Claudia Goss

Involving patients in decisions during psychiatric consultations

BACKGROUND Patient involvement in the decision-making process is a key element for good clinical practice. Few data are available on patient involvement in psychiatry. AIMS To assess in a psychiatric out-patient context how psychiatrists involve patients in therapeutic decisions and to determine the extent to which patient and psychiatrist characteristics contribute to patient involvement. METHOD Eighty transcripts from audiotaped first out-patient consultations, conducted by 16 psychiatrists, were rated with the OPTION (observing patient involvement) scale. Interrater reliability indices were obtained for 30 randomly selected interviews. Associations between OPTION scores and some clinical and socio-demographic variables were tested using t-test, ANOVA and Pearsons correlation coefficient where appropriate. The distribution of scores for each psychiatrist was assessed by intracluster correlation coefficients. RESULTS Interrater reliability and internal consistency of the OPTION scale in the psychiatric setting were satisfactory. The total score and the ratings for the single OPTION items showed a skewed distribution, with a prevalence of scores in the low range of abilities, corresponding to minimal attempts to involve patients or a minimal skill level. CONCLUSIONS The OPTION scale proves to be a reliable instrument to assess patient involvement in a psychiatric setting. Psychiatrists showed poor patient involvement abilities parallel to previous findings in psychiatry and primary care. They need to be encouraged to share treatment decisions with their patients and to apply patient involvement skills. Further research is needed to establish which patient variables and clinical settings in psychiatry are more amenable to shared decisions, and how participation of psychiatric patients in treatment decisions will affect the outcome.

Health promotion lifestyle interventions for weight management in psychosis: a systematic review and meta-analysis of randomised controlled trials

BackgroundPsychiatric patients have more physical health problems and much shorter life expectancies compared to the general population, due primarily to premature cardiovascular disease. A multi-causal model which includes a higher prevalence of risk factors has provided a valid explanation. It takes into consideration not only risks such as gender, age, and family history that are inherently non-modifiable, but also those such as obesity, smoking, diabetes, hypertension, and dyslipidemia that are modifiable through behavioural changes and improved care. Thus, it is crucial to focus on factors that increase cardiovascular risk. Obesity in particular has been associated with both the lifestyle habits and the side effects of antipsychotic medications. The present systematic review and meta-analysis aims at collecting and updating available evidence on the efficacy of non-pharmacological health promotion programmes for psychotic patients in randomised clinical trials.MethodsWe systematically reviewed the randomised controlled trials from 1990 onward, in which psychoeducational and/or cognitive-behavioural interventions aimed at weight loss or prevention of weight gain in patients with psychosis had been compared to treatment as usual. We carried out a meta-analysis and pooled the results of the studies with Body Mass Index as primary outcome.ResultsThe results of the meta-analysis show an effect toward the experimental group. At the end of the intervention phase there is a −0.98 kg/m2 reduction in the mean Body Mass Index of psychotic subjects. Notably, prevention studies with individual psychoeducational programmes that include diet and/or physical activity seem to have the highest impact.ConclusionsWhen compared with treatment as usual in psychotic patients, preventive and individual lifestyle interventions that include diet and physical activity generally prove to be effective in reducing weight. Physical screening and monitoring programmes are well accepted by patients and can be implemented in a variety of settings. A weight loss of 0.98 points in the Body Mass Index corresponds to a loss of 3.12% of the initial weight. This percentage is below the 5% to 10% weight loss deemed sufficient to improve weight-related complications such as hypertension, type II diabetes, and dyslipidemia. However, it is reported that outcomes associated with metabolic risk factors may have greater health implications than weight changes alone. Therefore, in addition to weight reduction, the assessment of metabolic parameters to monitor other independent risk factors should also be integrated into physical health promotion and management in people with mental disorders.

The psychosocial outcome of pregnancy in women with psychotic disorders

OBJECTIVE To investigate the psychosocial outcome of pregnancies in women with a history of psychotic disorder in an epidemiologically representative sample and to determine the predictors of having a baby looked after by social services in the first year of life. METHOD Historical matched controlled cohort study and nested case control study using the General Practice Research Database (GPRD), an anonymised primary care database, in women with a history of psychotic disorders who gave birth in 1996-1998 (199 cases and 787 controls). RESULTS Twenty-seven percent of cases had a psychotic episode and a further 38% had nonpsychotic depression in the first year after birth. Women with nonaffective psychoses were at a significantly higher risk of postnatal depression compared with controls (adjusted rate ratio 2.07, 95% CI 1.45-2.96, p<0.001). Cases were well supported with 72% in a cohabiting relationship and only 38% on benefits. The only significant predictor of parenting difficulties was recent contact with psychiatric services. CONCLUSIONS Women with a history of psychotic disorder are at high risk of psychiatric illness postpartum, particularly a twofold risk of postnatal depression, even if they have not been in contact with psychiatric services during pregnancy. However, this epidemiologically representative sample has better parenting outcomes than has been previously reported for specialist treated cases. Liaison between all professionals involved in the care of mothers with psychotic disorders during and after pregnancy is essential to optimise care for them and their families.

