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

Empowerment among treatment-engaged individuals living with schizophrenia in Tanzania

PURPOSE

As low-resource settings move to address the treatment and social service gap for people living with schizophrenia (PLWS), person-centered and recovery-oriented interventions should monitor impacts on empowerment. This study explores empowerment and associated factors among PLWS in Tanzania.

METHODS

This study uses endline data from the Culturally Adapted Family Psychoeducation for Adults with Psychotic Disorders in Tanzania (KUPAA) pilot trial. Participants included 66 dyads of PLWS and caregivers recruited from two tertiary-level hospitals. The main outcome variable of interest was empowerment (Rogers 28-item Empowerment Scale), and the main exposure variable was Participation in Society (Domain 6 of the WHO Disability Assessment Schedule, WHODAS 2.0). Key psychosocial correlates of interest included hopefulness, general self-efficacy, internalized stigma, and family functioning. Bivariate and multivariable analyses were used to explore variable relationships.

RESULTS

There were 21 women and 40 men with a mean age of 32 years. Bivariate analyses revealed greater participation in society (p < 0.0003) was correlated with greater empowerment, higher hopefulness (p < 0.0001) and higher self-efficacy (p < 0.0001). Lower empowerment was correlated with higher self-stigma (p < 0.0001) and worse family functioning (p < .001). Multivariable models indicated more participation in society was associated with higher empowerment, but when hope, self-efficacy, internalized stigma, and/or family functioning were added to the models, those factors were more strongly correlated with empowerment than participation in society.

CONCLUSION

Empowerment is increasingly being recognized as an important outcome of psychosocial interventions. Understanding empowerment and its possible effects on recovery-centered outcomes is important when thinking of future interventions for PLWS in low-resource settings. Future recovery-oriented interventions and research should both consider including empowerment measurement among PLWS and incorporate their lived experiences in psychosocial treatment programming.

The Role of Shared Decision-Making in Promoting Family Participation in Treatment for Adolescents and Young Adults with First-Episode Psychosis

We aimed to examine the role of shared decision-making (SDM) in family participation in the treatment of adolescents and young adults with first-episode psychosis (FEP). Based on responses of 144 family members of OnTrackNY (OTNY) participants, we divided the sample into low participators and high participators. We calculated the total SDM score for each participant by summing the ratings across items inquiring about SDM and assessed the extent to which loved ones encouraged family participation in their care. Our results indicated that the level of loved ones' encouragement was significantly related to family participation. When controlling for loved ones' encouragement, we found that the total SDM score was significantly higher in the high participator group. These findings suggest that SDM may be influenced by loved ones' attitudes towards family involvement in treatment and SDM may play a role in promoting family participation in care for individuals with FEP.

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.

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.

The schizophrenia syndrome, circa 2024: What we know and how that informs its nature

With new data about different aspects of schizophrenia being continually generated, it becomes necessary to periodically revisit exactly what we know. Along with a need to review what we currently know about schizophrenia, there is an equal imperative to evaluate the construct itself. With these objectives, we undertook an iterative, multi-phase process involving fifty international experts in the field, with each step building on learnings from the prior one. This review assembles currently established findings about schizophrenia (construct, etiology, pathophysiology, clinical expression, treatment) and posits what they reveal about its nature. Schizophrenia is a heritable, complex, multi-dimensional syndrome with varying degrees of psychotic, negative, cognitive, mood, and motor manifestations. The illness exhibits a remitting and relapsing course, with varying degrees of recovery among affected individuals with most experiencing significant social and functional impairment. Genetic risk factors likely include thousands of common genetic variants that each have a small impact on an individual's risk and a plethora of rare gene variants that have a larger individual impact on risk. Their biological effects are concentrated in the brain and many of the same variants also increase the risk of other psychiatric disorders such as bipolar disorder, autism, and other neurodevelopmental conditions. Environmental risk factors include but are not limited to urban residence in childhood, migration, older paternal age at birth, cannabis use, childhood trauma, antenatal maternal infection, and perinatal hypoxia. Structural, functional, and neurochemical brain alterations implicate multiple regions and functional circuits. Dopamine D-2 receptor antagonists and partial agonists improve psychotic symptoms and reduce risk of relapse. Certain psychological and psychosocial interventions are beneficial. Early intervention can reduce treatment delay and improve outcomes. Schizophrenia is increasingly considered to be a heterogeneous syndrome and not a singular disease entity. There is no necessary or sufficient etiology, pathology, set of clinical features, or treatment that fully circumscribes this syndrome. A single, common pathophysiological pathway appears unlikely. The boundaries of schizophrenia remain fuzzy, suggesting the absence of a categorical fit and need to reconceptualize it as a broader, multi-dimensional and/or spectrum construct.

A conceptual framework for how structural changes in emerging acute substance use service models can reduce stigma of medications for opioid use disorder

Stigma toward people taking medication for opioid use disorder (MOUD) is prevalent, harmful to the health and well-being of this population, and impedes MOUD treatment resource provision, help-seeking, and engagement in care. In recent years, clinicians have implemented new models of MOUD-based treatment in parts of the United States that integrate buprenorphine initiation into emergency departments and other acute general medical settings, with post-discharge linkage to office-based treatment. These service models increase access to MOUD and they have potential to mitigate stigma toward opioid use and MOUD. However, the empirical literature connecting these emerging service delivery models to stigma outcomes remains underdeveloped. This paper aims to bridge the stigma and health service literatures via a conceptual model delineating how elements of emerging MOUD service models can reduce stigma and increase behavior in pursuit of life goals. Specifically, we outline how new approaches to three key processes can counter structural, public, and self-stigma for this population: (1) community outreach with peer-to-peer influence, (2) clinical evaluation and induction of MOUD in acute care settings, and (3) transition to outpatient maintenance care and early recovery. Emerging service models that target these three processes can, in turn, foster patient empowerment and pursuit of life goals. There is great potential to increase the well-being of people who use opioids by reducing stigma against MOUD via these structural changes.

Accelerating the development of a psychological intervention to restore treatment decision-making capacity in patients with schizophrenia-spectrum disorder: a study protocol for a multi-site, assessor-blinded, pilot Umbrella trial (the DEC:IDES trial)

BACKGROUND

A high proportion of patients diagnosed with schizophrenia-spectrum disorders will at some point in their lives be assessed as not having the capacity to make their own decisions about pharmacological treatment or inpatient care ('capacity'). Few will be helped to regain it before these interventions proceed. This is partly because effective and safe methods to do so are lacking. Our aim is to accelerate their development by testing, for the first time in mental healthcare, the feasibility, acceptability and safety of running an 'Umbrella' trial. This involves running, concurrently and under one multi-site infrastructure, multiple assessor-blind randomised controlled trials, each of which is designed to examine the effect on capacity of improving a single psychological mechanism ('mechanism'). Our primary objectives are to demonstrate feasibility of (i) recruitment and (ii) data retention on the MacArthur Competence Assessment Tool-Treatment (MacCAT-T; planned primary outcome for a future trial) at end-of-treatment. We selected three mechanisms to test: 'self-stigma', low self-esteem and the 'jumping to conclusions' bias. Each is highly prevalent in psychosis, responsive to psychological intervention, and hypothesised to contribute to impaired capacity.

METHODS

Sixty participants with schizophrenia-spectrum diagnoses, impaired capacity and one or more mechanism(s) will be recruited from outpatient and inpatient mental health services in three UK sites (Lothian, Scotland; Lancashire and Pennine; North West England). Those lacking capacity to consent to research could take part if the key criteria were met, including either proxy consent (Scotland) or favourable Consultee advice (England). They will be allocated to one of three randomised controlled trials, depending on which mechanism(s) they have. They will then be randomised to receive, over an 8-week period and in addition to treatment as usual (TAU), 6 sessions of either a psychological intervention which targets the mechanism, or 6 sessions of assessment of the causes of their incapacity (control condition). Participants are assessed at 0 (baseline), 8 (end-of-treatment) and 24 (follow-up) weeks post-randomisation using measures of capacity (MacCAT-T), mechanism, adverse events, psychotic symptoms, subjective recovery, quality of life, service use, anxiety, core schemata and depression. Two nested qualitative studies will be conducted; one to understand participant and clinician experiences and one to investigate the validity of MacCAT-T appreciation ratings.

DISCUSSION

This will be the first Umbrella trial in mental healthcare. It will produce the first 3 single-blind randomised controlled trials of psychological interventions to support treatment decision-making in schizophrenia-spectrum disorder. Demonstrating feasibility will have significant implications not only for those seeking to support capacity in psychosis, but also for those who wish to accelerate the development of psychological interventions for other conditions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04309435 . Pre-registered on 16 March 2020.

