When does shared decision making is adopted in psychiatric clinical practice? Results from a European multicentric study.

To identify factors associated with the use of shared decision making in routine mental health care in a large multicenter European study. Data have been collected within the study "Clinical decision making and outcome in routine care for people with severe mental illness" (CEDAR), which is a naturalistic, longitudinal, observational study carried out in six European countries. Patients with a severe mental illness attending outpatient units and their treating clinicians have been recruited. Clinicians' Clinical Decision Making (CDM) styles have been explored through the Clinical Decision Making Style Scale. Patients' clinical and social outcomes have been assessed through validated assessment instruments. The sample consisted of 588 patients and 213 professionals. Professionals were mainly psychiatrists (35.7%), nurses (21.6%), support workers, social workers or occupational therapists (24.9%), psychologists (9.9%) or trainees in psychiatry (4.7%). In the majority of cases, clinicians adopted a shared CDM style. Shared CDM was more frequently adopted with patients with psychotic disorders, with a better quality of life and social functioning. At multivariate analyses, the likelihood of adopting shared decision making increased in patients with higher levels of interpersonal relationships' skills (p < 0.05) and global functioning (p < 0.01). On the contrary, being a trainee in psychiatry reduced the likelihood of adopting shared CDM (p < 0.008). Shared decision making has been adopted mainly when patients have a better functioning and less severe clinical symptomatology and by less trained clinicians, differently from national and international recommendations. More efforts should be made to implement interventions to promote shared CDM, with a specific focus for trainees in psychiatry.

Lack of glucuronidation products of trans-resveratrol in plasma and urine of cats.

Resveratrol has generated interest in cats due to reported health benefits. Cats have low activity of ß-glucuronidase, and we hypothesized they could not form two common resveratrol metabolites, resveratrol-3-O-glucuronide and resveratrol-4'-O-glucuronide. Resveratrol, 3 mg/cat/day, was given orally to intact male (n = 5) and female cats (n = 5) for 4 weeks. A control group (8 intact males) was used for comparison. Plasma and urine were collected weekly and analysed using high-pressure liquid chromatography coupled with tandem mass spectrometry. Resveratrol and resveratrol-3-O-sulphate, but no glucuronide metabolites, were detected in plasma and urine. Median (range 10-90th percentile) plasma resveratrol for control and treatment groups was 0.46 ng/ml (0.02-1.74 ng/ml) and 0.96 ng/ml (0.65-3.21 ng/ml). Median (range) plasma resveratrol-3-O-sulphate for control and treatment groups was 6.32 ng/ml (2.55-10.29 ng/ml) and 11.45 ng/ml (1.47-53.29 ng/ml). Plasma resveratrol differed from control in week 4, while plasma resveratrol-3-O-sulphate was different in all weeks (p < 0.05). Median (range) urine resveratrol for control and treatment groups was 0.28 ng/ml (0.05-1.59 ng/ml) and 19.98 ng/ml (8.44-87.54 ng/ml). Median (range) urine resveratrol-3-O-sulphate for control and treatment groups was 26.71 ng/ml (10.50-75.58 ng/ml) and 108.69 ng/ml (11.83-231.05 ng/ml). All time points for urine resveratrol and resveratrol-3-O-sulphate were significantly different from control (p < 0.05), except for weeks 1, 3 and 4 for resveratrol. The results support our hypothesis that cats are unlikely able to glucuronidate resveratrol, most likely due to a reduction in the activity of ß-glucuronidase.

[Determinants of psychotropic medication in adults with mild or moderate intellectual disabilities]. / Bedingungsfaktoren psychopharmakologischer Behandlung bei leichter oder mittelgradiger Intelligenzminderung.

