Effects of a question prompt sheet on active patient behaviour: a randomized controlled trial with depressed outpatients.

BACKGROUND: A deeper engagement into medical decision-making is demanded by treatment guidelines for patients with affective disorders. There is to date little evidence on what facilitates active behaviour of patients with depression. In general medicine 'question prompt sheets' (QPSs) have been shown to change patients' behaviour in the consultation and improve treatment satisfaction but there is no evidence for such interventions for mental health settings. AIMS: To study the effects of a QPS on active patient behaviour in the consultation. METHODS: Randomized controlled trial (involving N = 100 outpatients with depression) evaluating the effects of a QPS on patients' behaviour in the consultation. RESULTS: The QPS showed no influence on the number of topics raised by patients (p = .13) nor on the external rater's perception of 'Who made the decisions in today's consultation?' (p = .50). CONCLUSIONS: A QPS did not change depressed patients' behaviour in the consultation. More complex interventions might be needed to change depressed patients' behaviour within an established doctor-patient dyad. Patient seminars addressing behavioural aspects have been shown to be effective in other settings and may also be feasible for outpatients with affective disorders.

How should patients behave to facilitate shared decision making--the doctors' view.

OBJECTIVE: To study how physicians feel about patients' efforts to be engaged in shared decision making (SDM). STUDY SETTING AND DESIGN: Survey of physicians from distinctly different medical disciplines (238 psychiatrists and 169 vascular surgeons). Participants were requested to judge which patient behaviours they find helpful and which behaviours detrimental for SDM. RESULTS: Psychiatrists and surgeons had rather positive attitudes about active patient behaviours. However, there were quite a few patient behaviours (e.g. searching the Internet, being assertive towards the doctor) which provoked ambivalent or negative attitudes. DISCUSSION AND CONCLUSIONS: Physicians are generally quite open towards active patient behaviour in the consultation. They, however, do consider it as less helpful and become more annoyed if patients insist on their preferences and doubt their doctors' recommendations. Physicians must realize that SDM implies giving up decisional power and try to be more flexible in their interactions with patients.

Why do some patients with schizophrenia want to be engaged in medical decision making and others do not?

OBJECTIVE: Treatment guidelines for schizophrenia recommend that medical decisions should be shared between patients with schizophrenia and their physicians. Our goal was to determine why some patients want to participate in medical decision making and others do not. METHOD: To identify determinants of participation preferences in schizophrenia patients (ICD-10 criteria) and in a nonpsychiatric comparison group (multiple sclerosis), we undertook a cross-sectional survey in 4 psychiatric and neurologic hospitals in Germany. Inpatients suffering from schizophrenia or multiple sclerosis (but not both) were consecutively recruited (2007-2008), and 203 patients participated in the study (101 with schizophrenia and 102 with multiple sclerosis). Predictors for patients' participation preferences were identified using a structural equation model. RESULTS: Patients' reports about their participation preferences in medical decisions can be predicted to a considerable extent (52% of the variance). For patients with schizophrenia, poor treatment satisfaction (P < .001), negative attitudes toward medication (P < .05), better perceived decision making skills (P < .001), and higher education (P < .01) were related to higher participation preferences. In the comparison group, drug attitudes (P < .05) and education (P < .05) were also shown to be related with participation preferences. CONCLUSIONS: Patients with schizophrenia who want to participate in decision making are often dissatisfied with care or are skeptical toward medication. Patients who judge their decisional capacity as poor or who are poorly educated prefer not to participate in decision making. Future implementation strategies for shared decision making must address how dissatisfied patients can be included in decision making and how patients who currently do not want to share decisions can be enabled, empowered, and motivated for shared decision making.

Can psychiatrists and neurologists predict their patients' participation preferences?

There is evidence that an optimal match of patients' participation preferences improves health outcomes. Since it is unknown whether psychiatrists and neurologists can predict their patients' participation preferences we performed a cross-sectional survey involving N = 101 inpatients with schizophrenia/schizoaffective disorder and N = 102 inpatients with multiple sclerosis. Both patients and their physicians in charge were surveyed with respect to the patients' participation preferences, using the Autonomy Preference Index and a global estimate. Most patients wished to participate in medical decision making. Doctors performed poorly when predicting their individual patients' participation preferences and tended to overestimate their patients' participation preferences. A longer duration of the hospital stay did not improve the accuracy of doctors' estimates. Thus, neurologists and psychiatrists fail at predicting their patients' participation preferences accurately, which might challenge patients' treatment satisfaction. More attention in the consultation should be paid to patients' preferences.

