Shared decision making in the recovery of people with schizophrenia: The role of metacognitive capacities in insight and pragmatic language use

Measures of Shared Decision Making for People With Mental Disorders and Limited Decisional Capacity: A Systematic Review

OBJECTIVE

Shared decision making (SDM) is a health communication model to improve treatment decision making and is underused for people with mental health conditions and limited, impaired, or fluctuating decisional capacity. SDM measures are essential to enhancing the adoption and implementation of SDM practices, yet no tools or research findings exist that explicitly focus on measuring SDM with such patients. The aim of this review was to identify instruments that measure SDM involving individuals with mental health conditions and limited decisional capacity, their family members, and their health and social care providers.

METHODS

A systematic review was performed by searching the PubMed, Embase, Web of Science, and PsycInfo databases. The authors included peer-reviewed, quantitative articles published in English during 2009-2022 that focused on adults (≥18 years old). All authors performed the screening independently.

RESULTS

A total of 7,956 records were identified, six of which met the inclusion criteria for full-text review and five of which were analyzed (one full-text article was not available). No instruments were identified that measured forms of SDM involving patients with mental health conditions and limited, impaired, or fluctuating decisional capacity.

CONCLUSIONS

Measurement instruments to address and assess SDM in health care-related communication processes involving individuals with a mental health condition and limited decisional capacity are needed.

"It's That They Treated Me Like an Object": A Qualitative Study on the Participation of People Diagnosed with Psychotic Disorders in Their Health Care

The mental health recovery model is based on shared decision making, in which patients' preferences and perceptions of the care received are taken into account. However, persons with psychosis usually have very few opportunities to participate in this process. The present study explores the experiences and perceptions of a group of patients with psychosis-in some cases longstanding, in others more recently diagnosed-concerning their participation in the decisions taken about the approach to their condition and about the attention received from healthcare professionals and services. For this purpose, we performed a qualitative analysis of the outcomes derived from five focus groups and six in-depth interviews (36 participants). Two major themes, with five sub-themes, were identified: shared decision-making (drug-centred approach, negotiation process, and lack of information) and the care environment and styles of clinical practice as determinants (aggressive versus person-centred environments, and styles of professional practice). The main conclusions drawn are that users want to participate more in decision making, they want to be offered a range of psychosocial options from the outset and that their treatment should be based on accessibility, humanity and respect. These findings are in line with the guidelines for clinical practice and should be taken into account in the design of care programmes and the organisation of services for persons with psychosis.

The impact of perceived and internalised stigma on clinical and functional recovery among people with mental illness

The present study aimed to develop and validate a conceptual model linking public and internalised stigma to recovery attitudes, processes and outcomes among people with mental illness. Specifically, we sought to examine whether perceptions of public stigma (i.e., perceived stigma) would affect experiences of internalised stigma (i.e., self-stigma) and thereby influence recovery attitudes (i.e., recovery orientation), recovery processes (i.e., service engagement) and recovery outcomes (i.e., clinical recovery and functional recovery). A total of 205 people with mental illness from Hong Kong, China, completed questionnaire measures on perceived stigma, self-stigma, recovery orientation, service engagement, clinical recovery and functional recovery. The associations among these variables were analysed using path analyses and bootstrap analyses. Path analyses showed that perceived stigma was related to greater self-stigma, which was, in turn, linked to lower recovery orientation and then lesser service engagement and ultimately poorer clinical recovery and functional recovery. Bootstrap analyses further demonstrated that perceived stigma had significant indirect effects on recovery orientation via self-stigma, on service engagement via self-stigma and recovery orientation and on clinical recovery and functional recovery via self-stigma, recovery orientation and service engagement. Theoretically, our findings reveal how public and internalised stigma may adversely affect recovery attitudes, processes and outcomes among people with mental illness. Practically, our findings point to the vital and urgent need to develop effective interventions to mitigate stigma and self-stigma at community and individual levels in order to reduce the deleterious impact of stigma on recovery.