BACKGROUND: During the past years the provision of mental healthcare for adults with intellectual disabilities (ID) has repeatedly been criticized; however, the number of relevant studies is still relatively few. OBJECTIVE: The aim of the present study was to identify determinants for utilization of mental healthcare services and prescription of psychotropic medication in adults with mild to moderate ID. MATERIAL AND METHODS: Analyses were based on data from 417 adults with mild to moderate ID, which had been collected within the cross-sectional MEMENTA study in three different regions of Germany. Logistic regression analyses were conducted to identify clinical and sociodemographic variables as predictors of utilization of mental healthcare services (n = 282) and psychotropic medication (n = 351). RESULTS: Utilization of healthcare services and psychotropic medication were both associated with mental disorders and problem behavior. In addition, the likelihood of being treated with psychotropic medication and antipsychotic drugs was higher in adults living in residential homes. CONCLUSION: The findings indicate a lack of adherence to existing guidelines in the treatment of adults with ID living in residential homes.

Serum, milk, and tissue monensin concentrations in cattle with adequate and potentially toxic dietary levels of monensin: pharmacokinetics and diagnostic interpretation.

Used in both beef cattle and dairy cows, monensin can provide many health benefits but can, when unintended overexposures occur, result in adverse effects. Information on serum and tissue concentrations following overexposure and/or overt toxicosis which may aid in diagnostics and clinical outcome is lacking. The aim of this study was to determine concentrations of monensin in biological specimens following oral exposure for 10 days to an approved dose (1 mg/kg) and a higher dose (5 mg/kg) of monensin given daily on a body weight basis to 10 dairy cows. No deaths were reported; cows receiving 5 mg/kg showed early signs of toxicosis including depression, decreased feed intake, and diarrhea after 4 days of exposure. Histopathological findings were minimal in most cows. Pharmacokinetic modeling of the detected serum concentrations for the 1 and 5 mg/kg dose groups determined the Cmax , Tmax, and t1/2λ to be 0.87 and 1.68 ng/mL, 2.0 and 1.0 h, and 1.76 and 2.32 days, respectively. Mixed regression models showed that the dose level and days since last dose were significantly associated with monensin concentrations in all four tissues, and with cardiac troponin levels. The high dose resulted in a significant elevation of monensin in tissues at approximately 4.7 times compared to the monensin concentrations in the tissues of animals from the low-dose group. The cTnI concentrations in the high-dose group were 2.1 times that of cTnI in the low-dose group. Thus, the ability to diagnose monensin overexposure and/or toxicosis will improve from knowledge of biological monensin concentrations from this study.

Empowerment and satisfaction in a multinational study of routine clinical practice.

OBJECTIVE: Decision-making between mental health clinicians and patients is under-researched. We tested whether mental health patients are more satisfied with a decision made (i) using their preferred decision-making style and (ii) with a clinician with the same decision-making style preference. METHOD: As part of the CEDAR Study (ISRCTN75841675), a convenience sample of 445 patients with severe mental illness from six European countries were assessed for desired clinical decision-making style (rated by patients and paired clinicians), decision-specific experienced style and satisfaction. RESULTS: Patients who experienced more involvement in decision-making than they desired rated higher satisfaction (OR=2.47, P=0.005, 95% CI 1.32-4.63). Decisions made with clinicians whose decision-making style preference was for more active involvement than the patient preference were rated with higher satisfaction (OR=3.17, P=0.003, 95% CI 1.48-6.82). CONCLUSION: More active involvement in decision-making than the patient stated as desired was associated with higher satisfaction. A clinical orientation towards empowering, rather than shared, decision-making may maximise satisfaction.

Diagnostic exercise: hemolysis and sudden death in lambs.

Within a 24-hour period, 7 out of 200 three- to four-week-old pastured Katahdin lambs died after showing clinical signs of hemoglobinuria, red-tinged feces, weakness, and recumbency. One of the lambs that was examined clinically before natural death also had abdominal pain, trembling, tachycardia, and severe anemia with a packed cell volume of 4%. Pathologic findings included icterus, hemoglobinuric nephrosis, dark red urine, pulmonary edema, hydrothorax, splenomegaly, and acute centrilobular to midzonal hepatocellular degeneration and necrosis with cholestasis. The differential diagnoses and diagnostic workup to achieve the diagnosis are briefly discussed.

