Pharmacists’ Experiences, Perceptions, and Attitudes towards Suicide and Suicide Prevention: A Scoping Review

It is important to understand pharmacists’ experiences, stigmas, trainings, and attitudes to suicide, as they can affect the way pharmacists interact with at-risk individuals and influence outcomes. The aim of this scoping review is to explore pharmacists’ willingness, experiences, and attitudes towards suicide prevention, as well as to examine the impact of suicide prevention training programs. A systemic search was conducted using the following databases: PubMed, EMBASE, CINAHL, PsycINFO, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews. Studies included were from database inception to 31 August 2022, in English, with full-text available. A total of 13 studies were included. Training was a key factor which had an impact on pharmacists’ attitudes, experiences, and preparedness to participate in suicide care, with studies revealing the lack of training and the call for more training by pharmacists. Another key factor was closeness to mental illness, which also impacted pharmacists’ attitudes and experiences with at-risk patients. More research is needed worldwide to understand the different barriers and facilitators to pharmacist involvement in suicide care. Targeted training programs should also be developed to not only increase knowledge and competence, but also to address stigma related to suicide.


Introduction
According to the World Health Organization (WHO), over 700,000 individuals worldwide die by suicide annually.  year olds, it is the fourth leading cause of mortality, and for every suicide completed, there are approximately 20 times more suicide attempts [1] and 135 persons affected by it [2]. In 2019, the cost of suicide deaths and attempts was valued at USD 4.2 trillion in medical, work, quality of life, and value of statistical life costs [3].
The objective of the WHO mental health action plan is to reduce suicide rates by one-third in 2030 [1]. In order to have effective suicide prevention, collaboration among various parts of society is required. A study in the United States (US) reported that about 83% of people who completed suicide received healthcare services the year before their death. However, under 24% received a mental health assessment [4]. Another review found that more than 75% of individuals who committed suicide contacted primary care providers in the year prior to their death, instead of mental health services [5]. This indicates that the primary healthcare sector can play a leading role in suicide prevention. Considering suicide prevalence among patients with mental illnesses, there is an increasing need to train healthcare professionals on mental illnesses and suicide prevention [6].
Published work on healthcare professionals' experience in suicide have largely focused on physicians and practitioners [6]. One systemic review found that practitioners' knowledge, attitudes, trainings, and confidence when caring for individuals at risk of suicide can impact outcomes and affect patients' help-seeking behaviour [7]. Studies have Results were presented in tabular format and figures and common themes were identified.

Study Search
A total of 327 articles were identified from the database search. Following removal of duplicates and screening of titles and abstracts, 26 full texts and their references were screened, and of these, only 13 citations meeting the inclusion criteria were included in this review (Figure 1). The characteristics of included studies are outlined in Table 1.

Key Findings
Four key themes were developed from the included studies: (1) pharmacists' attitudes towards suicide and suicide assessment, (2) pharmacists' experiences in suicide prevention, (3) pharmacists' preparedness and (4) trainings in suicide prevention. These are illustrated below and in Table 1 and Figure 2. Theme 1: Pharmacists' attitudes towards suicide and suicide assessment Eight studies discussed pharmacists' attitudes towards suicide and suicide prevention [26,30,32,[35][36][37][38]41]. Some reported more neutral attitudes towards suicide, with pharmacists believing that suicide is preventable [35,41], while some were undecided about their personal attitudes towards suicide [37] and whether people who talk about suicide actually complete it [41]. Most, however, had either positive or negative attitudes towards suicide, as illustrated in subthemes 1 and 2 below.

