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)

Patient Decisional Preferences: A Systematic Review of Instruments Used to Determine Patients' Preferred Role in Decision-Making

Decision control preferences (DCPs) refer to the degree of control patients' desire over their medical treatment. Several validated tools exist to evaluate a patient's DCPs, yet there is no universally used instrument and their use in clinical settings is lacking. We provide a systematic comparative summary of available DCP tools. Following a systematic database search, English language studies across medical contexts and patient populations were eligible if a validated assessment tool to evaluate patient DCPs was reported. Among the 15 tools that met inclusion criteria, the autonomy preference index (API) and the control preference scale (CPS) were the most used tools (API: 40%, CPS: 26.6%). Most studies (n = 9) sought to identify the information-seeking preferences of patients as a critical component of decision-making. Only few studies evaluated providers' perceptions of patient preferences. Considering the variety of patients' DCPs, implementation of DCP tools can optimize shared decision-making and improve patient outcomes.

Which questionnaires can be used to elicit patients' preferences regarding patient-provider consultations? Results of a scoping review

OBJECTIVE

Active patient involvement and attention to patient preferences in patient-provider consultations are increasingly recognized as essential to improve patient satisfaction and outcomes. Aim of the review was to provide an overview of questionnaires that measure patient preferences regarding communication, information provision and involvement in decision-making in patient-provider consultations.

METHODS

Inclusion criteria were studies that provided primary data, were published in German or English, and included adult patients. The systematic search was conducted in PubMed and PsycInfo. Data extraction and summary focused on information about the development process, topic and structure, and reliability of instruments.

RESULTS

Of 6,667 abstracts screened, 34 articles were included, describing 37 different instruments, often originating from an Anglo-American context. Twelve articles reported patient involvement in the development process. Majority of questionnaires measures aspects of information and/or decision-making preferences. Fewer instruments focus on patient-centeredness or communication preferences. Length of questionnaires varied from one to 80 items. Only 15 studies reported reliability indices.

CONCLUSION

Due to the heterogeneous description, a more consistent reporting of data would be desirable for future publications as well as more participatory research.

PRACTICE IMPLICATIONS

Although there is a wide range of questionnaires available, more research is needed to determine the extent to which they can be used in everyday clinical practice to elicit preferences from individual patients with a wide range of conditions and cultural backgrounds.

Shared decision-making, anxiety, and post-traumatic growth among parents in the context of their child's medical care: The moderating role of parental style

AIM

The importance of parents' involvement in their child's medical care has been extensively discussed in the literature, and studies have indicated the need to expand the active role of parents in decision-making processes regarding such care. However, parents' actual wish to be active and informed in this context remains underexplored. The aim of the current study was to explore this gap by investigating the association between parents' shared decision-making (SDM) experience and their well-being during the course of their child's medical care, with a focus on parents' clinical decision-making style as a possible moderator.

METHOD

A total of 150 parents of children under the age of 18, who utilized various medical care services, participated in the study.

RESULTS

Shared decision-making was found to be associated with parents' anxiety levels during their child's medical treatment, as well as with their post-traumatic growth (PTG). A moderating effect of clinical decision-making style was also found; namely, the relations between SDM, anxiety during the child's treatment, and PTG were different among parents with a passive style than among parents with a shared-active style.

CONCLUSIONS

The findings emphasize the personalized nature of SDM, suggesting that its benefits are associated with parental preferences and attitudes. Healthcare professionals should assess parents' actual desire to be involved in SDM in order to tailor services effectively.

Path Analysis of Health Literacy, Social Support, and Self-Efficacy on Decisional Conflict in Patients with Stable Schizophrenia

Purpose

Constructing a multiple mediation model based on two mediating variables, social support and self-efficacy, to explore the mechanism of health literacy's effect on decisional conflict in patients with stable schizophrenia.

Patients and Methods

A total of 205 patients with stable schizophrenia who were hospitalized in a psychiatric hospital in Guangdong Province, China, were selected for the study. The All Aspects of Health Literacy Scale (AAHLS), Decisional Conflict Scale (DCS), Social Support Rating Scale (SSRS) and General Self-Efficacy Scale (GSES) were used to evaluate health literacy, decisional conflict, social support and self-efficacy. Path analysis was performed by constructing a structural equation model, and the mediating effect between variables was validated by the bias-corrected nonparametric percentile bootstrap method.

Results

Health literacy, social support, and self-efficacy together explained 20.4% of the variance in decisional conflict. (1) Severe decisional conflict group accounted for 82% of overall patients with stable schizophrenia. (2) there were strong and significant negative relationships between decisional conflict and health literacy, social support, self-efficacy and each of their dimensions (r=-0.14-0.27, P<0.01 or P<0.05). (3) The path analysis showed that health literacy directly affects decisional conflict (β=-0.282); additionally, health literacy indirectly affects decisional conflict through social support (β=-0.319), self-efficacy (β=-0.010) and through the chain mediating effect of social support and self-efficacy (β=-0.008).

