1
|
Silva B, Morandi S, Bachelard M, Bonsack C, Golay P. Pathways to experienced coercion during psychiatric admission: a network analysis. BMC Psychiatry 2024; 24:546. [PMID: 39095738 PMCID: PMC11295432 DOI: 10.1186/s12888-024-05968-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 07/15/2024] [Indexed: 08/04/2024] Open
Abstract
BACKGROUND In mental health care, experienced coercion, also known as perceived coercion, is defined as the patient's subjective experience of being submitted to coercion. Besides formal coercion, many other factors have been identified as potentially affecting the experience of being coerced. This study aimed to explore the interplay between these factors and to provide new insights into how they lead to experienced coercion. METHODS Cross-sectional network analysis was performed on data collected from 225 patients admitted to six psychiatric hospitals. Thirteen variables were selected and included in the analyses. A Gaussian Graphical Model (GGM) using Spearman's rank-correlation method and EBICglasso regularisation was estimated. Centrality indices of strength and expected influence were computed. To evaluate the robustness of the estimated parameters, both edge-weight accuracy and centrality stability were investigated. RESULTS The estimated network was densely connected. Formal coercion was only weakly associated with both experienced coercion at admission and during hospital stay. Experienced coercion at admission was most strongly associated with the patients' perceived level of implication in the decision-making process. Experienced humiliation and coercion during hospital stay, the most central node in the network, was found to be most strongly related to the interpersonal separation that patients perceived from staff, the level of coercion perceived upon admission and their satisfaction with the decision taken and the level of information received. CONCLUSIONS Reducing formal coercion may not be sufficient to effectively reduce patients' feeling of being coerced. Different factors seemed indeed to come into play and affect experienced coercion at different stages of the hospitalisation process. Interventions aimed at reducing experienced coercion and its negative effects should take these stage-specific elements into account and propose tailored strategies to address them.
Collapse
Affiliation(s)
- Benedetta Silva
- Community Psychiatry Service, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
- Cantonal Medical Office, General Directorate for Health, Canton of Vaud, Department of Health and Social Action, Lausanne, Switzerland.
| | - Stéphane Morandi
- Community Psychiatry Service, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Cantonal Medical Office, General Directorate for Health, Canton of Vaud, Department of Health and Social Action, Lausanne, Switzerland
| | - Mizue Bachelard
- Community Psychiatry Service, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Charles Bonsack
- Community Psychiatry Service, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Philippe Golay
- Community Psychiatry Service, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- General Psychiatry Service, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Institute of Psychology, Faculty of Social and Political Sciences, University of Lausanne, Lausanne, Switzerland
| |
Collapse
|
2
|
Marchi M, Venturi G, Visentini C, Pinelli M, Priebe S, Galeazzi GM. The therapeutic relationship in community mental health services: a systematic review of the literature. Soc Psychiatry Psychiatr Epidemiol 2024; 59:731-743. [PMID: 37875610 DOI: 10.1007/s00127-023-02581-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 10/05/2023] [Indexed: 10/26/2023]
Abstract
PURPOSE This systematic review aimed to investigate the therapeutic relationship (TR) between mental health professionals (MHPs) and their patients in community mental health services (CMHS). METHODS PubMed (Medline), PsycINFO, CINAHL, CENTRAL, and Web of Science were searched for studies that assessed TR in CMHS using quantitative measures developed specifically for this setting (i.e., Helping Alliance Scale [HAS] and the Scale to Assess the Therapeutic Relationship [STAR]). Studies were included if they considered adult patients with a psychiatric disorder and/or any MHP working in CMHS. Meta-analysis and narrative synthesis assessed the association between patients' and MHPs' ratings and identified predictors of TR. RESULTS Of 1934 studies, 15 were included in the review, including 3004 patients. A total of 1127 patients and 963 MHPs were considered in the meta-analysis. The heterogeneity of the studies was high, and there was no significant difference between the patients' and MHPs' TR ratings in the random-effects model (standardized mean difference [SMD]: - 0.39 [95% CI: - 1.03; 0.24]). In the multivariable meta-regression, only duration of illness was significantly associated with TR ratings (unstandardized regression coefficient [B]: 0.388 [95% CI: 0.217; 0.558]). A recovery-oriented service, shared decision-making, and the recognition of patient needs contributed to more positive TR ratings. CONCLUSION Patients and MHPs converged in their TR ratings, although patients gave lower ratings. Routine assessment of TR in CMHS can inform reflective practice and service development, as TR can be assessed easily and early in the treatment process. Future research should focus on developing and testing interventions to improve TR in CMHS.
Collapse
Affiliation(s)
- Mattia Marchi
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
- Dipartimento ad Attività Integrata di Salute Mentale e Dipendenze Patologiche, Azienda USL-IRCCS di Reggio Emilia, Via Giovanni Amendola 2, 42122, Reggio Emilia, Italy
| | - Giulia Venturi
- Dipartimento ad Attività Integrata di Salute Mentale e Dipendenze Patologiche, Azienda USL-IRCCS di Reggio Emilia, Via Giovanni Amendola 2, 42122, Reggio Emilia, Italy
| | - Chiara Visentini
- Department of Mental Health and Drug Abuse, AUSL Modena, Modena, Italy
| | - Margherita Pinelli
- Dipartimento ad Attività Integrata di Salute Mentale e Dipendenze Patologiche, Azienda USL-IRCCS di Reggio Emilia, Via Giovanni Amendola 2, 42122, Reggio Emilia, Italy
| | | | - Gian Maria Galeazzi
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy.
- Dipartimento ad Attività Integrata di Salute Mentale e Dipendenze Patologiche, Azienda USL-IRCCS di Reggio Emilia, Via Giovanni Amendola 2, 42122, Reggio Emilia, Italy.
| |
Collapse
|
3
|
Morandi S, Silva B, Pauli G, Martinez D, Bachelard M, Bonsack C, Golay P. How do decision making and fairness mediate the relationship between involuntary hospitalisation and perceived coercion among psychiatric inpatients? J Psychiatr Res 2024; 173:98-103. [PMID: 38518573 DOI: 10.1016/j.jpsychires.2024.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 02/19/2024] [Accepted: 03/15/2024] [Indexed: 03/24/2024]
Abstract
BACKGROUND Coercion perceived by psychiatric inpatients is not exclusively determined by formal measures such as involuntary admissions, seclusion or restraint, but is also associated with patients' characteristics and professionals' attitude. AIMS This study examined how inpatients' involvement in the decision making process, the respect of their decision making preference, and their feeling of having been treated fairly mediate the relationship between involuntary hospitalisation and perceived coercion both at admission and during hospital stay. METHODS Mediation analysis were performed in order to study the relationship between involuntary hospitalisation and perceived coercion among 230 patients, voluntarily and involuntarily admitted in six psychiatric hospitals. RESULTS 32.2% of the participants were involuntarily hospitalised. Taken individually, stronger participants' involvement in decision making process, better respect for their decision making preference and higher level of perceived fairness partially mediated the relationship between involuntary hospitalisation and perceived coercion by reducing the level of the latter both at admission and during the hospitalisation. In multiple mediator models, only involvement and respect played an important role at admission. During the hospitalisation, perceived fairness was the most relevant mediator, followed by involvement in decision making. CONCLUSIONS During psychiatric hospitalisation patients' involvement in decision making, respect of their decision making preference and perceived fairness determined the relationship between involuntary hospitalisation and perceived coercion, but not in the same way at admission and during the stay. Involving patients in decision making and treating them fairly may be more relevant than taking account of their decision making preference in order to reduce perceived coercion.
