring patient progress, and conducting regular follow-up appointments (Osterberg and Blaschke 2005; Brown and Bussell 2011). Motivational interviewing Pharmacists aim to establish trusting relationships with patients, which is essential for fostering open communication. By demonstrating empathy and neutrality, they create an environment where patients feel comfortable discussing their worries and challenges. This dialogue often encompasses obstacles such as stigma, adverse effects, or diminished motivation that can influence adherence to medication regimens. One effective approach employed by pharmacists is motivational interviewing, which empowers patients to engage actively in their treatment decisions. Through this technique, pharmacists facilitate discussions that allow patients to articulate their motivations for seeking improvement and to determine the continuation of their therapy. Regular consultation Pharmacists play a crucial role in educating patients about the advantages and potential hazards of medication use. They emphasize that adhering to prescribed medication regimens can significantly enhance patients’ symptoms and overall quality of life. Additionally, pharmacists highlight the dangers linked to improper or inconsistent medication intake, which may lead to worsened symptoms or complications arising from abrupt cessation of treatment. In instances where patients experience adverse effects, pharmacists are equipped to discuss strategies for symptom management and, if required, can refer patients to their physicians for adjustments in medication or dosage. This proactive approach aims to mitigate any hesitance patients may feel toward continuing their therapy due to negative experiences. Regular consultations between pharmacists and patients are a key element of modern pharmaceutical practice. These interactions aim not only to improve adherence to prescribed therapy but also to optimize clinical outcomes, reduce hospitalizations, and enhance patients’ quality of life. The most commonly used approach is the traditional one of conducting personal meetings in the pharmacy. This includes regular conversations with the patient during the receipt of medications and provides an opportunity to follow up on the therapeutic process and clarify any questions that arise. Another effective form is the planned outpatient consultation, in which the pharmacist offers specific times for individual meetings, similar to a doctor’s schedule. These methods assist the patient in correctly understanding the therapy, reduce the risk of medication errors, and ensure better communication. Studies have shown that patients who regularly receive pharmaceutical consultations demonstrate higher levels of adherence to therapy (Osterberg and Blaschke 2005). Furthermore, as technology advances, digital methods of consultation have also entered the market and are becoming a particularly useful alternative, especially for patients in remote areas. Telephone and video consultations have proven effective for conditions such as diabetes, hypertension, and mental disorders. A systematic review shows that digital interventions, including pharmaceutical telephone consultations, significantly improve adherence to therapy and lead to better clinical outcomes (Kruse et al. 2020). Reminders The involvement of pharmacists in the management of medication adherence is significant, as they assist in formulating reminders and schedules for the timely intake of prescribed drugs (Klang et al. 2015; McMillan et al. 2018). To promote adherence, pharmacists advocate for the use of mobile applications, weekly pill organizers, or the involvement of family members to bolster the treatment regimen. Furthermore, they often conduct regular follow-up appointments with patients to assess treatment efficacy and identify any required adjustments. This sustained support fosters patient motivation and enhances awareness of their treatment outcomes. Digital health initiatives are effectively enhancing adherence to treatment protocols among individuals with mental health disorders by improving the quality and accessibility of pharmaceutical services (Bhat et al. 2018; Bingham et al. 2020). Detecting and managing the interactions among psychiatric medications, other pharmaceuticals, and dietary supplements This aspect is a vital component of the pharmacist’s role. Pharmacists employ various strategies to mitigate the potential for adverse effects and to safeguard patient well-being (Freeman et al. 2010). To accurately assess drug interactions, pharmacists use specialized software and databases, such as Lexicomp, Micromedex, and UpToDate. These systems provide reliable information on the mechanism, severity, and clinical significance of interactions, as well as recommendations for their management (Vandenbroucke et al. 2012). Furthermore, to reduce the likelihood of adverse interactions, pharmacists evaluate not only the medications prescribed and their respective dosages but also consider individual patient characteristics, including age, weight, comorbidities, and Pharmacia 72: 1–14 5 lifestyle choices. This assessment is particularly crucial for patients with mental health conditions, who frequently utilize various medications and supplements, often without professional guidance. Pharmacists remain vigilant for indicators of such interactions, including dizziness, fluctuations in mood, sedation, or gastrointestinal disturbances (Moini and Ross 2019). A 2022 study shows that pharmacists significantly contribute to the detection of clinically relevant interactions that often go unnoticed in routine practice. The inclusion of a