Subtheme 1: Permissiveness
Five studies discussed pharmacists' permissive attitudes towards suicide [30,32,[36][37][38]. More than 90% of pharmacists agreed that suicidal ideation was a real disease [37], Key    • "Referral and triage" common theme: pharmacists assessed risks, triaged urgency, and made referrals • "Accessibility for confiding": suicidal thinking conveyed to pharmacists via telephone or face-to-face; challenges of phone interactions: (i) unable to fully evaluate patient's situation, (ii) difficulty balancing own work in pharmacy and focusing on someone in crisis; challenges with face-to-face interactions: (i) comfort of other patients and pharmacy staff when discussing suicide publicly, (ii) managing complex patients in retail environment, (iii) limitations in competency and education in conflict resolution in cases where it escalates; other roles adopted: (i) gatekeeper of medicine supply, (ii) sole discloser regarding suicidality, (iii) support for those affected by suicide, (iv) assessing validity of suicidality • "Emotional toll": (i) frustrated that patient's needs are not met due to gaps in healthcare system and lack of resources; (ii) disappointment and dissatisfaction with self for not asking directly, some due to fear despite training; (iii) felt ill-equipped to handle these situations due to lack of knowledge and skills, source of dissatisfaction and discomfort; (iv) pharmacists with knowledge, skills, and resources, had positive experiences after helping people with suicide risk, pharmacists with restricted resources (e.g., capacity, time, private areas) were more stressed and dissatisfied; (v) feeling of vulnerability and loss of power due to reliance on others to continue care for patient • "Stigma": felt patients were stigmatized and often labelled as attention-seeking by healthcare professionals and system, resulting in them being turned away without care • 104 who did not know someone close to them living with a mental illness agreed with words describing those who die by suicide as "pathetic" (p = 0.008), "stupid" (p = 0.007), "irresponsible" (p = 0.01), and "cowardly" (p = 0.01) • 261 who do not have a diagnosis of mental illness agreed with words such as "immoral" (p = 001), "irresponsible"(p = 0.001), "cowardly"(p = 0.02), and "vengeful"(p = 0.04) • None endorsed the word "immoral" if patients they cared for had died by suicide (p = 0.02) • With regard to perception of those who completed suicide, most were more likely to agree/strongly agree with the SOSS-SF items for isolation/depression versus stigma and glorification/normalization factors • Those with more preventable views of suicide were less likely to endorse stigmatizing terms (p = 0.0005) • Male gender (p = 0.001) and negative perception about suicide preventability (p < 0.0005) associated with higher stigma Item "I resent being asked to do more about suicide" had an M = 1.8 (±SD 0.63), which indicated a positive attitude towards suicide prevention -Items "It is easy for people not involved in clinical practice to make judgments about suicide prevention" and "I don't feel comfortable assessing someone for suicide risk" had means of M = 3.28 (±SD 0.9), M = 3.11 (±SD 0.97), which indicated more negative attitudes towards suicide prevention. -Inverse correlation found between ASP scores and participants' interests in direct involvement in suicide prevention, indirect involvement in suicide prevention, and receiving training in suicide prevention (p < 0.001) * -Perceived skills in suicide prevention had statistically significant correlations with interest in being directly involved in suicide prevention (p < 0.05) Items are rated on a 5-point Likert scale, ranging from 1 ("strongly agree") to 5 ("strongly disagree"). The total ATTS inventory score is the mean rating for all items. d DSS: Depression Stigma Scale; it measures stigma associated with depression. It has two subscales: personal and perceived stigma. Responses are measured on a five-point scale (ranging from zero "strongly disagree" to four "strongly agree"), with higher scores indicating higher levels of depression stigma. e IKT: Intervention Knowledge Test; it assesses knowledge about suicide, using 9 multiple-choice items which measure risk factors and intervention strategies for suicide. The total score is the number of correct responses. f MCS: Morris Confidence Scale; one item ("I feel confident that I could identify a person at risk for suicide"), that is measured on a ten-point Likert scale ranging from "not at all confident" to "very confident." g ASP: the Attitudes to Suicide Prevention Scale; a 14-item scale with 12 negative statements, as well as a positive statement on suicide prevention, and an additional statement about suicides that are considered preventable, which are reverse scored. Scoring is with a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). Total scores range from 14 to 70, with higher scores indicating more negative attitudes. h SOSS-SF: Stigma of Suicide Scale. Has 16 items (8 stigma, 4 isolation/depression, and 4 glorification/normalization) measured using a 5-point Likert-type scale (strongly disagree (1) to strongly agree (5)). i PSIS: Pharmacy Suicide Interaction Scale; 10 items that assess how often pharmacy staff members encountered patients with suicide risk factors or warning signs. Range from Theme 1: Pharmacists' attitudes towards suicide and suicide assessment Eight studies discussed pharmacists' attitudes towards suicide and suicide prevention [26,30,32,[35][36][37][38]41]. Some