Specificity of patients requests in the initial interview

A collaborative approach to the treatment alliance in bipolar disorder

OBJECTIVES

The treatment alliance is the arena in which psychopharmacological and other therapeutic interventions occur. The nature and quality of the treatment alliance may affect adherence to treatment and the realization of the benefits of effective pharmacological treatment in clinical practice. It is an area that has attracted little systematic study, despite the available evidence suggesting that it plays a measurable role in clinical outcomes.

METHODS

A literature search was undertaken using Medline, Ovid, Psychinfo and Science Direct from 1975 to 2004. The following key words were used: bipolar disorder, patient adherence, non-adherence to medication, compliance, doctor-patient relationship, doctor-patient communication, treatment alliance, therapeutic alliance, chronic illness management, collaborative care, self-management, health beliefs, self-efficacy, self-determination, autonomy support, motivational interviewing.

RESULTS

Psychosocial interventions have demonstrated positive effects on adherence problems. Studies of the impact of the treatment alliance on outcomes in mental illness highlight the possibilities of fruitful research in this area in bipolar disorder. Different theoretical models of changing health related behaviour may inform approaches to the treatment alliance.

CONCLUSIONS

Results suggest the usefulness of a collaborative approach to the treatment alliance. Attention needs to be given to developing intervention models that target modifiable risk factors for non-adherence and address patient, clinician and illness related variables to enhance medication adherence in the treatment alliance. Refinement of these models through controlled evaluation in real world settings may lead to integration in health care delivery systems.

What do patients want and do we want to know? A review of patients' requests of psychiatric services

OBJECTIVE

A systematic review was conducted of the literature concerning patients' requests of psychiatric care in order to identify the types of requests patients make, psychiatrists' perceptions of their patients' requests, and the relationship between requests and the outcome of care.

METHOD

A total of 28 published original articles which fulfilled specific inclusion criteria were reviewed.

RESULTS

The studies showed that there are certain core requests that patients make irrespective of the type of service attended. Patients mainly request psychological approaches, and the most common requests are for 'clarification', 'psychological expertise' and 'psychodynamic insight'. There is evidence that patients normally feel inhibited about making requests, and that psychiatrists often fail to identify what their patients want.

CONCLUSION

The majority of patients attending psychiatric services have requests which they will express when encouraged to do so, but little is known about the relationship between patients' requests and the outcome of care. Recommendations are made for future research.

Ego development and treatment requests

Ego development theory suggests that patients might differ in the forms of psychiatric treatment they find helpful, depending on the maturity of their ego functioning. In our study, 100 adults beginning outpatient psychiatric treatment completed the Sentence Completion Test of ego development and the Patient Request Form, which measures treatment modality preference. Ego development was related to treatment requests in patterns predicted from theory: higher ego stage patients were more likely to request insight therapy, while lower stage patients were more likely to request reality checks, social intervention, and triage. We argue that the ego development construct can help treaters match patients to treatment modalities that are compatible with their frames of reference.

A comparison of USA and New Zealand psychiatric patients' requests and clinicians understanding of patients' requests

This study compares USA and New Zealand psychiatric patients' requests at the initial psychiatric interview and examines clinician's accuracy in estimating patients' treatment request preferences. Eighty-five of the 146 consecutive nonacute patients to the psychiatric unit of a public New Zealand hospital completed a 14-item Patient Request Form before their initial interview and their clinician completed an equivalent form at the end of the interview. Patients' treatment request preferences were similar in the USA and New Zealand samples as were clinician's tendency to underestimate the importance their patients placed on requests. The results are discussed in relation to effective treatment planning.

Expression of patients' requests in the initial interview

The expressions of requests of 120 patients who came to the Walk-In Psychiatric Clinic of a general hospital were examined to determine whether patients verbalized specific requests during the intake interview. As 63% of the patients verbalized a specific request, 37% emitted and 27% elicited ones, we concluded that many patients could have been more specific but felt restrained by their role. To evaluate the effect of the patients' attitudes and interviewers' behavior on the expression of requests, in a two-by-two factorial design, we varied the number of patients taking the Patient Request Form and/or being probed for a request during a standardized pre-intake interview. These two procedures did not affect significantly the number expressing requests: experimental groups 73% versus control group 63%. Completing the form elicited more requests. The interviewer variables of number and wording of probes for requests significantly facilitated expression of requests. In the discussion we attempted to evaluate factors influencing patient's resistance to the expression of requests and to place the meaning of requests in the context of more effective clinical functioning, particularly a negotiated approach to the treatment of patients.