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Psychiatric patients’ attitudes towards concordance and shared decision making
Patient Education and Counseling 85 (2011) e245–e250
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Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Medical Decision Making
Psychiatric patients’ attitudes towards concordance and shared decision making Carlos De las Cuevas a,b,*, Amado Rivero c,d, Lilisbeth Perestelo-Perez b,c, Marien Gonzalez c,d, ˜ ate e Jeanette Perez c,d, Wenceslao Pen a
Department of Psychiatry, University of La Laguna, Tenerife, Spain CIBER en Epidemiologia y Salud Pu´blica (CIBERESP), Tenerife, Spain c Evaluation Unit of the Canary Islands Health Service (SESCS), Tenerife, Spain d Canary Islands Foundation of Health and Research (FUNCIS), Tenerife, Spain e Department of Personality, Assessment and Psychological Treatments, University of La Laguna, Tenerife, Spain b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 29 September 2010 Received in revised form 16 February 2011 Accepted 16 February 2011
Objectives: To assess psychiatric outpatients’ attitudes towards concordance and shared decision making in a psychiatric setting and to evaluate the role that self-perceived knowledge and beliefs about psychiatric medicines play in those attitudes. Methods: The Leeds Attitude to Concordance Scale (LATCon) was tested on a sample of 435 psychiatric outpatients. Principal Component Analysis was used to assess the structure of LATCon items. Regression analysis on LATCon scores was performed with sociodemographics, Belief about Medicines Questionnaire (BMQ) subscales, self-perceived knowledge, perceived psychiatrist behaviour and current medications as predictor variables. Results: The LATCon scale showed a good factorial validity, with a monofactorial structure and high internal consistency. Psychiatric outpatients tended to be in agreement with the concept of concordance, but they did not share some relevant aspects of the construct. Cognitive representations of psychiatric medications, assessed by the BMQ subscales, significantly predicted scores on the LATCon scale. Conclusion: Psychiatric outpatients show a considerable desire to participate in decision making about their treatment. The Spanish version of the LATCon Scale seems to be a valid instrument. Practice implications: Psychiatrists must consider their patients’ desire to participate in treatment decisions and explore how patients’ views about psychiatric medications influence their attitudes towards concordance. ß 2011 Elsevier Ireland Ltd. All rights reserved.
Keywords: Concordance Shared decision making Psychiatric patients Beliefs about medicines
1. Introduction One of the most noticeable changes in health care over the last few decades has been the increased involvement of patients in their treatment decisions [1,2]. Health care has been evolving from a ‘‘disease-centred model’’, where physicians make almost all treatment decisions based largely on clinical experience and data from various medical tests, towards a ‘‘patient-centred model’’, where patients become active participants in their own care and receive services designed to focus on their individual needs and preferences, in addition to advice and counsel from health professionals [3,4]. Within the domain of prescription medications, this new paradigm led to the introduction of the concept of ‘‘concordance’’
* Corresponding author at: Department of Psychiatry, University of La Laguna, School of Medicine, Campus de Ofra s/n, 38071 San Cristo´bal de La Laguna, Canary Islands, Spain. Tel.: +34 609521405; fax: +34 922319353. E-mail address: [email protected] (C. De las Cuevas). 0738-3991/$ – see front matter ß 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2011.02.015
[5–10], defined as an ‘‘agreement between the patient and healthcare professional, reached after negotiation that respects the beliefs and wishes of the patient in determining whether, when and how their medicine is taken, and (in which) the primacy of the patient’s decision (is recognised)’’ [6]. Concordance, as opposed to the more authoritarian terms ‘‘compliance’’ or ‘‘adherence’’, does not refer to a patient’s medication-taking behaviour; rather, it refers to the nature of the interaction between clinician and patient, which is considered to be a negotiation between equals that aims to establish a therapeutic alliance. Raynor et al. [11] developed and validated the Leeds Attitude to Concordance (LATCon) scale, a questionnaire designed to assess health professionals’ and patients’ attitudes towards the concept of concordance, which includes the ideas that the consultation is a negotiation between equals and that the patient’s decision is important. The scale has been used in a number of studies in the UK, Australia and Finland [11–14]. The definition of concordance is directly related to the more widespread concept of ‘‘shared decision making’’ (SDM), the process by which patients and physicians collaborate to make
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decisions about treatment. Shared decision making draws on the physician’s technical knowledge and the patient’s knowledge about his/her values and preferences regarding the different characteristics of available treatments [15–17]. It has been argued that concordance (i.e., an agreement) must be considered as the desired outcome of the entire process of communication and negotiation that is encompassed by the term SDM [18]. Alternatively, concordance has been conceptualised as a subset of SDM limited to the prescription of medications [19]. In either case, both the definition and the operationalisation of concordance emphasise the importance of the interaction between physician and patient in reaching a consensus about medication(s). The aim of this study was to assess Spanish psychiatric outpatients’ attitudes towards the concept of concordance. Therefore, we will assess: [1] the psychometric properties of a Spanish version of the LATCon, adapted to refer specifically to a psychiatric context, and [2] the level of patient agreement with the concept of concordance. Furthermore, we will assess the roles that subjective knowledge and beliefs about psychiatric medications play in the attitude towards concordance in a psychiatric setting. 2. Method 2.1. Sample From January to May 2010, four hundred and thirty-five consecutive psychiatric outpatients being continuously followed, for at least one year, in two Community Mental Health Centres at Tenerife Island (Canary Islands, Spain) were invited to participate in the study. Each participant received a full explanation of the study, after which he or she signed an informed consent document that had been approved by the local ethics committee. Each participant then filled out a brief socio-demographic survey and the rest of the questionnaires. 2.2. Measures 2.2.1. Socio-demographic characteristics and current medications Age, gender, educational level (no formal education, primary studies, secondary studies, and university degree), duration of treatment (in years), and type of psychoactive drugs currently taken were assessed (107 patients did not answer the question about medication). For evaluation purposes the drugs were divided into the common groups of psychotropics: antidepressants (tricyclics, selective serotonin reuptake inhibitors and serotonin and norepinephrine selective reuptake inhibitors), benzodiazepines, antipsychotics (conventional and atypical) and mood stabilisers. 2.2.2. Attitude towards concordance The Leeds Attitude to Concordance scale (LATCon) is a 12-item scale, developed and validated by Raynor et al. [11], in which the respondent scores each item on a four point Likert scale: strongly disagree (0), disagree (1), agree (2) or strongly agree (3). The original English version of the questionnaire was translated into Spanish by two members of the research team and then translated back into English by a native English speaker to check whether or not the Spanish translations conveyed the original meaning intended by the authors. To specifically assess patient–psychiatrist relationship, the term ‘‘physician’’ was replaced by ‘‘psychiatrist’’. 2.2.3. Preferences for participating in decision making As a way to explore the convergent and discriminant validity of LATCon scale, we used three items developed by Levinson et al. [20], based on a review of several models of decision making. These questions assessed patients’ participation preferences, and re-
sponse options ranged from a patient-directed to a physiciandirected style on three aspects of decision making (seeking information, discussing options and making the final decision). The response format was changed from the original six point scale to the same four point scale used in the rest of the LATCon. The items read as follows: ‘‘I prefer to rely on my doctor’s knowledge and not try to find out about my condition on my own’’ (Knowledge); ‘‘I prefer that my doctor offers me choices and asks my opinion’’ (Options); ‘‘I prefer to leave decisions about my medical care up to my doctor’’ (Decision). 2.2.4. Beliefs about psychiatric medicines The Beliefs about Medicines Questionnaire (BMQ) was developed in the United Kingdom by Horne et al. [21]. It includes a general and a specific scale, each with two subscales. The BMQ General scale assesses more general beliefs or social representations of pharmaceuticals as a class of treatment and includes eight items in two subscales of four items, Overuse and Harm. The BMQSpecific scale assesses the patient’s beliefs about the medication he is prescribed for a specific illness in terms of the necessity and concern about taking it. The scale includes 10 items in two subscales, Concern and Necessity, each with five items. The degree of agreement with each statement is indicated on a Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). The Spanish version of the BMQ [22] was used. According to the validation study for this version of the measure, the generalsubscale Harm included one item that in the English version loaded in the subscale Overuse. For the present study, instructions for both the General and Specific subscales explicitly stated that questionnaire referred to psychiatric medications. In addition, within the BMQ-General subscales, the term ‘‘physician’’ was replaced by ‘‘psychiatrist’’. 2.2.5. Self-perceived knowledge about medication The feeling of being informed about psychiatric medications was assessed by means of two dichotomous items: ‘‘Do you consider that you have enough information about your treatment?’’ and ‘‘Would you like to have more information about your medicines?’’ 2.2.6. Perceived psychiatrist interaction style The way in which the patient perceived that his/her doctor considers his/her opinion about treatment was assessed with another dichotomous item: ‘‘Does your psychiatrist ask your opinion about the treatment that would be prescribed?’’ 2.3. Statistical analyses Principal Component Analysis was used to assess the structure of adapted LATCon items. Components with eigenvalues greater than 1 were extracted in a first step. Then, inspection of the scree plot and alternative factorial solutions guided the final decision about the number of components to extract. Descriptive statistics and internal consistency (Cronbach’s alpha) were calculated. A stepwise linear regression on LATCon scores was performed, introducing sociodemographics, duration of treatment, BMQ subscales, and items about subjective knowledge and perceived psychiatrist interaction style as predictor variables. Educational level was previously transformed into three dummy variables, with those with no formal education as the reference group. Due to the fact that data regarding type of medication taken was available only for a subsample of participants (n = 328), a second stepwise linear regression was performed, adding four dichotomous variables to the previous ones: (current use of) antidepressants, antipsychotics, benzodiazepines, and mood stabilisers.
