C.A.J. de Jong

Systematic Review of the Effects of Shared Decision-Making on Patient Satisfaction, Treatment Adherence and Health Status

Background: In the last decade, the clinician-patient relationship has become more of a partnership. There is growing interest in shared decision-making (SDM) in which the clinician and patient go through all phases of the decision-making process together, share treatment preferences, and reach an agreement on treatment choice. The purpose of this review is to determine the extent, quality, and consistency of the evidence about the effectiveness of SDM. Method: This is a systematic review of randomised controlled trials (RCTs) comparing SDM interventions with non-SDM interventions. Eleven RCTs met the required criteria, and were included in this review. Results: The methodological quality of the studies included in this review was high overall. Five RCTs showed no difference between SDM and control, one RCT showed no short-term effects but showed positive longer-term effects, and five RCTs reported a positive effect of SDM on outcome measures. The two studies included of people with mental healthcare problems reported a positive effect of SDM. Conclusions: Despite the considerable interest in applying SDM clinically, little research regarding its effectiveness has been done to date. It has been argued that SDM is particularly suitable for long-term decisions, especially in the context of a chronic illness, and when the intervention contains more than one session. Our results show that under such circumstances, SDM can be an effective method of reaching a treatment agreement. Evidence for the effectiveness of SDM in the context of other types of decisions, or in general, is still inconclusive. Future studies of SDM should probably focus on long-term decisions.

Shared Decision-Making Reduces Drug Use and Psychiatric Severity in Substance-Dependent Patients

Background: In the last decades, shared decision-making (SDM) models have been developed to increase patient involvement in treatment decisions. The purpose of this study was to evaluate a SDM intervention (SDMI) for patients dependent on psychoactive substances in addiction health care programs. The intervention consisted of a structured procedure to reach a treatment agreement and comprised 5 sessions. Methods: Clinicians in 3 treatment centres in the Netherlands were randomly assigned to the SDMI or a standard procedure to reach a treatment agreement. Results: A total of 220 substance-dependent patients receiving inpatient treatment were randomised either to the intervention (n = 111) or control (n = 109) conditions. Reductions in primary substance use (F(1, 124) = 248.38, p < 0.01) and addiction severity (F(8) = 27.76, p < 0.01) were found in the total population. Significant change was found in the total population regarding patients’ quality of life measured at baseline, exit and follow-up (F(2, 146) = 5.66, p < 0.01). On the European Addiction Severity Index, SDMI showed significantly better improvements than standard decision-making regarding drug use (F(1, 164) = 7.40, p < 0.01) and psychiatric problems (F(1, 164) = 5.91, p = 0.02) at 3-month follow-up. Conclusion: SDMI showed a significant add-on effect on top of a well-established 3-month inpatient intervention. SDMI offers an effective, structured, frequent and well-balanced intervention to carry out and evaluate a treatment agreement.

Gamma-hydroxybutyrate detoxification by titration and tapering

Objective: To determine the effectiveness and safety of a new detoxification procedure in γ-hydroxybutyrate (GHB)-dependent patients. GHB is an endogenous inhibitory neurotransmitter and anesthetic agent that is being abused as a club drug. In many GHB-dependent patients a severe withdrawal syndrome develops that does not respond to treatment with high dosages of benzodiazepines and often requires an admission to an intensive care unit. Methods: Based on the knowledge of detoxification procedures in opioid and benzodiazepine dependence, we developed a titration and tapering procedure. A consecutive series of 23 GHB-dependent inpatients were transferred from illegal GHB (mostly self-produced) in various concentrations to pharmaceutical GHB. They were given initial doses that resulted in a balance between sedation and withdrawal symptoms. After this titration period, patients were placed on a 1-week taper. Results: We have found that after titration the patients experienced a low level of withdrawal symptoms. During tapering these symptoms decreased significantly and no patient developed a delirium or a psychosis. None of the patients had to be transferred to a medium or intensive care unit. Conclusions: This detoxification procedure proved to be safe and convenient in patients with moderate to severe GHB dependence.

