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PEC-4790; No. of Pages 7 Patient Education and Counseling xxx (2014) xxx–xxx
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Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Patient Perception, Preference and Participation
Psychiatric patients’ preferences and experiences in clinical decision-making: Examining concordance and correlates of patients’ preferences ˜ ate b, Luis de Rivera c Carlos De las Cuevas a,*, Wenceslao Pen a b c
Department of Internal Medicine, Dermatology and Psychiatry, University of La Laguna, San Cristo´bal de La Laguna, Spain Department of Personality, Assessment and Psychological Treatments, University of La Laguna, San Cristo´bal de La Laguna, Spain Department of Psychiatry, University Autonoma de Madrid, Madrid, Spain
A R T I C L E I N F O
A B S T R A C T
Article history: Received 22 February 2014 Received in revised form 13 April 2014 Accepted 8 May 2014
Objective: To assess the concordance between patients’ preferred role in clinical decision-making and the role they usually experience in their psychiatric consultations and to analyze the influence of sociodemographic, clinical and personality characteristics on patients’ preferences. Methods: 677 consecutive psychiatric outpatients were invited to participate in a cross-sectional survey and 507 accepted. Patients completed Control Preference Scale twice consecutively before consultation, one for their preferences of participation and another for the style they usually experienced until then, and locus of control and self-efficacy scales. Results: Sixty-three percent of psychiatric outpatients preferred a collaborative role in decision-making, 35% preferred a passive role and only a 2% an active one. A low concordance for preferred and experienced participation in medical decision-making was registered, with more than a half of patients wanting a more active role than they actually had. Age and doctors’ health locus of control orientation were found to be the best correlates for participation preferences, while age and gender were for experienced. Psychiatric diagnoses registered significant differences in patients’ preferences of participation but no concerning experiences. Conclusion: The limited concordance between preferred and experienced roles in psychiatric patients is indicative that clinicians need to raise their sensitivity regarding patient’s participation. Practice Implications: The assessment of patient’s attribution style should be useful for psychiatrist to set objectives and priority in the communication with their patients. ß 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Decision-making Psychiatric patients Preferences Experiences Health locus of control
1. Introduction Shared Decision Making (SDM) is a communication strategy to involve patients into a collaborative process for making their health care decisions. This implies a two-way exchange of information between doctor and patient where options are made explicit, appraisal of current best evidence is negotiated, and patient desires are elicited [1]. In mental health care SDM model endorses the values of choice, self-determination, and empowerment for psychiatric patients and implement the basic rights of this group of patients who have not sufficiently benefited from consumer empowerment in other medical fields [2]. Moreover,
* Corresponding author at: Department of Internal Medicine, Dermatology and Psychiatry School of Medicine, Campus de Ofra s/n, 38071 San Cristo´bal de La Laguna, Spain. Tel.: +34 609 521 405; fax: +34 922 319 353. E-mail address: [email protected] (C. De las Cuevas).
many psychiatric treatment decisions are preference sensitive, and the involvement of patients in the decision-making process can result in benefits for both the doctor and patient [3]. Although patient participation in medical care is generally considered to correlate with better health outcomes [4,5], the implementation of SDM in everyday practice is still hindered by time and budget constraints, and also by clinicians’ and patients’ attitudes, preferences, and expectations [6,7]. Previous research in our health care setting has shown positive attitudes toward SDM both in mental health professionals [8] and among psychiatric outpatients [9,10], but further studies are needed to address the extent and characteristics to which this apparently accepted model is implemented in psychiatric outpatient clinical encounters [11]. According to the concept of ‘‘health locus of control’’ [12], that refers to the belief individuals have about who or what is the agent that determines the state of their health, patients with low external and high internal locus of control would prefer more active
http://dx.doi.org/10.1016/j.pec.2014.05.009 0738-3991/ß 2014 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: De las Cuevas C, et al. Psychiatric patients’ preferences and experiences in clinical decision-making: Examining concordance and correlates of patients’ preferences. Patient Educ Couns (2014), http://dx.doi.org/10.1016/j.pec.2014.05.009
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problem solution strategies like seeking for information or discussing treatment decisions [13]. Although preferred and experienced patients’ participation roles during health care decision have been subject of study over the past two decades and there is evidence that an optimal match of patients’ participation preferences improves health outcomes [14], there is a lack of information on the degree of concordance between psychiatric patients’ preferred and experienced participation roles during decision making. The appropriateness of a decision in SDM depends on the clinical context, patient preferences, and the responsibility of healthcare professionals [15,16]. However, not all patients are prepared, suitable, or want to participate to the same degree in the process of making decisions about the treatment of their disease [17]. The aim of this study was to assess the concordance between patients’ preferred role in clinical decision-making and the role they usually experience in their psychiatric consultations and to analyze the influence of socio-demographic, clinical and personality characteristics on patients’ preferences of participation. 2. Materials and method 2.1. Sample From October 2013 to January 2014, 667 consecutive psychiatric outpatients seen in the Community Mental Health Services on Tenerife Island (Canary Islands, Spain) were invited to participate in a cross-sectional study; a total of 507 accepted. Patients were eligible for inclusion in the study if they were aged 18 and over and were diagnosed by their psychiatrists using the International Classification of Diseases, Tenth Edition (ICD-10) as F20 (schizophrenia), F31 (bipolar affective disorder), F32–33 (depressive episode and recurrent depressive disorder), F40–48 (obsessivecompulsive disorder and other neurotic, stress-related and somatoform disorders), and F60–69 (disorders of adult personality and behavior). Each participant received a full explanation of the study, after which they signed an informed consent document approved by the clinical research ethics committee of Nuestra ˜ ora de Candelaria University Hospital in Santa Cruz de Tenerife. Sen Each participant then filled out a brief socio-demographic survey and the remaining questionnaires.
These scores are grouped as: active (active–active or active– collaborative), collaborative (collaborative–active or collaborative– passive), or passive (passive–collaborative or passive–passive). The scale was administered twice consecutively in the waiting room before the psychiatric consultation. First administration asked patients about their preferred style of clinical decision-making in their clinical encounters with their psychiatrists. The second administration asked them about the style they usually experienced until then in their previous consultations with their psychiatrists. 3.2. Multidimensional Health Locus of Control (MHLC) Form C Scale Form C of the Multidimensional Health Locus of Control (MHLC) scale [19] is an 18-item, general purpose, condition-specific locus of control scale that could easily be adapted for use with any medical or health-related condition. There are four subscales of the form C of the MHLC: (1) internal health locus of control (IHLC), which is the belief that one’s own behaviors affect one’s health status, defined in a negative way (patients feel responsible of their disease); (2) chance health locus of control (CHLC), which is the belief that one’s health condition is a matter of fate, luck or chance; (3) doctors (DHCL) health locus of control, which is the belief that doctors are who determine the outcomes of patient health; and (4) other people health locus of control (PHLC), which is the belief that other people, such as family and friends have control over one’s health status. Internal and chance subscales are comprised of 6 items, while doctors and other people subscales are comprised of 3 items, totaling 18 items on the questionnaire. Patients are asked to rate, on a six-point Likert scale, the degree to which they agree or disagree with each statement. Higher scores on each subscale indicate a stronger belief in that type of control. We found moderates internal consistency coefficients (cronbach’s alpha) with our sample (IHLC: 0.73; CHLC: 0.63; DHLC: 0.54; and PHLC: 0.48).