Shared decision making with schizophrenic patients: a randomized controlled clinical trial with booster sessions (DECIDE Study)

BACKGROUND

The treatment of schizophrenia requires a prolonged, multidimensional intervention that includes antipsychotic drugs. Treatment adherence is essential to effectively control the disorder. Shared decision-making (SDM) is a strategy, supported by numerous practical and ethical arguments, that seeks to involve patients in the therapeutic process to improve treatment adherence and satisfaction. The use of this model in mental health has been limited for many intrinsic and extrinsic reasons. The results of clinical trials conducted to date have largely been disappointing, potential due to study design-related limitations.

AIM/QUESTION

To evaluate the efficacy, in terms of treatment adherence and improvement in clinical variables, such as severity of symptoms, days of hospitalization or insight, of a carefully timed SDM model initiated immediately prior to hospital discharge in patients with schizophrenia.

METHODS

Single-blind, randomized clinical trial in an acute psychiatric care unit within the Andalusian Health Department to compare SDM (experimental group) to treatment as usual (TAU; control group) in a sample of patients hospitalized for an acute episode of schizophrenia or schizoaffective disorder. The study was performed between January 2014 and June 2017. The experimental group participated in SDM sessions prior to discharge with regular booster sessions over the one-year follow-up. The health care team responsible for SDM was predisposed to concordance (LatCon II scale) and received specific training in SDM. A hierarchical multiple linear regression analysis was performed to evaluate the factors independently associated with adherence, controlling for sociodemographic, clinical, and admission-related variables. Variables were assessed at admission, discharge and at 3, 6 and 12 months after discharge during the one year follow up. BARS, DAI, WAI-S, COMRADE and PANSS were used to evaluate adherence, attitude to treatment, therapeutic alliance, satisfaction and confidence with decision and clinical status, respectively.

RESULTS

A total of 227 schizophrenic patients hospitalized with acute decompensation were evaluated; of these, 102 met all inclusion criteria and were included in the study. Most patients (95%) had prior experience with antipsychotics and most (82%) had experienced related side effects. Despite randomization, psychopathologic severity was greater in the experimental group, with a mean (SD) PANSS score of 104.08 (80) vs. 93.45 (20.30) (p < 0.05). The final regression model to explain adherence was significant (adjusted R2 = 0.384; F [df= 6] = 4.386; p < 0.001), with a direct, significant and independent association with SDM mediated by the number of booster sessions.

DISCUSSION

Shared decision making with booster sessions appears to increase treatment adherence in patients with severe mental disorders.

IMPLICATION ON PRACTICE

Ethical, practical, and clinical reasons support the use of strategies designed promote the use of long-term, shared decision-making in psychiatric patients, especially in schizophrenia spectrum disorder.

"It's That They Treated Me Like an Object": A Qualitative Study on the Participation of People Diagnosed with Psychotic Disorders in Their Health Care

The mental health recovery model is based on shared decision making, in which patients' preferences and perceptions of the care received are taken into account. However, persons with psychosis usually have very few opportunities to participate in this process. The present study explores the experiences and perceptions of a group of patients with psychosis-in some cases longstanding, in others more recently diagnosed-concerning their participation in the decisions taken about the approach to their condition and about the attention received from healthcare professionals and services. For this purpose, we performed a qualitative analysis of the outcomes derived from five focus groups and six in-depth interviews (36 participants). Two major themes, with five sub-themes, were identified: shared decision-making (drug-centred approach, negotiation process, and lack of information) and the care environment and styles of clinical practice as determinants (aggressive versus person-centred environments, and styles of professional practice). The main conclusions drawn are that users want to participate more in decision making, they want to be offered a range of psychosocial options from the outset and that their treatment should be based on accessibility, humanity and respect. These findings are in line with the guidelines for clinical practice and should be taken into account in the design of care programmes and the organisation of services for persons with psychosis.

Providers' shared decision-making as a predictor of healthcare outcomes for college-aged adults managing upper respiratory tract infections

OBJECTIVES

Strategies that assist patients with upper respiratory tract infections (URTIs) to endorse non-antibiotic treatments are vital to curbing antibiotic resistance. This study examines the potential of shared decision-making (SDM) for improving stewardship-relevant outcomes and investigates patient affect as a mechanism that explains the beneficial impact of perceived SDM.

METHOD

Patients (N = 433) seeking care for URTIs at a university student health center and not prescribed antibiotics completed a pre-visit questionnaire and two surveys one day and 14 days post-visit. The day-one survey assessed perceived SDM, affect, and immediate stewardship-relevant outcomes, and the day-14 survey assessed long-term stewardship-relevant outcomes.

RESULTS

Perceived SDM was negatively associated with negative affect and positively associated with positive affect, favorable perceptions of non-antibiotic treatments and providers, and self-efficacy to manage symptoms and obtain follow-up care. Patient affect and day-one outcomes were mediators between perceived SDM and retrospective self-efficacy two weeks post-visit.

CONCLUSION

The study illustrated the beneficial influence of patient perceived SDM on antibiotic stewardship in both short and long terms and elucidated the mechanisms through which the influence occurs.

PRACTICE IMPLICATIONS

SDM can be an effective strategy for primary care providers to improve patients' outcomes with URTI visits without prescribing unwarranted antibiotics.

Mental health recovery for people with schizophrenia in Southeast Asia: A systematic review

WHAT IS KNOWN ON THE SUBJECT?: Mental health recovery has become a more prevalent approach to empowering people with schizophrenia (PWS), especially in western countries. However, despite the benefits, there is a lack of evidence regarding its practice in developing countries such as Southeast Asian Countries. The optimal treatment for PWS has not yet been identified, since most mental health care is provided in hospital-based settings in Southeast Asia. Mental health treatment in Southeast Asia is highly influenced by cultural norms, values, and practices. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The findings highlight the importance of integrating cultural aspects into the treatment of people with schizophrenia. The sample of unique elements in Southeast Asian mental health recovery include using a close neighbour/cadre as social support and using religious activity to increase hope. Lack of government support, high level of employment, and stigma are the biggest barriers in the PWS recovery process. WHAT IS THE IMPLICATION FOR PRACTICE?: There is a research gap regarding the awareness and implementation of mental health recovery in psychiatric programs across the Southeast Asian region which likely impacts the effectiveness of the treatment. The review shows that little research has explored the concept of personal recovery in Southeast Asian Countries.

ABSTRACT

INTRODUCTION: Recovery has become an important approach used by mental health services around the world. Many mental health systems have taken steps to move towards more recovery-oriented practices and service delivery. Therefore, establishing recovery-oriented services in developing countries like those in the Southeast Asian region requires a detailed understanding of the cultural norms, values, and current mental health practices.

AIMS

To investigate the mental health practices that promote recovery, its barrier in Southeast Asia, and to determine if they align with the CHIME recovery model.

METHOD

Electronic databases MEDLINE, EMBASE, CINAHL, PsycINFO and SCOPUS, were searched [PROSPERO] (CRD42021227962). Peer-reviewed English language articles from 2004 to January 2021 were included. Methodological quality was assessed using the CASP checklist, and thematic synthesis of included studies was conducted.

RESULTS

Thirty-one studies met inclusion criteria. Several themes illustrated mental health recovery services and the current obstacles identified in South-east Asian studies. Connection includes peer support and support groups, relationship status, and limited opportunities to become involved in the community. Hope is found in cultural concepts of hope, stimulating recovery through mental health programs, whilst lack of knowledge and education are the main barriers. Ethnicity is linked to a high level of stigma, but ethnicity also builds identity. Meaning and spirituality manifest in religious activities as the catalyst for recovery. Finally, the opposite of Empowerment is seen in the tendency of people with schizophrenia to remain in a passive position. Further barriers to empowerment are unemployment and a lack of social support.

DISCUSSION

In Southeast Asia, the elements of culture, religiosity, and communality are essential to mental health recovery. The obstacles to recovery are relate to human rights, social support, family involvement, and continuity of care.

IMPLICATIONS FOR PRACTICE

This review explores the concept of mental health recovery for people who are experiencing psychosis and living in Southeast Asian countries. The evidence may contribute to the further development of mental health programs in this region.

Shared decision-making interventions for people with mental health conditions

BACKGROUND

One person in every four will suffer from a diagnosable mental health condition during their life. Such conditions can have a devastating impact on the lives of the individual and their family, as well as society.  International healthcare policy makers have increasingly advocated and enshrined partnership models of mental health care. Shared decision-making (SDM) is one such partnership approach. Shared decision-making is a form of service user-provider communication where both parties are acknowledged to bring expertise to the process and work in partnership to make a decision.  This review assesses whether SDM interventions improve a range of outcomes. This is the first update of this Cochrane Review, first published in 2010.

OBJECTIVES

To assess the effects of SDM interventions for people of all ages with mental health conditions, directed at people with mental health conditions, carers, or healthcare professionals, on a range of outcomes including: clinical outcomes, participation/involvement in decision-making process (observations on the process of SDM; user-reported, SDM-specific outcomes of encounters), recovery, satisfaction, knowledge, treatment/medication continuation, health service outcomes, and adverse outcomes.

