A Smartphone App to Promote Patient Activation and Support Shared Decision-making in People With a Diagnosis of Schizophrenia in Outpatient Treatment Settings (Momentum Trial): Randomized Controlled Assessor-Blinded Trial.

BACKGROUND: Shared decision-making (SDM) is a process aimed at facilitating patient-centered care by ensuring that the patient and provider are actively involved in treatment decisions. In mental health care, SDM has been advocated as a means for the patient to gain or regain control and responsibility over their life and recovery process. To support the process of patient-centered care and SDM, digital tools may have advantages in terms of accessibility, structure, and reminders. OBJECTIVE: In this randomized controlled trial, we aimed to investigate the effect of a digital tool to support patient activation and SDM. METHODS: The trial was designed as a randomized, assessor-blinded, 2-armed, parallel-group multicenter trial investigating the use of a digital SDM intervention for 6 months compared with treatment as usual. Participants with a diagnosis of schizophrenia, schizotypal or delusional disorder were recruited from 9 outpatient treatment sites in the Capital Region of Denmark. The primary outcome was the self-reported level of activation at the postintervention time point. The secondary outcomes included self-efficacy, hope, working alliance, satisfaction, preparedness for treatment consultation, symptom severity, and level of functioning. Explorative outcomes on the effect of the intervention at the midintervention time point along with objective data on the use of the digital tool were collected. RESULTS: In total, 194 participants were included. The intention-to-treat analysis revealed a statistically significant effect favoring the intervention group on patient activation (mean difference 4.39, 95% CI 0.99-7.79; Cohen d=0.33; P=.01), confidence in communicating with one's provider (mean difference 1.85, 95% CI 0.01-3.69; Cohen d=0.24; P=.05), and feeling prepared for decision-making (mean difference 5.12, 95% CI 0.16-10.08; Cohen d=0.27; P=.04). We found no effect of the digital SDM tool on treatment satisfaction, hope, self-efficacy, working alliance, severity of symptoms, level of functioning, use of antipsychotic medicine, and number or length of psychiatric hospital admissions. CONCLUSIONS: This trial showed a significant effect of a digital SDM tool on the subjective level of patient activation, confidence in communicating with one's provider, and feeling prepared for decision-making at the postintervention time point. The effect size was smaller than the 0.42 effect size that we had anticipated and sampled for. The trial contributes to the evidence on how digital tools may support patient-centered care and SDM in mental health care. TRIAL REGISTRATION: ClinicalTrials.gov NCT03554655; https://clinicaltrials.gov/ct2/show/NCT03554655. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-doi: 10.1186/s12888-019-2143-2.

The Intentional Differences: A Qualitative Study of the Views and Experiences of Non-peer Mental Health Providers on Working Together with Peer Support Colleagues in Mental Health.

The study reports the results of a qualitative study on the views and experiences of non-peer mental health providers on working together with peer colleagues in mental health. Semi-structured interviews were conducted with 20 providers in different mental health settings. Data were systematic analyzed using thematic analysis and resulted in three overall themes: (1) The relationship and collaboration between the mental health providers and their peer colleagues, (2) The benefits of working with peers, and (3) The challenges of working with peers. In analyzing the data material, the theme of the relationship and collaboration between the non-peer mental health providers and their peer colleagues could be organized into two subthemes on the differences that the providers perceived between themselves and their peer colleagues. One subtheme was on differences when the providers perceived the differences as positive and meaningful. The other subtheme was on differences between themselves and their peer colleagues when the providers perceived the differences as concerning. This study's findings show that the attitudes and experiences of peer support in mental health providers are in general positive, but also that mental health providers in the early phases of peer support implementation could have many concerns and may find the perceived and mainly valued differences between themselves and their peer support colleagues also distressing. The implications for practice include a need to address possible barriers to peer support, including frustration or feelings of injustice among mental health providers, especially as such issues are not easy to pinpoint or address by formal guidelines on peer support.

The Momentum trial: the efficacy of using a smartphone application to promote patient activation and support shared decision making in people with a diagnosis of schizophrenia in outpatient treatment settings: a randomized controlled single-blind trial.