3. Instruments
3.3. General Perceived Self-Efficacy Scale The General Perceived Self-Efficacy Scale [20] is a 10-item selfreport scale that measures general self-efficacy as a prospective and operative construct. In contrast to other scales designed to assess optimism, this scale explicitly refers to personal agency, i.e., the belief that one’s actions are responsible for successful outcomes. Each item is scored from 1 (not at all true) to 4 (completely true). The summary score ranges from 10 to 40, with the highest score indicating high self-efficacy. A high internal consistency was found with our sample (a = 0.90)
3.1. Preferences for participating in decision-making
4. Statistical methods
The Control Preferences Scale (CPS) was developed by Degner et al. [18] to evaluate the amount of control patients want to assume in the process of making decisions about the treatment of their diseases. There are two different formats of the scale: questionnaire and card-sorting version used in our study. It consists of five ‘‘cards’’ on a board, each illustrating a different role in decision-making by means of a cartoon and short descriptive statement. The examiner asks the respondent to choose the preferred card, which is then covered up and cannot be chosen again; the examiner then asks the respondent to choose the preferred card from the remaining four cards. The procedure continues (four choices) until one card is left. If the second preference is incongruent with the first (non adjacent pairing, such as card A with card C), the test is explained again, and immediately re-administered. In the event of a further incongruence, the test is not re-administered, and a preference is not assigned. Administration requires about 5 min. Six scores are possible based on the subject’s two most preferred roles: active–active, active–collaborative, collaborative–active, collaborative–passive, passive–collaborative, and passive–passive.
The patients’ preferred and experienced roles in medical decision-making are presented as percentages. Correlation coefficients were used to determine the relationship among CPS rating and continuous variables (age, number of drugs, time under treatment, number of psychiatrists, health locus of control beliefs). We analyzed differences in CPS rating between the categorical variables gender, education and diagnoses using chi-square test. Finally, regression analyses were performed to estimate the best predictors of preference and actual role scores. To identify only those variables that play a relevant role in the explanation of SDM scores, a step-by-step model was used. This model only introduces into the equation those variables with a significant contribution. Version 19 of the SPSS software package was used for statistical analysis. 5. Results We recorded a high response rate of 76% resulting in a sample of 507 psychiatric outpatients. Table 1 shows the sample distribution
Please cite this article in press as: De las Cuevas C, et al. Psychiatric patients’ preferences and experiences in clinical decision-making: Examining concordance and correlates of patients’ preferences. Patient Educ Couns (2014), http://dx.doi.org/10.1016/j.pec.2014.05.009
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PEC-4790; No. of Pages 7 C. De las Cuevas et al. / Patient Education and Counseling xxx (2014) xxx–xxx Table 1 Socio-demographic and clinical characteristics of the sample studied (n = 507). Variable
Category
Age
18–30 years
Number of cases 58
Table 1 (Continued ) Variable
% of the sample
Mean age 48.4 13.6 Rank 18–85
Sex Educational level
ICD-10 diagnosis
History of psychiatric admissions
146 216 73 14 192 314 29 160 225 93 98 67 109
28.8 42.6 14.4 2.8 37.9 62.1 5.7 31.6 44.4 18.3 19.3 13.2 21.5
121 9
23.9 1.8
78 19 6 319
15.4 3.7 1.2 62.9
1 2 3 4 1
71 39 32 46 163
14.0 7.7 6.3 9.1 32.1
2 3 4 5 No drugs
139 76 45 84 7
27.4 15.0 8.9 16.6 1.4
One drug Two drugs Three drugs Four drugs Five or more drugs Antidepressants Tricyclics SSRIs SNSRIs Benzodiazepines Antipsychotics conventional Atypical Mood stabilizers Anticholinergics
63 131 131 95 80 348 19 263 171 410 183 30 175 158 27
12.4 25.8 25.8 18.7 15.9 68.6 3.7 51.9 33.7 80.9 36.1 5.9 34.5 31.2 5.3
59.5% Involuntary
No. of psychiatrists Mean 2.7 2.0 Rank 1–12
Psychotropic drugs Mean 3.0 1.4 drugs Rank 0–8 Polypharmacy 86.2%
Treatment
Category
Number of cases
Collaborative–active Collaborative–passive Passive Passive–collaborative Passive–passive
11.4
30–45 years 45–60 years 60–75 years >75 years Male Female Can read and write Primary Secondary University Schizophrenia Bipolar disorder Recurrent depressive disorder Depressive episode Obsessive-compulsive disorder Anxiety disorders Personality Disorders Other diagnoses No
3
Form C MHLC Scales
General Self-Efficacy Scale
0.4 1.4
15 307
3.0 60.5
157 19
31.0 3.7
Experienced role Active Active–active Active–collaborative Collaborative
0 0
0 0
0.6 13
265 173
52.3 34.1
24.5 7.2 15.5 6.9 15.3 3.3 10.9 3.8 29.0 6.8
Abbreviations: ICD, International Classification of Diseases; SNRIs, selective noradrenaline reuptake inhibitors; SSRIs, selective serotonin reuptake inhibitors; MHLC, multidimensional health locus of control. Transformed = mean of items score.
according to socio-demographic and clinical variables included in the study as well as the preferred roles and experienced roles according Control preferences scale. Most psychiatric outpatients (322 patients, 63.5%) preferred shared decisional control, while 176 (34.7%) preferred a passive approach and only 9 (1.8%) an active decisional control. These percentages attained statistical significance (x2(2) = 290.28, p 0.001). The most common preferred role was for the doctor and patient sharing responsibility for deciding what treatment is best (63.5%). The experienced roles self-reported according CPS were mostly passive (438 patients, 86%) with the rest of the patients (69, 14%) informing of collaborative approach and no patients self-reporting active decisional control. Again, these different percentages registered statistical significance (x2(2) = 268.56, p 0.001). The most common experienced role was for the doctor to make the final decision after considering the patient’s opinion (52.3%). A w coefficient was calculated to analyze the relationship between preferred role and experienced role. The concordance was also statistically significance (w = .27; p 0.001). To analyze the relationship among both socio-demographical variables and psychological processes with preferred and experienced roles in decision-making, Pearson correlation analysis was performed. Table 2 summarizes the obtained coefficients. Eight coefficients raised statistical significance. Six of them correspond to preferences role: age had the highest correlation with preferred role in decision-making (a preference for a passive role as age increases); followed by the negative correlation of general perceived self-efficacy (as perceived self-efficacy increases, there is more preference for active/collaborative Table 2 Correlation coefficients among preferences and experienced role in shared decision-making with socio-demographical and health locus of control variables (n = 507). Preferred role
2 7
3 66
Mean SD Internal Chance Doctors Other People
Preferred role Active Active–active Active–collaborative Collaborative Collaborative–active Collaborative–passive Passive Passive–collaborative Passive–passive
% of the sample
Age Educational level Treatment duration Number of different drugs HLC internal HLC chance HLC doctors HLC other people General Self-Efficacy Scale Gender (1)
0.24** 0.11* 0.13** 0.06 0.02 0.10* 0.15** 0.07 0.16** 0.09
Experienced role 0.10* 0.07 0.01 0.02 0.04 0.05 0.01 0.02 0.16** 0.10
Abbreviations and notes: HLC = health locus of control; (1) Cramer’s V * p 0.05. ** p 0.01.
Please cite this article in press as: De las Cuevas C, et al. Psychiatric patients’ preferences and experiences in clinical decision-making: Examining concordance and correlates of patients’ preferences. Patient Educ Couns (2014), http://dx.doi.org/10.1016/j.pec.2014.05.009
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Table 3 Multiple regression analysis for patient’s preferences and experiences of participation in decision-making according to socio-demographical and locus of control variables (n = 507). Experiences
Preferences B Constant Gender Age Educational level Treatment duration No. of drugs HLC internal HLC chance LHC doctors HLC other people Self-efficacy
SE 2.486 0.073 0.010 0.026 0.000 0.015 0.009 0.007 0.022 0.005 0.014
0.294 0.064 0.002 0.031 0.000 0.022 0.004 0.005 0.009 0.008 0.005
t 8.453 1.147 4.101 0.857 0.737 0.692 2.128 1.621 2.406 0.594 2.946
P
B
SE
t
p
0.001 0.252 0.001 0.392 0.461 0.490 0.034 0.106 0.016 0.553 0.003
4.597 0.161 0.007 0.018 0.000 0.012 0.008 0.003 0.009 0.003 15.672
0.293 0.064 0.002 0.031 0.000 0.022 0.004 0.005 0.009 0.008 0.000
15.672 2.534 2.677 0.585 1.137 0.574 1.921 0.756 1.047 0.310 3.692
0.001 0.012 0.008 0.559 0.256 0.566 0.055 0.450 0.295 0.757 0.001
Abbreviation: IC = confidence interval; B = beta; SE = standard error; HLC = health locus of control.