pharmacist in the multidisciplinary team improves the safety of pharmacotherapy and reduces the risk of adverse reactions in psychiatric patients (Joel 2022). Consultations about supplement use Pharmacists frequently engage in discussions about the various supplements and natural products that patients may be consuming, including St. John’s wort, omega-3 fatty acids, vitamins, and minerals. Of particular concern is St. John’s wort (Hypericum perforatum), which induces cytochrome P450 enzymes (particularly CYP3A4), reducing plasma levels of many psychotropic drugs. Additionally, when combined with antidepressants containing serotonergic mechanisms, there is a risk of serotonin syndrome (Izzo and Ernst 2009). Pharmacists actively inform patients about the risks associated with introducing new medications or supplements without prior consultation with a healthcare professional. Furthermore, several dietary supplements and herbal products can function as inducers or inhibitors of hepatic enzyme systems that are crucial for drug metabolism. For instance, St. John’s wort, broccoli, Brussels sprouts, cauliflower, caffeine, and essential oils derived from rosemary and garlic are recognized as inducers of CYP450 isoenzymes, potentially diminishing the efficacy of concurrent drug therapy (Izzo and Ernst 2009). In contrast, herbs such as ginkgo biloba, red grapefruit, valerian, hops, and milk thistle exhibit inhibitory properties and may result in the accumulation and possible toxicity of specific medications (Gurley et al. 2004). Consultations about combinations with other pharmaceuticals, including psychotropic medicines A variety of clinically relevant drug interactions have been documented, occurring at both pharmacokinetic and pharmacodynamic levels (Wijesinghe 2016). Lithium salts are recognized as pharmacological agents with a narrow therapeutic index. Classical neuroleptics, which interact with various targets, are also included in this category, alongside numerous other medications. Tricyclic antidepressants are associated with cardiotoxic effects in cases of overdose and are readily available, raising concerns regarding potential suicide attempts. Recent advancements in antipsychotic medications that have been integrated into clinical practice in recent years may interact with other psychotropic drugs or medications prescribed for concurrent physical health conditions. The majority of pharmacokinetic interactions associated with these newer antipsychotics take place at the metabolic level, typically involving alterations in the function of key drug-metabolizing enzymes responsible for their biotransformation, specifically cytochrome P450 (CYP) monooxygenases and/or uridine diphosphate-glucuronosyltransferases (Spina and de Leon 2007). Among modern antidepressants, selective serotonin reuptake inhibitors (SSRIs) present a risk for serotonin syndrome when combined improperly with certain foods, supplements, or other medications, and they may increase the risk of suicide in younger individuals. Furthermore, the concurrent use of alcohol with long-term pharmacotherapy can alter drug efficacy; alcohol acts as an inducer of drug-metabolizing enzymes with regular consumption, while it functions as an inhibitor when consumed in a single instance. Methodological strategy for advising on the combined use of different medications • Information collection and evaluation of herbal product usage. Pharmacists meticulously collect data regarding the patient’s consumption of herbal and alternative remedies, including St. John’s wort, valerian, ginkgo biloba, ginger, garlic, and melatonin. They assess the dosage, frequency of administration, and whether these products are being used in conjunction with prescribed medications. This information is essential for evaluating potential drug interactions. • Detection of possible interactions and hazards. Numerous herbal products have the potential to interact with antidepressants and other psychotropic drugs. For instance, St. John’s wort, frequently utilized for managing depression, can lead to significant interactions with antidepressants and antipsychotics, heightening the risk of serotonin syndrome. Pharmacists utilize databases to identify such interactions and provide warnings to the patient. For example, valerian extract is commonly used for the management of anxiety and insomnia, and it frequently interacts with sedative-hypnotic medications. Melatonin is employed in the treatment of sleep disorders and is often administered alongside antidepressants or antipsychotics; however, its use requires monitoring. • Education and awareness for patients. Pharmacists elucidate the mechanisms of herbal products and their possible effects and limitations to the patient. They should inform patients that although herbal remedies are often perceived as “natural,” they are not inherently safe and should be approached with caution, particularly in the context of chronic illnesses or concurrent medications. Pharmacists advise patients to adhere to established guidelines for the safe use and dosage of herbal products, particularly those that may induce adverse effects. They may suggest initiating treatment with lower doses and monitoring for potential side effects while maintaining regular communication with the pharmacist. Dimitrova S et al.: Role of pharmacists as partners in the treatment of mental health disorders6 • Encouraging transparent communication. To foster trust and obtain comprehensive information from the patient, pharmacists must highlight the significance of transparency. Some patients may be reluctant to disclose their use of alternative