Breaking bad news: schizophrenia

Experience, impact and needs of informal parental caregivers around the communication of a diagnosis of schizophrenia

AIMS

To qualitatively characterize the experience, impact and needs of informal family caregivers around the communication of a diagnosis of schizophrenia.

METHODS

In all, 13 informal family caregivers were recruited. All were parents. Semi-structured interviews were used to explore their experience of the diagnosis of schizophrenia, the impacts of the diagnosis and the needs related to the diagnosis around its communication. Interviews were recorded, transcribed, codes generated and mixed deductive-inductive thematic analysis undertaken.

RESULTS

Participants described receiving the diagnosis of schizophrenia for their relative as a devastating experience, although some nuanced the experience with a sense of relief of finally naming the disorder and getting access to care. Caregivers' experience and representations prior to hearing the diagnosis played an important role in the way the 'news' was internalized. The communication of the diagnosis constituted a starting point for acceptance of the reality of the illness in participants. Numerous unmet needs around the communication of the diagnosis were reported by participants, including personnalized support, specific explanations about the disorder and guidance on their role as caregiver.

CONCLUSION

A specific attention must be given to the communication of the diagnosis of schizophrenia to the informal family caregivers. Information giving must be early, comprehensive, personalized and embedded into tailored education and support programmes for caregivers to facilitate illness acceptance and adaptation.

Knowledge of mental health diagnosis among patients and their family members: an inpatient survey in China

BACKGROUND

Patient-oriented information disclosure has been advocated by the National Mental Health Law (NMHL) in China since 2012; however, reporting on diagnostic disclosure to patients with mental disorders after the NMHL is limited.

AMIS

This study aims to investigate and compare the knowledge of mental health diagnosis among patients and their family members in China.

METHODS

An inpatient survey was conducted among 205 patients with mental disorders and their family members. Group differences of the correctness of self-reported mental health diagnosis were compared, and logistic regression was performed to investigate correlates among both patients and their family members.

RESULTS

Overall, 76.7% patients and 80.6% of their family members reported a correct diagnosis. Only 46.2% patients with psychotic disorders correctly knew their diagnosis, significantly lower than their family members and patients with non-psychotic disorders. Multivariate regression analysis found that the diagnosis of psychotic disorders was a risk factor of patients' diagnostic knowledge (AOR = 0.137; 95% CI = 0.044-0.429), while family members' diagnostic knowledge was associated with their employment (AOR = 6.125, 95% CI = 1.942-19.323) and parent-child relationship with patients (AOR = 3.719; 95% CI = 1.057-13.086).

CONCLUSIONS

The majority of patients with non-psychotic disorders know their diagnosis correctly and informing family members of patients' diagnosis remains a common practice in psychiatric setting after the implementation of China's NMHL.

Communicating diagnoses to individuals with a first episode psychosis: A qualitative study of individuals perspectives

BACKGROUND

Receiving the label of a psychotic disorder influences self-perception and may result in negative outcomes such as self-stigma and decreased self-esteem. The way the diagnosis is communicated to individuals may affect these outcomes.

AIMS

This study aims to explore the experiences and needs of individuals after a first episode of psychosis with regard to the way in which information about diagnosis, treatment options and prognosis is communicated with them.

DESIGN AND METHODS

A descriptive interpretative phenomenological approach was used. Fifteen individuals who experienced a first episode of psychosis participated in individual semi-structured open-ended interviews on their experiences and needs regarding the process of providing information about diagnosis, treatment options and prognosis. Inductive thematic analysis was used to analyze the interviews.

RESULTS

Four recurring themes where identified (1) timing (when); (2) content (what); and (3) the way information is provided (how). Individuals also reported that the provided information could elicit an emotional reaction, for which they would require specific attention, therefore the fourth theme is (4) reactions and feelings.

CONCLUSION

This study provides new insights into the experiences and specific information needed by individuals with a first episode of psychosis. Results suggest that individuals have different needs regarding the type of (what), how and when to receive information about diagnosis and treatment options. This requires a tailor-made process of communicating diagnosis. A guideline on when, how and what to inform, as well as providing personalized written information regarding the diagnosis and treatment options, is recommended.

