Shared treatment decision-making and empowerment-related outcomes in psychosis: systematic review and meta-analysis

Making decisions about antipsychotics: a qualitative study of patient experience and the development of a decision aid

BACKGROUND

Shared decision making is a widely accepted standard of patient-centred care that leads to improved clinical outcomes, yet it is commonly underutilised in the field of mental health. Furthermore, little is known regarding patient decision making around antipsychotic medication, which is often poorly adhered to. We aim to explore psychiatric patients' experiences of antipsychotic medication decision making in order to develop a patient decision aid to promote shared decision making.

METHODS

Focus groups were conducted with patients with chronic psychotic illnesses (n = 20) who had previously made a decision about taking or changing antipsychotic medication. Transcripts were coded and analysed for thematic content and continued until thematic saturation. These themes subsequently informed the development of a decision aid with the help of expert guidance. Further patient input was sought using the think aloud method (n = 3).

RESULTS

Twenty-three patients participated in the study. Thematic analysis revealed that 'adverse effects' was the most common theme identified by patients surrounding antipsychotic medication decision-making followed by 'mode and time of administration', 'symptom control' and 'autonomy'. The final decision aid is included to provoke further discussion and development of such aids.

CONCLUSIONS

Patients commonly report negative experiences of antipsychotic medication, in particular side-effects, which remain critical to future decision making around antipsychotic medication. Clinical encounters that increase patient knowledge and maximise autonomy in order to prevent early negative experiences with antipsychotic medication are likely to be beneficial.

Training to enhance user and carer involvement in mental health-care planning: the EQUIP research programme including a cluster RCT

Background

Service users and carers using mental health services want more involvement in their care and the aim of this research programme was to enhance service user and carer involvement in care planning in mental health services.

Objectives

Co-develop and co-deliver a training intervention for health professionals in community mental health teams, which aimed to enhance service user and carer involvement in care planning. Develop a patient-reported outcome measure of service user involvement in care planning, design an audit tool and assess individual preferences for key aspects of care planning involvement. Evaluate the clinical effectiveness and the cost-effectiveness of the training. Understand the barriers to and facilitators of implementing service user- and carer-involved care planning. Disseminate resources to stakeholders.

Methods

A systematic review, focus groups and interviews with service users/carers/health professionals informed the training and determined the priorities underpinning involvement in care planning. Data from focus groups and interviews were combined and analysed using framework analysis. The results of the systematic review, focus groups/interviews and a review of the training interventions were synthesised to develop the final training intervention. To develop and validate the patient-reported outcome measure, items were generated from focus groups and interviews, and a psychometric analysis was conducted. Patient-reported outcome measure items and a three-round consensus exercise were used to develop an audit tool, and a stated preference survey was undertaken to assess individual preferences for key aspects of care planning. The clinical effectiveness and cost-effectiveness of the training were evaluated using a pragmatic cluster trial with cohort and cross-sectional samples. A nested longitudinal qualitative process evaluation using multiple methods, including semistructured interviews with key informants involved locally and nationally in mental health policy, practice and research, was undertaken. A mapping exercise was used to determine current practice, and semistructured interviews were undertaken with service users and mental health professionals from both the usual-care and the intervention arms of the trial at three time points (i.e. baseline and 6 months and 12 months post intervention).

Results

The results from focus groups (n = 56) and interviews (n = 74) highlighted a need to deliver training to increase the quality of care planning and a training intervention was developed. We recruited 402 participants to develop the final 14-item patient-reported outcome measure and a six-item audit tool. We recruited 232 participants for the stated preference survey and found that preferences were strongest for the attribute ‘my preferences for care are included in the care plan’. The training was delivered to 304 care co-ordinators working in community mental health teams across 10 NHS trusts. The cluster trial and cross-sectional survey recruited 1286 service users and 90 carers, and the primary outcome was the Health Care Climate Questionnaire. Training was positively evaluated. The results showed no statistically significant difference on the primary outcome (the Health Care Climate Questionnaire) (adjusted mean difference –0.064, 95% confidence interval –0.343 to 0.215; p = 0.654) or secondary outcomes at the 6-month follow-up. Overall, the training intervention was associated with a net saving of –£54.00 (95% confidence interval –£193.00 to £84.00), with a net quality-adjusted life-year loss of –0.014 (95% confidence interval –0.034 to 0.005). The longitudinal process evaluation recruited 54 service users, professionals and carers, finding a failure of training to become embedded in routine care.

