A "Mental-Health-at-the-Workplace" Educational Workshop Reduces Managers' Stigma Toward Depression.

Stigma and discrimination are important factors hindering people with mental health conditions to stay employed or successfully make their careers. We surveyed 580 German managers before and after visiting a "mental-health-at-the-workplace" educational workshop using the Depression Stigma Scale. The workshop significantly reduced stigma toward depression. Managers at baseline already exhibited lower stigma toward depression compared with the general population. In addition, female gender and higher education predicted lower stigma, which is in line with findings from other studies. We conclude that an educational workshop giving practical guidance regarding "mental-health-at-the-workplace" reduces managers' stigma toward depression and improves knowledge regarding depression, its course, and its treatment.

Surrogate decision making for patients with end-stage dementia.

OBJECTIVE: We aim to explore how health surrogates of patients with dementia proceed in decision making, which considerations are decisive, and whether family surrogates and professional guardians decide differently. METHODS: We conducted an experimental vignette study using think aloud protocol analysis. Thirty-two family surrogates and professional guardians were asked to decide on two hypothetical case vignettes, concerning a feeding tube placement and a cardiac pacemaker implantation in patients with end-stage dementia. They had to verbalize their thoughts while deciding. Verbalizations were audio-recorded, transcribed, and analyzed according to content analysis. By experimentally changing variables in the vignettes, the impact of these variables on the outcome of decision making was calculated. RESULTS: Although only 25% and 31% of the relatives gave their consent to the feeding tube and pacemaker placement, respectively, 56% and 81% of the professional guardians consented to these life-sustaining measures. Relatives decided intuitively, referred to their own preferences, and focused on the patient's age, state of wellbeing, and suffering. Professional guardians showed a deliberative approach, relied on medical and legal authorities, and emphasized patient autonomy. Situational variables such as the patient's current behavior and the views of health care professionals and family members had higher impacts on decisions than the patient's prior statements or life attitudes. CONCLUSIONS: Both the process and outcome of surrogate decision making depend heavily on whether the surrogate is a relative or not. These findings have implications for the physician-surrogate relationship and legal frameworks regarding surrogacy.

Do physicians' recommendations pull patients away from their preferred treatment options?

CONTEXT AND OBJECTIVE: Shared decision making is especially advocated for preference-sensitive decisions. We investigated whether physicians' recommendations pull patients away from their preferred treatment option when making a preference-sensitive decision. DESIGN, PARTICIPANTS AND METHODS: Inpatients (N = 102 with schizophrenia, N = 101 with multiple sclerosis) were presented with a hypothetical scenario (the choice between two drugs). They were first asked about their preferences concerning the two drugs and then they received a (fictitious) clinician's recommendation that was contrary to their preferences. Subsequently they made a final choice between the two drugs. MAIN OUTCOME MEASURES: The main outcome measure was whether the patient followed the physician's advice in the hypothetical scenario. Thereby patient's (pre-recommendation) preferences served as a baseline. RESULTS: In the decision scenario, about 48% of the patients with schizophrenia and 26% of the patients with multiple sclerosis followed the advice of their physician and thus chose the treatment option that went against their initial preferences. Patients who followed their physician's advice were less satisfied with their decision than patients not following their physician's advice (schizophrenia: t = 2.61, P = 0.01; multiple sclerosis: t = 2.67, P = 0.009). DISCUSSION AND CONCLUSIONS: When sharing decisions with patients, physicians should be aware that their advice might influence patients' decisions away from their preferred treatment option. They should encourage their patients to identify their own preferences and help to find the treatment option most consistent with them.

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.

'What would you do if you were me, doctor?': randomised trial of psychiatrists' personal v. professional perspectives on treatment recommendations.

BACKGROUND: If patients are unsure whether a specific treatment is really good for them, they often pose the question, 'What would you do if you were me, doctor?' Patients want their psychiatrists to put themselves in their shoes and not to give a 'standard recommendation'. AIMS: To study whether this question really leads psychiatrists to reveal their personal preferences. METHOD: Randomised experimental study with 515 psychiatrists incorporating two decision scenarios (depression scenario: antidepressant v. watchful waiting; schizophrenia scenario: depot v. oral antipsychotic) and three experimental conditions (giving a recommendation to a patient asking, 'What would you do if you were me, doctor?'; giving a regular recommendation to a patient without being asked this question; and imagining being ill and deciding for yourself). Main outcome measures were the treatments chosen or recommended by physicians. RESULTS: Psychiatrists choosing treatment for themselves predominantly selected other treatments (mostly watchful waiting and oral antipsychotics respectively) than what psychiatrists recommended to patients when asked in the 'regular recommendation role' (i.e. antidepressant and depot respectively). Psychiatrists in the 'what-would-you-do role' gave recommendations similar to the 'regular recommendation role' (depression scenario: χ(2) = 0.12, P = 0.73; schizophrenia scenario: χ(2) = 2.60, P = 0.11) but distinctly different from the 'self role'. CONCLUSIONS: The question 'What would you do if you were me, doctor?' does not motivate psychiatrists to leave their professional recommendation role and to take a more personal perspective. Psychiatrists should try to find out why individuals are asking this question and, together with the individual, identify the most appropriate treatment option.