reported more neutral attitudes towards suicide, with pharmacists believing that suicide is preventable [35,41], while some were undecided about their personal attitudes towards suicide [37] and whether people who talk about suicide actually complete it [41]. Most, however, had either positive or negative attitudes towards suicide, as illustrated in subthemes 1 and 2 below. Subtheme 1: Permissiveness Five studies discussed pharmacists' permissive attitudes towards suicide [30,32,[36][37][38]. More than 90% of pharmacists agreed that suicidal ideation was a real disease [37], while more than 70% showed understanding for choosing to die by suicide [30]. A survey by Murphy et al. [26] to determine pharmacists' stigmas of suicide found that when describing those who completed suicide, there was more agreement with the isolation/depression factors (lost, isolated, lonely, disconnected) on the SOSS-SF scale versus glorification/normalisation factors (brave, strong, noble, dedicated). The authors also found that pharmacists who held more preventable views of suicide were significantly less likely to endorse stigmatizing terms [26].
Subtheme 2: Negative and stigmatizing attitudes Six studies highlighted the negative and stigmatizing attitudes of pharmacists [26,31,[36][37][38]41]. There was low agreement with the fact that it is acceptable to complete suicide due to a terminal disease [30], with more than 50% agreeing that suicide is never justified [41] and disagreeing that anyone has a right to complete suicide or that there are situations where suicide would be acceptable [30,41]. There was agreement with using words such as "irresponsible", "stupid", "pathetic" and "coward" to describe those who had died from suicide [26]. Male pharmacists (p = 0.001) and those who did not believe that suicide can be prevented (p = 0.0005) had significantly higher stigma levels [26].
There was also a general expression of discomfort and hesitation at talking to patients at risk or being involved, directly or indirectly, in suicide prevention [32,36,38]. This was complemented by the findings from the online survey by Gillette et al. [37] which employed the use of the ATTS to determine attitudes towards suicide, where less than 50% felt that it was their professional responsibility. It was found that those with more negative attitudes had significantly less interest in being involved in suicide prevention and in receiving training [38].
Subtheme 3: Impact of closeness to mental illness Five studies highlighted the influence of closeness to mental illness on pharmacists' attitudes [26,30,37,38,41]. Closeness to mental illness alludes here to the following: interaction or having a close relationship with someone at risk or died by suicide and personal experience or diagnosis of mental illness.
The study by Murphy et al. [30], involving Australians and Canadians, found no significant association between closeness to mental illness and the attitudes of pharmacists; similarly, in the Kodaka et al. [41] study, no significant association was found between the attitudes of Japanese pharmacists and knowing someone who completed suicide. However, the study by Murphy et al. revealed that those who did not know someone close living with mental illness or did not in themselves have a diagnosis of mental illness had significantly more stigmatizing attitudes [26]. Inversely, the influence of knowing someone who died by suicide was found to significantly lower ATTS scores (p = 0.002), indicating a positive effect on attitudes towards suicide prevention [37]. Kodaka et al. [41] found that pharmacists with a lifetime history of suicidal thoughts had significantly (p < 0.001) more permissive attitudes, while Murphy et al. [26] found that pharmacists would not endorse the word "immoral" if they had lost their patient to suicide. Theme 2: Pharmacists' experience in suicide prevention Six studies discussed pharmacists' experiences with patients at risk of suicide [31][32][33]36,37,39]. Findings are discussed in terms of the nature and perception of the interaction and the emotional toll on pharmacists due to the experience. Subtheme 1: Nature and perception of interaction While many had experience interacting with patients at risk, few enquired directly about suicidal thoughts and plans [32,36,37,41]. Many expressed dissatisfaction with the service provided and were often unsure if what was said was correct [31,32]. Pharmacists in the survey by Carpenter et al. [36] describing their interaction with patients at risk, talked about having no warning before patients completed suicide and shared their experiences with patients asking about lethal doses of medications they were on: "I had a patient call and ask how much insulin would be a lethal dose. I asked the caller why they were asking that question and the person hung up on me" [36].
Some of the strategies employed in suicide prevention were providing support, triaging, referring, listening, assessing for ideation, and engaging with patients until help arrived [31,32,36]. It was also suggested that pharmacists use medication review services to interact with patients at risk, other than restricting dispensation of high-risk medications [39]. Having a close relationship with patients was also highlighted as a facilitator, as it enabled pharmacists to recognise alarm signals and provide help immediately [39].