Conclusion

Patients with stable schizophrenia have serious decisional conflict in China, and necessary interventions have to be made. This study found that social support and self-efficacy mediate the relationship between health literacy and decisional conflict in patients with stable schizophrenia in China. Healthcare professionals should emphasize health literacy education for patients, and implement pathway-based targeted interventions to improve health literacy, reduce decisional conflict, and promote the recovery of patients with stable schizophrenia.

Measuring healthcare professionals' perceptions of their ability to adopt shared decision making: Translation and psychometric evaluation of the Danish version of the IcanSDM questionnaire

BACKGROUND

Shared  decision making in healthcare is a fundamental right for patients. Healthcare professionals' perception of their own abilities to enable shared decision making is crucial for implementing shared decision making within service. IcanSDM (I can shared decision making) is a brief measure to investigate healthcare professionals' perception of shared decision making approaches to their practices. It was developed in Canada with French and English versions, and recently translated into German. This study aims to adapt the IcanSDM measure for Danish-speaking healthcare professionals, and evaluate its psychometric properties.

METHODS

Cultural adaptation and translation based on Beaton et al.'s approach was applied. A forward translation by ten people and a backward translation by two people were performed. To assess comprehensibility, cognitive interviews were conducted with 24 healthcare professionals. Eighty healthcare professionals who were trained in shared decision making for either one hour (n = 65) or one day (n = 15) participated in the psychometric evaluation. The evaluation concerned acceptance, item characteristics, skewness, item difficulties, corrected item-total correlations, inter-item correlations, factorial structure, internal consistency, and responsiveness.

RESULTS

The forward and backward translation revealed few discrepancies, and participants understood the items well. The psychometric evaluation showed a high completion rate and acceptable item difficulties and discrimination values. Both the factor analysis and the internal consistency showed a 2-factor structure: 1) healthcare professionals' capacity to implement shared decision making; and 2) healthcare professionals' capacity to practise shared decision making. The IcanSDM_Danish obtained a Cronbach's alpha coefficient of 0.74. The evaluation of responsiveness showed improvement, but was not statistically significant.

CONCLUSION

The IcanSDM_Danish has good cross-cultural validity and internal consistency, and a 2-factor structure. The IcanSDM_Danish is capable of providing reliable and valid measurement when evaluating constructed knowledge about shared decision making, and may be able to support the implementation of shared decision making training and evaluation of its impact.

Exploring Patient Empowerment in Major Depressive Disorder: Correlations of Trust, Active Role in Shared Decision-Making, and Symptomatology in a Sample of Italian Patients

Background/Objectives: Empowerment in medicine and psychiatry involves patients gaining control over health-related decisions, improving treatment adherence, outcomes, and satisfaction. This concept is especially significant in psychiatric care due to the complex challenges of mental health conditions, including stigma and impairment of emotional and cognitive functioning. We aim to investigate the correlations between patient trust, decision-making involvement, symptom severity, and perceived empowerment among individuals with Major Depression. Methods: Patients with Major Depressive Disorder were recruited in the "Policlinico G. Rodolico" psychiatry outpatient clinic from November 2022 to June 2023. Inclusion criteria: ages 18-65, ability to consent, stable condition, psychiatric medication history, and recent consultation. Exclusion criteria: psychotic features, bipolar disorder, substance abuse, high suicide risk, and severe comorbidities. Measures included the User Scale for Measuring Empowerment in Mental Health Services (SESM), Trust in Oncologist Scale (TiOS), Clinical Decision-Making Style for Patients (CDMS-P), and Hamilton Depression Rating Scale (HAM-D). Analysis used Kendall's Tau correlation and Two-One-Sided Tests procedure. Results: Seventy-three patients completed the study. No relationship was found between decision-making involvement and perceived empowerment (τ = -0.0625; p = 0.448), or between trust in psychiatrists and empowerment (τ = 0.0747; p = 0.364). An inverse correlation existed between patient involvement in therapy management and trust (τ = -0.2505; p = 0.002). Depression severity inversely correlated with empowerment (τ = -0.2762; p = <.001), but not with trust or decision-making involvement. Conclusions: The lack of significant correlations suggests that decision-making involvement and trust alone may not suffice to enhance empowerment. Trust may encourage patient passivity, while skepticism might drive active involvement. Higher empowerment is associated with less depressive symptoms, highlighting its potential connection with patient outcomes.

Trust, discrimination and preference for shared decision-making in adolescents diagnosed with depression: Implications from Chinese mental health professionals

BACKGROUND

While evidence suggests that the attitudes of healthcare providers toward medical decision-making in adolescents diagnosed with depression merit exploration, research on their preferences for Shared Decision-Making (SDM) and the factors affecting these preferences remains limited.

OBJECTIVE

To investigate Chinese mental health professionals' (MHPs) preferences for SDM in adolescents with depression and identify the relationships between their preference for SDM and trust and discrimination.