Collapse
Affiliation(s)
- Stéphane Morandi
- Community Psychiatry Service, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; Cantonal Medical Office, Directorate General for Health of Canton of Vaud, Department of Health and Social Action (DSAS), Avenue des Casernes 2, 1014, Lausanne, Switzerland.
| | - Benedetta Silva
- Community Psychiatry Service, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; Cantonal Medical Office, Directorate General for Health of Canton of Vaud, Department of Health and Social Action (DSAS), Avenue des Casernes 2, 1014, Lausanne, Switzerland
| | - Guillaume Pauli
- Community Psychiatry Service, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Debora Martinez
- Community Psychiatry Service, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Mizué Bachelard
- Community Psychiatry Service, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Charles Bonsack
- Community Psychiatry Service, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Philippe Golay
- Community Psychiatry Service, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; Institute of Psychology, Faculty of Social and Political Science, University of Lausanne, Switzerland; General Psychiatry Service, Treatment and Early Intervention in Psychosis Program (TIPP-Lausanne), Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| |
Collapse
|
4
|
Yee A. Clinical decision-making in the intensive care unit: A concept analysis. Intensive Crit Care Nurs 2023. [DOI: 10.1016/j.iccn.2023.103430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2023]
|
5
|
Aoki Y, Yaju Y, Utsumi T, Sanyaolu L, Storm M, Takaesu Y, Watanabe K, Watanabe N, Duncan E, Edwards AG. Shared decision-making interventions for people with mental health conditions. Cochrane Database Syst Rev 2022; 11:CD007297. [PMID: 36367232 PMCID: PMC9650912 DOI: 10.1002/14651858.cd007297.pub3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND One person in every four will suffer from a diagnosable mental health condition during their life. Such conditions can have a devastating impact on the lives of the individual and their family, as well as society. International healthcare policy makers have increasingly advocated and enshrined partnership models of mental health care. Shared decision-making (SDM) is one such partnership approach. Shared decision-making is a form of service user-provider communication where both parties are acknowledged to bring expertise to the process and work in partnership to make a decision. This review assesses whether SDM interventions improve a range of outcomes. This is the first update of this Cochrane Review, first published in 2010. OBJECTIVES To assess the effects of SDM interventions for people of all ages with mental health conditions, directed at people with mental health conditions, carers, or healthcare professionals, on a range of outcomes including: clinical outcomes, participation/involvement in decision-making process (observations on the process of SDM; user-reported, SDM-specific outcomes of encounters), recovery, satisfaction, knowledge, treatment/medication continuation, health service outcomes, and adverse outcomes. SEARCH METHODS We ran searches in January 2020 in CENTRAL, MEDLINE, Embase, and PsycINFO (2009 to January 2020). We also searched trial registers and the bibliographies of relevant papers, and contacted authors of included studies. We updated the searches in February 2022. When we identified studies as potentially relevant, we labelled these as studies awaiting classification. SELECTION CRITERIA Randomised controlled trials (RCTs), including cluster-randomised controlled trials, of SDM interventions in people with mental health conditions (by Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD) criteria). DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Two review authors independently screened citations for inclusion, extracted data, and assessed risk of bias. We used GRADE to assess the certainty of the evidence. MAIN RESULTS This updated review included 13 new studies, for a total of 15 RCTs. Most participants were adults with severe mental illnesses such as schizophrenia, depression, and bipolar disorder, in higher-income countries. None of the studies included children or adolescents. Primary outcomes We are uncertain whether SDM interventions improve clinical outcomes, such as psychiatric symptoms, depression, anxiety, and readmission, compared with control due to very low-certainty evidence. For readmission, we conducted subgroup analysis between studies that used usual care and those that used cognitive training in the control group. There were no subgroup differences. Regarding participation (by the person with the mental health condition) or level of involvement in the decision-making process, we are uncertain if SDM interventions improve observations on the process of SDM compared with no intervention due to very low-certainty evidence. On the other hand, SDM interventions may improve SDM-specific user-reported outcomes from encounters immediately after intervention compared with no intervention (standardised mean difference (SMD) 0.63, 95% confidence interval (CI) 0.26 to 1.01; 3 studies, 534 participants; low-certainty evidence). However, there was insufficient evidence for sustained participation or involvement in the decision-making processes. Secondary outcomes We are uncertain whether SDM interventions improve recovery compared with no intervention due to very low-certainty evidence. We are uncertain if SDM interventions improve users' overall satisfaction. However, one study (241 participants) showed that SDM interventions probably improve some aspects of users' satisfaction with received information compared with no intervention: information given was rated as helpful (risk ratio (RR) 1.33, 95% CI 1.08 to 1.65); participants expressed a strong desire to receive information this way for other treatment decisions (RR 1.35, 95% CI 1.08 to 1.68); and strongly recommended the information be shared with others in this way (RR 1.32, 95% CI 1.11 to 1.58). The evidence was of moderate certainty for these outcomes. However, this same study reported there may be little or no effect on amount or clarity of information, while another small study reported there may be little or no change in carer satisfaction with the SDM intervention. The effects of healthcare professional satisfaction were mixed: SDM interventions may have little or no effect on healthcare professional satisfaction when measured continuously, but probably improve healthcare professional satisfaction when assessed categorically. We are uncertain whether SDM interventions improve knowledge, treatment continuation assessed through clinic visits, medication continuation, carer participation, and the relationship between users and healthcare professionals because of very low-certainty evidence. Regarding length of consultation, SDM interventions probably have little or no effect compared with no intervention (SDM 0.09, 95% CI -0.24 to 0.41; 2 studies, 282 participants; moderate-certainty evidence). On the other hand, we are uncertain whether SDM interventions improve length of hospital stay due to very low-certainty evidence. There were no adverse effects on health outcomes and no other adverse events reported. AUTHORS' CONCLUSIONS This review update suggests that people exposed to SDM interventions may perceive greater levels of involvement immediately after an encounter compared with those in control groups. Moreover, SDM interventions probably have little or no effect on the length of consultations. Overall we found that most evidence was of low or very low certainty, meaning there is a generally low level of certainty about the effects of SDM interventions based on the studies assembled thus far. There is a need for further research in this area.
Collapse
Affiliation(s)
- Yumi Aoki
- Department of Psychiatric and Mental Health Nursing, Graduate School of Nursing Science, St. Luke's International University, Tokyo, Japan
- Department of Neuropsychiatry, Kyorin University School of Medicine, Tokyo, Japan
| | - Yukari Yaju
- Department of Epidemiology and Biostatistics for Nursing, Graduate School of Nursing Science, St. Luke's International University, Tokyo, Japan
| | - Tomohiro Utsumi
- Department of Sleep-Wake Disorders, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan
- Department of Psychiatry, The Jikei University School of Medicine, Tokyo, Japan
| | - Leigh Sanyaolu
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Marianne Storm
- Department of Public Health, Faculty of Health Science, University of Stavanger, Stavanger, Norway
- Faculty of Health Sciences and Social Care, Molde University College, Molde, Norway
| | - Yoshikazu Takaesu
- Department of Neuropsychiatry, Kyorin University School of Medicine, Tokyo, Japan
- Department of Neuropsychiatry, University of the Ryukyus, Okinawa, Japan
| | - Koichiro Watanabe
- Department of Neuropsychiatry, Kyorin University School of Medicine, Tokyo, Japan
| | - Norio Watanabe
- Department of Psychiatry, Soseikai General Hospital, Kyoto, Japan
| | - Edward Duncan
- Nursing, Midwifery and Allied Health Professions Research Unit, The University of Stirling, Scotland, UK
| | | |
Collapse
|
6
|
Luciano M, Fiorillo A, Brandi C, Di Vincenzo M, Egerhazi A, Hiltensperger R, Kawhol W, Kovacs AI, Rossler W, Slade M, Pushner B, Sampogna G. Impact of clinical decision-making participation and satisfaction on outcomes in mental health practice: results from the CEDAR European longitudinal study. Int Rev Psychiatry 2022; 34:848-860. [PMID: 36786107 DOI: 10.1080/09540261.2022.2085507] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The present study aimed to assess: (1) whether a more active involvement of patients is associated with an improvement of clinical symptoms, global functioning, and quality-of-life; and (2) how patients' satisfaction with clinical decisions can lead to better outcome after 1 year. Data were collected as part of the study 'Clinical decision-making and outcome in routine care for people with severe mental illness (CEDAR)', a longitudinal observational study, funded by the European Commission and carried out in six European countries. Patients' inclusion criteria were: (a) aged between 18 and 60 years; (b) diagnosis of a severe mental illness of any kind according to the Threshold Assessment Grid (TAG) ≥ 5 and duration of illness ≥ 2 years; (c) expected contact with the local mental health service during the 12-month observation period; (d) adequate skills in the language of the host countries; and (e) the ability to provide written informed consent. The clinical decision-making styles of clinicians and the patient satisfaction with decisions were assessed using the Clinical Decision Making Style and the Clinical Decision Making Involvement and Satisfaction scales, respectively. Patients were assessed at baseline and 1 year after the recruitment. The sample consisted of 588 patients with severe mental illness, mainly female, with a mean age of 41.69 (±10.74) and a mean duration of illness of 12.5 (±9.27) years. The majority of patients were diagnosed with psychotic (45.75%) or affective disorders (34.01%). At baseline, a shared CDM style was preferred by 70.6% of clinicians and about 40% of patients indicated a high level of satisfaction with the decision and 31% a medium level of satisfaction. Higher participation in clinical decisions was associated with improved social functioning and quality-of-life, and reduced interpersonal conflicts, sense of loneliness, feelings of inadequacy, and withdrawal in friendships after 1 year (p < 0.05). Moreover, a higher satisfaction with decisions was associated with a better quality-of-life (p < 0.0001), reduced symptom severity (p < 0.0001), and a significantly lower illness burden associated with symptoms of distress (p < 0.0001), interpersonal difficulties (p < 0.0001), and problems in social roles (p < 0.05). Our findings clearly show that a higher involvement in and satisfaction of patients with clinical decision-making was associated with better outcomes. More efforts have to be made to increase the involvement of patients in clinical decision-making in routine care settings.