Psychiatrists' use of shared decision making in the treatment of schizophrenia: patient characteristics and decision topics.

OBJECTIVE: Shared decision making is advocated as a way of involving patients in medical decisions, but it can be achieved only when both patients and physicians commit to sharing decisions. This study explored psychiatrists' views of shared decision making in schizophrenia treatment. METHOD: A structured questionnaire was given to 352 psychiatrists at the 2007 congress of the German Society of Psychiatry, Psychotherapy, and Nervous Diseases to determine their self-reported decision-making styles. Approximately half of the psychiatrists (N=181) were then asked to rate how 19 patient characteristics would influence whether they would share in decision making, and the other half (N=171) were asked whether 19 decision topics would be suitable for shared decision making. RESULTS: Of the 352 participating psychiatrists, 51% reported regularly applying shared decision making, but decision-making styles were tailored to individual patients and decision topics. Shared decision making was seen as useful for well-informed and compliant patients and for those who currently dislike their antipsychotic, but it was not seen as useful in cases of potentially reduced decisional capacity. Psychosocial matters (for example, work therapy, future housing, and psychotherapy) were considered more suitable for shared decision making than were medical and legal decisions (for example, hospitalization, prescription of antipsychotics, and diagnostic procedures). CONCLUSIONS: It should be clarified whether and how patients with schizophrenia can be empowered and educated so they can share important treatment decisions.

Context, complexity, and cognitive processing in schizophrenia.

BACKGROUND: Cohen et al.'s (1990, 1999) concept of context has been employed to explain various schizophrenic cognitive deficits. Braver et al.'s (2001) modified definition allows us to link context to cognitive complexity and explain a range of our experimental findings. METHOD: Saccadic and manual responses to experimental paradigms involving familiar and unfamiliar versions of tasks varying in stimulus-response compatibility, response familiarity, and temporal factors were used. These include comparison of acoustic and visually driven saccades and antisaccades, manual and saccadic pattern reproduction, and colour (cognitively guided) saccades with two delay intervals. RESULTS: In one experiment, schizophrenic participants, unlike controls, made fewer errors on the auditory compared to the visual antisaccade task, suggesting that prepotent responses are more easily inhibited when stimulus-response compatibility is reduced. In a second experiment in which a left-right response sequence is reproduced manually or saccadically, schizophrenic performance is impaired when the novel and thus more complex saccadic response is required. In the third experiment, a colour signal is interpreted to determine the correct direction of a saccade. With two different blocked delay intervals, shortening the delay results in schizophrenic performance decline, suggesting difficulty adjusting to temporal context changes. CONCLUSION: These results, together with our previous findings (Schooler et al., 1997a; Zahn et al., 1998) suggest schizophrenic context processing deficits become increasingly evident as contexts become more complex. These results may be due to microgaps in schizophrenic individuals' maintenance of context.

Patients' and psychiatrists' perceptions of clinical decisions during schizophrenia treatment.

Shared decision making is advocated for patients with schizophrenia. However, there is limited knowledge as to which events are actually considered to be decisions by psychiatrists and patients. Semistructured interviews with regard to clinical decisions of the preceding week were performed with psychiatrists and inpatients with schizophrenia. There was good correspondence between patients and psychiatrists regarding decisional topics but poor correspondence regarding individual decisions. Medication issues were the most prominent, but other topics were also frequently cited. Not being included in decisions was associated with patients' desire to make the decisions differently. Patients treated involuntarily felt more often that they were not included in decisions and wanted to make different decisions. Thus, many patients do not feel involved in treatment decisions and are at the risk of noncompliance since they state that they would have made decisions differently from their psychiatrists. This is especially true of those being treated involuntarily.

Shared decision making and long-term outcome in schizophrenia treatment.