participation); treatment duration (a tendency to a more passive role as treatment is prolonged in time), and a doctors locus of control (as patients more rely on more in their psychiatrists, there is a tendency to a more passive role). Also remarkable is that age and general perceived self-efficacy were the only significant coefficients found for the experienced role, indicating that patients report experience a more passive role as their age increase and that the higher their self-efficacy, the greater their perception of participation in decision-making in psychiatric consultations. With these data in mind, a multiple regression was run to explain patient’s preferences for participation in decision-making (six point scale from active-active to passive-passive) for gender, age, educational level, psychiatric treatment duration, number of different drugs used, and multidimensional health locus of control scales (internal, chance, doctors and other people). The general model reached statistical significance (F10 = 5.87; p 0.001). Table 3 summarizes the results of the analysis performed. As can be observed, four variables attained statistical significance, age, self-efficacy, ‘doctors’ external locus of control, and negative internal locus of control: older patients, those with lower
self-efficacy and those with consistent beliefs that are their psychiatrists who determine the outcomes of their mental health and those who feel responsible of their mental disorders are more likely to prefer a paternalist/passive style of decision-making. Multiple regression analysis for experienced role shows a similar pattern comparing with preferred role: again, being older, male, those with lower perceived self-efficacy and those who feel responsible about their illness are related to report a more passive role experienced in decision-making in psychiatric consultations. The equation also reached statistical significance (F(10) = 3.02; p 0.001). Fig. 1 represents graphically the distribution of the patients’ preferred and experienced roles in decision making. Total agreement between preferred and experienced participation in medical decision making was seen in 240 patients (47%), while 52% wanted a more active role and only 1% a more passive role than they actually had. These discrepancies were statistically significant (x2(2) = 36.33; p 0.001), with psychiatric outpatients wanting a more active role in participation than what actually experienced.
Fig. 1. Concordance between psychiatric outpatients’ decisional-control preferences and experiences according to Control Preferences Scale.
Please cite this article in press as: De las Cuevas C, et al. Psychiatric patients’ preferences and experiences in clinical decision-making: Examining concordance and correlates of patients’ preferences. Patient Educ Couns (2014), http://dx.doi.org/10.1016/j.pec.2014.05.009
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Table 4 Distribution of both preferred and experienced roles in shared decision-making according psychiatric disorder. Diagnoses
n
Schizophrenia Bipolar disorder Recurrent depression Depressive episode OCD Anxiety disorders Personality disorders
98 67 109 121 9 78 19
Preferred role
Experienced role
Active
Collaborative
Passive
Active
Collaborative
Passive
12.5% 25.0% 11.1% 22.2% 0.0% 11.1% 12.5%
19.4% 12.5% 21.4% 23.3% 2.5% 15.8% 4.4%
20.1% 14.4% 22.2% 25.0% 0.6% 14.8% 2.3%
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
8.8% 16.2% 24.6% 24.6% 4.3% 17.4% 2.9%
21.2% 12.9% 21.0% 23.7% 1.4% 15.1% 3.9%
OCD: obsessive-compulsive disorder.
Table 4 shows the distribution of both preferred and experienced roles in shared decision-making according psychiatric disorder. Psychiatric diagnoses registered significant differences in patients’ preferences of participation in decision-making, while these differences were not apparent when reporting on their experience in their consultations (preferred role x2(40) = 65.23, p 0.007; experienced role x2(24) = 27.95, p 0.262). Regarding preferred roles, data are similar to general results with percentages around 60% preferring a collaborative role and around 30% preferring a passive one. However, patients with personality disorders increase the preference for a collaborative role over 70%. Concerning experienced roles in shared decision-making, again results are similar to those of general data: over 80% experienced a passive role, and around 15% a collaborative role. Two data are highlighted: an almost completely passive role for schizophrenic patients, and a percentage close to 90% of passive role for patients with personality disorders (those who initially asked for a more active role). When preferred and experienced roles are contrasted by diagnoses all reached statistical significance (bipolar disorders, x2(2) = 7.83; p 0.005; personality disorders, x2(2) = 6.04; p 0.014; depressive disorders, x2(2) = 22.53; p 0.001; anxiety disorders, x2(2) = 7.72; p 0.05; schizophrenia, x2(2) = 3.55; p 0.05). As general data showed, there is a considerable discrepancy between patients’ preferences of participation in decision-making and patients perceptions of involvement in decision-making by their psychiatrists: patients wish a more collaborative role in shared decision-making, but they usually perceive experiencing a passive role. 6. Discussion This is the first large, community psychiatry-based survey to explore the degree to which psychiatric outpatients experienced their preferred style of clinical decision-making. Psychiatric outpatients expressed their preferences to participate in a variety of ways although most expressed their preference to play a collaborative role in discussing treatment options, but ultimately wanted their psychiatrists to be the ones who make decisions on their behalf. For this reason, healthcare professionals and health organizations should not assume that all patients want to participate in clinical decision-making, but must assess each patient’s preferences and tailor care accordingly. Further, this data allows us to have a reflexive position about a well-intentioned shared decision-making: perhaps the discrepancies also reflect the clinical situation of some patients with specific mental disorders, and clinicians need to adopt a more active role, since patient crisis can not allows a truly shared decision-making. Previous studies at other medical settings have shown that being older, being a woman, and being less educated are related to the preference for a more passive role, although this relationship is not constant [13,21–23]. Our results confirm these relations only for age, but not for gender or educational level. Age is also related
to the experience of an experienced passive role, which indicates a greater congruence between role expectation and role experience as patients grow older. Age is also related to the experience of an experienced passive role, which indicates a greater congruence between role expectation and role experience as patients grow older. It seems that there is a symbiotic relationship between clinicians and patients, as a function of patient’s age. The process of this relationship can not be explained with our results, and we can not know if there is a process with patients prefering a more passive role, and clinicians feeling that preference; or patients adapting to a clinicians more active role (of both processes). Gender, however, is only related to the role experienced, with more men reporting the experience of a passive role. The lack of effect of education level in both role preference and role experience may be related to the relative homogeneity of our sample for this variable, with most of the patients (76%) pertaining to the primary/ secondary level. The relation between doctors’ health locus of control and the preference for a passive role coincides with the intuitive analysis that the higher the reliance on the doctor’s criteria, the more would the patient prefer the passive role, leaving final decisions regarding treatment to their psychiatrists. This perception is accompanied by feeling of responsibility about their disorder (negative internal locus of control), as an attribution style, usually in several affective mental disorders [24]. Our finding that duration of treatment relates with the preference for a passive role may indicate a progressive adaptation of the patients to a general tendency in the psychiatrists to expect from them such a role in clinical decision-making. The possibility that this finding is an artifact related to age is excluded by the regression analysis. The relation between high general self-efficacy and both the preference and the experience of a collaborative role is consistent with the self-efficacy construct. Obviously, the belief that the own behavior influences outcomes has to gear the patient to seek a collaborative role and this may influence the doctor’s willingness to accept his collaboration. However, there also is the possibility that the patient may perceive his relation with the doctor as more active that it has really been, as he may tend to consider his interventions during the consultation as effective in influencing doctor’s behavior. The influence of psychiatric diagnosis on concordance between preference and experienced role is interesting. The highest preference for a collaborative role is registered by patients with the diagnosis of obsessive compulsive disorder (88.9%) followed by those with personality disorder (73.7%). The preferences of the rest of the patients are closer to the general pattern. Patients with obsessive-compulsive disorder report likewise the highest percentage of experiencing a collaborative role (33.3%); albeit there is still a mismatch between preferences and experiences, this is the lowest in the whole group. Although many authors have argued that clinicians should try to explore patient preferences for decision-making, and attempt to
Please cite this article in press as: De las Cuevas C, et al. Psychiatric patients’ preferences and experiences in clinical decision-making: Examining concordance and correlates of patients’ preferences. Patient Educ Couns (2014), http://dx.doi.org/10.1016/j.pec.2014.05.009
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accommodate this preference [25–27], few data on the congruence between patients’ preferred style and the style they usually experience are available at present time. Our results confirm findings registered in other patient groups by showing considerable discrepancies between preferred and experienced roles in decision-making with patients wanting more participation than what actually experienced [28], although our figures of congruence are lower than those published in other studies ranging from 60 to 70% [29,30]. In overall, most of the patients prefer either a passive or a collaborative role, with a very little preference for an active role, which suggests a basic reliance on the doctor’s advice. However, the low concordance between their preferred role and the role experienced indicates that patients desire greater participation on clinical decisions that is actually allowed. This lack of concordance is maximal for the patients preferring a collaborative role, as only 20% of them report experiencing such a role in clinical decisionmaking. The current research was limited in some ways. However, there were also a number of strengths. Limitations of this study include the fact that we did not study patient consultations directly, but only registered patients’ perceptions of decision-making styles. Since a cross-sectional survey was carried out, the study could only demonstrate associations and not causality. Another limitation is that preferences for decision-making were measured, as a state trait and role preferences are dynamic and could vary during decision making, requiring regular clinical assessment to meet patients’ expectations. Also, we measure a general role in a general process of decision-making, but patients can prefer different roles according the different stages (information, alternatives, treatment election. . .) in decision-making process [7]. CPS does not allow this stage-by-stage differentiation. The strengths of this study include the large number of psychiatric outpatients who agreed to participate in the study and the large number of socio-demographic, clinical and personality variables included. Another strength of the current study is that regression analyses performed were controlled for the contribution of these variables. Finally, the results of our study should be interpreted with caution given the explorative nature of the study carried out. Further research is required to replicate and evaluate the relevance of our findings. The limited concordance evidenced at our study between preferred and experienced roles in decision making in psychiatric patients make necessary that psychiatrists need to raise their sensitivity regarding patient’s participation in health care decisions each time a relevant treatment decision is about to be made. It seems necessary to encourage patients in a more balanced partnership in medical decision-making since the benefits of increased patient participation have been widely demonstrated [3,31].
