Rose McCabe

The effect of clinician-patient alliance and communication on treatment adherence in mental health care: a systematic review

BackgroundNonadherence to mental health treatment incurs clinical and economic burdens. The clinician-patient alliance, negotiated through clinical interaction, presents a critical intervention point. Recent medical reviews of communication and adherence behaviour exclude studies with psychiatric samples. The following examines the impact of clinician-patient alliance and communication on adherence in mental health, identifying the specific mechanisms that mobilise patient engagement.MethodsIn December 2010, a systematic search was conducted in Pubmed, PsychInfo, Web of Science, Cochrane Library, Embase and Cinahl and yielded 6672 titles. A secondary hand search was performed in relevant journals, grey literature and reference.Results23 studies met the inclusion criteria for the review. The methodological quality overall was moderate. 17 studies reported positive associations with adherence, only four of which employed intervention designs. 10 studies examined the association between clinician-patient alliance and adherence. Subjective ratings of clinical communication styles and messages were assessed in 12 studies. 1 study examined the association between objectively rated communication and adherence. Meta-analysis was not possible due to heterogeneity of methods. Findings were presented as a narrative synthesis.ConclusionsClinician-patient alliance and communication are associated with more favourable patient adherence. Further research of observer rated communication would better facilitate the application of findings in clinical practice. Establishing agreement on the tasks of treatment, utilising collaborative styles of communication and discussion of treatment specifics may be important for clinicians in promoting cooperation with regimens. These findings align with those in health communication. However, the benefits of shared decision making for adherence in mental health are less conclusive than in general medicine.

Trust, choice and power in mental health care: Experiences of patients with psychosis

Background: Trust, choice and power are critical issues in clinical practice, public policies and a post-modern understanding of mental health care. We aimed to investigate the experiences and attitudes of patients with psychosis in relation to trust, choice and power. Method: We conducted 20 in-depth interviews with patients with psychotic disorders in care of NHS services. The interviews were subjected to thematic analysis. Discussion: Patients discussed aspects of their care in terms of dimensions that enhance or undermine trust, choice and power. Two interpretive themes emerged from this data. First, patients perceive the need for a shifting balance of power, according to the severity of their illness and their own experience of care, but feel that threats of coercion and neglect disable them. Second, they appreciate the expertise of clinicians, but particularly value ‘the personal touch’ that goes beyond this expertise, including personal disclosure about their own lives, common acts of kindness and conversation outside clinical matters. Patients view trust as a two-way process with responsibility shared between patient and clinician. Conclusions: The active involvement of patients with psychosis in their individual care may be strengthened, particularly when they are not acutely ill and have more experience of their illness. While patients value expertise and respect in interactions with clinicians, they also appreciate a ‘personal touch’, which may go beyond current notions of professionalism.

Financial incentives to improve adherence to anti-psychotic maintenance medication in non-adherent patients - a cluster randomised controlled trial (FIAT)

BackgroundVarious interventions have been tested to achieve adherence to anti-psychotic maintenance medication in non-adherent patients with psychotic disorders, and there is no consistent evidence for the effectiveness of any established intervention. The effectiveness of financial incentives in improving adherence to a range of treatments has been demonstrated; no randomised controlled trial however has tested the use of financial incentives to achieve medication adherence for patients with psychotic disorders living in the community.Methods/DesignIn a cluster randomised controlled trial, 34 mental health teams caring for difficult to engage patients in the community will be randomly allocated to either the intervention group, where patients will be offered a financial incentive for each anti-psychotic depot medication they receive over a 12 month period, or the control group, where all patients will receive treatment as usual. We will recruit 136 patients with psychotic disorders who use these services and who have problems adhering to antipsychotic depot medication, although all conventional methods to achieve adherence have been tried. The primary outcome will be adherence levels, and secondary outcomes are global clinical improvement, number of voluntary and involuntary hospital admissions, number of attempted and completed suicides, incidents of physical violence, number of police arrests, number of days spent in work/training/education, subjective quality of life and satisfaction with medication. We will also establish the cost effectiveness of offering financial incentives.DiscussionThe study aims to provide new evidence on the effectiveness and cost effectiveness of offering financial incentives to patients with psychotic disorders to adhere to antipsychotic maintenance medication. If financial incentives improve adherence and lead to better health and social outcomes, they may be recommended as one option to improve the treatment of non-adherent patients with psychotic disorders.Trial RegistrationCurrent controlled trials ISRCTN77769281.