SEARCH METHODS

We ran searches in January 2020 in CENTRAL, MEDLINE, Embase, and PsycINFO (2009 to January 2020). We also searched trial registers and the bibliographies of relevant papers, and contacted authors of included studies.  We updated the searches in February 2022. When we identified studies as potentially relevant, we labelled these as studies awaiting classification.

SELECTION CRITERIA

Randomised controlled trials (RCTs), including cluster-randomised controlled trials, of SDM interventions in people with mental health conditions (by Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD) criteria).

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently screened citations for inclusion, extracted data, and assessed risk of bias. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

This updated review included 13 new studies, for a total of 15 RCTs. Most participants were adults with severe mental illnesses such as schizophrenia, depression, and bipolar disorder, in higher-income countries. None of the studies included children or adolescents.  Primary outcomes We are uncertain whether SDM interventions improve clinical outcomes, such as psychiatric symptoms, depression, anxiety, and readmission, compared with control due to very low-certainty evidence. For readmission, we conducted subgroup analysis between studies that used usual care and those that used cognitive training in the control group. There were no subgroup differences. Regarding participation (by the person with the mental health condition) or level of involvement in the decision-making process, we are uncertain if SDM interventions improve observations on the process of SDM compared with no intervention due to very low-certainty evidence. On the other hand, SDM interventions may improve SDM-specific user-reported outcomes from encounters immediately after intervention compared with no intervention (standardised mean difference (SMD) 0.63, 95% confidence interval (CI) 0.26 to 1.01; 3 studies, 534 participants; low-certainty evidence). However, there was insufficient evidence for sustained participation or involvement in the decision-making processes. Secondary outcomes We are uncertain whether SDM interventions improve recovery compared with no intervention due to very low-certainty evidence. We are uncertain if SDM interventions improve users' overall satisfaction. However, one study (241 participants) showed that SDM interventions probably improve some aspects of users' satisfaction with received information compared with no intervention: information given was rated as helpful (risk ratio (RR) 1.33, 95% CI 1.08 to 1.65); participants expressed a strong desire to receive information this way for other treatment decisions (RR 1.35, 95% CI 1.08 to 1.68); and strongly recommended the information be shared with others in this way (RR 1.32, 95% CI 1.11 to 1.58). The evidence was of moderate certainty for these outcomes. However, this same study reported there may be little or no effect on amount or clarity of information, while another small study reported there may be little or no change in carer satisfaction with the SDM intervention. The effects of healthcare professional satisfaction were mixed: SDM interventions may have little or no effect on healthcare professional satisfaction when measured continuously, but probably improve healthcare professional satisfaction when assessed categorically. We are uncertain whether SDM interventions improve knowledge, treatment continuation assessed through clinic visits, medication continuation, carer participation, and the relationship between users and healthcare professionals because of very low-certainty evidence. Regarding length of consultation, SDM interventions probably have little or no effect compared with no intervention (SDM 0.09, 95% CI -0.24 to 0.41; 2 studies, 282 participants; moderate-certainty evidence). On the other hand, we are uncertain whether SDM interventions improve length of hospital stay due to very low-certainty evidence. There were no adverse effects on health outcomes and no other adverse events reported.

AUTHORS' CONCLUSIONS

This review update suggests that people exposed to SDM interventions may perceive greater levels of involvement immediately after an encounter compared with those in control groups. Moreover, SDM interventions probably have little or no effect on the length of consultations.  Overall we found that most evidence was of low or very low certainty, meaning there is a generally low level of certainty about the effects of SDM interventions based on the studies assembled thus far. There is a need for further research in this area.

Moving shared decision-making forward in Iran

Although there have been breakthroughs in patients' rights and informed consent legislation in Iran during the last few years, there is still no policy regarding shared decision-making (SDM). Besides, SDM training and clinical implementation initiatives remain scarce within the country. In this article, we aim to provide an update on the current state of SDM in Iran and discuss future directions. Lastly, we propose an SDM model adapted to the Iranian context, through a consensus-building process with Iranian clinicians and SDM experts, to assist in its implementation in a culturally sensitive manner.

Personalized values in life as point of interaction with the world: Developmental/neurobehavioral basis and implications for psychiatry

Behavioral neuroscience has dealt with short-term decision making but has not defined either daily or longer-term life actions. The individual brain interacts with the society/world, but where that point of action is and how it interacts has never been an explicit scientific question. Here, we redefine value as an intrapersonal driver of medium- and long-term life actions. Value has the following three aspects. The first is value as a driving force of action, a factor that commits people to take default-mode or intrinsic actions daily and longer term. It consists of value memories based on past experiences, and a sense of values, the source of choosing actions under uncertain circumstances. It is also a multilayered structure of unconscious/automatic and conscious/self-controlled. The second is personalized value, which focuses not only on the value of human beings in general, but on the aspect that is individualized and personalized, which is the foundation of diversity in society. Third, the value is developed through the life course. It is necessary to clarify how values are personalized through the internalization of parent-child, peer, and social experiences through adolescence, a life stage almost neglected in neuroscience. This viewpoint describes the brain and the behavioral basis of adolescence in which the value and its personalization occur, and the importance of this personalized value as a point of interaction between the individual brain and the world. Then the significance of personalized values in psychiatry is discussed, and the concept of values-informed psychiatry is proposed.

How can we best help this patient? Exploring mental health therapists’ reflections on medication-free care for patients with psychosis in Norway

Background

Since 2015, Norwegian Regional Health Authorities have followed new government policy and gradually implemented medication-free services for patients with psychosis. The aim of this qualitative study was to explore the tension between policy and practice, and how health care workers in Bergen reflect on their role in implementing medication-free treatment.

Methods

We performed three focus group discussions including 17 therapists working within medication free services, asking about their experiences with this new treatment program. We used Systematic Text Condensation for data analysis. The findings were discussed using Michael Lipsky’s theoretical framework on the role public health workers play in policy implementation.

Findings

Following Norway’s new policy was challenging for the therapists in our study, particularly balancing a patient’s needs with treatment guidelines, the legal framework and available resources. Therapists had an overarching wish to help patients through cooperation and therapeutic alliance, but their alliance was sometimes fragile, and the therapists worried about patients’ conditions worsening.

Conclusions

Democratization of treatment choices, with the aim of empowering patients in mental health care, challenges the level of professional discretion given that patients and therapists might have conflicting goals. Balancing the desire to help, professional responsibility, the perceived lack of resources, and certain patient choices created conditions that can leave therapists feeling disempowered in and alienated from their work.

Trial registration: N/A.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13033-022-00529-8.

Health professionals' perspectives on shared decision-making in secondary mental healthcare: a qualitative study

BACKGROUND

Shared decision-making is widely recommended but has not been widely implemented in mental healthcare. There is a lack of direct evidence about health professionals' perspectives on shared decision-making in Asian cultures, particularly Taiwan. Such knowledge is of key importance to facilitate shared decision-making. Therefore, further studies are needed to clarify this issue.

AIM

To explore health professionals' perspectives of shared decision-making in secondary mental healthcare in Taiwan.

METHOD

Qualitative semi-structured interviews were used. Purposive sampling was applied to recruit health professionals. Data were analysed using thematic analysis.

RESULTS

Twenty-four health professionals were recruited. This study found the absence of shared decision-making was acceptable to them. Barriers included: powerful status of health professionals and families, patients with impaired decisional ability due to mental illness, health professionals' lack of understanding of shared decision-making, and insufficient time. Facilitators included: awareness of patients' right to autonomy and understanding of potential benefits of shared decision-making.

CONCLUSIONS

The study found that the absence of patient involvement in decision-making was widely reported. A discussion of barriers and facilitators is provided. Barriers and facilitators are highlighted to build a foundation for implementing shared decision-making in the future.

A Systematic Review of Shared Decision-Making Interventions for Service Users With Serious Mental Illnesses: State of the Science and Future Directions

OBJECTIVE

Shared decision making (SDM) is a health communication model that may be particularly appealing to service users with serious mental illnesses, who often want to be involved in making decisions about their mental health care. The purpose of this systematic review was to describe and evaluate participant, intervention, methodological, and outcome characteristics of SDM intervention studies conducted within this population.

METHODS

Systematic searches of the literature through April 2020 were conducted and supplemented by hand searching of reference lists of identified studies. A total of 53 independent studies of SDM interventions that were conducted with service users with serious mental illnesses and that included a quantitative or qualitative measure of the intervention were included in the review. Data were independently extracted by at least two authors.

RESULTS

Most studies were conducted with middle-age, male, White individuals from Western countries. Interventions fell into the following categories: decision support tools only, multicomponent interventions involving decision support tools, multicomponent interventions not involving decision support tools, and shared care planning and preference elicitation interventions. Most studies were randomized controlled trials with sufficient sample sizes. Outcomes assessed were diverse, spanning decision-making constructs, clinical and functional, treatment engagement or adherence, and other constructs.

