Clinical Decision-Making During Psychiatric Ward Rounds.

Introduction: For psychiatric in-patients, ward rounds are a prominent occasion for decision making. As previous findings on shared decision-making (SDM) patterns mostly derive from out-patients and one-to-one-consultations, it was our aim to investigate SDM during psychiatric ward rounds. Methods: We conducted a cross-sectional study and included n = 62 in-patients from seven different psychiatric wards. We collected data from the patient and the treating physician before and after ward rounds and recorded the interaction. Results: We identified two groups of patients regarding their attitude toward ward rounds (no expectations vs. clear agenda). The latter showed higher active engagement, expected more decisions to be made and discussed more topics. Generally, observer rated SDM was low, with vast differences between the doctors' and the patients' perception. Conclusion: Doctors and patients perceive ward rounds differently and there is a discrepancy between subjective and objective involvement. A rather paternalistic doctor-patient-relationship is observed, while patients feel sufficiently involved and vastly satisfied. The potential of ward rounds maximizes if patients have an agenda. Consequently, motivating patients to prepare themselves toward ward rounds should be part of the weekly routine, as well as improving patient participation and information procedures during ward rounds.

Barriers and facilitators of shared decision making in acutely ill inpatients with schizophrenia-Qualitative findings from the intervention group of a randomised-controlled trial.

BACKGROUND: Shared decision making (SDM) is appreciated as a promising model of communication between clinicians and patients. However, in acute mental health settings, its implementation is still unsatisfactory. OBJECTIVE: The aim of this study is to examine barriers and facilitators of SDM with acutely ill inpatients with schizophrenia. DESIGN: A qualitative interview study was performed. SETTING AND PARTICIPANTS: The analysis is based on interviews with participants (patients and staff members) of the intervention group of the randomised-controlled SDMPLUS trial that demonstrated a significant improvement of SDM measures for patients with schizophrenia on acute psychiatric wards. MAIN VARIABLES STUDIED: Interviews addressed treatment decisions made during the current inpatient stay. The interviews were analysed using qualitative content analysis. RESULTS: A total of 40 interviews were analysed and 131 treatment decisions were identified. According to the interviewees, SDM had taken place in 29% of the decisions, whereas 59% of the decisions were made without SDM. In 16%, a clear judgement could not be made. Barriers and facilitators of SDM were categorised into patient factors, clinician factors, setting factors and others. Clinicians mostly reported patient factors (e.g., symptoms) as barriers towards SDM, which were not mirrored on the patients' side. Facilitators included patient as well as clinician behaviour during consultations. CONCLUSION: Even in the context of a successful SDM intervention, the implementation of SDM for patients in the very acute stages of schizophrenia is often not possible. However, strong facilitators for SDM have also been identified, which should be used for further implementation of SDM. PATIENT OR PUBLIC CONTRIBUTION: During the development of the study protocol, meetings with user representatives were held.

'Triadic' shared decision making in mental health: Experiences and expectations of service users, caregivers and clinicians in Germany.

BACKGROUND: Shared decision making (SDM) in mental health may contribute to greater patient satisfaction and is sometimes associated with better health outcomes. Here, SDM should not only involve service users and clinicians but also involve the service users' caregivers. AIM: This study aimed to achieve better insight into the current SDM patterns of triads of service users, caregivers and clinicians in inpatient mental health care and the three parties' expectations towards the prospects of triadic SDM. DESIGN: The current research uses data from a representative cross-sectional study on caregivers in psychiatric inpatient treatment. We analysed data on n = 94 triads of service users, their caregivers and their clinicians. RESULTS: All three parties acknowledge caregivers to be of great support to monitor the progress with mental disease. The caregiver's role during consultations is most often described as being an expert, receiving or providing information and supporting service users. However, caregivers at times try to seek support for themselves during caregiver-clinician interaction, or their behaviour was described as unhelpful. The potential prospects of caregiver involvement are clearly acknowledged despite the low implementation of caregiver involvement in this sample (only in one-third of the cases). CONCLUSION: Triadic SDM rarely takes place in routine inpatient care. First, there should be a focus on interventions aiming at inviting caregivers to consultations. Only in the second step should a better conceptualisation of triadic SDM be undertaken. PUBLIC CONTRIBUTION: Early results were discussed with a local peer support group for caregivers of individuals living with mental illness.

Nocebo effects by providing informed consent in shared decision making? Not necessarily: a randomized pilot-trial using an open-label placebo approach.