What do psychiatrists think about renaming schizophrenia in Turkey?

In this study, it was aimed to evaluate the opinions of psychiatrists in Turkey on whether to change the name of schizophrenia in order to reduce stigma. This cross-sectional survey was conducted with psychiatrists (resident in psychiatry, specialist, and lecturer) in Turkey. An online survey was created via the Google Forms public web address. Online questionnaires were delivered through Google Forms by emailing and messaging on WhatsApp, Telegram, Google and Yahoo groups and asking them to pass the questionnaire to other possible participants in their network. The study was performed between June 20, 2021 and July 10, 2021. 460 psychiatrists participated in the study. Forty-five-point 2 % of psychiatrists think that the name of schizophrenia should be renamed to reduce stigma. Forty-two-point 8 % of those who support the name change state that this change should be done as soon as possible. While 64.1 % of psychiatrists stated that naming the disease with another (new) name instead of schizophrenia could increase the hopes of patients and their relatives for recovery, 12.6 % stated that renaming would not cause any positive or negative changes. There is no statistical difference between psychiatrists who have a relative diagnosed with schizophrenia and psychiatrists who do not, in terms of thinking that the name of schizophrenia should be renamed to reduce stigma. In order to remove the stigma on schizophrenia, many interventions are required in social, cultural, economic and political fields. Renaming schizophrenia may be a good start for interventions.

Delivering Difficult News: Simulation-Enhanced Training Improves Psychiatry Residents' Clinical Communication Skills

Background: Delivering difficult news to individuals diagnosed with mental health disorders and their family members can be challenging. The use of simulated patients (SP) is an effective teaching method to enhance clinical skills, particularly those around communication. We developed, implemented, and evaluated the effectiveness of an SP-based training module to improve psychiatric residents' clinical communication skills in delivering difficult news. Methods: We conducted 5-h workshops consisting of 3 components: (1) a high-fidelity simulation session with a professional actor; (2) a 30-min lecture; and (3) role-playing of 3 short scenarios, during which residents rotated taking on different roles (as psychiatrist, patient, or family member). We observed through a 1-way mirror and videotaped each resident's simulation session and followed it with personalized debriefing. Following the workshop, each resident received the full-length video of their simulated interview, together with a list of questions as a take-home assignment. Two months after the workshop, the residents were invited to a second SP-based session, during which 2 independent evaluators, each a board-certified psychiatrist with expertise in medical simulation, evaluated the participants' communication skills using a previously validated instrument. To avoid observation bias, the 2 evaluators rated the videotapes blind to the timing of the simulation (pre- vs. post-training). Participants completed self-report questionnaires on satisfaction and self-confidence, before, after, and 2 months following the workshop. Findings: Of the 28 psychiatric residents who participated in the training day, 24 (86%) completed the post-workshop evaluation. Mean communication score increased from 24.9 to 27.8 (paired t-test: 5.6, p < 0.001). The mean score for the self-confidence questionnaire, calculated on a 1 to 5 Likert scale, increased from 3.4 to 4.0 after the training day, and remained unchanged (4.2) 2 months later (p < 0.001). Conclusions: An SP-based training module proved useful in improving the objectively measured communication skills of psychiatric residents delivering difficult news. The training further enhanced participants' subjective sense of confidence in those clinical skills.