Limitations

Our pragmatic study was designed to improve service user and care involvement in care planning among routine community mental health services. We intervened in 18 sites with > 300 care co-ordinators. However, our volunteer sites may not be fully representative of the wider population, and we lacked data with which to compare our participants with the eligible population.

Conclusions

We co-developed and co-delivered a training intervention and developed a unidimensional measure of service user and carer involvement in care planning and an audit tool. Despite a high level of satisfaction with the training, no significant effect was found; therefore, the intervention was ineffective. There was a failure of training to become embedded and normalised because of a lack of organisational readiness to accept change. Working with NHS trusts in our ‘Willing Adopters’ programme with enhanced organisational buy-in yielded some promising results.

Future work

Research should focus on developing and evaluating new organisational initiatives in addition to training health-care professionals to address contextual barriers to service and carer involvement in care planning, and explore co-designing and delivering new ways of enhancing service users’ and carers’ capabilities to engage in care planning.

Trial registration

Current Controlled Trials ISRCTN16488358.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 7, No. 9. See the NIHR Journals Library website for further project information.

Giving Patients Choices During Involuntary Admission: A New Intervention

Background: People who receive involuntary treatment are some of the most vulnerable in psychiatric services. They are more likely to have poorer social and clinical outcomes and to be disillusioned with and disengaged from care. Research indicates that patients' experience in the first week of involuntary treatment is a critical period: a better experience of care in the first week predicts better quality of life and reduced readmission 1 year later. Patients have identified involvement in clinical decisions as key to improving their experience of care. The aim of this study was to test the feasibility and acceptability of an intervention to facilitate involvement in decision making for involuntary inpatients called OPeNS (Options, Preferences, Negotiate, and Summarise). Methods: This was a mixed method study. The OPeNS intervention was developed based on previous research carried out by a multidisciplinary team. Clinicians were trained to deliver it to involuntary inpatients. Feasibility indices (rates of participation in the intervention and time required to deliver it) were collected. Patients (N = 14) and clinicians (N = 5) provided qualitative data on their experience of the intervention in semi-structured interviews which were analysed using thematic analysis. Results: The OPeNS intervention was found to be acceptable by both patients and clinicians and feasible to conduct within the first week of involuntary treatment. Patients' and clinicians' experiences of the intervention fall into two themes: 'Enabling a different dynamic' and 'Clashing with usual practices and priorities'. Conclusion: The OPeNS intervention provides a structure that can be used by clinicians across disciplines to facilitate involving involuntary patients in decision making. Although challenges related to changing usual practices were identified, the intervention was received positively and was feasible to conduct in the first week of involuntary treatment.

The Effect of Reducing the "Jumping to Conclusions" Bias on Treatment Decision-Making Capacity in Psychosis: A Randomized Controlled Trial With Mediation Analysis

BACKGROUND

Evidence-based psychological interventions to support treatment decision-making capacity (capacity) in psychosis do not currently exist. This study sought to establish whether reducing the extent to which this group form conclusions based on limited evidence, also known as the "jumping-to-conclusions" (JTC) bias, could improve capacity.

METHODS

In a randomized controlled open trial, 37 patients aged 16-65 years diagnosed with schizophrenia-spectrum disorders were randomly assigned (1:1) to receive a single-session intervention designed to reduce the JTC bias (MCT-JTC; adapted from Metacognitive Training [MCT]) or an attention control (AC) condition designed to control for therapist attention, duration, modality, and face validity. Primary outcomes were treatment decision-making capacity measured by the MacArthur Competency Assessment Tool for Treatment (MacCAT-T) and the jumping-to-conclusions reasoning bias measured by draws to decision on the beads task, each of which were administered by the psychologist delivering the intervention.

