Shared decision making is advocated as a way of involving patients in medical decisions, but it can be achieved only when both patients and physicians commit to sharing decisions. This study explored ...psychiatrists' views of shared decision making in schizophrenia treatment.
A structured questionnaire was given to 352 psychiatrists at the 2007 congress of the German Society of Psychiatry, Psychotherapy, and Nervous Diseases to determine their self-reported decision-making styles. Approximately half of the psychiatrists (N=181) were then asked to rate how 19 patient characteristics would influence whether they would share in decision making, and the other half (N=171) were asked whether 19 decision topics would be suitable for shared decision making.
Of the 352 participating psychiatrists, 51% reported regularly applying shared decision making, but decision-making styles were tailored to individual patients and decision topics. Shared decision making was seen as useful for well-informed and compliant patients and for those who currently dislike their antipsychotic, but it was not seen as useful in cases of potentially reduced decisional capacity. Psychosocial matters (for example, work therapy, future housing, and psychotherapy) were considered more suitable for shared decision making than were medical and legal decisions (for example, hospitalization, prescription of antipsychotics, and diagnostic procedures).
It should be clarified whether and how patients with schizophrenia can be empowered and educated so they can share important treatment decisions.
The aim of this review is to summarize the literature on psychoeducation in schizophrenia published during the past year; this literature shows that pragmatic approaches and new adaptations have been ...developed.
The current literature indicates that studies on psychoeducation in schizophrenia in real-world settings show results comparable to those in experimental settings; brief psychoeducational interventions may have long-term effects on relapse and rehospitalization rates; and combining diagnoses may be helpful for new, short psychoeducational formats, but also for smaller hospitals with too few patients with the same diagnosis for group psychoeducation. Peer-to-peer education programs for families and patients have been developed, and culturally sensitive topics, the patients' perspective, quality-of-life issues and sex aspects were integrated into psychoeducation. A new meta-analysis on psychoeducation shows that there is a medium effect size for relapse and rehospitalization reduction if both the patient and the family participate.
Up to the present, patient-directed approaches are much more frequent in clinical practice than bifocal psychoeducation. Therefore, future research must focus on patient-directed psychoeducation and, here especially, on integrating the more stable outpatients, who appear to profit more from psychoeducation than do symptomatic inpatients.
Criteria for remission in schizophrenia have recently been presented. It is unclear how many acutely ill patients meet these criteria and how they compare with previously suggested definitions.
We ...re-analysed seven anti-psychotic drug trials (n = 1,708) of patients with schizophrenia to find out how many met the new remission criteria and their single components, how many met two previously used remission criteria, and how many met simpler measures of response (at least 50% Brief Psychiatric Rating Scale BPRS reduction, a Clinical Global Impressions CGI improvement score of at least 'much better' or a CGI severity score of 'mild or better').
Thirty-seven percent/41% (last observation carried forward LOCF/completer analysis CO) of the initially acutely ill patients with positive symptoms met the severity criteria of remission at 4 weeks, and 27%/52% (worst case/CO) met the severity and time criteria at 1 year. Only 13%/21% (LOCF) met the severity criteria at 4 weeks/1 year when an item threshold 'at best very mild symptoms' was applied, and almost no patients were absolutely symptom-free. The psychotic symptoms component was more difficult to achieve than the negative component. The criteria were more stringent than 'at least 50% BPRS reduction' and than 'CGI improvement score of at least much better.' However, the definition 'CGI severity score mild or better' was of a stringency similar to the new remission criteria, which probably explains why fewer patients met previously defined criteria that included this scale.
The new remission criteria proved to be an achievable goal for clinical trials. A consensus on the application of their time component is still needed.
Recently, new polymorphisms were described in connection with intermediate and ultrarapid CYP2D6 metabolism. These may allow a much desired prediction of metabolic activity within the extensive ...metabolizer group. The functional consequences are still being discussed with few data available for clinical patients.
We conducted a prospective, blinded two-center study seeking correlations between CYP2C19 (*2,*3, and *4; conventional PCR) and CYP2D6 genotypes (*1 to *10, *35, and *41; real-time and multiplex PCR) and drug concentrations (Emit and HPLC) in 50 Caucasians receiving amitriptyline (AT; 75 mg twice a day).
