The Effect of Intensive Implementation Support on Fidelity for Four Evidence‑Based Psychosis Treatments: A Cluster Randomized Trial

Abstract Purpose: Service providers need effective strategies to implement evidence-based practices (EBPs) with high fidelity. This study aimed to evaluate an intensive implementation support strategy to increase fidelity to EBP standards in treatment of patients with psychosis. Methods: The study used a cluster randomized design with pairwise assignment of practices within each of 39 Norwegian mental health clinics. Each site chose two of four practices for implementation: physical health care, antipsychotic medication management, family psychoeducation, illness management and recovery. One practice was assigned to the experimental condition (toolkits, clinical training, implementation facilitation, data-based feedback) and the other to the control condition (manual only). The outcome measure was fidelity to the EBP, measured at baseline and after 6, 12, and 18 months, analyzed using linear mixed models and effect sizes. Results: The increase in fidelity scores (within a range 1-5) from baseline to 18 months was significantly greater for experimental sites than for control sites for the combined four practices, with mean difference in change of 0.86 with 95% CI (0.21; 1.50), p = 0.009). Effect sizes for increase in group difference of mean fidelity scores were 2.24 for illness management and recovery, 0.68 for physical health care, 0.71 for antipsychotic medication management, and 0.27 for family psychoeducation. Most improvements occurred during the first 12 months. Conclusions: Intensive implementation strategies (toolkits, clinical training, implementation facilitation, data-based feedback) over 12 months can facilitate the implementation of EBPs for psychosis treatment. The approach may be more effective for some practices than for others. Keywords: Evidence-based practice; Fidelity scale; Implementation support; Mental health services; Psychoses. © 2021. The Author(s).publishedVersio

Oppfølging av legemiddelbruken til pasienter underlagt tvungent psykisk helsevern uten døgnopphold

Hensikt: Bruk av tvang er omstridt. Det foreligger lite håndfaste data om pasienter som behandles med tvangsmidler. Ved bruk av tvang påhviler det helsetjenesten et ekstra ansvar for å gi disse pasientene best mulig behandling og oppfølging. Hensikten med denne studien var å beskrive den medikamentelle behandlingen og oppfølgingen av pasienter underlagt tvungent psykisk helsevern uten døgnopphold ved Klinikk for psykisk helse, Sørlandet sykehus HF. Videre var det ønsket å kartlegge eventuelt potensial for forbedret medikamentell behandling gjennom spesifikk rådgivning fra farmasøyt i det tverrfaglige behandlingsteamet. Metode: Det ble innhentet opplysninger om den medikamentelle behandlingen og andre på forhånd definerte data fra pasientenes sykehistorie. Det ble utført legemiddelgjennomganger slik den nasjonale veilederen beskriver. Identifiserte LRP (legemiddelrelaterte problemer) ble presentert for behandler eller behandlingsteam og eventuelle tiltak ble dokumentert. Tallmaterialet fra de innhentede opplysninger og utfallet etter diskusjonen med behandler eller behandlingsteam team ble analysert. Resultater: Av 101 pasienter underlagt TUD på inklusjonsdatoen, møtte 77 pasienter inklusjonskriteriet som var bruk av to eller flere legemidler. Det var 56 % menn i studiepopulasjonen, og median alder var 47 år. Disse brukte i gjennomsnitt 3,6 legemidler totalt. Alle brukte minst ett antipsykotikum, 83 % brukte legemiddelformen depotinjeksjon. De fleste hadde diagnosen schizofreni F20. Det ble identifisert 68 LRP fordelt på 51 pasienter. Av disse ble 54 LRP anerkjent. Det var flest anerkjente LRP av typen manglende monitorering . Det vanligste tiltaket var diskusjon i tverrfaglig team eller med pasienten . Av de ikke anerkjente LRP var tillegg av legemiddel den vanligste. Det var flest ikke anerkjente LRP hos kvinner over 70 år. Konklusjon: Pasientene i denne studien brukte færre legemidler enn andre pasienter i behandling i spesialisthelsetjenesten. Legemidler ble ikke alltid brukt, eller brukt i for lave doser, selv om det var klar indikasjon. Dette fordi pasientene ikke ønsket medikamentell behandling. 79 % av presenterte LRP ble anerkjent, men få tiltak ble iverksatt umiddelbart. Farmasøyt bidrar til forbedret medikamentell behandling ved å avdekke LRP og foreslå tiltak, men er i dag ikke en ordinær del av det tverrfaglige behandlingsteamet