Temporal and geographic clustering of polyomavirus-associated olfactory tumors in 10 free-ranging raccoons (Procyon lotor).

Reports of primary nervous system tumors in wild raccoons are extremely rare. Olfactory tumors were diagnosed postmortem in 9 free-ranging raccoons from 4 contiguous counties in California and 1 raccoon from Oregon within a 26-month period between 2010 and 2012. We describe the geographic and temporal features of these 10 cases, including the laboratory diagnostic investigations and the neuropathologic, immunohistochemical, and ultrastructural characteristics of these tumors in the affected animals. All 9 raccoons from California were found within a localized geographic region of the San Francisco Bay Area (within a 44.13-km radius). The tight temporal and geographic clustering and consistent anatomic location in the olfactory system of tumor types not previously described in raccoons (malignant peripheral nerve sheath tumors and undifferentiated sarcomas) strongly suggest either a common cause or a precipitating factor leading to induction or potentiation of neuro-oncogenesis and so prompted an extensive diagnostic investigation to explore possible oncogenic infectious and/or toxic causes. By a consensus polymerase chain reaction strategy, a novel, recently reported polyomavirus called raccoon polyomavirus was identified in all 10 tumors but not in the normal brain tissue from the affected animals, suggesting that the virus might play a role in neuro-oncogenesis. In addition, expression of the viral protein T antigen was detected in all tumors containing the viral sequences. We discuss the potential role of raccoon polyomavirus as an oncogenic virus.

Preliminary study to assess mycotoxin concentrations in whole corn in the California feed supply.

Mycotoxins are naturally occurring environmental contaminants recognized worldwide in a variety of food and feed products. Produced as secondary metabolites by filamentous fungi, mycotoxins can have acute and chronic effects. Differing seasonal weather patterns and harvesting and storage conditions put corn grain at high risk for mycotoxin contamination. The objective of this study was to assess the risk of mycotoxin exposure posed to California livestock from whole corn. Random samples (n=50) of whole corn were collected and analyzed for 6 different mycotoxins, including aflatoxins, fumonisins, ochratoxins, trichothecenes (deoxynivalenol and T-2 toxin), and zearalenone. The samples represented a cross section of the corn entering California from various corn-growing states (n=43) as well as additional samples from California-grown corn (n=7). The experiment was a randomized sampling design. Over the course of a 6-mo period, 16 trains in California (100-110 railcars) and 5 California grain elevators were randomly sampled. Aflatoxins were detected in 14 samples, with 1 sample containing a concentration of 41.3 µg/kg (as-is basis), which was above the action level of 20 µg/kg for corn fed to dairy cattle. The average concentration of aflatoxins for the 13 samples below the regulatory action level was 8.69 µg/kg (range 4.67 to 13.82 µg/kg). Deoxynivalenol was found in 15 samples and averaged 553 µg/kg (range 340 to 1,072 µg/kg), which was below the federal advisory level of 5,000 µg/kg for grain fed to dairy cattle. Fumonisins were found in 38 samples and averaged 1,687 µg/kg (range 435 to 4,843 µg/kg), which was below the federal guidance level of 30,000 µg/kg in corn for dairy cattle. Ochratoxins, T-2 toxins, and zearalenone were not detected in any samples of whole corn. Fumonisins were the most prevalent mycotoxins found.

Toxic equine parkinsonism: an immunohistochemical study of 10 horses with nigropallidal encephalomalacia.