Calibration and Validation of a PREMIUM-DT Item Bank to Measure the Experience of Drug Therapy for Patients with Severe Mental Illness

The aim of this study was to (1) calibrate an item bank to measure patients’ experience of drug therapy for adult patients with SMIs and (2) develop computerized adaptive testing (CAT) to improve its use in routine practice. This is a cross-sectional, multicentric study involving 541 patients with schizophrenia, bipolar disorder, and major depressive disorder. Analyses based on classical test and item response theories were performed. After 7 highly inter-correlated items and 4 items with low factor loadings were removed, the remaining 26 items were sufficiently unidimensional (RMSEA = 0.069, CFI = 0.969, TLI = 0.963) and showed adequate fit to the generalized partial credit model. There was no differential item functioning by gender, age, care setting, or diagnosis from moderate- to large-magnitude. The mean score was 46.0 ± 16.9 and was significantly higher for patients reporting good medication adherence. The resulting PREMIUM-DT item bank has strong psychometric properties, and CAT facilitates widespread use in clinical settings (an average of 8 items administered, corresponding to a reliability of >0.90). Our results suggest that practical information and information about the side effects of psychotropic treatments and how to cope with them should be targeted as a priority to improve patients’ experience of drug therapy.

Experiences of shared decision making among patients with psychotic disorders in Norway: a qualitative study

BACKGROUND

Shared decision making (SDM) is a process where the patient and the health professional collaborate to make decisions based on both the patient's preferences and the best available evidence. Patients with psychotic disorders are less involved in making decisions than they would like. More knowledge of these patients' experiences of SDM may improve implementation. The study aim was to describe and explore experiences of SDM among patients with psychotic disorders in mental health care.

METHODS

Individual interviews were conducted with ten persons with a psychotic disorder. They were service users of two community mental health centres. The transcribed material was analysed using qualitative content analysis.

RESULTS

Four-fifths of the participants in this study found that they received insufficient information about their health situation and treatment options. All participants experienced that only one kind of treatment was often presented, which was usually medication. Although the study found that different degrees of involvement were practised, two thirds of the participants had little impact on choices to be made. This was despite the fact that they wanted to participate and felt capable of participating, even during periods of more severe illness. The participants described how important it was that SDM in psychosis was based on a trusting relationship, but stated that it took time to establish such a relationship.

CONCLUSIONS

This study with ten participants indicates that patients with psychotic disorders experienced that they were not allowed to participate as much as they wanted to and believed they were capable of. Some patients were involved, but to a lesser degree than in SDM. More and better tailored information communicated within a trusting relationship is needed to provide psychotic patients with a better basis for active involvement in decisions about their health care.

Shared decision making in a semi-secluded chronic psychiatric ward: The reflective lifeworld experiences of patients with schizophrenia or schizoaffective disorders and nursing staff

BACKGROUND

Shared decision making (SDM) enhances recovery-oriented mental healthcare, but literature predominately focuses on doctor-patient collaboration leaving the role of mental health nurses (MHN's) underexposed.

AIM

This study describes the experiences of patients with schizophrenia or schizoaffective disorder with SDM in a semi-secluded psychiatric facility, and the attitudes toward SDM by MHN's.

METHOD

A hermeneutic phenomenological design.

RESULTS

Seven patients and six MHN's were interviewed. Although MHNs were skeptical to utilize SDM, and patients often feel omitted, investing in inter-human contact increased the therapeutic alliance.

CONCLUSION

Tailored plan making and attainable goal setting, building trust, and providing hope are important incentives to enhance SDM.

Interventions involving own treatment choice for people living with coexisting severe mental illness and type 1 or 2 diabetes: A scoping review

AIM

The objective of this scoping review was to summarize, understand and provide an overview of the empirical literature on interventions involving own treatment choice for people with coexisting diabetes (type 1 and 2) and severe mental illness (SMI).

METHODS

This scoping review undertook a systematic literature assessment. Searches were performed in MEDLINE, Embase, PsycINFO, Web of Science, CINAHL, the Cochrane Library and grey literature (OpenGrey, Google Scholar and Danish Health and Medicine Authority databases). Publications from 2000 to July 2020 were of interest. Studies were included if they involved the users' own choice of treatment.

INCLUDED STUDIES

RCT, intervention, cohort and case-based studies.

RESULTS

A total of 4320 articles were screened, of which nine were included. The review identified eight studies from the United States and one from Canada testing different interventions for people with SMI and diabetes (one diabetes education program, five randomized controlled trials, one retrospective cohort study, one naturalistic intervention program and one case vignette). The interventions described in the nine articles involved service users, the majority incorporated individualized healthcare plans, and all interventions were based on multidisciplinary teamwork.

