To what extent psychiatric patients feel involved in decision making about their mental health care? Relationships with socio-demographic, clinical, and psychological variables

A scoping review into the explanations for differences in the degrees of shared decision making experienced by patients

OBJECTIVES

In order to improve the degree of shared decision making (SDM) experienced by patients, it is necessary to gain insight into the explanations for the differences in these degrees.

METHODS

A scoping review of the literature on the explanations for differences in the degree of SDM experienced by patients was conducted. We assessed 21,329 references. Ultimately, 308 studies were included. The explanations were divided into micro, meso, and macro levels.

RESULTS

The explanations are mainly related to the micro level. They include explanations related to the patient and healthcare professionals, the relationship between the patient and the physician, and the involvement of the patient's relatives. On the macro level, explanations are related to restrictions within the healthcare system such as time constraints, and adequate information about treatment options. On the meso level, explanations are related to the continuity of care and the involvement of other healthcare professionals.

CONCLUSIONS

SDM is not an isolated process between the physician and patient. Explanations are connected to the macro, meso, and micro levels.

PRACTICE IMPLICATIONS

This scoping review suggests that there could be more focus on explanations related to the macro and meso levels, and on how explanations at different levels are interrelated.

Shared decision making and associated factors among patients with psychotic disorders: a cross-sectional study

BACKGROUND

Shared decision making is a process where patients and clinicians collaborate to make treatment choices based on the patients' preferences and best available evidence. The implementation of shared decision making remains limited for patients with psychotic disorders despite being recommended at policy level, being advocated as ethical right and wanted by the patient's. A barrier to implementation that is often mentioned is reduced decision-making capacity among patients. The challenges of implementing shared decision making highlights a need for more knowledge on shared decision making for these patients. Moreover, the association between patient-related characteristics and shared decision making is unclear, and further research have been suggested. More knowledge of factors associated with involvement in shared decision making can enhance understanding and help to empower patients in the decision-making process. The current study examined the extent of reported shared decision making among patients with a psychotic disorder in mental health care and factors associated with shared decision making.

METHODS

This study included 305 participants with a psychotic disorder from 39 clinical inpatient and outpatient sites across Norway. Shared decision making was assessed using the CollaboRATE survey. A linear mixed model was estimated to assess characteristics associated with shared decision making scores.

RESULTS

The CollaboRATE mean score was 6.3 (ranging from 0 to 9), the top score was 14.1% and increased global satisfaction with services was significantly associated with a higher level of shared decision making (regression coefficient 0.27, 95% confidence interval (0.23; 0.32), p < 0.001).

CONCLUSIONS

The low top score shows that few patients felt that they received the highest possible quality of shared decision making, indicating that many patients found room for improvement. This suggests that services for patients with psychotic disorders should be designed to give them a greater role in decision making. Shared decision making might play a key role in mental health care, ensuring that patients with psychotic disorders are satisfied with the services provided.

TRIAL REGISTRATION

NCT03271242, date of registration: 5 Sept. 2017.

Factors Influencing Participation in Shared Decision-Making Among Patients with Glaucoma in China: A Cross-Sectional Study

Purpose

To explore the level of participation in shared decision-making by patients with glaucoma and identify influencing factors, to subsequently provide references to promote shared decision-making in ophthalmology, and achieve patient-centered care.

Patients and Methods

A questionnaire was completed by 148 patients with glaucoma who had been admitted to a specialized ophthalmic hospital in China, between October 2021 and January 2022. The participants' responses to the nine-item Shared Decision-Making Questionnaire (SDM-Q-9) and a general information survey were analyzed to determine their level of participation in shared decision-making and influencing factors. Multiple linear regression was used to identify factors that influence shared decision-making at the time of clinical practice.

Results

The mean score of SDM-Q-9 was 71.73±21.27 (n=140). Multiple linear regression analysis showed that patients with negative attitudes towards participation in decision-making (P=0.023) and those who had rural insurance (P=0.017) had significantly lower SDM-Q-9 scores than those with positive attitudes and those with medical insurance. Patients who were more satisfied with their medical service had higher SDM-Q-9 scores (P<0.05).

Conclusion

Patients with glaucoma presented a high level of shared decision-making. Patients' attitudes towards participating in decision-making, the payment method of medical expenses, and the level of satisfaction with medical services are factors that influence their level of participation in shared decision-making.