Communication skills in psychiatry residents-- how do they handle patient concerns? An application of sequence analysis to interviews with simulated patients.

Background: The main focus of the training of psychiatrists is on diagnosis and treatment based on the traditional doctor-centered approach to the psychiatric interview. Less attention is given to the correct handling of patients’ emotional concerns, which is crucial for the patient-physician relationship, but also for improving diagnostic and treatment decisions. The aim of this study is to assess psychiatrists’ responses to patients’ concerns and worries. Method: 118 consultations, conducted by 10 residents in psychiatry with 20 simulated patients, have been coded using the Verona Psychiatric Interview Classification System. Lag1 sequential analysis and a multinomial logit regression analysis were performed to investigate the relationship between patients’ expressions of concern and psychiatrists’ subsequent interventions in terms of patient-centered skills. Results: Compared to doctor-centered interventions, all patients’ expressions of concern increased the probability of passive listening (odds ratios between 2.4 and 4.2). They also increased the occurrence of emotion focusing interventions (odds ratios between 3.3 and 1.7), which however remained rare (4% of residents’ total responses). A small although significant increase in the likelihood of active listening expressions was observed as a response to two types of patient expressions of concern: statements of feelings (odds ratio 1.4) and expression of opinions regarding problematic psychosocial issues (odds ratio of 1.7). Conclusions: Young psychiatrists are good passive listeners but need to improve active listening skills which, together with emotion focusing skills, should be a major learning target in psychiatry. These patient-centered interviewing skills should integrate those traditionally used for attributing ICD-10 and/or DSM-IV categories.

The assessment of patient involvement across consultation. The Italian version of the OPTION scale

AIM To present the Italian version of the OPTION (observing patient involvement) rating scale, developed in UK by Elwyn et al. (2005), and its psychometric characteristics, together with some findings when applied on the consultations transcripts of a group of Italian General Practitioners. METHODS The OPTION scale assesses the extent to which clinicians involve patients in decisions and consists of 12 items to be rated on a 5 point scale (from 0--behaviour not observed to 4--high standard). The scale was applied to 235 transcripts of audiotaped consultations conducted by 6 male GPs. Interrater and test-retest reliability and internal validity indices were calculated on a subsample of 30 transcripts. RESULTS The Italian language version of OPTION showed good psychometric properties, similar to those reported for the original version. The ratings obtained for 235 consultations showed for each OPTION item a skewed distribution: the majority of scores (> 70%) were between 0 (behaviour absent) and 2 (minimum skill level). CONCLUSIONS The Italian language version of OPTION seems a reliable instrument to assess patient involvement in primary care settings also in Italy. The clustering of low scores confirms previous findings that clinicians without a specific training obtain very low levels of patient involvement in the decision making process.

People-centred care: new research needs and methods in doctor–patient communication. Challenges in mental health

Communication in psychiatry is nowadays called to create bridges between different levels of observation (biological, functional and relational levels) and therapeutic intervention (social and educational) with important implications for therapeutic practice and communication research in the mental health context. New research challenges and windows of opportunity for therapeutic practice will be addressed in this contribution, as they relate to the three main tasks that psychiatrists have to meet when talking with their patients: understanding patients problems and concerns; establishing the therapeutic alliance by acknowledging and responding to patients emotion; informing and involving patients and their families, when appropriate. Therapeutic decisions need the elaboration of valid strategies of shared decision-making, which still have to be implemented and adapted to psychiatric context. Moreover, in the research field, emerging biomarker research may contribute to better explain what makes the difference in an empathic relationship either in terms of psycho-physiological reactions and in brain changes. Finally, the influence of new technologies and of Internet has to be more and more considered during clinical consultations.

Participation of patients and citizens in healthcare decisions in Italy.