Collapse
Affiliation(s)
- Mario Luciano
- Department of Psychiatry, University of Campania "L. Vanvitelli", Naples, Italy
| | - Andrea Fiorillo
- Department of Psychiatry, University of Campania "L. Vanvitelli", Naples, Italy
| | - Carlotta Brandi
- Department of Psychiatry, University of Campania "L. Vanvitelli", Naples, Italy
| | - Matteo Di Vincenzo
- Department of Psychiatry, University of Campania "L. Vanvitelli", Naples, Italy
| | - Aniko Egerhazi
- Department of Psychiatry and Psychotherapy Clinical Center, University of Debrecen, Debrecen, Hungary
| | | | - Wolfram Kawhol
- Clienia Schlössli AG, Oetwil am See, Switzerland.,Department of Psychiatry, Psychotherapy and Psychosomatics (KPPP), University Hospital of Psychiatry, Zurich, Switzerland
| | - Attila Istvan Kovacs
- Department of Psychiatry and Psychotherapy Clinical Center, University of Debrecen, Debrecen, Hungary
| | - Wulf Rossler
- Department of Psychiatry and Psychotherapy, Charité University of Medicine, Berlin, Germany
| | - Mike Slade
- School of Health Sciences, Institute of Mental Health, University of Nottingham, Nottingham, UK.,Nord University, Namsos, Norway
| | - Bernd Pushner
- Department of Psychiatry II, Ulm University, Ulm, Germany
| | - Gaia Sampogna
- Department of Psychiatry, University of Campania "L. Vanvitelli", Naples, Italy
| |
Collapse
|
7
|
Clements-Cortés A, Yip JJY. The Impact of Systemic Language in Music Therapy and Western Healthcare Systems: A Canadian Perspective. ARTS IN PSYCHOTHERAPY 2022. [DOI: 10.1016/j.aip.2022.101965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
8
|
Patient Participation and the Environment: A Scoping Review of Instruments. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19042003. [PMID: 35206191 PMCID: PMC8872044 DOI: 10.3390/ijerph19042003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 01/28/2022] [Accepted: 02/05/2022] [Indexed: 12/04/2022]
Abstract
Patient participation and the environment are critical factors in achieving qualitative healthcare. We conducted a systematic scoping review using Arksey and O'Malley's framework to identify instruments intended to measure patient participation. We assessed those instruments' characteristics, which areas of the healthcare continuum they target, and whether environmental factors are considered. Instruments were considered eligible if they represented the patient perspective and measured patient participation in healthcare. The search was limited to articles written in English and published in the last 10 years. We extracted concepts (i.e., patient empowerment, patient participation, and patient-centeredness) based on the framework developed by Castro et al. and outcomes of significance regarding the review questions and specific objectives. The search was conducted in PsycINFO, CINHAL/EBSCO, and PubMed in September 2019 and July 2020. Of 4802 potential titles, 67 studies reported on a total of 45 instruments that met the inclusion criteria for this review. The concept of patient participation was represented most often in these studies. Although some considered the social environment, no instrument was found to incorporate and address the physical environment. Thirteen instruments were generic and the remaining instruments were intended for specific diagnoses or healthcare contexts. Our work is the first to study instruments from this perspective, and we conclude that there is a lack of instruments that measure aspects of the social and physical environment coherently as part of patient participation.
Collapse
|
9
|
Charles A, Korde P, Newby C, Grayzman A, Hiltensperger R, Mahlke C, Moran G, Nakku J, Niwemuhwezi J, Nixdorf R, Paul E, Puschner B, Ramesh M, Ryan GK, Shamba D, Kalha J, Slade M. Proportionate translation of study materials and measures in a multinational global health trial: methodology development and implementation. BMJ Open 2022; 12:e058083. [PMID: 35058270 PMCID: PMC8783829 DOI: 10.1136/bmjopen-2021-058083] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES Current translation guidelines do not include sufficiently flexible translation approaches for different study materials. We aimed to develop a proportionate methodology to inform translation of all types of study materials in global health trials. DESIGN The design included three stages: (1) categorisation of study materials, (2) integration of existing translation frameworks and (3) methodology implementation (Germany, India, Israel, Tanzania and Uganda) and refinement. PARTICIPANTS The study population comprised 27 mental health service users and 27 mental health workers who were fluent in the local language in stage 7 (pretesting), and 54 bilingual mental health service users, aged 18 years or over, and able to give consent as judged by a clinician for step 9 (psychometric evaluation). SETTING The study took place in preparation for the Using Peer Support in Developing Empowering Mental Health Services (UPSIDES) randomised controlled trial (ISRCTN26008944). PRIMARY OUTCOME MEASURE The primary outcome measure was the Social Inclusion Scale (SIS). RESULTS The typology identifies four categories of study materials: local text, study-generated text, secondary measures and primary measure. The UPSIDES Proportionate Translation Methodology comprises ten steps: preparation, forward translation, reconciliation, back translation, review, harmonisation, pretesting, finalisation, psychometric evaluation and dissemination. The translated primary outcome measure for the UPSIDES Trial (SIS) demonstrated adequate content validity (49.3 vs 48.5, p=0.08), convergent validity and internal consistency (0.73), with minimal floor/ceiling effects. CONCLUSION This methodology can be recommended for translating, cross-culturally adapting and validating all study materials, including standardised measures, in future multisite global trials. The methodology is particularly applicable to multi-national studies involving sites with differing resource levels. The robustness of the psychometric findings is limited by the sample sizes for each site. However, making this limitation explicit is preferable to the typical practice of not reporting adequate details about measure translation and validation. TRAIL REGISTRATION NUMBER ISRCTN26008944.