Renaming schizophrenia? A survey among psychiatrists, mental health service users and family members in Italy

This survey explores how psychiatrists, service users and family members in Italy perceive the term schizophrenia and if they consider a name change a useful option in order to overcome the stigma attached to it. Opinions on the term schizophrenia were collected by a self-rated questionnaire used in previous international surveys. Questionnaires were delivered members of the Italian Psychiatric Association. Survey of mental health users was conducted among members of the main users' association of the Veneto region; survey of family members was conducted among one of the most representative Italian family association. Overall, 350 psychiatrists, 71 mental health users and 110 family members filled in the questionnaires. Considering the whole sample, 41.5% found the term inappropriate, 67.6% stigmatizing and 72.3% advocated a name change. Among psychiatrists 57% reported that schizophrenia was inappropriate, 70% considered the term stigmatizing and 71% was in favor of a name change. Similarly, 56% of service users and 71% of family members found schizophrenia a stigmatizing term and, respectively, 75% and 77% advocated a name change. Conflicting results were found on possible alterative terms: psychiatrists proposed a wide range of possible options, most of which referred to the term 'psychosis' (53%), whereas users and family members preferred terms referring to the broad category of 'mental health suffering'. Overall, most of respondents in the three stakeholders' groups agree that schizophrenia should be renamed to reduce the stigma attached to it; the main challenge, however, is the lack of consensus on the best alternative term to use.

European Psychiatric Association policy paper on ethical aspects in communication with patients and their families

BACKGROUND

Establishing a valid communication is not only a basic clinical need to be met but also a relevant ethical commitment.

METHODS

On the basis of the relevant literature, ethical issues arising from specific, important situations in clinical practice were identified.

RESULTS

The main ethical problems regarding communication about the disorder, both in general and in relation to prodromal stages, were described and discussed together with those regarding communication about voluntary and involuntary treatments, "dual roles" enacted in clinical practice, genetic counseling, and end-of-life conditions; on the basis of what emerged, ethically driven indications and suggestions were provided.

CONCLUSIONS

Several situations put the psychiatrist in front of relevant dilemmas and doubts which are no easy to face with; an ethically driven approach based upon the principle of the best interest of patients may support clinicians in their decisions.

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.

An evaluation of communication barriers and facilitators at the time of a mental health diagnosis: a survey of health professional practices

AIMS

To examine health professionals' views and practices relating to the specific barriers to communication that arise at the time of mental health diagnosis, and the strategies used to support individuals throughout this process.

METHODS

An online survey of the beliefs and practices of 131 mental health clinicians working in different clinical settings across Australia was conducted.

RESULTS

Exploratory factor analysis of the items relating to barriers to communication resulted in three latent factors ('stigma, diagnosis and risk'; 'service structure'; and 'individual circumstances' such as the person receiving the diagnosis being young, having a culturally and linguistically diverse background or being unwell at the time of conversation). Using linear regression it was found that variance in 'stigma, diagnosis and risk' was significantly explained by whether participating clinicians had medical training, their experience working with serious mental health problems, their confidence handling distress and attitude towards diagnosis. Variance in 'individual circumstances' was significantly explained by participating clinicians' confidence handling distress. The most frequently used strategies to support diagnostic discussions centred on the health professionals' communication skills, gauging the individual's perception of their circumstances, responding with empathy, following-up after discussion, addressing stigma concerns, using collaborative practice and setting up for the conversation.

CONCLUSIONS

Three main areas for health professionals to reflect on, plan for and ultimately address when discussing news with the individual concerned emerged ('stigma, diagnosis and risk'; 'service structure'; and 'individual circumstances'). Variations in practice indicate that practitioners should be cognisant of their own beliefs and background and how this impacts their communication practice.

Different communication strategies for disclosing a diagnosis of schizophrenia and related disorders

BACKGROUND

Delivering the diagnosis of a serious illness is an important skill in most fields of medicine, including mental health. Research has found that communication skills can impact on a person's recall and understanding of the diagnosis, treatment options and prognosis. People may feel confused and perplexed when information about their illness is not communicated properly. Sharing information about diagnosis of a serious mental illness is particularly challenging. The nature of mental illness is often difficult to explain since there may be no clear aetiology, and the treatment options and prognosis may vary enormously. In addition, newly diagnosed psychiatric patients, who are actively ill, often may not accept their diagnosis due to lack of insight or stigma attached to the condition. There are several interventions that aim to help clinicians to communicate life changing medical diagnoses to people; however, little is known specifically for delivering a diagnosis of schizophrenia.