Eighteen CYP2C19 heterozygotes (*1/*2) had higher AT (P = 0.033) and lower nortriptyline (NT; P = 0.059) concentrations than 30 homozygotes (*1/*1). For CYP2D6, we calculated two new indices, i.e., the allele-specific change of concentration on identical background (ASCOC) and a quantitative functional gene dose. The ASCOC describes the change in NT concentration attributable to a mutant allele compared with the wild type. We found significantly higher concentrations for alleles *4 (95.6%; P <0.0001), *10 (63.3%; P <0.001), and *41 (39.8%; P <0.0001) but not for *2 and *35. Assigning of semiquantitative gene doses of 0, 0.5, or 1 to each allele instead of applying the current classification system (predicted phenotypes: 3 intermediate metabolizers, 46 extensive metabolizers, and 1 ultrarapid metabolizer) produced significant NT concentration differences: gene doses of 0.5 (n =3), 1 (n = 14), 1.5 (n = 11), 2 (n = 21) and 3 (n = 1; P <0.00001).
AT and NT concentrations can be predicted within the group of CYP2D6 extensive metabolizers. The ASCOC provides substantial advantages compared with current methods of analysis. CYP2D6 but not CYP2C19 correlates with the sum of both concentrations used to guide AT therapy.
Objective To study how physicians feel about patients’ efforts to be engaged in shared decision making (SDM).
Study setting and design Survey of physicians from distinctly different medical ...disciplines (238 psychiatrists and 169 vascular surgeons). Participants were requested to judge which patient behaviours they find helpful and which behaviours detrimental for SDM.
Results Psychiatrists and surgeons had rather positive attitudes about active patient behaviours. However, there were quite a few patient behaviours (e.g. searching the Internet, being assertive towards the doctor) which provoked ambivalent or negative attitudes.
Discussion and conclusions Physicians are generally quite open towards active patient behaviour in the consultation. They, however, do consider it as less helpful and become more annoyed if patients insist on their preferences and doubt their doctors’ recommendations. Physicians must realize that SDM implies giving up decisional power and try to be more flexible in their interactions with patients.
Abstract Objective To use the degree of response after 2 weeks of treatment to predict non-response at 4 to 6 weeks. Method Post-hoc re-analysis of a large multi-centered double-blind trial including ...1996 patients with schizophrenia using receiver–operator curves and logistic regression analyses to predict non-response at 4 weeks and at 4–6 weeks from the percentage BPRS change at weeks 1 and 2. The primary non-response criterion was a less than 25% BPRS reduction from baseline. Results A 0% BPRS reduction at 2 weeks predicted non-response at 4 weeks with a positive predictive value of 77.1%; and sustained non-response at weeks 4, 5 and 6 with a positive predictive value of 75.8%. In a secondary last-observation-carried forward-analysis a less stringent cutoff of ≤ 15% BPRS reduction was associated with an acceptable positive predictive value (75%), with even higher sensitivity (76%). Conclusions Those patients who showed little to no reduction of symptoms at week 2 were unlikely to show even minimal response at weeks 4 to 6. There is increasing evidence that such patients may benefit from a change in treatment.
Shared decision-making (SDM) is a model of how doctors and patients make medical decisions, which is seen as very applicable to mental health. This review addresses the following issues: Do patients ...and professionals see the need for SDM? Does SDM actually take place for patients with schizophrenia? What are facilitators and barriers of SDM in schizophrenia treatment? What are the outcomes of SDM?
Publications in the last 18 months showed the following: Both patients and providers acknowledge the desirability of SDM. SDM occurs less often in mental health than desired by patients and less frequently compared with general practice. SDM in mental health is complex, takes time and involves more than just two participants; patients' lack of decisional capacity is seen as the major barrier. There are only a few interventional studies measuring the outcome of SDM; existing research constantly shows positive, but small effects.
SDM is highly accepted and wanted in the treatment of schizophrenia and related disorders, but more research is needed regarding how SDM can be implemented in regular care. Healthcare professionals need more training in how to deal with difficult decisional situations.
Abstract The aim was to study the distribution of psychoeducation for anxiety disorders using a two-part survey addressing all psychiatric institutions in Germany, Austria and Switzerland. We found ...that 77% of the patients with anxiety disorders participated in psychoeducation when it was offered. However, only 8% of the institutions offered such an intervention. Health care costs and patient suffering could be reduced substantially by offering adequate psychoeducation for anxiety disorders.
The efficacy of psychopharmacological treatments has been called into question. Psychiatrists are unfamiliar with the effectiveness of common medical drugs.
To put the efficacy of psychiatric drugs ...into the perspective of that of major medical drugs.
We searched Medline and the Cochrane Library for systematic reviews on the efficacy of drugs compared with placebo for common medical and psychiatric disorders, and systematically presented the effect sizes for primary efficacy outcomes.
We included 94 meta-analyses (48 drugs in 20 medical diseases, 16 drugs in 8 psychiatric disorders). There were some general medical drugs with clearly higher effect sizes than the psychotropic agents, but the psychiatric drugs were not generally less efficacious than other drugs.