products, necessitating reassurance that the pharmacist’s role is to assist rather than judge their choices. • Ongoing monitoring. Pharmacists should encourage patients to schedule regular follow-ups and report any changes in their health status, as well as the outcomes of alternative therapies. This practice enables pharmacists to evaluate the efficacy of herbal interventions. A proposal for a systematic, comprehensive guide on pharmaceutical care—providing advice regarding the combined use of psychotropic medications in individuals with mental health disorders, based on updated guidelines—is available in the Suppl. material 1: S1. The pharmacist‘s challenges in communicating with patients with mental health conditions Pharmacists frequently encounter challenges in their interactions with patients suffering from mental health disorders. Successful communication requires particular skills and an understanding of the distinct needs and situations of these individuals. Challenges in comprehending and processing information, or hindered communication Certain psychiatric conditions, including schizophrenia and bipolar disorder, frequently present cognitive impairments that hinder patients’ ability to comprehend intricate medication details, such as dosage, potential side effects, and drug interactions (Millan et al. 2012). This situation creates significant obstacles for pharmaceutical counseling and underscores the necessity for customized communication strategies, employing straightforward and lucid language, along with the repetition and verification of understanding through methods such as the “teach-back” technique (O’Reilly et al. 2010). It is essential for pharmacists to adopt a patient and organized approach, integrating both verbal and visual aids to support patients with cognitive challenges in effectively managing their treatment (Morrison et al. 2018). In these scenarios, effective communication not only enhances adherence to therapy but also minimizes the likelihood of medication errors. Noncompliance with prescribed treatment, lack of motivation Adherence to medication presents a prevalent challenge for individuals suffering from psychiatric disorders. Contributing factors include adverse drug reactions, personal perceptions of ineffectiveness, psychopathological symptoms such as apathy or diminished motivation, and cognitive deficits that result in forgetfulness (Kane et al. 2013). These elements collectively hinder the ability to sustain long-term adherence to treatment. Pharmacists are essential in mitigating this issue by overseeing adherence, fostering trust, and providing tailored strategies. Such strategies may involve electronic reminders, dosing containers, structured medication regimens, and motivational interviewing designed to bolster the patient’s intrinsic motivation (Brown and Bussell 2011). Furthermore, educating patients and maintaining an ongoing dialogue regarding the advantages of therapy and setting realistic expectations can greatly enhance treatment adherence (Osterberg and Blaschke 2005). Inadequate communication abilities during crises, lack of focus In periods of mental health crises or when symptoms intensify, individuals suffering from mental health disorders often exhibit manifestations of anxiety, irritability, aggression, or emotional instability. These behaviors can hinder effective communication with healthcare professionals, including pharmacists. This necessitates that pharmacists develop particular crisis communication competencies such as patience, active listening, emotional steadiness, and empathy. Utilizing a calm tone, demonstrating open body language, and steering clear of confrontational remarks have proven to be successful de-escalation techniques in high-risk scenarios (Moore et al. 2018). Ensuring a secure environment and offering clear and predictable instructions also contribute to fostering trust and collaboration, even in the acute stages of a mental health disorder. The role of pharmacists in providing consultation and education to the public regarding mental health care Pharmacists are instrumental in enhancing public understanding and education regarding mental health. In addition to providing individualized patient counseling, pharmacists are increasingly engaging in prevention and educational initiatives aimed at reducing the stigma linked to mental health issues and promoting open conversations about the topic (Kremin 2023). As stated by the World Health Organization (WHO) and the International Pharmaceutical Federation (FIP), the contemporary pharmacist’s role extends well beyond the conventional task of dispensing medications. The document WHO/ PHARM/97/599 delineates essential professional responsibilities that encompass effective communication, training and education, care provision, informed decision-making, leadership in change, and commitment to lifelong learning (World Health Organization 1997). These responsibilities provide a framework for the proactive involvement of pharmacists within the community, particularly in the realms of mental health and educational assistance (International Pharmaceutical Federation 2020). Key aspects of the pharmacist’s role in public education: • Enhancing awareness of mental health. In countries such as the United States and Canada, pharmacists play a key role in raising public awareness about Pharmacia 72: 1–14 7 mental health. They participate in national and regional public health programs, use digital educational tools, and disseminate information about anxiety, depression, and stress (National Institute of Mental Health 2025). By participating in mental health campaigns and