BACKGROUND: Shared decision making (SDM) is often defined as an interactive process that ensures that both patient and practitioner are actively involved in the treatment and that they share all relevant information to arrive at a mental health decision. Previous SDM interventions have found improvements in outcomes such as personal recovery, higher perceived involvement in treatment decisions and knowledge about one's disease. Still, SDM occurs less frequently in mental health care than in primary care. Electronic aids developed to support patient activation and SDM could be a promising mean to engage patients in their mental healthcare. The aim of this trial is to investigate the effects of using a smartphone app to promote patient activation and support SDM for people with schizophrenia-spectrum disorders in an outpatient treatment setting. METHODS: This randomised controlled trial will allocate participants to one of two groups: (1) Intervention group: smartphone app and TAU (treatment as usual) or (2) Control group: TAU without the smartphone app. A total sample size of 260 people with a diagnosis of schizophrenia, schizotypal or delusional disorder will be recruited from five OPUS teams (a specialized early intervention program) in Denmark between 2019 and 2020. The intervention will last for 6 months with data collection at baseline, and at 3 and 6 months. Primary outcome will be self-perceived patient activation. Secondary outcomes will be feeling of being prepared for SDM; self-efficacy; working alliance; treatment satisfaction; positive and negative symptoms; level of functioning; hope; and perceived efficacy in patient-provider interaction. Patients' and health providers' preferences in clinical decision making will be assessed. Patients' usage and perceived usefulness of the app will be explored. DISCUSSION: This study will investigate the efficacy of using the smartphone app to support people with severe mental illness in engaging in their own healthcare management. The study may provide evidence to the idea that linking client and practitioner in digital solutions can have advantages in facilitating SDM in mental health. The trial will provide new knowledge of whether a digital healthcare solution can improve patient activation and support SDM for people with severe mental illness. TRIAL REGISTRATION: ClinicalTrials.gov number: NCT03554655 Registered on: June 13, 2018.

Illness management and recovery: one-year follow-up of a randomized controlled trial in Danish community mental health centers: long-term effects on clinical and personal recovery.

BACKGROUND: Illness Management and Recovery (IMR) is a curriculum-based rehabilitation program for people with severe mental illness with the short-term aim of improving illness self-management and the long-term aim of helping people achieve clinical and personal recovery. METHOD: Participants with schizophrenia or bipolar disorders were recruited from three community mental health centers in the Capital Region of Denmark and randomized to receive group-based IMR and treatment as usual or only the usual intervention. All outcomes were assessed at baseline, postintervention, and the one-year follow-up. Long-term outcomes were categorized according to clinical recovery (i.e., symptoms, global functioning, and hospitalization) and personal recovery (i.e., hope and personal agency). Generalized linear mixed model regression analyses were used in the intent-to-treat analysis. RESULTS: A total of 198 participants were included. No significant differences were found between the IMR and control groups in the Global Assessment of Functioning one year after the intervention, nor were there significant differences in symptoms, number of hospital admissions, emergency room visits, or outpatient treatment. CONCLUSION: The present IMR trial showed no significant effect on clinical and personal recovery at the one-year follow-up. Together with the results of other IMR studies, the present study indicates that the effect of IMR on symptom severity is unclear, which raises questions regarding the impact of IMR on functioning. Additionally, IMR did not affect personal recovery. Although more research is needed, the results indicate that the development of other interventions should be considered to help people with severe mental illness achieve a better level of functioning and personal recovery. TRIAL REGISTRATION: Trial registered at http://www.clinicaltrials.gov ( NCT01361698 ).

Participants' and staffs' evaluation of the Illness Management and Recovery program: a randomized clinical trial.

BACKGROUND: Psychoeducational interventions for people with severe mental illness are developed to enable them to manage their illness effectively to improve prognosis and recovery. AIM: The aim was to investigate the benefits and harms of the Illness Management and Recovery (IMR) program among people with severe mental illness in Denmark. IMR builds among other approaches on a psychoeducational approach. METHODS: A randomized, multi-center, clinical trial of the IMR program compared with treatment as usual among 198 participants with schizophrenia or bipolar disorder investigating outcomes related to illness self-management assessed by the IMR scale, recovery, hope and participants' satisfaction at the end of the 9 months intervention period. RESULTS: No statistical differences were seen between the two groups regarding illness self-management, hope, recovery, or satisfaction with treatment. CONCLUSIONS: IMR appears not to be better than treatment as usual in any of the outcomes. Further studies with a longer follow-up period, better assessments of recovery and a systematic review of the existing trials are needed to assess if the program is effective.