METHODS

A cross-sectional design was used in this study. Clinical Decision-making Style-Staff (CDMS-S) was applied to evaluate their preferences for SDM. Physician Trust in the Patient Scale (PTPS) was utilised to assess their trust in consumers. Social Distance Scale to Mental Illness (SDSMI) was utilised to measure their discrimination against people with mental illness.

RESULTS

A total of 581 MHPs were identified in China. MHPs rated their preference for participation in decision making (PD) as shared (1.89 ± 0.472), information (IN) as moderate (2.62 ± 0.682), and family involvement (FI) as high (3.13 ± 0.840). The preferences for three decision topics ranked from the highest to the lowest score were working-related decision (2.35 ± 0.681), general preferences in decision (1.82 ± 0.581) and medication-related decision (1.74 ± 0.826). The mean score of PTPS and SDSMI were 34.71 (SD=9.709) and 15.17 (SD=4.299), respectively. Logistic regression indicated that the preference for PD was associated with discrimination; the preference for IN was associated with trust, discrimination and SDM-related training experience; and the preference for FI was associated with both trust and discrimination.

CONCLUSIONS

While MHPs generally exhibit a favourable attitude toward SDM, this positivity is not universally observed across all contexts. There remains room for improvement in the willingness to co-develop medication regimens and share health information. Rational recognition of depression, and building trusting and friendly therapeutic relationships are key to promoting MHPs' preferences for SDM.

PRACTICAL VALUE

MHPs' preferences for SDM have a significant impact on SDM implementation, which will be promoted by implementing SDM-related training.

How do decision making and fairness mediate the relationship between involuntary hospitalisation and perceived coercion among psychiatric inpatients?

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.

Impact of clinical decision-making participation and satisfaction on outcomes in mental health practice: results from the CEDAR European longitudinal study

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.

Smartphone App to Promote Patient Activation and Support Shared Decision Making in People With a Diagnosis of Schizophrenia in Outpatient Treatment Settings (Momentum Trial): Randomized Controlled Assessor-blinded Trial (Preprint)

Background

Shared decision-making (SDM) is a process aimed at facilitating patient-centered care by ensuring that the patient and provider are actively involved in treatment decisions. In mental health care, SDM has been advocated as a means for the patient to gain or regain control and responsibility over their life and recovery process. To support the process of patient-centered care and SDM, digital tools may have advantages in terms of accessibility, structure, and reminders.

Objective

In this randomized controlled trial, we aimed to investigate the effect of a digital tool to support patient activation and SDM.

Methods

The trial was designed as a randomized, assessor-blinded, 2-armed, parallel-group multicenter trial investigating the use of a digital SDM intervention for 6 months compared with treatment as usual. Participants with a diagnosis of schizophrenia, schizotypal or delusional disorder were recruited from 9 outpatient treatment sites in the Capital Region of Denmark. The primary outcome was the self-reported level of activation at the postintervention time point. The secondary outcomes included self-efficacy, hope, working alliance, satisfaction, preparedness for treatment consultation, symptom severity, and level of functioning. Explorative outcomes on the effect of the intervention at the midintervention time point along with objective data on the use of the digital tool were collected.

Results

In total, 194 participants were included. The intention-to-treat analysis revealed a statistically significant effect favoring the intervention group on patient activation (mean difference 4.39, 95% CI 0.99-7.79; Cohen d=0.33; P=.01), confidence in communicating with one’s provider (mean difference 1.85, 95% CI 0.01-3.69; Cohen d=0.24; P=.05), and feeling prepared for decision-making (mean difference 5.12, 95% CI 0.16-10.08; Cohen d=0.27; P=.04). We found no effect of the digital SDM tool on treatment satisfaction, hope, self-efficacy, working alliance, severity of symptoms, level of functioning, use of antipsychotic medicine, and number or length of psychiatric hospital admissions.

Conclusions

This trial showed a significant effect of a digital SDM tool on the subjective level of patient activation, confidence in communicating with one’s provider, and feeling prepared for decision-making at the postintervention time point. The effect size was smaller than the 0.42 effect size that we had anticipated and sampled for. The trial contributes to the evidence on how digital tools may support patient-centered care and SDM in mental health care.

Trial Registration

ClinicalTrials.gov NCT03554655; https://clinicaltrials.gov/ct2/show/NCT03554655

International Registered Report Identifier (IRRID)

RR2-doi: 10.1186/s12888-019-2143-2

Proportionate translation of study materials and measures in a multinational global health trial: methodology development and implementation

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.

Clinical decision-making style preferences of European psychiatrists: Results from the Ambassadors survey in 38 countries

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.

Cross-cultural validation of the patient-practitioner orientation scale among primary care professionals in Spain

BACKGROUND

In recent decades, many self-report instruments have been developed to assess the extent to which patients want to be informed and involved in decisions about their health as part of the concept of person-centred care (PCC). The main objective of this research was to translate, adapt and validate the Patient-Practitioner Orientation Scale (PPOS) using a sample of primary care health-care professionals in Spain.

