Maria Angela Mazzi

The perception of needs for care in staff and patients in community-based mental health services. The South-Verona Outcome Project 3.

Objective: The present study aims to assess needs for care rated by patients and staff and their agreement on needs assessment in a community‐based mental health service by using the Camberwell Assessment of Need (CAN).

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.

Sex differences in the subjective tolerability of antipsychotic drugs.

Abstract: In recent years, research efforts have been directed to better characterize the subjective experience of taking psychotropic drugs. This study investigated the sex difference in the subjective tolerability of antipsychotic drugs. Participants were recruited from patients under the care of psychiatric services serving geographical catchment areas in Croydon (UK), Verona (Italy), Amsterdam (Netherlands), and Leipzig (Germany). Clinically unstable patients with a clinical diagnosis of schizophrenia and a research diagnosis of schizophrenia, established using the Item Group Checklist of the Schedule for Clinical Assessment in Neuropsychiatry, were enrolled. Antipsychotic subjective tolerability was rated by means of the Liverpool University Neuroleptic Side Effect Rating Scale. During the recruitment period, 245 men and 164 women with schizophrenia were recruited. In both sexes, the most frequently reported side effects were difficulty in concentrating, tiredness, and weight gain; these side effects occurred in approximately 50% of men and in up to 70% of women. Extrapyramidal and anticholinergic reactions were reported more often by women, whereas men reported sexual problems more often. After background group differences were controlled for, sex was the strongest determinant of the subjective tolerability of antipsychotic drugs. We therefore conclude that sex differences in the subjective tolerability of antipsychotic drugs should be taken into account in the pharmacological management of patients with schizophrenia. Studies should no longer consider men and women as a homogeneous group, given that the subjective tolerability of antipsychotic drugs substantially differs between sexes.

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 biopsychosocial domains and the functions of the medical interview in primary care: construct validity of the Verona Medical Interview Classification System

Factor analysis (FA) is a powerful method of testing the construct validity of coding systems of the medical interview. The study uses FA to test the underlying assumptions of the Verona Medical Interview Classification System (VR-MICS). The relationship between factor scores and patient characteristics was also examined. The VR-MICS coding categories consider the three domains of the biopsychosocial model and the main functions of the medical interview-data gathering, relationship building and patient education. FA was performed on the frequencies of the VR-MICS categories based on 238 medical interviews. Seven factors (62.5% of variance explained) distinguished different strategies patients and physicians use to exchange information, build a relationship and negotiate treatment within the domains of the biopsychosocial model. Three factors, Psychological, Social Inquiry and Management of Patient Agenda, were related to patient data: sociodemographic (female gender, age and employment), social (stressful events), clinical (GHQ-12 score), personality (chance external health locus of control) and clinical characteristics (psychiatric history, chronic illness, attributed presence of emotional distress).

Comparison of Patient and Clinician Perspectives in the Assessment of Antipsychotic Medication Adherence

Background: Factors influencing patient and clinician perspectives in the assessment of medication adherence have never been compared. Method: This study used baseline and 12-month follow-up data from the QUATRO study, an international multicentre study. At baseline, information on patient sociodemographic characteristics, treatment factors, psychopathology, functioning and experience of antipsychotic side effects was gathered. After 12 months of follow-up, psychopathology, functioning and patient experience of antipsychotic side effects were measured once more, and a patient and clinician rating of adherence was obtained by means of the Medication Adherence Rating Scale (MARS) and the Compliance Rating Scale (CRS). Results: During the recruitment period, 409 subjects with a diagnosis of schizophrenia were recruited. Patients were more often men and single. Mean age was 41.5 years. At the time of the assessment, more than 40% were unemployed and on average had been on antipsychotic treatment for more than 10 years. Nearly 70% were receiving second-generation antipsychotics, and 50% received adherence therapy during the 12 months after enrolment. The relationship between the MARS and the CRS scores showed only a small overlap (correlation coefficient = 0.26). In the multivariate model, the only factor significantly associated with both patient and clinician ratings of adherence was psychopathology. Unemployment and poor subjective tolerability of antipsychotics were significantly associated with low levels of patient ratings of adherence. Conversely, length of treatments and use of newer antipsychotics were significantly associated with better clinician ratings of adherence. Conclusion: Patient and clinician ratings of adherence do not measure the same dimension. Factors that may positively affect adherence in terms of compliance with prescribed medication regimens may not affect patients’ views on adherence, and this should be taken into consideration when planning and negotiating treatment modalities with each individual patient suffering from schizophrenia.

What do people appreciate in physicians' communication? An international study with focus groups using videotaped medical consultations

The literature shows that the quality of communication is usually determined from a professional perspective. Patients or lay people are seldom involved in the development of quality indicators or communication.

Quality of doctor-patient communication through the eyes of the patient: variation according to the patient's educational level

Abstract Good doctor–patient communication may lead to better compliance, higher patient satisfaction, and finally, better health. Although the social variance in how physicians and patients communicate is clearly demonstrated, little is known about what patients with different educational attainments actually prefer in doctor–patient communication. In this study we describe patients’ perspective in doctor–patient communication according to their educational level, and to what extent these perspectives lean towards the expert opinion on doctor–patient communication. In a multi-center study (Belgium, The Netherlands, UK and Italy), focus group discussions were organised using videotaped medical consultations. A mixed methods approach was used to analyse the data. Firstly, a difference in perspective in communication style was found between the lower educated participants versus the middle and higher educated participants. Secondly, lower educated participants referred positively most to aspects related to the affective/emotional area of the medical consultation, followed by the task-oriented/problem-focused area. Middle and higher educated participants positively referred most to the task-oriented/problem-focused area. The competency of the physician was an important category of communication for all participants, independent of social background. The results indicate that the preferences of lower educated participants lean more towards the expert opinion in doctor–patient communication than the middle and higher educated participants. Patients’ educational level seems to influence their perspective on communication style and should be taken into account by physicians. Further quantitative research is needed to confirm these results.

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

A theory‐based proposal to evaluate patient‐centred communication in medical consultations: The Verona Patient‐centred Communication Evaluation scale (VR‐COPE)

– The prupose of this paper is to present the development of the Verona Patient‐Centred Communication Evaluation (VR‐COPE) scale, together with its psychometric properties. The nine item rating scale assesses the content and relational aspects of patient‐centred communication during medical consultations on the basis of a multidimensional evaluation as suggested by the more recent literature in the field. Each item is defined by operational definitions., – A sample of 246 transcribed primary care consultations was rated with the VR‐COPE. Explorative factor analysis, Pearson correlation coefficients and internal consistency using Cronbachs alpha were calculated. Convergent validity with the Verona Medical Interview Classification System (VR‐MICS) was also tested. A sub sample of 32 consultations was used to assess inter‐rater reliability., – Interrater reliability and internal consistency were good (overall Cronbach alpha=0.75). Four factors (explaining 74 per cent of the variance) were extracted by exploratory factor analysis. Six items of the VR‐COPE correlated significantly with specific communication skills evidenced by the VR‐MICS and pertained to the physicians ability to explore medical or psychosocial issues. The VR‐COPE items on interview structure and shared decision, more related to process than to specific skills, had no equivalent in the VR‐MICS., – The new rating scale responds to the need in communication research for a multidimensional scale that combines the evaluation of specific skills and process aspects.