events, pharmacists contribute to improving public understanding of the importance of early intervention and access to treatment. • Instruction on the appropriate use of psychotropic medications. Pharmacists offer essential advice to patients and their families concerning the appropriate use of psychotropic medications, which encompasses dosage, length of treatment, possible drug interactions (such as with alcohol or tyramine), and adverse effects. They stress the importance of rigorous compliance with the prescribed treatment regimen to ensure stabilization of the condition and to avert relapse. • Addressing stigma and promoting early intervention. The stigma associated with mental illness frequently discourages individuals from pursuing assistance. In the UK, pharmacists participate in initiatives and programs designed to diminish stigma and facilitate informed communication with patients experiencing mental health issues (Royal Pharmaceutical Society 2018). They actively advocate for a constructive perspective on mental health and clarify that these conditions are manageable just like any other medical ailment. • Supporting mental health initiatives and preventive programs. Pharmacists are involved in preventive initiatives addressing risk factors such as stress, substance abuse, and sleep disorders. As part of these programs, they conduct informational sessions and facilitate the distribution of materials that educate the public on effective stress management techniques and strategies to enhance mental well-being. • Referrals to additional professionals and resources. Pharmacists assist patients in accessing essential resources by referring them to psychologists, psychiatrists, and mental health support services. They provide information about local resources, including crisis hotlines and self-help groups. • Engagement in digital and online educational programs. Pharmacists are increasingly leveraging online platforms and social media to share information regarding mental health. This encompasses awareness initiatives, webinars, e-newsletters, and publications directed toward the general populace. In different areas, pharmacists are engaging in online campaigns and employing social media channels to spread knowledge pertaining to mental health education. In Bulgaria, the role of pharmacists in the field of mental health is developing. There are initiatives by pharmacies and professional organizations to provide educational information and consultations. The Ministry of Health’s document on national mental health policy (2004–2012) emphasizes the need for inter-institutional cooperation, including with the pharmaceutical sector (Ministry of Health 2004–2012). Suggested methodology for certain particular conditions Approach in patients with depressive conditions Pharmacists can be instrumental in elevating a patient’s quality of life and facilitating their path to recovery (Kamusheva et al. 2020). Addressing the needs of a patient in a state of depression demands a comprehensive and thoughtful approach that encompasses not only the prescription and administration of medication but also the provision of support during the therapeutic process (see Suppl. material 1: S2). • Guidance on the appropriate administration of antidepressants. Pharmacists offer patients detailed information regarding their prescribed medications, including the timing and method of ingestion, as well as anticipated outcomes. They clarify that the therapeutic effects of antidepressants typically manifest within a period of 2 to 4 weeks, which is crucial for sustaining the patient’s motivation during the initial treatment phase (Capoccia et al. 2004; Brown and Bussell 2011). • Clarification of potential adverse effects associated with the medications and strategies for their management (Kelly et al. 2008). Patients may be deterred from continuing their treatment due to common side effects of antidepressants, such as sedation or sexual dysfunction. Sexual dysfunction represents a relatively unexplored negative consequence of antidepressant medications and may elevate the likelihood of treatment discontinuation and non-adherence to antidepressant therapy (Higgins et al. 2010; Clayton et al. 2014; Jing and Straw-Wilson 2016). Pharmacists provide insights into these possible side effects, explore methods to alleviate discomfort, and advise on when it is necessary to seek medical assistance if the side effects become excessively severe. • Monitoring the patient’s condition and providing emotional support. During each consultation, pharmacists can assess the patient’s condition and inquire about both physical and emotional well-being. Encouraging patients to communicate any perceived changes in their health, whether positive or negative, is essential. Additionally, pharmacists can provide guidance on managing everyday stress and anxiety. When appropriate, they may also refer patients to mental health professionals, such as psychologists or psychiatrists, for more specialized assistance (Chavez and Kosirog 2019). • Assessing potential drug interactions. Numerous individuals diagnosed with depression concurrently utilize additional medications that could potentially Dimitrova S et al.: Role of pharmacists as partners in the treatment of mental health disorders8 interact with antidepressants. Pharmacists are responsible for identifying possible interactions and providing guidance to patients regarding particular drug or food combinations that should be avoided, including the combination of MAOIs and foods high in tyramine (Rieck and Kim 2014). • Educational initiatives focused on managing depressive symptoms. Pharmacists