WHAT ABOUT POLICY REGARDING SDM? The Italian National Health Plan and many regional and local health authorities explicitly recognise the importance of patient/citizen participation. These official documents rarely mention the specific concept of SDM, but they use terms such as patient involvement, participation, and empowerment. Patient associations are actively involved in promoting patient/citizen participation, but still play a marginal role in the health debate compared to health professionals, clinicians and healthcare managers. WHAT ABOUT TOOLS - DECISION SUPPORT FOR PATIENTS? There are only a few examples of decision aids designed for patients according to SDM concepts. A critical point is the lack of specific tools for the evaluation of SDM processes. Exceptions include the Italian versions of the OPTION scale and the SDM-Q, used at the micro-level for the evaluation of SDM. What about professional interest and real implementation? Health professionals recognise that doctor-patient communication is an important area. Italian research in SDM has grown and improved. It is very promising, but still limited. Undergraduate and postgraduate courses of some medical schools include specific programs on doctor-patient communication skills, focusing also on promotion of patient participation. WHAT DOES THE FUTURE LOOK LIKE? In conclusion, there is room for improving the Italian efforts to implement SDM into practice at both the individual and public level.

INvolvement of breast CAncer patients during oncological consultations: A multicentre randomised controlled trial-the INCA study protocol

Introduction Studies on patient involvement show that physicians make few attempts to involve their patients who ask few questions if not facilitated. On the other hand, the patients who participate in the decision-making process show greater treatment adherence and have better health outcomes. Different methods to encourage the active participation during oncological consultation have been described; however, similar studies in Italy are lacking. The aims of the present study are to (1) assess the effects of a preconsultation intervention to increase the involvement of breast cancer patients during the consultation, and (2) explore the role of the attending companions in the information exchange during consultation. Methods and analysis All female patients with breast cancer who attend the Oncology Out-patient Services for the first time will provide an informed consent to participate in the study. They are randomly assigned to the intervention or to the control group. The intervention consists of the presentation of a list of relevant illness-related questions, called a question prompt sheet. The primary outcome measure of the efficacy of the intervention is the number of questions asked by patients during the consultation. Secondary outcomes are the involvement of the patient by the oncologist; the patients perceived achievement of her information needs; the patients satisfaction and ability to cope; the quality of the doctor–patient relationship in terms of patient-centeredness; and the number of questions asked by the patients companions and their involvement during the consultation. All outcome measures are supposed to significantly increase in the intervention group. Ethics and dissemination The study was approved by the local Ethics Committee of the Hospital Trust of Verona. Study findings will be disseminated through peer-reviewed publications and conference presentations. Trial registration ClinicalTrials.gov identifier: NCT01510964

Interprofessional education about patient decision support in specialty care.

Specialty care involves services provided by health professionals who focus on treating diseases affecting one body system. In contrast to primary care – aimed at providing continuous, comprehensive care – specialty care often involves intermittent episodes of care focused around specific medical conditions. In addition, it typically includes multiple providers who have unique areas of expertise that are important in supporting patients’ care. Interprofessional care involves multiple professionals from different disciplines collaborating to provide an integrated approach to patient care. For patients to experience continuity of care across interprofessional providers, providers need to communicate and maintain a shared sense of responsibility to their patients. In this article, we describe challenges inherent in providing interprofessional patient decision support in specialty care. We propose ways for providers to engage in interprofessional decision support and discuss promising approaches to teaching an interprofessional decision support to specialty care providers. Additional evaluation and empirical research are required before further recommendations can be made about education for interprofessional decision support in specialty care.

How psychiatrist's communication skills and patient's diagnosis affect emotions disclosure during first diagnostic consultations

OBJECTIVE To describe how emotions are disclosed during psychiatric diagnostic consultations and the contribution of the psychiatrists in facilitating their expression. METHODS Descriptive naturalistic study. Sixteen psychiatrists recorded their first consultations with 104 patients. Emotions and the immediate response given by the psychiatrist were coded with the Verona Coding Definitions of Emotional Sequences. For each disclosed emotion, the potential link to preceding expressions with affective content (cue or concern) was checked and the immediate response given by the psychiatrist was coded. RESULTS Most emotions were expressions of anxiety in terms of psycho-physiological or cognitive correlates. Concerns were present in 94% of the consultations, 47.6% were not linked to previous cues/concerns. Cues which became concerns and concerns which were further elaborated by the patient were those that had been acknowledged and handled by the psychiatrist by actively providing space to their expression. Compared to all other diagnostic groups, patients with mood disorders talked more explicitly and more often about their feelings. CONCLUSION The type and frequency of expressed emotions varies with patient diagnosis, suggesting different cognitive processes underlining psychopathology. PRACTICE IMPLICATIONS Psychiatrists competence in providing space by using active listening skills is essential to uncover patients emotions.