2-COM: an instrument to facilitate patient-professional communication in routine clinical practice

Effectiveness of the Boston University Approach to Psychiatric Rehabilitation in Improving Social Participation in People With Severe Mental Illnesses: A Randomized Controlled Trial

BACKGROUND

People with severe mental illnesses (SMIs) have difficulty participating in society through work or other daily activities.

AIMS

To establish the effectiveness with which the Boston University Approach to Psychiatric Rehabilitation (BPR) improves the level of social participation in people with SMIs, in the Netherlands.

METHOD

In a randomized controlled trial involving 188 people with SMIs, we compared BPR (n = 98) with an Active Control Condition (ACC, n = 90) (Trial registration ISRCTN88987322). Multilevel modeling was used to study intervention effects over two six-month periods. The primary outcome measure was level of social participation, expressed as having participated in paid or unpaid employment over the past six months, as the total hours spent in paid or unpaid employment, and as the current level of social participation. Secondary outcome measures were clients' views on rehabilitation goal attainment, Quality of Life (QOL), personal recovery, self-efficacy, and psychosocial functioning.

RESULTS

During the study, social participation, QOL, and psychosocial functioning improved in patients in both groups. However, BPR was not more effective than ACC on any of the outcomes. Better social participation was predicted by previous work experience and a lower intensity of psychiatric symptoms.

CONCLUSIONS

While ACC was as effective as BPR in improving the social participation of individuals with SMIs, much higher percentages of participants in our sample found (paid) work or other meaningful activities than in observational studies without specific support for social participation. This suggests that focused rehabilitation efforts are beneficial, irrespective of the specific methodology used.

Patients with schizophrenia assessing psychiatrists' communication skills

Communication plays a central role in mental health care. Yet, studies fail to address the adequacy of psychiatrists' communication according to patients' needs. We examined how patients with schizophrenia assess their psychiatrists' communication skills, inspecting the importance that these aspects have for patients. Thirty patients with schizophrenia filled the Communication Assessment Tool after the appointment with their psychiatrists. An external observer also rated the videotaped appointments using the same instrument. Patients' mean rating of their psychiatrists' communication was 4.28 (mean proportion of excellent, "5" scores, was 57.4%). "Treated me with respect" received the highest mean, whereas "Encouraged me to ask questions" received the lowest. The assessment by the external observer was concordant, though lower (mean = 3.39) than patients'. Psychiatrists' communication skills correlated positively with the importance that patients gave to the respective communication aspects (overall mean importance = 2.77). Main discrepancies were related with "Understood my concerns" and "Involved me in decisions". Patients who were non-married, with higher education level and in medical treatment for less time gave significantly higher scores to psychiatrists' communication. Patients with schizophrenia consider clinical communication important and their psychiatrists' communication adequate. Room for improvement exists, namely regarding more elicitation of patients' health concerns and involvement in the encounter.

Needs of Patients with Schizophrenia Among an Ethnic Minority Group in Latin America

The aim of the study is to describe the need profile of outpatients with schizophrenia belonging to an Aymara ethnic group in Latin-America and to compare that profile to non-Aymara patients. A sample of 253 patients were evaluated with the Two-Way Communication Checklist (2-COM Checklist) measuring the needs and satisfaction of the patient; Positive and Negative Syndrome scale for Schizophrenia (PANSS) and Attitude to the Drugs (DAI-10). No significant differences were found between Aymara and non-Aymara, either in the total number of needs or in the subscales of satisfaction or in the types of needs. After adjustment for socio-demographic and clinical factors, patients with higher severity (PANSS) had higher number of needs and lower level of satisfaction. Higher score on DAI-10 is related to a higher total number of needs and better satisfaction with medication. Age, sex, ethnicity and employment were also associated with specific needs. The profile of the needs of schizophrenic Aymara patients does not differ from that of non-Aymara patients, and that in both groups it is necessary that the treatment primarily address symptom management and the subjective aspects of quality of life.

Effects of the two-way communication checklist (2-COM): a one-year cluster randomized study in a group of severely mentally ill persons

BACKGROUND

In a health-care service with the emphasis on improvement related to functioning and well-being, the communication process between patient and professionals is essential. There is a lack of research on this matter.

AIM

The aim was to investigate, in a group of severely mentally ill persons, whether the use of a simple communication tool could influence the sense of empowerment, satisfaction with care, therapeutic alliance and unmet needs.

METHOD

The study had a cluster randomized design. The intervention was a communication tool (2-COM) applied in two teams during one year. In a comparison group of two other teams, the treatment was as usual. At baseline, after six months, and after one year, assessments were made.