7. Clinical implications These data clearly show that there is a limited concordance between preferred and experienced roles in decision making in psychiatric care. Psychiatric patients wanted more participation than what actually experienced. This limited concordance between psychiatric patients’ preferred and experienced roles during decision making is indicative that psychiatrists need to increase their sensitivity regarding patient’s participation in mental health care decisions. Our results also suggest that the assessment of patient’s attribution style should be useful for psychiatrist to set objectives and priority in the communication with their patients. Those with high doctors’ health locus of control over their health would prefer a more passive role. Since patients’ role preferences are dynamic and can change during decision-making process, it
seems necessary regular clinical assessments to meet patients’ expectations and improve satisfaction with treatment decisions. Conflict of interest None of the authors of the above manuscript has declared any conflict of interest within the last three years which may arise from being named as an author on the manuscript. Acknowledgement This work was supported by Instituto de Salud Carlos III, FEDER (Fondo Europeo de Desarrollo Regional) Unio´n Europea (PI10/ 00955). References [1] Charles C, Gafni A, Whelan T. Shared decision-making in the medical encounter – what does it mean (or: it takes at least two to tango). Soc Sci Med 1997;44: 681–92. [2] Hamann J, Leucht S, Kissling W. Shared decision making in psychiatry. Acta Psychiatr Scand 2003;107:403–9. [3] Simmons M, Hetrick S, Jorm A. Shared decision-making: benefits, barriers and current opportunities for application. Australas Psychiatry 2010;18:394–7. [4] Charles C, Gafni A, Whelan T, O’Brien MA. Cultural influences on the physicianpatient encounter: the case of shared treatment decision-making. Patient Educ Couns 2006;63:262–7. [5] Chow S, Teare G, Basky G. Shared decision making: helping the system and patients make quality health care decisions. Saskatoon: Health Quality Council; September 2009. [6] Solari A, Giordano A, Kasper J, Drulovic J, van Nunen A, et al. Role preferences of people with multiple sclerosis: image-revised, computerized self-administered version of the control preference scale. PLoS ONE 2013 June;8:e66127. ˜ ate W, Perestelo-Pe´rez L, Serrano-Aguilar P. Shared [7] De las Cuevas C, Pen decision-making in psychiatric practice and the primary care setting is by no means the same, according to SDM-Q-9. Neuropsychiatr Dis. Treat 2013;9: 1045–52. [8] De las Cuevas C, Rivero-Santana A, Perestelo-Pe´rez L, Serrano-Aguilar P. Attitudes toward concordance in psychiatry: a comparative, cross-sectional study of psychiatric patients and mental health professionals. BMC Psychiatry 2012;12:53. ˜ ate W. [9] De las Cuevas C, Rivero A, Perestelo-Pe´rez L, Gonza´lez M, Pe´rez J, Pen Psychiatric patients’ attitudes towards concordance and shared decision making. Patient Educ Couns 2011;85:e245–50. [10] De las Cuevas C, Rivero-Santana A, Perestelo-Pe´rez L, Pe´rez-Ramos J, Gona´lezLorenzo M, Serrano-Aguilar P, Sanz EJ. Mental health professionals’ attitudes to partnership in medicine taking: a validation study of Leeds attitude to Concordance Scale II. Pharmacoepidemiol Drug Saf 2012;21:123–9. ˜ ate W. Preferences for participation in shared decision [11] De las Cuevas C, Pen making of psychiatric outpatients with affective disorders. Open J Psychiatry 2014;4:16–23. [12] Rotter JB. Generalized expectancies for internal versus external control of reinforcement. Psychol Monogr 1966;80:1–28. [13] Schneider A, Ko¨rner T, Mehring M, Wensing M, Elwyn G, Szecsenyi J. Impact of age, health locus of control and psychological co-morbidity on patients’ preferences for shared decision making in general practice. Patient Educ Couns 2006;61:292–8. [14] Hamann J, Mendel R, Schebitz M, Reiter S, Bu¨hner M, Cohen R, Berthele A, Kissling W. Can psychiatrists and neurologists predict their patients’ participation preferences? J Nerv Ment Dis 2010;198:309–11. [15] Trevena L, Barratt A. Integrated decision making: definitions for a new discipline. Patient Educ Couns 2003;50:265–8. [16] Duncan E, Best C, Hagen S. Shared decision making interventions for people with mental health conditions. Cochrane Database Syst Rev 2010. CD007297. [17] Levinson W, Kao A, Kuby A, Thisted RA. Not all patients want to participate in decision making. A national study of public preferences. J Gen Intern Med 2005;20:531–5. [18] Degner LF, Sloan JA, Venkatesh P. The Control Preferences Scale. Can J Nurs Res 1997;29:21–43. [19] Wallston KA, Stein MJ, Smith CA. Form C of the MHLC Scales: a conditionspecific measure of locus of control. J Pers Assess 1994;63:534–55. [20] Schwarzer R, Jerusalem M. Generalized Self-Efficacy scale. In: Weinman J, Wright S, Johnston M, editors. Measures in health psychology: a user’s portfolio. Causal and control beliefs. Windsor, England: NFER-NELSON; 1995. p. 35–7. [21] Say R, Murtagh M, Thomson R. Patients’ preference for involvement in medical decision making: a narrative review. Patient Educ Couns 2006;60:102–14. [22] O’Donnell M, Hunskaar S. Preferences for involvement in treatment decisionmaking generally and in hormone replacement and urinary incontinence treatment decision-making specifically. Patient Educ Couns 2007;68:243–51. [23] Florin J, Ehrenberg A, Ehnfors M. Clinical decision-making: predictors of patient participation in nursing care. J Clin Nurs 2008;17:2935–44.
