Shared decision-making in ongoing outpatient psychiatric treatment

doi:10.1016/j.pec.2012.12.020

Patient Education and Counseling

Volume 91, Issue 3, June 2013, Pages 326-328

https://doi.org/10.1016/j.pec.2012.12.020 Get rights and content

Abstract

Objective

Research on patient involvement in decision-making in psychiatry has focused on first encounters. This study investigated what decisions are made, level of patient involvement and factors influencing patient involvement in ongoing outpatient visits.

Methods

72 visits conducted by 20 psychiatrists were video recorded. Patients had a diagnosis of depression or schizophrenia.

Results

On average, there was one medication related and one other decision per visit. Some psychiatrists involved patients more in decisions, as did female psychiatrists. Involvement was lower when patients had more negative symptoms.

Conclusion

Involvement in decision-making appears to be influenced by the individual psychiatrist and specific symptoms but not visit length.

Practice implications

It is noteworthy that patient involvement is not influenced by length of the visit given that this would be a barrier in busy clinical practice. The next step would be to identify the communication patterns of psychiatrists who involve patients more in decision-making.

Introduction

Shared decision-making (SDM) is widely recognised as the preferred approach to patient–clinician interaction in medical encounters and is supported by government policy [1]. The Department of Health paper ‘Equity and Excellence: Liberating the NHS’ [1] reflects the importance of SDM by stipulating that SDM should become the ‘norm’ in clinical practice. The application of SDM requires clinicians and patients to actively collaborate on treatment decisions, share information and to ultimately reach a consensus on treatment decisions [2].

The importance of SDM is well established in the medical literature [3] with a growing evidence base in mental health. Emerging evidence suggests that SDM can help patients feel more informed about their illness and treatment and improve satisfaction with care [4]. Better clinical outcomes have also been reported, in particular improvements in depression [5] and reduced hospitalisation for patients with schizophrenia [6]. While two previous studies have observed SDM in first encounters in outpatient psychiatric settings with non-psychotic patients [7], [8], no research has explored SDM in ongoing outpatient psychiatric treatment. Most people with schizophrenia and many with depression will receive treatment in secondary mental health care over many years, sometimes a lifetime. There are high dropout rates from treatment, which adversely affect patient outcomes [9]. Patients’ symptoms fluctuate considerably over time, in response to which treatment is modified frequently. Hence, ongoing collaboration between patient and psychiatrist in decision-making about treatment is important for continued patient engagement in and adherence to treatment to optimise patient outcomes. Moreover very little research has explored what types of decisions are taken in outpatient psychiatric consultations. Within an inpatient setting, Hamann et al. [10] found that social decisions play only a minor role in the decisions that are taken which may suggest an emphasis on the need to address clinical goals.

The aim of this study was to investigate patient involvement in on-going psychiatric visits to identify: what decisions are made; the degree of patient involvement in decision-making; and the factors influencing patient involvement.

Section snippets

Method

Psychiatric outpatient visits in secondary mental health care in the publicly funded National Health Service in the United Kingdom were video recorded with consent. Patients had a diagnosis of Schizophrenia or Depression (ICD-10) [11]. Symptoms were assessed using the Positive and Negative Syndrome Scale (PANSS) [12] for patients with schizophrenia and the Beck Depression Inventory (BDI) [13] for patients with depression. As the focus of the study was on communication, visits involving an

Results

The analysis was carried out on 72 visits, with 42 male patients and 30 female. Patients were aged between 19 and 65 (mean = 45 years; SD = 10.7) and were diagnosed with schizophrenia (N = 36) or depression (N = 36). Over one half (65%) were White/White British, 14% Black/Black British, 13% Asian/Asian British and 8% other ethnic group. Most patients were unemployed (63%), whilst 30% were employed and the remaining 7% were retired or made redundant. Mean length of illness was 13.4 years (range = 0.5–45

Discussion

Decision-making in repeat psychiatric visits was concerned with a wide range of topics covering patients’ multi-faceted needs. While approximately half of all decisions were medication related, with a medication decision occurring in almost all visits, half were concerned with issues such as physical health (e.g. weight, blood monitoring), referrals to other services (e.g. alcohol, psychology, day opportunities) and employment. Some psychiatrists consistently involved patients more in

