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“How to Speak to Your Psychiatrist”: Shared Decision-Making

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Brief Reports
“How to Speak to Your Psychiatrist”:
Shared Decision-Making Training
for Inpatients With Schizophrenia
Johannes Hamann, M.D.
Rosmarie Mendel, Ph.D.
Anna Meier
Florim Asani, R.N.
Esther Pausch, R.N.
Stefan Leucht, M.D.
Werner Kissling, M.D.
Objective: Involving patients with
mental illness in shared decision
making about their treatment has
recently attracted attention, but
existing interventions may insufficiently motivate or enable patients with schizophrenia to behave more actively. This study
evaluated a new intervention.
Methods: In a pilot study 61 inpatients with schizophrenia or
schizoaffective disorder from a
psychiatric hospital in Germany
were randomly assigned to receive shared decision-making
training (N=32) or cognitive training (N=29, control condition). Results: The shared decision-making
training yielded higher participation preferences and increased
patients’ desire to have more responsibility in treatment decisions, which continued to the sixmonth follow-up. Patients in the
intervention group became more
skeptical of treatment and were
perceived as more “difficult” by
their psychiatrists. Conclusions:
Training in shared decision making was highly accepted by patients and changed attitudes toward participation in decision
The authors are affiliated with the Psychiatric Department, Technische Universität
MГјnchen, Moehlstrasse 26, Munich 81675,
Germany (e-mail: j.hamann@lrz.tum.de).
1218
making. There were some hints
that it might generate beneficial
long-term effects. (Psychiatric
Services 62:1218–1221, 2011)
S
hared decision making is being
promoted as a promising approach for engaging patients with
schizophrenia in medical decisions
and improving satisfaction with and
adherence to treatment (1,2). To implement shared decision making,
both physicians and patients must
commit to it and engage in a mutual
decision process (3). Most research,
however, has addressed interventions
that either focus on the physician’s
side (in regard to the physician’s communication skills) or on informing patients about treatment options
(known as decision aids) (4). These
approaches have been shown to be
feasible in clinical practice but have
had no strong effects on treatment
patterns or adherence (4), possibly
because they are insufficient to motivate and enable patients to engage actively in decision making (5). Moreover, these interventions rely on the
physician’s willingness to share responsibility in making treatment decisions, which has been shown to vary
considerably (6).
To overcome these limitations and
because many patients do not feel
competent to participate in decision
making (7), we developed an intervention that focuses on patients’ comPSYCHIATRIC SERVICES
municative competencies. In somatic
medicine similar programs have been
shown to be effective in engaging patients in medical decisions and improving long-term compliance (8–10).
Methods
The training consisted of five onehour sessions for a group of five to
eight patients. The content of the
training was derived from theoretical
considerations about patients’ contributions to the shared decision-making process (3), from an adaptation of
related approaches from somatic
medicine (10), and from pilot testing
the training. The training sessions included motivational aspects (such as
prospects of participation) and behavioral aspects (including role-play exercises). The training emphasized interaction between moderators and
patients as well as mutual support. All
sessions were led by a psychiatrist and
a psychologist, neither of whom was
in charge of the specific care of these
patients. Patients in the control condition participated in a five-session
cognitive training group.
Patients were recruited from a university psychiatric hospital in Munich, Germany, from May 2009 to
February 2010. Male and female inpatients with schizophrenia or
schizoaffective disorder according to
the ICD-10 who were 18–60 years of
age were eligible for the study provided they were capable of tolerating a
♦ ps.psychiatryonline.org ♦ October 2011 Vol. 62 No. 10
60-minute interactive patient group.
Patients were recruited until group
size was reached and then randomly
assigned to the intervention or control condition. A randomization list
and numbered closed-allocation concealment envelopes were prepared
before the study. Institutional review
board approval was obtained for the
study, and patients gave written informed consent before participating.
Before the intervention, patients’
sociodemographic characteristics,
participation preferences (based on
the Autonomy Preference Index), decision self-efficacy (based on the Decision Self-Efficacy Scale), attitudes
toward medication (based on the Beliefs in Medication Questionnaire),
and satisfaction with treatment (satisfaction with treatment scale of the
ZUF8) were obtained. Psychiatrists
provided Positive and Negative Syndrome Scale (PANSS) scores.
After the intervention, patients’
participation preferences, decision
self-efficacy, attitudes toward medication, and treatment satisfaction
were surveyed. In addition, the Trust
in Physician Scale, the Multidimensional Health Locus of Control
Scales, and a rating of the groups
were administered. Finally, we administered a questionnaire on who
should take responsibility for decision
making. Here, patients answered 14
questions on different aspects of the
treatment process (“Who is responsible [for ensuring] that there is a discussion about your treatment if you
are suffering from side effects?”). Because internal consistency was high
(О±=.82), we used the sum score of all
14 items (“responsibility for decision
making”) for further analyses.
Psychiatrists provided ratings of
their patients’ decisional capacity (10point rating scale) and the therapeutic
alliance, and they filled out the Difficult Doctor-Patient Relationship
Questionnaire. Six months after discharge from the hospital, patients
completed the Autonomy Preference
Index and our questionnaire on “responsibility for decision making.”