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[28] Tariman JD, Berry DL, Cochrane B, Doorenbos A, Schepp K. Preferred and actual participation roles during health care decision making in persons with cancer: a systematic review. Ann Oncol 2010;21:1145–51. [29] Ford S, Schofield T, Hope T. Are patients’ decision-making preferences being met? Health Expect 2003;6:72–80. [30] Murray E, Pollack L, White M, Lo B. Clinical decision-making: patients’ preferences and experiences. Patient Educ Couns 2007;65:189–96. [31] Patel SR, Bakken S, Ruland C. Recent advances in shared decision making for mental health. Curr Opin Psychiatry 2008;21:606–12.
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PEC-4790; No. of Pages 7 Patient Education and Counseling xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Patient Perception, Preference and Participation
Psychiatric patients’ preferences and experiences in clinical decision-making: Examining concordance and correlates of patients’ preferences ˜ ate b, Luis de Rivera c Carlos De las Cuevas a,*, Wenceslao Pen a b c
Department of Internal Medicine, Dermatology and Psychiatry, University of La Laguna, San Cristo´bal de La Laguna, Spain Department of Personality, Assessment and Psychological Treatments, University of La Laguna, San Cristo´bal de La Laguna, Spain Department of Psychiatry, University Autonoma de Madrid, Madrid, Spain
A R T I C L E I N F O
A B S T R A C T
Article history: Received 22 February 2014 Received in revised form 13 April 2014 Accepted 8 May 2014
Objective: To assess the concordance between patients’ preferred role in clinical decision-making and the role they usually experience in their psychiatric consultations and to analyze the influence of sociodemographic, clinical and personality characteristics on patients’ preferences. Methods: 677 consecutive psychiatric outpatients were invited to participate in a cross-sectional survey and 507 accepted. Patients completed Control Preference Scale twice consecutively before consultation, one for their preferences of participation and another for the style they usually experienced until then, and locus of control and self-efficacy scales. Results: Sixty-three percent of psychiatric outpatients preferred a collaborative role in decision-making, 35% preferred a passive role and only a 2% an active one. A low concordance for preferred and experienced participation in medical decision-making was registered, with more than a half of patients wanting a more active role than they actually had. Age and doctors’ health locus of control orientation were found to be the best correlates for participation preferences, while age and gender were for experienced. Psychiatric diagnoses registered significant differences in patients’ preferences of participation but no concerning experiences. Conclusion: The limited concordance between preferred and experienced roles in psychiatric patients is indicative that clinicians need to raise their sensitivity regarding patient’s participation. Practice Implications: The assessment of patient’s attribution style should be useful for psychiatrist to set objectives and priority in the communication with their patients. ß 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Decision-making Psychiatric patients Preferences Experiences Health locus of control
1. Introduction Shared Decision Making (SDM) is a communication strategy to involve patients into a collaborative process for making their health care decisions. This implies a two-way exchange of information between doctor and patient where options are made explicit, appraisal of current best evidence is negotiated, and patient desires are elicited [1]. In mental health care SDM model endorses the values of choice, self-determination, and empowerment for psychiatric patients and implement the basic rights of this group of patients who have not sufficiently benefited from consumer empowerment in other medical fields [2]. Moreover,
* Corresponding author at: Department of Internal Medicine, Dermatology and Psychiatry School of Medicine, Campus de Ofra s/n, 38071 San Cristo´bal de La Laguna, Spain. Tel.: +34 609 521 405; fax: +34 922 319 353. E-mail address: [email protected] (C. De las Cuevas).
many psychiatric treatment decisions are preference sensitive, and the involvement of patients in the decision-making process can result in benefits for both the doctor and patient [3]. Although patient participation in medical care is generally considered to correlate with better health outcomes [4,5], the implementation of SDM in everyday practice is still hindered by time and budget constraints, and also by clinicians’ and patients’ attitudes, preferences, and expectations [6,7]. Previous research in our health care setting has shown positive attitudes toward SDM both in mental health professionals [8] and among psychiatric outpatients [9,10], but further studies are needed to address the extent and characteristics to which this apparently accepted model is implemented in psychiatric outpatient clinical encounters [11]. According to the concept of ‘‘health locus of control’’ [12], that refers to the belief individuals have about who or what is the agent that determines the state of their health, patients with low external and high internal locus of control would prefer more active
http://dx.doi.org/10.1016/j.pec.2014.05.009 0738-3991/ß 2014 Elsevier Ireland Ltd. All rights reserved.
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problem solution strategies like seeking for information or discussing treatment decisions [13]. Although preferred and experienced patients’ participation roles during health care decision have been subject of study over the past two decades and there is evidence that an optimal match of patients’ participation preferences improves health outcomes [14], there is a lack of information on the degree of concordance between psychiatric patients’ preferred and experienced participation roles during decision making. The appropriateness of a decision in SDM depends on the clinical context, patient preferences, and the responsibility of healthcare professionals [15,16]. However, not all patients are prepared, suitable, or want to participate to the same degree in the process of making decisions about the treatment of their disease [17]. The aim of this study was to assess the concordance between patients’ preferred role in clinical decision-making and the role they usually experience in their psychiatric consultations and to analyze the influence of socio-demographic, clinical and personality characteristics on patients’ preferences of participation. 2. Materials and method 2.1. Sample From October 2013 to January 2014, 667 consecutive psychiatric outpatients seen in the Community Mental Health Services on Tenerife Island (Canary Islands, Spain) were invited to participate in a cross-sectional study; a total of 507 accepted. Patients were eligible for inclusion in the study if they were aged 18 and over and were diagnosed by their psychiatrists using the International Classification of Diseases, Tenth Edition (ICD-10) as F20 (schizophrenia), F31 (bipolar affective disorder), F32–33 (depressive episode and recurrent depressive disorder), F40–48 (obsessivecompulsive disorder and other neurotic, stress-related and somatoform disorders), and F60–69 (disorders of adult personality and behavior). Each participant received a full explanation of the study, after which they signed an informed consent document approved by the clinical research ethics committee of Nuestra ˜ ora de Candelaria University Hospital in Santa Cruz de Tenerife. Sen Each participant then filled out a brief socio-demographic survey and the remaining questionnaires.
These scores are grouped as: active (active–active or active– collaborative), collaborative (collaborative–active or collaborative– passive), or passive (passive–collaborative or passive–passive). The scale was administered twice consecutively in the waiting room before the psychiatric consultation. First administration asked patients about their preferred style of clinical decision-making in their clinical encounters with their psychiatrists. The second administration asked them about the style they usually experienced until then in their previous consultations with their psychiatrists. 3.2. Multidimensional Health Locus of Control (MHLC) Form C Scale Form C of the Multidimensional Health Locus of Control (MHLC) scale [19] is an 18-item, general purpose, condition-specific locus of control scale that could easily be adapted for use with any medical or health-related condition. There are four subscales of the form C of the MHLC: (1) internal health locus of control (IHLC), which is the belief that one’s own behaviors affect one’s health status, defined in a negative way (patients feel responsible of their disease); (2) chance health locus of control (CHLC), which is the belief that one’s health condition is a matter of fate, luck or chance; (3) doctors (DHCL) health locus of control, which is the belief that doctors are who determine the outcomes of patient health; and (4) other people health locus of control (PHLC), which is the belief that other people, such as family and friends have control over one’s health status. Internal and chance subscales are comprised of 6 items, while doctors and other people subscales are comprised of 3 items, totaling 18 items on the questionnaire. Patients are asked to rate, on a six-point Likert scale, the degree to which they agree or disagree with each statement. Higher scores on each subscale indicate a stronger belief in that type of control. We found moderates internal consistency coefficients (cronbach’s alpha) with our sample (IHLC: 0.73; CHLC: 0.63; DHLC: 0.54; and PHLC: 0.48).