"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.

Personalized care planning and shared decision making in collaborative care programs for depression and anxiety disorders: A systematic review

BACKGROUND

Collaborative care is an evidence-based approach to improving outcomes for common mental disorders in primary care. Efforts are underway to broadly implement the collaborative care model, yet the extent to which this model promotes person-centered mental health care has been little studied. The aim of this study was to describe practices related to two patient and family engagement strategies-personalized care planning and shared decision making-within collaborative care programs for depression and anxiety disorders in primary care.

METHODS

We conducted an update of a 2012 Cochrane review, which involved searches in Cochrane CCDAN and CINAHL databases, complemented by additional database, trial registry, and cluster searches. We included programs evaluated in a clinical trials targeting adults or youth diagnosed with depressive or anxiety disorders, as well as sibling reports related to these trials. Pairs of reviewers working independently selected the studies and data extraction for engagement strategies was guided by a codebook. We used narrative synthesis to report on findings.

RESULTS

In total, 150 collaborative care programs were analyzed. The synthesis showed that personalized care planning or shared decision making were practiced in fewer than half of programs. Practices related to personalized care planning, and to a lesser extent shared decision making, involved multiple members of the collaborative care team, with care managers playing a pivotal role in supporting patient and family engagement. Opportunities for quality improvement were identified, including fostering greater patient involvement in collaborative goal setting and integrating training and decision aids to promote shared decision making.

CONCLUSION

This review suggests that personalized care planning and shared decision making could be more fully integrated within collaborative care programs for depression and anxiety disorders. Their absence in some programs is a missed opportunity to spread person-centered mental health practices in primary care.

How are patient-related characteristics associated with shared decision-making about treatment? A scoping review of quantitative studies

OBJECTIVES

To identify what patient-related characteristics have been reported to be associated with the occurrence of shared decision-making (SDM) about treatment.

DESIGN

Scoping review.

ELIGIBILITY CRITERIA

Peer-reviewed articles in English or Dutch reporting on associations between patient-related characteristics and the occurrence of SDM for actual treatment decisions.

INFORMATION SOURCES

COCHRANE Library, Embase, MEDLINE, PsycInfo, PubMed and Web of Science were systematically searched for articles published until 25 March 2019.

RESULTS

The search yielded 5289 hits of which 53 were retained. Multiple categories of patient characteristics were identified: (1) sociodemographic characteristics (eg, gender), (2) general health and clinical characteristics (eg, symptom severity), (3) psychological characteristics and coping with illness (eg, self-efficacy) and (4) SDM style or preference. Many characteristics showed no association or unclear relationships with SDM occurrence. For example, for female gender positive, negative and, most frequently, non-significant associations were seen.

CONCLUSIONS

A large variety of patient-related characteristics have been studied, but for many the association with SDM occurrence remains unclear. The results will caution often-made assumptions about associations and provide an important step to target effective interventions to foster SDM with all patients.

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.

Relationships among Antecedents, Processes, and Outcomes for Shared Decision Making: A Cross-Sectional Survey of Patients with Lumbar Degenerative Disease

BACKGROUND

Among musculoskeletal disorders, lumbar degenerative disease (LDD) is the leading cause of total disability-adjusted life years globally. Clinical guidelines for LDD describe multiple treatment options in which shared decision making becomes appropriate.

OBJECTIVES

To explore the relationships among measures of decision antecedents, process, and outcomes in patients with LDD.

METHODS

Patients with LDD were recruited from outpatient clinics in a teaching hospital in Taiwan and administered surveys to collect measures of decision antecedents, processes, and outcomes. Multiple linear regression was conducted to assess the association between decision antecedents and the decision making process. Hierarchical linear regression was conducted to assess the relationships among decision antecedents, the decision making process, and decision outcomes.

RESULTS

A total of 132 patients (mean age, 61 years) completed the survey. After adjustment for personal factors, 2 decision antecedents (namely, decision making self-efficacy and readiness) significantly predicted patients' experiences of engaging in shared decision making (SDM). Decision making readiness and process were associated with fewer decisional conflicts and greater decision satisfaction.

LIMITATIONS

Models derived from cross-sectional surveys cannot establish causal relationships among decision antecedents, decision making processes, and decision outcomes.

CONCLUSIONS

Our results support the SDM framework, which proposes relationships among decision antecedents, the decision making process, and decision outcomes.