CONCLUSIONS

Research in the area is limited. Care management interventions tend to focus on a single condition, paradoxically excluding SMI during enrolment. Interventions aimed at people with both conditions often prioritize one condition treatment leading to an unbalanced care.

Lived Experiences of a Sustained Mental Health Recovery Process Without Ongoing Medication Use

Serious mental health conditions have historically been considered lifelong conditions, with substantial literature supporting pharmaceutical approaches to remission. More recently, the recovery movement has emphasized lasting recovery, which can occur through a variety of pathways. With the traditional focus on medication, less is known about the recovery process of persons who achieve sustained recovery without ongoing medication use. This qualitative study used a grounded theory approach to explore the recovery process of 19 participants with diagnoses of schizophrenia, bipolar disorder, or major depression who were in recovery and not taking medications for at least twelve months. Participants identified internal recovery processes (cognitive changes, emotional processes, and spirituality/faith) leading to a perspective change about self and symptoms. Participants also identified external recovery processes including both support received and productive ways of giving back. The study findings highlight the importance of self-efficacy, emotion management, and social giving in mental health recovery.

Shared Risk Taking: Shared Decision Making in Serious Mental Illness

Shared decision making (SDM) is an interpersonal health communication model that is underutilized with people with serious mental illness. Although research has emphasized the role of patient capacity-, clinician-, and system-related barriers in SDM underutilization, the risk taking that affects SDM with people with mental illness is less often discussed. This Open Forum presents a reconceptualization of SDM as a process of shared risk taking that often occurs during different phases of illness management and recovery. The concepts of intersubjectivity, meaning making, and metacognition are offered to inform clinical interventions needed to address risk in SDM.

Evaluating the feasibility of a decision aid to promote shared decision making among young adults with first-episode psychosis: protocol for a pilot study

BACKGROUND

Young adults ages 18 to 25 with first episode psychosis (FEP) have an increased risk of discontinuation antipsychotic medications and psychiatric service disengagement that lead to symptom exacerbation and deterioration. We seek to (1) examine the feasibility, usability, and potential impact of a Shared Decision Making (SDM) Antipsychotic Medication Decision Aid (DA) on decision-making, adherence to the decision made, and service engagement among young adults with FEP and (2) understand the role of additional patient-level factors on SDM.

METHODS

A randomized controlled trial is being conducted in a coordinated specialty care community program for FEP in an urban setting. Eligible patients are randomly assigned to receive an intervention, the Antipsychotic Medication Decision Aid, or treatment as usual. Patients receive their assigned intervention before their medication appointment with the psychiatrist and complete four interviews: before the appointment (T0), after the appointment (T1), and at 3- and 6-month follow-ups (T2 and T3). The study staff and participating psychiatrists are not blinded to the intervention. The data are de-identified to maintain blinding during the analysis process. The primary aims are feasibility of intervention delivery and research procedures and preliminary impact of the intervention on SDM-related outcomes, medication adherence, and service engagement. As a secondary aim, we will explore the contribution of personality and motivation variables, clinical relationships, cognitive functioning, and mental-health-related stigma to SDM. If the sample size permits, we plan to conduct parametric tests such as independent-samples t tests at T1 to compare differences in SDM, adherence, and engagement scales. In the case of a small sample size, we will use non-parametric tests and descriptive statistics.

DISCUSSION

This protocol outlines the methodology for a feasibility pilot comparing the effect of a novel SDM Antipsychotic Medication encounter DA with treatment as usual on SDM, medication adherence, and service engagement in FEP care. SDM is endorsed as a framework for use in FEP and antipsychotic pharmacotherapy, but its impact on adherence and health outcomes is unclear. Understanding the potential contribution of an SDM Antipsychotic Medication DA compared with usual care in psychosis pharmacotherapy is critical. The study will help answer several key questions new to SDM research, including the contribution of personality and clinical relationships to SDM in mental health and psychosis in particular. The study will serve to gather feasibility data to inform future studies and scale-up.

TRIAL REGISTRATION

Ethics approval was obtained through Temple University's institutional review board (IRB) and the City of Philadelphia's Department of Public Health IRB. The study has been retrospectively registered with ClinicalTrials.gov as NCT04373590 on 29 April 2020. https://clinicaltrials.gov/ct2/show/NCT04373590?term=NCT04373590&draw=2&rank=1.