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.

Identifying the profile of optimal candidates for antipsychotic depot therapy A cluster analysis.

OBJECTIVE: The prescription rate of antipsychotic depots for patients suffering from schizophrenia is currently low. Among these patients the assumable acceptance rate of depot as treatment of choice is markedly higher, but psychiatrists do report that patients frequently reject the offer of depot treatment. In a first step to highlight this contradiction we aimed at identifying attributes of patients that indicate their qualification for depot treatment in the eyes of the psychiatrists. METHOD: We surveyed 201 psychiatrists about their evaluation of patients' attributes potentially influencing their qualification for depot treatment. Multidimensional and cluster analyses were applied to detect associated attributes. A second sample of further 248 psychiatrists was asked about their proposal of depot treatment to patients depending on the number of relapses in the past. RESULTS: Two clusters of attributes were identified characterizing patients' qualification for depot treatment. In cluster I episodes of non-compliance and relapses in the past were considered as favoring the qualification. cluster II included a high level of insight, openness to drug treatment and profound knowledge about the disease representing attributes that increase patients' qualification. Patients were significantly more likely to be offered depot treatment after their fourth reexacerbation compared to their first relapse. CONCLUSIONS: Attributes comprised in cluster I highly qualify a patient for depot treatment which is in line with the current prescription stereotype. This conservative notion of depot use is supplemented by an alternative cluster II patient profile. Patients fitting this cluster also potentially qualify for depot treatment according to the surveyed psychiatrists and should be offered depot in clinical routine considering the advantages of this form of administration.

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.

Does it matter whether physicians' recommendations are given early or late in the decision-making process? An experimental study among patients with schizophrenia.

OBJECTIVES: Physicians' recommendations are seen as an essential component in many models of medical decision-making, including shared decision-making. It is, however, unclear at what time in the decision-making process the recommendation is best given, not to adversely influence patient preferences. Within the present study we wanted to evaluate at what time in the decision-making process a doctor's recommendation is best given, not to adversely influence patient preferences. DESIGN: We performed an experimental study involving hypothetical decisions vignettes and compared the influence of 3 conditions (no advice, early advice, late advice) on patients' decision-making. SETTING: N=21 psychiatric hospitals in Germany. PARTICIPANTS: N=208 inpatients suffering from schizophrenia. PRIMARY AND SECONDARY OUTCOME MEASURES: The main outcome was the number of patients choosing the option in each experimental condition that had been less preferable to most patients during pretests. Additional outcome measures were patient satisfaction and reactance. RESULTS: Patients in the 'late advice' condition more often (n=49) accepted an advice that was against their preferences compared with the other conditions (n=36 for 'early advice', p=0.024). CONCLUSIONS: Although giving advice is an important part of every doctor's daily practice and is seen as an essential element of shared decision-making, hitherto there has been little empirical evidence relating to the influence of physicians' advice on patients' decision-making behaviour. With our study we could show that the point in time an advice is given by a physician does have an influence on patients' decisional behaviour even if the mechanism of this effect is not yet understood.

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.

[Mental health at the workplace - the view of companies]. / Psychische Erkrankungen am Arbeitsplatz aus Sicht von Unternehmensmitarbeitern.

OBJECTIVE: To assess the views of employees (human resource, works council, supervisors, and executives) of German business companies and administrations toward the issue of mental health at the workplace. METHODS: Cross sectional survey of N = 348 employees with staff responsibility. RESULTS: Employees of German companies see their colleagues as moderately mentally stressed. About 14 % of all employees are judged to suffer from a mental disease. These numbers have risen in recent years. About 37 % of all mental illnesses are seen as caused by work conditions. The handling of mental illness at the workplace is seen as insufficient and in many cases stigmatizing. CONCLUSION: At least subjectively the issue of mental illness in the workplace has gained in importance in recent years. Possible interventions should especially address executives and supervisors.