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.

Shared Decision-Making and Role Preference Among Patients With Schizophrenia in Malaysia: A Cross-Sectional Study

Introduction: Shared decision-making (SDM) is recognized as a promising strategy for improving collaboration between clinicians and their patients in achieving recovery. In Malaysia, SDM among people with schizophrenia is still lacking both in practice and in research. This study aimed to determine the level of SDM and role preference and their associated factors among patients with schizophrenia in Malaysia. Methods: A cross-sectional study was conducted on 86 outpatient attendees with schizophrenia at a teaching hospital in Kuala Lumpur, Malaysia. The nine-item Shared Decision Making Questionnaire and Control Preference Scale were used to assess perceived SDM experience and role preference, respectively. Linear and logistic regression models were used to analyze the factors associated with SDM and role preference, respectively. Factors with a p <0.25 from the simple regression analyses were controlled as the covariates in the multiple regression analyses. Results: The study respondents were predominantly female, single, and unemployed, with a mean age of 44 years. Only 35% of the participants reported having high SDM experiences, even though the majority (56%) preferred autonomous role preference. Among the participants who preferred autonomous roles, only 40% experienced high SDM. High SDM was found to be significantly associated with being younger (B = -0.33, 95% CI = -0.67 to -0.003) and being non-clozapine users (B = 19.90, 95% CI = 9.39-30.41), while autonomous role preference was significantly associated with a lower level of insight [adjusted odds ratio (AOR) = 0.84, 95% CI = 0.72-0.99] and being on oral antipsychotic drugs only (AOR = 2.94, 95% CI = 1.10-7.82). Conclusion: The practice of SDM is still lacking in the treatment of patients with schizophrenia in Malaysia, even though many of them preferred to be involved in the decision-making pertaining to their treatment. This study indicates the need for clinicians to improve their patients' involvement in the treatment process. More research is needed on how SDM can be implemented in patients with schizophrenia, especially in Asian population settings.

Exploring goal planning in mental health service delivery: a systematic review protocol

INTRODUCTION

Goal planning is widely recognised as an integral part of mental health service delivery and an important element in supporting recovery. Goal planning identifies priorities for treatment through discussion and negotiation between service users and health practitioners. Goal planning enhances motivation, directs effort, and focuses the development of strategies and treatment options to improve recovery outcomes and promote service users' ownership of the recovery process. While goal planning is a common practice in mental health settings, evidence regarding its impact on treatment outcomes is lacking. This paper outlines a protocol for a systematic review that aims to explore the types of goals planned, experiences of service users and practitioners, and the effectiveness of goal planning as a mental health intervention.

METHODS AND ANALYSIS

A systematic search will be conducted during March 2021 by searching Medline, CINAHL, Embase, Scopus and PsycINFO electronic databases to answer the following questions: (1) What types of goals are being developed within mental healthcare?; (2) What is the evidence for the effectiveness of goal planning on health and well-being for mental health service users?; (3) What are the experiences of mental health service users and their treating healthcare practitioners in relation to goal planning?; and (4) What are the barriers and facilitators to effective goal planning in mental health settings? Two independent researchers will screen the articles, selecting literature that meets criteria. All literature, regardless of study design that involves adult participants, with a mental illness and reporting on goal planning will be considered for inclusion. Data will be extracted from all eligible articles regardless of study design and summarised in a table. Appropriate quality assessment and data synthesis methods will be determined based on included study designs.

ETHICS AND DISSEMINATION

No ethics approval is required. The results will be disseminated through peer-reviewed publications and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42020220595.

Exploring patterns in psychiatric outpatients' preferences for involvement in decision-making: a latent class analysis approach

BACKGROUND

Shared decision-making (SDM), a collaborative approach that includes and respects patients' preferences for involvement in decision-making about their treatment, is increasingly advocated. However, in the practice of clinical psychiatry, implementing SDM seems difficult to accomplish. Although the number of studies related to psychiatric patients' preferences for involvement is increasing, studies have largely focused on understanding patients in public mental healthcare settings. Thus, investigating patient preferences for involvement in both public and private settings is of particular importance in psychiatric research. The objectives of this study were to identify different latent class typologies of patient preferences for involvement in the decision-making process, and to investigate how patient characteristics predict these typologies in mental healthcare settings.