METHODS

Baseline analysis of PPOS scores for 321 primary care professionals (general practitioners and nurses) from 63 centres and 3 Spanish regions participating in a randomized controlled trial. We analysed missing values, distributions and descriptive statistics, item-to-scale correlations and internal consistency. Performed were confirmatory factor analysis (CFA) of the 2-factor model (sharing and caring dimensions), scale depuration and principal component analysis (PCA).

RESULTS

Low inter-item correlations were observed, and the CFA 2-factor model only obtained a good fit to the data after excluding 8 items. Internal consistency of the 10-item PPOS was acceptable (0.77), but low for individual subscales (0.70 and 0.55). PCA results suggest a possible 3-factor structure. Participants showed a patient-oriented style (mean = 4.46, SD = 0.73), with higher scores for caring than sharing.

CONCLUSION

Although the 2-factor model obtained empirical support, measurement indicators of the PPOS (caring dimension) could be improved. Spanish primary care health-care professionals overall show a patient-oriented attitude, although less marked in issues such as patients' need for and management of medical information.

Translation and psychometric testing of a decision-making scale

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.

When does shared decision making is adopted in psychiatric clinical practice? Results from a European multicentric study

To identify factors associated with the use of shared decision making in routine mental health care in a large multicenter European study. Data have been collected within the study "Clinical decision making and outcome in routine care for people with severe mental illness" (CEDAR), which is a naturalistic, longitudinal, observational study carried out in six European countries. Patients with a severe mental illness attending outpatient units and their treating clinicians have been recruited. Clinicians' Clinical Decision Making (CDM) styles have been explored through the Clinical Decision Making Style Scale. Patients' clinical and social outcomes have been assessed through validated assessment instruments. The sample consisted of 588 patients and 213 professionals. Professionals were mainly psychiatrists (35.7%), nurses (21.6%), support workers, social workers or occupational therapists (24.9%), psychologists (9.9%) or trainees in psychiatry (4.7%). In the majority of cases, clinicians adopted a shared CDM style. Shared CDM was more frequently adopted with patients with psychotic disorders, with a better quality of life and social functioning. At multivariate analyses, the likelihood of adopting shared decision making increased in patients with higher levels of interpersonal relationships' skills (p < 0.05) and global functioning (p < 0.01). On the contrary, being a trainee in psychiatry reduced the likelihood of adopting shared CDM (p < 0.008). Shared decision making has been adopted mainly when patients have a better functioning and less severe clinical symptomatology and by less trained clinicians, differently from national and international recommendations. More efforts should be made to implement interventions to promote shared CDM, with a specific focus for trainees in psychiatry.

Shared decision-making in serious mental illness: A comparative study

OBJECTIVE

To compare consumer and mental health professionals' (MHPs) preferences for decision-making in China and Europe.

METHODS

This study used cross-sectional design; Chinese data were collected by questionnaires and European data were obtained from the literature. Data were analysed using t-test, One-way ANOVA and Pearson correlation coefficient as appropriate.

RESULTS

This study involved 800 people diagnosed with severe mental illness and 506 MHPs. Chinese participants rated lower scores on preference for participation in decision-making (PD = 1.88) and information (IN = 2.70) than European participants (PD = 2.05, IN = 2.83). Chinese consumers rated a higher score on IN (2.78) but lower on for PD (1.75) than MHPs (IN = 2.64, PD = 1.97). Chinese consumers' education level is positively associated with preference for PD and IN. The gender, occupation and age of Chinese MHPs are associated with preference for PD.

CONCLUSION

Both Chinese and Europeans had preference for shared involvement in mental health, while the preference in China is less. Opinions of consumers and MHPs might be different, regarding the level of patient involvement in specific decisions.

PRACTICE IMPLICATION

It is essential that consumers' preferences are understood for provision of optimal support for a shared decision-making approach.

Impact of psychiatric advance directive facilitation on mental health consumers: empowerment, treatment attitudes and the role of peer support specialists

BACKGROUND

A psychiatric advance directive (PAD) is designed to prevent involuntary mental health interventions by enabling people with serious mental illnesses to plan ahead for their own treatment during a future incapacitating crisis. This study implemented PAD facilitation in assertive community treatment (ACT) teams.

AIMS

We examined ACT clients' attitudes toward PAD facilitators, satisfaction with PAD facilitation, the short-term impact of PAD completion on subjective sense of empowerment and attitudes toward treatment, and whether the type of PAD facilitator made a difference.

METHODS

Participants were randomly assigned to be offered PAD facilitation by a peer support specialist or non-peer ACT team clinician, and interviewed at baseline (n = 145) and post-facilitation 1-2-month follow-up (n = 116), to assess perceived consumer-directedness of PAD facilitation, empowerment and various treatment attitudes. Mean scores before and after the intervention were compared for PAD-completers, non-completers, and those who completed a PAD with a peer vs. non-peer. The effect of PAD completion was assessed using logistic and linear regression analysis.

RESULTS

There was no evidence of bias against peer-facilitators. There was a modest positive impact of PAD facilitation on treatment attitudes and empowerment.

CONCLUSIONS

PAD facilitation by peer support specialists and others working in community mental health settings supports recovery.