CONCLUSIONS

Findings suggest important future directions for research, including the need to evaluate the impact of SDM in special populations (e.g., young adults and racial-ethnic minority groups); to expand interventions to a broader array of decisions, users, and contexts; and to establish consensus measures to assess intervention effectiveness.

Practitioner opinions of crisis plans within early intervention in psychosis services: A mixed methods study

The efficacy of crisis planning in mental health services is contested. As recovery and self-management are core to Early Intervention in Psychosis (EIP) services and the Care Programme Approach (CPA), the views of EIP practitioners of the most useful aspects of crisis planning can inform this vital aspect of practice. We conducted a mixed methods study using a national cross-sectional survey (n = 70) and semi-structured interviews (n = 12) with EIP practitioners in England in 2019. Data were analysed using non-parametric tests and thematic analysis. A Joint Crisis Plan (JCP) template was used as a benchmark to judge current practice by (Sutherby et al., 1999; Henderson et al., 2004; Thornicroft et al., 2013). The most useful crisis plan themes identified by practitioners included early warning signs, triggers and helpful treatments, although not all elements were considered useful. Additionally, the interviews identified that collaboration with clients, carers and other services; personalisation; and self-management were all considered important in effective crisis planning. The practitioners also identified barriers to effective crisis planning, such as the electronic records system, lack of time and lack of available service provision. The research highlighted the important aspects of EIP and was significant in impacting the service and wider EIP network further. While crisis planning is a significant part of EIP, it does not appear to be consistently applied in practice. Fully implementing collaborative crisis planning in EIP services may require changes to policy, practice and local systems to ensure that crisis planning is as effective as possible.

NICE shared decision making guidelines and mental health: challenges for research, practice and implementation

The National Institute for Health and Care Excellence (NICE) initiated an ambitious effort to develop the first shared decision making guidelines. The purpose of this commentary is to identify three main concerns pertaining to the new published guidelines for shared decision making research, practice, implementation and cultural differences in mental health.

Psychiatry in the Digital Age: A Blessing or a Curse?

Social distancing and the shortage of healthcare professionals during the COVID-19 pandemic, the impact of population aging on the healthcare system, as well as the rapid pace of digital innovation are catalyzing the development and implementation of new technologies and digital services in psychiatry. Is this transformation a blessing or a curse for psychiatry? To answer this question, we conducted a literature review covering a broad range of new technologies and eHealth services, including telepsychiatry; computer-, internet-, and app-based cognitive behavioral therapy; virtual reality; digital applied games; a digital medicine system; omics; neuroimaging; machine learning; precision psychiatry; clinical decision support; electronic health records; physician charting; digital language translators; and online mental health resources for patients. We found that eHealth services provide effective, scalable, and cost-efficient options for the treatment of people with limited or no access to mental health care. This review highlights innovative technologies spearheading the way to more effective and safer treatments. We identified artificially intelligent tools that relieve physicians from routine tasks, allowing them to focus on collaborative doctor-patient relationships. The transformation of traditional clinics into digital ones is outlined, and the challenges associated with the successful deployment of digitalization in psychiatry are highlighted.

Family Group Conferences as a Shared Decision-Making Strategy in Adults Mental Health Work

Family Group conferences (FGC) provide a system by which a client and their family reach jointly key intervention decisions, from a number of options proposed by professionals. The system originated in child protection social work. Conceptually FGC is based on the assumption that the family is potentially a supportive social system for an individual with a variety of difficulties, including mental ill health. Reaching a family network agreement can lead to long term positive outcomes in self-confidence and social relationships. This strategy of shared decision making (SDM) can re-unite the family around the client's needs and wishes. It fits well the strengths based and the recovery-oriented approaches to mental ill health. Methodologically, this article provides a narrative review of existing empirical research about FGC in the context of adult mental health. In addition, two community case studies consisting of videos of a mother experiencing mental ill health and a daughter are analysed in terms of their subjective experience of the FGCs they were involved in, and looks at both the process and the outcomes of FGCs. The key findings demonstrate a high level of satisfaction from participating in the FGC meeting, while the evidence pertaining to the outcomes is inconclusive. Only very few systematic review studies, or comparative studies of different approaches to family decision making, exist, and there are no studies which offer cost effectiveness analysis. Discussion: The observed gap between the satisfaction from the process of FGC by the participants vs. the inconclusive outcomes relates to the implementation phase, in which the decisions made by the family are tested. Evaluating FGC processes and outcomes is complex. A systematic and comprehensive research of the implementation process is missing at this stage. In conclusion, FGC is a promising strategy of SDM in adult mental health. The research evidence indicates the need for further exploration of its implementation process, evaluative methodology and methods.

"I think that everybody should be involved": What informs experiences of shared decision-making in supporting people living with schizophrenia spectrum disorders?

OBJECTIVE

To identify facilitators and barriers associated with shared decision-making (SDM) in Australians affected by schizophrenia spectrum disorders.

METHODS

We surveyed 78 participants with lived experience and held 12 in-depth interviews, including seven carers.

RESULTS

A multiple linear regression model identified two independent variables significantly associated with degree of SDM: Personal Wellbeing Index scores (ß = .32, t = 3.3, p = .001) and treatment satisfaction rating (ß =.46, t = 4.7, p < .001), indicating that higher personal wellbeing and higher treatment satisfaction were significantly related to higher degree of SDM. Two key themes were identified through interview data: a complex pathway to SDM and impacts on wellbeing. Sub-themes included: self and carer characteristics, holistic care, education and knowledge, and power balance. Generally, participants reported a desire for SDM, noting that healthcare professionals inconsistently involve them in treatment decisions.

CONCLUSION

SDM is associated with treatment satisfaction and personal wellbeing among people living with schizophrenia spectrum disorders, but can be difficult to implement due to a range of challenges.

PRACTICE IMPLICATIONS

There is a need to improve SDM in this population by decreasing stigma and discrimination, balancing power in consultations, increasing access to holistic treatment, and improving education and knowledge.

Correlates of preferring a passive role in decision-making among patients with schizophrenia or bipolar disorder

OBJECTIVE

To assess the factors associated with the persistence of clinician-led style in the therapeutic relationship in cases of serious mental illness, and the conditioning factors that the patients identify as determinants of their health.

METHOD

Assessment of preferences in the decision-making process and health-related control locus of 107 outpatients with DSM-5 diagnosis of schizophrenia or bipolar disorder. Demographic and clinical information was also obtained through review of available records and using several scales.

RESULTS

64.4 % patients preferred to adopt a passive role in the therapeutic relationship. In the multivariate analysis, the preference of playing a passive role in the decision-making process was significantly associated with the elderly, being disabled, or the view that one's health depends on doctors (AUC ROC value: 0.80).

CONCLUSIONS

Patients with severe mental illness more frequently preferred a passive role in the decision-making process. We found several factors associated with a preference for the "expert role" model.

PRACTICE IMPLICATIONS

The identified factors may permit care to be tailored to the most probable expectations as regard decision-making. Since the populations concerned may be vulnerable and suffer inequalities in the provision of health services, promoting participation in the care process could help improve clinical parameters ethically.

Efficacy of interventions to reduce coercive treatment in mental health services: umbrella review of randomised evidence

BACKGROUND

Coercive treatment comprises a broad range of practices, ranging from implicit or explicit pressure to accept certain treatment to the use of forced practices such as involuntary admission, seclusion and restraint. Coercion is common in mental health services.

AIMS

To evaluate the strength and credibility of evidence on the efficacy of interventions to reduce coercive treatment in mental health services. Protocol registration: https://doi.org/10.17605/OSF.IO/S76T3.

METHOD

Systematic literature searches were conducted in MEDLINE, Cochrane Central, PsycINFO, CINAHL, Campbell Collaboration, and Epistemonikos from January 2010 to January 2020 for meta-analyses of randomised studies. Summary effects were recalculated using a common metric and random-effects models. We assessed between-study heterogeneity, predictive intervals, publication bias, small-study effects and whether the results of the observed positive studies were more than expected by chance. On the basis of these calculations, strength of associations was classified using quantitative umbrella review criteria, and credibility of evidence was assessed using the GRADE approach.

RESULTS

A total of 23 primary studies (19 conducted in European countries and 4 in the USA) enrolling 8554 participants were included. The evidence on the efficacy of staff training to reduce use of restraint was supported by the most robust evidence (relative risk RR = 0.74, 95% CI 0.62-0.87; suggestive association, GRADE: moderate), followed by evidence on the efficacy of shared decision-making interventions to reduce involuntary admissions of adults with severe mental illness (RR = 0.75, 95% CI 0.60-0.92; weak association, GRADE: moderate) and by the evidence on integrated care interventions (RR = 0.66, 95% CI 0.46-0.95; weak association, GRADE: low). By contrast, community treatment orders and adherence therapy had no effect on involuntary admission rates.