METHODS

We conducted latent class analysis (LCA) to identify groups of psychiatric outpatients with similar preferences for involvement in decision-making to estimate the probability that each patient belonged to a certain class based on sociodemographic, clinical and health belief variables.

RESULTS

The LCA included 224 consecutive psychiatric outpatients' preferences for involvement in treatment decisions in public and private psychiatric settings. The LCA identified three distinct preference typologies, two collaborative and one passive, accounting for 78% of the variance. Class 1 (26%) included collaborative men aged 34-44 years with an average level of education who were treated by public services for a depressive disorder, had high psychological reactance, believed they controlled their disease and had a pharmacophobic attitude. Class 2 (29%) included collaborative women younger than 33 years with an average level of education, who were treated by public services for an anxiety disorder, had low psychological reactance or health control belief and had an unconcerned attitude toward medication. Class 3 (45%) included passive women older than 55 years with lower education levels who had a depressive disorder, had low psychological reactance, attributed the control of their disease to their psychiatrists and had a pharmacophilic attitude.

CONCLUSIONS

Our findings highlight how psychiatric patients vary in pattern of preferences for treatment involvement regarding demographic variables and health status, providing insight into understanding the pattern of preferences and comprising a significant advance in mental healthcare research.

Mental health professionals' experiences with shared decision-making for patients with psychotic disorders: a qualitative study

BACKGROUND

Shared decision-making (SDM) is a process whereby clinicians and patients work together to select treatments based on both the patient's preferences and clinical evidence. Although patients with psychotic disorders want to participate more in decisions regarding their care, they have limited opportunities to do so because of various barriers. Knowing about health professionals' experiences with SDM is important toward achieving successful implementation. The study aim was to describe and explore health professionals' SDM experiences with patients with psychotic disorders.

METHODS

Three focus group interviews were conducted, with a total of 18 health professionals who work at one of three Norwegian community mental health centres where patients with psychotic disorders are treated. We applied a descriptive and exploratory approach using qualitative content analysis.

RESULTS

Health professionals primarily understand the SDM concept to mean giving patients information and presenting them with a choice between different antipsychotic medications. Among the barriers to SDM, they emphasized that patients with psychosis have a limited understanding of their health situation and that time is needed to build trust and alliances. Health professionals mainly understand patients with psychotic disorders as a group with limited abilities to make their own decisions. They also described the concept of SDM with little consideration of presenting different treatment options. Psychological or social interventions were often presented as complementary to antipsychotic medications, rather than as an alternative to them.

CONCLUSION

Health professionals' understanding of SDM is inconsistent with the definition commonly used in the literature. They consider patients with psychotic disorders to have limited abilities to participate in decisions regarding their own treatment. These findings suggest that health professionals need more theoretical and practical training in SDM.

Assessment of shared decision-making in community mental health care: Validation of the CollaboRATE

Background/Objective

CollaboRATE is a 3-item self-report measure of the patient experience of shared decision-making (SDM) process. The objective of this study is to assess the psychometric properties of CollaboRATE in community mental health care.

Method

A cross-sectional study was conducted at a Community Mental Health Center of the Canary Islands Health Service. Two hundred and fifty consecutive psychiatric outpatients were invited to participate. Of those, 191 accepted (76.40% of response rate) and completed the CollaboRATE, the Control Preferences Scale (CPS), and a form with sociodemographic and clinical variables.

Results

Exploratory factor analysis ratified the unidimensionality of the measure. High internal consistency was found (α Cronbach = .95, Guttman's λ = .93, and ω = .95). Strong positive correlations (p < .0001) were found between the CollaboRATE and the CPS. Only 39.80% of respondents gave the best possible score on CollaboRATE.

Conclusions

This study provides evidence for the reliability and validity of the Spanish version of the CollaboRATE as a measure of SDM. The measure is quick to complete and feasible for use in outpatient mental health care. At present, a significative number of psychiatric outpatients are not involved in SDM. The use of this measure in psychiatric routine care can be a key tool in assessing and implementing SDM.