OBJECTIVE: Compliance with antipsychotic medication is a major issue in schizophrenia treatment, and noncompliance with antipsychotic treatment is closely related to relapse and rehospitalization. An enhanced involvement of patients with schizophrenia in treatment decisions ("shared decision making") is expected to improve long-term compliance and reduce rehospitalizations. The aim of the present analysis was to study whether shared decision making (SDM) in antipsychotic drug choice would influence long-term outcome. METHOD: From February 2003 to January 2004, psychiatric state hospital inpatients with a diagnosis of schizophrenia (ICD-10; N = 107) were recruited for the trial using a cluster-randomized controlled design. An SDM program on antipsychotic drug choice consisting of a decision aid and a planning talk between patient and physician was compared with routine care with respect to long-term compliance and rehospitalizations (6-month and 18-month follow-up). RESULTS: On the whole, we found high rates of noncompliance and rehospitalization. There were no differences between intervention and control groups in the univariate analyses. However, when controlling for confounding factors in a multivariate analysis, there was a positive trend (p = .08) that patients in the SDM intervention had fewer rehospitalizations. Additionally, a higher desire of the patient for autonomy and better knowledge at discharge were associated with higher hospitalization rates. CONCLUSION: The intervention studied showed a positive trend but no clear beneficial effect on long-term outcomes. A more thorough implementation of SDM (e.g., iterative administration of decision aid) might yield larger effects. Those patients with higher participation preferences are at higher risk for poor treatment outcomes and therefore require special attention. Strategies to match these patients' needs might improve compliance and long-term outcomes.

Motoric neurological soft signs and psychopathological symptoms in schizophrenic psychoses.

Motoric neurological soft signs (NSS) were investigated by means of the Brief Motor Scale (BMS) in 82 inpatients with DSM-III-R schizophrenic psychoses. To address potential fluctuations of psychopathological symptoms and extrapyramidal side effects, patients were examined in the subacute state, twice at an interval of 14 days on the average. NSS were significantly correlated with severity of illness, lower social functioning, and negative symptoms. Modest, but significant correlations were found between NSS and extrapyramidal side effects as assessed on the Simpson-Angus Scale. Neither the neuroleptic dose prescribed to the patient, nor scores for tardive dyskinesia and akathisia were significantly correlated with NSS. Moreover, NSS scores did not significantly differ between patients receiving clozapine and conventional neuroleptics. Patients in whom psychopathological symptoms remained stable or improved over the clinical course showed a significant reduction of NSS scores. This finding did not apply to those patients in whom psychopathological symptoms deteriorated. Our findings demonstrate that NSS in schizophrenic psychoses are relatively independent of neuroleptic side effects, but they are associated with the severity and persistence of psychopathological symptoms and with poor social functioning.

The Brief Motor Scale (BMS) for the assessment of motor soft signs in schizophrenic psychoses and other psychiatric disorders.

Subtle motor impairment is an important aspect of neurological soft signs (NSS) which are frequently found in psychiatric patients-particularly schizophrenic patients. On the basis of data collected in previous studies using two different NSS scales, the most reliable and discriminative signs of motor impairment were identified to construct a brief 10-item rating scale. Subsequently, the new scale was applied to a sample of subacute patients with schizophrenic psychoses (N = 82) and healthy controls (N = 33). Factor analysis identified two factors which were labeled "motor coordination" and "motor sequencing". Both the total score and the subscores showed high internal consistency and test-retest reliability. There were highly significant group differences on the total score and the subscores as well as on each individual task. The scale has high sensitivity (84.1%) and specificity (87.9%) indicating that it may provide an effective instrument for the screening of subjects with neurodysfunction as well as for monitoring motor dysfunction in the clinical course of psychiatric disorders.

Do patients with schizophrenia wish to be involved in decisions about their medical treatment?

OBJECTIVE: Little is known about the desire of patients with schizophrenia to be involved in medical decisions affecting their treatment. METHOD: The authors administered the Autonomy Preference Index to 122 inpatients with schizophrenia. In addition, the patients filled out the Drug Attitude Inventory. Sociodemographic data and Positive and Negative Syndrome Scale ratings were available for all patients. RESULTS: The patients expressed a desire for shared decision making that was slightly greater than that of primary care patients. Negative attitudes toward medical treatment and younger age were associated with a higher desire for participation. CONCLUSIONS: It is important to meet the participation needs of patients who are dissatisfied with their psychiatric treatment.