Evaluation of an e-therapy program for problem drinkers: a pilot study.

An e-therapy program with therapist involvement for problem drinkers was evaluated in a population of 527 Dutch-speaking patients. In a pre–post design weekly alcohol consumption, alcohol-consumption-related health problems, and motivation were assessed. Although the dropout rate was high, patients showed a significant decrease of alcohol consumption and alcohol-consumption-related health complaints. Patients’ satisfaction with the e-therapy program was high. The e-therapy program proved to be feasible and attracted patients who were otherwise unlikely to seek help. A randomized controlled trial has to provide more information about reasons for dropout, effectiveness, and the population that benefits most from the e-therapy program. The studys limitations are noted.

Treatment Goals in Addiction Healthcare: the Perspectives of Patients and Clinicians

Background: Little is known about the perspectives of either patients or clinicians regarding treatment goals in addiction healthcare. In general, treatment goals involve abstinence or at least reduction of substance use. Aim: To examine and compare the treatment goals indicated by both patients and clinicians at baseline, interim and exit measurement. Method: A descriptive study was performed with multiple measurements of treatment goals. Patients (n = 111) and clinicians (n = 20) were recruited from three addiction treatment centres in the Netherlands. A Shared Decision Making Intervention (SDMI) was undertaken to promote and evaluate treatment agreement. Results: Patients identified treatment goals of daytime activities and abstinence or reduced alcohol consumption as most important. Clinicians indicated psychological distress, daytime activities and substance use as most important. Differences between patients and clinicians were found for the treatment goals of physical health (patient > clinician) and psychological distress (clinician > patient). The results further showed that treatment goals of both patients and clinicians become more closely aligned during the course of treatment. Conclusion: SDMI provides a method to explore and discuss discrepancy between patients’ and clinicians’ goals of treatment which leads to convergence. Such convergence is likely to be a necessary prerequisite for positive treatment outcomes.

Characteristics of Problem Drinkers in E-therapy versus Face-to-Face Treatment

Background: The availability of online treatment programs offers the potential to reach more problem drinkers. This study compared the client populations of an e-therapy program (asynchronous client–therapist communication via the Internet) and a face-to-face treatment program. Objective: To determine whether e-therapy and face-to-face groups differed from each other and changed over time. Methods: We compared the baseline characteristics of four naturalistic groups (N = 4593): two e-therapy groups (2005–2006 and 2008–2009) and two consecutive series of ambulant face-to-face clients admitted for treatment as usual. The characteristics we were interested in were gender, age, education level, working situation, and earlier treatment for drinking problems. Results: The results showed that the baseline characteristics of e-therapy and face-to-face clients differed by gender, education level, work situation, prior alcohol treatment, and age. We also found that both e-therapy groups differed over time by gender, work situation, and prior alcohol treatment. Conclusions: The e-therapy program successfully attracted clients who were different from those who were represented in regular face-to-face alcohol treatment services. This indicates that e-therapy decreases the barriers to treatment facilities and enhances the accessibility. However, the e-therapy population changed over time. Although the e-therapy program still reached an important new group of clients in 2008–2009, this group showed more overlap with the traditional face-to-face group of clients probably as a result of improved acceptance of e-therapy in the general population. Scientific Significance: Although e-therapy seems to be better accepted in the general population, anonymous treatment seems necessary to reach a broader range of problem drinkers.