Collapse
Affiliation(s)
- Ashleigh Charles
- School of Health Sciences, Institute of Mental Health, University of Nottingham, Nottingham, UK
| | - Palak Korde
- Centre for Mental Health Law and Policy, Indian Law Society, Pune, Maharashtra, India
| | - Chris Newby
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Alina Grayzman
- Department of Social Work, Ben Gurion University of the Negev, Be'er Sheva, Israel
| | | | - Candelaria Mahlke
- Department of Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Galia Moran
- Department of Social Work, Ben Gurion University of the Negev, Be'er Sheva, Israel
| | - Juliet Nakku
- Butabika National Referral Hospital, Kampala, Uganda
- Makerere University, Kampala, Uganda
| | | | - Rebecca Nixdorf
- Department of Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eva Paul
- Department of Psychiatry II, Ulm University, Ulm, Germany
| | - Bernd Puschner
- Department of Psychiatry II, Ulm University, Ulm, Germany
| | - Mary Ramesh
- Department of Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Ifakara, Morogoro, United Republic of Tanzania
| | - Grace Kathryn Ryan
- Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Donat Shamba
- Department of Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Ifakara, Morogoro, United Republic of Tanzania
| | - Jasmine Kalha
- Centre for Mental Health Law and Policy, Indian Law Society, Pune, Maharashtra, India
| | - Mike Slade
- School of Health Sciences, Institute of Mental Health, University of Nottingham, Nottingham, UK
| |
Collapse
|
10
|
Rojnic Kuzman M, Slade M, Puschner B, Scanferla E, Bajic Z, Courtet P, Samochowiec J, Arango C, Vahip S, Taube M, Falkai P, Dom G, Izakova L, Carpiniello B, Bellani M, Fiorillo A, Skugarevsky O, Mihaljevic-Peles A, Telles-Correia D, Novais F, Mohr P, Wancata J, Hultén M, Chkonia E, Balazs J, Beezhold J, Lien L, Mihajlovic G, Delic M, Stoppe G, Racetovic G, Babic D, Mazaliauskiene R, Cozman D, Hjerrild S, Chihai J, Flannery W, Melartin T, Maruta N, Soghoyan A, Gorwood P. Clinical decision-making style preferences of European psychiatrists: Results from the Ambassadors survey in 38 countries. Eur Psychiatry 2022; 65:e75. [DOI: 10.1192/j.eurpsy.2022.2330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Abstract
Background
While shared clinical decision-making (SDM) is the preferred approach to decision-making in mental health care, its implementation in everyday clinical practice is still insufficient. The European Psychiatric Association undertook a study aiming to gather data on the clinical decision-making style preferences of psychiatrists working in Europe.
Methods
We conducted a cross-sectional online survey involving a sample of 751 psychiatrists and psychiatry specialist trainees from 38 European countries in 2021, using the Clinical Decision-Making Style – Staff questionnaire and a set of questions regarding clinicians’ expertise, training, and practice.
Results
SDM was the preferred decision-making style across all European regions ([central and eastern Europe, CEE], northern and western Europe [NWE], and southern Europe [SE]), with an average of 73% of clinical decisions being rated as SDM. However, we found significant differences in non-SDM decision-making styles: participants working in NWE countries more often prefer shared and active decision-making styles rather than passive styles when compared to other European regions, especially to the CEE. Additionally, psychiatry specialist trainees (compared to psychiatrists), those working mainly with outpatients (compared to those working mainly with inpatients) and those working in community mental health services/public services (compared to mixed and private settings) have a significantly lower preference for passive decision-making style.
Conclusions
The preferences for SDM styles among European psychiatrists are generally similar. However, the identified differences in the preferences for non-SDM styles across the regions call for more dialogue and educational efforts to harmonize practice across Europe.
Collapse
|
11
|
Manners D, Pettigrew S, Lake FR, Piccolo F, McWilliams AM, Brims FJH. Development and evaluation of a consumer information resource, including Patient Decision Aid, for lung cancer screening: a quasi-experimental study. Transl Behav Med 2021; 10:404-412. [PMID: 30855087 DOI: 10.1093/tbm/ibz029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Lung cancer screening of high-risk individuals with computed tomography is a promising intervention to reduce lung cancer mortality. Patient Decision Aids (PtDAs) may assist eligible individuals assess the risks and benefits associated with screening. Screening preference is high among lower-risk, screening-ineligible individuals and strategies are needed to reduce screening demand among this group. We developed and evaluated a resource comprising a recruitment pamphlet combined with either a PtDA for screening-eligible individuals or an education pamphlet for screening-ineligible individuals. Quasi-experimental pre-post pamphlet exposure design. Ever-smokers aged 55-80 years attending hospital outpatient clinics were invited. Among screening-eligible participants, the assessed outcome was change in score on the Decisional Conflict Scale (DCS). Among screening-ineligible participants, the assessed outcomes were change in screening preference. In the study 51% (55/107) of invited individuals participated, with mean ± standard deviation age 66.9 ± 6.4 years, 53% (29/55) male, and 65% (36/55) eligible for screening. Median (interquartile range) DCS among screening-eligible participants reduced from 28.9 (22.7-45.3) pre-PtDA to 25 (1.6-29.7) post-PtDA (p < .001), but there was no significant change in the proportion that reached the accepted threshold for decisional certainty (DCS < 25, 10/36 [28%] pre-exposure vs. 14/36 [39%] post-exposure, p = .1). Screening preference among screening-ineligible individuals reduced after viewing the screening-ineligible brochure (pre-exposure median of "Prefer" to post-exposure median of "Unsure," p = .001). Our consumer information pamphlets about lung cancer screening may reduce decisional conflict and improve alignment of screening preference with eligibility.
Collapse
Affiliation(s)
- David Manners
- St John of God Midland Public and Private Hospital, Midland, Western Australia, Australia.,Curtin Medical School, Curtin University, Bentley, Western Australia, Australia
| | - Simone Pettigrew
- School of Psychology, Curtin University, Bentley, Western Australia, Australia
| | - Fiona R Lake
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.,Medical School, University of Western Australia, Nedlands, Western Australia, Australia
| | - Francesco Piccolo
- St John of God Midland Public and Private Hospital, Midland, Western Australia, Australia
| | - Annette M McWilliams
- Department of Respiratory Medicine, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Fraser J H Brims
- Curtin Medical School, Curtin University, Bentley, Western Australia, Australia.,Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| |
Collapse
|
12
|
Soltmann B, Neumann A, March S, Weinhold I, Häckl D, Kliemt R, Baum F, Romanos M, Schwarz J, von Peter S, Ignatyev Y, Arnold K, Swart E, Heinze M, Schmitt J, Pfennig A. Multiperspective and Multimethod Evaluation of Flexible and Integrative Psychiatric Care Models in Germany: Study Protocol of a Prospective, Controlled Multicenter Observational Study (PsychCare). Front Psychiatry 2021; 12:659773. [PMID: 34140902 PMCID: PMC8205541 DOI: 10.3389/fpsyt.2021.659773] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 05/10/2021] [Indexed: 11/13/2022] Open
Abstract
Background: New cross-sectoral mental health care models have been initiated in Germany to overcome the fragmentation of the German health care system. Starting in 2013, flexible and integrative psychiatric care model projects according to §64b SGB V German Social Law (FIT64b) have been implemented. The study "PsychCare" combines quantitative and qualitative primary data with routine health insurance data for the evaluation of these models. Effects, costs and cost-effectiveness from the perspectives of patients, relatives and care providers are compared with standard care. Additionally, quality indicators for a modern, flexible and integrated care are developed. This article describes the rationale, design and methods of the project. Methods: "PsychCare" is built on a multiperspective and multimethod design. A controlled prospective multicenter cohort study is conducted with three data collection points (baseline assessment, follow-up after 9 and 15 months). A total of 18 hospitals (10 FIT64b model and 8 matched control hospitals) have consecutively recruited in- and outpatients with pre-specified common and/or severe psychiatric disorders. Primary endpoints are differences in change of health-related quality of life and treatment satisfaction. Sociodemographic and service receipt data of the primary data collection are linked with routine health insurance data. A cost-effectiveness analysis, a mixed method, participatory process evaluation by means of qualitative surveys and the development of quality indicators are further elements of "PsychCare." Discussion and Practical Implications: The results based on data from different methodological approaches will provide essential conclusions for the improvement of hospital based mental health care in Germany. This should result in the identification of key FIT64b elements that can be efficiently implemented into standard care in Germany and re-structure the care strongly aligned to patient needs. Clinical Trial Registration: German Clinical Trial Register, identifier DRKS 00022535.