How do psychiatrists choose among different antipsychotics?

OBJECTIVE: We attempted to determine the decision rules psychiatrists use in the choice of antipsychotic drugs for inpatients with schizophrenia. METHODS: Interviews were conducted with 50 hospital psychiatrists in Southern Germany. Each physician was interviewed with respect to the reasons for his antipsychotic drug choice in the cases of three patients with a diagnosis of schizophrenia. Interviews were audiotaped and subsequently analyzed using a standardized coding scheme. RESULTS: The clinical decision rules identified are highly complex, with a mean of eight categories cited per patient. Categories named included the patient's past treatment response, side effects, intended route of administration and co-morbidities. Moreover, psychiatrists strongly take the patient's target symptoms and the assumed efficacy of certain compounds into account in their choice of medication. CONCLUSION: Psychiatrists' explanations for their antipsychotic drug choice seem for the most part reasonable and overlap substantially with drug-choice algorithms of clinical guidelines. However, psychiatrists additionally use indicators that--in their view--might predict treatment response. For these indicators, which are derived from personal experience, it is still unclear whether they are valid and simply have not yet been proven in clinical trials or whether they merely represent unfounded assumptions on the part of the doctors.

Semantic categorization in the human brain: spatiotemporal dynamics revealed by magnetoencephalography.

We examined the cortical representation of semantic categorization using magnetic source imaging in a task that revealed both dissociations among superordinate categories and associations among different base-level concepts within these categories. Around 200 ms after stimulus onset, the spatiotemporal correlation of brain activity elicited by base-level concepts was greater within than across superordinate categories in the right temporal lobe. Unsupervised clustering of data showed similar categorization between 210 and 450 ms mainly in the left hemisphere. This pattern suggests that well-defined semantic categories are represented in spatially distinct, macroscopically separable neural networks, independent of physical stimulus properties. In contrast, a broader, task-required categorization (natural/man-made) was not evident in our data. The perceptual dynamics of the categorization process is initially evident in the extrastriate areas of the right hemisphere; this activation is followed by higher-level activity along the ventral processing stream, implicating primarily the left temporal lobe.

Slow event-related brain activity of aphasic patients and controls in word comprehension and rhyming tasks.

Slow event-related potentials (ERP) were examined in healthy and aphasic subjects in two-stimulus designs comprising a word comprehension and a rhyming task. Aphasics, though selected to perform above chance level, made significantly more errors and responded more slowly than controls, although canonical correlations did not indicate a statistical relationship between performance measures and ERP amplitudes. A discriminant analysis of ERP amplitudes distinguished the groups for the slow wave (SW; 0.5-1.0 s post-S1 onset) in the word comprehension, for the SW and the initial contingent negative variation (iCNV; 1.0-2.0 s post-S1 onset) in the rhyming task. Similarly for both tasks, ERP topography showed left-anterior predominance of the negative SW and iCNV in controls, whereas participants with aphasia showed smaller anterior and larger left-posterior amplitudes. The centroparietal terminal CNV (tCNV; 1 s pre-S2) was smaller in participants with aphasia than in controls, but similar in topography. Results suggest left-anterior activation for those language processes that were presumably provoked in the present tasks, like lexical access, or phonological encoding. The pattern of participants with aphasia may indicate effects of language impairment and recovery, but also consequences of the brain damage.

Brain activity during syntactic and semantic processing--a magnetoencephalographic study.

Drawings of objects were presented in series of 54 each to 14 German speaking subjects with the tasks to indicate by button presses a) whether the grammatical gender of an object name was masculine ("der") or feminine ("die") and b) whether the depicted object was man-made or nature-made. The magnetoencephalogram (MEG) was recorded with a whole-head neuromagnetometer and task-specific patterns of brain activity were determined in the source space (Minimum Norm Estimates, MNE). A left-temporal focus of activity 150-275 ms after stimulus onset in the gender decision compared to the semantic classification task was discussed as indicating the retrieval of syntactic information, while a more expanded left hemispheric activity in the gender relative to the semantic task 300-625 ms after stimulus onset was discussed as indicating phonological encoding. A predominance of activity in the semantic task was observed over right fronto-central region 150-225 ms after stimulus-onset, suggesting that semantic and syntactic processes are prominent in this stage of lexical selection.