RESULTS

Those receiving MCT-JTC had large improvements in overall capacity (d = 0.96, P < .05) and appreciation (d = 0.87, P < .05) compared to those receiving AC. Reduction in JTC mediated a large proportion of the effect of group allocation on understanding, appreciation, reasoning, and overall MacCAT-T scores.

CONCLUSION

This is the first experimental investigation of the effect of a psychological intervention on treatment decision-making capacity in psychosis. It provides early evidence that reducing the JTC bias is associated with large and rapid improvements in capacity. Due to limited resources, assessments were administered by the researchers delivering the intervention. Results should therefore be considered preliminary and a larger, definitive trial addressing methodological limitations is warranted.

Why and How Family Caregivers Should Participate in Shared Decision Making in Mental Health

Patient involvement (shared decision making ) and caregiver involvement (family involvement, etc.) are mostly seen as different aspects of care, and efforts to integrate them are limited. This Open Forum posits that both approaches are critical and that caregiver involvement should always be considered during shared decision making, potentially as an integral component. The authors argue that the two approaches can overlap and work synergistically rather than antagonistically. When caregiver involvement is integrated into shared decision making, caregivers may assume any of a variety of roles and need to develop certain competencies to better engage in decision making.

A qualitative exploration of service user views about using digital health interventions for self-management in severe mental health problems

BACKGROUND

The development of digital health interventions (DHIs) for severe mental health problems is fast-paced. Researchers are beginning to consult service users to inform DHIs; however, much of this involvement has been limited to feedback on specific interventions post-DHI development. This study had two aims: 1. explore service user views towards DHIs for severe mental health problems; and 2. make recommendations for specific content within DHIs based on service user needs and suggestions.

METHODS

Qualitative interviews with eighteen people with severe mental health problems focussed on two domains: 1) views about DHIs for severe mental health problems; and 2) ideas for future DHI content and design features. Data were analysed thematically.

RESULTS

Participants responses were captured in five key themes: 1) DHIs could be empowering tools that instigate reflection and change; 2) society is already divided; DHIs will further increase this divide; 3) considerations must be made about who has access to DHI data and how this data may be used; 4) DHIs should not be delivered without other support options; and 5) DHIs should provide a positive, fun, practical and interactive method for self-management.

CONCLUSIONS

Participants found DHIs acceptable due to the empowering nature of self-management and ability to take ownership of their own healthcare needs. However, concerns included the potential for digital exclusion, privacy and confidentiality and fears about DHIs being used to replace other mental health services. Service users want tools to help them self-manage their mental health, but also provide positive and recovery-focussed content that can be used in conjunction with other support options.

Should people with psychosis be supported in choosing cognitive therapy as an alternative to antipsychotic medication: A commentary on current evidence

Evidence from randomised controlled trials suggest that both antipsychotic medication and cognitive behaviour therapy (CBT) can be helpful to people with a diagnosis of a schizophrenia spectrum disorder. On this basis, many clinical guidelines recommend that people with psychosis should be offered both antipsychotic medication and CBT and that they should be collaboratively involved in the decisions about which treatment options they choose. The reality of service provision is often very different, with data regarding the availability of such treatment options and the extent of user involvement in decision making suggesting that medication is much more widely available and that service users are often not involved in these decisions, despite retaining decision making capacity. Many patients choose not to take antipsychotic medication, often due to inefficacy or side effects, but there is little evidence regarding whether CBT can be effective as an alternative to antipsychotic medication. However, several recent trials suggest that CBT without medication may be a safe and acceptable option for people with psychosis. The implications for clinical practice and future research are considered and it is recommended that informed choices that include the option to try CBT without antipsychotic medication are supported.