Collapse
Affiliation(s)
- Bettina Soltmann
- Department of Psychiatry and Psychotherapy, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Anne Neumann
- Center of Evidence-Based Health Care, Medical Faculty Carl Gustav Carus, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Stefanie March
- Department of Social Work, Health and Media, University of Applied Sciences Magdeburg-Stendal, Magdeburg, Germany.,Institute of Social Medicine and Health Systems Research, Medical Faculty, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Ines Weinhold
- WIG2 Scientific Institute for Health Economics and Health System Research Leipzig, Leipzig, Germany
| | - Dennis Häckl
- WIG2 Scientific Institute for Health Economics and Health System Research Leipzig, Leipzig, Germany
| | - Roman Kliemt
- WIG2 Scientific Institute for Health Economics and Health System Research Leipzig, Leipzig, Germany
| | - Fabian Baum
- Center of Evidence-Based Health Care, Medical Faculty Carl Gustav Carus, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Marcel Romanos
- Department of Child and Adolescent Psychiatry, Centre of Mental Health, Psychosomatics and Psychotherapy, University of Würzburg, Würzburg, Germany
| | - Julian Schwarz
- Department of Psychiatry and Psychotherapy, Brandenburg Medical School Theodor Fontane, Immanuel Klinik Rüdersdorf, Rüdersdorf, Germany
| | - Sebastian von Peter
- Department of Psychiatry and Psychotherapy, Brandenburg Medical School Theodor Fontane, Immanuel Klinik Rüdersdorf, Rüdersdorf, Germany
| | - Yuriy Ignatyev
- Department of Psychiatry and Psychotherapy, Brandenburg Medical School Theodor Fontane, Immanuel Klinik Rüdersdorf, Rüdersdorf, Germany
| | - Katrin Arnold
- Center of Evidence-Based Health Care, Medical Faculty Carl Gustav Carus, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Enno Swart
- Institute of Social Medicine and Health Systems Research, Medical Faculty, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Martin Heinze
- Department of Psychiatry and Psychotherapy, Brandenburg Medical School Theodor Fontane, Immanuel Klinik Rüdersdorf, Rüdersdorf, Germany
| | - Jochen Schmitt
- Center of Evidence-Based Health Care, Medical Faculty Carl Gustav Carus, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Andrea Pfennig
- Department of Psychiatry and Psychotherapy, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| |
Collapse
|
13
|
Fernandes S, Fond G, Zendjidjian XY, Baumstarck K, Lançon C, Berna F, Schurhoff F, Aouizerate B, Henry C, Etain B, Samalin L, Leboyer M, Llorca PM, Coldefy M, Auquier P, Boyer L. Measuring the Patient Experience of Mental Health Care: A Systematic and Critical Review of Patient-Reported Experience Measures. Patient Prefer Adherence 2020; 14:2147-2161. [PMID: 33192054 PMCID: PMC7653683 DOI: 10.2147/ppa.s255264] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/23/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND There is growing concern about measuring patient experience with mental health care. There are currently numerous patient-reported experience measures (PREMs) available for mental health care, but there is little guidance for selecting the most suitable instruments. The objective of this systematic review was to provide an overview of the psychometric properties and the content of available PREMs. METHODS A comprehensive review following the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines was conducted using the MEDLINE database with no date restrictions. The content of PREMs was analyzed using an inductive qualitative approach, and the methodological quality was assessed according to Pesudovs quality criteria. RESULTS A total of 86 articles examining 75 PREMs and totaling 1932 items were included. Only four PREMs used statistical methods from item response theory (IRT). The 1932 items covered seven key mental health care domains: interpersonal relationships (22.6%), followed by respect and dignity (19.3%), access and care coordination (14.9%), drug therapy (14.1%), information (9.6%), psychological care (6.8%) and care environment (6.1%). Additionally, a few items focused on patient satisfaction (6.7%) rather than patient experience. No instrument covered the latent trait continuum of patient experience, as defined by the inductive qualitative approach, and the psychometric properties of the instruments were heterogeneous. CONCLUSION This work is a critical step in the creation of an item library to measure mental health care patient-reported experience that will be used in France to develop, validate, and standardize item banks and computerized adaptive testing (CAT) based on IRT. It will also provide internationally replicable measures that will allow direct comparisons of mental health care systems. TRIAL REGISTRATION NCT02491866.
Collapse
Affiliation(s)
- Sara Fernandes
- Aix-Marseille University, School of Medicine - La Timone Medical Campus, EA 3279: CEReSS - Health Service Research and Quality of Life Center, Marseille, France
| | - Guillaume Fond
- Aix-Marseille University, School of Medicine - La Timone Medical Campus, EA 3279: CEReSS - Health Service Research and Quality of Life Center, Marseille, France
| | - Xavier Yves Zendjidjian
- Aix-Marseille University, School of Medicine - La Timone Medical Campus, EA 3279: CEReSS - Health Service Research and Quality of Life Center, Marseille, France
| | - Karine Baumstarck
- Aix-Marseille University, School of Medicine - La Timone Medical Campus, EA 3279: CEReSS - Health Service Research and Quality of Life Center, Marseille, France
| | - Christophe Lançon
- Aix-Marseille University, School of Medicine - La Timone Medical Campus, EA 3279: CEReSS - Health Service Research and Quality of Life Center, Marseille, France
| | | | | | | | | | | | | | | | | | - Magali Coldefy
- Institute for Research and Information in Health Economics (IRDES), Paris, France
| | - Pascal Auquier
- Aix-Marseille University, School of Medicine - La Timone Medical Campus, EA 3279: CEReSS - Health Service Research and Quality of Life Center, Marseille, France
| | - Laurent Boyer
- Aix-Marseille University, School of Medicine - La Timone Medical Campus, EA 3279: CEReSS - Health Service Research and Quality of Life Center, Marseille, France
| | - On behalf of the French PREMIUM Group
- Aix-Marseille University, School of Medicine - La Timone Medical Campus, EA 3279: CEReSS - Health Service Research and Quality of Life Center, Marseille, France
- FondaMental Foundation, Créteil, France
- Institute for Research and Information in Health Economics (IRDES), Paris, France
| |
Collapse
|
14
|
Huang C, Plummer V, Lam L, Cross W. Translation and psychometric testing of a decision-making scale. J Psychiatr Ment Health Nurs 2020; 27:533-542. [PMID: 31976586 DOI: 10.1111/jpm.12601] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 01/15/2020] [Accepted: 01/20/2020] [Indexed: 11/27/2022]
Abstract
WHAT IS KNOWN ABOUT SHARED DECISION-MAKING?: There is increasing investigation of shared decision-making in mental health services. Exploration of shared decision-making and relevant instrument is scant in China. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: In this study, the Clinical Decision-making Involvement and Satisfaction (CDIS) was translated into Chinese and validated with patients and mental health professionals. The Chinese version of the CDIS is a reliable and valid instrument for measuring perception of involvement and satisfaction with treatment decision for schizophrenia WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental health nurses could use the CDIS patient-rated and health professional-rated versions to compare their perceptions of the decision-making process. ABSTRACT: Introduction There is growing interest in shared decision-making in Chinese mental health services. However, few specific instruments are available to measure decision-making satisfaction and involvement. Aim To translate and validate Clinical Decision-making Involvement and Satisfaction (CDIS) in a Chinese population. Methods The translation process was completed based on the Brislin translation method. Convenience sampling of 505 participants including 212 people diagnosed with schizophrenia and 293 mental health professionals for psychometric testing (e.g., content and construct validity, and test-retest reliability). Results The CDIS Chinese version has good internal consistency and temporal stability. Factor analysis determined two factors including satisfaction and involvement subscales, explaining 60.08% of the total variance. The Cronbach's α was 0.70, and the intraclass correlation coefficient ranged from 0.83 to 0.89. The composite reliability value was 0.85, and the average variance extracted was 0.50. Critical Ratio values ranged from 5.28 to 17.95, and item-total correlation values ranged from 0.48 to 0.75. Discussion The CDIS Chinese version is a feasible and reliable instrument.