They were asked who was making important medical decisions concerning
their health and whether they were
still taking medication. The outpatient
psychiatrists were surveyed independPSYCHIATRIC SERVICES
Table 1
Postintervention ratings by patients and physicians concerning schizophrenia
treatment decisions
Rating
By patients
Autonomy Preference Indexa
Responsibility for decision makingb
Decision Self-Efficacy Scalec
Beliefs in Medication Questionnaire
Necessityd
Concernse
General overusef
General harmg
Satisfaction With Treatmenth
Multidimensional Health Locus of
Control Scale
Self-responsibilityi
Self-blamej
Powerful othersk
Chancel
Trust in Physician Scalem
“Who makes important decisions
about your medical treatment?”n
By physicians
Difficult Doctor-Patient Relationship
Questionnaireo
Decisional capacityp
Therapeutic allianceq
Intervention
group (N=32)
Control
group (N=29)
M
M
SD
SD
p
(from
t test)
18.3
41.8
56.7
3.2
4.6
8.4
15.6
38.0
56.3
5.0
7.8
9.5
.01
.02
.87
18.1
16.1
12.0
9.1
25.5
3.6
5.0
3.5
3.2
4.1
19.3
13.9
10.4
8.1
26.7
3.8
4.1
2.3
2.6
3.2
.22
.07
.04
.20
.23
8.2
9.9
9.3
11.1
41.8
2.3
2.0
2.2
2.2
7.4
8.1
10.0
8.5
10.8
46.4
2.4
2.6
1.8
2.6
7.2
.98
.96
.13
.59
.02
2.52
40.4
62.7
23.8
.50
7.6
11.1
4.7
2.62
44.6
66.9
24.1
.60
8.4
13.3
4.8
.67
.05
.18
.83
a
Possible scores range from 6 to 30, with higher scores indicating higher participation preferences.
Possible scores range from 14 to 70, with higher scores indicating that the patient wants to take on
more responsibility for decision making.
c Possible scores range from 14 to 70, with higher scores indicating better decision self-efficacy.
d Possible scores range from 5 to 25, with higher scores indicating higher perceived necessity of the
medication.
e Possible scores range from 5 to 25, with higher scores indicating more concerns about medication.
f Possible scores range from 4 to 20, with higher scores indicating more concerns about medication
overuse.
g Possible scores range from 4 to 20, with higher scores indicating more perceived harm from medication.
h Possible scores range from 8 to 32, with higher scores indicating higher satisfaction.
i Possible scores range from 3 to 15, with higher scores indicating lower self-responsibility.
j Possible scores range from 3 to 15, with higher scores indicating lower self-blame.
k Possible scores range from 3 to 15, with higher scores indicating lower power attribution to others.
l Possible scores range from 3 to 15, with higher scores indicating lower power attribution to
chance.
m Possible scores range from 11 to 55, with higher scores indicating higher trust.
n Possible scores range from 1, “only you,” to 5, “only the doctor.”
o Possible scores range from 10 to 60, with higher scores indicating a better relationship.
p Possible scores range from 16 to 96, with higher scores indicating better decisional capacity.
q Possible scores range from 6 to 36, with higher scores indicating a better relationship.
b
ently regarding their patients’ compliance and rehospitalizations during the
preceding six-month period.
The intervention and control group
outcomes were compared with t tests
and chi square tests. A p value less
than .05 was considered significant.
[An appendix includes additional
references concerning the instruments, information on the training
sessions, and a CONSORT diagram
♦ ps.psychiatryonline.org ♦ October 2011 Vol. 62 No. 10
of participation and is available online
as a supplement to this brief report at
ps.psychiatryonline.org.]
Results
A total of 61 patients participated in
the study (32 in the intervention and
29 in the control group). There were
more female (N=38, 62%) than male
(N=23, 38%) patients, and the
meanВ±SD age was 40.7В±11.7. Dura1219
Table 2
Six-month follow-up ratings by patients and physicians concerning schizophrenia
treatment decisions
Rating
By patients
Autonomy Preference Index (MВ±SD)d
Responsibility for decision making (MВ±SD)e
“Who makes important decisions about your
medical treatment?” (M±SD)f
“Are you still in psychiatric treatment?” (yes)
“Are you still taking medication for your
psychiatric condition” (yes)
By physicians
“Has this patient shown up at your practice since
being discharged from the hospital?” (yes)g
Has this patient been hospitalized in the
preceding 6 months? (yes)
How do you estimate your patient’s compliance?
(MВ±SD)h
How much does this patient engage in planning
for his or her therapy? (MВ±SD)i
a
b
c
d
e
f
g
h
i
Intervention
groupa
Control
groupb
N
N
%
pc
%
Discussion and conclusions
18.2
38.2
3.8
5.3
15.1
34.1
4.5
8.0
.01
.04
3.36
.50
25
100
4.09
.80 .04
21
91
.22
25
100
20
87
.10
30
94
26
90
.45
5
17
4
15
.57
4.0
1.1
4.2
.9
.78
3.5
.9
3.2
.9
.19
Except where otherwise noted, N=25 for patients’ ratings and N=29 for physicians’ ratings.