Chronic ingestion of yellow star thistle (Centaurea solstitialis) or Russian knapweed (Acroptilon repens) causes nigropallidal encephalomalacia (NPE) in horses with an abrupt onset of neurologic signs characterized by dystonia of lips and tongue, inability to prehend food, depression, and locomotor deficits. The objectives of this study were to reexamine the pathologic alterations of NPE and to conduct an immunohistochemistry study using antibodies to tyrosine hydroxylase and α-synuclein, to determine whether NPE brains show histopathologic features resembling those in human Parkinson disease. Results confirm that the NPE lesions are located within the substantia nigra pars reticulata, sparing the cell bodies of the dopaminergic neurons in the substantia nigra pars compacta, and in the rostral portion of the globus pallidus, with partial disruption of dopaminergic (tyrosine hydroxylase-positive) fibers passing through the globus pallidus. No abnormal cytoplasmic inclusions like the Lewy bodies of human Parkinson disease were seen in these NPE brains. These findings indicate that equine NPE may serve as a large animal model of environmentally acquired toxic parkinsonism, with clinical phenotype directly attributable to lesions in globus pallidus and substantia nigra pars reticulata rather than to the destruction of dopaminergic neurons.

Ronidazole toxicosis in 3 society finches (Lonchura striata).

A group of finches were accidentally overdosed with ronidazole, a 5-nitroimidazole used for treatment of trichomoniasis. Finches developed neurologic signs on the third day of treatment and were euthanized (or died). Three finches were submitted for necropsy. Focal necrosis of the cerebellar nucleus was seen in all 3 birds, as characterized by neuronal necrosis, vacuolation of the neuropil, gemistocytic astrocytosis, hemorrhage, and axonal swelling (spheroids) with demyelination. The liver from 1 finch was analyzed for ronidazole and its metabolite, 2-hydroxymethyl-1-methyl-5-nitroimidazole, by high-performance liquid chromatography-mass spectrometry. Ronidazole was detected in the liver tissue at 2,700 ng/g (wet weight), and 2-hydroxymethyl-1-methyl-5-nitroimidazole was detected at 140 ng/g (wet weight).

Outcome management in in-patient psychiatric care.

OBJECTIVE: To delineate methods and to describe patient appraisal as well as effect of outcome management in in-patient psychiatric care. METHOD: Two hundred and ninety-four adults with mental illness receiving in-patient treatment at a psychiatric hospital in rural Bavaria gave informed consent to participate in this cluster-randomised trial. Participants were asked to provide information on treatment outcome via weekly computerised standardised assessments. Patients and clinicians in the intervention group received continuous feedback of outcome. RESULTS: Patients were willing and able to regularly provide outcome data and valued feedback. However, use of feedback in conversations between patient and clinician was rare. Outcome management failed to impact on patient-rated outcome during in-patient treatment. CONCLUSION: Outcome management is feasible in people receiving in-patient psychiatric care, but failed to show an overall short-term effect. Strategies need to be developed to improve active use of routinely collected treatment outcome data in mental health care.

Discharge planning in mental health care: a systematic review of the recent literature.

OBJECTIVE: To determine and estimate the efficacy of discharge planning interventions in mental health care from in-patient to out-patient treatment on improving patient outcome, ensuring community tenure, and saving costs. METHOD: A systematic review and meta-analysis identified studies through an electronic search on the basis of defined inclusion and exclusion criteria and extracted data. RESULTS: Of eleven studies included, six were randomised controlled trials, three were controlled clinical trials, and two were cohort studies. The discharge planning strategies used varied widely, most were limited to preparation of discharge during in-patient treatment. Pooled risk ratios were 0.66 (95% CI = 0.51 to 0.84; P < 0.001) for hospital readmission rate, and 1.25 (1.07 to 1.47; P < 0.001) for adherence to out-patient treatment. Effect sizes (Hedge's g) were -0.25 (-0.45 to -0.05; P = 0.02) for mental health outcome, and 0.11(-0.05 to 0.28; NS) for quality of life. CONCLUSION: Discharge planning interventions are effective in reducing rehospitalisation and in improving adherence to aftercare among people with mental disorders.

Short communication: Attempts to identify Clostridium botulinum toxin in milk from three experimentally intoxicated Holstein cows.