RESULTS

After one year the 2-COM groups seemed to have a larger reduction in unmet needs compared to the treatment-as-usual group. However, there were large problems with attrition in the study, and it was not possible to draw relevant conclusions.

CONCLUSIONS

The methodological problems were substantial, and the study may be considered as a pilot study. In a main study the researchers ought to take control over the selection of patients on the basis of the experiences from this study.

The diffusion and the reason for the use of complementary and alternative medicine among users of mental health services: a systematic review of literature

Aims- A systematic review of the studies on use of alternative and complementary medicine by mental health services' users to investigate the prevalence and motivations of CAM used to treat mental disorders.Methods- This paper shows a part of the results of a literature review, limited to studies between 1966 and 2005, was carried out using Ovid Medline, PsycINFO and EBM Reviews databases. This was supplemented by hand searching of reference lists.Results- Ninety-one studies on CAM's use by psychiatric patients were analyzed. In this paper the twenty-five articles about the CAM's prevalence and use's motivations are described. The use of complementary and alternative medicine (CAM) varies across countries: data suggest that from 50% to 80% of people suffering of mental disorders use CAM. Heterogeneous methods, samples and results characterizing the studies make generalizations results difficult. Patients motivations of CAM's use were poorly investigated by research, however it seems that persons affected by mental disorders use MAC prevalently because they are dissatisfied with conventional medicine and/or because these alternatives approaches are congruent with their own values, beliefs and philosophical orientation toward health care.Conclusions- The review emphasize the importance of a best physicians' education and information about CAM to improve the management of non-conventional and orthodox medicine relationship. The motivations of CAM's use underline the relevance of patient's holistic conception and the therapeutic role of a patient-physician relationship based on emphaty. Besides it seems important to investigate furtherly patients' psychological and social aspects that influence their choise to use CAM.

Is it possible to assess subjective well-being among bipolar inpatients? An 18-week follow-up study

OBJECTIVE

The study evaluates the association between subjective well-being and psychopathology in bipolar inpatients at the time of hospitalization and during a follow-up period.

METHOD

One hundred twenty consecutive inpatients with a diagnosis of bipolar affective disorder were studied on admission (T0), at discharge (T1) and every 6 weeks for 18 weeks after hospitalization. The Young's Mania Rating Scale (YMRS) and the Hamilton Rating Scale for Depression (HAM-D) were used to determine affective symptoms, while subjective well-being was assessed by subjective well-being under neuroleptic (SWN). Associations between SWN and HAM-D or YMRS scores and between their changes were analyzed across the different time points by using Pearson correlation coefficients. Linear regression models were constructed using SWN as the dependent variable and demographic and clinical characteristics as possible predictors.

RESULTS

At baseline, depression explained 24% and mania explained an additional 16% of baseline SWN variance. Changes in SWN and HAM-D total score displayed an inverse correlation during hospitalization and follow-up. End point severity of depression was associated with the end point SWN total score explaining additional 26% of SWN total score variance, whereas severity of mania was inversely associated with SWN total score.

CONCLUSION

Data of this study provide further support for the need to consider the subjective well-being as a personal variable associated to psychopathological state in bipolar patients. However, results seem to be in line with authors who suggest to use other subjective quality of life scales in acute mania.

Evidence that the Two-Way Communication Checklist identifies patient-doctor needs discordance resulting in better 6-month outcome

OBJECTIVE

To assess an intervention aimed at reducing patient-professional carer needs discordance.

METHOD

In a group of 460 patients with schizophrenia, the Two-Way Communication Checklist (2-COM), an instrument to rate needs, was completed at baseline, 2 months and 6 months by both the patient and the professional carer, allowing for the quantification of patient-carer needs discordance.

RESULTS

Reduction in patient-reported 2-COM needs in the group with low baseline needs discordance was much greater at 2 and 6 months (2 months: beta = -0.65, P < 0.001; 6 months: beta = -1.00, P < 0.001) than in the group with high baseline discordance (2 months: beta = -0.35, P < 0.001; 6 months: beta = -0.49, P < 0.001). Reduction in needs discordance between baseline and 2 months (beta = -0.07, P = 0.004) as well between 2 and 6 months (beta = -0.05, P = 0.020) was associated with greater levels of CGI clinical improvement.

CONCLUSION

The fact that patient-carer needs discordance impacts negatively, and its reduction positively, on 6-month outcome suggests that systematic inventory of patient-carer views on needs is necessary.