Determinants of Therapeutic Alliance With People With Psychotic Disorders: A Systematic Literature Review

Therapeutic alliance determines medical treatment adherence, the success of psychotherapy, and the effectiveness of care. This systematic review aims at better understanding its determinants. The electronic databases Pubmed, Cochrane Library, and Web of Science were searched, using combinations of terms relating to psychosis and therapeutic alliance. Studies were selected and data were extracted using a PRISMA statement. Forty-one studies were selected, including 20 cross-sectional studies, 10 cohort studies, five randomized controlled trials, four literature reviews, and two retrospective studies. The quality of therapeutic alliance correlates with clinical symptoms, insight, social and family support, the therapist's qualities, the availability of shared therapeutic decision making, and the types of hospitalization. Although current evidence needs to be completed with further studies, it is already clear that group and family psychoeducation, cognitive remediation, community-based psychiatric services, and shared therapeutic decision making are essential approaches in the management of patients with psychosis.

Shared decision-making in mental and behavioural health interventions

Elements of shared decision-making (ie, collaboration, patient preferences, and working alliance) have long been discussed and studied in the field of clinical psychology; however, research indicates that shared decision-making is not typically used in clinical practice. Instead, clinicians often rely on a paternalistic approach. In this article, we provide a narrative review of the existing research supporting shared decision-making for mental and behavioural health concerns, we discuss several barriers that impede its use in actual clinical practice, and we provide recommendations for increasing shared decision-making when working with patients.

The Importance of Being Acceptable - Psychiatric Staffs' Talk about Women Patients in Forensic Care

Currently, women comprise about ten percent of those sentenced to psychiatric forensic clinics in Sweden. Those who are sentenced to forensic care because of offending and violent behaviour have already taken a step away from the usually expected female behaviour. On the other hand, there are many women in forensic care who have not committed crimes, but who instead self-harm. Studies have identified a gender bias in diagnosing and care in psychiatric settings, but there are few studies conducted on women in forensic care. The present study therefore examined how the situation of women patients and female norms are expressed in the staff's talk about these women during verbal handovers and ward rounds at a forensic clinic in Sweden. The aim was to explore how psychiatric staff, in a context of verbal handovers and ward rounds, talk about women who have been committed to forensic psychiatric care, and what consequences this might have for the care of the patients. The content of speech was examined using audio recordings and a method of analysis that was inspired by thematic analysis. The analysis identified that the staff talked about the women in a way that indicates that they expected the women to follow the rules and take responsibility for their bodies in order to be regarded as acceptable patients.

Unraveling the insight paradox: One-year longitudinal study on the relationships between insight, self-stigma, and life satisfaction among people with schizophrenia spectrum disorders

The promotion of insight among people with schizophrenia spectrum disorders has posed a dilemma to service providers as higher insight has been linked to positive clinical outcomes but negative psychological outcomes. The negative meaning that people attached to the illness (self-stigma content) and the recurrence of such stigmatizing thoughts (self-stigma process) may explain why increased insight is associated with negative outcomes. The present study examined how the presence of high self-stigma content and self-stigma process may contribute to the negative association between insight and life satisfaction. A total of 181 people with schizophrenia spectrum disorders were assessed at baseline. 130 and 110 participants were retained and completed questionnaire at 6-month and 1-year follow-up, respectively. Results showed that baseline insight was associated with lower life satisfaction at 6-month when self-stigma process or self-stigma content was high. Furthermore, baseline insight was predictive of better life satisfaction at 1-year follow-up when self-stigma process was low. Findings suggested that the detrimental effects of insight can be a result from both the presence of cognitive content and habitual process of self-stigma. Future insight promotion interventions should also address self-stigma content and process among people with schizophrenia spectrum disorders so as to maximize the beneficial effects of insight.