Treatment alliance and adherence in bipolar disorder

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

Study protocol design and evaluation of a hospital-based multi-professional educational intervention: Person-Centred Psychosis Care (PCPC)

BACKGROUND

While patient involvement in mental health care is repeatedly stressed in policy documents, there are actually few studies that evaluate person-centred care interventions within psychiatric services. We present here the design and planned evaluation of an educational intervention for inpatient staff involved in the care of persons with schizophrenia and similar psychoses.

METHODS/DESIGN

The care intervention will be assessed using a non-randomised trial with a before and after approach. The intervention involves an educational and experimental learning phase for hospital staff, followed by an implementation phase. The intervention is multi-professional; psychiatrists, psychiatric nurses, psychiatric carers, social workers, occupational therapists, and a medical secretary will be engaged in a participatory approach where they practice how to create a partnership and explore recovery-related goals together with patients. Patient-related outcomes include empowerment and satisfaction with care. Ward-level outcomes include daily ward burden, length of inpatient stay, and number of days with involuntary care. In addition, qualitative methods will be applied to capture patient, next-of-kin, and staff perspectives.

DISCUSSION

The care intervention is expected to contribute to the improvement of inpatient care for persons with severe and complex mental health issues.

TRIAL REGISTRATION

The trial was retrospectively registered at ClinicalTrials.gov June 9, 2017, identifier: NCT03182283 .

Psychiatric service staff perceptions of implementing a shared decision-making tool: a process evaluation study

PURPOSE

Shared decision making, SDM, in psychiatric services, supports users to experience a greater sense of involvement in treatment, self-efficacy, autonomy and reduced coercion. Decision tools adapted to the needs of users have the potential to support SDM and restructure how users and staff work together to arrive at shared decisions. The aim of this study was to describe and analyse the implementation process of an SDM intervention for users of psychiatric services in Sweden.

METHOD

The implementation was studied through a process evaluation utilizing both quantitative and qualitative methods. In designing the process evaluation for the intervention, three evaluation components were emphasized: contextual factors, implementation issues and mechanisms of impact.

RESULTS

The study addresses critical implementation issues related to decision-making authority, the perceived decision-making ability of users and the readiness of the service to increase influence and participation. It also emphasizes the importance of facilitation, as well as suggesting contextual adaptations that may be relevant for the local organizations.

CONCLUSION

The results indicate that staff perceived the decision support tool as user-friendly and useful in supporting participation in decision-making, and suggest that such concrete supports to participation can be a factor in implementation if adequate attention is paid to organizational contexts and structures.

Involvement of people with schizophrenia in decision-making in rural Ethiopia: a qualitative study

BACKGROUND

The involvement of people with psychosocial disabilities in decision-making is a fundamental component of a person-centred and recovery-oriented model of care, but there has been little investigation of this approach in low- and middle-income countries. The aim of this study was to explore the involvement of people with schizophrenia in decision-making relating to their care in rural Ethiopia.

METHODS

A qualitative study was conducted in rural Ethiopia as part of the Rehabilitation Intervention for people with Schizophrenia in Ethiopia (RISE) project, involving two focus group discussions (n = 10) with community-based rehabilitation workers, and 18 in-depth interviews with people with schizophrenia, caregivers, health officers, supervisors and a community-based rehabilitation worker. Thematic analysis was used to examine major themes related to involvement in decision-making in this specific setting.

RESULTS

Involvement of people with schizophrenia in decision-making in this rural Ethiopian setting was limited and coercive practices were evident. People with schizophrenia tended to be consulted about their care only when they were considered clinically 'recovered'. Caregivers typically had a prominent role in decision-making, but they also acquiesced to the views of health care professionals. People with schizophrenia and caregivers were often unable to execute their desired choice due to inaccessible and unaffordable treatment.

CONCLUSIONS

Community-based rehabilitation, as a model of care, may give opportunities for involvement of people with schizophrenia in decision-making. In order to increase involvement of people with schizophrenia in rural Ethiopia there needs to be greater empowerment of service users, wider availability of treatment choices and a facilitating policy environment. Further studies are needed to explore concepts of person-centred care and recovery across cultural settings.