Collapse
Affiliation(s)
- Chongmei Huang
- School of Nursing and Midwifery, Monash University, Clayton, Vic., Australia
| | - Virginia Plummer
- School of Nursing and Midwifery, Monash University and Peninsula Health, Clayton, Vic., Australia
| | - Louisa Lam
- School of Nursing and Healthcare Professions, Federation University Australia, Melbourne, Vic., Australia
| | - Wendy Cross
- School of Nursing and Healthcare Professions, Federation University Australia, Melbourne, Vic., Australia
| |
Collapse
|
15
|
Perceived Patient Satisfaction and Associated Factors among Psychiatric Patients Who Attend Their Treatment at Outpatient Psychiatry Clinic, Jimma University Medical Center, Southwest Ethiopia, Jimma, 2019. PSYCHIATRY JOURNAL 2020; 2020:6153234. [PMID: 32206668 PMCID: PMC7077051 DOI: 10.1155/2020/6153234] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 02/12/2020] [Indexed: 11/17/2022]
Abstract
Background In health care, patient satisfaction is an attitudinal response and a pillar for quality assurance, but there is reluctance to measure it among mentally ill patients. Satisfied patients become more compliant. However, no study was done in this study area before. Therefore, this study was conducted to determine the magnitude of perceived patient satisfaction and associated factor at Jimma University Medical Center, outpatient psychiatry clinic. Methods Cross-sectional study design was conducted, and systematic random sampling technique was used to get study participants. The 24-item Mental Health Service Satisfaction Scale (a validated tool in Ethiopia) was used to assess patient satisfaction. Data was entered using Epi-data 3.1 and exported to the Statistical Package for the Social Sciences 22.0 for analysis. Linear regression analysis (P < 0.05) was used to identify the association between the outcome and independent variable. Result 414 respondents participated in the study with response rate of 98%. The overall percentage of patient satisfaction was 50.3% (95% CI 48.4%-51.2%). Being male (β = -0.651, 95% CI (-0.969, -0.332)), having secondary and above educational status (β = -0.651, 95% CI (-0.969, -0.332)), having secondary and above educational status (β = -0.651, 95% CI (-0.969, -0.332)), having secondary and above educational status (β = -0.651, 95% CI (-0.969, -0.332)), having secondary and above educational status (β = -0.651, 95% CI (-0.969, -0.332)), having secondary and above educational status (β = -0.651, 95% CI (-0.969, -0.332)), having secondary and above educational status (β = -0.651, 95% CI (-0.969, -0.332)), having secondary and above educational status (β = -0.651, 95% CI (-0.969, -0.332)), having secondary and above educational status (β = -0.651, 95% CI (-0.969, -0.332)), having secondary and above educational status (Conclusion and Recommendation. This study found that half of the study participants are satisfied with the service. Distance from the hospital, current substance use, waiting time, and having good social support were identified as modifiable factors that can be improved through working with stakeholders to increase patient satisfaction.
Collapse
|
16
|
Jennings H, Slade M, Bates P, Munday E, Toney R. Best practice framework for Patient and Public Involvement (PPI) in collaborative data analysis of qualitative mental health research: methodology development and refinement. BMC Psychiatry 2018; 18:213. [PMID: 29954373 PMCID: PMC6022311 DOI: 10.1186/s12888-018-1794-8] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 06/17/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Patient and Public Involvement (PPI) in mental health research is increasing, especially in early (pre-funding) stages. PPI is less consistent in later stages, including in analysing qualitative data. The aims of this study were to develop a methodology for involving PPI co-researchers in collaboratively analysing qualitative mental health research data with academic researchers, to pilot and refine this methodology, and to create a best practice framework for collaborative data analysis (CDA) of qualitative mental health research. METHODS In the context of the RECOLLECT Study of Recovery Colleges, a critical literature review of collaborative data analysis studies was conducted, to identify approaches and recommendations for successful CDA. A CDA methodology was developed and then piloted in RECOLLECT, followed by refinement and development of a best practice framework. RESULTS From 10 included publications, four CDA approaches were identified: (1) consultation, (2) development, (3) application and (4) development and application of coding framework. Four characteristics of successful CDA were found: CDA process is co-produced; CDA process is realistic regarding time and resources; demands of the CDA process are manageable for PPI co-researchers; and group expectations and dynamics are effectively managed. A four-meeting CDA process was piloted to co-produce a coding framework based on qualitative data collected in RECOLLECT and to create a mental health service user-defined change model relevant to Recovery Colleges. Formal and informal feedback demonstrated active involvement. The CDA process involved an extra 80 person-days of time (40 from PPI co-researchers, 40 from academic researchers). The process was refined into a best practice framework comprising Preparation, CDA and Application phases. CONCLUSIONS This study has developed a typology of approaches to collaborative analysis of qualitative data in mental health research, identified from available evidence the characteristics of successful involvement, and developed, piloted and refined the first best practice framework for collaborative analysis of qualitative data. This framework has the potential to support meaningful PPI in data analysis in the context of qualitative mental health research studies, a previously neglected yet central part of the research cycle.
Collapse
Affiliation(s)
- Helen Jennings
- Department of Occupational Therapy, School of Health Sciences, York St. John University, York, UK
| | - Mike Slade
- School of Health Sciences, Institute of Mental Health, University of Nottingham, Triumph Road, Nottingham, NG7 2TU UK
| | | | - Emma Munday
- RECOLLECT Lived Experience Advisory Panel, Nottingham, UK
| | - Rebecca Toney
- School of Health Sciences, Institute of Mental Health, University of Nottingham, Triumph Road, Nottingham, NG7 2TU UK
| |
Collapse
|
17
|
Samalin L, Honciuc M, Boyer L, de Chazeron I, Blanc O, Abbar M, Llorca PM. Efficacy of shared decision-making on treatment adherence of patients with bipolar disorder: a cluster randomized trial (ShareD-BD). BMC Psychiatry 2018; 18:103. [PMID: 29653535 PMCID: PMC5899333 DOI: 10.1186/s12888-018-1686-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 04/08/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Shared decision-making (SDM) is a model of interaction between doctors and patients in which both actors contribute to the medical decision-making process. SDM has raised great interest in mental healthcare over the last decade, as it is considered a fundamental part of patient-centered care. However, there is no research evaluating the efficacy of SDM compared to usual care (CAU), as it relates to quality of care and more specifically treatment adherence, in bipolar disorder (BD). METHODS/DESIGN This is a 12-month multi-centre, cluster-randomized controlled trial comparing the efficacy of SDM to CAU. Adult BD patients (n = 300) will be eligible after stabilization for at least 4 weeks following an acute mood episode. The intervention will consist of applying the standardized SDM process as developed by the Ottawa Hospital Research Institute in order to choose the maintenance treatment of BD. A multidisciplinary team developed a decision aid "choose my long-term treatment with my doctor" for BD patients to clarify possible therapeutic options. Primary outcome will assess the patient's level of adherence (based on hetero-evaluation) of ongoing treatment at 12 months. Secondary outcomes will assess the difference between the 2 groups of patients in terms of adherence to maintenance drug therapy based on other measures (self-assessment scale and plasma levels of mood stabilizers). Additionally, other dimensions will be assessed: decisional conflict, satisfaction with care and involvement in decision making, beliefs about treatment, therapeutic relationship, knowledge about information for medical decision and clinical outcomes (depression, mania, functioning and quality of life). The primary endpoint will be analysed without adjustment by comparison of adherence scores between the two groups using Student t-tests or Mann-Whitney tests according to the variable distribution. A set of secondary analyses will be adjusted for covariates of clinical interest using generalized linear mixed regression models. DISCUSSION This will be the first study evaluating the effect of an SDM intervention on patient adherence in BD. This is also an innovative protocol because it proposes the development of an evidence-based tool that should help patients and clinicians to initiate discussions regarding the use of BD treatment. TRIAL REGISTRATION The study has been registered with ClinicalTrials.gov as NCT03245593 .