Patient-reported outcome measurements (PROMs) and provider assessment in mental health: a systematic review of the context of implementation

Purpose

To review and integrate the vast amount of literature yielded by recent growing interest in patient-reported outcome measurement and routine outcome measures (PROMs/ROMs), in order to suggest options and improvements for implementation. PROMs are the systematic assessment of service users’ health using standardized self-report measures. Specifically, for ROMs, it includes routine provider or caretaker assessment measures. Both are administered to ascertain routinely, the impact of treatment in mental health settings and to improve care. A review is needed because of the large differences in setting, conceptualization, practice and implementation. Here, we examine the different major projects worldwide.

Data sources

Psych INFO and PubMed including Medline, Biomed Central, EMBASE Psychiatry and Elsevier Science’s Direct.

Study selection

We conducted a systematized review of the literature published from 2000 to 2018 on the implementation and sustainability of PROMs and ROMs in mental health services for adults.

Data extraction, synthesis and Results

We described and characterized the programs in different countries worldwide. We identified 103 articles that met the inclusion criteria, representing over 80 PROMs/ROMs initiatives in 15 countries. National policy and structure of mental health services were found to be major factors in implementation. We discuss the great variability in PROMs/ROMs models in different countries, making suggestions for their streamlining and improvement.

Conclusion

We extracted valuable information on the different characteristics of the numerous PROMs/ROMs initiatives worldwide. However, in the absence of a strong nationwide policy effort and support, implementation seems scattered and irregular. Thus, development of the implementation of PROMs/ROMs is left to groups of enthusiastic clinicians and researchers, making sustainability problematic.

The Momentum trial: the efficacy of using a smartphone application to promote patient activation and support shared decision making in people with a diagnosis of schizophrenia in outpatient treatment settings: a randomized controlled single-blind trial

BACKGROUND

Shared decision making (SDM) is often defined as an interactive process that ensures that both patient and practitioner are actively involved in the treatment and that they share all relevant information to arrive at a mental health decision. Previous SDM interventions have found improvements in outcomes such as personal recovery, higher perceived involvement in treatment decisions and knowledge about one's disease. Still, SDM occurs less frequently in mental health care than in primary care. Electronic aids developed to support patient activation and SDM could be a promising mean to engage patients in their mental healthcare. The aim of this trial is to investigate the effects of using a smartphone app to promote patient activation and support SDM for people with schizophrenia-spectrum disorders in an outpatient treatment setting.

METHODS

This randomised controlled trial will allocate participants to one of two groups: (1) Intervention group: smartphone app and TAU (treatment as usual) or (2) Control group: TAU without the smartphone app. A total sample size of 260 people with a diagnosis of schizophrenia, schizotypal or delusional disorder will be recruited from five OPUS teams (a specialized early intervention program) in Denmark between 2019 and 2020. The intervention will last for 6 months with data collection at baseline, and at 3 and 6 months. Primary outcome will be self-perceived patient activation. Secondary outcomes will be feeling of being prepared for SDM; self-efficacy; working alliance; treatment satisfaction; positive and negative symptoms; level of functioning; hope; and perceived efficacy in patient-provider interaction. Patients' and health providers' preferences in clinical decision making will be assessed. Patients' usage and perceived usefulness of the app will be explored.

DISCUSSION

This study will investigate the efficacy of using the smartphone app to support people with severe mental illness in engaging in their own healthcare management. The study may provide evidence to the idea that linking client and practitioner in digital solutions can have advantages in facilitating SDM in mental health. The trial will provide new knowledge of whether a digital healthcare solution can improve patient activation and support SDM for people with severe mental illness.

TRIAL REGISTRATION

ClinicalTrials.gov number: NCT03554655 Registered on: June 13, 2018.

The development and evaluation of a computerized decision aid for the treatment of psychotic disorders

BACKGROUND

Routinely monitoring of symptoms and medical needs can improve the diagnostics and treatment of medical problems, including psychiatric. However, several studies show that few clinicians use Routine Outcome Monitoring (ROM) in their daily work. We describe the development and first evaluation of a ROM based computerized clinical decision aid, Treatment-E-Assist (TREAT) for the treatment of psychotic disorders. The goal is to generate personalized treatment recommendations, based on international guidelines combined with outcomes of mental and physical health acquired through ROM. We present a pilot study aimed to assess the feasibility of this computerized clinical decision aid in daily clinical practice by evaluating clinicians' experiences with the system.

METHODS

Clinical decision algorithms were developed based on international schizophrenia treatment guidelines and the input of multidisciplinary expert panels from multiple psychiatric institutes. Yearly obtained diagnostic (ROM) information of patients was presented to treating clinicians combined with treatment suggestions generated by the algorithms of TREAT. In this pilot study 6 clinicians and 16 patients of Lentis Psychiatric Institute used the application. Clinicians were interviewed and asked to fill out self-report questionnaires evaluating their opinions about ROM and the effectiveness of TREAT.