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Our findings indicated that female and older MHPs and mental health nurses equally preferred more consumer involvement. An observational study reported that female psychiatrists did spend more time on consultations and involve consumers more [42]. This might be because the female and older health professionals and nurses are assumed to be good listeners and to be skilled at involving consumers in decision-making.
To compare consumer and mental health professionals’ (MHPs) preferences for decision-making in China and Europe.
This study used cross-sectional design; Chinese data were collected by questionnaires and European data were obtained from the literature. Data were analysed using t-test, One-way ANOVA and Pearson correlation coefficient as appropriate.
This study involved 800 people diagnosed with severe mental illness and 506 MHPs. Chinese participants rated lower scores on preference for participation in decision-making (PD = 1.88) and information (IN = 2.70) than European participants (PD = 2.05, IN = 2.83). Chinese consumers rated a higher score on IN (2.78) but lower on for PD (1.75) than MHPs (IN = 2.64, PD = 1.97). Chinese consumers’ education level is positively associated with preference for PD and IN. The gender, occupation and age of Chinese MHPs are associated with preference for PD.
Both Chinese and Europeans had preference for shared involvement in mental health, while the preference in China is less. Opinions of consumers and MHPs might be different, regarding the level of patient involvement in specific decisions.
It is essential that consumers’ preferences are understood for provision of optimal support for a shared decision-making approach.
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Data from patient-reported measures of SDM typically provide scores at the upper end of scales while independent assessments of behavioral SDM as documented by audio- or video-recordings of clinical encounters rarely indicate high performance [22]. Although some research has evaluated the third-party assessment of decision talk by an independent rater within the context of ongoing psychiatric practice [23–25], very little observer-rated SDM has been conducted with parents making treatment decisions about pediatric mental healthcare [26]. Moreover, to our knowledge, no observer-rated SDM has been published in the area of Latino mental healthcare.
To evaluate shared decision-making (SDM) and delineate SDM processes in audio-recorded conversations between language congruent Spanish-/English-speaking clinicians and parents of pediatric mental health patients.
Transcripts from audio-recorded consultations were rated using the 5-Item Observing Patient Involvement in Decision Making (Observer OPTION⁵) instrument. One hundred encounters between seventeen clinicians and 100 parents were rated. Interrater reliability for total score was 0.98 between two trained coders (ICC range: 0.799-0.879).
Scores ranged between 0 and 70 on a 100-point scale, with an average total Observer OPTION⁵ score of 33.2 (SD = 17.36). This corresponded to modest success at mutual shared decision-making. Clinicians and parents both showed effort at identifying a problem with treatment options and engaging in team talk. However, preference elicitation and integration were largely lacking.
The present sample performed on par with other populations studied to date. It expands the evaluation of observed SDM to include Latino patients and new clinician populations.
Use of the Observer OPTION^{5 Item} instrument highlights that eliciting and integrating parent/patient preferences is a skill that requires attention when delivering culturally competent interventions.
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In medicine, including psychiatry, there is increased interest regarding engagement of patients in their own care (Hamann et al., 2008; Johansson and Eklund, 2003; McCabe et al., 2013; Jo Anne et al., 2001; Angermeyer et al., 2001; Strupp and Hadley, 1977); this includes not only treatment options but also knowledge of the illness (Estroff, 1989).
Patient input as part of health care has taken on increased importance recently. To look at whether patients with treatment resistant schizophrenia (TRS) are able to provide a valid self-assessment of symptoms, the present study investigated patient versus rater evaluation of clinical symptoms. Ninety-three patients diagnosed with TRS and treated with clozapine were recruited. Both patients and raters completed the 7-point Clinical Global Impression – Schizophrenia Version (CGI-SCH) scale, thereby providing evaluations for positive, negative, depressive, and cognitive symptoms as well as overall illness severity. Patients rated their clinical symptoms significantly lower than raters. A positive correlation was found between patients and raters for all symptom domains, while the strength of correlation varied. Age, gender and years of education did not impact the relationship between patient and rater scores. The conclusion is that patients provided valid information in self-assessments of symptoms when compared to raters, and this was consistent over time. In addition, the greatest heterogeneity between rater and patient ratings occurred with regard to cognitive symptoms. Patient assessments may help further engage individuals in their care and permit clinicians to identify where discrepancies exist. Addressing these issues offers opportunities for improved therapeutic alliance, education, and shared decision-making within treatment.
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We extracted the age-standardised rates (ASRs) of prevalence and disability-adjusted life years (DALYs) and their 95% uncertainty intervals (UIs) of eating disorders, including anorexia nervosa and bulimia nervosa, between 1990 and 2017 from the GBD 2017 data. The estimated annual percentage changes (EAPCs) were calculated to quantify the secular trends of the burden of eating disorders.
The ASRs of prevalence and the DALYs of eating disorders continuously increased worldwide from 1990 to 2017 by an average of 0.65 (95% UI: 0.59–0.71) and 0.66 (95% UI: 0.60–0.72), respectively. The burden of eating disorders was higher in females than in males, but the increment in ASRs was greater in males than in females over time. In 2017, the highest burden of eating disorders was observed in the high sociodemographic index (SDI) regions, especially Australasia (ASR of prevalence = 807.13, 95% UI: 664.20–982.30; ASR of DALYs = 170.74, 95% UI: 113.43–244.14, per 100 000 population), Western Europe and high-income North America. However, the most significant increment of the burden of eating disorders was observed in East Asia (EAPC for prevalence = 2.23, 95% UI: 2.14–2.32; EAPC for DALYs = 2.22, 95% UI: 2.13–2.31), followed by South Asia. An increasing trend in the burden of eating disorders at the national level was observed among most countries or territories. The countries with the top three highest increasing trends were Equatorial Guinea, Bosnia and Herzegovina and China. Positive associations were found between the burden estimates and the SDI levels in almost all geographic regions during the observed 28-year period. We also found that the human development indexes in 2017 were positively correlated with the EAPCs of the ASRs of prevalence (ρ = 0.222, P = 0.002) and DALYs (ρ = 0.208, P = 0.003).
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Medical Decision MakingShared decision-making in ongoing outpatient psychiatric treatment

Abstract

Objective

Methods

Results

Conclusion

Practice implications

Introduction

Section snippets

Method

Results

Discussion

Soc Sci Med

Patient Educ Couns

Soc Sci Med

Patient Educ Couns

Soc Sci Med

Equity and excellence: liberating the NHS

Decision aids for people facing health treatment or screening decisions

Cochrane Database Syst Rev

Shared decision-making for in-patients with schizophrenia

Acta Psychiatr Scand

Primary care patient's involvement in decision making is associated with improvement in depression

Med Care

Shared decision-making and long-term outcome in schizophrenia treatment

J Clin Psychiatry

Involving patients in decisions during psychiatric visits

Br J Psychiatry

Medical Decision Making
Shared decision-making in ongoing outpatient psychiatric treatment