can enhance community well-being by facilitating brief educational initiatives aimed at managing depressive symptoms and stress. These sessions may include guidance on maintaining a healthy lifestyle, engaging in physical exercise, adhering to a balanced diet, and establishing a daily routine conducive to mental well-being. Bingham et al. (2019) emphasized the importance of pharmacist participation, indicating the possibility of enhanced nutrition, increased physical activity, and better sleep for patients with mental health conditions, particularly in the short term (Bingham et al. 2019). • Recognizing potential indicators of suicide risk. Individuals suffering from depression are particularly vulnerable to suicidal thoughts, especially during the early phases of treatment when the initiation of antidepressants may lead to increased energy levels prior to mood improvement. Pharmacists should be vigilant for signs such as mood fluctuations, expressions of hopelessness, and alterations in behavior (Fergusson et al. 2005). Upon observing these indicators, it is imperative to refer the patient to emergency medical services. Approach in individuals exhibiting dependence on psychoactive substances The role of pharmacists in assisting patients with addictions requires a compassionate, empathetic, and nonjudgmental demeanor, alongside adherence to professional ethics and expertise in motivational interviewing techniques, brief interventions, and appropriate treatment referrals. Individuals suffering from substance use disorders frequently encounter complex medical, behavioral, and social obstacles, which may include stigma, coexisting mental health issues, and social marginalization (Babor 2018). Pharmacists, especially those working in community and hospital environments, are positioned to provide educational, therapeutic, and motivational assistance as part of a collaborative care model. This encompasses the identification of risky behaviors, referrals for medication-assisted treatment (MAT), and the dissemination of information regarding the safety and efficacy of various treatment modalities, including naltrexone, methadone, or buprenorphine (National Institute on Drug Abuse 2023). Key strategies for counseling patients with addictions (see Suppl. material 1: S3): • Recognizing indicators of addiction. Indicators that may suggest the presence of addiction include a heightened frequency of requests for prescribed medications (such as opioids or benzodiazepines), premature requests for new prescriptions, or claims of lost medications, as well as shopping between different pharmacies (“doctor/pharmacy shopping”). It is essential to approach these situations with sensitivity, exercising discretion and avoiding premature judgments (Cochran et al. 2017). • Educating on safety and risk factors. It is crucial to inform patients about the dangers associated with prolonged use and improper dosages of psychoactive substances. Implementing harm reduction strategies, including strict adherence to prescribed dosages and the avoidance of combining specific medications with alcohol or other substances, can be advantageous (American Society of Health-System Pharmacists 2019). • Support for cessation and motivational interviewing. Motivational interviewing assists patients in recognizing their addiction issues and fostering their motivation for change. Pharmacists should employ open-ended questions that encourage patients to contemplate the potential repercussions of their addiction while providing support throughout the decision-making process. Ensuring discretion and maintaining confidentiality are paramount in creating a supportive atmosphere for patients (Lindson et al. 2023). Adopting a nonjudgmental demeanor fosters trust and facilitates open dialogue. An empathetic approach is fundamental in encouraging patients to communicate candidly (International Pharmaceutical Federation 2019). • Support with maintenance medication therapy. Patients dealing with opioid or other substance addictions may be prescribed maintenance medications, such as methadone or buprenorphine. Pharmacists play a critical role in monitoring these patients and can offer guidance on the appropriate use and possible side effects of these treatments (Wakeman and Barnett 2018; Winstanley and Clark 2018). • Referrals to specialized assistance and resources. Pharmacists can guide patients toward addiction specialists, including psychiatrists, counselors, or rehabilitation programs. Additionally, they may provide information about hotlines or support services that offer counseling or assistance for addiction (Rubio-Valera et al. 2014). The engagement of clinical pharmacists in the hospital-based therapeutic care of patients experiencing mental health issues The clinical pharmacist holds a crucial position in the multidisciplinary management of patients suffering from mental health disorders within the hospital environment. Their specialized knowledge in pharmacotherapy is essential to ensure the safe, effective, and personalized use of psychotropic medicines within hospital mental health services. Through this collaborative effort, clinical pharmacists play a significant role in enhancing therapeutic outcomes, ensuring patient safety, and promoting adherence to psychiatric treatment plans (Rubio-Valera et al. 2014). Pharmacia 72: 1–14 9 Although the organization and execution of clinical pharmacy services differ worldwide, numerous healthcare systems are increasingly acknowledging the pharmacist as a vital element of inpatient mental health care. Nations such as the United Kingdom, Canada, and Australia have well-established