Embedding shared decision-making in the care of patients with severe and enduring mental health problems: The EQUIP pragmatic cluster randomised trial

Background

Severe mental illness is a major driver of worldwide disease burden. Shared decision-making is critical for high quality care, and can enhance patient satisfaction and outcomes. However, it has not been translated into routine practice. This reflects a lack of evidence on the best way to implement shared decision-making, and the challenges of implementation in routine settings with limited resources. Our aim was to test whether we could deliver a practical and feasible intervention in routine community mental health services to embed shared decision-making for patients with severe mental illness, by improving patient and carer involvement in care planning.

Methods

We cluster randomised community mental health teams to the training intervention or usual care, to avoid contamination. Training was co-delivered to a total of 350 staff in 18 teams by clinical academics, working alongside patients and carers. The primary outcome was the Health Care Climate Questionnaire, a self-report measure of ‘autonomy support’. Primary and secondary outcomes were collected by self-report, six months after allocation.

Findings

In total, 604 patients and 90 carers were recruited to main trial cohort. Retention at six months was 82% (n = 497). In the main analysis, results showed no statistically significant difference in the primary outcome between the intervention and usual care at 6 months (adjusted mean difference -0.064, 95% CI -0.343 to 0.215, p = 0.654). We found significant effects on only 1 secondary outcome.

Conclusions

An intervention to embed shared decision-making in routine practice by improving involvement in care planning was well attended and acceptable to staff, but had no significant effects on patient outcomes. Enhancing shared decision-making may require considerably greater investment of resources and effects may only be apparent over the longer term.

Patient perceived participation in decision making on their antipsychotic treatment: Evidence of validity and reliability of the COMRADE scale in a sample of schizophrenia spectrum disorders

OBJECTIVE

The aim of this paper is to provide evidence of the validity and reliability of the COMRADE scale (Combined Outcome Measure for Risk communication And treatment Decision making Effectiveness) in patients suffering from schizophrenia spectrum disorders.

METHOD

150 patients recruited at five mental health centers were assessed using a cross-sectional study design. The COMRADE, WAIS-S (therapeutic alliance) and TSQM (satisfaction with medication) scales were used.

RESULTS

Exploratory Factor Analysis identified three factors from the COMRADE (F1: "Risk communication"; F2: "Confidence in decision" and F3: "Knowledge of decisional balance") which explain 45.2, 8.5 and 6% of the variance, respectively. Statistically significant correlations were observed between the scores of the COMRADE subscales with the subscales of the WAI-S and the TSQM. The internal consistency observed for each of the factorial scores of the COMRADE were (Cronbach's alpha values) 0.90, 0.89 and 0.74, respectively.

CONCLUSION

The COMRADE scale offers appropriate psychometric properties for its use as a measure of perceived patient involvement in the shared decision making process in antipsychotic treatment.

PRACTICE IMPLICATIONS

The use of the COMRADE measure in psychiatric clinical practice and in research studies provides an outcome measure of interventions from the shared decision making model.

Practitioner Review: Therapist variability, patient-reported therapeutic alliance, and clinical outcomes in adolescents undergoing mental health treatment - a systematic review and meta-analysis

BACKGROUND

Previous meta-analyses have only found small correlations (r = .10 to r = .19) between therapeutic alliance and clinical outcomes in samples of adolescents receiving psychological therapy. Although study-level variables have been found to moderate this, little is known about the impact of therapist variability. The present meta-analysis aimed to address this gap by using patient-therapist ratio as a moderator variable.

METHODS

Contrary to previous reviews of adolescent alliance, individual effect sizes were extracted using a preregistered conceptual hierarchy. Controlling for treatment-level confounds, a random effects meta-analysis assessed the moderating effect of patient-therapist ratio on the alliance-outcome relationship in predefined single-predictor and multipredictor meta-regressions.