3. Instruments
3.3. General Perceived Self-Efficacy Scale The General Perceived Self-Efficacy Scale [20] is a 10-item selfreport scale that measures general self-efficacy as a prospective and operative construct. In contrast to other scales designed to assess optimism, this scale explicitly refers to personal agency, i.e., the belief that one’s actions are responsible for successful outcomes. Each item is scored from 1 (not at all true) to 4 (completely true). The summary score ranges from 10 to 40, with the highest score indicating high self-efficacy. A high internal consistency was found with our sample (a = 0.90)
3.1. Preferences for participating in decision-making
4. Statistical methods
The Control Preferences Scale (CPS) was developed by Degner et al. [18] to evaluate the amount of control patients want to assume in the process of making decisions about the treatment of their diseases. There are two different formats of the scale: questionnaire and card-sorting version used in our study. It consists of five ‘‘cards’’ on a board, each illustrating a different role in decision-making by means of a cartoon and short descriptive statement. The examiner asks the respondent to choose the preferred card, which is then covered up and cannot be chosen again; the examiner then asks the respondent to choose the preferred card from the remaining four cards. The procedure continues (four choices) until one card is left. If the second preference is incongruent with the first (non adjacent pairing, such as card A with card C), the test is explained again, and immediately re-administered. In the event of a further incongruence, the test is not re-administered, and a preference is not assigned. Administration requires about 5 min. Six scores are possible based on the subject’s two most preferred roles: active–active, active–collaborative, collaborative–active, collaborative–passive, passive–collaborative, and passive–passive.
The patients’ preferred and experienced roles in medical decision-making are presented as percentages. Correlation coefficients were used to determine the relationship among CPS rating and continuous variables (age, number of drugs, time under treatment, number of psychiatrists, health locus of control beliefs). We analyzed differences in CPS rating between the categorical variables gender, education and diagnoses using chi-square test. Finally, regression analyses were performed to estimate the best predictors of preference and actual role scores. To identify only those variables that play a relevant role in the explanation of SDM scores, a step-by-step model was used. This model only introduces into the equation those variables with a significant contribution. Version 19 of the SPSS software package was used for statistical analysis. 5. Results We recorded a high response rate of 76% resulting in a sample of 507 psychiatric outpatients. Table 1 shows the sample distribution
Please cite this article in press as: De las Cuevas C, et al. Psychiatric patients’ preferences and experiences in clinical decision-making: Examining concordance and correlates of patients’ preferences. Patient Educ Couns (2014), http://dx.doi.org/10.1016/j.pec.2014.05.009
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PEC-4790; No. of Pages 7 C. De las Cuevas et al. / Patient Education and Counseling xxx (2014) xxx–xxx Table 1 Socio-demographic and clinical characteristics of the sample studied (n = 507). Variable
Category
Age
18–30 years
Number of cases 58
Table 1 (Continued ) Variable
% of the sample
Mean age 48.4 13.6 Rank 18–85
Sex Educational level
ICD-10 diagnosis
History of psychiatric admissions
146 216 73 14 192 314 29 160 225 93 98 67 109
28.8 42.6 14.4 2.8 37.9 62.1 5.7 31.6 44.4 18.3 19.3 13.2 21.5
121 9
23.9 1.8
78 19 6 319
15.4 3.7 1.2 62.9
1 2 3 4 1
71 39 32 46 163
14.0 7.7 6.3 9.1 32.1
2 3 4 5 No drugs
139 76 45 84 7
27.4 15.0 8.9 16.6 1.4
One drug Two drugs Three drugs Four drugs Five or more drugs Antidepressants Tricyclics SSRIs SNSRIs Benzodiazepines Antipsychotics conventional Atypical Mood stabilizers Anticholinergics
63 131 131 95 80 348 19 263 171 410 183 30 175 158 27
12.4 25.8 25.8 18.7 15.9 68.6 3.7 51.9 33.7 80.9 36.1 5.9 34.5 31.2 5.3
59.5% Involuntary
No. of psychiatrists Mean 2.7 2.0 Rank 1–12
Psychotropic drugs Mean 3.0 1.4 drugs Rank 0–8 Polypharmacy 86.2%
Treatment
Category
Number of cases
Collaborative–active Collaborative–passive Passive Passive–collaborative Passive–passive
11.4
30–45 years 45–60 years 60–75 years >75 years Male Female Can read and write Primary Secondary University Schizophrenia Bipolar disorder Recurrent depressive disorder Depressive episode Obsessive-compulsive disorder Anxiety disorders Personality Disorders Other diagnoses No
3
Form C MHLC Scales
General Self-Efficacy Scale
0.4 1.4
15 307
3.0 60.5
157 19
31.0 3.7
Experienced role Active Active–active Active–collaborative Collaborative
0 0
0 0
0.6 13
265 173
52.3 34.1
24.5 7.2 15.5 6.9 15.3 3.3 10.9 3.8 29.0 6.8
Abbreviations: ICD, International Classification of Diseases; SNRIs, selective noradrenaline reuptake inhibitors; SSRIs, selective serotonin reuptake inhibitors; MHLC, multidimensional health locus of control. Transformed = mean of items score.
according to socio-demographic and clinical variables included in the study as well as the preferred roles and experienced roles according Control preferences scale. Most psychiatric outpatients (322 patients, 63.5%) preferred shared decisional control, while 176 (34.7%) preferred a passive approach and only 9 (1.8%) an active decisional control. These percentages attained statistical significance (x2(2) = 290.28, p 0.001). The most common preferred role was for the doctor and patient sharing responsibility for deciding what treatment is best (63.5%). The experienced roles self-reported according CPS were mostly passive (438 patients, 86%) with the rest of the patients (69, 14%) informing of collaborative approach and no patients self-reporting active decisional control. Again, these different percentages registered statistical significance (x2(2) = 268.56, p 0.001). The most common experienced role was for the doctor to make the final decision after considering the patient’s opinion (52.3%). A w coefficient was calculated to analyze the relationship between preferred role and experienced role. The concordance was also statistically significance (w = .27; p 0.001). To analyze the relationship among both socio-demographical variables and psychological processes with preferred and experienced roles in decision-making, Pearson correlation analysis was performed. Table 2 summarizes the obtained coefficients. Eight coefficients raised statistical significance. Six of them correspond to preferences role: age had the highest correlation with preferred role in decision-making (a preference for a passive role as age increases); followed by the negative correlation of general perceived self-efficacy (as perceived self-efficacy increases, there is more preference for active/collaborative Table 2 Correlation coefficients among preferences and experienced role in shared decision-making with socio-demographical and health locus of control variables (n = 507). Preferred role
2 7
3 66
Mean SD Internal Chance Doctors Other People
Preferred role Active Active–active Active–collaborative Collaborative Collaborative–active Collaborative–passive Passive Passive–collaborative Passive–passive
% of the sample
Age Educational level Treatment duration Number of different drugs HLC internal HLC chance HLC doctors HLC other people General Self-Efficacy Scale Gender (1)
0.24** 0.11* 0.13** 0.06 0.02 0.10* 0.15** 0.07 0.16** 0.09
Experienced role 0.10* 0.07 0.01 0.02 0.04 0.05 0.01 0.02 0.16** 0.10
Abbreviations and notes: HLC = health locus of control; (1) Cramer’s V * p 0.05. ** p 0.01.