When does shared decision making is adopted in psychiatric clinical practice? Results from a European multicentric study

To identify factors associated with the use of shared decision making in routine mental health care in a large multicenter European study. Data have been collected within the study "Clinical decision making and outcome in routine care for people with severe mental illness" (CEDAR), which is a naturalistic, longitudinal, observational study carried out in six European countries. Patients with a severe mental illness attending outpatient units and their treating clinicians have been recruited. Clinicians' Clinical Decision Making (CDM) styles have been explored through the Clinical Decision Making Style Scale. Patients' clinical and social outcomes have been assessed through validated assessment instruments. The sample consisted of 588 patients and 213 professionals. Professionals were mainly psychiatrists (35.7%), nurses (21.6%), support workers, social workers or occupational therapists (24.9%), psychologists (9.9%) or trainees in psychiatry (4.7%). In the majority of cases, clinicians adopted a shared CDM style. Shared CDM was more frequently adopted with patients with psychotic disorders, with a better quality of life and social functioning. At multivariate analyses, the likelihood of adopting shared decision making increased in patients with higher levels of interpersonal relationships' skills (p < 0.05) and global functioning (p < 0.01). On the contrary, being a trainee in psychiatry reduced the likelihood of adopting shared CDM (p < 0.008). Shared decision making has been adopted mainly when patients have a better functioning and less severe clinical symptomatology and by less trained clinicians, differently from national and international recommendations. More efforts should be made to implement interventions to promote shared CDM, with a specific focus for trainees in psychiatry.

Shared decision-making preferences in mental health: does age matter? A systematic review

BACKGROUND

Research to date suggests older adults prefer a passive involvement in the clinical decision-making process; however, the empirical evidence underlying this claim in the mental health context is yet to be reviewed systematically.

AIMS

To understand whether older adults desire involvement in mental health-related clinical decisions.

METHOD

A systematic review was conducted to identify primary research that explored mental-health decision-making preferences of people with a mean age of over 55 from January 1990 through to December 2018.

RESULTS

Three independent studies of varying design and quality were included. Study settings were in the USA, Germany, and the UK. A preference for shared decision-making was seen in two studies, while a preference for active decision-making was identified in one.

CONCLUSIONS

In contrast to other reviews on clinical decision-making, this review focused on mental health-related decisions of older adults. The evidence suggests older adults desire involvement in mental health-related clinical decisions. Given the political drive to empower patients and the need to ensure evidence-based clinical practice, more high-quality research regarding the shared decision-making preferences and outcomes of older adults with mental ill-health is needed. Systematic Review Registration PROSPERO: CRD42018102009.

Treatment Attitudes and Adherence Among Patients with Bipolar Disorder: A Systematic Review of Quantitative and Qualitative Studies

BACKGROUND

Systematic reviews about treatment attitudes of patients influencing adherence in bipolar disorder (BD) are rare.

METHODS

A systematic review was conducted according to the PRISMA guidelines and principles of thematic synthesis. Selectively identified quantitative and qualitative studies were used to examine the attitude-adherence relationship in BD, the types and correlates of treatment attitudes, and the impact of psychosocial interventions on attitudes.

RESULTS

The final list of 163 articles included 114 observational reports (incorporating 21 psychosocial intervention trials), 45 qualitative/descriptive studies, and 4 patient surveys. A positive association between treatment attitudes and adherence was found in most quantitative and qualitative studies, though the strength of the relationship was unclear. Thematic analysis of qualitative studies suggested that patient attitudes influencing adherence were based on perceived advantages and disadvantages of treatment. The principal correlates of patients' attitudes were family attitudes, the clinician-patient alliance, social support, and patients' knowledge of BD. Though negative attitudes such as denial, concerns about adverse treatment consequences, and stigmatizing effects of treatment were common, many patients believed treatment to be beneficial and necessary. The limited data on the effect of psychosocial interventions indicated that treatments selectively targeting attitudes enhanced adherence.

LIMITATIONS

The studies were heterogeneous in design; the quality was uneven (fair to poor); and the risk of bias moderate to high.

CONCLUSIONS

Despite these flaws, awareness of the existing evidence on the attitude-adherence association and other aspects of treatment attitudes in BD can help in efforts to address nonadherence in BD.

