Shared decision making and serious mental illness

A Qualitative Study on Primary Care Integration into an Asian Immigrant-specific Behavioural Health Setting in the United States

Introduction

Integrating primary care and behavioural health services improves access to services and health outcomes among individuals with serious mental illness. Integrated care is particularly promising for racial and ethnic minority individuals given higher rates of chronic illnesses and poorer access to and quality of care compared to Whites. However, little is known about integrated care implementation in non-White populations. The aim of this study is to identify facilitators and barriers to successful implementation of primary care-behavioural health integration in a multilingual behavioural healthcare setting.

Methods

Seven focus groups and five semi-structured interviews were conducted with 41 patients and 5 providers participating in integrated care in a community mental health clinic in California serving Asian immigrants.

Results

Themes generated from constant comparative analysis suggest limited system-level preconditions and cross-organisational dynamics challenged integrated care. At the same time, changing organisational culture and practice, improving patient-provider and provider-provider communication, and increasing patient involvement enhanced clinical outcomes and facilitated successful implementation.

Discussion and conclusions

Findings highlight the importance of patient involvement, peer services and interdisciplinary communication to successfully implement integrated care in the face of linguistic and operational challenges in settings serving multilingual and multicultural patients.

Patient experience with healthcare services among older adults with serious mental illness compared to the general older population

Objective To compare patient experience with healthcare services and providers among older patients (≥50 years old) with and without serious mental illness. Methods Using secondary data from the Medical Expenditures Panel Survey from 2003 through 2013, we compared adults aged 50 years and older with schizophrenia spectrum disorder ( n = 106), mood disorders (i.e., major depressive disorder and bipolar disorder) ( n = 419), and no serious mental illness ( n = 34,921). Results Older adults with schizophrenia spectrum disorder reported significantly worse provider communication than older adults without serious mental illness. Older adults with mood disorders reported the greatest barriers to shared decision-making and the greatest difficulty accessing services. Conclusions Our results highlight the need to improve the patient experience of older adults with serious mental illness. Addressing provider communication, shared decision-making, and access to care among this vulnerable group of older adults may impact clinical outcomes and costs. Future research examining the extent to which improving the patient experience may improve health outcomes and enhance treatment for this highly vulnerable older group is warranted.

Effective Strategies for Nurses Empowering Clients With Schizophrenia: Medication Use as a Tool in Recovery

Clients with schizophrenia require maintenance treatment with antipsychotic medication and psychosocial therapy to maintain symptom control. Rates of medication adherence or follow-through are low in clients with schizophrenia. This increases the risk of relapse and contributes to poor quality of life. As educators and advisers, psychiatric nurses can collaborate with clients to improve adherence and other outcomes using shared decision-making techniques and tools that engage and empower clients to actively participate in decisions about their treatment. This article outlines effective strategies used by psychiatric nurses to improve outcomes in clients with schizophrenia and uses a case example for demonstrating this strategy in a client with schizophrenia.

Participation in medical decision-making across Europe: An international longitudinal multicenter study

BACKGROUND

The purpose of this paper was to examine national differences in the desire to participate in decision-making of people with severe mental illness in six European countries.

METHODS

The data was taken from a European longitudinal observational study (CEDAR; ISRCTN75841675). A sample of 514 patients with severe mental illness from the study centers in Ulm, Germany, London, England, Naples, Italy, Debrecen, Hungary, Aalborg, Denmark and Zurich, Switzerland were assessed as to desire to participate in medical decision-making. Associations between desire for participation in decision-making and center location were analyzed with generalized estimating equations.

RESULTS

We found large cross-national differences in patients' desire to participate in decision-making, with the center explaining 47.2% of total variance in the desire for participation (P<0.001). Averaged over time and independent of patient characteristics, London (mean=2.27), Ulm (mean=2.13) and Zurich (mean=2.14) showed significantly higher scores in desire for participation, followed by Aalborg (mean=1.97), where scores were in turn significantly higher than in Debrecen (mean=1.56). The lowest scores were reported in Naples (mean=1.14). Over time, the desire for participation in decision-making increased significantly in Zurich (b=0.23) and decreased in Naples (b=-0.14). In all other centers, values remained stable.