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3. Results
3.2. Adapted LATCon factorial structure and descriptive statistics
3.1. Baseline data
The Leeds Attitude to Concordance Scale (LATCon) mean item score was 1.96 0.5, with a median score of 1.92. As Table 1 shows, patients scored under the theoretical mean of the scale on only two items: ‘‘During the psychiatrist-patient consultation, it is the patient’s decision that is most important’’ (item 10; mean score 1.12) and ‘‘Just as prescribing is an experiment conducted by the psychiatrist, so too is taking medication an experiment conducted by the patient’’ (item 4; mean score 1.40), with 74% and 52% of patients, respectively, strongly disagreeing or disagreeing with these statements. However, on items 6 (‘‘Better health would follow from co-operation between doctors and patients’’) and 9 (‘‘Doctors should try to help patients to make as informed a choice as possible about benefits and risks of alternative treatments’’) patients in this study scored higher than the theoretical means (2.49 and 2.38, respectively). Principal Component Analysis of LATCon items yielded three components with eigenvalues greater than 1, but the scree plot inspection clearly recommended the extraction of one component. This monofactorial solution explained 35.02% of the variance, with all items except two loading above the 0.45 level. Item 4 (‘‘Just as prescribing is an experiment carried out by the doctor, so too is medication taking an experiment carried out by the patient’’) and 10 (‘‘During the doctor–patient consultation, it is the patient’s decision that is most important’’) had factor loadings of 0.44 and 0.31, respectively. A high alpha coefficient (a = 0.82) was obtained, indicating internal consistency. Eliminating items 4 and 10 produced a small increase in the explained variance (39.8%) and no change in the internal consistency of the scale; therefore, the whole scale was used for the subsequent analyses.
The 435 patients who agreed to participate in the study had a mean age of 42.8 11.8 years (range, 18–84), and 65% were female. Concerning educational level, 9.7% of patients could only read and write, 44.8% had completed primary studies, 31.5% had completed secondary studies and 14% had a university degree. Fourteen participants did not complete all questionnaires, so they were excluded from the analyses. The percentage of patients who reported that they do not have enough information about their medicines was 24.6%, and 21.9% stated that they would like to get more information about it. Fifty one percent stated that their psychiatrist does not ask them their opinion about their treatment. Average duration of treatment was 7.3 8.1 years (range 0.08–40). For the 328 patients with data about current medications, the mean number of psychotropic drugs used was 2.7 1.2 (range 0–6). Only 18.8% of the patients were under monotherapy treatment, whereas 26.2% received two drugs, 32.9% received three, and 21.8% received four or more drugs. Benzodiazepine tranquillisers were the most common medications, used by 69.8% of the patients followed by antidepressants (used by 61.3%), antipsychotics (used by 39%) and mood stabilisers (used by 28.7%). In response to questions about preferences for participation in decision making, the great majority of patients (90.4%) agreed or strongly agreed to be offered choices and to be asked their opinions. In contrast, 76.1% of the respondents agreed or strongly agreed to leave final decisions to their physicians, and 73.9% agreed or strongly agreed to rely on physicians for medical knowledge, as opposed to seeking out information themselves.
Table 1 Means, standard deviations and percentages of patients scoring disagree or strongly disagree on each item, and Principal Component Analysis of Adapted LATCon items (n = 426). Factor loading
h2
LATCon items
Mean SD
% Disagree or strongly disagree
1. The consultation between the psychiatrist and patient should be viewed as a negotiation between equals 2. Psychiatrists should respect their patients’ personal beliefs & how they cope 3. The best use of medicine is when it is what the patient wants and is able to achieve 4. Just as prescribing is an experiment conducted by the psychiatrist, so too is taking medication an experiment conducted by the patient 5. Psychiatrists should give patients the opportunity to talk about their thoughts about their illness and negotiate how it is treated 6. Better health would follow from co-operation between psychiatrists and patients 7. A high priority in the consultation between psychiatrist and patients is to establish agreement about the need for medicine 8. Psychiatrists should be sensitive to patient desires, needs and abilities 9. Psychiatrists should try to help patients to make as informed a choice as possible about benefits and risks of alternative treatments 10. During the psychiatrist-patient consultation, it is the patient’s decision that is most important 11. Psychiatrists should be more sensitive to how patients react to the information they give 12. Psychiatrists should try to learn about the beliefs their patients hold about their medicines Percentage variance explained
1.7 1.0
39.2
0.49
0.24
2.3 0.7
8.7
0.63
0.40
1.9 0.8
22.1
0.59
0.35
1.4 1.0
51.6
0.44
0.20
2.1 0.9
21.1
0.66
0.43
2.5 0.7
4.7
0.55
0.31
2.1 0.9
16.7
0.63
0.39
2.2 0.8
12.2
0.71
0.50
2.4 0.7
7.7
0.70
0.50
1.1 0.9
73.9
0.31
0.10
2.0 0.8
20.0
0.63
0.39
1.8 0.9
29.3
0.63
0.40
Kaiser–Meyer–Olkin = 0.866; x2 = 1288.342; p < 0.001.