User involvement in mental health care: the role of nurses. A literature review

This literature review was carried out to examine the effects of user involvement in shared decision-making processes and the methods/tools available to psychiatric nurses to measure and encourage user involvement. A systematic literature review was then used in this study. Many studies indicate that an increased involvement of service users leads to better care, better treatment compliance, improved health outcomes and higher levels of patient satisfaction. The tools and methods described are designed to measure the ability to participate, the process of implementation and the evaluation of healthcare services. An adequate instrument to measure user involvement will be necessary to underpin the positive effects. Although care providers have a statutory duty to help shape user involvement, and the tools required are available, care providers are still insufficiently inclined to take up this duty.

Subjective response to neuroleptics: the effect of a questionnaire about neuroleptic side effects

BACKGROUND

A patient's subjective response to neuroleptics is an important factor in pharmacotherapy of schizophrenia. In this study, we conducted an intervention to assess the effect of a questionnaire about neuroleptic side effects. We hypothesized that paying more attention to a patient's subjective distress associated with neuroleptic side effects would improve the patient's subjective response to neuroleptics. So we made a questionnaire about neuroleptic side effects, and used this questionnaire repeatedly in the usual clinical setting as an intervention.

METHOD

We administered this study to 210 outpatients who met the following criteria: (1) diagnosis of schizophrenia or schizoaffective disorder as defined by DSM-IV and (2) no worsening of symptoms in the past 6 months. The patients were divided into the intervention and the control groups. Patients of the intervention group filled out the questionnaire four times during 6 months and were given routine clinical care. Patients of the control group had routine clinical care only. The 10-item Drug Attitude Inventory (DAI-10) was used to evaluate the patients' subjective responses to neuroleptics.

RESULTS

After 6 months, the patients' subjective responses to neuroleptics assessed by the DAI-10 significantly improved in the intervention group (p<0.05 for within-group comparison). The most improved response was that the patients felt they were taking medications of their own free choice.

CONCLUSION

Paying more attention to the patient's subjective distress associated with neuroleptic side effects may have encouraged patients to participate in pharmacotherapy on their own initiative. This study suggests that our 19-item questionnaire is a useful tool to improve a patient's subjective response to neuroleptics.

Nurses' collaboration with physicians in managing medication improves patient outcome in acute psychiatric care

The aim of the present paper was to examine the impact of nurses' collaboration with physicians in medication management on patient outcome in acute psychiatric care. Data for 143 patients with schizophrenia were assessed based on information given by nurses and physicians in charge. Twenty-two patients were defined as a collaborative group when physicians changed medication after receiving reports that nurses perceived the necessity to change. A control group was formed from the 50 patients when nurses perceived the necessity to change medication but did not tell physicians, or nurses advised of the necessity to physicians but medication was not changed. Physicians retrospectively evaluated patients' social functioning and acceptance of medication at admission and discharge. Social functioning was measured by Global Assessment of Functioning (GAF), and acceptance of medication by a single item using Japanese version of Schedule for Assessment of Insight (SAI-J). Changes in the scores from admission to discharge on GAF and acceptance of medication were defined as outcome measures. Nurses recognized the necessity to change medication for patients with frequent aggressive behavior and younger age. Compared with the control group, the collaborative group had less instruction for use of drugs, and more perceived necessity to decrease the current dose or the number of drugs because of stable symptoms. The collaborative group demonstrated significantly greater improvement in social functioning. The collaborative group improved acceptance of medication, although there were no significant differences between the two groups. Nurses' collaboration with physicians in medication management improved patient outcome in acute psychiatric care.

Mapping the onset of psychosis: the Comprehensive Assessment of At-Risk Mental States

OBJECTIVE

Recognizing the prodrome of a first psychotic episode prospectively creates the opportunity of intervention, which could delay, ameliorate or even prevent onset. Valid criteria and a reliable methodology for identifying possible prodromes are needed. This paper describes an instrument, the Comprehensive Assessment of At-Risk Mental States (CAARMS), which has been designed for such a purpose. It has two functions: (i) to assess psychopathology thought to indicate imminent development of a first-episode psychotic disorder; and (ii) to determine if an individual meets criteria for being at ultra high risk (UHR) for onset of first psychotic disorder. This paper describes the pilot evaluation of the CAARMS.