BACKGROUND: Thorough information of the patient is an integral part of the process of shared decision making. We aimed to investigate if detailed information about medication may induce nocebo (or placebo) effects. METHODS: We conducted a randomized, single-blind, pilot-study including n = 51 psychiatric in-patients aged between 18 and 80 years with a depressive disorder and accompanying sleeping disorders. In the intervention group we provided thorough information about adverse effects, while the control group received only a simple consent procedure. In both groups, patients received an open-label placebo pill instead of their sleeping medication. RESULTS: No statistically significant differences between the intervention group and the control group were found regarding the main outcome parameter (a visual analogue scale indicating impairment by the new pill). CONCLUSION: In this study, we were not able detect an effect of informed consent vs. simple consent on the emergence of placebo or nocebo effects. This finding is contrary to most assumptions and publications about this topic. TRIAL REGISTRATION: Trial registration number: DRKS00017653, registered August 30th 2018. Retrosprectively registered.

Shared decision making, aggression, and coercion in inpatients with schizophrenia.

BACKGROUND: The present study aimed at answering three research questions: (a) Does shared decision making (SDM) yield similar effects for patients with involuntary admission or incidents of aggression compared to patients with voluntary admission or without incidents of aggression? (b) Does SDM reduce the number of patients with incidents of aggression and the use of coercive measures? (c) Does the use of coercion have a negative impact on patients' perceived involvement in decision making? METHODS: We used data from the cluster-randomized SDM-PLUS trial in which patients with schizophrenia or schizoaffective disorder in 12 acute psychiatric wards of 4 German psychiatric hospitals either received an SDM-intervention or treatment as usual. In addition, data on aggression and coercive measures were retrospectively obtained from patients' records. RESULTS: The analysis included n = 305 inpatients. Patient aggression as well as coercive measures mostly took place in the first days of the inpatient stay and were seldom during the study phase of the SDM-PLUS trial.Patients who had been admitted involuntarily or showed incidents of aggression profited similarly from the intervention with regard to perceived involvement, adherence, and treatment satisfaction compared to patients admitted voluntarily or without incidents of aggression. The intervention showed no effect on patient aggression and coercive measures. Having previously experienced coercive measures did not predict patients' rating of perceived involvement. CONCLUSION: Further research should focus on SDM-interventions taking place in the very first days of inpatients treatment and potential beneficial long effects of participatory approaches that may not be measurable during the current inpatient stay.

[COVID-19 Concerns and Worries in Patients with Mental Illness]. / Psychisch krank in Krisenzeiten: Subjektive Belastungen durch COVID-19.

OBJECTIVE:  This study examines the impact of the COVID-19 pandemic and the lock-down on patients with mental illness. METHODS:  Patients in inpatient or outpatient psychiatric treatment received a questionnaire, examining psychological distress and psychiatric care during the COVID-19 pandemic. RESULTS:  More than half of the patients indicated that the state of emergency had a negative impact on their mental illness. Severely ill patients were more affected. CONCLUSION:  Patients with mental illness are a particularly vulnerable group in the current crisis. Psychiatric and psychotherapeutic care needs to be adapted accordingly; the specific burden and distress needs to be examined actively in patients from all diagnostic groups.

Shared decision making PLUS - a cluster-randomized trial with inpatients suffering from schizophrenia (SDM-PLUS).

BACKGROUND: Shared decision making (SDM) is a model of how doctors and patients interact with each other. It aims at changing the traditional power asymmetry between doctors and patients by strengthening the exchange of information and the decisional position of the patient. Although SDM is generally welcomed by mental health patients as well as by mental health professionals its implementation in routine care, especially in the more acute settings, is still lacking. SDM-PLUS has been developed as an approach that addresses both patients and mental health professionals and aims at implementing SDM even for the very acutely ill patients. METHODS: The SDM-PLUS study will be performed as a matched-pair cluster-randomized trial in acute psychiatric wards. On wards allocated to the intervention group personnel will receive communication training (addressing how to implement SDM for various scenarios) and patients will receive a group intervention addressing patient skills for SDM. Wards allocated to the control condition will continue treatment as usual. A total sample size of 276 patients suffering from schizophrenia or schizoaffective disorder on 12 wards is planned. The main outcome parameter will be patients' perceived involvement in decision making during the inpatient stay measured with the SDM-Q-9 questionnaire. Secondary objectives include the therapeutic relationship and long term outcomes such as medication adherence and rehospitalization rates. In addition, process measures and qualitative data will be obtained to allow for the analysis of potential barriers and facilitators of SDM-PLUS. The primary analysis will be a comparison of SDM-Q-9 sum scores 3 weeks after study inclusion (or discharge, if earlier) between the intervention and control groups. To assess the effect of the intervention on this continuous primary outcome, a random effects linear regression model will be fitted with ward (cluster) as a random effect term and intervention group as a fixed effect. DISCUSSION: This will be the first trial examining the SDM-PLUS approach for patients with schizophrenia or schizoaffective disorder in very acute mental health inpatient settings. Within the trial a complex intervention will be implemented that addresses both patients and health care staff to yield maximum effects. TRIAL REGISTRATION: German Clinical Trials Register DRKS00010880 . Registered 09 August 2016.