35.02
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3.3. Correlations with preferences for participating in decision making Correlations between the LATCon Scale and the three items about preferences for participating in decision making were calculated. A clear pattern can be observed, where the LATCon obtains a significant and moderate correlation with the Options item only (r = 0.39; p < 0.001). In contrast, the Knowledge and Decision items correlate moderately (r = 0.44; p < 0.001) and [what correlates?] weakly with the Options item (r = 0.17; p = 0.013). 3.4. Predictors of attitude to concordance Associations between the LATCon Scale and the rest of variables were calculated, by means of Pearson correlations (for continuous variables) and mean differences contrasts (t-test and one-way ANOVA, for categorical variables). Significant correlations were obtained for all BMQ subscales: Harm (r = 0.31; p < 0.001), Overuse (r = 0.37; p < 0.001), Necessity (r = 0.17; p = 0.001) and Concern (r = 0.33; p < 0.001). Patients who feel that they have enough information about their treatment obtained significant lower scores on the LATCon Scale than those who do not (t = 3.53; p < 0.001) and, related to this, patients who wish to have more information about their medications obtained significantly higher scores than those who do not (t = 4.09; p < 0.001). Finally, patients who report that their psychiatrists ask for their opinions regarding treatment obtained significantly higher scores on the LATCon Scale than those who do not (t = 1.98; p = 0.048). No significant associations were found between the LATCon Scale and age, gender, education, duration of treatment, or type of psychoactive drugs currently taken. Two stepwise linear regressions were performed on LATCon scores. In the first, sociodemographic variables, duration of treatment, BMQ subscales, and items about subjective knowledge and perceived psychiatrist interaction style were introduced as predictor variables. Type of medication was added in a second analysis, because this measure was available only for a subsample of 328 patients. Table 2 shows the final models obtained in both analyses. In the first, the global model was significant (F = 19.16; p < 0.001), with adjusted R2 = 0.237. All BMQ subscales, one item about subjective knowledge, the item about psychiatrist interaction style and educational level were significant predictors, with the BMQ subscale Overuse accounting for the greatest portion of the variance. Specifically, higher scores on BMQ subscales, perceiving that the psychiatrist asks patient opinion and feeling uninformed about medications were associated with a more positive attitude towards concordance, whereas having primary studies (compared to those with no formal education) was associated with a less positive attitude towards concordance. When type of current medication was added to the regression analysis, only the BMQ subscales Overuse and Concern, and the item about perceived psychiatrist interaction style were included at the final model. 4. Discussion and conclusion 4.1. Discussion Concordance has been proposed as an alternative approach in the field of medicine. It is based on a patient-centred model and stands in contrast to the concepts of compliance or adherence, in which the patient plays a passive role in treatment decisions. The Spanish version of LATCon scale, adapted for a psychiatric context, shows a good factorial validity, yielding a monofactorial solution with a high internal consistency. The mean items score indicates that patients agree with the concept of concordance as it is
assessed by the total scale. Research on psychiatric patients’ preferences for participation in decision making has shown that these patients express a strong desire for being involved in the decision process [23–29]. If attitude towards concordance is considered synonymous with preference for participation in SDM about medications, our results can be interpreted as supporting previous findings. Within our study, patients tended to disagree with the statement ‘‘patient’s decision is the most important’’ (item 10), the item that also obtained the lower loading in the factor solution. Correlation analyses of the LATCon scale and three items about preferences for participating in SDM showed no significant association between LATCon score and the item named ‘‘Decision’’ (which largely reflects the opposite idea to LATCon item 10) and a moderate relation between LATCon score and the item named ‘‘Options’’ (‘‘I prefer that my doctor offers me choices and asks my opinion’’). These results are in line with recent proposals in the field of SDM regarding the need for a conceptual differentiation between the process of deliberation and the act of decision determination [30,31]. It has been argued that it is reasonable to think that patients will show different preferences depending on whether they are asked about being offered options and having their opinions considered, or about who must take the clinical decisions [32]. In this study, 90% of participants agreed or strongly agreed with the idea of being offered options and asked their opinions, but 76% preferred to leave final decisions to their physicians, a result very similar to that obtained by the developers of these SDM indicators in a population-based study [20]. Cognitive representations of psychiatric medicines, assessed by the BMQ subscales, were the most powerful predictors of LATCon scores, accounting for about a 20% of the variation in patients’ responses. Specifically, the more the patients believed that psychiatric medications were overprescribed and the more concerned they were about the potential adverse effects of their own prescribed medication, the more they agreed with the concept of concordance. This finding is in line with Hamann et al. [23,27], who studied a group of inpatients with schizophrenia and found a significant association between negative attitudes towards medication, assessed with the Drug Attitude Inventory [33], and the desire for participation. We have found no significant associations between the LATCon scale and sociodemographic variables, except for a marginal effect of educational level. Although previous research in other medical conditions has shown that higher desire for involvement in decision making is associated with younger age, female gender and higher educational level [34], in the field of mental health studies have obtained mixed results [23–29]. Although this study represents the first systematic attempt to measure psychiatric outpatients’ attitudes towards concordance and shared decision making in a psychiatric setting in Spain, there are several limitations that should be kept in mind. Despite the fact that we employed a wide sample, the interpretation of the results must be restricted to outpatients attending Community Mental Health Centres. It would have been interesting to compare responses between different diagnostic categories, but patients’ diagnoses were not collected due to confidentially issues. However, previous studies that include patients with different mental disorders did not obtain significant differences between diagnostic categories [24,29], and mean scores on the Autonomy Preference Index (API – decision making subscale) are quite similar across two studies that included patients with schizophrenia [23] and depression [35]. The measure of preference for participation in decision making is based on three simple items developed by Levinson et al. [20]. We choose this measure because it allowed us to combine economy of administration and an assessment of different SDM
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Table 2 Stepwise linear regression models on LATCon scores. Confidence interval
p
Change in R2
0.144 0.071 0.093 0.135 0.087 0.121 0.094 0.799
0.088–0.200 0.013–0.129 0.046–0.140 0.051–0.219 0.023–0.151 0.020–0.221 0.179 to 0.009 0.543–1.055
0.000 0.016 0.000 0.002 0.008 0.018 0.031 0.000
0.137 0.051 0.019 0.016 0.012 0.008 0.009
0.174 0.120 0.152 1.098
0.118–0.231 0.062–0.177 0.058–0.245 0.882–1.313
0.000 0.000 0.002 0.000
0.151 0.046 0.025
b a
Regression model (n = 410) BMQ_Overuse BMQ_Concern BMQ_Necessity Psychiatrist ask patient opinion BMQ_Harm Insufficient information about treatment Primary studiesb (Constant) F = 19.16; p < 0.001; adjusted R2 = 0.237 Regression modelc (n = 317) BMQ_Overuse BMQ_Concern Psychiatrist ask patient opinion (Constant) F = 29.84; p < 0.001; adjusted R2 = 0.215
a Including as predictor variables: sociodemographics, duration of treatment, BMQ subscales, self-perceived knowledge about medications and perceived psychiatrist interaction style. b Reference is ‘‘no formal education’’. c Adding four dichotomous variables about current medication (antidepressants, antipsychotics, benzodiazepines, mood stabilisers) to the previous variables.
processes (seeking information, being listened to and offered options and making the decision). Descriptive statistics and correlations between these items were quite similar to those found by Levinson et al. [20], suggesting a dual SDM process. However, in future studies it would be desirable to use other validated measures of preferences for participation, like the API, to establish more convincingly the convergent validity of the LATCon scale. Furthermore, we did not incorporate objective measures of SDM in practice or physician decision making style. It would also be important to assess other potential predictors of patients’ preferences, like personality traits, self-efficacy or locus of control. Finally, longitudinal designs are needed to better understand the evolution of patients’ preferences and the dynamic interaction between preferences, the experience of illness and outcomes of treatment. The feasibility of shared decision making in psychiatric care depends on the specific psychiatric disorder as well as on the phase of the illness. For example, at advanced stages of dementia, shared decision making will not be possible any longer. Shared decision making in acutely ill, schizophrenic, manic or severely depressed patients might be difficult to perform because there are justified fears to the effect that psychiatric patients have a reduced decisional capacity as a result of the symptoms of their illness (e.g. disorganisation of thought). However, there seem to be no obvious limitations for patients suffering from less severe conditions, which tend to be the most common conditions and the ones included in the community sample of this study. Like Hamann et al. [17], we believe that a successful inclusion of psychiatric patients in the therapeutic process could not only counteract existing prejudices about reduced decisional capacity, but also increase the self-respect (empowerment) and the quality of life of psychiatric patients. Nevertheless, the barriers to change of consulting behaviour should not be underestimated, and psychiatrists need to recognise that change is both important and achievable. Britten [36] cites five pre-requisites for concordance in consultations, which include: a willingness to share power and a commitment to giving appropriate weight to patient values and goals; open discussion of the options with explicit enquiry as to patients views without making assumptions; adequate sharing of information, including uncertainties, to arrive at a decision; listening as much as talking; and, finally, time.