Communication and psychosis : it's good to talk, but how?

Communication between clinicians and patients is at the heart of psychiatric practice and particularly challenging with psychotic patients. It may influence patient outcome indirectly or be therapeutic in its own right. Appropriate conceptual models, evidence on effective interventions and specific training are required to optimise communication in everyday routine practice.

Shared decision-making in ongoing outpatient psychiatric treatment

OBJECTIVE Research on patient involvement in decision-making in psychiatry has focused on first encounters. This study investigated what decisions are made, level of patient involvement and factors influencing patient involvement in ongoing outpatient visits. METHODS 72 visits conducted by 20 psychiatrists were video recorded. Patients had a diagnosis of depression or schizophrenia. RESULTS On average, there was one medication related and one other decision per visit. Some psychiatrists involved patients more in decisions, as did female psychiatrists. Involvement was lower when patients had more negative symptoms. CONCLUSION Involvement in decision-making appears to be influenced by the individual psychiatrist and specific symptoms but not visit length. PRACTICE IMPLICATIONS It is noteworthy that patient involvement is not influenced by length of the visit given that this would be a barrier in busy clinical practice. The next step would be to identify the communication patterns of psychiatrists who involve patients more in decision-making.

Friends and symptom dimensions in patients with psychosis: a pooled analysis.

Background Having friends is associated with more favourable clinical outcomes and a higher quality of life in mental disorders. Patients with schizophrenia have fewer friends than other mentally ill patients. No large scale studies have evaluated so far what symptom dimensions of schizophrenia are associated with the lack of friendships. Methods Data from four multi-centre studies on outpatients with schizophrenia and related disorders (ICD F20-29) were included in a pooled analysis (N = 1396). We established whether patients had close friends and contact with friends by using the equivalent items on friendships of the Manchester Short Assessment of Quality of Life or of the Lancashire Quality of Life Profile. Symptoms were measured by the Brief Psychiatric Rating Scale or by the identical items included in the Positive and Negative Syndrome Scale. Results Seven hundred and sixty-nine patients (55.1%) had seen a friend in the previous week and 917 (65.7%) had someone they regarded as a close friend. Low levels of negative symptoms and hostility were significantly associated with having a close friend and contact with a friend. Overall, almost twice as many patients with absent or mild negative symptoms had met a friend in the last week, compared with those with moderate negative symptoms. Conclusions Higher levels of negative symptoms and hostility are specifically associated with the lack of friendships in patients with psychotic disorders. These findings suggest the importance of developing effective treatments for negative symptoms and hostility in order to improve the probability of patients with schizophrenia to have friends.

Communication in healthcare interactions in dementia: a systematic review of observational studies.

BACKGROUND Communication is affected by dementia, even in the early stages. Studies directly observing how patients, companions and healthcare professionals communicate have not yet been reviewed. METHODS Eight databases were searched, and hand searches of relevant journals and grey literature were performed up to August 2014. Two authors reviewed abstracts independently and collectively reviewed for agreement of inclusion. Findings were narratively synthesized. RESULTS 23 studies were identified observing: diagnostic, follow up, day center, primary care and research consent interactions. Companions were present in 14 studies. Three themes emerged: emotional impact of diagnosis, level of patient involvement and participant strategies to save face and cope with cognitive impairment. Eight studies observed diagnostic disclosure describing emotional reactions, with professionals using mitigating language and rarely checking patient understanding. Studies reported varying patient involvement, showing marginalization in primary care but not in assessments or diagnostic feedback. Patients used humor and metaphor to compensate for difficulties retrieving information and responding appropriately, suggesting preserved awareness of the pragmatics of interaction. Companion roles fluctuated between patient advocate and professional informant. Professionals encountered challenges adapting to heterogeneous patient groups with varying capabilities and needs. CONCLUSIONS Patient-companion-professional communication in dementia care raises various ethical questions: how to strike a balance between different communicative needs of patients and companions; clarity versus sensitivity in delivery of the diagnosis; and whether to minimize or expose interactional difficulties and misunderstanding to enrich patient understanding and involvement. Healthcare professionals need guidance in delivering a diagnosis and strategies to optimize patient and companion participation.