Psychiatrists' decision making between branded and generic drugs.

To study psychiatrists' decision making between generic and branded antipsychotics or antidepressants a hypothetical decision scenario involving decisions between branded and generic drugs was presented to a sample of German psychiatrists. Factors influencing this decision were identified using a regression analysis. n=410 Psychiatrists participated in the survey. Psychiatrists were more likely to choose branded drugs when imagining choosing the drug for themselves (vs. recommending a drug to a patient). In addition, psychiatrists were more likely to choose generic antidepressants than generic antipsychotics. Additional predictors for choosing a generic drug were a higher share of outpatients, less negative attitudes toward generics and higher uncertainty tolerance. In conclusion, psychiatrists' decision making in choosing between branded or generic antidepressants or antipsychotics is to a large extent influenced by vague attitudes towards properties of generics and branded drugs as well as by "non-evidence based" factors such as uncertainty tolerance.

Patient participation in medical and social decisions in Alzheimer's disease.

OBJECTIVES: To analyze the preferences of people with amnestic mild cognitive impairment (aMCI) and mild dementia in Alzheimer's disease (AD) regarding different aspects of healthcare-related decisions, to correlate these findings with different measures of decision-making capacity, and to explore the views of relatives and referring physicians. DESIGN: Cross-sectional survey. SETTING: University-based memory clinic in Munich, Germany. PARTICIPANTS: One hundred people with aMCI or mild AD, their relatives (N = 99), and their referring physicians (N = 93). MEASUREMENTS: Participation preferences and decisional capacity and assessment of these measures according to relatives and physicians. RESULTS: Patients had a preference for participation in healthcare-related decisions, especially in social ones. Overall, individuals wanted their relatives to play a secondary role in decision-making. Relatives and referring physicians performed poorly in predicting the individuals' participation preferences, and relatives wanted to attribute less decision-making power to patients than the patients did themselves. Patients refrained from participation if they had lower Mini-Mental State Examination scores or were unsure about their decisional capacity. There were deficits in decision-making capacity, which mostly related to understanding of the information presented. There was only weak correlation between the different measures (patient's, relative's, and physician's estimate, MacArthur Competence Assessment Tool for Treatment) of the patients' decisional capacity. CONCLUSION: The combination of marked participation preferences and impairments in the decisional capacity of individuals with aMCI and early AD constitute an ethical and practical challenge. A thorough implementation of structured probes of the patients' decisional capacity combined with interventions that aid patients in their decision-making capability might help to overcome some of these challenges.

"How to speak to your psychiatrist": shared decision-making training for inpatients with schizophrenia.

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 six-month 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 making. There were some hints that it might generate beneficial long-term effects.

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.

How much more effective do depot antipsychotics have to be compared to oral antipsychotics before they are prescribed?

Antipsychotic depots are less frequently prescribed than oral compounds. In an experimental study involving N=106 psychiatrists we studied how much more effective with respect to relapse prevention depot antipsychotics have to be compared to oral antipsychotics before they are chosen for prescription. Most psychiatrists have to judge depot as clearly superior with respect to relapse prevention before they recommend it to patients. If psychiatrists judge depot as unpleasant for the patients and do not see much need for checking their patients' compliance they are less likely to prescribe depot. Other psychiatrist-related factors (e.g. age, gender, and work experience) did not influence attitudes toward depot.

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.

[Complaint-management in psychiatry - a nationwide survey in Germany]. / Patientenfürsprecher und unabhängige Beschwerdestellen für Nutzer psychiatrischer Dienste - eine deutschlandweite Umfrage.

OBJECTIVE: To describe and characterize the work of independent complaint offices for users of psychiatric services and of ombudsmen in psychiatric hospitals. METHODS: Nationwide survey addressed to all independent complaint offices and to all psychiatric hospitals in Germany. RESULTS: The authors were able to identify n = 37 independent complaint offices. About 50 % (n = 215) of the hospitals surveyed reported having a patient's advocate ("Patientenfürsprecher"). While complaint offices are regularly staffed by psychiatry-experienced, their relatives and professionals, patient's advocates are often retired employees of the respective hospitals. Among the most frequent complaints were complaints about the behaviour of psychiatric staff towards patients and complaints about the correctness or necessity of treatments and constraints. Ombudsmen were additionally faced with complaints about food and sanitation in hospitals. CONCLUSIONS: Patients' complaints can be used to improve psychiatric services. However, the existing complaint management system in German psychiatry should be improved with respect to publicity, user acceptance and accessibility.