CONCLUSIONS

This study demonstrates that patients' desire for participation in decision-making varies by location. We suggest that more research attention be focused on identifying specific cultural and social factors in each country to further explain observed differences across Europe.

Development of the My Medicines and Me (M3Q) side effect questionnaire for mental health patients: a qualitative study

OBJECTIVE

The objective of this study was to assess the acceptability, content validity and usability of the My Medicines and Me (M3Q) self-report side effect questionnaire.

METHODS

Eight focus groups consisting of mental health patients, carers, general practitioners, psychiatrists, mental health nurses and pharmacists were conducted, involving 78 participants. Two researchers independently examined the transcriptions and analysed the data thematically using an inductive method.

RESULTS

The findings supported changes to the formatting, length and phrasing of questions in the original version of the questionnaire. Although the groups provided differing views on the usability of the M3Q in clinical practice, the patient and carer groups were unconditionally in favour of such a tool to be used systematically to describe patients' subjective experiences with side effects.

CONCLUSION

The differing contribution made by all groups involved in the administration and completion of the M3Q assisted with content validity of the questionnaire. The acceptability and usability of this novel side effect questionnaire was also explored, with many participants agreeing it was a necessary tool for a patient centred approach to treatment. Following implementation of the changes to the current format of the questionnaire, investigation into the uptake and use in clinical practice should be carried out.

Where is the evidence? A systematic review of shared decision making and patient outcomes

BACKGROUND

Despite widespread advocacy for shared decision making (SDM), the empirical evidence regarding its effectiveness to improve patient outcomes has not been systematically reviewed. The purpose of this study was to systematically review the empirical evidence linking patient outcomes and SDM, when the decision-making process has been explicitly measured, and to identify under what measurement perspectives SDM is associated with which types of patient outcomes (affective-cognitive, behavioral, and health).

DATA SOURCES

PubMed (through December 2012) and hand search of article bibliographies.

STUDY SELECTION

Studies were included if they empirically 1) measured SDM in the context of a patient-clinician interaction and 2) evaluated the relationship between SDM and at least 1 patient outcome.

DATA EXTRACTION

Study results were categorized by SDM measurement perspective (patient-reported, clinician-reported, or observer-rated) and outcome type (affective-cognitive, behavioral, or health).

DATA SYNTHESIS

Thirty-nine studies met inclusion criteria. Thirty-three used patient-reported measures of SDM, 6 used observer-rated measures, and 2 used clinician-reported measures. Ninety-seven unique patient outcomes were assessed; 51% affective-cognitive, 28% behavioral, and 21% health. Only 43% of assessments (n = 42) found a significant and positive relationship between SDM and the patient outcome. This proportion varied by SDM measurement perspective and outcome category. It was found that 52% of outcomes assessed with patient-reported SDM were significant and positive, compared with 21% with observer-rated and 0% with clinician-reported SDM. Regardless of measurement perspective, SDM was most likely to be associated with affective-cognitive patient outcomes (54%), compared with 37% of behavioral and 25% of health outcomes.

LIMITATIONS

The relatively small number of studies precludes meta-analysis. Because the study inclusion and exclusion criteria required both an empirical measure of SDM and an assessment of the association between that measure and a patient outcome, most included studies were observational in design.

CONCLUSIONS

SDM, when perceived by patients as occurring, tends to result in improved affective-cognitive outcomes. Evidence is lacking for the association between empirical measures of SDM and patient behavioral and health outcomes.

The development and evaluation of a five-language multi-perspective standardised measure: clinical decision-making involvement and satisfaction (CDIS)

BACKGROUND

The aim of this study was to develop and evaluate a brief quantitative five-language measure of involvement and satisfaction in clinical decision-making (CDIS) - with versions for patients (CDIS-P) and staff (CDIS-S) - for use in mental health services.