Three adult lactating Holstein cows were injected in the subcutaneous abdominal vein with 175 ng/kg of body weight of Clostridium botulinum type C toxin (451 cow median toxic doses) to determine if this botulinum toxin crosses the blood-milk barrier. Whole blood (in sodium heparin) and clotted blood serum samples were taken at 0 min, 10 min, and 3, 6, 9, and 12 h postinoculation. Milk samples were taken at 0 min and at 3, 6, 9 and 12 h postinoculation. All samples were tested for the presence of the toxin using the mouse bioassay and immunostick ELISA test. The immunostick ELISA identified the toxin in whole blood and the mouse bioassay identified the toxin in serum at all times examined in all 3 animals. Toxin was not identified by either detection method in milk samples collected from the 3 animals. From these results, it appears that Clostridium botulinum type C toxin does not cross from the blood to the milk in detectable concentrations.

[Innovative structuring in German care for schizophrenics]. / Innovative Versorgungsstrukturen in der Behandlung von Menschen mit Schizophrenie in Deutschland.

In a narrative literature review, innovative models of mental health care for people with schizophrenia are described. Structural aspects of mental health care such as the integration of services, new care paradigms, and innovative research questions are discussed. Key targets of innovative care include: improving continuity of care, introducing team-based community care, improving cooperation of all therapists, and integrating mental health, medical care, and social services. Models of current care for people with schizophrenia such as case management, crisis intervention, home treatment, and supported employment are described; and the evidence supporting these interventions is discussed. In the models of integrated care, there is an enhanced integration of psychosocial modules or service elements. One of the key challenges in mental health service systems is to consider the needs and aims of people with severe mental illness, to take into account biological vulnerability, symptoms of illness, and cognitive impairment of patients (whenever interventions are possible). One of the guiding principles is patient/user autonomy and a focus on user perspective. This implies that people suffering from schizophrenia should have the right to live in the least restrictive environment possible.

Effects of oral tetrachlorvinphos fly control (Equitrol) administration in horses: physiological and behavioural findings.

Highly reactive horses may pose risks to humans involved in equestrian activities. Among the factors that may affect horses' reactivity to external stimuli are pesticides used for fly control in equine facilities. The organophosphorus (OP) insecticide tetrachlorvinphos (TCVP) is used as a feed-through larvicide to prevent completion of the fly larval life cycle in horse manure. TCVP exerts its effect by inhibiting the enzyme cholinesterase (ChE) leading to the accumulation of the neurotransmitter acetylcholine (AChE) in synapses of the central and peripheral nervous systems. The aim of the present study was to investigate alterations of whole-blood ChE levels associated with feeding a commercially available product (Equitrol, Farnam Companies, Inc.) to horses for fly control. A second aim was to report neurological, physiological and behavioural findings in addition to profiles of selected immune markers (IFN-gamma, IL-12p40 and COX-2) and serum thyroid hormones during and after a 30-day treatment period of TCVP feeding. The results indicated significant decreases in whole-blood ChE activity and concomitant behavioural alterations, manifested as increased reactivity and decreased controllability in treated horses. No changes were detected in physiological or neurological parameters, immune markers or thyroid hormones in treated (n=6) or control (n=4) horses during the course of the study.

Polychlorinated biphenyl and polybrominated diphenyl ether profiles in serum from cattle, sheep, and goats across California.

