Community pharmacists' recommendations for natural products for stress in Melbourne, Australia: a simulated patient study

Background: Community pharmacists are often the first health professional approached to provide treatment for health issues, including the important mental health challenge, stress. Over-the-counter products for stress almost always are complementary and alternative medicines (CAM) and in Australia no protocol exists for their recommendation and sale in community pharmacies. Objective: To assess the quality and relevance of community pharmacists' information gathering (questioning), counselling and product selection when interacting with customers requesting a CAM product for stress and consequently determine whether Australian pharmacy practice indicates the need for guidelines similar to those provided for 'pharmacy only' (S2) and 'pharmacist only' (S3) medicines. Methods: A covert simulated patient was used to investigate the response of pharmacists to a request for a natural product for stress. The SPs documented the details of the pharmacist-simulated patient interaction immediately on leaving the pharmacy and then re-entered the pharmacy to debrief the pharmacist. The quality of the interaction was scored as a Total CARE (check, assess, respond, explain) Score, based on anticipated questions and counselling advice. The appropriateness of the product was scored as a Product Efficacy Score, based on evidence-based literature. Results: Data from 100 pharmacies was provided. Information gathering illustrated by the questioning components Check and Assess (C and A) of the total CARE score by pharmacists was poor. The number of questions asked ranged from zero (13 pharmacists) to 7 (four pharmacists), the average being 3.1 (SD 1.9). Provision of advice was generally better (a description of the suggested product was offered by 87 pharmacists) but was lacking in other areas (duration of use and side effects were explained by only 41 and 16 pharmacists respectively). The most common product suggested was B-group vitamins (57 pharmacists) followed by a proprietary flower essence product (19 pharmacists). A two-step cluster analysis revealed two sub-groups of pharmacists: one cluster (74 pharmacists) with a high Total CARE score provided an appropriate product. The other cluster (20 pharmacists) had a low total CARE score and provided an inappropriate product. Conclusions: The pharmacy visits revealed major shortcomings in questioning, counselling and product recommendation. There is a need to develop guidelines for pharmacists to make evidence-based decisions in recommending complementary and alternative medicine.