4.2. Conclusion Psychiatric outpatients show a considerable desire to participate in decision making about their treatment. The Spanish version of LATCon Scale, specifically adapted for a patient–psychiatrist context, shows a good factorial validity, yielding a monofactorial solution with a high internal consistency, so it seems to be a valid instrument for assessing attitude towards concordance in Spanish psychiatric samples. Future studies must analyse other psychometric properties of the scale, such as convergent validity and testretest reliability. Negative beliefs about psychiatric medication significantly predict attitude towards concordance. 4.3. Practice implications Psychiatrists must consider their patients’ desire for participating in treatment decisions and explore how patients’ views about psychiatric medicines influence their attitudes towards concordance. 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 Unio´n Europea (PI10/00955). References [1] Coulter A. Paternalism or partnership? Brit Med J 1999;319:719–20. [2] Nair K, Dolovich L, Cassels A, McCormack J, Levine M, Gray J, et al. What patients want to know about their medications. Focus group study of patient and clinician perspectives. Can Fam Physician 2002;48:104–10. [3] Stewart M. Towards a global definition of patient centred care. Brit Med J 2001;322:444–5. [4] Anderson EB. Patient-centeredness: a new approach. Nephrol News Issues 2002;16:80–2. [5] RPSGB. From compliance to concordance: achieving shared goals in medicine taking. London: Royal Pharmaceutical Society of Great Britain; 1997.
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[6] Marinker M, Blenkinsopp A, Bond C, Briten N, Feely M, George C, et al. From compliance to concordance: achieving shared goals in medicine taking. London: Royal Pharmaceutical Society of Great Britain; 1997. [7] Marinker M. Compliance is not all. Brit Med J 1998;316:150–1. [8] Bell JS, Airaksinen MS, Lyles A, Chen TF, Aslani P. Concordance is not synonymous with compliance or adherence. Br J Clin Pharmacol 2007;64:710–1. author reply 711-3.. [9] Aronson JK. Compliance, concordance, adherence. Br J Clin Pharmacol 2007;63:383–4. [10] Horne R, National Co-ordinating Centre for NHS Service Delivery and Organisation (Great Britain). Concordance, adherence and compliance in medicine taking: report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R & D (NCCSDO) [London]: NCCSDO; 2005. [11] Raynor DK, Thistlethwaite JE, Hart K, Knapp P. Are health professionals ready for the new philosophy of concordance in medicine taking? Int J Pharm Pract 2001;9:81–4. [12] Kansanaho HM, Puumalainen II, Varunki MM, Airaksinen MSA, Aslani P. Attitudes of Finnish community pharmacists toward concordance. Ann Pharmacother 2004;38:1946–53. [13] Thistlethwaite JE, Raynor DK, Knapp P. Medical students’ attitudes towards concordance in medicine taking: exploring the impact of an educational intervention. Educ Health (Abingdon) 2003;16:307–17. [14] Stokes M, Knapp P, Thistlethwaite JE, Raynor DK. Using the LATCon scale to measure patients attitudes to concordance. In: Presented at the Health Services Research & Pharmacy Practice conference, Leeds 2002; 2002 (accessed 21.04.08)http://www.hsrpp.org.uk/abstracts/2002_18.shtml. [15] 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. [16] Edwards A. Shared decision-making in health care: achieving evidence-based patient choice, 2nd ed., Oxford/New York: Oxford University Press; 2009. [17] Hamann J, Leucht S, Kissling W. Shared decision making in psychiatry. Acta Psychiatr Scand 2003;107:403–9. [18] Jordan JL, Ellis SJ, Chambers R. Defining shared decision making and concordance: are they one and the same? Postgrad Med J 2002;78:383–4. [19] Cushing A, Metcalfe R. Optimizing medicines management: From compliance to concordance. Ther Clin Risk Manage 2007;3:1047–58. [20] 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.
[21] Horne R, Weinman J, Hankins M. The beliefs about medicines questionnaire: the development and evaluation of a new method for assessing the cognitive representation of medication. Psychol Health 1999;14:1–24. [22] Bele´ndez M, Herna´ndez A, Horne R, Weinman J. Evaluacio´n de las creencias ˜ ola del Beliefs sobre el tratamiento: Validez y fiabilidad de la versio´n Espan about Medicines Questionnaire. Int J Health Clin Psychol 2007;7:767–79. [23] Hamann J, Cohen R, Leucht S, Busch R, Kissling W. Do patients with schizophrenia wish to be involved in decisions about their medical treatment? Am J Psychiatry 2005;162:2382–4. [24] Adams JR, Drake RE, Wolford GL. Shared decision making preferences of people with severe mental illness. Psychiatr Serv 2007;58:1219–21. [25] Hamann J, Mendel RT, Fink B, Pfieffer H, Cohen R, Kissling W. Patients’ and psychiatrists’ perceptions of clinical decisions during schizophrenia treatment. J Nerv Ment Dis 2008;196:329–32. [26] O’Neal EL, Adams JR, McHugo GJ, Van Citters AD, Drake RE, Bartels SJ. Preferences of older and younger adults with serious mental illness for involvement in decision-making in medical and psychiatric settings. Am J Geriatr Psychiatry 2008;16:826–33. [27] Hamann J, Kruse J, Schmitz FS, Kissling W, Pajonk FG. Patient participation in antipsychotic drug decisions. Psychiatry Res 2010;178:63–7. [28] Patel SR, Bakken S. Preferences for participation in decision making among ethnically diverse patients with anxiety and depression. Commun Ment Health J 2010;46:466–73. [29] Hill SA, Laugharne R. Decision making and information seeking preferences among psychiatric patients. J Ment Health 2006;15:75–84. [30] Elwyn G, Miron-Shatz T. Deliberation before determination: the definition and evaluation of good decision making. Health Expect 2010;13:139–47. [31] Entwistle VA, Skea ZC, O’Donnell MT. Decisions about treatment: interpretations of two measures of control by women having a hysterectomy. Soc Sci Med 2001;53:721–32. [32] Hanson J. Shared decision making: have we missed the obvious? Arch Intern Med 2008;168:1368–70. [33] Awad AG. Subjective responses to neuroleptics in schizophrenia. Schizophr Bull 1993;19:609–18. [34] Say R, Murtagh M, Thompson R. Patients’ preference for involvement in medical decision making: a narrative review. Patient Educ Couns 2006;60:102–14. [35] Loh A, Kremer N, Giersdorf N, Jahn H, Hanselmann S, Bermejo I, et al. Information and participation interests of patients with depression in clinical decision making in primary care. Z Arztl Fortbild Qualitatssich 2004;98:101–7. German. [36] Britten N. Patients’ expectations of consultations. Brit Med J 2004;328:416–7.