RESULTS

Six clinicians and 16 patients with psychotic disorders participated in the pilot study. The clinicians were psychiatrists, physicians and nurse-practitioners which all worked at least 8 years in mental health care of which at least 3 years treating patients with psychotic illnesses. All Clinicians found TREAT easy to use and would like to continue using the application. They reported that TREAT offered support in using diagnostic ROM information when drafting the treatment plans, by creating more awareness of current treatment options.

CONCLUSION

This article presents a pilot study on the implementation of a computerized clinical decision aid linking routine outcome monitoring to clinical guidelines in order to generate personalized treatment advice. TREAT was found to be feasible for daily clinical practice and effective based on this first evaluation by clinicians. However, adjustments have to be made to the system and algorithms of the application. The ultimate goal is to provide appropriate evidence based care for patients with severe mental illnesses.

Implementing shared decision making in routine mental health care

Shared decision making (SDM) in mental health care involves clinicians and patients working together to make decisions. The key elements of SDM have been identified, decision support tools have been developed, and SDM has been recommended in mental health at policy level. Yet implementation remains limited. Two justifications are typically advanced in support of SDM. The clinical justification is that SDM leads to improved outcome, yet the available empirical evidence base is inconclusive. The ethical justification is that SDM is a right, but clinicians need to balance the biomedical ethical principles of autonomy and justice with beneficence and non-maleficence. It is argued that SDM is "polyvalent", a sociological concept which describes an idea commanding superficial but not deep agreement between disparate stakeholders. Implementing SDM in routine mental health services is as much a cultural as a technical problem. Three challenges are identified: creating widespread access to high-quality decision support tools; integrating SDM with other recovery-supporting interventions; and responding to cultural changes as patients develop the normal expectations of citizenship. Two approaches which may inform responses in the mental health system to these cultural changes - social marketing and the hospitality industry - are identified.

Recovery and decision-making involvement in people with severe mental illness from six countries: a prospective observational study

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).

Information and Decision-Making Needs Among People with Anxiety Disorders: Results of an Online Survey

BACKGROUND

People with anxiety disorders are faced with treatment decisions considerably affecting their life. Patient decision aids are aimed at enabling patients to deliberate treatment options based on individual values and to participate in medical decisions.

OBJECTIVE

This is the first study to determine patients' information and decision-making needs as a pre-requisite for the development of patient decision aids for anxiety disorders.

METHODS

An online cross-sectional survey was conducted between January and April 2013 on the e-health portal http://www.psychenet.de by using a self-administered questionnaire with items on internet use, online health information needs, role in decision making and important treatment decisions. Descriptive and inferential statistical as well as qualitative data analyses were performed.

RESULTS

A total of 60 people with anxiety disorders with a mean age of 33.3 years (SD 10.5) participated in the survey. The most prevalent reasons for online health information search were the need for general information on anxiety disorders, the search for a physician or psychiatrist and the insufficiency of information given by the healthcare provider. Respondents experienced less shared and more autonomous decisions than they preferred. They assessed decisions on psychotherapy, medication, and treatment setting (inpatient or outpatient) as the most difficult decisions.

CONCLUSION

Our results confirm the importance of offering patient decision aids for people with anxiety disorders that encourage patients to participate in decision making by providing information about the pros and cons of evidence-based treatment options.

[Social psychiatry and neurobiology : A long overdue convergence exemplified by schizophrenia]

BACKGROUND

The proliferation of biological psychiatry has greatly increased over the last two decades. With the possibility to carry out brain research using modern technical methods, it seemed that social influencing factors would lose importance in the development of mental diseases; however, in actual fact this does not seem to be justified. It is necessary to overcome this separation, in that social factors are incorporated into a conceptual framework in the development of mental diseases, which simultaneously also takes the results of current neurobiological research into consideration.

OBJECTIVES AND METHODS

The aims of this review article are to summarize the current state of sociopsychiatric research and to emphasize the perspectives of the biological principles and their validity with respect to the social dimensions of psychiatry, as exemplified by schizophrenic disorders. The article presents the options for a biosocial approach in social psychiatry and gives an overview of the currently available literature.

RESULTS AND CONCLUSION

There is an abundance of neurobiological research approaches, which are closely associated with sociopsychiatric topics, such as social cognition. Social psychiatry and biological psychiatry should no longer be considered as diametrically opposed subdisciplines. On the contrary, the options which could emerge from a synthesis must be used in research and clinical practice.

Participation in medical decision-making across Europe: An international longitudinal multicenter study

BACKGROUND

The purpose of this paper was to examine national differences in the desire to participate in decision-making of people with severe mental illness in six European countries.

METHODS

The data was taken from a European longitudinal observational study (CEDAR; ISRCTN75841675). A sample of 514 patients with severe mental illness from the study centers in Ulm, Germany, London, England, Naples, Italy, Debrecen, Hungary, Aalborg, Denmark and Zurich, Switzerland were assessed as to desire to participate in medical decision-making. Associations between desire for participation in decision-making and center location were analyzed with generalized estimating equations.