Perceptions of shared decision-making in severe mental illness: An integrative review

WHAT IS KNOWN ABOUT SHARED DECISION-MAKING?: There is increasing evidence of the positive impact of shared decision-making on health outcomes. There has been little exploration of shared decision-making regarding people diagnosed with serious mental illness from the perspectives of key stakeholders including consumers, families and mental health professionals. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Consumers show variability in the preference for their involvement. Most stakeholders acknowledge the importance of family involvement. MHPs should share the responsibility and right to facilitate consumer involvement. There is bidirectional association between shared decision-making and therapeutic relationships. The practice of shared decision-making is related to multiple factors, and one main perceived barrier is time. The majority of studies are from Western countries. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Elicit consumer preferences and establish a collaborative therapeutic relationship. Encourage and engage families in treatment decision-making. Inter-professional collaboration should be integrated into shared decision-making. It might require lengthier consultation time. Studies in non-Western countries are needed to fully understand the impact of culture on shared decision-making. Abstract Introduction Shared decision-making (SDM) has been broadly advocated in health services and constitutes an important component of patient-centred care and relationship-based care. Aim To review available literature related to perceptions of key stakeholders about shared decision-making in serious mental illness. Method An integrative review was conducted through a search of four online databases from January 2012 to June 2019. Results Forty-six articles were included. Six themes were generated from the data analysis: (a) dynamic preferences for SDM, (b) various stakeholders are rarely involved, (c) SDM is not routinely implemented, (d) multiple facilitators and barriers to SDM, (e) SDM and therapeutic relationships interact, (f) SDM has a promising impact on health outcomes. Discussion Overall, most stakeholders have recognized the importance and flexibility of SDM in serious mental illness, although it is not routine in mental health service. Consumer preferences show variability in their involvement. Most stakeholders acknowledged the importance of family involvement to treatment decision-making. There are several significant challenges to practice SDM. It may require extended consultation times and increasing empirical evidence regarding the SDM outcomes, as well as integrating inter-professional collaboration into SDM. Most studies were conducted in Western culture. Implications for practice Mental health nurses should elicit consumer preferences and establish a collaborative therapeutic relationship. Encourage and engage families in treatment decision-making when consumers prefer their families to be involved. Inter-professional collaboration should be integrated into shared decision-making. The practice of shared decision-making might need extended consultation time and more robust evidence about the outcome of shared decision-making. Studies in non-Western cultures are needed to fully understand cultural issues of shared decision-making.

Socio-economic differences in patient participation behaviours in doctor-patient interactions-A systematic mapping review of the literature

Background

The degree to which patients participate in their care can have a positive impact on health outcomes. This review aimed to map the current literature on patient participation behaviours in interactions with physicians and the extent to which differences in these behaviours can be explained by socio‐economic status (SES).

Search strategy

Four electronic databases were searched from 1980 onwards using key words related to socio‐economic status and patient participation behaviours.

Study selection

Titles, abstracts and full texts were screened by two reviewers, with the second reviewer screening 20% of all entries.

Data extraction

Data on year of publication, country, patient population, setting, patient participation behaviour studied, and SES measure used were extracted.

Main results

Forty‐nine studies were included in the review. Most studies were conducted in the United States, and the most commonly studied patient participation behaviour was involvement in decision making. Most studies measured SES using education as an indicator, with very few studies using occupation as a measure. Many studies did not report on participants’ medical condition or study setting. Patient participation in their health‐care appointment increased with increasing SES in 24 studies, although in 27 studies no significant association was found.

Discussion and conclusions

Current literature was found to be mainly US‐centric. Many studies did not specify participants’ medical condition or in what setting the study was undertaken. More studies are needed on less commonly studied patient participation behaviours. It would be helpful for further studies to also include a wider range of SES indicators.

Treatment alliance and adherence in bipolar disorder

The clinician patient relationship lies at the core of psychiatric practice and delivery of mental health care services. The concept of treatment alliance in psychiatry has its origins in psychotherapy, but has also been influenced by several other constructs such as patient-centred care (PCC) and shared decision-making (SDM). Similarly, there has been a shift in conceptualization of treatment-adherence in psychiatric disorders including bipolar disorder (BD) from illness-centred and clinician-centred approaches to patient-centred ones. Moreover, the traditional compliance based models are being replaced by those based on concordance between clinicians and patients. Newer theories of adherence in BD place considerable emphasis on patient related factors and the clinician patient alliance is considered to be one of the principal determinants of treatment-adherence in BD. Likewise, current notions of treatment alliance in BD also stress the importance of equal and collaborative relationships, sensitivity to patients' viewpoints, sharing of knowledge, and mutual responsibility and agreement regarding decisions related to treatment. Accumulated evidence from quantitative research, descriptive accounts, qualitative studies and trials of psychosocial interventions indicates that efficacious treatment alliances have a positive influence on adherence in BD. Then again, research on the alliance-adherence link in BD lags behind the existing literature on the subject in other medical and psychiatric conditions in terms of the size and quality of the evidence, the consistency of its findings and clarity about underlying processes mediating this link. Nevertheless, the elements of an effective alliance which could have a positive impact on adherence in BD are reasonably clear and include PCC, collaborative relationships, SDM, open communication, trust, support, and stability and continuity of the relationship. Therefore, clinicians involved in the care of BD would do well to follow these principles and improve their interpersonal and communication skills in order to build productive alliances with their patients. This could go a long way in confronting the ubiquitous problem of non-adherence in BD. The role of future research in firmly establishing the alliance-adherence connection and uncovering the processes underlying this association will also be vital in devising effective ways to manage non-adherence in BD.