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Medical Decision Making
Psychiatric patients’ attitudes towards concordance and shared decision making Carlos De las Cuevas a,b,*, Amado Rivero c,d, Lilisbeth Perestelo-Perez b,c, Marien Gonzalez c,d, ˜ ate e Jeanette Perez c,d, Wenceslao Pen a
Department of Psychiatry, University of La Laguna, Tenerife, Spain CIBER en Epidemiologia y Salud Pu´blica (CIBERESP), Tenerife, Spain c Evaluation Unit of the Canary Islands Health Service (SESCS), Tenerife, Spain d Canary Islands Foundation of Health and Research (FUNCIS), Tenerife, Spain e Department of Personality, Assessment and Psychological Treatments, University of La Laguna, Tenerife, Spain b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 29 September 2010 Received in revised form 16 February 2011 Accepted 16 February 2011
Objectives: To assess psychiatric outpatients’ attitudes towards concordance and shared decision making in a psychiatric setting and to evaluate the role that self-perceived knowledge and beliefs about psychiatric medicines play in those attitudes. Methods: The Leeds Attitude to Concordance Scale (LATCon) was tested on a sample of 435 psychiatric outpatients. Principal Component Analysis was used to assess the structure of LATCon items. Regression analysis on LATCon scores was performed with sociodemographics, Belief about Medicines Questionnaire (BMQ) subscales, self-perceived knowledge, perceived psychiatrist behaviour and current medications as predictor variables. Results: The LATCon scale showed a good factorial validity, with a monofactorial structure and high internal consistency. Psychiatric outpatients tended to be in agreement with the concept of concordance, but they did not share some relevant aspects of the construct. Cognitive representations of psychiatric medications, assessed by the BMQ subscales, significantly predicted scores on the LATCon scale. Conclusion: Psychiatric outpatients show a considerable desire to participate in decision making about their treatment. The Spanish version of the LATCon Scale seems to be a valid instrument. Practice implications: Psychiatrists must consider their patients’ desire to participate in treatment decisions and explore how patients’ views about psychiatric medications influence their attitudes towards concordance. ß 2011 Elsevier Ireland Ltd. All rights reserved.
Keywords: Concordance Shared decision making Psychiatric patients Beliefs about medicines
1. Introduction One of the most noticeable changes in health care over the last few decades has been the increased involvement of patients in their treatment decisions [1,2]. Health care has been evolving from a ‘‘disease-centred model’’, where physicians make almost all treatment decisions based largely on clinical experience and data from various medical tests, towards a ‘‘patient-centred model’’, where patients become active participants in their own care and receive services designed to focus on their individual needs and preferences, in addition to advice and counsel from health professionals [3,4]. Within the domain of prescription medications, this new paradigm led to the introduction of the concept of ‘‘concordance’’
* Corresponding author at: Department of Psychiatry, University of La Laguna, School of Medicine, Campus de Ofra s/n, 38071 San Cristo´bal de La Laguna, Canary Islands, Spain. Tel.: +34 609521405; fax: +34 922319353. E-mail address: [email protected] (C. De las Cuevas). 0738-3991/$ – see front matter ß 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2011.02.015
[5–10], defined as an ‘‘agreement between the patient and healthcare professional, reached after negotiation that respects the beliefs and wishes of the patient in determining whether, when and how their medicine is taken, and (in which) the primacy of the patient’s decision (is recognised)’’ [6]. Concordance, as opposed to the more authoritarian terms ‘‘compliance’’ or ‘‘adherence’’, does not refer to a patient’s medication-taking behaviour; rather, it refers to the nature of the interaction between clinician and patient, which is considered to be a negotiation between equals that aims to establish a therapeutic alliance. Raynor et al. [11] developed and validated the Leeds Attitude to Concordance (LATCon) scale, a questionnaire designed to assess health professionals’ and patients’ attitudes towards the concept of concordance, which includes the ideas that the consultation is a negotiation between equals and that the patient’s decision is important. The scale has been used in a number of studies in the UK, Australia and Finland [11–14]. The definition of concordance is directly related to the more widespread concept of ‘‘shared decision making’’ (SDM), the process by which patients and physicians collaborate to make
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decisions about treatment. Shared decision making draws on the physician’s technical knowledge and the patient’s knowledge about his/her values and preferences regarding the different characteristics of available treatments [15–17]. It has been argued that concordance (i.e., an agreement) must be considered as the desired outcome of the entire process of communication and negotiation that is encompassed by the term SDM [18]. Alternatively, concordance has been conceptualised as a subset of SDM limited to the prescription of medications [19]. In either case, both the definition and the operationalisation of concordance emphasise the importance of the interaction between physician and patient in reaching a consensus about medication(s). The aim of this study was to assess Spanish psychiatric outpatients’ attitudes towards the concept of concordance. Therefore, we will assess: [1] the psychometric properties of a Spanish version of the LATCon, adapted to refer specifically to a psychiatric context, and [2] the level of patient agreement with the concept of concordance. Furthermore, we will assess the roles that subjective knowledge and beliefs about psychiatric medications play in the attitude towards concordance in a psychiatric setting. 2. Method 2.1. Sample From January to May 2010, four hundred and thirty-five consecutive psychiatric outpatients being continuously followed, for at least one year, in two Community Mental Health Centres at Tenerife Island (Canary Islands, Spain) were invited to participate in the study. Each participant received a full explanation of the study, after which he or she signed an informed consent document that had been approved by the local ethics committee. Each participant then filled out a brief socio-demographic survey and the rest of the questionnaires. 2.2. Measures 2.2.1. Socio-demographic characteristics and current medications Age, gender, educational level (no formal education, primary studies, secondary studies, and university degree), duration of treatment (in years), and type of psychoactive drugs currently taken were assessed (107 patients did not answer the question about medication). For evaluation purposes the drugs were divided into the common groups of psychotropics: antidepressants (tricyclics, selective serotonin reuptake inhibitors and serotonin and norepinephrine selective reuptake inhibitors), benzodiazepines, antipsychotics (conventional and atypical) and mood stabilisers. 2.2.2. Attitude towards concordance The Leeds Attitude to Concordance scale (LATCon) is a 12-item scale, developed and validated by Raynor et al. [11], in which the respondent scores each item on a four point Likert scale: strongly disagree (0), disagree (1), agree (2) or strongly agree (3). The original English version of the questionnaire was translated into Spanish by two members of the research team and then translated back into English by a native English speaker to check whether or not the Spanish translations conveyed the original meaning intended by the authors. To specifically assess patient–psychiatrist relationship, the term ‘‘physician’’ was replaced by ‘‘psychiatrist’’. 2.2.3. Preferences for participating in decision making As a way to explore the convergent and discriminant validity of LATCon scale, we used three items developed by Levinson et al. [20], based on a review of several models of decision making. These questions assessed patients’ participation preferences, and re-
sponse options ranged from a patient-directed to a physiciandirected style on three aspects of decision making (seeking information, discussing options and making the final decision). The response format was changed from the original six point scale to the same four point scale used in the rest of the LATCon. The items read as follows: ‘‘I prefer to rely on my doctor’s knowledge and not try to find out about my condition on my own’’ (Knowledge); ‘‘I prefer that my doctor offers me choices and asks my opinion’’ (Options); ‘‘I prefer to leave decisions about my medical care up to my doctor’’ (Decision). 2.2.4. Beliefs about psychiatric medicines The Beliefs about Medicines Questionnaire (BMQ) was developed in the United Kingdom by Horne et al. [21]. It includes a general and a specific scale, each with two subscales. The BMQ General scale assesses more general beliefs or social representations of pharmaceuticals as a class of treatment and includes eight items in two subscales of four items, Overuse and Harm. The BMQSpecific scale assesses the patient’s beliefs about the medication he is prescribed for a specific illness in terms of the necessity and concern about taking it. The scale includes 10 items in two subscales, Concern and Necessity, each with five items. The degree of agreement with each statement is indicated on a Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). The Spanish version of the BMQ [22] was used. According to the validation study for this version of the measure, the generalsubscale Harm included one item that in the English version loaded in the subscale Overuse. For the present study, instructions for both the General and Specific subscales explicitly stated that questionnaire referred to psychiatric medications. In addition, within the BMQ-General subscales, the term ‘‘physician’’ was replaced by ‘‘psychiatrist’’. 2.2.5. Self-perceived knowledge about medication The feeling of being informed about psychiatric medications was assessed by means of two dichotomous items: ‘‘Do you consider that you have enough information about your treatment?’’ and ‘‘Would you like to have more information about your medicines?’’ 2.2.6. Perceived psychiatrist interaction style The way in which the patient perceived that his/her doctor considers his/her opinion about treatment was assessed with another dichotomous item: ‘‘Does your psychiatrist ask your opinion about the treatment that would be prescribed?’’ 2.3. Statistical analyses Principal Component Analysis was used to assess the structure of adapted LATCon items. Components with eigenvalues greater than 1 were extracted in a first step. Then, inspection of the scree plot and alternative factorial solutions guided the final decision about the number of components to extract. Descriptive statistics and internal consistency (Cronbach’s alpha) were calculated. A stepwise linear regression on LATCon scores was performed, introducing sociodemographics, duration of treatment, BMQ subscales, and items about subjective knowledge and perceived psychiatrist interaction style as predictor variables. Educational level was previously transformed into three dummy variables, with those with no formal education as the reference group. Due to the fact that data regarding type of medication taken was available only for a subsample of participants (n = 328), a second stepwise linear regression was performed, adding four dichotomous variables to the previous ones: (current use of) antidepressants, antipsychotics, benzodiazepines, and mood stabilisers.