Collapse
Affiliation(s)
- L. Samalin
- CHU Clermont-Ferrand, Department of Psychiatry, University of Clermont Auvergne, EA7280 Clermont-Ferrand, France
- Aix-Marseille University, Public Health, Chronic Diseases and Quality of Life research Unit, EA 3279 Marseille, France
| | - M. Honciuc
- CHU Clermont-Ferrand, Department of Psychiatry, University of Clermont Auvergne, EA7280 Clermont-Ferrand, France
| | - L. Boyer
- Aix-Marseille University, Public Health, Chronic Diseases and Quality of Life research Unit, EA 3279 Marseille, France
| | - I. de Chazeron
- CHU Clermont-Ferrand, Department of Psychiatry, University of Clermont Auvergne, EA7280 Clermont-Ferrand, France
| | - O. Blanc
- CHU Clermont-Ferrand, Department of Psychiatry, University of Clermont Auvergne, EA7280 Clermont-Ferrand, France
| | | | - P. M. Llorca
- CHU Clermont-Ferrand, Department of Psychiatry, University of Clermont Auvergne, EA7280 Clermont-Ferrand, France
| |
Collapse
|
18
|
Popa D, Druguș D, Leașu F, Azoicăi D, Repanovici A, Rogozea LM. Patients' perceptions of healthcare professionalism-a Romanian experience. BMC Health Serv Res 2017; 17:463. [PMID: 28683756 PMCID: PMC5501103 DOI: 10.1186/s12913-017-2412-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 06/28/2017] [Indexed: 11/10/2022] Open
Abstract
Background The main objective of this cross sectional study was to assess the psychometric properties of a new research instrument. The secondary aim was to analyze patients’ levels of dissatisfaction with the professionalism of medical staff. Methods A social survey questionnaire was created and administered online. The instrument consisted of two scales: the 30-item patient dissatisfaction scale and the 10 items institutional scale. In this article, we assessed only the patient dissatisfaction scale. The research population includes 1838 subjects. The statistical procedures used were descriptive statistics, Pearson’s correlation, and factorial analyses with the SPSS.19 software. The internal consistency of the instrument was determined using the Cronbach’s alpha coefficient. We used a principal component analysis to investigate the factorial validity of the scale. Results The patients’ scale of dissatisfaction obtained an alpha Cronbach score of 0.81. Three latent factors corresponding to three dimensions of dissatisfaction emerged from the data: medical staff’s ability to communicate, medical staff’s hygiene, as well as sanitary and privacy conditions within the hospital. The first factor explained 43.47% of the variance in patient dissatisfaction, the second factor explained 10.24%, and the third factor explained 7.59%; overall, the three factors explained 61.30% of the total variance. Conclusion The Romanian healthcare system has an organization and management structure which has shown few changes since the communist period. Our study indicates that although more than 25 years have passed since the political regime changed in Romania and the introduction of a different system of social care, there have been no corresponding changes in the medical staff’s mentality or in the way that patients are approached. The present assessment of patient dissatisfaction is not a strictly theoretical exercise; it also represents a valuable instrument for healthcare system management. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2412-z) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Daniela Popa
- Department of Psychology and Training in Education, Transilvania University of Brasov, Str. Nicolae Balcescu no. 56, 500019, Brasov, Romania.
| | - Daniela Druguș
- Department of Medicine, University of Medicine and Pharmacy, Iasi, Romania
| | - Florin Leașu
- Department of Fundamental Disciplines and Clinical Prevention, Transilvania University of Brasov, Brasov, Romania
| | - Doina Azoicăi
- Department of Medicine, University of Medicine and Pharmacy, Iasi, Romania
| | - Angela Repanovici
- Department of Product Design and Environment, Transilvania University of Brasov, Brasov, Romania
| | - Liliana Marcela Rogozea
- Department of Fundamental Disciplines and Clinical Prevention, Transilvania University of Brasov, Brasov, Romania
| |
Collapse
|
19
|
Loos S, Clarke E, Jordan H, Puschner B, Fiorillo A, Luciano M, Ivánka T, Magyar E, Krogsgaard-Bording M, Østermark-Sørensen H, Rössler W, Kawohl W, Mayer B, Slade M. Recovery and decision-making involvement in people with severe mental illness from six countries: a prospective observational study. BMC Psychiatry 2017; 17:38. [PMID: 28114913 PMCID: PMC5260092 DOI: 10.1186/s12888-017-1207-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 01/16/2017] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Clinical decision-making is the vehicle of health care provision, and level of involvement predicts implementation and satisfaction. The aim of this study was to investigate the impact of decision-making experience on recovery. METHODS Data derived from an observational cohort study "Clinical decision making and outcome in routine care for people with severe mental illness" (CEDAR). Adults (aged 18-60) meeting standardised criteria for severe mental illness were recruited from caseloads of outpatient and community mental health services in six European countries. After consenting, they were assessed using standardised measures of decision-making, clinical outcome and stage of recovery at baseline and 1 year later. Latent class analysis was used to identify course of recovery, and proportional odds models to investigate predictors of recovery stage and change. RESULTS Participants (n = 581) clustered into three stages of recovery at baseline: Moratorium (N = 115; 19.8%), Awareness/Preparation (N = 145; 25.0%) and Rebuilding/Growth (N = 321; 55.2%). Higher stage was cross-sectionally associated with being male, married, living alone or with parents, and having better patient-rated therapeutic alliance and fewer symptoms. The model accounted for 40% of the variance in stage of recovery. An increased chance of worse outcome (change over 1 year to lower stage of recovery) was found for patients with active involvement compared with either shared (OR = 1.84, 95% CI 1.15-2.94) or passive (OR = 1.71, 95% CI = 1.00-2.95) involvement. Overall, both process (therapeutic relationship) and outcome (symptomatology) are cross-sectionally associated with stage of recovery. CONCLUSIONS Patient-rated decision-making involvement and change in stage of recovery are associated. Joint consideration of decision practise within the recovery process between patient and clinician is supposed to be a useful strategy to improve clinical practice (ISRCTN registry: ISRCTN75841675. Retrospectively registered 15 September 2010).
Collapse
Affiliation(s)
- Sabine Loos
- Section Process-Outcome Research, Department of Psychiatry II, Ulm University, Ludwig-Heilmeyer-Str. 2, D-89312, Günzburg, Germany.
| | - Eleanor Clarke
- 0000 0001 2322 6764grid.13097.3cKing’s College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Harriet Jordan
- 0000 0001 2322 6764grid.13097.3cKing’s College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Bernd Puschner
- 0000 0004 1936 9748grid.6582.9Section Process-Outcome Research, Department of Psychiatry II, Ulm University, Ludwig-Heilmeyer-Str. 2, D-89312 Günzburg, Germany
| | - Andrea Fiorillo
- 0000 0001 0790 385Xgrid.4691.aDepartment of Psychiatry, University of Naples SUN, Naples, Italy
| | - Mario Luciano
- 0000 0001 0790 385Xgrid.4691.aDepartment of Psychiatry, University of Naples SUN, Naples, Italy
| | - Tibor Ivánka
- 0000 0001 1088 8582grid.7122.6Department of Psychiatry, University of Debrecen Medical Centre, Debrecen, Hungary
| | - Erzsébet Magyar
- 0000 0001 1088 8582grid.7122.6Department of Psychiatry, University of Debrecen Medical Centre, Debrecen, Hungary
| | - Malene Krogsgaard-Bording
- 0000 0004 0646 7349grid.27530.33Unit for Psychiatric Research, Aalborg Psychiatric Hospital, Aalborg University Hospital, Aalborg, Denmark
| | - Helle Østermark-Sørensen
- 0000 0004 0646 7349grid.27530.33Unit for Psychiatric Research, Aalborg Psychiatric Hospital, Aalborg University Hospital, Aalborg, Denmark
| | - Wulf Rössler
- 0000 0004 1937 0650grid.7400.3Psychiatric Hospital, University of Zurich, Zurich, Switzerland
| | - Wolfram Kawohl
- 0000 0004 1937 0650grid.7400.3Psychiatric Hospital, University of Zurich, Zurich, Switzerland
| | - Benjamin Mayer
- 0000 0004 1936 9748grid.6582.9Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
| | - Mike Slade
- 0000 0001 2322 6764grid.13097.3cKing’s College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | | |
Collapse
|
20
|
Clinical decision making and outcome in the routine care of people with severe mental illness across Europe (CEDAR). Epidemiol Psychiatr Sci 2016; 25:69-79. [PMID: 25600424 PMCID: PMC6998762 DOI: 10.1017/s204579601400078x] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
AIMS Shared decision making has been advocated as a means to improve patient-orientation and quality of health care. There is a lack of knowledge on clinical decision making and its relation to outcome in the routine treatment of people with severe mental illness. This study examined preferred and experienced clinical decision making from the perspectives of patients and staff, and how these affect treatment outcome. METHODS "Clinical Decision Making and Outcome in Routine Care for People with Severe Mental Illness" (CEDAR; ISRCTN75841675) is a naturalistic prospective observational study with bimonthly assessments during a 12-month observation period. Between November 2009 and December 2010, adults with severe mental illness were consecutively recruited from caseloads of community mental health services at the six study sites (Ulm, Germany; London, UK; Naples, Italy; Debrecen, Hungary; Aalborg, Denmark; and Zurich, Switzerland). Clinical decision making was assessed using two instruments which both have parallel patient and staff versions: (a) The Clinical Decision Making Style Scale (CDMS) measured preferences for decision making at baseline; and (b) the Clinical Decision Making Involvement and Satisfaction Scale (CDIS) measured involvement and satisfaction with a specific decision at all time points. Primary outcome was patient-rated unmet needs measured with the Camberwell Assessment of Need Short Appraisal Schedule (CANSAS). Mixed-effects multinomial regression was used to examine differences and course over time in involvement in and satisfaction with actual decision making. The effect of clinical decision making on the primary outcome was examined using hierarchical linear modelling controlling for covariates (study centre, patient age, duration of illness, and diagnosis). Analysis were also controlled for nesting of patients within staff. RESULTS Of 708 individuals approached, 588 adults with severe mental illness (52% female, mean age = 41.7) gave informed consent. Paired staff participants (N = 213) were 61.8% female and 46.0 years old on average. Shared decision making was preferred by patients (χ 2 = 135.08; p < 0.001) and staff (χ 2 = 368.17; p < 0.001). Decision making style of staff significantly affected unmet needs over time, with unmet needs decreasing more in patients whose clinicians preferred active to passive (-0.406 unmet needs per two months, p = 0.007) or shared (-0.303 unmet needs per two months, p = 0.015) decision making. CONCLUSIONS Decision making style of staff is a prime candidate for the development of targeted intervention. If proven effective in future trials, this would pave the ground for a shift from shared to active involvement of patients including changes to professional socialization through training in principles of active decision making.