A thematic analysis assessing clinical decision-making in antipsychotic prescribing for schizophrenia

BACKGROUND

In recent decades atypical antipsychotics have increased treatment options available for schizophrenia, however there is conflicting evidence concerning the trade-off between clinical efficacy and side effects for the different classes of antipsychotics. There has been a consistent increase in atypical antipsychotic prescribing compared to typical, despite evidence showing that neither class is superior. This leads to the question of whether prescribers are selective in their uptake of research evidence and clinical guidelines and if so, what influences their choice.. This study aims to identify the factors that contribute to the prescribing choice and how these can be used to aid knowledge translation and guideline implementation.

METHODS

A thematic analysis study was conducted using data from 11 semi-structured interviews with clinicians with experience in prescribing for schizophrenia.

RESULTS

The analysis identified five themes underpinning prescribing behaviour: (1) ownership and collaboration; (2) compromise; (3) patient involvement; (4) integrating research evidence; and (5) experience.

CONCLUSION

The themes mapped to various degrees onto current models of evidence-based decision making and suggest that there is scope to re-think the guideline implementation frameworks to incorporate recurring themes salient to clinicians who ultimately use the guidelines. This will further translation of future evidence into clinical practice, accelerating clinical progress.

The Art of Pharmacotherapy: Reflections on Pharmacophobia

PURPOSE/BACKGROUND

This commentary deals with the neglected issue of the art of psychopharmacology by recounting the authors' journeys.

METHODS/PROCEDURES

First, a model of medical science situated within the history of medicine is described including (1) a limitation of the mathematical model of science, (2) the distinction between mechanistic science and mathematical science, (3) how this distinction is applied to medicine, and (4) how this distinction is applied to explain pharmacology to psychiatrists. Second, the neglected art of psychopharmacology is addressed by explaining (1) where the art of psychopharmacotherapy was hiding in the first author's psychopharmacology research, (2) how the Health Belief Model was applied to the art of medicine, (3) how the second author became interested in the Health Belief Model, and (4) his studies introducing the Health Belief Model in psychopharmacology. The authors' collaboration led to: (1) study of the effect of pharmacophobia on poor adherence and (2) reflection on the limits of the art of psychopharmacology.

FINDINGS/RESULTS

Low adherence was found in 45% (116/258) of psychiatric patients with pharmacophobia versus 22% (149/682) in those with no pharmacophobia, providing an odds ratio of 2.9 (95% confidence interval, 2.2-4.0) and an adjusted odds ratio of 2.5 (95% confidence interval, 1.8-3.5) after adjusting for other variables contributing to poor adherence.

IMPLICATIONS/CONCLUSIONS

Different cognitive patterns in different patients may contribute to poor adherence. Specific interventions targeting these varying cognitive styles may be needed in different patients to improve drug adherence.

Effectiveness of Shared Decision-Making Training Program in People With Schizophrenia in South Korea

PURPOSE

This study aimed to investigate the effects of shared decision-making (SDM) training program on self-esteem, problem-solving ability, and quality of life in people with schizophrenia.

DESIGN AND METHODS

A quasi-experiment with a nonequivalent control group pre-posttest design was conducted. The self-esteem scale, the problem-solving ability scale, and the WHOQOL Scale were used.

FINDINGS

The SDM training program was effective in improving their self-esteem, problem-solving ability, and quality of life in people with schizophrenia.

PRACTICE IMPLICATIONS

The SDM training program can be used in various mental health fields such as hospitals, mental health centers, and rehabilitation facilities.