OBJECTIVES

To evaluate evidence from randomised controlled trials (RCTs) for the efficacy of different communication strategies used by clinicians to inform people about the diagnosis and outcome of schizophrenia compared with treatment as usual and to compare efficacy between different communication strategies.

SEARCH METHODS

On 22 June 2015 and 29 June 2016, we searched the Cochrane Schizophrenia Group's Study-Based Register of Trials. We also searched sources of grey literature (e.g., dissertations, theses, clinical reports, evaluations published on websites, clinical guidelines and reports from regulatory agencies).

SELECTION CRITERIA

We planned to include all relevant RCTs that included adults with schizophrenia or related disorders, including schizophreniform disorder, schizoaffective disorder and delusional disorder. The trials would have investigated the effects of communication strategy or strategies that helped clinicians deliver information specifically about a diagnosis of schizophrenia (which can also include communication regarding the treatment options available and prognosis).

DATA COLLECTION AND ANALYSIS

Review authors independently examined all reports from the searches for any relevant studies. We planned to extract data independently. For binary outcomes, we would have calculated risk ratio (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For continuous data, we would have estimated the mean difference (MD) between groups and its 95% CI. We would have employed a random-effects model for analyses. We planned to assess risk of bias for included studies. We created a 'Summary of findings' table using GRADE.

MAIN RESULTS

The searches identified 44 records which appeared to be relevant to the aims of the review. We obtained full reports for seven potential studies; however, after close inspection none of these studies met the inclusion criteria.

AUTHORS' CONCLUSIONS

Good communication of diagnosis can affect treatment planning, compliance and patient outcomes, especially in the case of conditions such as schizophrenia, which has the potential to cause serious life disruption for both people with schizophrenia and their carers. Currently, there is no evidence based on findings from RCTs assessing the effects of communication strategies for disclosing the diagnosis of schizophrenia and related disorders. Research is required.

Disclosure of Diagnosis in Early Recognition of Psychosis

There is a debate concerning risks and benefits of early intervention in psychosis, especially concerning diagnosis disclosure. The present study reports preliminary findings on self-reported locus of control and psychological distress after the disclosure of diagnosis in an early recognition center. We compared the ratings of the locus of control and psychological distress before and after communication of diagnosis. The study included individuals with an at-risk mental state (ARMS) (n = 10), schizophrenia (n = 9), and other psychiatric disorders (n = 11). Results indicate greater endorsement of the internal locus of control in individuals with ARMS after communication of diagnosis in contrast to the other groups. Our results suggest that disclosure of diagnosis in an early recognition center leads to a reduction of psychological distress and increased feelings of control over one's health. Persons with ARMS seem to particularly benefit from disclosure of diagnosis as part of early intervention.

Communication skills in the training of psychiatrists: A systematic review of current approaches

OBJECTIVES

A range of communication skills training programmes have been developed targeting trainees in various medical specialties, predominantly in oncology but to a lesser extent in psychiatry. Effective communication is fundamental to the assessment and treatment of psychiatric conditions, but there has been less attention to this in clinical practice for psychiatrists in training. This review examines the outcomes of communication skills training interventions in psychiatric specialty training.

METHODS

The published English-language literature was examined using multiple online databases, grey literature and hand searches. The review was conducted and reported using Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Studies examining the efficacy of communication skills training were included. Randomised controlled trials, pseudo-randomised studies and quasi-experimental studies, as well as observational analytical studies and qualitative studies that met criteria, were selected and critically appraised. No limits were applied for date of publication up until 16 July 2016.

RESULTS

Total search results yielded 2574 records. Of these, 12 studies were identified and reviewed. Two were randomised controlled trials and the remaining 10 were one-group pretest/posttest designs or posttest-only designs, including self-report evaluations of communication skills training and objective evaluations of trainee skills. There were no studies with outcomes related to behaviour change or patient outcomes. Two randomised controlled trials reported an improvement in clinician empathy and psychotherapeutic interviewing skills due to specific training protocols focused on those areas. Non-randomised studies showed varying levels of skills gains and self-reported trainee satisfaction ratings with programmes, with the intervention being some form of communication skills training.