CONCLUSIONS

Different levels of evidence indicate the benefit of staff training, shared decision-making interventions and integrated care interventions to reduce coercive treatment in mental health services. These different levels of evidence should be considered in the development of policy, clinical and implementation initiatives to reduce coercive practices in mental healthcare, and should lead to further studies in both high- and low-income countries to improve the strength and credibility of the evidence base.

The clinical characterization of the patient with primary psychosis aimed at personalization of management

The current management of patients with primary psychosis worldwide is often remarkably stereotyped. In almost all cases an antipsychotic medica-tion is prescribed, with second-generation antipsychotics usually preferred to first-generation ones. Cognitive behavioral therapy is rarely used in the vast majority of countries, although there is evidence to support its efficacy. Psychosocial interventions are often provided, especially in chronic cases, but those applied are frequently not validated by research. Evidence-based family interventions and supported employment programs are seldom implemented in ordinary practice. Although the notion that patients with primary psychosis are at increased risk for cardiovascular diseases and diabetes mellitus is widely shared, it is not frequent that appropriate measures be implemented to address this problem. The view that the management of the patient with primary psychosis should be personalized is endorsed by the vast majority of clinicians, but this personalization is lacking or inadequate in most clinical contexts. Although many mental health services would declare themselves "recovery-oriented", it is not common that a focus on empowerment, identity, meaning and resilience is ensured in ordinary practice. The present paper aims to address this situation. It describes systematically the salient domains that should be considered in the characterization of the individual patient with primary psychosis aimed at personalization of management. These include positive and negative symptom dimensions, other psychopathological components, onset and course, neurocognition and social cognition, neurodevelopmental indicators; social functioning, quality of life and unmet needs; clinical staging, antecedent and concomitant psychiatric conditions, physical comorbidities, family history, history of obstetric complications, early and recent environmental exposures, protective factors and resilience, and internalized stigma. For each domain, simple assessment instruments are identified that could be considered for use in clinical practice and included in standardized decision tools. A management of primary psychosis is encouraged which takes into account all the available treatment modalities whose efficacy is supported by research evidence, selects and modulates them in the individual patient on the basis of the clinical characterization, addresses the patient's needs in terms of employment, housing, self-care, social relationships and education, and offers a focus on identity, meaning and resilience.

Chinese mental health professionals' perceptions of shared decision-making regarding people diagnosed with schizophrenia: A qualitative study

The implementation of shared decision-making regarding people diagnosed with schizophrenia is limited, although it is reported to have a positive impact on improving treatment adherence, therapeutic relationships and saving medical costs. The successful implementation of it is mainly dependent on the active engagement of mental health professionals. This study aims to identify mental health professionals' perceptions of shared decision-making regarding people diagnosed with schizophrenia in collectivist cultures such as Chinese culture. A qualitative descriptive approach was used, involving ten individual interviews with psychiatrists and four focus groups with twenty-three mental health nurses from the psychiatry department of a tertiary hospital in mainland China. An inductive thematic approach was used to analyze the data. Two main themes with five subthemes generated: willingness to engage in shared decision-making and perceiving shared decision-making as unachievable. The last theme included five subthemes: (i) deference to authority, (ii) tension between family decision-making and patient autonomy, (iii) uncertainty of trusting therapeutic relationships, (iv) implicit persuasion and (v) insufficient consultation time. Patients often lack opportunity and support to engage in decision-making. Mental health nurses in other countries need to be aware that Chinese patients and patients with a similar background are not knowledgeable about or value shared decision-making to the extent that other countries might. They need to evaluate and support them, including encouraging them to engage in decision-making as well as providing appropriate information. Mental health nurses need to collaborate with patients and their families to achieve patient-centred care when family involvement is expected.

Challenges to Employing Shared Decision Making With Adults Under Community Supervision Who Have a Mental Illness

Adults under community corrections supervision and who have a mental illness (MI) are expected to comply with conditions of release which often include involvement with supportive social services. The rates of technical violation, arrest, and incarceration that result from failure to comply with these mandates are exceedingly high. Shared decision making among officer-supervisors and client-supervisees is a promising approach to promote engagement in community corrections services among supervisees who have MI. This paper reviews recent research on shared decision making and identifies three barriers to its implementation in this context: (1) a lack of role clarity, (2) a predilection for risk avoidance, and (3) stigma toward supervisees. Empirically supported recommendations are suggested to aid in overcoming these obstacles, facilitate shared decision making, and promote recovery among this population: (1) unification of supervisor rehabilitative and public safety roles, (2) maximizing opportunities for self-determination through low-stakes events and/or enhancement of supervisee strengths and capabilities, and (3) supervisor training in principles of mental health recovery.

Barriers and Enablers to Shared Decision Making in Psychiatric Medication Management: A Qualitative Investigation of Clinician and Service Users' Views

Shared decisionmaking (SDM) is a recommended health communication approach in mental health settings. Yet, implementation of SDM in psychiatric consultations discussing medication management is challenging. Insufficient attention has been given to examine the views of both clinicians and service users together about the experiences of SDM in psychiatric medication management. The purpose of this paper is to examine the views of service users, community psychiatric nurses, and psychiatrists about enablers and barriers of SDM. A thematic analysis of 30 semi structured interviews with service users, psychiatrists, and community psychiatric nurses, in a community mental health team in the UK, was conducted. A service user advisory group was involved in all phases of the research cycle, including data collection, analysis, and dissemination. The results offer a detailed contextualized account of how medication decisions are made. For psychiatrists and service user participants SDM is seen as a way of enhancing service users' engagement in and control over treatment decisions. While psychiatrists value the transactional benefits of SDM, service user participants and psychiatric nurses conceptualize SDM as a long-term endeavor embedded within therapeutic partnerships. For service users these partnerships mitigate acknowledged problems of feeling unable to be fully involved during times of crisis. This study identified a range of barriers and facilitators to SDM concerning psychiatric medications from the lived experience of service users and the professional experience of clinicians. Furthermore, it indicates new potential intervention points to support SDM in psychiatric medication decisions.

Digital Shared Decision-Making Interventions in Mental Healthcare: A Systematic Review and Meta-Analysis

Background: Shared decision-making (SDM) in mental healthcare has received increased attention as a process to reinforce person-centered care. With the rapid development of digital health technology, researchers investigate how digital interventions may be utilized to support SDM. Despite the promise of digital interventions to support SDM, the effect of these in mental healthcare has not been evaluated before. Thus, this paper aims to assess the effect of SDM interventions complimented by digital technology in mental healthcare. Objective: The objective of this review was to systematically examine the effectiveness of digital SDM interventions on patient outcomes as investigated in randomized trials. Methods: We performed a systematic review and meta-analysis of randomized controlled trials on digital SDM interventions for people with a mental health condition. We searched for relevant studies in MEDLINE, PsycINFO, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials. The search strategy included terms relating to SDM, digital systems, mental health conditions, and study type. The primary outcome was patient activation or indices of the same (e.g., empowerment and self-efficacy), adherence to treatment, hospital admissions, severity of symptoms, and level of functioning. Secondary outcomes were satisfaction, decisional conflict, working alliance, usage, and adherence of medicine; and adverse events were defined as harms or side effects. Results: Sixteen studies met the inclusion criteria with outcome data from 2,400 participants. Digital SDM interventions had a moderate positive effect as compared with a control condition on patient activation [standardized mean difference (SMD) = 0.56, CI: 0.10, 1.01, p = 0.02], a small effect on general symptoms (SMD = -0.17, CI: -0.31, -0.03, p = 0.02), and working alliance (SMD = 0.21, CI: 0.02, 0.41, p = 0.03) and for improving decisional conflict (SMD = -0.37, CI: -0.70, -0.05, p = 0.02). No effect was found on self-efficacy, other types of mental health symptoms, adverse events, or patient satisfaction. A total of 39 outcomes were narratively synthesized with results either favoring the intervention group or showing no significant differences between groups. Studies were generally assessed to have unclear or high risk of bias, and outcomes had a Grading of Recommendations Assessment, Development and Evaluation (GRADE) rating of low- or very low-quality evidence. Conclusions: Digital interventions to support SDM may be a promising tool in mental healthcare; but with the limited quality of research, we have little confidence in the estimates of effect. More quality research is needed to further assess the effectiveness of digital means to support SDM but also to determine which digital intervention features are most effective to support SDM. Systematic Review Registration: PROSPERO, identifier CRD42020148132.