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3. Results
3.2. Adapted LATCon factorial structure and descriptive statistics
3.1. Baseline data
The Leeds Attitude to Concordance Scale (LATCon) mean item score was 1.96 0.5, with a median score of 1.92. As Table 1 shows, patients scored under the theoretical mean of the scale on only two items: ‘‘During the psychiatrist-patient consultation, it is the patient’s decision that is most important’’ (item 10; mean score 1.12) and ‘‘Just as prescribing is an experiment conducted by the psychiatrist, so too is taking medication an experiment conducted by the patient’’ (item 4; mean score 1.40), with 74% and 52% of patients, respectively, strongly disagreeing or disagreeing with these statements. However, on items 6 (‘‘Better health would follow from co-operation between doctors and patients’’) and 9 (‘‘Doctors should try to help patients to make as informed a choice as possible about benefits and risks of alternative treatments’’) patients in this study scored higher than the theoretical means (2.49 and 2.38, respectively). Principal Component Analysis of LATCon items yielded three components with eigenvalues greater than 1, but the scree plot inspection clearly recommended the extraction of one component. This monofactorial solution explained 35.02% of the variance, with all items except two loading above the 0.45 level. Item 4 (‘‘Just as prescribing is an experiment carried out by the doctor, so too is medication taking an experiment carried out by the patient’’) and 10 (‘‘During the doctor–patient consultation, it is the patient’s decision that is most important’’) had factor loadings of 0.44 and 0.31, respectively. A high alpha coefficient (a = 0.82) was obtained, indicating internal consistency. Eliminating items 4 and 10 produced a small increase in the explained variance (39.8%) and no change in the internal consistency of the scale; therefore, the whole scale was used for the subsequent analyses.
The 435 patients who agreed to participate in the study had a mean age of 42.8 11.8 years (range, 18–84), and 65% were female. Concerning educational level, 9.7% of patients could only read and write, 44.8% had completed primary studies, 31.5% had completed secondary studies and 14% had a university degree. Fourteen participants did not complete all questionnaires, so they were excluded from the analyses. The percentage of patients who reported that they do not have enough information about their medicines was 24.6%, and 21.9% stated that they would like to get more information about it. Fifty one percent stated that their psychiatrist does not ask them their opinion about their treatment. Average duration of treatment was 7.3 8.1 years (range 0.08–40). For the 328 patients with data about current medications, the mean number of psychotropic drugs used was 2.7 1.2 (range 0–6). Only 18.8% of the patients were under monotherapy treatment, whereas 26.2% received two drugs, 32.9% received three, and 21.8% received four or more drugs. Benzodiazepine tranquillisers were the most common medications, used by 69.8% of the patients followed by antidepressants (used by 61.3%), antipsychotics (used by 39%) and mood stabilisers (used by 28.7%). In response to questions about preferences for participation in decision making, the great majority of patients (90.4%) agreed or strongly agreed to be offered choices and to be asked their opinions. In contrast, 76.1% of the respondents agreed or strongly agreed to leave final decisions to their physicians, and 73.9% agreed or strongly agreed to rely on physicians for medical knowledge, as opposed to seeking out information themselves.
Table 1 Means, standard deviations and percentages of patients scoring disagree or strongly disagree on each item, and Principal Component Analysis of Adapted LATCon items (n = 426). Factor loading
h2
LATCon items
Mean SD
% Disagree or strongly disagree
1. The consultation between the psychiatrist and patient should be viewed as a negotiation between equals 2. Psychiatrists should respect their patients’ personal beliefs & how they cope 3. The best use of medicine is when it is what the patient wants and is able to achieve 4. Just as prescribing is an experiment conducted by the psychiatrist, so too is taking medication an experiment conducted by the patient 5. Psychiatrists should give patients the opportunity to talk about their thoughts about their illness and negotiate how it is treated 6. Better health would follow from co-operation between psychiatrists and patients 7. A high priority in the consultation between psychiatrist and patients is to establish agreement about the need for medicine 8. Psychiatrists should be sensitive to patient desires, needs and abilities 9. Psychiatrists should try to help patients to make as informed a choice as possible about benefits and risks of alternative treatments 10. During the psychiatrist-patient consultation, it is the patient’s decision that is most important 11. Psychiatrists should be more sensitive to how patients react to the information they give 12. Psychiatrists should try to learn about the beliefs their patients hold about their medicines Percentage variance explained
1.7 1.0
39.2
0.49
0.24
2.3 0.7
8.7
0.63
0.40
1.9 0.8
22.1
0.59
0.35
1.4 1.0
51.6
0.44
0.20
2.1 0.9
21.1
0.66
0.43
2.5 0.7
4.7
0.55
0.31
2.1 0.9
16.7
0.63
0.39
2.2 0.8
12.2
0.71
0.50
2.4 0.7
7.7
0.70
0.50
1.1 0.9
73.9
0.31
0.10
2.0 0.8
20.0
0.63
0.39
1.8 0.9
29.3
0.63
0.40
Kaiser–Meyer–Olkin = 0.866; x2 = 1288.342; p < 0.001.