METHODS

An English CDIS was developed by reviewing existing measures, focus groups, semistructured interviews and piloting. Translations into Danish, German, Hungarian and Italian followed the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Task Force principles of good practice for translation and cultural adaptation. Psychometricevaluation involved testing the measure in secondary mental health services in Aalborg, Debrecen, London, Naples, Ulm and Zurich.

RESULTS

After appraising 14 measures, the Control Preference Scale and Satisfaction With Decision-making English-language scales were modified and evaluated in interviews (n = 9), focus groups (n = 22) and piloting (n = 16). Translations were validated through focus groups (n = 38) and piloting (n = 61). A total of 443 service users and 403 paired staff completed CDIS. The Satisfaction sub-scale had internal consistency of 0.89 (0.86-0.89 after item-level deletion) for staff and 0.90 (0.87-0.90) for service users, both continuous and categorical (utility) versions were associated with symptomatology and both staff-rated and service userrated therapeutic alliance (showing convergent validity), and not with social disability (showing divergent validity), and satisfaction predicted staff-rated (OR 2.43, 95%CI 1.54- 3.83 continuous, OR 5.77, 95%CI 1.90-17.53 utility) and service user-rated (OR 2.21, 95%CI 1.51-3.23 continuous, OR 3.13, 95%CI 1.10-8.94 utility) decision implementation two months later. The Involvement sub-scale had appropriate distribution and no floor or ceiling effects, was associated with stage of recovery, functioning and quality of life (staff only) (showing convergent validity), and not with symptomatology or social disability (showing divergent validity), and staff-rated passive involvement by the service user predicted implementation (OR 3.55, 95%CI 1.53-8.24). Relationships remained after adjusting for clustering by staff.

CONCLUSIONS

CDIS demonstrates adequate internal consistency, no evidence of item redundancy, appropriate distribution, and face, content, convergent, divergent and predictive validity. It can be recommended for research and clinical use. CDIS-P and CDIS-S in all 3 five languages can be downloaded at http://www.cedar-net.eu/instruments.

TRIAL REGISTRATION

ISRCTN75841675.

Congruence between patients' preferred and perceived participation in medical decision-making: a review of the literature

Background

Patients are increasingly expected and asked to be involved in health care decisions. In this decision-making process, preferences for participation are important. In this systematic review we aim to provide an overview the literature related to the congruence between patients’ preferences and their perceived participation in medical decision-making. We also explore the direction of mismatched and outline factors associated with congruence.

Methods

A systematic review was performed on patient participation in medical decision-making. Medline, PsycINFO, CINAHL, EMBASE and the Cochrane Library databases up to September 2012, were searched and all studies were rigorously critically appraised. In total 44 papers were included, they sampled contained 52 different patient samples.

Results

Mean of congruence between preference for and perceived participation in decision-making was 60% (49 and 70 representing 25^th and 75^th percentiles). If no congruence was found, of 36 patient samples most patients preferred more involvement and of 9 patient samples most patients preferred less involvement. Factors associated with preferences the most investigated were age and educational level. Younger patients preferred more often an active or shared role as did higher educated patients.

Conclusion

This review suggests that a similar approach to all patients is not likely to meet patients’ wishes, since preferences for participation vary among patients. Health care professionals should be sensitive to patients individual preferences and communicate about patients’ participation wishes on a regular basis during their illness trajectory.

Patient involvement in mental health care: one size does not fit all

BACKGROUND

Involvement of mental health-care patients in the decision-making processes is considered to be an ethical requirement. Health-care systems worldwide are increasingly emphasizing the value of participatory approaches. There is, however, no consensus on the definition of patient involvement. The literature is particularly inconsistent and lacks clarity.