Psychometric evaluation of the Dutch version of the Subjective Opiate Withdrawal Scale (SOWS)

Aim: To evaluate the psychometric properties of the Dutch version of the 16-item Subjective Opiate Withdrawal Scale (SOWS). The SOWS measures withdrawal symptoms at the time of assessment. Methods: The Dutch SOWS was repeatedly administered to a sample of 272 opioid-dependent inpatients of four addiction treatment centers during rapid detoxification with or without general anesthesia. Examination of the psychometric properties of the SOWS included exploratory factor analysis, internal consistency, test-retest reliability, and criterion validity. Results: Exploratory factor analysis of the SOWS revealed a general pattern of four factors with three items not always clustered in the same factors at different points of measurement. After excluding these items from factor analysis four factors were identified during detoxification (‘temperature dysregulation’, ‘tractus locomotorius’, ‘tractus gastro-intestinalis’ and ‘facial disinhibition’). The 13-item SOWS shows high internal consistency and test-retest reliability and good validity at different stages of withdrawal. Conclusion: The 13-item SOWS is a reliable and valid instrument to assess opioid withdrawal during rapid detoxification. Three items were deleted because their content does not correspond directly with opioid withdrawal symptoms.

Prediction of abstinence in opioid-dependent patients.

Objectives:Opioid detoxification with subsequent naltrexone is found to be an effective method as the first step in an abstinence-oriented approach. The aim of this study is to investigate the predictive value of variables for abstinence in opioid-dependent patients. Methods:Opioid-dependent patients were followed up to 1 month after detoxification. Predictor variables were assessed at baseline, during detoxification, and at discharge. Primary outcome was abstinence assessed by analyzing urine samples and self-reports. Logistic regression was used to identify predictors of abstinence. Results:Of 272 participants, 211 could be rated as abstinent (59.2%) or nonabstinent (40.8%) at 1 month follow-up. Significant baseline predictors were severity score of justice/police (ASI) and physical quality of life (SF-36); discharge predictors were general quality of health (SF-36) and sleeping problems (SCL-90); change in sleeping problems (SCL-90) during detoxification was also a predictor. The explained variance of these predictors was very low and clinical significance was limited. Conclusions:Considering the results it seems not possible to predict who will be abstinent or not 1 month after detoxification. Because rapid detoxification is found to be an effective detoxification method in selected patients, it seems warranted to recommend that patients with similar characteristics (ie, patients motivated for an abstinence-based treatment and low non–drug-related severity scores on the ASI) should be regarded as eligible for rapid detoxification.

Validation of the observational version of the motivation for treatment scale

In this study, the psychometric properties of a clinicians observation version of Motivation for Treatment (MfT-O) were assessed and compared with the patients version (MfT). The sample was composed of 243 inpatients that started inpatient treatment for substance dependence in The Netherlands. The EuropASI and the Motivation for Treatment (MfT) scales were administered to patients while the MfT-O was completed by clinicians during the first week of treatment. With minor adjustments, the MfT-O replicated the factorial structure of the MfT. The items were distributed into four scales: General Problem Recognition (PR1), Specific Problem Recognition (PR2), Desire for Help (DH), and Treatment Readiness. The MfT-O had an adequate reliability for all the scales (all α > 0.72). The MfT-O was related to the severity of problems as assessed by the EuropASI. The DH MfT-O scale was more predictive of time in treatment than the DH MfT scale.

Association between interpersonal behaviour and helping alliance in substance-dependent patients

This paper focuses on exploring the association between the patient’s perception of his own interpersonal behaviour on the one hand, and that of the therapist’s behaviour and of helping alliance on the other hand. A cross-sectional study was conducted, including 83 patients from substance dependence programs in The Netherlands. They completed the Helping Alliance Questionnaire (HAQ) and the Interpersonal Check List (ICL). Results indicate that the patient’s perception of the therapeutic alliance, and his perception of his own and of the therapist’s interpersonal behaviour are three separate domains, each playing their role in the context of the therapeutic relationship. Helping Alliance scores are predicted by both the patient’s (complaisance) and the therapist’s interpersonal behaviour (dominance). We conclude that patient’s cognitions about himself and about his therapist do contribute significantly to the perception of the therapeutic relationship. Limitations to the study are discussed, as well as some clinical implications.