Disclosure: What is the point and for whom?

BACKGROUND: Today mental health is embedded in a discourse of disclosure. Many people with lived experience of mental illness have decided to move out of the closet to talk about their personal experiences. AIMS: To look at the context of disclosure and on the questions of why disclose and for whom. How much do we know and how does our knowledge correspond with today's discourse of disclosure in mental health? METHODS: Narrative reviewing today's discourse of disclosure on the basis of both scientific and experience-based knowledge as well as from my personal experience. RESULTS: The scientific and experience-based knowledge of the benefits and costs of disclosure is limited, but points to mixed results and many risks on a personal level. At the same time, it leaves us with several unanswered questions. CONCLUSIONS: There is a need to always define the context of disclosure and to make professionals aware of different disclosure strategies and respond to the dilemmas. It is also crucial to emphasise that the planning and patterns of disclosure belong to the person with lived experience of mental illness and nobody else.

The Effectiveness of Peer Support in Personal and Clinical Recovery: Systematic Review and Meta-Analysis.

OBJECTIVE: Peer support has been shown to support personal recovery from mental illness. It is unclear whether the effects of peer support across different mental illnesses depend on the organizational setting. The authors reviewed the effectiveness of peer support for both personal recovery and clinical recovery of adults with any mental illness and evaluated the effectiveness of peer support in different settings. METHODS: A systematic review of randomized controlled trials (RCTs) was conducted in PubMed, PsycInfo, CINAHL, Cochrane Library, and Web of Science. A meta-analysis of outcomes of personal and clinical recoveries at the end of interventions was conducted. RESULTS: In total, 49 RCTs with 12,477 participants with any mental illness were included. Most of the trials had a high risk for bias. Results of the meta-analysis indicated that peer support in general had a small positive effect on personal recovery (standard mean difference [SMD]=0.20; 95% CI=0.11-0.29) and decreased anxiety symptoms (SMD=-0.21; 95% CI=-0.40 to -0.02), with most trials evaluating peers added to mental health-related hospital services. No data for peers in established service roles were available for the meta-analysis. Peer-designed interventions developed to be provided independently of hospital services and delivered in community settings had a modest effect on self-advocacy. A small nonsignificant effect on personal recovery for peer support delivered online was also observed. CONCLUSIONS: The effect on personal recovery from mental illness was most evident in peer support added to hospital services. High-quality RCTs with comparable cocreated interventions and clear descriptions of mechanisms of change are needed to further investigate peer support efficacy.

Digital Shared Decision-Making Interventions in Mental Healthcare: A Systematic Review and Meta-Analysis.

Background: Shared decision-making (SDM) in mental healthcare has received increased attention as a process to reinforce person-centered care. With the rapid development of digital health technology, researchers investigate how digital interventions may be utilized to support SDM. Despite the promise of digital interventions to support SDM, the effect of these in mental healthcare has not been evaluated before. Thus, this paper aims to assess the effect of SDM interventions complimented by digital technology in mental healthcare. Objective: The objective of this review was to systematically examine the effectiveness of digital SDM interventions on patient outcomes as investigated in randomized trials. Methods: We performed a systematic review and meta-analysis of randomized controlled trials on digital SDM interventions for people with a mental health condition. We searched for relevant studies in MEDLINE, PsycINFO, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials. The search strategy included terms relating to SDM, digital systems, mental health conditions, and study type. The primary outcome was patient activation or indices of the same (e.g., empowerment and self-efficacy), adherence to treatment, hospital admissions, severity of symptoms, and level of functioning. Secondary outcomes were satisfaction, decisional conflict, working alliance, usage, and adherence of medicine; and adverse events were defined as harms or side effects. Results: Sixteen studies met the inclusion criteria with outcome data from 2,400 participants. Digital SDM interventions had a moderate positive effect as compared with a control condition on patient activation [standardized mean difference (SMD) = 0.56, CI: 0.10, 1.01, p = 0.02], a small effect on general symptoms (SMD = -0.17, CI: -0.31, -0.03, p = 0.02), and working alliance (SMD = 0.21, CI: 0.02, 0.41, p = 0.03) and for improving decisional conflict (SMD = -0.37, CI: -0.70, -0.05, p = 0.02). No effect was found on self-efficacy, other types of mental health symptoms, adverse events, or patient satisfaction. A total of 39 outcomes were narratively synthesized with results either favoring the intervention group or showing no significant differences between groups. Studies were generally assessed to have unclear or high risk of bias, and outcomes had a Grading of Recommendations Assessment, Development and Evaluation (GRADE) rating of low- or very low-quality evidence. Conclusions: Digital interventions to support SDM may be a promising tool in mental healthcare; but with the limited quality of research, we have little confidence in the estimates of effect. More quality research is needed to further assess the effectiveness of digital means to support SDM but also to determine which digital intervention features are most effective to support SDM. Systematic Review Registration: PROSPERO, identifier CRD42020148132.