RESULTS

We found large cross-national differences in patients' desire to participate in decision-making, with the center explaining 47.2% of total variance in the desire for participation (P<0.001). Averaged over time and independent of patient characteristics, London (mean=2.27), Ulm (mean=2.13) and Zurich (mean=2.14) showed significantly higher scores in desire for participation, followed by Aalborg (mean=1.97), where scores were in turn significantly higher than in Debrecen (mean=1.56). The lowest scores were reported in Naples (mean=1.14). Over time, the desire for participation in decision-making increased significantly in Zurich (b=0.23) and decreased in Naples (b=-0.14). In all other centers, values remained stable.

CONCLUSIONS

This study demonstrates that patients' desire for participation in decision-making varies by location. We suggest that more research attention be focused on identifying specific cultural and social factors in each country to further explain observed differences across Europe.

Clinical decision making and outcome in the routine care of people with severe mental illness across Europe (CEDAR)

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.

Content and implementation of clinical decisions in the routine care of people with severe mental illness

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.

Factor structure of the autonomy preference index in people with severe mental illness

People vary in the amount of control they want to exercise over decisions about their healthcare. Given the importance of patient-centered care, accurate measurement of these autonomy preferences is critical. This study aimed to assess the factor structure of the Autonomy Preference Index (API), used widely in general healthcare, in individuals with severe mental illness. Data came from two studies of people with severe mental illness (N=293) who were receiving mental health and/or primary care/integrated care services. Autonomy preferences were assessed with the API regarding both psychiatric and primary care services. Confirmatory factor analysis was used to evaluate fit of the hypothesized two-factor structure of the API (decision-making autonomy and information-seeking autonomy). Results indicated the hypothesized structure for the API did not adequately fit the data for either psychiatric or primary care services. Three problematic items were dropped, resulting in adequate fit for both types of treatment. These results suggest that with relatively minor modifications the API has an acceptable factor structure when asking people with severe mental illness about their preferences to be involved in decision-making. The modified API has clinical and research utility for this population in the burgeoning field of autonomy in patient-centered healthcare.

Empowerment and satisfaction in a multinational study of routine clinical practice

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.

Efficacy of psychoeducational family intervention for bipolar I disorder: A controlled, multicentric, real-world study

BACKGROUND

This study assessed the efficacy of the Falloon model of psychoeducational family intervention (PFI), originally developed for schizophrenia management and adapted to bipolar I disorder. The efficacy of the intervention was evaluated in terms of improvement of patients׳ social functioning and reduction of family burden.

METHODS

This was a multicentre, real-world, controlled, outpatient trial carried out in 11 randomly recruited Italian mental health centres. Enroled patients and key-relatives were consecutively allocated either to receive PFI and Treatment As Usual (TAU) or to a waiting list receiving TAU alone. The efficacy of the intervention was evaluated in terms of improvement in patients׳ social functioning (primary outcome) and reduction of family burden (secondary outcome).

RESULTS

Of the 137 recruited families, 70 were allocated to the experimental group and 67 to the control group. At the end of the intervention, significant improvements in patients׳ social functioning and in relatives׳ burden were found in the treated group compared to TAU. This effect of the intervention remained also after controlling for several confounding patient׳s socio-demographic and clinical factors. The experimental intervention had an impact also on other outcome measures, such as patients׳ clinical status and personal burden.

LIMITATIONS

Lack of an active control group.

CONCLUSIONS

The results of this study clearly show that the psychoeducational family intervention according to the Falloon model is effective in improving the social outcome of patients with bipolar I disorder.

Information and decision-making needs among people with affective disorders - results of an online survey

BACKGROUND

Patient decision aids are one possibility for enabling and encouraging patients to participate in medical decisions.

OBJECTIVE

This paper aims to describe patients' information and decision-making needs as a prerequisite for the development of high-quality, web-based patient decision aids for affective disorders.

DESIGN

We conducted an online cross-sectional survey by using a self-administered questionnaire including items on Internet use, online health information needs, role in decision making, and important treatment decisions, performing descriptive and comparative statistical analyses.

PARTICIPANTS

A total of 210 people with bipolar disorder/mania as well as 112 people with unipolar depression participated in the survey.

RESULTS

Both groups specified general information search as their most relevant information need and decisions on treatment setting (inpatient or outpatient) as well as decisions on pharmacological treatment as the most difficult treatment decisions. For participants with unipolar depression, decisions concerning psychotherapeutic treatment were also especially difficult. Most participants of both groups preferred shared decisions but experienced less shared decisions than desired.

DISCUSSION AND CONCLUSION

Our results show the importance of information for patients with affective disorders, with a focus on pharmacological treatment and on the different treatment settings, and highlight patients' requirements to be involved in the decision-making process. Since our sample reported a chronic course of disease, we do not know if our results are applicable for newly diagnosed patients. Further studies should consider how the reported needs could be addressed in health care practice.

Desire for information of people with severe mental illness

PURPOSE

To assess (1) the desire of people with severe mental illness for information on their treatment and (2) whether the desire for information is associated with socio-demographic variables, diagnosis, illness duration, therapeutic relationship, needs and symptom severity.