CONCLUSION

The heterogeneity of communication skills training is a barrier to evaluating the efficacy of different communication skills training programmes. Further validation studies examining specific models and frameworks would support a stronger evidence base for communication skills training in psychiatry. It remains a challenge to develop research to investigate behaviour change over time in clinical practice or to measure patient outcomes due to the effects of communication skills training.

Views and experience of communication when receiving a serious mental health diagnosis: satisfaction levels, communication preferences, and acceptability of the SPIKES protocol

BACKGROUND

There is limited research investigating how information about a mental health diagnosis is discussed and received.

AIMS

To measure community-based service users' satisfaction and preferences toward receiving news of a serious mental health diagnosis and to assess the acceptability of a diagnostic communication protocol (SPIKES: Setting; Perception; Invitation; Knowledge; Empathy; Summarizing).

METHOD

A survey was conducted with 101 participants.

RESULTS

Participants rated the methods clinicians use to facilitate diagnostic discussions are highly important; however, they were not wholly satisfied with their experience. Higher satisfaction was reported if participants were provided with information in a face-to-face meeting (p < 0.001), and if they received supplementary support at the time of diagnosis from additional health professionals rather than only a sole practitioner (p < 0.001). The SPIKES protocol was rated as highly acceptable, with Empathy being rated as the most important feature.

CONCLUSIONS

This research indicates there were specific areas of communication practices which can be improved within mental health service provision, as a gap existed between participants' desire for support and their experience. Strategies outlined in the SPIKES protocol, and others such as addressing stigma concerns, may prove useful in development of clinician training and service improvement.

Communication of a schizophrenia diagnosis: A qualitative study of patients' perspectives

BACKGROUND

Transparent diagnostic communication is considered best practice for clinicians. However, while patients expect to receive a schizophrenia diagnosis from their psychiatrist, research suggests mental health clinicians are often reluctant to provide this information to patients.

AIM

This study examines the perceptions of people with schizophrenia surrounding the communication of this diagnosis.

METHODS

A generic qualitative methodological approach was used. A total of 14 patients with schizophrenia were recruited through community mental health services (n = 10) and the Australia Schizophrenia Research Bank (ASRB; n = 4) in New South Wales (NSW), Australia. Semi-structured interviews were used to explore the experiences and perceptions of people with schizophrenia about the way a schizophrenia diagnosis was communicated by mental health clinicians. Interviews were recorded, transcribed, codes generated and thematic analysis undertaken aided by NVivo.

RESULTS

The majority of participants felt it was beneficial to receive a diagnosis despite acknowledging the distress this information sometimes caused, with many reporting this knowledge gave a sense of relief. It helped to understand their experiences and behaviours, improved their trust in the psychiatric system and increased treatment adherence. However, many reported difficulty in obtaining information about their condition, its treatment and prognosis, and expressed dissatisfaction with the way a diagnosis of schizophrenia was communicated.

DISCUSSION

Insight into the perceptions and experiences of patients with schizophrenia about how a diagnosis of schizophrenia is communicated is a key outcome of this research. This knowledge will inform the development of future training programmes for mental health clinicians, and influence the clinical practice of health professionals treating patients with schizophrenia.

Improving clinician competency in communication about schizophrenia: a pilot educational program for psychiatry trainees

OBJECTIVE

Important gaps are observed in clinicians' communication with patients and families about psychiatric disorders such as schizophrenia. Communication skills can be taught, and models for education in these skills have been developed in other fields of medicine, such as oncology, providing a framework for training communication skills relevant to psychiatric practice. This study evaluated a pilot communication skills education program for psychiatry trainees, focusing on discussing schizophrenia diagnosis and prognosis.

METHOD

Communication skills training modules were developed based on an existing theoretical framework (ComSkil), adapted for discussing a schizophrenia diagnosis and prognosis. Pre-post training rating of self-reported confidence in a range of communication tasks was obtained, along with trainee views on the training methods.