Subtheme 2: Emotional toll Pharmacists expressed frustration, anxiety, and anger after interacting with patients, mainly with themselves for not knowing what to do or not assessing ideation directly with patients [31][32][33]. This is highlighted in the following feedback: "I was disappointed in myself as I was afraid to ask her in detail about her plan. I was also hesitant to discuss suicidal ideation with her despite knowing/having done mental health first aid because I didn't want to worsen the situation/felt very under qualified for this discussion" [31]. There was also frustration with the healthcare system which was perceived as not meeting the needs of the patient and stigmatised against them [31,33]. In addition, there was a sense of helplessness and vulnerability about having to rely on others to continue the care for the patient [31,33]. Those with more skills and resources reported more positive experiences, while those with limited resources reported more stress [31].
Theme 3: Pharmacists' preparedness: Pharmacists' preparedness to be involved in suicide prevention was mentioned in five studies [32,[36][37][38][39]41]. Responses were mixed, with pharmacists in some studies being more prepared and knowing what to do [32,39] compared to others [36,37,41]. Pharmacists with better knowledge on what to do were significantly more likely to assess a patient for suicidal ideation [37], while the lack of training and confidence was significantly negatively associated with preparedness to help [32].
Subtheme 1: Barriers Two key barriers to pharmacists' involvement in suicide prevention were identified. The main one was the lack of knowledge, resources, and training in suicide prevention, which resulted in pharmacists not knowing what to say or how to care for these patients [31][32][33]36,37,39]. The second key barrier was workplace related, where pharmacists reported the lack of time and privacy to undertake these conversations and assessments [31][32][33]36,37,39], with one pharmacist lamenting: " . . . patient was loud and very upset, I work in a busy pharmacy and it is a difficult setting to address this type of emergency" [31]. There was also frustration at the lack of a clear referral pathway [17,33,36] with pharmacists underlining the need for the establishment of better referral and follow-up pathways: "There has to be a better way of follow-up to let these people know someone is looking after them and cares" [33]. Subtheme 2: Facilitators Two work environment-related factors facilitated pharmacists' participation in suicide prevention: the first was the accessibility of pharmacies compared to other general practices such as the lack of need for an appointment, availability of private rooms, and the extended opening hours, which facilitated pharmacists to establish a relationship with patients who visit the pharmacy continuously [39]. This enabled pharmacists to identify alarming suicidal signs and intervene instantly [39]. It also helped some patients to talk to pharmacists regarding their physical or psychological issues [39]. Three studies stated that patients directly talked to pharmacists about suicide, either in person or by phone [31,32,36]. The second factor was pharmacists' role as gatekeepers of medicine, as they used triage judgment to dispense lower quantities to patients who expressed suicidal signs and used this as a method to keep in contact with them [30]. Pharmacists were also significantly more likely to perform a suicide risk assessment if there were lower numbers of barriers [37].
Theme 4: Training in suicide prevention Only 20% of pharmacists in the sample received training in suicide prevention. A key factor significantly associated with encouraging pharmacists to upskill in mental health care and crisis was closeness to mental illness (p < 0.05) [33] Subtheme 1: Need and attitude towards training Pharmacists were mainly positive towards attending training, highlighting its importance in helping them interact with at-risk patients [33,36,38]. This could be attributed to the below-average knowledge on suicide and lack of confidence in identifying suicide behaviour as found in the study by Coppens et al. [40], and the feedback from pharmacists who shared that they were often unsure if what they had said was correct [39]. This sentiment is also captured in the study by El-Den et al. which sought to determine the impact of providing suicide care on pharmacists: "I realized how unequipped I was to deal with these situations and [it] has helped me want to pursue caring more for these patients and learning more about mental health" [33].
Subtheme 2: Impact of training Seven studies found that suicide-related training had positively affected pharmacists' attitudes towards suicide, including believing that suicide is a common occurrence and rejecting the idea that those who make threats are not serious [33][34][35][38][39][40][41]. Pharmacists reported that training increased their confidence and awareness in recognising suicidal signs, confidence in responding appropriate, confidence in their ability to listen without judgment, and their preparedness and willingness to assess and communicate with those at risk [34,35,41]. It also significantly increased pharmacists' desires to uptake knowledge in suicide prevention and make proper interventions (p = 0.024) [33,35]. In the study by Coppens et al. [40] involving pharmacists from Germany, Hungary, Ireland, and Portugal, training improved pharmacists' competencies across all countries, and these improvements were sustained after six months. However, one study reported that training was significantly associated with less self-confidence (p = 0.003) [35].