Recovery-oriented practice: Participant observations of the interactions between patients and health professionals in mental health inpatient settings.

Despite an increasing attention towards recovery orientation in the mental health services, the provision of recovery-oriented practice is challenged in the inpatient wards. Moreover, the existing research within this area is modest and we currently have limited knowledge of how recovery-oriented practice is integrated into inpatient settings. A cornerstone of recovery-oriented practice is the collaboration, patient involvement, and choices, particularly when deciding and planning treatment options. Thus, this ethnographic study aimed to explore how recovery-oriented practice is reflected in the interactions between patients and health professionals around treatment in two mental health inpatient wards in Denmark. Participant observations were conducted in two mental health inpatient wards from November 2014 to January 2015. The Recovery Self-Assessment scale inspired the observation guide and the initial data analysis. Field notes were analysed deductively and inductively using qualitative content analysis. One theme with four subthemes emerged showing that interactions were characterized by an 'as-if collaboration' where 'negotiating on limited grounds' was an important feature of interactions, in which health professionals seemed to have superiority, acting on behalf of 'competing demands'. Patients had to navigate in a field of 'inconsistent guidance and postponed decisions' and faced tendencies of 'control and condescending communication'. The results suggest that recovery oriented values such as equal collaboration, choice and patients' personal preferences are reflected rhetorically in the interactions between patients and health professionals. However, they are negotiated within organizational logics and often overruled by competing demands.

Recovery orientation in mental health inpatient settings: Inpatient experiences?

Offering mental health treatment in line with a recovery-oriented practice has become an objective in the mental health services in many countries. However, applying recovery-oriented practice in inpatient settings seems challenged by unclear and diverging definitions of the concept in and the organization of these settings. In Denmark, educational and organizational efforts have been made to organize inpatient services with a recovery-oriented approach. Hence, we aimed to explore whether and how these efforts are reflected in the inpatients' experiences of their care and treatment. Semi-structured interviews were conducted with 14 inpatients from two mental health inpatient wards using an interview guide based on factors from the Recovery Self-Assessment. Qualitative content analysis was applied in the analysis. Six themes covering the participants' experiences were identified. The participants felt accepted and protected in the ward and found comfort in being around other people but missed talking and engaging with health professionals. They described limited choice and influence on the course of their treatment, and low information levels regarding their treatment, which they considered to consist predominantly of medication. Furthermore, they described feeling continuously observed and assessed from a distance by health professionals. Like the sparse previous research among inpatients, the results highlight ambivalent experiences of health professionals' support and ward structure as well as the medical treatment hegemony. As such, the educational and organizational efforts of introducing recovery-oriented practices in the wards seemed not very well reflected in the participants' experiences of their stay.

Illness management and recovery: Clinical outcomes of a randomized clinical trial in community mental health centers.