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Table 3 Multiple regression analysis for patient’s preferences and experiences of participation in decision-making according to socio-demographical and locus of control variables (n = 507). Experiences
Preferences B Constant Gender Age Educational level Treatment duration No. of drugs HLC internal HLC chance LHC doctors HLC other people Self-efficacy
SE 2.486 0.073 0.010 0.026 0.000 0.015 0.009 0.007 0.022 0.005 0.014
0.294 0.064 0.002 0.031 0.000 0.022 0.004 0.005 0.009 0.008 0.005
t 8.453 1.147 4.101 0.857 0.737 0.692 2.128 1.621 2.406 0.594 2.946
P
B
SE
t
p
0.001 0.252 0.001 0.392 0.461 0.490 0.034 0.106 0.016 0.553 0.003
4.597 0.161 0.007 0.018 0.000 0.012 0.008 0.003 0.009 0.003 15.672
0.293 0.064 0.002 0.031 0.000 0.022 0.004 0.005 0.009 0.008 0.000
15.672 2.534 2.677 0.585 1.137 0.574 1.921 0.756 1.047 0.310 3.692
0.001 0.012 0.008 0.559 0.256 0.566 0.055 0.450 0.295 0.757 0.001
Abbreviation: IC = confidence interval; B = beta; SE = standard error; HLC = health locus of control.
participation); treatment duration (a tendency to a more passive role as treatment is prolonged in time), and a doctors locus of control (as patients more rely on more in their psychiatrists, there is a tendency to a more passive role). Also remarkable is that age and general perceived self-efficacy were the only significant coefficients found for the experienced role, indicating that patients report experience a more passive role as their age increase and that the higher their self-efficacy, the greater their perception of participation in decision-making in psychiatric consultations. With these data in mind, a multiple regression was run to explain patient’s preferences for participation in decision-making (six point scale from active-active to passive-passive) for gender, age, educational level, psychiatric treatment duration, number of different drugs used, and multidimensional health locus of control scales (internal, chance, doctors and other people). The general model reached statistical significance (F10 = 5.87; p 0.001). Table 3 summarizes the results of the analysis performed. As can be observed, four variables attained statistical significance, age, self-efficacy, ‘doctors’ external locus of control, and negative internal locus of control: older patients, those with lower
self-efficacy and those with consistent beliefs that are their psychiatrists who determine the outcomes of their mental health and those who feel responsible of their mental disorders are more likely to prefer a paternalist/passive style of decision-making. Multiple regression analysis for experienced role shows a similar pattern comparing with preferred role: again, being older, male, those with lower perceived self-efficacy and those who feel responsible about their illness are related to report a more passive role experienced in decision-making in psychiatric consultations. The equation also reached statistical significance (F(10) = 3.02; p 0.001). Fig. 1 represents graphically the distribution of the patients’ preferred and experienced roles in decision making. Total agreement between preferred and experienced participation in medical decision making was seen in 240 patients (47%), while 52% wanted a more active role and only 1% a more passive role than they actually had. These discrepancies were statistically significant (x2(2) = 36.33; p 0.001), with psychiatric outpatients wanting a more active role in participation than what actually experienced.
Fig. 1. Concordance between psychiatric outpatients’ decisional-control preferences and experiences according to Control Preferences Scale.
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Table 4 Distribution of both preferred and experienced roles in shared decision-making according psychiatric disorder. Diagnoses
n
Schizophrenia Bipolar disorder Recurrent depression Depressive episode OCD Anxiety disorders Personality disorders
98 67 109 121 9 78 19
Preferred role
Experienced role
Active
Collaborative
Passive
Active
Collaborative
Passive
12.5% 25.0% 11.1% 22.2% 0.0% 11.1% 12.5%
19.4% 12.5% 21.4% 23.3% 2.5% 15.8% 4.4%
20.1% 14.4% 22.2% 25.0% 0.6% 14.8% 2.3%
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
8.8% 16.2% 24.6% 24.6% 4.3% 17.4% 2.9%
21.2% 12.9% 21.0% 23.7% 1.4% 15.1% 3.9%
OCD: obsessive-compulsive disorder.
Table 4 shows the distribution of both preferred and experienced roles in shared decision-making according psychiatric disorder. Psychiatric diagnoses registered significant differences in patients’ preferences of participation in decision-making, while these differences were not apparent when reporting on their experience in their consultations (preferred role x2(40) = 65.23, p 0.007; experienced role x2(24) = 27.95, p 0.262). Regarding preferred roles, data are similar to general results with percentages around 60% preferring a collaborative role and around 30% preferring a passive one. However, patients with personality disorders increase the preference for a collaborative role over 70%. Concerning experienced roles in shared decision-making, again results are similar to those of general data: over 80% experienced a passive role, and around 15% a collaborative role. Two data are highlighted: an almost completely passive role for schizophrenic patients, and a percentage close to 90% of passive role for patients with personality disorders (those who initially asked for a more active role). When preferred and experienced roles are contrasted by diagnoses all reached statistical significance (bipolar disorders, x2(2) = 7.83; p 0.005; personality disorders, x2(2) = 6.04; p 0.014; depressive disorders, x2(2) = 22.53; p 0.001; anxiety disorders, x2(2) = 7.72; p 0.05; schizophrenia, x2(2) = 3.55; p 0.05). As general data showed, there is a considerable discrepancy between patients’ preferences of participation in decision-making and patients perceptions of involvement in decision-making by their psychiatrists: patients wish a more collaborative role in shared decision-making, but they usually perceive experiencing a passive role. 6. Discussion This is the first large, community psychiatry-based survey to explore the degree to which psychiatric outpatients experienced their preferred style of clinical decision-making. Psychiatric outpatients expressed their preferences to participate in a variety of ways although most expressed their preference to play a collaborative role in discussing treatment options, but ultimately wanted their psychiatrists to be the ones who make decisions on their behalf. For this reason, healthcare professionals and health organizations should not assume that all patients want to participate in clinical decision-making, but must assess each patient’s preferences and tailor care accordingly. Further, this data allows us to have a reflexive position about a well-intentioned shared decision-making: perhaps the discrepancies also reflect the clinical situation of some patients with specific mental disorders, and clinicians need to adopt a more active role, since patient crisis can not allows a truly shared decision-making. Previous studies at other medical settings have shown that being older, being a woman, and being less educated are related to the preference for a more passive role, although this relationship is not constant [13,21–23]. Our results confirm these relations only for age, but not for gender or educational level. Age is also related
to the experience of an experienced passive role, which indicates a greater congruence between role expectation and role experience as patients grow older. Age is also related to the experience of an experienced passive role, which indicates a greater congruence between role expectation and role experience as patients grow older. It seems that there is a symbiotic relationship between clinicians and patients, as a function of patient’s age. The process of this relationship can not be explained with our results, and we can not know if there is a process with patients prefering a more passive role, and clinicians feeling that preference; or patients adapting to a clinicians more active role (of both processes). Gender, however, is only related to the role experienced, with more men reporting the experience of a passive role. The lack of effect of education level in both role preference and role experience may be related to the relative homogeneity of our sample for this variable, with most of the patients (76%) pertaining to the primary/ secondary level. The relation between doctors’ health locus of control and the preference for a passive role coincides with the intuitive analysis that the higher the reliance on the doctor’s criteria, the more would the patient prefer the passive role, leaving final decisions regarding treatment to their psychiatrists. This perception is accompanied by feeling of responsibility about their disorder (negative internal locus of control), as an attribution style, usually in several affective mental disorders [24]. Our finding that duration of treatment relates with the preference for a passive role may indicate a progressive adaptation of the patients to a general tendency in the psychiatrists to expect from them such a role in clinical decision-making. The possibility that this finding is an artifact related to age is excluded by the regression analysis. The relation between high general self-efficacy and both the preference and the experience of a collaborative role is consistent with the self-efficacy construct. Obviously, the belief that the own behavior influences outcomes has to gear the patient to seek a collaborative role and this may influence the doctor’s willingness to accept his collaboration. However, there also is the possibility that the patient may perceive his relation with the doctor as more active that it has really been, as he may tend to consider his interventions during the consultation as effective in influencing doctor’s behavior. The influence of psychiatric diagnosis on concordance between preference and experienced role is interesting. The highest preference for a collaborative role is registered by patients with the diagnosis of obsessive compulsive disorder (88.9%) followed by those with personality disorder (73.7%). The preferences of the rest of the patients are closer to the general pattern. Patients with obsessive-compulsive disorder report likewise the highest percentage of experiencing a collaborative role (33.3%); albeit there is still a mismatch between preferences and experiences, this is the lowest in the whole group. Although many authors have argued that clinicians should try to explore patient preferences for decision-making, and attempt to
Please cite this article in press as: De las Cuevas C, et al. Psychiatric patients’ preferences and experiences in clinical decision-making: Examining concordance and correlates of patients’ preferences. Patient Educ Couns (2014), http://dx.doi.org/10.1016/j.pec.2014.05.009
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accommodate this preference [25–27], few data on the congruence between patients’ preferred style and the style they usually experience are available at present time. Our results confirm findings registered in other patient groups by showing considerable discrepancies between preferred and experienced roles in decision-making with patients wanting more participation than what actually experienced [28], although our figures of congruence are lower than those published in other studies ranging from 60 to 70% [29,30]. In overall, most of the patients prefer either a passive or a collaborative role, with a very little preference for an active role, which suggests a basic reliance on the doctor’s advice. However, the low concordance between their preferred role and the role experienced indicates that patients desire greater participation on clinical decisions that is actually allowed. This lack of concordance is maximal for the patients preferring a collaborative role, as only 20% of them report experiencing such a role in clinical decisionmaking. The current research was limited in some ways. However, there were also a number of strengths. Limitations of this study include the fact that we did not study patient consultations directly, but only registered patients’ perceptions of decision-making styles. Since a cross-sectional survey was carried out, the study could only demonstrate associations and not causality. Another limitation is that preferences for decision-making were measured, as a state trait and role preferences are dynamic and could vary during decision making, requiring regular clinical assessment to meet patients’ expectations. Also, we measure a general role in a general process of decision-making, but patients can prefer different roles according the different stages (information, alternatives, treatment election. . .) in decision-making process [7]. CPS does not allow this stage-by-stage differentiation. The strengths of this study include the large number of psychiatric outpatients who agreed to participate in the study and the large number of socio-demographic, clinical and personality variables included. Another strength of the current study is that regression analyses performed were controlled for the contribution of these variables. Finally, the results of our study should be interpreted with caution given the explorative nature of the study carried out. Further research is required to replicate and evaluate the relevance of our findings. The limited concordance evidenced at our study between preferred and experienced roles in decision making in psychiatric patients make necessary that psychiatrists need to raise their sensitivity regarding patient’s participation in health care decisions each time a relevant treatment decision is about to be made. It seems necessary to encourage patients in a more balanced partnership in medical decision-making since the benefits of increased patient participation have been widely demonstrated [3,31].