Shared Decision Making With Young People at Ultra High Risk of Psychotic Disorder

Introduction: While the majority of young people who meet the criteria for being considered at increased risk of psychosis do not go on to develop a psychotic disorder, young people are currently being identified and treated in early intervention services. Ethical concerns have been raised concerning the decision about whether or not to provide treatment, and if so, what type of treatment. This study sought to support young people themselves to make these decisions with support from their clinician through a shared decision-making approach, facilitated by an online decision aid. Methods: This project used the International Patient Decision Aid Standards (IPDAS) to guide the development and piloting of an online decision aid across two phases: (1) qualitative, semi-structured focus groups with young people who were past clients and clinicians from an early psychosis service; and (2) pilot testing of the decision aid with clinicians and young people who were current clients to finalize the development. Results: Issues discussed by clinicians in the focus group were grouped into three main areas: (1) engagement phase; (2) assessment and priorities for treatment; and (3) initial and ongoing decision making. Clients focused on the context in which the decisions were made, including as they experienced initial feelings of resistance, and then acceptance of efforts made to describe and treat their mental health challenges. Clients highlighted the need for collaboration between themselves and their clinician, and the need to be equipped with the knowledge and tools to take care of themselves. These focus group data were used to refine the online decision aid. Pilot testing revealed that while it was overall useful and relevant, important limitations were noted by both clients and clinicians. Discussion: The use of a decision aid to facilitate shared decision making (SDM) in this area is feasible and has utility for both clients and clinicians. Use of such a tool can help to address the need to uphold the rights of young people as decision makers about their own care. Future efforts should embed decision aids within complex SDM interventions, and research to understand issues relating to implementation of these interventions.

Shared Decision-Making: An Autoethnography About Service User Perspectives in Making Choices About Mental Health Care and Treatment

Shared decision-making (SDM) between mental health medication prescribers and service users is a central pillar in the recovery approach, because it supports people experiencing mental ill-health to explore their care and treatment options to promote their well-being and to enable clinicians to gain knowledge of the choices the service user prefers. SDM is receiving increasing recognition both in the delivery of physical and mental health services; and as such, is of significance to current practice. As an expert-by-experience with over 30 years of receiving mental health treatment, I have made many choices about taking medication and accessing other forms of support. The experiences of SDM have been variable over my career as a service user: both encounters when I have felt utterly disempowered and interactions when I have led decision-making process based on my expertise-by-experience. In this article, I recount two experiences of exploring care and treatment options: firstly, a discharge planning meeting; and secondly, the choice to take medication over the long-term, despite the side effects. The article will explore both opportunities and barriers to effective shared decision-making, as well as skills and processes to facilitate this approach. The need to balance power between service users and professionals in this interaction is highlighted, including the need to respect expertise built on lived experience, alongside that of clinical expertise. This narrative is framed within an autoethnographic approach which allows me to contextualize my personal experiences in the wider environment of mental health care and support.

Shared Decision-making in Orthopaedic Surgery

Shared decision-making (SDM) is the process by which the physician and the patient collaborate to arrive at the evidence-based treatment that best aligns with the patient's individual goals of care. The implementation of SDM practices is especially important when an invasive surgical procedure is among the treatment options. Ideally, the variation in the patient treatment choice would mirror the variability in patient goals rather than variation in a physician's ability to communicate effectively. Potentially aiding in these communication efforts, decision aids are tools gaining popularity for their ability to help physicians facilitate the SDM process with patients. This article is intended to give the practicing orthopaedic surgeon an understanding of the concept of SDM and how it can improve physician-patient communication. We will explore the key elements of SDM, attendant benefits, indications, and barriers to implementation and propose steps to begin the incorporation of SDM into practice.

Perspective on medication decisions following remission from first-episode psychosis

While antipsychotics (APs) could provide rapid relief of positive symptoms in psychotic disorders, their usage is often associated with side effects, stigma and inconveniences. For these and other reasons, many psychosis patients, particularly those of first-episode psychosis (FEP) in remission, wish to discontinue maintenance treatment. The current review aims to discuss the strategies of AP treatment following remission from FEP, with particular emphasis on the evaluation of outcomes following AP discontinuation. Upon review of relevant literature, three potential strategies are put forth for treatment-responsive, remitted FEP patients: a) life-long maintenance treatment, b) AP discontinuation during second year of treatment, or c) AP discontinuation after three years of treatment. In theory, the first strategy presents the safest option for maximal symptom control. However, a rigorous RCT indicates that if AP discontinuation is to be attempted, the third strategy best prevents poor long-term clinical outcomes. Further data is needed to address the costs and benefits of each treatment strategy, compare AP-free patients with those on different types of APs, as well as explore even longer-term outcomes.

Shared decision making, aggression, and coercion in inpatients with schizophrenia

Background

The present study aimed at answering three research questions: (a) Does shared decision making (SDM) yield similar effects for patients with involuntary admission or incidents of aggression compared to patients with voluntary admission or without incidents of aggression? (b) Does SDM reduce the number of patients with incidents of aggression and the use of coercive measures? (c) Does the use of coercion have a negative impact on patients’ perceived involvement in decision making?

Methods

We used data from the cluster-randomized SDM-PLUS trial in which patients with schizophrenia or schizoaffective disorder in 12 acute psychiatric wards of 4 German psychiatric hospitals either received an SDM-intervention or treatment as usual. In addition, data on aggression and coercive measures were retrospectively obtained from patients’ records.

Results

The analysis included n = 305 inpatients. Patient aggression as well as coercive measures mostly took place in the first days of the inpatient stay and were seldom during the study phase of the SDM-PLUS trial.

Patients who had been admitted involuntarily or showed incidents of aggression profited similarly from the intervention with regard to perceived involvement, adherence, and treatment satisfaction compared to patients admitted voluntarily or without incidents of aggression. The intervention showed no effect on patient aggression and coercive measures. Having previously experienced coercive measures did not predict patients’ rating of perceived involvement.

Conclusion

Further research should focus on SDM-interventions taking place in the very first days of inpatients treatment and potential beneficial long effects of participatory approaches that may not be measurable during the current inpatient stay.

Co-creating a process of user involvement and shared decision-making in coordinated care planning with users and caregivers in social services

Purpose

Although user participation and shared decision-making in formal statutory coordinated care planning are described as central, they remain to be implemented. The aim of this study is to explore how collaboration and shared decision-making in the social services can be realized in formal care planning activities with people with mental disabilities.

Methods

We conducted eight workshops with 12 users and 17 caregivers to investigate existing barriers to and possible solutions for participation in coordinated care planning.

Results

Workshop formats and techniques from participatory design generated rich research materials illustrating challenges currently experienced by users and caregivers in care planning work, as well as a large variety of solutions to these challenges. They also illustrated differences in how participation is understood and the conditions required to realize shared decision-making between users and caregivers.

Conclusions

An improved coordinated individual plan (CIP) process emerged, based on the active participation of users and caregivers. This process is a familiar and transparent process for users and caregivers, reflecting the needs and preferences of users at all stages. It requires careful preparation and collaboration with the users, as well as caregiver flexibility.

Qualitative analysis of clinicians' perspectives on the use of a computerized decision aid in the treatment of psychotic disorders

Background

Clinical decision aids are used in various medical fields to support patients and clinicians when making healthcare decisions. Few attempts have been made to implement such tools in psychiatry. We developed Treatment E-Assist (TREAT); a routine outcome monitoring based computerized clinical decision aid, which generates personalized treatment recommendations in the care of people with psychotic disorders. The aim of this study is to investigate how TREAT is used and evaluated by clinicians and how this tool can be improved.

Methods

Clinicians working with TREAT during a clinical trial were asked to participate in semi-structured interviews. The Unified Theory of Acceptance and Use of Technology (UTAUT) was used as a sensitizing theory to structure a part of the interview questions. The transcripts were analyzed using inductive thematic analysis to uncover the main themes.

Results

Thirteen clinicians (mean age: 49) of which eight psychiatrists and five nurse practitioners, participated in this study. Eight clinicians experienced TREAT as beneficial, whereas five experienced no additional benefits. Thematic analysis revealed five themes surrounding usage and evaluation of TREAT, views on TREAT’s graphic representation of routine outcome monitoring results, guideline based treatment recommendations, contextual factors, effects on patients and effects on shared decision-making. Performance and effort expectancy were perceived as high by clinicians. The facilitating conditions were optimal and perceived social influence was low.

Conclusion

This article presents a qualitative evaluation by clinicians of a computerized clinical decision aid in psychosis care. TREAT was viewed by most clinicians as beneficial during their consultations. The graphic representation of routine outcome monitoring results was well-appreciated and provided input to discuss treatment planning with patients. The treatment recommendations did not change most treatment decisions but supported clinical reasoning. However, some clinicians were unconvinced about TREAT’s benefits. The delivery, applicability and the availability of resources require improvement to increase TREAT’s efficacy. Not all patients responded well to TREAT but the observed facilitation of shared decision-making is promising. All four predictors of the Unified Theory of Acceptance and Use of Technology were positively evaluated by the majority of clinicians.

Health State Utility Values in Schizophrenia: A Systematic Review and Meta-Analysis

OBJECTIVES

Patient preferences are increasingly important in informing clinical and policy decisions. Health-state utility values (HSUVs) are quantitative measures of people's preferences over different health states. In schizophrenia, there is no clarity about HSUVs across the symptoms' severity spectrum. This meta-analysis aims to synthesize the literature on HSUVs in people with schizophrenia.