OBJECTIVE

The purpose of this article is to clarify the concept of patient involvement in mental health care (MHC), taking into account its multidimensional nature.

SEARCH STRATEGY

We searched the literature in online databases from January 1998 until August 2010 using synonyms of 'patient involvement', combined with the terms 'mental health(care)'.

DATA SYNTHESIS

Based on 45 different descriptions found in the literature, we constructed a definition of patient involvement and we drew up a model identifying its determinants and outcomes.

RESULTS

We propose a comprehensive model of patient involvement to be used in MHC. This model can serve as a guide for policy makers and field workers to shape policies to stimulate involvement.

DISCUSSION AND CONCLUSIONS

There are three main problems in the literature concerning patient involvement. First, there is a proliferation of conceptualizations of the topic, leading to conceptual vagueness. Furthermore, there is a lack of quantitative data, and some aspects of involvement remain underexposed, such as the involvement of specific target groups and practical ways to shape the involvement processes. Involvement processes should be tailored to the specific target group and context.

Does experienced seclusion or restraint affect psychiatric patients' subjective quality of life at discharge?

Background

In Finland major effort has been invested in reducing the use of coercion in psychiatric treatment, and the goal is to diminish the use of coercion by 40% by 2015. Improving patients’ quality of life (QoL) has gained prominence in psychiatric treatment during the past decade. Numerous studies have shown that most secluded or restrained patients (S/R patients) would prefer not to have had this experience. Experience of S/R could affect negatively patients’ QoL, but empirical data on this issue are lacking.

Aim

The study aimed to explore the effect of experienced S/R on the subjective QoL of psychiatric in-patients.

Method

This study explored subjective QoL of the S/R patients. At discharge, S/R patients completed the Short Form of the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q-SF).

Results

We found that S/R patients’ (n = 36) subjective QoL was significantly better than that of non-S/R patients’ (n = 228). Most non-S/R patients were diagnosed with mood disorders (mostly depression). Most of S/R patients were diagnosed with schizophrenia, schizotypal and delusional disorders. The mean duration of S/R was 2.3 days, median was one day and mean length of the hospitalization after S/R episode was 2.5 months.

Conclusion

Our cross-sectional findings suggest that S/R does not considerably influence patients’ QoL or that the influence is short-lived. Because baseline QoL was not measured this remains uncertain. There are also many other factors, such as negative mood, which decrease the patients’ QoL ratings. These factors may either mask the influence of S/R on QoL or modify the experience of QoL to such an extent that no independent association can be found at the time of discharge.

Activating older adults with serious mental illness for collaborative primary care visits

OBJECTIVE

Persons with serious mental illness frequently receive inadequate medical care and are more likely to experience difficulty navigating the health care system compared with the general population. To address this gap in quality, we developed a program of peer co-led collaborative activation training for primary care (CAT-PC) designed to improve "patient activation" and person-centered care in primary care visits for middle-aged and older adults with serious mental illness and cardiovascular risk. This report presents pilot study feasibility and participant outcomes for CAT-PC.

METHOD

A pre-post pilot evaluation of CAT-PC included N = 17 adults (age ≥ 50) with serious mental illness and cardiovascular health risk conditions, and N = 6 primary care providers. CAT-PC consists of 9 weekly peer co-led patient education and skills training sessions and a 45-min video-based training for primary care providers. Pre-post measures included the Patient Activation Measure (PAM), Perceived Efficacy in Patient-Physician Interactions (PEPPI), Autonomy Preference Index (API) for preferred role in primary care encounters, and Social Skills Performance Assessment (SSPA) role-play test for medical visits.

RESULTS

All 17 participants attended 5 or more sessions. Post-intervention improvement was found for patient activation and simulated performance of medical visit communication skills. Trends were observed for improved self-efficacy in provider interactions and greater preference for a more collaborative role in decision-making.

CONCLUSIONS AND IMPLICATIONS

CAT-PC is a brief, peer co-led education and skills training intervention potentially improving patient activation in primary care encounters and providing an important missing component in emerging models of "patient-centered behavioral health homes" for this high-risk group.