7. Clinical implications These data clearly show that there is a limited concordance between preferred and experienced roles in decision making in psychiatric care. Psychiatric patients wanted more participation than what actually experienced. This limited concordance between psychiatric patients’ preferred and experienced roles during decision making is indicative that psychiatrists need to increase their sensitivity regarding patient’s participation in mental health care decisions. Our results also suggest that the assessment of patient’s attribution style should be useful for psychiatrist to set objectives and priority in the communication with their patients. Those with high doctors’ health locus of control over their health would prefer a more passive role. Since patients’ role preferences are dynamic and can change during decision-making process, it
seems necessary regular clinical assessments to meet patients’ expectations and improve satisfaction with treatment decisions. Conflict of interest None of the authors of the above manuscript has declared any conflict of interest within the last three years which may arise from being named as an author on the manuscript. Acknowledgement This work was supported by Instituto de Salud Carlos III, FEDER (Fondo Europeo de Desarrollo Regional) Unio´n Europea (PI10/ 00955). References [1] Charles C, Gafni A, Whelan T. Shared decision-making in the medical encounter – what does it mean (or: it takes at least two to tango). Soc Sci Med 1997;44: 681–92. [2] Hamann J, Leucht S, Kissling W. Shared decision making in psychiatry. Acta Psychiatr Scand 2003;107:403–9. [3] Simmons M, Hetrick S, Jorm A. Shared decision-making: benefits, barriers and current opportunities for application. Australas Psychiatry 2010;18:394–7. [4] Charles C, Gafni A, Whelan T, O’Brien MA. Cultural influences on the physicianpatient encounter: the case of shared treatment decision-making. Patient Educ Couns 2006;63:262–7. [5] Chow S, Teare G, Basky G. Shared decision making: helping the system and patients make quality health care decisions. Saskatoon: Health Quality Council; September 2009. [6] Solari A, Giordano A, Kasper J, Drulovic J, van Nunen A, et al. Role preferences of people with multiple sclerosis: image-revised, computerized self-administered version of the control preference scale. PLoS ONE 2013 June;8:e66127. ˜ ate W, Perestelo-Pe´rez L, Serrano-Aguilar P. Shared [7] De las Cuevas C, Pen decision-making in psychiatric practice and the primary care setting is by no means the same, according to SDM-Q-9. Neuropsychiatr Dis. Treat 2013;9: 1045–52. [8] De las Cuevas C, Rivero-Santana A, Perestelo-Pe´rez L, Serrano-Aguilar P. Attitudes toward concordance in psychiatry: a comparative, cross-sectional study of psychiatric patients and mental health professionals. BMC Psychiatry 2012;12:53. ˜ ate W. [9] De las Cuevas C, Rivero A, Perestelo-Pe´rez L, Gonza´lez M, Pe´rez J, Pen Psychiatric patients’ attitudes towards concordance and shared decision making. Patient Educ Couns 2011;85:e245–50. [10] De las Cuevas C, Rivero-Santana A, Perestelo-Pe´rez L, Pe´rez-Ramos J, Gona´lezLorenzo M, Serrano-Aguilar P, Sanz EJ. Mental health professionals’ attitudes to partnership in medicine taking: a validation study of Leeds attitude to Concordance Scale II. Pharmacoepidemiol Drug Saf 2012;21:123–9. ˜ ate W. Preferences for participation in shared decision [11] De las Cuevas C, Pen making of psychiatric outpatients with affective disorders. Open J Psychiatry 2014;4:16–23. [12] Rotter JB. Generalized expectancies for internal versus external control of reinforcement. Psychol Monogr 1966;80:1–28. [13] Schneider A, Ko¨rner T, Mehring M, Wensing M, Elwyn G, Szecsenyi J. Impact of age, health locus of control and psychological co-morbidity on patients’ preferences for shared decision making in general practice. Patient Educ Couns 2006;61:292–8. [14] Hamann J, Mendel R, Schebitz M, Reiter S, Bu¨hner M, Cohen R, Berthele A, Kissling W. Can psychiatrists and neurologists predict their patients’ participation preferences? J Nerv Ment Dis 2010;198:309–11. [15] Trevena L, Barratt A. Integrated decision making: definitions for a new discipline. Patient Educ Couns 2003;50:265–8. [16] Duncan E, Best C, Hagen S. Shared decision making interventions for people with mental health conditions. Cochrane Database Syst Rev 2010. CD007297. [17] Levinson W, Kao A, Kuby A, Thisted RA. Not all patients want to participate in decision making. A national study of public preferences. J Gen Intern Med 2005;20:531–5. [18] Degner LF, Sloan JA, Venkatesh P. The Control Preferences Scale. Can J Nurs Res 1997;29:21–43. [19] Wallston KA, Stein MJ, Smith CA. Form C of the MHLC Scales: a conditionspecific measure of locus of control. J Pers Assess 1994;63:534–55. [20] Schwarzer R, Jerusalem M. Generalized Self-Efficacy scale. In: Weinman J, Wright S, Johnston M, editors. Measures in health psychology: a user’s portfolio. Causal and control beliefs. Windsor, England: NFER-NELSON; 1995. p. 35–7. [21] Say R, Murtagh M, Thomson R. Patients’ preference for involvement in medical decision making: a narrative review. Patient Educ Couns 2006;60:102–14. [22] O’Donnell M, Hunskaar S. Preferences for involvement in treatment decisionmaking generally and in hormone replacement and urinary incontinence treatment decision-making specifically. Patient Educ Couns 2007;68:243–51. [23] Florin J, Ehrenberg A, Ehnfors M. Clinical decision-making: predictors of patient participation in nursing care. J Clin Nurs 2008;17:2935–44.
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