RESULTS

The alliance-outcome relationship was found to be larger than previously thought (k = 28, N = 2,911, r = .29, 95% Confidence Interval 0.21, 0.37; p < .0001, I²  = 80%). When study samples exceeding the adolescent 12-19 age range were removed, the correlation rose (k = 15, N = 1,797, r = .34, 95% Confidence Interval 0.23, 0.45; p < .0001, I²  = 83%). In contrast to research with adults, patient-therapist ratio did not moderate this relationship in either single-predictor (p = .26) or multi-predictor (p = .22) models.

CONCLUSIONS

The alliance-outcome relationship for adolescents was larger than previously thought, and comparable to estimates in adult samples. The failure of patient-therapist ratio to moderate its strength, however, challenges the hypothesis that variability in therapist characteristics is an important determinant of the alliance-outcome effect in this age group.

Shared decision making in mental health: the importance for current clinical practice

OBJECTIVES

We reviewed the literature on shared decision making (regarding treatments in psychiatry), with a view to informing our understanding of the decision making process and the barriers that exist in clinical practice.

METHODS

Narrative review of published English-language articles.

RESULTS

After culling, 18 relevant articles were included. Themes identified included models of psychiatric care, benefits for patients, and barriers. There is a paucity of published studies specifically related to antipsychotic medications.

CONCLUSIONS

Shared decision making is a central part of the recovery paradigm and is of increasing importance in mental health service delivery. The field needs to better understand the basis on which decisions are reached regarding psychiatric treatments. Discrete choice experiments might be useful to inform the development of tools to assist shared decision making in psychiatry.

Shared decision-making for psychiatric medication: A mixed-methods evaluation of a UK training programme for service users and clinicians

BACKGROUND

Shared decision making (SDM) is recognised as a promising strategy to enhance good collaboration between clinicians and service users, yet it is not practised regularly in mental health.

AIMS

Develop and evaluate a novel training programme to enhance SDM in psychiatric medication management for service users, psychiatrists and care co-ordinators.

METHODS

The training programme design was informed by existing literature and local stakeholders consultations. Parallel group-based training programmes on SDM process were delivered to community mental health service users and providers. Evaluation consisted of quantitative measures at baseline and 12-month follow-up, post-programme participant feedback and qualitative interviews.

RESULTS

Training was provided to 47 service users, 35 care-coordinators and 12 psychiatrists. Participant feedback was generally positive. Statistically significant changes in service users' decisional conflict and perceptions of practitioners' interactional style in promoting SDM occurred at the follow-up. Qualitative data suggested positive impacts on service users' and care co-ordinators confidence to explore medication experience, and group-based training was valued.

CONCLUSIONS

The programme was generally acceptable to service users and practitioners. This indicates the value of conducting a larger study and exploring application for non-medical decisions.

Experiences of antipsychotic use in patients with early psychosis: a two-year follow-up study

BACKGROUND

Non-adherence is a major public health problem despite treatment advances. Poor drug adherence in patients with psychosis is associated with more frequent relapse, re-hospitalization, increased consumption of health services and poor outcomes on a variety of measures. Adherence rate in patients with first episode psychosis have been found to vary from 40 to 60%. However, most previous studies have addressed the consequences of non-adherence rather than its potential causes. The purpose of this study was, therefore, to investigate experiential factors which may affect adherence to medication in adults with psychotic disorders, during the 24-month period after the onset of treatment.

METHODS

Twenty first episode patients (7 male, 13 female) were included in our qualitative sub-study from the ongoing TIPS2 (Early Intervention in Psychosis study). Each person participated in semi-structured interviews at 2-year follow-up. All had used antipsychotics, with some still using them. Data were analyzed within an interpretative-phenomenological framework using an established meaning condensation procedure.

RESULTS

The textual analysis revealed four main themes that affected adherence largely: 1) Positive experiences of admission, 2) Sufficient timely information, 3) Shared decision-making and 4) Changed attitudes to antipsychotics due to their beneficial effects and improved insight into illness.