METHODS

588 outpatients with severe mental illness were recruited in six European countries (Germany, Denmark, Hungary, Italy, Switzerland, United Kingdom) during the "Clinical decision making and outcome in routine care of people with severe mental illness (CEDAR)" study (ISRCTN75841675). Desire for information was assessed by the Information subscale of the Clinical Decision Making Style Scale. Study participants with high desire for information were compared with those with moderate or low desire for information.

RESULTS

80 % of study participants (n = 462) wanted to receive information on all aspects of their treatment (management, prognosis, alternative options for care). Participants with a high desire for information had less severe symptoms (OR = 0.988, CI = 0.977-1.000) and a better self-rated therapeutic alliance (OR = 1.304, CI = 1.130-1.508) with their clinician.

CONCLUSIONS

Most, but not all, people with severe mental illness have a high desire for information. Desire for information is associated with variables, such as therapeutic relationship and symptom severity, which are amenable to change during treatment.

Information and decision-making needs among people with mental disorders: a systematic review of the literature

BACKGROUND

Assessment of users' information and decision-making needs is one key step in the development of decision-support interventions.

OBJECTIVE

To identify patients' information and decision-making needs as a pre-requisite for the development of high-quality web-based patient decision aids (PtDAs) for common mental disorders.

SEARCH STRATEGY

A systematic MEDLINE search for papers published until December 2012 was conducted, and reference lists of included articles and relevant reviews were searched.

INCLUSION CRITERIA

Original studies containing data on information or decision-making needs of adults with depression, anxiety disorders, somatoform disorders, alcohol-related disorders and schizophrenia were included.

DATA EXTRACTION AND SYNTHESIS

Data extraction was performed using a standardized form, and data synthesis was conducted using a theory-based deductive approach by two independent reviewers. Studies were quality assessed using the Mixed Methods Appraisal Tool.

MAIN RESULTS

Twelve studies were included focusing on information needs or the identification of decisions patients with depression and schizophrenia were facing. No studies were found for the other mental disorders. Overall, seven information needs categories were identified with the topics 'basic facts', 'treatment' and 'coping' being of major relevance. Six decision categories were identified of which decisions on 'medication' and 'treatment setting' were most often classified.

CONCLUSIONS

This review reveals that patients with schizophrenia and depression show extensive information and decision-making needs. The identified needs can initially inform the design of PtDAs for schizophrenia and depression. However, there is an urgent need to investigate information and decision-making needs among patients with other mental disorders.

The development and evaluation of a five-language multi-perspective standardised measure: clinical decision-making involvement and satisfaction (CDIS)

BACKGROUND

The aim of this study was to develop and evaluate a brief quantitative five-language measure of involvement and satisfaction in clinical decision-making (CDIS) - with versions for patients (CDIS-P) and staff (CDIS-S) - for use in mental health services.

METHODS

An English CDIS was developed by reviewing existing measures, focus groups, semistructured interviews and piloting. Translations into Danish, German, Hungarian and Italian followed the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Task Force principles of good practice for translation and cultural adaptation. Psychometricevaluation involved testing the measure in secondary mental health services in Aalborg, Debrecen, London, Naples, Ulm and Zurich.

RESULTS

After appraising 14 measures, the Control Preference Scale and Satisfaction With Decision-making English-language scales were modified and evaluated in interviews (n = 9), focus groups (n = 22) and piloting (n = 16). Translations were validated through focus groups (n = 38) and piloting (n = 61). A total of 443 service users and 403 paired staff completed CDIS. The Satisfaction sub-scale had internal consistency of 0.89 (0.86-0.89 after item-level deletion) for staff and 0.90 (0.87-0.90) for service users, both continuous and categorical (utility) versions were associated with symptomatology and both staff-rated and service userrated therapeutic alliance (showing convergent validity), and not with social disability (showing divergent validity), and satisfaction predicted staff-rated (OR 2.43, 95%CI 1.54- 3.83 continuous, OR 5.77, 95%CI 1.90-17.53 utility) and service user-rated (OR 2.21, 95%CI 1.51-3.23 continuous, OR 3.13, 95%CI 1.10-8.94 utility) decision implementation two months later. The Involvement sub-scale had appropriate distribution and no floor or ceiling effects, was associated with stage of recovery, functioning and quality of life (staff only) (showing convergent validity), and not with symptomatology or social disability (showing divergent validity), and staff-rated passive involvement by the service user predicted implementation (OR 3.55, 95%CI 1.53-8.24). Relationships remained after adjusting for clustering by staff.

CONCLUSIONS

CDIS demonstrates adequate internal consistency, no evidence of item redundancy, appropriate distribution, and face, content, convergent, divergent and predictive validity. It can be recommended for research and clinical use. CDIS-P and CDIS-S in all 3 five languages can be downloaded at http://www.cedar-net.eu/instruments.

TRIAL REGISTRATION

ISRCTN75841675.

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)

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.