OBJECTIVE: Illness Management and Recovery (IMR) is a psychosocial intervention with a recovery-oriented approach. The program has been evaluated in different settings; however evidence for the effects of IMR is still deficient. The aim of this trial was to investigate the benefits and harms of the IMR program compared with treatment as usual in Danish patients with schizophrenia or bipolar disorder. METHOD: The trial was designed as a randomized, assessor-blinded, multi-center, clinical trial investigating the IMR program compared with usual treatment. 198 people diagnosed with schizophrenia or bipolar disorder participated. The primary outcome was the Global Assessment of Functioning (GAF-F) at the end of intervention and the secondary and explorative outcomes included severity of symptoms and service utilization. RESULTS: IMR had no significant effect on functioning, symptoms, substance use or service utilization. CONCLUSION: This randomized trial contributes to the evidence base of IMR by providing a methodological solid base for its conclusions; however the trial has some important limitations. More research is needed to get a firm answer on the effectiveness of the IMR.

Momentum: A smartphone application to support shared decision making for people using mental health services.

OBJECTIVE: The aim of the pilot study was to examine the use of a smartphone application as a modern decision aid to support shared decision making in mental health. METHOD: 78 people using mental health services and 116 of their providers participated in a 4-month pilot study. At the end of the intervention, we conducted 3 focus group interviews with 12 multidisciplinary staff members, 1 focus group interview with doctors, and 7 individual interviews with consumers. Each interview was recorded and systematically reviewed to identify common themes and both similar and different traits between respondents through a process of induction. RESULTS: Consumers and providers found the application a useful tool to support people in recovery in providing an overview and setting an agenda. However, the pilot study found more technological obstacles to its use. Some results indicate an obstacle perhaps relating to the power asymmetry between people using mental health services and staff. Contrary to our hypothesis that peer support would be crucial, the use of the application was most widespread when it was presented to consumers by providers who found it was a useful tool. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The results indicate the relevance of using modern technology to support shared decision making (SDM) and the recovery model, though raise the question of how the actual use in the study is to be understood. The study thereby points to a need of further research into the understanding of the central consumer-provider relationship in SDM and in how decision aids are presented. (PsycINFO Database Record

Recovery-Oriented Practice in Mental Health Inpatient Settings: A Literature Review.

OBJECTIVE: Implementation of recovery-oriented practice has proven to be challenging, and little is known about the extent to which recovery-oriented principles are integrated into mental health inpatient settings. This review of the literature examined the extent to which a recovery-oriented approach is an integrated part of mental health inpatient settings. METHODS: A systematic search (2000-2014) identified quantitative and qualitative studies that made explicit reference to the concept of recovery and that were conducted in adult mental health inpatient settings or that used informants from such settings. The quality and relevance of the studies were assessed with the Critical Appraisal Skills Program, and a text-driven content analysis identified three organizing themes: definitions and understandings, current practice, and challenges. RESULTS: Eight studies from Canada, the United Kingdom, the United States, Australia, and Ireland were included. The results highlight the limited number of studies of recovery-oriented practice in mental health inpatient settings and the limited extent to which such an approach is integrated into these settings. Findings raise the question of whether recovery-oriented practice can or should be an approach used in these settings, which are primarily aimed at stabilization and symptom relief. CONCLUSIONS: Research is needed to clarify the concept of recovery and how it applies to mental health inpatient settings. The challenges to recovery-oriented practice posed by the current organization of such settings should be examined.

[Shared decision making in psychiatry]. / Fælles beslutningstagning i psykiatrien.

In the paradigm of recovery-oriented care in mental health the central decision model is shared decision making (SDM). In the article we describe the model of SDM and the reason why it has been identified as important in mental health care. We also review the central literature of SDM in mental health and some of the decision aids just beginning to be developed to enhance SDM, thereby pointing to the need of documenting the effect of using decision aids and to further research on the effect of SDM on the recovery process of people in mental health care.

[Shared decision making in psychiatry].

In the paradigm of recovery-oriented care in mental health the central decision model is shared decision making (SDM). In the article we describe the model of SDM and the reason why it has been identified as important in mental health care. We also review the central literature of SDM in mental health and some of the decision aids just beginning to be developed to enhance SDM, thereby pointing to the need of documenting the effect of using decision aids and to further research on the effect of SDM on the recovery process of people in mental health care.

Illness insight and recovery: how important is illness insight in peoples' recovery process?