CONCLUSION

Patients reported several factors to have a prominent impact on adherence to their antipsychotics. The patients do not independently choose to jeopardize their medication regime. Health care staff play an important role in maintaining good adherence by being empathetic and supportive in the admission phase, giving tailored information according to patients' condition and involving patients when making treatment decisions.

Does shared decision making results in better health related outcomes for individuals with painful musculoskeletal disorders? A systematic review

Background: Shared Decision-Making (SDM) is a dynamic process by which the health care professional and the patient influence each other in making health-related choices or decisions. SDM is strongly embedded in today's health care approaches, and is advocated as an ideal model since it renders individuals more control towards the health care they choose to receive, and has been shown to improve patient outcomes. Objectives: The goal of this systematic review was to investigate the added-value of SDM on clinical health-related outcomes in patients with a variety of musculoskeletal conditions. Data sources: PubMed and CINAHL. Study selection: PRISMA guidelines were followed for this review. To be considered for review, the study had to meet all the following criteria: (1) prospective studies that involved treatment decision-making; (2) randomized controlled trial design; (3) involving patients faced with having to make a treatment decision; (4) comparing SDM with a control intervention and (5) including one or more of the following outcome measures: well-being, costs, health-related pain or disability measures, or quality of life. Study appraisal: A priori, we determined to perform methodological quality assessment using the Cochrane Risk of Bias tool for randomized controlled trials. Results: We did not find a single study that looked at the true effect of SDM on patient reported outcomes in a population with musculoskeletal pain. Conclusion: For the management of painful musculoskeletal conditions, in the light of the current evidence (none), we estimate that it would be wise to explore the effectiveness of SDM before forcing its large-scale implementation in rehabilitation.

Results of a pilot cluster randomised trial of the use of a Medication Review Tool for people taking antipsychotic medication

BACKGROUND

Government policy encourages increasing involvement of patients in their long-term care. This paper describes the development and pilot evaluation of a 'Medication Review Tool' designed to assist people to participate more effectively in discussions about antipsychotic drug treatment.

METHODS

The Medication Review Tool developed consisted of a form to help patients identify pros and cons of their current antipsychotic treatment and any desired changes. It was associated with a website containing information and links about antipsychotics. For the trial, participants diagnosed with psychotic disorders were recruited from community mental health services. Cluster randomisation was used to allocate health professionals (care co-ordinators) and their associated patients to use of the Medication Review Tool or usual care. All participants had a medical consultation scheduled, and those in the intervention group completed the Medication Review Tool, with the help of their health professional prior to this, and took the completed Form into the consultation. Two follow-up interviews were conducted up to three months after the consultation. The principal outcome was the Decision Self Efficacy Scale (DSES). Qualitative feedback was collected from patients in the intervention group.

RESULTS

One hundred and thirty patients were screened, sixty patients were randomised, 51 completed the first follow-up assessment and 49 completed the second. Many patients were not randomised due to the timing of their consultation, and involvement of health professionals was inconsistent. There was no difference between the groups on the DSES (-4.16 95 % CI -9.81, 1.49), symptoms, side effects, antipsychotic doses or patient satisfaction. Scores on the Medication Adherence Questionnaire indicated an increase in participants' reported inclination to adherence in the intervention group (coefficient adjusted for baseline values -0.44; 95 % CI -0.76, -0.11), and there was a small increase in positive attitudes to antipsychotic medication (Drug Attitude Inventory, adjusted coefficient 1.65; 95 % CI -0.09, 3.40). Qualitative feedback indicated patients valued the Tool for identifying both positive and negative aspects of drug treatment.

CONCLUSIONS

The trial demonstrated the design was feasible, although challenges included service re-configurations and maintaining health professional involvement. Results may indicate a more intensive and sustained intervention is required to facilitate participation in decision-making for this group of patients.

TRIAL REGISTRATION

Current controlled trials ISRCTN12055530 , Retrospectively registered 9/12/2013.