The effect of clinician-patient alliance and communication on treatment adherence in mental health care: a systematic review

BACKGROUND

Nonadherence to mental health treatment incurs clinical and economic burdens. The clinician-patient alliance, negotiated through clinical interaction, presents a critical intervention point. Recent medical reviews of communication and adherence behaviour exclude studies with psychiatric samples. The following examines the impact of clinician-patient alliance and communication on adherence in mental health, identifying the specific mechanisms that mobilise patient engagement.

METHODS

In December 2010, a systematic search was conducted in Pubmed, PsychInfo, Web of Science, Cochrane Library, Embase and Cinahl and yielded 6672 titles. A secondary hand search was performed in relevant journals, grey literature and reference.

RESULTS

23 studies met the inclusion criteria for the review. The methodological quality overall was moderate. 17 studies reported positive associations with adherence, only four of which employed intervention designs. 10 studies examined the association between clinician-patient alliance and adherence. Subjective ratings of clinical communication styles and messages were assessed in 12 studies. 1 study examined the association between objectively rated communication and adherence. Meta-analysis was not possible due to heterogeneity of methods. Findings were presented as a narrative synthesis.

CONCLUSIONS

Clinician-patient alliance and communication are associated with more favourable patient adherence. Further research of observer rated communication would better facilitate the application of findings in clinical practice. Establishing agreement on the tasks of treatment, utilising collaborative styles of communication and discussion of treatment specifics may be important for clinicians in promoting cooperation with regimens. These findings align with those in health communication. However, the benefits of shared decision making for adherence in mental health are less conclusive than in general medicine.

Opportunity lost? Psychiatric medications and problems with sexual function: a role for nurses in mental health

AIM

To explore patients' non-adherence to psychiatric medication with mental health nurses.

BACKGROUND

The ability of consumers to maintain normal sexual behaviours is complicated by abnormally high incidence of sexual problems arising from the medications they are prescribed. Sexual side effects of psychiatric medications are identified as a major reason for non-adherence to psychiatric medication regimes yet it remains an issue mental health nurses tend to avoid in their practice with consumers.

DESIGN

An exploratory, descriptive qualitative approach.

METHOD

Individual interviews were conducted with 14 nurses currently working with adult consumers of mental health services. Data analysis followed the framework approach developed by Ritchie and Spencer as the process for identification of the main themes.

RESULTS

Problems with sexual function in relation to psychiatric medication issues was one major theme to emerge from this research. More specifically the participants referred to: assessment of sexual function, the side effects of psychiatric medication, consumer embarrassment, and, the pros and cons of information. Participants recognised that sexual side effects were likely to have an impact on adherence to medication and that this was an important consideration but most did not discuss this issue with consumers. Consumer embarrassment and the belief that knowledge itself might cause non-adherence were the two main reasons for not discussing this topic.

CONCLUSIONS

Problems with sexual function of consumers presents an important practice consideration for nurses working in mental health settings. There is an urgent need for strategies to enhance awareness and confidence among nurses in exploring this topic with consumers.

RELEVANCE TO CLINICAL PRACTICE

Mental health nurses can adopt a leadership role in recognising the relevance of sexuality in care and treatment for consumers of mental health services. Strategies to assist in developing skill and confidence in this domain are required as a matter of priority.

Shared decision making in mental health treatment: qualitative findings from stakeholder focus groups

PURPOSE

This article reports on findings from seven stakeholder focus groups conducted in exploring shared decision making (SDM) between provider and consumer in mental health (MH) treatment in public MH.

BASIC PROCEDURES

Seven focus groups were conducted with stakeholders-consumers, family members, prescribers, MH clinicians, and rural providers. Each of the focus groups was recorded digitally, transcribed into text, and analyzed qualitatively for recurring themes.