35.02
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3.3. Correlations with preferences for participating in decision making Correlations between the LATCon Scale and the three items about preferences for participating in decision making were calculated. A clear pattern can be observed, where the LATCon obtains a significant and moderate correlation with the Options item only (r = 0.39; p < 0.001). In contrast, the Knowledge and Decision items correlate moderately (r = 0.44; p < 0.001) and [what correlates?] weakly with the Options item (r = 0.17; p = 0.013). 3.4. Predictors of attitude to concordance Associations between the LATCon Scale and the rest of variables were calculated, by means of Pearson correlations (for continuous variables) and mean differences contrasts (t-test and one-way ANOVA, for categorical variables). Significant correlations were obtained for all BMQ subscales: Harm (r = 0.31; p < 0.001), Overuse (r = 0.37; p < 0.001), Necessity (r = 0.17; p = 0.001) and Concern (r = 0.33; p < 0.001). Patients who feel that they have enough information about their treatment obtained significant lower scores on the LATCon Scale than those who do not (t = 3.53; p < 0.001) and, related to this, patients who wish to have more information about their medications obtained significantly higher scores than those who do not (t = 4.09; p < 0.001). Finally, patients who report that their psychiatrists ask for their opinions regarding treatment obtained significantly higher scores on the LATCon Scale than those who do not (t = 1.98; p = 0.048). No significant associations were found between the LATCon Scale and age, gender, education, duration of treatment, or type of psychoactive drugs currently taken. Two stepwise linear regressions were performed on LATCon scores. In the first, sociodemographic variables, duration of treatment, BMQ subscales, and items about subjective knowledge and perceived psychiatrist interaction style were introduced as predictor variables. Type of medication was added in a second analysis, because this measure was available only for a subsample of 328 patients. Table 2 shows the final models obtained in both analyses. In the first, the global model was significant (F = 19.16; p < 0.001), with adjusted R2 = 0.237. All BMQ subscales, one item about subjective knowledge, the item about psychiatrist interaction style and educational level were significant predictors, with the BMQ subscale Overuse accounting for the greatest portion of the variance. Specifically, higher scores on BMQ subscales, perceiving that the psychiatrist asks patient opinion and feeling uninformed about medications were associated with a more positive attitude towards concordance, whereas having primary studies (compared to those with no formal education) was associated with a less positive attitude towards concordance. When type of current medication was added to the regression analysis, only the BMQ subscales Overuse and Concern, and the item about perceived psychiatrist interaction style were included at the final model. 4. Discussion and conclusion 4.1. Discussion Concordance has been proposed as an alternative approach in the field of medicine. It is based on a patient-centred model and stands in contrast to the concepts of compliance or adherence, in which the patient plays a passive role in treatment decisions. The Spanish version of LATCon scale, adapted for a psychiatric context, shows a good factorial validity, yielding a monofactorial solution with a high internal consistency. The mean items score indicates that patients agree with the concept of concordance as it is
assessed by the total scale. Research on psychiatric patients’ preferences for participation in decision making has shown that these patients express a strong desire for being involved in the decision process [23–29]. If attitude towards concordance is considered synonymous with preference for participation in SDM about medications, our results can be interpreted as supporting previous findings. Within our study, patients tended to disagree with the statement ‘‘patient’s decision is the most important’’ (item 10), the item that also obtained the lower loading in the factor solution. Correlation analyses of the LATCon scale and three items about preferences for participating in SDM showed no significant association between LATCon score and the item named ‘‘Decision’’ (which largely reflects the opposite idea to LATCon item 10) and a moderate relation between LATCon score and the item named ‘‘Options’’ (‘‘I prefer that my doctor offers me choices and asks my opinion’’). These results are in line with recent proposals in the field of SDM regarding the need for a conceptual differentiation between the process of deliberation and the act of decision determination [30,31]. It has been argued that it is reasonable to think that patients will show different preferences depending on whether they are asked about being offered options and having their opinions considered, or about who must take the clinical decisions [32]. In this study, 90% of participants agreed or strongly agreed with the idea of being offered options and asked their opinions, but 76% preferred to leave final decisions to their physicians, a result very similar to that obtained by the developers of these SDM indicators in a population-based study [20]. Cognitive representations of psychiatric medicines, assessed by the BMQ subscales, were the most powerful predictors of LATCon scores, accounting for about a 20% of the variation in patients’ responses. Specifically, the more the patients believed that psychiatric medications were overprescribed and the more concerned they were about the potential adverse effects of their own prescribed medication, the more they agreed with the concept of concordance. This finding is in line with Hamann et al. [23,27], who studied a group of inpatients with schizophrenia and found a significant association between negative attitudes towards medication, assessed with the Drug Attitude Inventory [33], and the desire for participation. We have found no significant associations between the LATCon scale and sociodemographic variables, except for a marginal effect of educational level. Although previous research in other medical conditions has shown that higher desire for involvement in decision making is associated with younger age, female gender and higher educational level [34], in the field of mental health studies have obtained mixed results [23–29]. Although this study represents the first systematic attempt to measure psychiatric outpatients’ attitudes towards concordance and shared decision making in a psychiatric setting in Spain, there are several limitations that should be kept in mind. Despite the fact that we employed a wide sample, the interpretation of the results must be restricted to outpatients attending Community Mental Health Centres. It would have been interesting to compare responses between different diagnostic categories, but patients’ diagnoses were not collected due to confidentially issues. However, previous studies that include patients with different mental disorders did not obtain significant differences between diagnostic categories [24,29], and mean scores on the Autonomy Preference Index (API – decision making subscale) are quite similar across two studies that included patients with schizophrenia [23] and depression [35]. The measure of preference for participation in decision making is based on three simple items developed by Levinson et al. [20]. We choose this measure because it allowed us to combine economy of administration and an assessment of different SDM
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Table 2 Stepwise linear regression models on LATCon scores. Confidence interval
p
Change in R2
0.144 0.071 0.093 0.135 0.087 0.121 0.094 0.799
0.088–0.200 0.013–0.129 0.046–0.140 0.051–0.219 0.023–0.151 0.020–0.221 0.179 to 0.009 0.543–1.055
0.000 0.016 0.000 0.002 0.008 0.018 0.031 0.000
0.137 0.051 0.019 0.016 0.012 0.008 0.009
0.174 0.120 0.152 1.098
0.118–0.231 0.062–0.177 0.058–0.245 0.882–1.313
0.000 0.000 0.002 0.000
0.151 0.046 0.025
b a
Regression model (n = 410) BMQ_Overuse BMQ_Concern BMQ_Necessity Psychiatrist ask patient opinion BMQ_Harm Insufficient information about treatment Primary studiesb (Constant) F = 19.16; p < 0.001; adjusted R2 = 0.237 Regression modelc (n = 317) BMQ_Overuse BMQ_Concern Psychiatrist ask patient opinion (Constant) F = 29.84; p < 0.001; adjusted R2 = 0.215
a Including as predictor variables: sociodemographics, duration of treatment, BMQ subscales, self-perceived knowledge about medications and perceived psychiatrist interaction style. b Reference is ‘‘no formal education’’. c Adding four dichotomous variables about current medication (antidepressants, antipsychotics, benzodiazepines, mood stabilisers) to the previous variables.
processes (seeking information, being listened to and offered options and making the decision). Descriptive statistics and correlations between these items were quite similar to those found by Levinson et al. [20], suggesting a dual SDM process. However, in future studies it would be desirable to use other validated measures of preferences for participation, like the API, to establish more convincingly the convergent validity of the LATCon scale. Furthermore, we did not incorporate objective measures of SDM in practice or physician decision making style. It would also be important to assess other potential predictors of patients’ preferences, like personality traits, self-efficacy or locus of control. Finally, longitudinal designs are needed to better understand the evolution of patients’ preferences and the dynamic interaction between preferences, the experience of illness and outcomes of treatment. The feasibility of shared decision making in psychiatric care depends on the specific psychiatric disorder as well as on the phase of the illness. For example, at advanced stages of dementia, shared decision making will not be possible any longer. Shared decision making in acutely ill, schizophrenic, manic or severely depressed patients might be difficult to perform because there are justified fears to the effect that psychiatric patients have a reduced decisional capacity as a result of the symptoms of their illness (e.g. disorganisation of thought). However, there seem to be no obvious limitations for patients suffering from less severe conditions, which tend to be the most common conditions and the ones included in the community sample of this study. Like Hamann et al. [17], we believe that a successful inclusion of psychiatric patients in the therapeutic process could not only counteract existing prejudices about reduced decisional capacity, but also increase the self-respect (empowerment) and the quality of life of psychiatric patients. Nevertheless, the barriers to change of consulting behaviour should not be underestimated, and psychiatrists need to recognise that change is both important and achievable. Britten [36] cites five pre-requisites for concordance in consultations, which include: a willingness to share power and a commitment to giving appropriate weight to patient values and goals; open discussion of the options with explicit enquiry as to patients views without making assumptions; adequate sharing of information, including uncertainties, to arrive at a decision; listening as much as talking; and, finally, time.