Discussion
Closeness to mental illness, the lack of training and knowledge, and emotional toll affected pharmacists' experience as well as attitudes. Our findings showed that the majority of pharmacists are not yet prepared to be involved in suicide prevention due to personal barriers such as a lack of confidence and knowledge or system-related barriers such as the lack of time and privacy, workload, and the lack of a clear referral pathway. However, factors that facilitated pharmacists' participation in suicide prevention included the accessible environment and gatekeeper role. Training improved pharmacists' attitudes and had a positive influence on pharmacists' experiences.
From this scoping review, it was found that studies published on pharmacists' willingness to be part of suicide prevention were lacking, matching the findings of another scoping review in 2017 [12], which suggests the need for further research in this area. There is also a need to assess patients' opinions about involving pharmacists in suicide prevention. Identified barriers to suicide prevention in this study were similar to those reported in a qualitative study involving primary healthcare professionals where barriers included a lack of time and confidence, heavy workload, and unclear referral pathways [6].
Studies that explored pharmacists' roles in suicide were mainly conducted in developed countries. No data were found in poor or developing countries, although suicide rates are higher in low-and middle-income countries [1]. This can be a result of mental illness stigma since it is more prevalent in these countries due to cultural or religious beliefs [44]. More research on stigma of suicide and mental illness in developing and poor countries is thus required. Additionally, most published studies focused on pharmacists in community settings, with some extended to other settings, which indicates the need to determine other pharmacists' attitudes and experiences with suicide, especially those who work in the hospital settings.
Across the included studies, few pharmacists received suicide prevention training, and this was noted to be a key barrier to participating in suicide-prevention activities. Two notable training programmes were offered to pharmacists, the suicide prevention gatekeeper training [31,32,35,38,40,42] and mental health first aid training [31][32][33]37,42]. Even though different training programs were used, this study found that training positively influenced pharmacists' experiences in suicide prevention. Since suicide prevention training programs are diverse and recent, they need to be evaluated, and training perceived barriers should be assessed. In order to increase pharmacists' willingness to participate in suicide prevention and to improve their attitudes and experiences in this field, offering a proper training program is suggested. Training programs should address culture barriers and incorporate the following: role of medications in suicide [45], minimizing stigma [26], overcoming barriers, and improving knowledge and communication [37]. The 20 min, Veterans Administration (VA's) S.A.V.E. training program (signs of suicide, asking about suicide, validating feelings, encouraging help and expediting treatment), might be helpful, as it includes simulated scenarios, with public and phone interactions, that help comprehend skills and attitudes required in such situations [36]. Although the effect of training was sustained over three to six months [40], little is known about the long-term influence on pharmacists' attitudes, experiences, or their management of at-risk individuals. This matches the findings of another scoping review that explored suicide prevention training programmes given to pharmacists, which noted that additional research is needed to evaluate the impact of training on pharmacists' self-efficacy and communication skills [45].
This scoping review identified several barriers to pharmacist involvement in suicide prevention, and the first step to increasing pharmacist involvement in this area, other than offering training [46,47], would be to identify and address or offer solutions to these barriers. It has been observed that while pharmacists might feel they should be involved in health promotional activities, the reality of it is very different, and many do not offer such services due to barriers faced [48]. Other methods which can be adopted or ways in which pharmacists can be involved in suicide prevention, as highlighted in this scoping review and other studies, are by assuming the role of a gatekeeper where limited quantities of potentially toxic medication is dispensed to those at risk [30,46], using "referral and triage" systems where a multidisciplinary approach is adopted to refer patients [31,39], using counselling as a tool to develop a therapeutic relationship with patients as well as educate patients on both the pharmacological and non-pharmacological options available for managing mental health issues, provide information to patients on other sources of help for suicidal ideation such as Befrienders, Samaritans, etc., and educating them on the dangers of drug misuse [49], and using medication review sessions to identify those at risk [39,47].
This study had limitations. Three included studies were not solely about pharmacists; thus, demographics and findings could not be extracted. Moreover, studies used different study instruments, and different versions of the same instrument were also used such as the SOSS and ATTS scales. While the end number of included studies was "13", four of the included papers were reporting on the findings of one study which involved the same participants or respondents [26,[30][31][32]. Most studies also involved more than 70% female participants and those below the age of 50, which may have had an impact on responses. In addition, in the study by Coppen et al., only 10% of the participants were pharmacists [40].