Any comparison of different outcomes in different diseases can only serve the purpose of a qualitative perspective. The increment of improvement by drug over placebo must be viewed in the context of the disease's seriousness, suffering induced, natural course, duration, outcomes, adverse events and societal values.
The symptoms and signs of schizophrenia have been linked to high levels of dopamine in specific areas of the brain (limbic system). Antipsychotic drugs block the transmission of dopamine in the brain ...and reduce the acute symptoms of the disorder. An original version of the current review, published in 2012, examined whether antipsychotic drugs are also effective for relapse prevention. This is the updated version of the aforesaid review.
To review the effects of maintaining antipsychotic drugs for people with schizophrenia compared to withdrawing these agents.
We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials including the registries of clinical trials (12 November 2008, 10 October 2017, 3 July 2018, 11 September 2019).
We included all randomised trials comparing maintenance treatment with antipsychotic drugs and placebo for people with schizophrenia or schizophrenia-like psychoses.
We extracted data independently. For dichotomous data we calculated risk ratios (RR) and their 95% confidence intervals (CIs) on an intention-to-treat basis based on a random-effects model. For continuous data, we calculated mean differences (MD) or standardised mean differences (SMD), again based on a random-effects model.
The review currently includes 75 randomised controlled trials (RCTs) involving 9145 participants comparing antipsychotic medication with placebo. The trials were published from 1959 to 2017 and their size ranged between 14 and 420 participants. In many studies the methods of randomisation, allocation and blinding were poorly reported. However, restricting the analysis to studies at low risk of bias gave similar results. Although this and other potential sources of bias limited the overall quality, the efficacy of antipsychotic drugs for maintenance treatment in schizophrenia was clear. Antipsychotic drugs were more effective than placebo in preventing relapse at seven to 12 months (primary outcome; drug 24% versus placebo 61%, 30 RCTs, n = 4249, RR 0.38, 95% CI 0.32 to 0.45, number needed to treat for an additional beneficial outcome (NNTB) 3, 95% CI 2 to 3; high-certainty evidence). Hospitalisation was also reduced, however, the baseline risk was lower (drug 7% versus placebo 18%, 21 RCTs, n = 3558, RR 0.43, 95% CI 0.32 to 0.57, NNTB 8, 95% CI 6 to 14; high-certainty evidence). More participants in the placebo group than in the antipsychotic drug group left the studies early due to any reason (at seven to 12 months: drug 36% versus placebo 62%, 24 RCTs, n = 3951, RR 0.56, 95% CI 0.48 to 0.65, NNTB 4, 95% CI 3 to 5; high-certainty evidence) and due to inefficacy of treatment (at seven to 12 months: drug 18% versus placebo 46%, 24 RCTs, n = 3951, RR 0.37, 95% CI 0.31 to 0.44, NNTB 3, 95% CI 3 to 4). Quality of life might be better in drug-treated participants (7 RCTs, n = 1573 SMD -0.32, 95% CI to -0.57 to -0.07; low-certainty evidence); probably the same for social functioning (15 RCTs, n = 3588, SMD -0.43, 95% CI -0.53 to -0.34; moderate-certainty evidence). Underpowered data revealed no evidence of a difference between groups for the outcome 'Death due to suicide' (drug 0.04% versus placebo 0.1%, 19 RCTs, n = 4634, RR 0.60, 95% CI 0.12 to 2.97,low-certainty evidence) and for the number of participants in employment (at 9 to 15 months, drug 39% versus placebo 34%, 3 RCTs, n = 593, RR 1.08, 95% CI 0.82 to 1.41, low certainty evidence). Antipsychotic drugs (as a group and irrespective of duration) were associated with more participants experiencing movement disorders (e.g. at least one movement disorder: drug 14% versus placebo 8%, 29 RCTs, n = 5276, RR 1.52, 95% CI 1.25 to 1.85, number needed to treat for an additional harmful outcome (NNTH) 20, 95% CI 14 to 50), sedation (drug 8% versus placebo 5%, 18 RCTs, n = 4078, RR 1.52, 95% CI 1.24 to 1.86, NNTH 50, 95% CI not significant), and weight gain (drug 9% versus placebo 6%, 19 RCTs, n = 4767, RR 1.69, 95% CI 1.21 to 2.35, NNTH 25, 95% CI 20 to 50).
For people with schizophrenia, the evidence suggests that maintenance on antipsychotic drugs prevents relapse to a much greater extent than placebo for approximately up to two years of follow-up. This effect must be weighed against the adverse effects of antipsychotic drugs. Future studies should better clarify the long-term morbidity and mortality associated with these drugs.
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