Collapse
|
21
|
Konrad J, Loos S, Neumann P, Zentner N, Mayer B, Slade M, Jordan H, De Rosa C, Del Vecchio V, Égerházi A, Nagy M, Bording MK, Sørensen HØ, Kawohl W, Rössler W, Puschner B. Content and implementation of clinical decisions in the routine care of people with severe mental illness. J Ment Health 2015; 24:15-9. [PMID: 25734210 DOI: 10.3109/09638237.2014.951478] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Clinical decision making (CDM) in the treatment of people with severe mental illness relates to a wide range of life domains. AIMS To examine content of CDM in mental health care from the perspectives of service users and staff and to investigate variation in implementation of decisions for differing content. METHOD As part of the European multicenter study clinical decision making and outcome in routine care for people with severe mental illness (ISRCTN75841675), 588 service users and their clinicians were asked to identify the decisions made during their last meeting. Decisions were then coded into content categories. Two months later, both parties reported if these decisions had been implemented. RESULTS Agreement between patients and staff regarding decision making was moderate (k = 0.21–0.49; p < 0.001). Decisions relating to medication and social issues were most frequently identified. Overall reported level of implementation was 73.5% for patients and 74.7% for staff, and implementation varied by decision content. CONCLUSIONS A variety of relevant decision topics were shown for mental health care.Implementation rates varied in relation to topic and may need different consideration within the therapeutic dyad.
Collapse
|
22
|
Clarke E, Puschner B, Jordan H, Williams P, Konrad J, Kawohl W, Bär A, Rössler W, Del Vecchio V, Sampogna G, Nagy M, Süveges A, Krogsgaard Bording M, Slade M. Empowerment and satisfaction in a multinational study of routine clinical practice. Acta Psychiatr Scand 2015; 131:369-78. [PMID: 25471821 DOI: 10.1111/acps.12365] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/16/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Decision-making between mental health clinicians and patients is under-researched. We tested whether mental health patients are more satisfied with a decision made (i) using their preferred decision-making style and (ii) with a clinician with the same decision-making style preference. METHOD As part of the CEDAR Study (ISRCTN75841675), a convenience sample of 445 patients with severe mental illness from six European countries were assessed for desired clinical decision-making style (rated by patients and paired clinicians), decision-specific experienced style and satisfaction. RESULTS Patients who experienced more involvement in decision-making than they desired rated higher satisfaction (OR=2.47, P=0.005, 95% CI 1.32-4.63). Decisions made with clinicians whose decision-making style preference was for more active involvement than the patient preference were rated with higher satisfaction (OR=3.17, P=0.003, 95% CI 1.48-6.82). CONCLUSION More active involvement in decision-making than the patient stated as desired was associated with higher satisfaction. A clinical orientation towards empowering, rather than shared, decision-making may maximise satisfaction.
Collapse
Affiliation(s)
- E Clarke
- King's College London, Institute of Psychiatry, Psychology & Neuroscience, London, UK
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Puschner B, Neumann P, Jordan H, Slade M, Fiorillo A, Giacco D, Égerházi A, Ivánka T, Bording MK, Sørensen HØ, Bär A, Kawohl W, Loos S. Development and psychometric properties of a five-language multiperspective instrument to assess clinical decision making style in the treatment of people with severe mental illness (CDMS). BMC Psychiatry 2013; 13:48. [PMID: 23379280 PMCID: PMC3570278 DOI: 10.1186/1471-244x-13-48] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Accepted: 01/29/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The aim of this study was to develop and evaluate psychometric properties of the Clinical Decision Making Style (CDMS) scale which measures general preferences for decision making as well as preferences regarding the provision of information to the patient from the perspectives of people with severe mental illness and staff. METHODS A participatory approach was chosen for instrument development which followed 10 sequential steps proposed in a current guideline of good practice for the translation and cultural adaptation of measures. Following item analysis, reliability, validity, and long-term stability of the CDMS were examined using Spearman correlations in a sample of 588 people with severe mental illness and 213 mental health professionals in 6 European countries (Germany, UK, Italy, Denmark, Hungary, and Switzerland). RESULTS In both patient and staff versions, the two CDMS subscales "Participation in Decision Making" and "Information" reliably measure distinct characteristics of decision making. Validity could be demonstrated to some extent, but needs further investigation. CONCLUSIONS Together with two other five-language patient- and staff-rated measures developed in the CEDAR study (ISRCTN75841675) - "Clinical Decision Making in Routine Care" and "Clinical Decision Making Involvement and Satisfaction" - the CDMS allows empirical investigation of the complex relation between clinical decision making and outcome in the treatment of people with severe mental illness across Europe.
Collapse
Affiliation(s)
- Bernd Puschner
- Department of Psychiatry II, Ulm University, Ludwig-Heilmeyer-Str. 2, Günzburg, 89312, Germany
| | - Petra Neumann
- Department of Psychiatry II, Ulm University, Ludwig-Heilmeyer-Str. 2, Günzburg, 89312, Germany
| | - Harriet Jordan
- King’s College London, Section for Recovery, Institute of Psychiatry, London, U.K
| | - Mike Slade
- King’s College London, Section for Recovery, Institute of Psychiatry, London, U.K
| | - Andrea Fiorillo
- Department of Psychiatry, Second University of Naples, Naples, Italy
| | - Domenico Giacco
- Department of Psychiatry, Second University of Naples, Naples, Italy
| | - Anikó Égerházi
- Department of Psychiatry, University of Debrecen Medical and Health Science Center, Debrecen, Hungary
| | - Tibor Ivánka
- Department of Psychiatry, University of Debrecen Medical and Health Science Center, Debrecen, Hungary
| | - Malene Krogsgaard Bording
- Unit for Psychiatric Research, Aalborg Psychiatric Hospital, Aalborg University Hospital, Aalborg, Denmark
| | - Helle Østermark Sørensen
- Unit for Psychiatric Research, Aalborg Psychiatric Hospital, Aalborg University Hospital, Aalborg, Denmark
| | - Arlette Bär
- Department of General and Social Psychiatry, University of Zurich, Zurich, Switzerland
| | - Wolfram Kawohl
- Department of General and Social Psychiatry, University of Zurich, Zurich, Switzerland
| | - Sabine Loos
- Department of Psychiatry II, Ulm University, Ludwig-Heilmeyer-Str. 2, Günzburg, 89312, Germany
| |
Collapse
|