It has been previously been shown by our lab and others that persistent organic pollutants, such as polychlorinated biphenyls (PCBs) and polybrominated diphenyl ethers (PBDEs), are contaminants in milk produced for human consumption. To further this research we determined the concentration of 21 PCB and 14 PBDE congeners in livestock serum, mainly bovine, across California. Congeners were extracted from serum using solid phase extraction (SPE), cleaned up by silica cartridge and quantified using gas chromatography-triple quadruple mass spectrometry. We detected significant differences among species and the production class of cattle (beef or dairy). The sum of all 21 PCB congeners (ΣPCBs) in caprine and ovine sera had a mean value of 9.26 and 9.13 ng/mL, respectively, compared to 3.98 ng/mL in bovine sera. The mean value for the sum of all 14 PBDE congeners (ΣPBDEs) in caprine and ovine sera was 2.82 and 2.39 ng/mL, respectively, compared to 0.91 ng/mL in bovine sera. Mean ΣPCBs in dairy cattle was 5.92 ng/mL compared to 2.70 ng/mL in beef cattle. Mean ΣPBDEs in dairy cattle was 1.33 ng/mL compared to 0.70 ng/mL in beef cattle. There were no regional differences in the ΣPCBs or ΣPBDEs in cattle distributed across California. These results highlight the fact that livestock are still being exposed to these pollutants yet little is known about where this exposure may be coming from.

Vitamin A deficiency in turkey poults.

Vitamin A deficiency was diagnosed in a commercial flock of 13,000 4-6-week-old turkey poults in the summer of 2004. The birds were initially submitted for examination because of a 3% increase in the reported daily mortality of the flock. Clinically, affected birds had stunted growth and ruffled feathers, showed signs of incoordination, and were depressed. At necropsy, pale white pseudomembranous to mucoid material was observed on the mucosal surface of the tongue, oral cavity, portions of the esophagus, and the crop of some birds. Histologically, there was squamous metaplasia of the mucosal epithelium of the oral mucosa, esophagus, sinuses, nasal glands, bronchi, proventriculus, and the bursa of Fabricius. Vitamin A was not detected in the feed sample at a detection limit of 0.5 mg/kg. Serum vitamin A concentrations in 7 birds were very low and ranged from 0.05 to 0.1 mg/L. Vitamin A concentrations in livers were extremely low (0.1 mg/kg wet weight, 1/7 poults) or undetectable (< 0.1 mg/kg wet weight, 6/7 poults). A diagnosis of vitamin A deficiency was made based on gross and microscopic lesions and vitamin A concentrations in serum, liver, and feed. To the authors' knowledge, this is the first documented case of vitamin A deficiency in poults submitted from a commercial meat turkey producer comparatively depicting the gross and microscopic lesions with those found in other species of birds and mammals.

Alfalfa hay induced primary photosensitization in horses.

Photosensitization, also known as photodermatitis, occurs when phototoxic or photoactive substances accumulate in the skin and interact with sunlight to result in an often severe, crusting, itching or painful dermatitis in unpigmented and/or lightly haired areas of the skin. Primary photosensitization, caused by direct ingestion of photosensitizing agents, has been reported anecdotally in horses after ingestion of alfalfa hay. Between 2004 and 2014, several large outbreaks of primary photosensitization in horses fed primarily alfalfa hay were investigated in California. Alfalfa hay samples were collected and carefully examined for the presence of known photosensitizing plants and pesticide residues but none were identified. Select hay samples were evaluated for unusual fungal infestation and for phototoxicity assay using a specific Candida albicans assay; results were negative. In the 2004 outbreak, a feeding study was conducted with three horses exclusively fed alfalfa hay that was suspected to have caused the outbreak. Two weeks after ingestion of alfalfa hay, two horses developed several lesions in non-pigmented skin characterized as chronic ulcerative and necrotizing dermatitis with superficial vasculitis, which was consistent with photosensitization. In the 2014 outbreak, seven different implicated alfalfa hay samples were analyzed for chlorophyll a and b, and pheophorbide a. These compounds had been suspected to play a role in alfalfa-induced primary photosensitization. The chlorophyll contents ranged from 0.90 to 2.30 mg/g in the alfalfa hay samples, compared to 1.37 and 2.94 mg/g in locally grown alfalfa and orchard grass hay. The pheophorbide a levels ranged from 3.36 to 89.87 µg/g in alfalfa samples compared to 81.39 and 42.33 µg/g in control alfalfa and orchard grass hay samples. These findings eliminate chlorophyll a, chlorophyll b, and pheophorbide a as possible causes for alfalfa-hay induced primary photosensitization.