Factors affecting shared decision-making in mental health care: A cross-sectional explorative study in specialist mental health care and addiction services

Presently, the health care service experiences increased expectations of patient involvement in decisions about treatment. Shared decision-making (SDM) is a conceptualization of patient involvement, described as a meeting of two equal parts with different expertise: the professional as expert on the discipline, and the patient as expert on his or her own life. Present descriptions of patient preconditions for SDM are mainly restricted to patient education. However, the concept needs a broader approach, where the contributions from health professionals and service structures, as well as further sides of patient contribution should be included. We performed a cross-sectional study at Division of mental health at Sørlandet hospital in Norway January 2017. We included 992 patients and 312 clinicians. We explored the patients’ experiences of SDM; the concurrence of experienced SDM between patients and their clinicians; how the attitudes of the clinician influenced the patient experiences of SDM, and if patients experienced support with medication issues. The participants reported adequate experiences of SDM. Male patients, patients with diagnoses involving psychotic symptoms, patients with longer treatment durations, and involuntary treated patients experienced less SDM. Patients with longer treatment durations and involuntarily treated patients had a higher probability of reporting less SDM than their clinician. Patients, whose clinicians expressed a patient-centred attitude, experienced more SDM. Older patients and patients with beliefs of stronger needs for medication experienced more medication support. Patients with beliefs of higher concern to medication experienced less support

Practitioners' positive attitudes promote shared decision-making in mental health care

Rationale and aims: There is a growing expectation of implementing shared decision making (SDM) in today's health care service, including mental health care. Traditional understanding of SDM may be too narrow to capture the complexity of treatments of mental health problems. Although the patients' contribution to SDM is well described, the contribution from the health care practitioners is less explored. Therefore, our aim was to explore the attitudes of practitioners in mental health care and the associations between practitioners' attitudes and SDM. Method: We performed a cross‐sectional study where practitioners reported their sharing and caring attitudes on the Patient‐Practitioner Orientation Scale (PPOS) and age, gender, profession, and clinical working site. The patients reported SDM using the CollaboRate tool. We used a mixed effect model linking the data from each practitioner to one or more patients. We presented the findings and used them as background for a more philosophic reflection. Results: We included 312 practitioners with mean age 46.1 years. Of the practitioners, 60 held a medical doctors degree, 97 were psychologists, and 127 held a college degree in nursing, social science, or pedagogy. Female practitioners reported higher sharing (4.79 vs 4.67 [range 1‐6], P = .04) and caring scores (4.77 vs 4.65 [range 1‐6], P = .02) than males. The regression model contained 206 practitioners and 772 patients. We found a higher probability for the patient to report high SDM score if the practitioner reported higher sharing scores, and lower probability if the practitioner worked in ambulatory care. Conclusions: SDM in mental health care is complex and demands multifaceted preparations from practitioners as well as patients. The practitioners' attitudes are not sufficiently explored using one instrument. The positive association between practitioners' patient‐centred attitudes and SDM found in this study implies a relevance of the practitioners' attitudes for accomplishment of SDM processes in mental health care

Enabling patients to cope with psychotropic medication in mental health care: Evaluation and reports of the new inventory MedSupport