METHODS

We searched Medline, PsycInfo, Embase, EconLit, The Cochrane Library, and specialized databases. The studies reporting HSUVs in people with schizophrenia were selected and pooled in a random-effects meta-analysis. The primary outcome was the mean HSUV obtained from participants.

RESULTS

A total of 54 studies involving 87 335 participants were included. The pooled estimate using direct elicitation was a mean HSUV of 0.79 (95% CI: 0.70-0.88) for mild symptomatic states, 0.69 (95% CI: 0.54-0.85) in moderate states, and 0.34 (95% CI: 0.13-0.56) in severe states. Studies using indirect techniques resulted in a pooled mean HSUV of 0.73 (95% CI: 0.67-0.78) applying the EuroQol 5-dimension, 0.66 (95% CI: 0.62-0.71) in the Short-Form 6-dimension, and 0.59 (95% CI: 0.57-0.61) using the Quality of Well-Being scale. All the estimates resulted in considerable heterogeneity, partially reduced by meta-regression.

CONCLUSION

Our findings suggest that the severity of psychotic symptoms has an important effect on HSUVs in schizophrenia, with values mirroring patients with disabling physical conditions such as cancer and stroke. Decision makers should be aware of these results when including people's preferences in trials, models, and policy decisions.

A meta-review of literature reviews assessing the capacity of patients with severe mental disorders to make decisions about their healthcare

BACKGROUND

Determining the mental capacity of psychiatric patients for making healthcare related decisions is crucial in clinical practice. This meta-review of review articles comprehensively examines the current evidence on the capacity of patients with a mental illness to make medical care decisions.

METHODS

Systematic review of review articles following PRISMA recommendations. PubMed, Scopus, CINAHL and PsycInfo were electronically searched up to 31 January 2020. Free text searches and medical subject headings were combined to identify literature reviews and meta-analyses published in English, and summarising studies on the capacity of patients with serious mental illnesses to make healthcare and treatment related decisions, conducted in any clinical setting and with a quantitative synthesis of results. Publications were selected as per inclusion and exclusion criteria. The AMSTAR II tool was used to assess the quality of reviews.

RESULTS

Eleven publications were reviewed. Variability on methods across studies makes it difficult to precisely estimate the prevalence of decision-making capacity in patients with mental disorders. Nonetheless, up to three-quarters of psychiatric patients, including individuals with serious illnesses such as schizophrenia or bipolar disorder may have capacity to make medical decisions in the context of their illness. Most evidence comes from studies conducted in the hospital setting; much less information exists on the healthcare decision making capacity of mental disorder patients while in the community. Stable psychiatric and non-psychiatric patients may have a similar capacity to make healthcare related decisions. Patients with a mental illness have capacity to judge risk-reward situations and to adequately decide about the important treatment outcomes. Different symptoms may impair different domains of the decisional capacity of psychotic patients. Decisional capacity impairments in psychotic patients are temporal, identifiable, and responsive to interventions directed towards simplifying information, encouraging training and shared decision making. The publications complied satisfactorily with the AMSTAR II critical domains.

CONCLUSIONS

Whilst impairments in decision-making capacity may exist, most patients with a severe mental disorder, such as schizophrenia or bipolar disorder are able to make rational decisions about their healthcare. Best practice strategies should incorporate interventions to help mentally ill patients grow into the voluntary and safe use of medications.

Compulsory admissions and preferences in decision-making in patients with psychotic and bipolar disorders

PURPOSE

Participation in medical decisions and taking into account patients' values and preferences are especially important for psychiatric patients who may be treated against their will. The increasing rates of coercive measures and the underlying clinical, ethical, and legal issues highlight the need to examine their use in psychiatry. Although limited congruence in decision-making preferences may be on the basis of these coercive practices, this issue has not been adequately addressed. We explore the relationship between compulsory admissions and congruence in decision-making preferences in mental health settings.

METHODS

Cross-sectional study among 107 outpatients with DSM diagnoses of schizophrenia of bipolar disorder using the Control Preference Scale to assess congruence in decision-making experienced and preferred style. History of compulsory admissions was obtained through review of available records. Descriptive statistics and multivariate analyses were used.

RESULTS

70% of patients reported experiencing their preferred style of decision-making and 44% patients had history of compulsory admissions. These patients were more autonomous and preferred to take a more active role. The degree of congruence was lower in patients with previous compulsory admissions. The best predictors of compulsory admissions were not having a regular doctor and the unmatched participation preferences.

CONCLUSIONS

Patients who experienced a different level of participation in decision-making than desired more frequently had compulsory admissions. We propose to assess participation preferences each time a relevant treatment decision is about to be made and tailor care accordingly. We identified several factors leading to compulsory admissions that can be modified to prevent further coercive measures.

Discrepancy in Ratings of Shared Decision Making Between Patients and Health Professionals: A Cross Sectional Study in Mental Health Care

Background

A defined goal in mental health care is to increase the opportunities for patients to more actively participate in their treatment. This goal includes integrating aspects of user empowerment and shared decision-making (SDM) into treatment courses. To achieve this goal, more knowledge is needed about how patients and therapists perceive this integration.

Objective

To explore patient experiences of SDM, to describe differences between patient and therapist experiences, and to identify patient factors that might reduce SDM experiences for patients compared to the experiences of their therapists.

Methods

This cross-sectional study included 992 patients that had appointments with 267 therapists at Sørlandet Hospital, Division of Mental Health during a 1-week period. Both patients and therapists completed the CollaboRATE questionnaire, which was used to rate SDM experiences. Patients reported demographic and treatment-related information. Therapists provided clinical information.

Results

The analysis included 953 patient-therapist responder pairs that completed the CollaboRATE questionnaire. The mean SDM score was 80.7 (SD 20.8) among patients, and 86.6 (SD 12.1) among therapists. Females and patients that did not use medication for mental health disorders reported higher SDM scores than males and patients that used psychiatric medications (83.3 vs. 77.7; p < 0.001 and 82.6 vs. 79.8; p = 0.03, respectively). Patients with diagnoses involving psychotic symptoms reported lower SDM scores than all the other patients (66.8 vs. 82.3; p < 0.001). The probability that a patient would report lower SDM scores than their therapist was highest among patients that received involuntary treatment (OR 3.2, p = 0.02), patients with treatment durations longer than 2.2 years (OR 1.9, p = 0.001), and patients that required day care or in-patient care (OR 3.2, p = 0.01 and OR 3.2, p < 0.001, respectively).

Conclusion

We showed that both therapists and patients reported good SDM experiences in decisional situations, which indicated that SDM was implemented well. However, the SDM scores reported by in-patients and patients with prolonged or involuntary treatments were significantly lower than scores reported by their therapists. Our findings suggested that it remains a struggle in mental health care to establish a common understanding between patients and therapists in decisional processes regarding treatments for some patient groups.

Metacognitive Reflection and Insight Therapy: A Recovery-Oriented Treatment Approach for Psychosis

Recent research has suggested that recovery from psychosis is a complex process that involves recapturing a coherent sense of self and personal agency. This poses important challenges to existing treatment models. While current evidence-based practices are designed to ameliorate symptoms and skill deficits, they are less able to address issues of subjectivity and self-experience. In this paper, we present Metacognitive Insight and Reflection Therapy (MERIT), a treatment approach that is explicitly concerned with self-experience in psychosis. This approach uses the term metacognition to describe those cognitive processes that underpin self-experience and posits that addressing metacognitive deficits will aid persons diagnosed with psychosis in making sense of the challenges they face and deciding how to effectively manage them. This review will first explore the conceptualization of psychosis as the interruption of a life and how persons experience themselves, and then discuss in more depth the construct of metacognition. We will next examine the background, practices and evidence supporting MERIT. This will be followed by a discussion of how MERIT overlaps with other emerging treatments as well as how it differs. MERIT's capacity to engage patients who reject the idea that they have mental illness as well as cope with entrenched illness identities is highlighted. Finally, limitations and directions for future research are discussed.

Considering Health Literacy, Health Decision Making, and Health Communication in the Social Networks of Vulnerable New Mothers in Hawai'i: A Pilot Feasibility Study

Health literacy is understudied in the context of social networks. Our pilot study goal was to consider this research gap among vulnerable, low-income mothers of minority ethnic background in the state of Hawai'i, USA. Recruitment followed a modified snowball sampling approach. First, we identified and interviewed seven mothers ("egos") in a state-sponsored home visiting program. We then sought to interview individuals whom each mother said was part of her health decision-making network ("first-level alters") and all individuals whom the first-level alters said were part of their health decision-making networks ("second-level alters"). Health literacy was self-reported using a validated item. A total of 18 people were interviewed, including all mothers (n = 7), 35% of the first-level alters (n = 7/20), and 36% of the second-level alters (n = 4/11). On average, the mothers made health decisions with 2.9 people (range: 1-6); partners/spouses and mothers/mothers-in-law were most common. One mother had low health literacy; her two first-level alters also had low health literacy. Across the full sample, the average number of people in individuals' health decision networks was 2.5 (range: 0-7); 39% of those interviewed had low health literacy. This can inform the design of future studies and successful interventions to improve health literacy.