Which medical and social decision topics are important after early diagnosis of Alzheimer's Disease from the perspectives of people with Alzheimer's Disease, spouses and professionals?

BackgroundThe relevance of early decision making will rise with increasing availability of early detection of Alzheimer’s disease (AD) using brain imaging or biomarkers.ResultsFive people with mild AD, six relatives and 13 healthcare professionals with experience in the management of AD were interviewed in a qualitative study regarding medical and social decision topics that emerge after early diagnosis of Alzheimer’s disease. Medical treatment, assistance in everyday life and legal issues emerged as the main decision topics after an early diagnosis of AD. People with AD mostly got in contact with the health and social care system through the initiative of their spouses. They were usually aware of their illness and most received antidementia drugs and/or behavioural interventions. Following diagnosis people with AD received support by their spouses. Healthcare professionals were aware of the risk of excessive demand on relatives due to supporting their family member with AD. In the opinion of healthcare professionals legal issues should be arranged in time before patients lose their decisional capacity. In addition, people with AD and spouses reported various coping strategies, in particular “carry on as normal” after diagnosis but mostly are reluctant to actively plan for future stages of the disease.ConclusionsDue to the common desire to “carry on as usual” after a diagnosis of AD, many people with AD and spouses may miss the opportunity to discuss and decide on important medical and social topics. A structured approach e.g. a decision aid might support people with AD and spouses in their decision making process and thereby preserve persons’ with AD autonomy before they lose the capacity in decision-making.

Interventions to improve therapeutic communications between Black and minority ethnic patients and professionals in psychiatric services: systematic review.

Background Communication may be an influential determinant of inequality of access to, engagement with and benefit from psychiatric services. Aims To review the evidence on interventions designed to improve therapeutic communications between Black and minority ethnic patients and clinicians who provide care in psychiatric services. Method Systematic review and evidence synthesis (PROSPERO registration: CRD42011001661). Data sources included the published and the ‘grey’ literature. A survey of experts and a consultation with patients and carers all contributed to the evidence synthesis, interpretation and recommendations. Results Twenty-one studies were included in our analysis. The trials showed benefits mainly for depressive symptoms, experiences of care, knowledge, stigma, adherence to prescribed medication, insight and alliance. The effect sizes were smaller for better-quality trials (range of d 0.18–0.75) than for moderate- or lower-quality studies (range of d 0.18–4.3). The review found only two studies offering weak economic evidence. Conclusions Culturally adapted psychotherapies, and ethnographic and motivational assessment leading to psychotherapies were effective and favoured by patients and carers. Further trials are needed from outside of the UK and USA, as are economic evaluations and studies of routine psychiatric care practices.

Linguistic Indicators of Severity and Progress in Online Text-based Therapy for Depression

Mental illnesses such as depression and anxiety are highly prevalent, and therapy is increasingly being offered online. This new setting is a departure from face-toface therapy, and offers both a challenge and an opportunity ‐ it is not yet known what features or approaches are likely to lead to successful outcomes in such a different medium, but online text-based therapy provides large amounts of data for linguistic analysis. We present an initial investigation into the application of computational linguistic techniques, such as topic and sentiment modelling, to online therapy for depression and anxiety. We find that important measures such as symptom severity can be predicted with comparable accuracy to face-to-face data, using general features such as discussion topic and sentiment; however, measures of patient progress are captured only by finergrained lexical features, suggesting that aspects of style or dialogue structure may also be important.