This cross sectional study examined patients’ perceptions of professional support regarding use of psychotropic medication in a specialist mental health care setting. The aims were to evaluate reliability and validity of the MedSupport inventory, and investigate possible associations between MedSupport scores and patient characteristics. A cross-sectional study was performed. The patients completed the MedSupport, a newly developed self-reported 6 item questionnaire on a Likert scale ranged 1 to 5 (1 = strongly disagree to 5 = strongly agree), and the Beliefs about Medicines Questionnaire. Diagnosis and treatment information were obtained at the clinical visits and from patient records. Among the 992 patients recruited, 567 patients (57%) used psychotropic medications, and 514 (91%) of these completed the MedSupport and were included in the study. The MedSupport showed an adequate internal consistency (Cronbach alpha.87; 95% CI.86–89) and a convergent validity toward the available variables. The MedSupport mean score was 3.8 (standard deviation.9, median 3.8). Increasing age and the experience of stronger needs for psychotropic medication were associated with perception of more support to cope with medication, whereas higher concern toward use of psychotropic medication was associated with perception of less support. Patients diagnosed with behavioral and emotional disorders, onset in childhood and adolescence perceived more support than patients with Mood disorders. The MedSupport inventory was suitable for assessing the patients’ perceived support from health care service regarding their medication. Awareness of differences in patients’ perceptions might enable the service to provide special measures for patients who perceive insufficient medication support

Discrepancy in Ratings of Shared Decision Making Between Patients and Health Professionals: A Cross Sectional Study in Mental Health Care

Background: A defined goal in mental health care is to increase the opportunities for patients to more actively participate in their treatment. This goal includes integrating aspects of user empowerment and shared decision-making (SDM) into treatment courses. To achieve this goal, more knowledge is needed about how patients and therapists perceive this integration. Objective: To explore patient experiences of SDM, to describe differences between patient and therapist experiences, and to identify patient factors that might reduce SDM experiences for patients compared to the experiences of their therapists. Methods: This cross-sectional study included 992 patients that had appointments with 267 therapists at Sørlandet Hospital, Division of Mental Health during a 1-week period. Both patients and therapists completed the CollaboRATE questionnaire, which was used to rate SDM experiences. Patients reported demographic and treatment-related information. Therapists provided clinical information. Results: The analysis included 953 patient-therapist responder pairs that completed the CollaboRATE questionnaire. The mean SDM score was 80.7 (SD 20.8) among patients, and 86.6 (SD 12.1) among therapists. Females and patients that did not use medication for mental health disorders reported higher SDM scores than males and patients that used psychiatric medications (83.3 vs. 77.7; p < 0.001 and 82.6 vs. 79.8; p = 0.03, respectively). Patients with diagnoses involving psychotic symptoms reported lower SDM scores than all the other patients (66.8 vs. 82.3; p < 0.001). The probability that a patient would report lower SDM scores than their therapist was highest among patients that received involuntary treatment (OR 3.2, p = 0.02), patients with treatment durations longer than 2.2 years (OR 1.9, p = 0.001), and patients that required day care or in-patient care (OR 3.2, p = 0.01 and OR 3.2, p < 0.001, respectively). Conclusion: We showed that both therapists and patients reported good SDM experiences in decisional situations, which indicated that SDM was implemented well. However, the SDM scores reported by in-patients and patients with prolonged or involuntary treatments were significantly lower than scores reported by their therapists. Our findings suggested that it remains a struggle in mental health care to establish a common understanding between patients and therapists in decisional processes regarding treatments for some patient groups

Discrepancy in Ratings of Shared Decision Making Between Patients and Health Professionals: A Cross Sectional Study in Mental Health Care

Background: A defined goal in mental health care is to increase the opportunities for patients to more actively participate in their treatment. This goal includes integrating aspects of user empowerment and shared decision-making (SDM) into treatment courses. To achieve this goal, more knowledge is needed about how patients and therapists perceive this integration. Objective: To explore patient experiences of SDM, to describe differences between patient and therapist experiences, and to identify patient factors that might reduce SDM experiences for patients compared to the experiences of their therapists. Methods: This cross-sectional study included 992 patients that had appointments with 267 therapists at Sørlandet Hospital, Division of Mental Health during a 1-week period. Both patients and therapists completed the CollaboRATE questionnaire, which was used to rate SDM experiences. Patients reported demographic and treatment-related information. Therapists provided clinical information. Results: The analysis included 953 patient-therapist responder pairs that completed the CollaboRATE questionnaire. The mean SDM score was 80.7 (SD 20.8) among patients, and 86.6 (SD 12.1) among therapists. Females and patients that did not use medication for mental health disorders reported higher SDM scores than males and patients that used psychiatric medications (83.3 vs. 77.7; p < 0.001 and 82.6 vs. 79.8; p = 0.03, respectively). Patients with diagnoses involving psychotic symptoms reported lower SDM scores than all the other patients (66.8 vs. 82.3; p < 0.001). The probability that a patient would report lower SDM scores than their therapist was highest among patients that received involuntary treatment (OR 3.2, p = 0.02), patients with treatment durations longer than 2.2 years (OR 1.9, p = 0.001), and patients that required day care or in-patient care (OR 3.2, p = 0.01 and OR 3.2, p < 0.001, respectively). Conclusion: We showed that both therapists and patients reported good SDM experiences in decisional situations, which indicated that SDM was implemented well. However, the SDM scores reported by in-patients and patients with prolonged or involuntary treatments were significantly lower than scores reported by their therapists. Our findings suggested that it remains a struggle in mental health care to establish a common understanding between patients and therapists in decisional processes regarding treatments for some patient groups