A multicenter, randomized controlled trial of individualized occupational therapy for patients with schizophrenia in Japan

The individualized occupational therapy (IOT) program is a psychosocial program that we developed to facilitate proactive participation in treatment and improve cognitive functioning and other outcomes for inpatients with acute schizophrenia. The program consists of motivational interviewing, self-monitoring, individualized visits, handicraft activities, individualized psychoeducation, and discharge planning. This multicenter, open-labeled, blinded-endpoint, randomized controlled trial evaluated the impact of adding IOT to a group OT (GOT) program as usual for outcomes in recently hospitalized patients with schizophrenia in Japanese psychiatric hospitals setting compared with GOT alone. Patients with schizophrenia were randomly assigned to the GOT+IOT group or the GOT alone group. Among 136 randomized patients, 129 were included in the intent-to-treat population: 66 in the GOT+IOT and 63 in the GOT alone groups. Outcomes were administered at baseline and discharge or 3 months following hospitalization including the Brief Assessment of Cognition in Schizophrenia Japanese version (BACS-J), the Schizophrenia Cognition Rating Scale Japanese version, the Social Functioning Scale Japanese version, the Global Assessment of Functioning scale, the Intrinsic Motivation Inventory Japanese version (IMI-J), the Morisky Medication Adherence Scale-8 (MMAS-8), the Positive and Negative Syndrome Scale (PANSS), and the Japanese version of Client Satisfaction Questionnaire-8 (CSQ-8J). Results of linear mixed effects models indicated that the IOT+GOT showed significant improvements in verbal memory (p <0.01), working memory (p = 0.02), verbal fluency (p < 0.01), attention (p < 0.01), and composite score (p < 0.01) on the BACS-J; interest/enjoyment (p < 0.01), value/usefulness (p < 0.01), perceived choice (p < 0.01), and IMI-J total (p < 0.01) on the IMI-J; MMAS-8 score (p < 0.01) compared with the GOT alone. Patients in the GOT+IOT demonstrated significant improvements on the CSQ-8J compared with the GOT alone (p < 0.01). The present findings provide support for the feasibility in implementing an IOT program and its effectiveness for improving cognitive impairment and other outcomes in patients with schizophrenia.

Exploring the potential implementation of a tool to enhance shared decision making (SDM) in mental health services in the United Kingdom: a qualitative exploration of the views of service users, carers and professionals

BACKGROUND

As a response to evidence that mental health service users and carers expect greater involvement in decisions about antipsychotic medication choice and prescribing, shared decision-making (SDM) has increasingly come to be viewed as an essential element of person-centred care and practice. However, this aspiration has yet to be realised in practice, as service users and carers continue to feel alienated from healthcare services. Existing understanding of the factors affecting the use of tools to support SDM is limited to inter-individual influences and wider factors affecting potential implementation are underexplored.

AIM

To explore the potential use of a tool designed to enhance collaborative antipsychotic prescribing from the perspectives of secondary care mental health service users, carers and professionals.

METHODS

We conducted a qualitative study (semi-structured interviews and focus groups) using a convenience sample of 33 participants (10 mental health service users, 10 carers and 13 professionals) involved in antipsychotic prescribing in one Trust in the North of England. Participants were asked about the potential implementation of a tool to support SDM within secondary mental health services. Framework analysis incorporating the use of constant comparative method was used to analyse the data.

RESULTS

The study identified a divergence in the views of service users and professionals, including a previously undocumented tendency for stakeholder groups to blame each other for potential implementation failure. This dissonance was shaped by meso and macro level influences relating to paternalism, legislative frameworks, accountability and lack of resources. Participants did not identify any macro level (policy or structural) facilitators to the use of the tool highlighting the negative impact of mental health contexts. Our study indicated that inter-individual factors are likely to be most important to implementation, given their potential to transcend meso and macro level barriers.

CONCLUSIONS

Consideration of the meso and macro level influences identified areas for potential intervention, including challenging professionals' and service users' perceptions of each other, rebalancing the notion of accountability within services and introducing new means for service user feedback on the quality of SDM. Multi-level strategies for facilitating the implementation of tools to support SDM are also presented.

Common sense model of mental illness: Understanding the impact of cognitive and emotional representations of mental illness on recovery through the mediation of self-stigma

The present study applied the common sense model to understand the underlying mechanism of how cognitive and emotional representations of mental illness among people in recovery of mental illness would impact their endorsement of self-stigma, and how that would, in turn, affect clinical and personal recovery. A cross-sectional survey was administered to 376 people in recovery. Participants were recruited from seven public specialty outpatient clinics and substance abuse assessment clinics across various districts in Hong Kong. They were asked to report their perception towards their mental illness, self-stigma, symptom severity, and personal recovery. The results of structural equation modeling partially supported the hypothesized mediation model indicating that controllability, consequences, and emotional concern of mental illness, but not cause, timeline, and identity, were associated with self-stigma, which was subsequently negatively associated with clinical and personal recovery. The present study demonstrated the mediating role of self-stigma in the relationship between individuals' illness representations towards their mental illness and their recovery. Illness management programs aimed at addressing the maladaptive mental illness-related beliefs and emotions are recommended. Implications on developing self-directed and empowering mental health services are discussed.