METHOD

Several methodologies were used to test the CAARMS. First, CAARMS scores in a group of UHR young people and the association between CAARMS scores and the risk of transition to psychotic disorder, were analysed. Second, CAARMS scores in a UHR group were compared to a control group. To assess concurrent validity, CAARMS-defined UHR criteria were compared to the existing criteria for identifying the UHR cohort. To assess predictive validity, the CAARMS-defined UHR criteria were applied to a sample of 150 non-psychotic help-seekers and rates of onset of psychotic disorder at 6-month follow-up determined for the CAARMS-positive (i.e. met UHR criteria) group and the CAARMS-negative (i.e. did not meet UHR criteria) group. The inter-rater reliability of the CAARMS was assessed by using pairs of raters.

RESULTS

High CAARMS score in the UHR group was significantly associated with onset of psychotic disorder. The control group had significantly lower CAARMS scores than the UHR group. The UHR criteria assessed by the CAARMS identified a similar group to the criteria measured by existing methodology. In the sample of non-psychotic help-seekers those who were CAARMS-positive were at significantly increased risk of onset of psychotic disorder compared to those who were CAARMS-negative (relative risk of 12.44 (95% CI = 1.5-103.41, p = 0.0025)). The CAARMS had good to excellent reliability.

CONCLUSIONS

In these preliminary investigations, the CAARMS displayed good to excellent concurrent, discriminant and predictive validity and excellent inter-rater reliability. The CAARMS instrument provides a useful platform for monitoring subthreshold psychotic symptoms for worsening into full-threshold psychotic disorder.

Tools for measuring clinical effectiveness

Efficacy studies fail to consider the multiple aspects of schizophrenia that determine the overall clinical effectiveness of treatment. We address this shortcoming by proposing definitions of six schizophrenia outcome domains which we believe contribute to clinical effectiveness: symptoms of disease, tolerability, everyday functioning, subjective well-being, family/career burden, and treatment adherence. Numerous specialised rating scales are in widespread use; however, these only assess specific aspects of schizophrenia within individual domains and are of limited use for measuring clinical effectiveness. New rating instruments that measure treatment outcomes across all six domains of schizophrenia need to be developed. One such scale is the revised Global Outcome Assessment of Life in Schizophrenia (GOALS) scale. We propose that further development of this scale should include validation in long-term studies, incorporation of the patient perspective of treatment within assessments, and education of clinicians on how to score this scale. If this approach to evaluating treatment outcomes is adopted, clinicians will be better placed to differentiate therapeutic interventions on the basis of clinical effectiveness.

Systematic assessments of need and care planning in severe mental illness: cluster randomised controlled trial

BACKGROUND

Surveys have shown high levels of unmet need in representative samples of people with severe mental illness. Introducing standardised needs assessment into the care planning process might reduce these needs and improve outcome.

AIMS

To determine whether feedback from a standardised assessment of need enhances the effectiveness of care planning and whether exposing care coordinators to feedback on some patients improves their care of other patients.

METHOD

A single-blind, cluster randomised trial involving a within-cluster individually randomised arm: patients' needs were evaluated using the Cardinal Needs Schedule and the findings were fed back to their care coordinators under the care programme approach. A total of 304 patients were recruited from 72 care coordinators and 242 patients (79.6%) were reassessed at 12 months.

RESULTS

The only significant effect of the intervention was on patient satisfaction. Patients cluster-randomised to receive feedback were more satisfied than controls, but patients individually randomised to receive feedback were not.

CONCLUSIONS

Standardised needs assessment did not substantially enhance care planning in this trial. However, giving care coordinators some experience of feedback from a standardised assessment of need could improve satisfaction.

Evaluation of the Two-Way Communication Checklist as a clinical intervention. Results of a multinational, randomised controlled trial

BACKGROUND

Patients and doctors often have divergent views on care needs.

AIMS

To examine whether providing patients with an opportunity to identify and discuss their needs would improve communication and induce changes in care.

METHOD

Patients with schizophrenia (n=134) were randomly allocated to either standard care or use of the Two-Way Communication Checklist (2-COM). Before seeing their clinician for a routine follow-up, participants in the active intervention group were given 2-COM, a list of 20 common needs, and told to indicate those areas they wanted to discuss with their doctor. Outcomes were assessed immediately and again after 6 weeks.

RESULTS

Using 2-COM induced a stable improvement of patient-reported quality of patient-doctor communication (B=0.33, P=0.031), and induced changes in management immediately after the intervention (OR=3.7, P=0.009; number needed to treat, 6). Treatment change was more likely inpatients with more reported needs, and needs most likely to induce treatment change displayed stronger associations with non-medication than with medication changes.

CONCLUSIONS

A simple intervention to aid people in discussion of their needs results in improved communication and changes in management.