The Effect of Intensive Implementation Support on Fidelity for Four Evidence‑Based Psychosis Treatments: A Cluster Randomized Trial

Abstract Purpose: Service providers need effective strategies to implement evidence-based practices (EBPs) with high fidelity. This study aimed to evaluate an intensive implementation support strategy to increase fidelity to EBP standards in treatment of patients with psychosis. Methods: The study used a cluster randomized design with pairwise assignment of practices within each of 39 Norwegian mental health clinics. Each site chose two of four practices for implementation: physical health care, antipsychotic medication management, family psychoeducation, illness management and recovery. One practice was assigned to the experimental condition (toolkits, clinical training, implementation facilitation, data-based feedback) and the other to the control condition (manual only). The outcome measure was fidelity to the EBP, measured at baseline and after 6, 12, and 18 months, analyzed using linear mixed models and effect sizes. Results: The increase in fidelity scores (within a range 1-5) from baseline to 18 months was significantly greater for experimental sites than for control sites for the combined four practices, with mean difference in change of 0.86 with 95% CI (0.21; 1.50), p = 0.009). Effect sizes for increase in group difference of mean fidelity scores were 2.24 for illness management and recovery, 0.68 for physical health care, 0.71 for antipsychotic medication management, and 0.27 for family psychoeducation. Most improvements occurred during the first 12 months. Conclusions: Intensive implementation strategies (toolkits, clinical training, implementation facilitation, data-based feedback) over 12 months can facilitate the implementation of EBPs for psychosis treatment. The approach may be more effective for some practices than for others. Keywords: Evidence-based practice; Fidelity scale; Implementation support; Mental health services; Psychoses. © 2021. The Author(s)

The Effect of Intensive Implementation Support on Fidelity for Four Evidence‑Based Psychosis Treatments: A Cluster Randomized Trial

Purpose Service providers need effective strategies to implement evidence-based practices (EBPs) with high fidelity. This study aimed to evaluate an intensive implementation support strategy to increase fidelity to EBP standards in treatment of patients with psychosis. Methods The study used a cluster randomized design with pairwise assignment of practices within each of 39 Norwegian mental health clinics. Each site chose two of four practices for implementation: physical health care, antipsychotic medication management, family psychoeducation, illness management and recovery. One practice was assigned to the experimental condition (toolkits, clinical training, implementation facilitation, data-based feedback) and the other to the control condition (manual only). The outcome measure was fidelity to the EBP, measured at baseline and after 6, 12, and 18 months, analyzed using linear mixed models and effect sizes. Results The increase in fidelity scores (within a range 1–5) from baseline to 18 months was significantly greater for experimental sites than for control sites for the combined four practices, with mean difference in change of 0.86 with 95% CI (0.21; 1.50), p = 0.009). Effect sizes for increase in group difference of mean fidelity scores were 2.24 for illness management and recovery, 0.68 for physical health care, 0.71 for antipsychotic medication management, and 0.27 for family psychoeducation. Most improvements occurred during the first 12 months. Conclusions Intensive implementation strategies (toolkits, clinical training, implementation facilitation, data-based feedback) over 12 months can facilitate the implementation of EBPs for psychosis treatment. The approach may be more effective for some practices than for others