Development of an Individualized Occupational Therapy Programme and its Effects on the Neurocognition, Symptoms and Social Functioning of Patients with Schizophrenia

We described an individualized occupational therapy (IOT) programme and examined the effects of adding IOT to group OT (GOT) on improving neurocognition, symptoms and social functioning among recently hospitalized patients with schizophrenia. The Brief Assessment of Cognition in Schizophrenia-Japanese version (BACS-J), the Positive and Negative Syndrome Scale (PANSS) and the Global Assessment of Functioning scale were used for outcome evaluations. Fifty-one patients were voluntarily assigned to either the GOT + IOT (n = 30) or GOT alone (n = 21) groups based on their preferences. Retention in the GOT + IOT group was 100%. Three-month baseline to discharge assessments in the GOT + IOT group showed significant improvements in BACS-J verbal memory, working memory, verbal fluency, attention, executive function and composite score, and in PANSS positive subscale, general psychopathology subscale, and total score compared to the GOT alone group. Study limitations notwithstanding, the present findings provide preliminary support for the feasibility of implementing IOT and its effectiveness for improving cognitive impairment and symptoms in patients with schizophrenia. The results of this study indicate that IOT in psychiatric facilities may improve psychosocial treatment of schizophrenia. Additional study is warranted to replicate the effects of IOT as demonstrated in this Japanese study. Copyright © 2016 John Wiley & Sons, Ltd.

The Talk About the Psychiatric Patient

Essential to psychiatric nursing practice and care, verbal handovers and ward rounds are reporting systems for communication that shapes psychiatric staff's ability to recognize, understand, and construct patients, as well as patients' ability to construct themselves. Given the centrality of such language in psychiatric practice, the aim of this study was to describe how psychiatric staff talk about patients in psychiatric wards, what their talk encompasses, and what consequences it might pose for patient care. Empirical data were collected from audio recordings of staff discussions of patients during nine verbal handovers and three ward rounds in six different general psychiatric wards in mid and southern Sweden. Findings showed that to describe patients' mood, characteristics, and behavior, nurses used culturally common words and concepts related to three themes-good patients, bad patients, and to stay or be discharged-and six subthemes-looking well, looking poorly, desirable patients, undesirable patients, continuing work, and being discharged. However, since assessments of and decisions about patients' conditions and care used everyday language and did not involve patients' participation, opportunities for patients to participate in their own care were rare.

Associations of symptoms, neurocognition, and metacognition with insight in schizophrenia spectrum disorders

Many persons with schizophrenia experience poor insight and, as a result, are at risk for treatment non-adherence and numerous negative outcomes. However, to date, the etiology of poor insight has not yet been fully elucidated. One recent theory concerning the roots of poor insight in schizophrenia has proposed that it may result, in part, from impairments in metacognition, or the capacity to think about thinking. The present study thus aims to examine whether metacognition is associated with insight even after controlling for the effects of psychiatric symptomatology and neurocognition. In this study, 95 adults with a schizophrenia spectrum disorder were assessed on measures of insight (i.e., awareness of symptoms, treatment needs, and illness consequences), psychiatric symptoms (i.e., positive symptoms, negative symptoms, and general psychopathology), neurocognitive functions (i.e., executive function, memory, and attention), and metacognitive capacities (i.e., self-reflectivity and theory of mind). Univariate correlations followed by stepwise multiple regressions, which controlled for symptoms and neurocognition, indicated that both self-reflectivity and theory of mind were significantly linked with awareness of symptoms; theory of mind was linked with awareness of treatment needs; and self-reflectivity was linked with awareness of illness consequences. Importantly, these findings suggest that metacognitive capacities may be related to insight independent of concurrent psychiatric symptoms and neurocognitive deficits. Moreover, awareness of different facets of the illness may require contributions from different components of metacognition. Future research should investigate how existing metacognitive skill training programs could potentially be tailored, or modified, to help persons with schizophrenia to develop and enhance insight.