TOPIC: This account reflects on the topic of illness insight and recovery. PURPOSE: The purpose of the account is to clarify our understanding about the importance of illness insight in peoples' recovery process, especially when relating the question of illness insight to the question of identity. SOURCES USED: The writing is based on research literature related to illness insight and on personal recovery experiences. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: It is helpful to consider the integration of the issue of illness insight when addressing the questions and consequences of diagnosis, and to assist individuals to work through the false analogy between illness and identity while supporting the transformation from patient to person. It is also necessary for clinicians to develop a clear understanding of peoples' actual needs and gain more knowledge about peoples' own views and experiences in relation to the importance of illness insight in the recovery process.

Illness management and recovery (IMR) in Danish community mental health centres.

BACKGROUND: Schizophrenia and bipolar disorder are severe mental illnesses that can have a significant disabling impact on the lives of people. Psychosocial interventions that stress hope and recovery as a part of a multi-dimensional approach are possibly indicated to support people with severe mental illness in facilitating recovery. Illness Management and Recovery (IMR) is a curriculum-based psychosocial intervention designed as structured program with a recovery-oriented approach. The aim of IMR is to rehabilitate people with severe mental illnesses by helping them acquire knowledge and skills in managing their illness and achieve personal recovery goals. Previous randomised clinical trials indicate that IMR can be implemented with a good effect and a high fidelity though further trials are crucial to demonstrate the potential effectiveness of IMR. METHODS/DESIGN: The trial design is a randomised, assessor-blinded, multi-centre, clinical trial of the IMR program compared with treatment as usual for 200 participants diagnosed with schizophrenia or bipolar disorder under the care of two community mental health centres in the Capital Region of Denmark. The primary outcome is level of functioning at the end of treatment. The secondary outcomes are disease symptoms; use of alcohol/drugs; individual meaning of recovery; hope; hospital admissions and out-patient psychiatric treatment at the end of treatment and the abovementioned and level of functioning at follow-up 21 months after baseline. DISCUSSION: If the results of this trial show IMR to be effective these positive results will strengthen the evidence of IMR as an effective comprehensive psychosocial intervention with a recovery-oriented approach for people with severe mental illness. This will have significant implications for the treatment and recovery of people with severe mental illness.

Assessment of the quality of mini-HTA.

OBJECTIVES: Mini-HTA (health technology assessment) is increasingly being applied in Denmark as an input for decisions on the use of health technologies. Mini-HTA is a form or check list with questions concerning the prerequisites for and consequences of health technologies. At the national level, the National Board of Health uses mini-HTA when hospitals apply for permission to introduce new treatments. Mini-HTA is also compulsory in Danish Regions' annual collection of early warnings. At the local level some hospitals have made mini-HTA compulsory when clinical departments apply for funding for new technologies. The objective of this study is to assess the quality of the information included in mini-HTA used at Danish hospitals and to discuss the consequences of this to decision making. METHODS: The quality of mini-HTA is assessed by use of an INATHA checklist for HTA reports. Data consists of reviews of the quality in fifty-two mini-HTAs produced by Danish hospitals in 2008. RESULTS: The mini-HTAs generally include descriptions of the assessed technology and the comparator, but information about the selection and interpretation of the clinical literature and other data is often missing. The level of evidence for the clinical effects and the main references are generally included. Only 25 percent of the mini-HTAs include a quantitative estimate of the size of the clinical effects. Organizational consequences inside the clinical department is described in 81percent of the cases and 92 percent includes a cost estimate. CONCLUSIONS: The results show that the quality of the information in many cases is insufficient. There is a strong need for quality assurance of mini-HTAs to improve the accuracy of the information, however, without harming the timeliness and the limited use of resources in producing the reports.

[Profile of a systematic search. Search areas, databases and reports]. / Profil af en systematisk søgning. Søgeområde, databaser og afrapportering.

Systematic literature search is a fundamental in evidence-based medicine. But systematic literature search is not yet a very well used way of retrieving evidence-based information. This article profiles a systematic literature search for evidence-based literature. It goes through the most central databases and gives an example of how to document the literature search. The article also sums up the literature search in all reviews in Ugeskrift for Laeger in the year 2004.