Content and implementation of clinical decisions in the routine care of people with severe mental illness.

BACKGROUND: Clinical decision making (CDM) in the treatment of people with severe mental illness relates to a wide range of life domains. AIMS: To examine content of CDM in mental health care from the perspectives of service users and staff and to investigate variation in implementation of decisions for differing content. METHOD: As part of the European multicenter study clinical decision making and outcome in routine care for people with severe mental illness (ISRCTN75841675), 588 service users and their clinicians were asked to identify the decisions made during their last meeting. Decisions were then coded into content categories. Two months later, both parties reported if these decisions had been implemented. RESULTS: Agreement between patients and staff regarding decision making was moderate (k = 0.21­0.49; p < 0.001). Decisions relating to medication and social issues were most frequently identified. Overall reported level of implementation was 73.5% for patients and 74.7% for staff, and implementation varied by decision content. CONCLUSIONS: A variety of relevant decision topics were shown for mental health care.Implementation rates varied in relation to topic and may need different consideration within the therapeutic dyad.

Development and psychometric properties of a five-language multiperspective instrument to assess clinical decision making style in the treatment of people with severe mental illness (CDMS).

BACKGROUND: The aim of this study was to develop and evaluate psychometric properties of the Clinical Decision Making Style (CDMS) scale which measures general preferences for decision making as well as preferences regarding the provision of information to the patient from the perspectives of people with severe mental illness and staff. METHODS: A participatory approach was chosen for instrument development which followed 10 sequential steps proposed in a current guideline of good practice for the translation and cultural adaptation of measures. Following item analysis, reliability, validity, and long-term stability of the CDMS were examined using Spearman correlations in a sample of 588 people with severe mental illness and 213 mental health professionals in 6 European countries (Germany, UK, Italy, Denmark, Hungary, and Switzerland). RESULTS: In both patient and staff versions, the two CDMS subscales "Participation in Decision Making" and "Information" reliably measure distinct characteristics of decision making. Validity could be demonstrated to some extent, but needs further investigation. CONCLUSIONS: Together with two other five-language patient- and staff-rated measures developed in the CEDAR study (ISRCTN75841675) - "Clinical Decision Making in Routine Care" and "Clinical Decision Making Involvement and Satisfaction" - the CDMS allows empirical investigation of the complex relation between clinical decision making and outcome in the treatment of people with severe mental illness across Europe.

Different transport mechanisms in plant and human AMT/Rh-type ammonium transporters.

The conserved family of AMT/Rh proteins facilitates ammonium transport across animal, plant, and microbial membranes. A bacterial homologue, AmtB, forms a channel-like structure and appears to function as an NH3 gas channel. To evaluate the function of eukaryotic homologues, the human RhCG glycoprotein and the tomato plant ammonium transporter LeAMT1;2 were expressed and compared in Xenopus oocytes and yeast. RhCG mediated the electroneutral transport of methylammonium (MeA), which saturated with Km = 3.8 mM at pHo 7.5. Uptake was strongly favored by increasing the pHo and was inhibited by ammonium. Ammonium induced rapid cytosolic alkalinization in RhCG-expressing oocytes. Additionally, RhCG expression was associated with an alkali-cation conductance, which was not significantly permeable to NH4+ and was apparently uncoupled from the ammonium transport. In contrast, expression of the homologous LeAMT1;2 induced pHo-independent MeA+ uptake and specific NH4+ and MeA+ currents that were distinct from endogenous currents. The different mechanisms of transport, including the RhCG-associated alkali-cation conductance, were verified by heterologous expression in appropriate yeast strains. Thus, homologous AMT/Rh-type proteins function in a distinct manner; while LeAMT1;2 carries specifically NH4+, or cotransports NH3/H+, RhCG mediates electroneutral NH3 transport.

[Shared decision-making in the treatment of people with severe mental illness: a focus group study]. / Gemeinsame Entscheidungsfindung in der Behandlung von Patienten mit schweren psychischen Erkrankungen: Eine Fokusgruppenuntersuchung.

OBJECTIVE: Shared decision-making during the course of treatment is important for people with severe mental illness. However, there is still insufficient knowledge about how people with mental illness view decisions, what kind of decisions are made and how patients experience and perceive the process of participation in routine care. METHODS: A qualitative study with focus groups was conducted with patients with chronic mental illness currently receiving outpatient care (N=23). Interviews were audio-taped, transcribed, coded and content analysed. RESULTS: Three main themes were extracted from the data: 1. perception of the clinician and participation, 2. process of communication and flow of information, 3. decisions and transfer. CONCLUSIONS: The perception of participation in the decision process depends on a good patient-doctor relationship. Decisions made in the course of an outpatient long-term treatment are complex and are often not made during one single appointment. Frequently, patients seek the advice of people from their social network and/or other health professionals.