Service users' experiences of participation in decision making in mental health services

ACCESSIBLE SUMMARY

Despite the potential positive impact of shared decision making on service users knowledge and experience of decisional conflict, there is a lack of qualitative research on how participation in decision making is promoted from the perspective of psychiatric service users. This study highlights the desire of users to participate more actively in decision making and demonstrates that persons with SMI struggle to be seen as competent and equal partners in decision-making situations. Those interviewed did not feel that their strengths, abilities and needs were being recognized, which resulted in a feeling of being omitted from involvement in decision-making situations. The service users describe some essential conditions that could work to promote participation in decision making. These included having personal support, having access to knowledge, being involved in a dialogue and clarity about responsibilities. Mental health nurses can play an essential role for developing and implementing shared decision making as a tool to promote recovery-oriented mental health services.

ABSTRACT

Service user participation in decision making is considered an essential component of recovery-oriented mental health services. Despite the potential of shared decision making to impact service users knowledge and positively influence their experience of decisional conflict, there is a lack of qualitative research on how participation in decision making is promoted from the perspective of psychiatric service users. In order to develop concrete methods that facilitate shared decision making, there is a need for increased knowledge regarding the users' own perspective. The aim of this study was to explore users' experiences of participation in decisions in mental health services in Sweden, and the kinds of support that may promote participation. Constructivist Grounded Theory (CGT) was utilized to analyse group and individual interviews with 20 users with experience of serious mental illness. The core category that emerged in the analysis described a 'struggle to be perceived as a competent and equal person' while three related categories including being the underdog, being controlled and being omitted described the difficulties of participating in decisions. The data analysis resulted in a model that describes internal and external conditions that influence the promotion of participation in decision making. The findings offer new insights from a user perspective and these can be utilized to develop and investigate concrete methods in order to promote user's participation in decisions.

Pursuing concordance: moving away from paternalism

In the second of two articles exploring the value and application of concordance across nursing practice the discussion is aimed at clinical settings and patient groups where concordance may have been viewed as impractical. The author harnesses Cribb and Entwhistle's broader conception of shared decision making and the notion of decision-making capacity as a continuum to argue that concordance can be pursued effectively in challenging settings such as childcare practice, mental health and the care of older people. As in the first paper ( McKinnon, 2013 ) the discussion is not limited to medicines management but remains engaged with all aspects of nursing practice. Legal and ethical frameworks, social participation theory and research across healthcare practice are sourced to argue for concordant approaches in the care of patients who may at times have compromised decision-making capacity. Ideas of direct and indirect concordance are explored.

Consultant psychiatrists' experiences of and attitudes towards shared decision making in antipsychotic prescribing, a qualitative study

BACKGROUND

Shared decision making represents a clinical consultation model where both clinician and service user are conceptualised as experts; information is shared bilaterally and joint treatment decisions are reached. Little previous research has been conducted to assess experience of this model in psychiatric practice. The current project therefore sought to explore the attitudes and experiences of consultant psychiatrists relating to shared decision making in the prescribing of antipsychotic medications.

METHODS

A qualitative research design allowed the experiences and beliefs of participants in relation to shared decision making to be elicited. Purposive sampling was used to recruit participants from a range of clinical backgrounds and with varying length of clinical experience. A semi-structured interview schedule was utilised and was adapted in subsequent interviews to reflect emergent themes.Data analysis was completed in parallel with interviews in order to guide interview topics and to inform recruitment. A directed analysis method was utilised for interview analysis with themes identified being fitted to a framework identified from the research literature as applicable to the practice of shared decision making. Examples of themes contradictory to, or not adequately explained by, the framework were sought.

RESULTS

A total of 26 consultant psychiatrists were interviewed. Participants expressed support for the shared decision making model, but also acknowledged that it was necessary to be flexible as the clinical situation dictated. A number of potential barriers to the process were perceived however: The commonest barrier was the clinician's beliefs regarding the service users' insight into their mental disorder, presented in some cases as an absolute barrier to shared decision making. In addition factors external to the clinician - service user relationship were identified as impacting on the decision making process, including; environmental factors, financial constraints as well as societal perceptions of mental disorder in general and antipsychotic medication in particular.

CONCLUSIONS

This project has allowed identification of potential barriers to shared decision making in psychiatric practice. Further work is necessary to observe the decision making process in clinical practice and also to identify means in which the identified barriers, in particular 'lack of insight', may be more effectively managed.