clinical pharmacy practices in psychiatric units, where pharmacists engage in medication reconciliation, treatment planning, and psychoeducation (Finley et al. 2003). In Bulgaria, the clinical pharmacy profession is currently undergoing gradual integration. National initiatives are ongoing to improve hospital-based pharmaceutical care through the establishment of clinical pharmacist roles and the formulation of protocols for collaborative practice. These initiatives align with European recommendations aimed at broadening the pharmacist’s responsibilities in psychiatry and enhancing the continuity of care for patients with complex mental health requirements (Ministry of Health 2020). Main responsibilities of the clinical pharmacist in psychiatric care include the following: • Assessment of pharmacotherapy and management of drug interactions. In psychiatric care environments, the clinical pharmacist plays a crucial role in assessing pharmacotherapeutic regimens to detect and address possible drug-drug interactions, duplications, and contraindications. Particular emphasis is placed on the intricate pharmacokinetics and pharmacodynamics of psychiatric medications, especially in situations involving polypharmacy. Furthermore, the pharmacist evaluates interactions between psychotropic medications and non-psychiatric drugs or dietary supplements that patients might be using simultaneously, such as St. John’s wort, omega-3 fatty acids, or over-the-counter products, which could influence the effectiveness or safety of the treatment (Spina and de Leon 2007). • Development of personalized treatment strategies. Clinical pharmacists work in conjunction with psychiatrists, nurses, and other healthcare professionals to create personalized treatment plans that take into account the patient’s diagnosis, treatment history, comorbidities, and reactions to prior therapies. They play a crucial role in: • Adjusting psychotropic dosages for therapeutic efficacy • Monitoring therapeutic drug levels (e.g., lithium, valproate) • Addressing medication resistance or sensitivity • Reducing the risk of side effects, such as sedation, metabolic disturbances, or extrapyramidal symptoms Their expertise contributes to therapeutic drug monitoring, pharmacogenetic considerations, and the rational selection of alternative regimens in complex or treatment-resistant cases (Finley et al. 2003). • Monitoring treatment efficacy and patient status. Clinical pharmacists are integral to the ongoing monitoring of therapeutic outcomes in hospitalized patients receiving psychotropic medications. Their role involves systematic documentation of clinical responses, including improvement in psychiatric symptoms, stabilization of mood, or reduction in agitation or psychosis. They also monitor for early signs of adverse drug reactions, toxicity, or insufficient therapeutic effect, enabling timely adjustments to the regimen. Additionally, pharmacists play a key role in the management of medication discontinuation, where they observe for withdrawal symptoms and ensure that tapering protocols are followed appropriately to minimize clinical deterioration or rebound effects. In many hospital systems, their direct collaboration with the care team enhances real-time decision-making and supports safer transitions between pharmacologic phases (e.g., initiation, maintenance, and discontinuation) (Rubio-Valera et al. 2014). • Providing guidance to patients and their families. Clinical pharmacists act as readily available educators for patients and their caregivers, providing clear, evidence-based advice on the proper use of prescribed psychotropic medications. They highlight the significance of adhering to medication regimens, clarify dosing schedules, and address common issues related to effectiveness, side effects, and treatment expectations. Moreover, they assist in dispelling myths surrounding psychiatric medications and promote open discussions about potential concerns, which is essential for encouraging informed, stigma-free engagement in long-term mental health care (O’Reilly et al. 2010). • Training healthcare professionals. Clinical pharmacists play a crucial educational role within multidisciplinary teams, aiding in the continuous training and professional growth of physicians, nurses, and allied healthcare professionals. They provide insights on new psychopharmacological agents, the rollout of psychotropic pharmacogenomics, revised clinical guidelines, and methods to reduce medication-related errors in psychiatric care. Through in-service presentations, case discussions, and the development of protocols, pharmacists improve evidence-based medication practices and encourage adherence to optimal standards in psychiatric pharmacotherapy. In nations such as the United States, Australia, and certain regions of Europe, clinical pharmacists have clearly defined responsibilities within mental health facilities, directly contributing to protocol education and enhancing team efficacy (Eaves et al. 2020; El-Den et al. 2021; Farag et al. 2022). The role of the clinical pharmacist in the therapy of patients with mental disorders is summarized in Fig. 2. In Bulgaria, the role of clinical pharmacists within hospital settings is still in a developmental phase, with ongoing institutional and educational efforts aimed at formally integrating clinical pharmacy services into multidisciplinary care models (Getov et al. 2013). Although the number of clinical pharmacists with specialization in psychiatric care remains limited, their presence in hospitals is gradually expanding, particularly in tertiary and university-affiliated medical centers.