MAIN FINDINGS

Provider barriers to SDM include history of the medical model, MH crises, lack of system support, and time. Consumer-related barriers included consumer competency, fears, insight, literacy, and trauma from past experiences. Information-exchange issues include consumer passivity, whether consumers could be viewed as experts, and importance of adequate history information. New skills needed to practice SDM included provider's knowledge about alternative treatments, mastery of person-first language, and listening skills; consumer's ability to articulate their expert information; and computer skills for both providers and consumers. Outcomes expected from practice of SDM include greater sharing of power between provider and consumer, greater follow-through with treatment plans, greater self-management on the part of consumers, and improved therapeutic alliances.

PRINCIPAL CONCLUSIONS

Implementing SDM in public MH will impact consumers and their families, providers, prescribers, and administrators. More SDM trials in public MH are needed to answer some of the many questions that remain.

Participatory Action Research in Public Mental Health and a School of Nursing: Qualitative Findings from an Academic-Community Partnership

An academic-community partnership between a school of nursing (SON) at a public university (the University of Virginia, or UVA) and a public mental health clinic developed around a shared goal of finding an acceptable shared decision making (SDM) intervention targeting medication use by persons with serious mental illness. The planning meetings of the academic-community partnership were recorded and analyzed. Issues under the partnership process included 1) clinic values and priorities, 2) research agenda, 3) ground rules, and 4) communication. Issues under the SDM content included: 1) barriers, 2) information exchange, 3) positive aspects of shared decision making, and 4) technology. Using participatory-action research (PAR), the community clinic was able to raise questions and concerns throughout the process, be actively involved in research activities (such as identifying stakeholders and co-leading focus groups), participate in the reflective activities on the impact of SDM on practice and policy, and feel ownership of the SDM intervention.

Descriptive study of shared decision making about lifestyle modifications with individuals who have psychiatric disabilities

BACKGROUND

Shared decision making (SDM) is a process of active participation by clients with practitioners in weighing the risks and benefits of treatments. It has not been extended to decisions about making lifestyle modifications.

OBJECTIVE

Describe how frequently health lifestyle behaviors are addressed in 15- to 20-minute medicine clinic visits with individuals who have psychiatric disabilities and how often SDM is used in reaching decisions.

DESIGN

Content analysis of 98 audiotaped transcripts from practitioner and client medicine clinic visits.

RESULTS

The most frequently discussed lifestyle behaviors discussed were sleep (89%) and diet (61%). SDM, defined as sharing information and options about behavior by either or both practitioner and client and affirmation of a decision by both, occurred 48 times (44%) when a problem existed.

CONCLUSION

Discussion of lifestyle behaviors along with use of SDM in negotiating changes in behavior is feasible in a 15- to 20-minute visit.

Assessment of the capacity to express informed consent for organ donation in patients with schizophrenia

In Italy, the "silent-consent" principle of donor's willingness regulates organ donation for postmortem transplantation, but civil incompetence excludes it. We investigated decisional capacity for organ donation for transplantation of 30 controls and 30 nonincompetent patients with schizophrenia as related to clinical symptoms, cognition, and functioning. Assessments were carried out through the Competence for Donation Assessment Scale (CDAS), Brief Psychiatric Rating Scale (BPRS), Scale for the Assessment of Positive Symptoms (SAPS), Scale for the Assessment of Negative Symptoms, Life Skills Profile (LSP), Raven's Colored Progressive Matrices (RCPM), Wisconsin Card Sorting Test, Rey RI, Rey RD, and Visual Search. Patients and controls differed on the CDAS Understanding and Choice Expression areas. Patients showed significant inverse bivariate correlations between CDAS Understanding and scores on total BPRS, LSP self-care scale, and RCPM cognitive test. Our results show that decisional capacity for participating in research does not predict decisional capacity for postmortem organ donation in patients with schizophrenic or schizoaffective psychosis; hence, before judging consent for donation, patients must be provided with enhanced information to better understand this delicate issue.