RESULTS

Thirty-eight participants completed the training. Significant improvements in confidence were reported post training for discussing schizophrenia prognosis, including an increased capacity to critically evaluate their own communication skills. Participants reported high levels of satisfaction with the program.

CONCLUSION

This preliminary study provides support for the translation of a well-established educational model to psychiatric training addressing core clinical communication tasks and provides the foundation for the development of a more comprehensive evaluation and an extended curriculum regarding other aspects of care for patients with schizophrenia: ongoing management and recovery, dealing with conflict, and conducting a family interview.

'We didn't have a clue': Family caregivers' experiences of the communication of a diagnosis of schizophrenia

BACKGROUND

Despite widespread acceptance of the principle that patients should be informed about their diagnosis, many clinicians are reluctant to provide a diagnosis of schizophrenia. This study examines family caregivers' experiences of the communication of a schizophrenia diagnosis and related information.

METHODS

A generic qualitative methodological approach was used. In all, 13 family caregivers were recruited in regional New South Wales, Australia. Semi-structured interviews were used to explore their experiences and perceptions of discussing the diagnosis, prognosis and treatment of schizophrenia with mental health professionals. Interviews were recorded, transcribed, codes generated and thematic analysis undertaken.

RESULTS

Family caregivers described long and difficult pathways to being given a diagnosis, haphazard means of finding out the diagnosis, high unmet needs for information, exclusion from the medical care process and problematic communication and general interactions with mental health clinicians. Caregivers were unanimous about the importance of receiving a timely diagnosis, for them and their relative with schizophrenia.

CONCLUSION

Family caregivers are an integral part of the mental health-care system, and they should be included early in discussions of diagnosis and treatment of a person with schizophrenia. Their perspectives on communicating a diagnosis of schizophrenia provide important information for communication skills training of psychiatrists and other mental health professionals.

Psychiatrists' challenges in considering disclosure of schizophrenia diagnosis in Israel

Doctors' clear disclosure of diagnoses to patients is fundamental to patient autonomy and patient-centered approaches in health care. Although diagnosis disclosure is common in general health, it is less so in psychiatry. The aim of this study was to explore psychiatrists' experiences of schizophrenia diagnosis disclosure to patients and/or family members. We conducted in-depth interviews with 14 psychiatrists from hospital and community settings in Israel and used a phenomenological framework to analyze the interviews. Overall, psychiatrists experienced disclosure as problematic, unproductive, and harmful. We identified 10 themes of psychiatrist experiences and concerns conceptualized under three domains: (a) characteristics of schizophrenia, (b) the doctor-patient/family relationship, and (c) psychiatrists' difficulties with the disclosure task. We discuss the results suggesting a multilayered model of medical, relational, social, and personal disclosure challenges. We suggest that a constructive schizophrenia diagnosis disclosure needs to take into account psychiatrist- and patient-related factors and specify possible directions.

Diagnosis telling in people with psychosis

PURPOSE OF REVIEW

There are complexities in communicating diagnostic information relating to schizophrenia spectrum disorders. There is a current dearth of research in understanding how clinicians effectively communicate with service users about such diagnostic news. In this review, we aim to synthesize the latest research throughout 2012 and 2013 that presented data relating to the communication of a diagnosis of schizophrenia spectrum disorders, including individuals who had experienced first-episode psychosis or were in at-risk mental states. Comprehensive database and manual searches were conducted which obtained data from both service users and health professional groups.

RECENT FINDINGS

Fourteen quantitative and qualitative studies were found. The majority of studies were descriptive and heterogeneous in content. Key themes included service user preferences towards disclosure and diagnostic terminology, health professional training, stigma-related issues and the use of diagnostic communication models.

SUMMARY

Overall, communication models that foster therapeutic relationships and actively encourage the health professional to reduce stigma may be a key to initial diagnostic discussions in clinical practice. Such communication models and intervention require further more rigorous evaluation, as none have been tested through randomized controlled protocols in clinical settings.