Implementing civic engagement within mental health services in South East Asia: a systematic review and realist synthesis of current evidence

INTRODUCTION

Civic engagement (CE) has the potential to transform mental health services and could be particularly important for low and middle-income countries (LMICs), which are rapidly developing to respond to the burden of poor mental health. Research from high income countries has found many challenges associated with the meaningful implementation of CE in practice, but this has been underexplored in LIMCS and in South East Asia (SEA) in particular.

METHODS

We completed a realist synthesis and systematic review of peer reviewed publications and grey literature to identify the context and actions which promote successful implementation of CE approaches in SEA. We used a theory-driven approach-realist synthesis-to analyse data and develop context-mechanism-outcome configurations that can be used to explain how civic engagement approaches operate in South East Asian contexts. We worked closely with patient and public representatives to guide the review from the outset.

RESULTS

Fifty-seven published and unpublished articles were included, 24 were evaluations of CE, including two Randomized Controlled Trials. The majority of CE interventions featured uptake or adaptation of Western models of care. We identified important cultural differences in the enactment of civic engagement in SEA contexts and four mechanisms which, alongside their contextual barriers and facilitators, can be used to explain how civic engagement produces a range of outcomes for people experiencing mental health problems, their families and communities. Our review illustrates how CE interventions can be successfully implemented in SEA, however Western models should be adapted to fit with local cultures and values to promote successful implementation. Barriers to implementation included distrust of services/outside agencies, stigma, paternalistic cultures, limited resource and infrastructure.

CONCLUSION

Our findings provide guidance for the implementation of CE approaches within SEA contexts and identify areas for further research. Due to the collectivist nature of many SEA cultures, and the impact of shared traumas on community mental health, CE might best be implemented at community level, with a focus on relational decision making.Registration This review is registered on PROSPERO: CRD42018087841.

Predictors of Outcome of Acute Partial Hospitalization: An Exploratory Study

To identify predictors of outcome of acute partial hospital (PH) treatment, patients admitted during a 15-month period were studied. Outcomes were change in the Behavior and Symptom Identification Scale and readmission within 30 days. Predictors were clinical and demographic variables obtained on all patients. Most patients (92%) improved during acute PH treatment, only 5% were readmitted, and average changes were moderate to large. However, many patients still had significant symptoms and behavioral problems at discharge, 56.5% missed at least 1 day, and 16.5% dropped out. Less acute improvement was associated with greater long-term impairment, worse treatment attendance, more previous treatment episodes, and fewer medication changes. Readmission was associated with less acute improvement and its predictors, and with nonattendance. In summary, acute outcome in PH was predicted by functioning more generally. Factors that affect patients' acute PH responses may also affect functioning in other areas. These findings suggest possible modifications of PH practices and programs.

Decisional conflict among adolescents and parents making decisions about genomic sequencing results

Genomic testing of adolescents is increasing yet engaging them in decision-making is not routine. We assessed decisional conflict in adolescents and a parent making independent decisions about actual genomic testing results and factors that influenced their choices. We enrolled 163 dyads consisting of an adolescent (13-17 years) not selected based on a specific clinical indication and one parent. After independently choosing categories of conditions to learn for the adolescent, participants completed the validated Decisional Conflict Scale and a survey assessing factors influencing their respective choices. Adolescents had higher decisional conflict scores than parents (15.6 [IQR:4.7-25.6] vs 9.4 [IQR:1.6-21.9]; P = .0007). Adolescents with clinically significant decisional conflict were less likely to choose to learn all results than adolescents with lower decisional conflict (19.6% vs 80.4%; P < .0001) and less likely to report their choices were influenced by actionability of results (33.3% vs 18.9%; P = .044) and feeling confident they can deal with the results (71.2% vs 91.9%; P = .0005). Our findings suggest higher decisional conflict in adolescents may influence the type and amount of genomic results they wish to learn. Additional research assessing decisional conflict and factors influencing testing choices among adolescents in clinical settings are required.

Practitioners' positive attitudes promote shared decision-making in mental health care

RATIONALE AND AIMS

There is a growing expectation of implementing shared decision making (SDM) in today's health care service, including mental health care. Traditional understanding of SDM may be too narrow to capture the complexity of treatments of mental health problems. Although the patients' contribution to SDM is well described, the contribution from the health care practitioners is less explored. Therefore, our aim was to explore the attitudes of practitioners in mental health care and the associations between practitioners' attitudes and SDM.

METHOD

We performed a cross-sectional study where practitioners reported their sharing and caring attitudes on the Patient-Practitioner Orientation Scale (PPOS) and age, gender, profession, and clinical working site. The patients reported SDM using the CollaboRate tool. We used a mixed effect model linking the data from each practitioner to one or more patients. We presented the findings and used them as background for a more philosophic reflection.

RESULTS

We included 312 practitioners with mean age 46.1 years. Of the practitioners, 60 held a medical doctors degree, 97 were psychologists, and 127 held a college degree in nursing, social science, or pedagogy. Female practitioners reported higher sharing (4.79 vs 4.67 [range 1-6], P = .04) and caring scores (4.77 vs 4.65 [range 1-6], P = .02) than males. The regression model contained 206 practitioners and 772 patients. We found a higher probability for the patient to report high SDM score if the practitioner reported higher sharing scores, and lower probability if the practitioner worked in ambulatory care.

CONCLUSIONS

SDM in mental health care is complex and demands multifaceted preparations from practitioners as well as patients. The practitioners' attitudes are not sufficiently explored using one instrument. The positive association between practitioners' patient-centred attitudes and SDM found in this study implies a relevance of the practitioners' attitudes for accomplishment of SDM processes in mental health care.

Shared decision-making in outpatients with mental disorders: Patients´ preferences and associated factors

RATIONALE, AIMS AND OBJECTIVES

Over the last years, traditional paternalistic model is being questioned. Shared Decision-Making (SDM) model has been proposed as a way to improve patient-physician interaction. Little is known to what extent people with severe mental illness want to be involved in decision-making process. This study evaluates their preferences about making clinical decisions and which variables influence these desires.

METHOD

One hundred seven patients with DSM diagnoses of bipolar disorder or schizophrenia and 100 Non Psychiatric Comparison (NPC) subjects recruited from mental health and primary care departments completed a self-reported questionnaire about preferences in decision-making process. Demographic and clinical information was obtained through review of available records and the Brief Psychiatric Rating Scale (BPRS).

RESULTS

Patients and NPCs differed as regards their preferences about their participation in medical decisions. NPCs were 18 times more likely to prefer options about their treatment and 2 times more likely to prefer to take medical decisions by their own than psychiatric patients. The best predictors of the preference of a SDM model were a lower BPRS global score and the absence of previous compulsory admissions.

CONCLUSIONS

Psychiatric patients more frequently preferred a passive role in the decision-making process. Interventions to promote SDM should be tailored to the values and needs of each patient because not everyone wants to participate to the same degree. We found several factors to take into account in patient engagement in SDM as these populations may be more vulnerable.

Feeling coerced during psychiatric hospitalization: Impact of perceived status of admission and perceived usefulness of hospitalization

INTRODUCTION

Perceived coercion is not exclusively related to the patient's legal status at admission. Patients are not always aware of their correct status and voluntary patients often report having felt coerced. Moreover, involuntary patients commonly report that their hospitalization was justified. The first goal was to disentangle the contribution of the legal and of the perceived status of admission in predicting perceived coercion. The second goal of this study was to investigate to which extent perception of the usefulness of the hospitalization affected perceived coercion.

MATERIAL AND METHODS

152 inpatients were interviewed about their knowledge of their legal status of admission, perceived need for hospitalization and subjective improvement. They completed the MacArthur's Admission Experience Survey and the Coercion Experience Scale.

RESULTS

6.6% of voluntarily admitted patients and 30.4% of involuntarily admitted patients reported an erroneous status of admission. 88.2% of voluntarily admitted patients and 44.7% of involuntarily admitted patients felt that they needed hospitalization during their stay. Levels of perceived coercion at admission and during hospitalization were mostly predicted by their perceived legal status. While involuntary patients frequently perceived the need for hospitalization and reported subjective improvement after admission, their perception of coercion markedly differed from voluntary patients.

CONCLUSIONS

Perceived coercion was marginally related to the legal admission status, which leaves room for interventions that reduce the patients' feeling of being coerced and avoid its negative effects. If many patients revised their belief on the need for and benefits of hospitalization during their stay, their perception of coercion was left partially unchanged.