Clinical decision making and outcome in the routine care of people with severe mental illness across Europe (CEDAR).

AIMS: Shared decision making has been advocated as a means to improve patient-orientation and quality of health care. There is a lack of knowledge on clinical decision making and its relation to outcome in the routine treatment of people with severe mental illness. This study examined preferred and experienced clinical decision making from the perspectives of patients and staff, and how these affect treatment outcome. METHODS: "Clinical Decision Making and Outcome in Routine Care for People with Severe Mental Illness" (CEDAR; ISRCTN75841675) is a naturalistic prospective observational study with bimonthly assessments during a 12-month observation period. Between November 2009 and December 2010, adults with severe mental illness were consecutively recruited from caseloads of community mental health services at the six study sites (Ulm, Germany; London, UK; Naples, Italy; Debrecen, Hungary; Aalborg, Denmark; and Zurich, Switzerland). Clinical decision making was assessed using two instruments which both have parallel patient and staff versions: (a) The Clinical Decision Making Style Scale (CDMS) measured preferences for decision making at baseline; and (b) the Clinical Decision Making Involvement and Satisfaction Scale (CDIS) measured involvement and satisfaction with a specific decision at all time points. Primary outcome was patient-rated unmet needs measured with the Camberwell Assessment of Need Short Appraisal Schedule (CANSAS). Mixed-effects multinomial regression was used to examine differences and course over time in involvement in and satisfaction with actual decision making. The effect of clinical decision making on the primary outcome was examined using hierarchical linear modelling controlling for covariates (study centre, patient age, duration of illness, and diagnosis). Analysis were also controlled for nesting of patients within staff. RESULTS: Of 708 individuals approached, 588 adults with severe mental illness (52% female, mean age = 41.7) gave informed consent. Paired staff participants (N = 213) were 61.8% female and 46.0 years old on average. Shared decision making was preferred by patients (χ 2 = 135.08; p < 0.001) and staff (χ 2 = 368.17; p < 0.001). Decision making style of staff significantly affected unmet needs over time, with unmet needs decreasing more in patients whose clinicians preferred active to passive (-0.406 unmet needs per two months, p = 0.007) or shared (-0.303 unmet needs per two months, p = 0.015) decision making. CONCLUSIONS: Decision making style of staff is a prime candidate for the development of targeted intervention. If proven effective in future trials, this would pave the ground for a shift from shared to active involvement of patients including changes to professional socialization through training in principles of active decision making.

Participation in medical decision-making across Europe: An international longitudinal multicenter study.

BACKGROUND: The purpose of this paper was to examine national differences in the desire to participate in decision-making of people with severe mental illness in six European countries. METHODS: The data was taken from a European longitudinal observational study (CEDAR; ISRCTN75841675). A sample of 514 patients with severe mental illness from the study centers in Ulm, Germany, London, England, Naples, Italy, Debrecen, Hungary, Aalborg, Denmark and Zurich, Switzerland were assessed as to desire to participate in medical decision-making. Associations between desire for participation in decision-making and center location were analyzed with generalized estimating equations. RESULTS: We found large cross-national differences in patients' desire to participate in decision-making, with the center explaining 47.2% of total variance in the desire for participation (P<0.001). Averaged over time and independent of patient characteristics, London (mean=2.27), Ulm (mean=2.13) and Zurich (mean=2.14) showed significantly higher scores in desire for participation, followed by Aalborg (mean=1.97), where scores were in turn significantly higher than in Debrecen (mean=1.56). The lowest scores were reported in Naples (mean=1.14). Over time, the desire for participation in decision-making increased significantly in Zurich (b=0.23) and decreased in Naples (b=-0.14). In all other centers, values remained stable. CONCLUSIONS: This study demonstrates that patients' desire for participation in decision-making varies by location. We suggest that more research attention be focused on identifying specific cultural and social factors in each country to further explain observed differences across Europe.