Compliance with antipsychotic medication is a major issue in schizophrenia treatment, and noncompliance with antipsychotic treatment is closely related to relapse and rehospitalization. An enhanced ...involvement of patients with schizophrenia in treatment decisions ("shared decision making") is expected to improve long-term compliance and reduce rehospitalizations. The aim of the present analysis was to study whether shared decision making (SDM) in antipsychotic drug choice would influence long-term outcome.
From February 2003 to January 2004, psychiatric state hospital inpatients with a diagnosis of schizophrenia (ICD-10; N = 107) were recruited for the trial using a cluster-randomized controlled design. An SDM program on antipsychotic drug choice consisting of a decision aid and a planning talk between patient and physician was compared with routine care with respect to long-term compliance and rehospitalizations (6-month and 18-month follow-up).
On the whole, we found high rates of noncompliance and rehospitalization. There were no differences between intervention and control groups in the univariate analyses. However, when controlling for confounding factors in a multivariate analysis, there was a positive trend (p = .08) that patients in the SDM intervention had fewer rehospitalizations. Additionally, a higher desire of the patient for autonomy and better knowledge at discharge were associated with higher hospitalization rates.
The intervention studied showed a positive trend but no clear beneficial effect on long-term outcomes. A more thorough implementation of SDM (e.g., iterative administration of decision aid) might yield larger effects. Those patients with higher participation preferences are at higher risk for poor treatment outcomes and therefore require special attention. Strategies to match these patients' needs might improve compliance and long-term outcomes.
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.
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.
Motoric neurological soft signs (NSS) were investigated by means of the Brief Motor Scale (BMS) in 82 inpatients with DSM-III-R schizophrenic psychoses. To address potential fluctuations of ...psychopathological symptoms and extrapyramidal side effects, patients were examined in the subacute state, twice at an interval of 14 days on the average. NSS were significantly correlated with severity of illness, lower social functioning, and negative symptoms. Modest, but significant correlations were found between NSS and extrapyramidal side effects as assessed on the Simpson-Angus Scale. Neither the neuroleptic dose prescribed to the patient, nor scores for tardive dyskinesia and akathisia were significantly correlated with NSS. Moreover, NSS scores did not significantly differ between patients receiving clozapine and conventional neuroleptics. Patients in whom psychopathological symptoms remained stable or improved over the clinical course showed a significant reduction of NSS scores. This finding did not apply to those patients in whom psychopathological symptoms deteriorated. Our findings demonstrate that NSS in schizophrenic psychoses are relatively independent of neuroleptic side effects, but they are associated with the severity and persistence of psychopathological symptoms and with poor social functioning.
Little is known about the desire of patients with schizophrenia to be involved in medical decisions affecting their treatment.
The authors administered the Autonomy Preference Index to 122 inpatients ...with schizophrenia. In addition, the patients filled out the Drug Attitude Inventory. Sociodemographic data and Positive and Negative Syndrome Scale ratings were available for all patients.
The patients expressed a desire for shared decision making that was slightly greater than that of primary care patients. Negative attitudes toward medical treatment and younger age were associated with a higher desire for participation.
It is important to meet the participation needs of patients who are dissatisfied with their psychiatric treatment.
Treatment guidelines for schizophrenia recommend that medical decisions should be shared between patients with schizophrenia and their physicians. Our goal was to determine why some patients want to ...participate in medical decision making and others do not.
To identify determinants of participation preferences in schizophrenia patients (ICD-10 criteria) and in a nonpsychiatric comparison group (multiple sclerosis), we undertook a cross-sectional survey in 4 psychiatric and neurologic hospitals in Germany. Inpatients suffering from schizophrenia or multiple sclerosis (but not both) were consecutively recruited (2007-2008), and 203 patients participated in the study (101 with schizophrenia and 102 with multiple sclerosis). Predictors for patients' participation preferences were identified using a structural equation model.
Patients' reports about their participation preferences in medical decisions can be predicted to a considerable extent (52% of the variance). For patients with schizophrenia, poor treatment satisfaction (P < .001), negative attitudes toward medication (P < .05), better perceived decision making skills (P < .001), and higher education (P < .01) were related to higher participation preferences. In the comparison group, drug attitudes (P < .05) and education (P < .05) were also shown to be related with participation preferences.
Patients with schizophrenia who want to participate in decision making are often dissatisfied with care or are skeptical toward medication. Patients who judge their decisional capacity as poor or who are poorly educated prefer not to participate in decision making. Future implementation strategies for shared decision making must address how dissatisfied patients can be included in decision making and how patients who currently do not want to share decisions can be enabled, empowered, and motivated for shared decision making.
Background:
A deeper engagement into medical decision-making is demanded by treatment guidelines for patients with affective disorders. There is to date little evidence on what facilitates active ...behaviour of patients with depression. In general medicine ‘question prompt sheets’ (QPSs) have been shown to change patients’ behaviour in the consultation and improve treatment satisfaction but there is no evidence for such interventions for mental health settings.
Aims:
To study the effects of a QPS on active patient behaviour in the consultation.
Methods:
Randomized controlled trial (involving N = 100 outpatients with depression) evaluating the effects of a QPS on patients’ behaviour in the consultation.
Results:
The QPS showed no influence on the number of topics raised by patients (p = .13) nor on the external rater’s perception of ‘Who made the decisions in today’s consultation?’ (p = .50).
Conclusions:
A QPS did not change depressed patients’ behaviour in the consultation. More complex interventions might be needed to change depressed patients’ behaviour within an established doctor–patient dyad. Patient seminars addressing behavioural aspects have been shown to be effective in other settings and may also be feasible for outpatients with affective disorders.
Shared decision making is advocated for patients with schizophrenia. However, there is limited knowledge as to which events are actually considered to be decisions by psychiatrists and patients. ...Semistructured interviews with regard to clinical decisions of the preceding week were performed with psychiatrists and inpatients with schizophrenia. There was good correspondence between patients and psychiatrists regarding decisional topics but poor correspondence regarding individual decisions. Medication issues were the most prominent, but other topics were also frequently cited. Not being included in decisions was associated with patients' desire to make the decisions differently. Patients treated involuntarily felt more often that they were not included in decisions and wanted to make different decisions. Thus, many patients do not feel involved in treatment decisions and are at the risk of noncompliance since they state that they would have made decisions differently from their psychiatrists. This is especially true of those being treated involuntarily.
Evoked and induced magnetic brain activity measured
over the left hemisphere were tested for their specificity
to language-related processing. Induced activity refers
to oscillatory alterations time ...locked but not phase locked
to the stimulus. Words, false font stimuli, and two types
of nonverbal patterns were presented visually while subjects
performed a nonlinguistic visual feature detection task.
The comparison of evoked and induced brain activity around
200 ms after stimulus onset revealed differential sensitivity
to the stimuli. The M180 component of the evoked magnetic
field was larger at the processing of words and false font
stimuli compared with nonverbal stimuli. The induced magnetic
brain activity in the 60-Hz band at a compatible latency
range was correlated with the familiarity of the visual
Gestalt. Sensitivity to language-specific information processing
can be concluded if a parameter differentiates the word
condition from the nonlexical conditions. Such a difference
was observed at sensors located over the frontal-temporal
scalp regions for induced but not evoked magnetic brain
activity. Thus, evoked and induced magnetic brain activity
revealed a differential sensitivity to elements of cognitive
processing during the given task.
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