Except where otherwise noted, N=23 for patients’ ratings and N=26 for physicians’ ratings.
By t test or chi square test
Possible scores range from 6 to 30, with higher scores indicating higher participation preferences.
Possible scores range from 14 to 70, with higher scores indicating that the patient wants to take on
more responsibility for decision making.
Possible scores range from 1, “only you,” to 5, “only the doctor.”
N=32 for the intervention group, and N=29 for the control group.
Possible scores range from 1, very poor, to 5, very good.
Possible scores range from 1, not at all, to 5, very much.
tion of illness was 11.1В±9.6 years; patients had a mean of five previous
hospitalizations. At study entry patients had been hospitalized for a
mean of four weeks, and their illness
was considered moderate (PANSS
score 75.5±19.0, range 30–210).
There were more women in the control group, and patients in the intervention group had higher PANSS
scores. However, there were no significant differences between the intervention and control groups for any
baseline measure.
After the group sessions, patients in
the intervention group compared
with patients in the control group
showed higher participation preferences and wanted to take on more responsibility in decision making (Table
1). This effect was still present six
months after discharge from the hospital (Table 2).
Intervention group patients expressed lower trust in their physicians, and psychiatrists perceived in1220
ences between the groups with regard
to rehospitalizations, engagement in
decision making, or patients’ compliance. For the three control group patients who stated that they no longer
took medication, the psychiatrists estimated compliance to be good.
tervention group patients as more difficult than control group patients. Finally, intervention group patients became more skeptical about their
treatment. There were no differences
in patients’ satisfaction with treatment, self-esteem about decision
making, or perceived necessity of
treatment. Physicians did not rate intervention and control group patients
differently with respect to their decisional capacity or therapeutic alliance
(Table 1).
Overall, patients rated the training
as very positive and helpful. Most patients (N=28, 88%) indicated that they
would aim to play a more active role in
future consultations. At follow-up, intervention group patients felt more involved in decision making than did
control group patients, and there was a
trend, according to self-ratings, that a
higher proportion of intervention
group patients continued their medication (Table 2). Among the physicians’ ratings, there were no differPSYCHIATRIC SERVICES
Our study had several limitations. It
was conducted at a single center and
involved the same moderators for all
group sessions. Results may thus not
be generalizable to other settings and
should be judged as generating
rather than confirming hypotheses.
Finally, there were some baseline differences between the intervention
and control groups that may have affected the results.
Patients who participated in the
shared decision-making training were
more interested and also more motivated to engage in decision making.
This effect was still present six
months after the intervention. Moreover, our intervention also changed
patients’ behavior, in that psychiatrists perceived patients in the intervention group as more difficult to
treat (stressful) than control group
patients. There were no effects on patients’ decisional self-efficacy, which
might be explained by a ceiling effect.
With respect to locus of control, there
was only a trend that intervention
group patients gave slightly higher
ratings on the “powerful others” subscale, indicating that they attributed
less power to their physicians. In addition there was a trend for intervention patients to feel more involved in
the decision-making process and to
be more persistent about taking medication (self-rating) at follow-up. The
latter finding, however, was not replicated by physicians’ ratings.
Alongside these encouraging findings, we also found a drop in patients’
trust in physicians and more skepticism toward psychiatric treatment.
On the one hand one could argue that
the training brought unnecessary discord into the doctor-patient relationship by making patients skeptical and
less cooperative. This fits the traditional model of compliance, in which
patients are expected to follow their
physician’s advice without disagreeing
(11). Accordingly, our intervention
♦ ps.psychiatryonline.org ♦ October 2011 Vol. 62 No. 10
may have worsened some mediators
of patients’ compliance. Apparently,
some psychiatrists might have felt this
way and rated intervention patients as
more difficult. Simultaneous shared
decision-making training for physicians (including skills to deal with assertive patients) might have quelled
some of the irritations shown in our
study.
On the other hand, from the mental health care consumers’ perspective, patients have a right to disagree
with their physicians and to argue for
treatment they believe to be best.
Here, the concept of “adherence”
might suit better, whereby patients
actively influence treatment decisions
and decide whether they want to consent to them (12). Thus our results
might be interpreted as patients who
no longer follow their doctors blindly
but ask for explanations or challenge
doctors’ recommendations when they
go against the patient’s preferences
(13). Therefore, our intervention
might have boosted patients’ behavior in the direction of adherence,
even if some psychiatrists were unhappy with the results. This interpretation may be supported by our follow-up findings, in which a greater
proportion of intervention group pa-
PSYCHIATRIC SERVICES
tients than control group patients indicated that they were still taking
medication.
Acknowledgments and disclosures
This work was supported by research project
grant 2168-1746.1/2007 from the German-Israeli Foundation for Scientific Research and
Development to Dr. Hamann and is registered
as NCT00885716 at clinicaltrials.gov. The follow-up of the patients was made possible
through a Young Minds in Psychiatry Award to
Dr. Hamann from the American Psychiatric
Association.
The authors report no competing interests.
References
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♦ ps.psychiatryonline.org ♦ October 2011 Vol. 62 No. 10
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