Reviving Research on Medication Attitudes for Improving Pharmacotherapy: Focusing on Adherence

There is little current interest in research into patients' attitudes toward medications. In the 1960s, psychiatric researchers including Uhlenhuth, Rickels and Covi focused on this area, but this research topic needs to be revived in the 21st century. The Health Belief Model may hold potential for doing this. This model was initially developed by 2 health psychologists, Rosenstock and Becker, to explain why patients did not follow medical interventions. The application of this model to study medication adherence in psychiatric outpatients has provided multiple findings including the conclusions that adherence is associated with: (1) the balance between internal and external health control beliefs, (2) psychological reactance, (3) patients' attitudes toward prescribed drug treatment in general and (4) the balance between the necessity of taking medications versus the concerns derived from adverse drug reactions (ADRs). Poor adherence is associated with several cognitive styles of patients, including: (1) high internal and external health control beliefs (patients who feel that their health is controlled both by external factors and their own beliefs), (2) higher psychological reactance, (3) pharmacophobia (present in 1/6 patients) and (4) skepticism about medications (a high concern for ADRs and a low belief in the necessity of taking medications). All of these findings suggest that shared decision-making is particularly important in fostering adherence in psychiatric patients. Two wider applications of this article can be made: (1) opening psychiatry to advances in clinical psychology and (2) expanding studies on attitudes toward medications to other medical disciplines.

Treatment-related decisional conflict in patients with depressive and anxious disorders

PURPOSE

To determine the level of treatment-related decisional conflict in patients with emotional disorders and to establish its relationship with sociodemographic and clinical variables.

METHODS

We conducted a cross-sectional survey on a convenience sample of 321 consecutive psychiatric outpatients with emotional disorders. All patients completed self-report questionnaires assessing sociodemographic and clinical variables, patients' preference of participation in decision making, perceived decisional conflict about treatment, adherence to prescribed treatment, and satisfaction with the psychiatric care provided. Multiple correspondences analysis was used to investigate relationships of decisional conflict with the variables of interest.

RESULTS

Approximately, two-thirds of psychiatric outpatients self-reported decisional conflict regarding their treatment. Interestingly, the presence of decisional conflict did not influence significantly patients' preferences of participation or their adherence to prescribed treatment. Patients without decisional conflict registered significantly higher satisfaction. Multiple correspondences analysis evidenced two clear profiles: patients without decisional conflict received the treatment they preferred, mainly psychotherapy or combined treatment, had been under psychiatric treatment for longer than 5 years, and self-reported high satisfaction with health care received; on the other hand, patients with decisional conflict did not receive the treatment they preferred, were treated with pharmacotherapy alone for a period of time between 1 and 5 years, and self-reported medium satisfaction with received health care.

CONCLUSION

The high level of decisional conflict found in patients with depression and anxiety attending a secondary care service could be an important driving force when personalizing and tailoring information and teaching skills to patients about their illnesses and their treatments.

Treatment engagement of individuals experiencing mental illness: review and update

Individuals living with serious mental illness are often difficult to engage in ongoing treatment, with high dropout rates. Poor engagement may lead to worse clinical outcomes, with symptom relapse and rehospitalization. Numerous variables may affect level of treatment engagement, including therapeutic alliance, accessibility of care, and a client's trust that the treatment will address his/her own unique goals. As such, we have found that the concept of recovery-oriented care, which prioritizes autonomy, empowerment and respect for the person receiving services, is a helpful framework in which to view tools and techniques to enhance treatment engagement. Specifically, person-centered care, including shared decision making, is a treatment approach that focuses on an individual's unique goals and life circumstances. Use of person-centered care in mental health treatment models has promising outcomes for engagement. Particular populations of people have historically been difficult to engage, such as young adults experiencing a first episode of psychosis, individuals with coexisting psychotic and substance use disorders, and those who are homeless. We review these populations and outline how various evidence-based, recovery-oriented treatment techniques have been shown to enhance engagement. Our review then turns to emerging treatment strategies that may improve engagement. We focus on use of electronics and Internet, involvement of peer providers in mental health treatment, and incorporation of the Cultural Formulation Interview to provide culturally competent, person-centered care. Treatment engagement is complex and multifaceted, but optimizing recovery-oriented skills and attitudes is essential in delivery of services to those with serious mental illness.