4.2. Conclusion Psychiatric outpatients show a considerable desire to participate in decision making about their treatment. The Spanish version of LATCon Scale, specifically adapted for a patient–psychiatrist context, shows a good factorial validity, yielding a monofactorial solution with a high internal consistency, so it seems to be a valid instrument for assessing attitude towards concordance in Spanish psychiatric samples. Future studies must analyse other psychometric properties of the scale, such as convergent validity and testretest reliability. Negative beliefs about psychiatric medication significantly predict attitude towards concordance. 4.3. Practice implications Psychiatrists must consider their patients’ desire for participating in treatment decisions and explore how patients’ views about psychiatric medicines influence their attitudes towards concordance. 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 Unio´n Europea (PI10/00955). References [1] Coulter A. Paternalism or partnership? Brit Med J 1999;319:719–20. [2] Nair K, Dolovich L, Cassels A, McCormack J, Levine M, Gray J, et al. What patients want to know about their medications. Focus group study of patient and clinician perspectives. Can Fam Physician 2002;48:104–10. [3] Stewart M. Towards a global definition of patient centred care. Brit Med J 2001;322:444–5. [4] Anderson EB. Patient-centeredness: a new approach. Nephrol News Issues 2002;16:80–2. [5] RPSGB. From compliance to concordance: achieving shared goals in medicine taking. London: Royal Pharmaceutical Society of Great Britain; 1997.
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[6] Marinker M, Blenkinsopp A, Bond C, Briten N, Feely M, George C, et al. From compliance to concordance: achieving shared goals in medicine taking. London: Royal Pharmaceutical Society of Great Britain; 1997. [7] Marinker M. Compliance is not all. Brit Med J 1998;316:150–1. [8] Bell JS, Airaksinen MS, Lyles A, Chen TF, Aslani P. Concordance is not synonymous with compliance or adherence. Br J Clin Pharmacol 2007;64:710–1. author reply 711-3.. [9] Aronson JK. Compliance, concordance, adherence. Br J Clin Pharmacol 2007;63:383–4. [10] Horne R, National Co-ordinating Centre for NHS Service Delivery and Organisation (Great Britain). Concordance, adherence and compliance in medicine taking: report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R & D (NCCSDO) [London]: NCCSDO; 2005. [11] Raynor DK, Thistlethwaite JE, Hart K, Knapp P. Are health professionals ready for the new philosophy of concordance in medicine taking? Int J Pharm Pract 2001;9:81–4. [12] Kansanaho HM, Puumalainen II, Varunki MM, Airaksinen MSA, Aslani P. Attitudes of Finnish community pharmacists toward concordance. Ann Pharmacother 2004;38:1946–53. [13] Thistlethwaite JE, Raynor DK, Knapp P. Medical students’ attitudes towards concordance in medicine taking: exploring the impact of an educational intervention. Educ Health (Abingdon) 2003;16:307–17. [14] Stokes M, Knapp P, Thistlethwaite JE, Raynor DK. Using the LATCon scale to measure patients attitudes to concordance. In: Presented at the Health Services Research & Pharmacy Practice conference, Leeds 2002; 2002 (accessed 21.04.08)http://www.hsrpp.org.uk/abstracts/2002_18.shtml. [15] 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. [16] Edwards A. Shared decision-making in health care: achieving evidence-based patient choice, 2nd ed., Oxford/New York: Oxford University Press; 2009. [17] Hamann J, Leucht S, Kissling W. Shared decision making in psychiatry. Acta Psychiatr Scand 2003;107:403–9. [18] Jordan JL, Ellis SJ, Chambers R. Defining shared decision making and concordance: are they one and the same? Postgrad Med J 2002;78:383–4. [19] Cushing A, Metcalfe R. Optimizing medicines management: From compliance to concordance. Ther Clin Risk Manage 2007;3:1047–58. [20] 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.
[21] Horne R, Weinman J, Hankins M. The beliefs about medicines questionnaire: the development and evaluation of a new method for assessing the cognitive representation of medication. Psychol Health 1999;14:1–24. [22] Bele´ndez M, Herna´ndez A, Horne R, Weinman J. Evaluacio´n de las creencias ˜ ola del Beliefs sobre el tratamiento: Validez y fiabilidad de la versio´n Espan about Medicines Questionnaire. Int J Health Clin Psychol 2007;7:767–79. [23] Hamann J, Cohen R, Leucht S, Busch R, Kissling W. Do patients with schizophrenia wish to be involved in decisions about their medical treatment? Am J Psychiatry 2005;162:2382–4. [24] Adams JR, Drake RE, Wolford GL. Shared decision making preferences of people with severe mental illness. Psychiatr Serv 2007;58:1219–21. [25] Hamann J, Mendel RT, Fink B, Pfieffer H, Cohen R, Kissling W. Patients’ and psychiatrists’ perceptions of clinical decisions during schizophrenia treatment. J Nerv Ment Dis 2008;196:329–32. [26] O’Neal EL, Adams JR, McHugo GJ, Van Citters AD, Drake RE, Bartels SJ. Preferences of older and younger adults with serious mental illness for involvement in decision-making in medical and psychiatric settings. Am J Geriatr Psychiatry 2008;16:826–33. [27] Hamann J, Kruse J, Schmitz FS, Kissling W, Pajonk FG. Patient participation in antipsychotic drug decisions. Psychiatry Res 2010;178:63–7. [28] Patel SR, Bakken S. Preferences for participation in decision making among ethnically diverse patients with anxiety and depression. Commun Ment Health J 2010;46:466–73. [29] Hill SA, Laugharne R. Decision making and information seeking preferences among psychiatric patients. J Ment Health 2006;15:75–84. [30] Elwyn G, Miron-Shatz T. Deliberation before determination: the definition and evaluation of good decision making. Health Expect 2010;13:139–47. [31] Entwistle VA, Skea ZC, O’Donnell MT. Decisions about treatment: interpretations of two measures of control by women having a hysterectomy. Soc Sci Med 2001;53:721–32. [32] Hanson J. Shared decision making: have we missed the obvious? Arch Intern Med 2008;168:1368–70. [33] Awad AG. Subjective responses to neuroleptics in schizophrenia. Schizophr Bull 1993;19:609–18. [34] Say R, Murtagh M, Thompson R. Patients’ preference for involvement in medical decision making: a narrative review. Patient Educ Couns 2006;60:102–14. [35] Loh A, Kremer N, Giersdorf N, Jahn H, Hanselmann S, Bermejo I, et al. Information and participation interests of patients with depression in clinical decision making in primary care. Z Arztl Fortbild Qualitatssich 2004;98:101–7. German. [36] Britten N. Patients’ expectations of consultations. Brit Med J 2004;328:416–7.