Conclusions
Understanding pharmacists' attitudes to suicide is important because the way they interact with suicide at-risk patients can affect outcomes and prevent death. Multiple interactable factors can influence pharmacists' attitudes, either by making it an acceptable choice Pharmacy 2023, 11, 25 23 of 26 or by making it a driver to prevent suicide. A proper training program for pharmacists needs to be designed and adapted to increase pharmacists' preparedness to be involved in suicide prevention.
Supplementary Materials: The following supporting information can be downloaded at: https: //www.mdpi.com/article/10.3390/pharmacy11010025/s1, Table S1: Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist. Reference [50] are cited in the supplementary materials.

Data Availability Statement:
The data presented in this study are available on request from the corresponding author.

Data Availability Statement:
The data presented in this study are available on request from the corresponding author.

Conflicts of Interest:
The authors declare no conflict of interest. -Reviews, systemic reviews, scoping reviews, meta-analyses, in vitro or in vivo studies, studies on animals; -Conference abstracts, proceedings, reports, letters to the editor, comments; -Studies where full text and/or abstract were not available; -Papers reporting only pharmacy students' experience in suicide prevention programs; -Papers reporting on multiple health care professionals, where pharmacists' data could not be extracted separately; -Studies examining pharmacists' perspectives on dispensing medications with risk of misuse or being used in suicide; -Studies focused on pharmacists' trainings and roles in mental illnesses not related to suicide.  Search terms:

Appendix
To obtain the final search terms, we used Mesh PubMed, looked at keywords from related articles, and consulted a librarian and researcher.

Data Availability Statement:
The data presented in this study are available on request from the corresponding author.

Conflicts of Interest:
The authors declare no conflict of interest. -Reviews, systemic reviews, scoping reviews, meta-analyses, in vitro or in vivo studies, studies on animals; -Conference abstracts, proceedings, reports, letters to the editor, comments; -Studies where full text and/or abstract were not available; -Papers reporting only pharmacy students' experience in suicide prevention programs; -Papers reporting on multiple health care professionals, where pharmacists' data could not be extracted separately; -Studies examining pharmacists' perspectives on dispensing medications with risk of misuse or being used in suicide; -Studies focused on pharmacists' trainings and roles in mental illnesses not related to suicide.  Search terms:

Appendix
To obtain the final search terms, we used Mesh PubMed, looked at keywords from related articles, and consulted a librarian and researcher.
a. (People): Pharmacist*; b. (Outcome): Suicide OR suicide prevention; OR suicide control OR self-killing OR self-harm OR Suicide* Ideation OR Suicide, Attempted; OR completed sui-