The mediating role of self-stigma and unmet needs on the recovery of people with schizophrenia living in the community

PURPOSE

For people with schizophrenia living in the community and receiving outpatient care, the issues of stigma and discrimination and dearth of recovery-oriented services remain barriers to recovery and community integration. The experience of self-stigma and unmet recovery needs can occur regardless of symptom status or disease process, reducing life satisfaction and disrupting overall well-being. The present study examined the mediating role of self-stigma and unmet needs in the relationship between psychiatric symptom severity and subjective quality of life.

METHODS

Structural equation modeling and mediation analyses were conducted based on a community sample of 400 mental health consumers with schizophrenia spectrum disorders in Hong Kong.

RESULTS

The model of self-stigma and unmet needs as mediators between symptom severity and subjective quality of life had good fit to the data (GFI = .93, CFI = .93, NNFI = .92, RMSEA = .06, χ(2)/df ratio = 2.62). A higher level of symptom severity was significantly associated with increased self-stigma (R (2) = .24) and a greater number of unmet needs (R (2) = .53). Self-stigma and unmet needs were in turn negatively related to subjective quality of life (R (2) = .45).

CONCLUSIONS

It is essential that service providers and administrators make greater efforts to eliminate or reduce self-stigma and unmet recovery needs, which are associated with the betterment of the overall quality of life and long-term recovery. Both incorporating empowerment and advocacy-based interventions into recovery-oriented services and providing community-based, person-centered services to people based on personally defined needs are important directions for future recovery-oriented efforts.

A virtual reality-integrated program for improving social skills in patients with schizophrenia: a pilot study

BACKGROUND AND OBJECTIVES

Social skills training (SST) intervention has shown its efficacy to improve social dysfunction in patients with psychosis; however the implementation of new skills into patients' everyday functioning is difficult to achieve. In this study, we report results from the application of a virtual reality (VR) integrated program as an adjunct technique to a brief social skills intervention for patients with schizophrenia. It was predicted that the intervention would improve social cognition and performance of patients as well as generalisation of the learned responses into patient's daily life.

METHODS

Twelve patients with schizophrenia or schizoaffective disorder completed the study. They attended sixteen individual one-hour sessions, and outcome assessments were conducted at pre-treatment, post-treatment and four-month follow-up.

RESULTS

The results of a series of repeated measures ANOVA revealed significant improvement in negative symptoms, psychopathology, social anxiety and discomfort, avoidance and social functioning. Objective scores obtained through the use of the VR program showed a pattern of learning in emotion perception, assertive behaviours and time spent in a conversation. Most of these gains were maintained at four-month follow-up.

LIMITATIONS

The reported results are based on a small, uncontrolled pilot study. Although there was an independent rater for the self-reported and informant questionnaires, assessments were not blinded.

CONCLUSIONS

The results showed that the intervention may be effective for improving social dysfunction. The use of the VR program contributed to the generalisation of new skills into the patient's everyday functioning.

A brief cognitive-behavioural social skills training for stabilised outpatients with schizophrenia: a preliminary study

Achieving social functioning and achieving social competence are two main objectives of psychosocial interventions for people suffering from schizophrenia. The present preliminary study presents a novel approach of social skills training (SST) based on the proposals of Kopelowicz et al. (Kopelowicz, A., Liberman, R. P., and Zarate, R., 2006. Schizophr. Bull. 32 (1): S12-23) that link the treatment to seven specific target behaviours: social perception, social information processing, responding and sending skills, affiliative skills, interactional skills, and behaviour governed by social norms. Thirty-one stabilised outpatients were randomly assigned to one of two groups, SST (n=13) or treatment-as-usual (n=18) (TAU; case management, medication adherence, psychotherapy, leisure engagement, and family support) and were assessed at baseline in cognitive performance, clinical symptomatology, social cognition, and psychosocial functioning. These outcomes were evaluated across post-treatment and at the 6-month follow-up appointment. SST subjects showed improvements in psychopathology, social discomfort, social cognition (self-regulation statements during interactions), social withdrawal, interpersonal communication, and quality of life compared with the TAU group. At the 6-month follow-up, results were maintained for negative symptoms, social discomfort, and some functioning outcomes. Neuropsychological variables were also examined, as mediators of benefit from skills training. Results support the efficacy of the brief SST for outpatients with schizophrenia and show the need to implement empirically supported interventions in mental health services to enhance patients' social functioning and quality of life.