Psychiatric decision making in the emergency room: a research overview

In an overview of the research on psychiatric decision making in the emergency room, the authors discuss studies done between 1963 and 1977, which suffered from an overreliance on univariate statistical techniques, problems with the reliability and validity of the instruments used for data collection, and the lack of alternatives to hospitalization for emergency room patients. More recent studies of emergency room decision making are then reviewed, with particular attention to those that had multivariate statistical designs. The article concludes with a synthesis of the research findings to date and recommends multivariate approaches and choices of variables for future studies.     

Medical decision making in antipsychotic drug choice for schizophrenia

OBJECTIVE: The influence of patient and physician variables on antipsychotic drug choice for patients with schizophrenia was assessed. METHOD: Interviews with 100 psychiatrists on drug choice for 200 patients suffering from schizophrenia were conducted. Data were analyzed by using multiple logistic regression. RESULTS: Older physicians were up to five times more likely to prescribe first-generation antipsychotics. Patient variables did not influence treatment decisions significantly. CONCLUSIONS: There is an urgent need for more research on clinical decision making and quality management.     

Psychiatric expertise in clinical decision making for psychiatric inpatients

Hospital boards and medical staffs are faced with difficult decisions about whether nonphysician mental health professionals should be given admitting privileges to psychiatric hospitals or treatment units. The authors describe the special medical expertise of the psychiatrist and define 11 indicators, such as a patient's need for new psychotropic medication or the presence of symptoms requiring medical or laboratory procedures, that can be used to determine whether psychiatric expertise is needed. The indicators were applied to a group of ten patients who constituted all admissions to a treatment unit in a private, nonprofit psychiatric hospital in a one-month period. At least half of the indicators were relevant to all the patients studied, suggesting the need for management by a psychiatrist.     

Psychiatric decision making in family practice. Future research directions

Psychiatric illnesses in family practice are significantly underdiagnosed because of factors associated with both the physician and patient. Clinicians too often fail to utilize a biopsychosocial approach in the assessment process, tending to assess symptoms as organic regardless of their etiology. Patients similarly tend to emphasize the physical nature of their complaints when presenting in medical settings. Efforts have been made to improve the physician's diagnostic accuracy through the use of screening scores. The results, however, are inconclusive. It remains unclear whether the physician disregards this information or considers it irrelevant. We suggest that future research investigate not only the accuracy of the clinician's diagnostic formulation but also the processes whereby the family practitioner elicits, analyzes, and synthesizes or discards cues pertinent to mental illness. By combining statistical analyses with the analytic techniques developed in studies of medical decision making and general problem solving, detailed leads should emerge for the design of improved didactic and experiential training programs.     

Psychiatric reform in Germany

OBJECTIVE: To describe the ongoing process of German psychiatric reform and the structure and functioning of mental health services. METHOD: Information sources used include official reports describing mental health services, relevant publications related to organization and functioning of services. RESULTS: There has been far-reaching change in mental health care since the late 1960s: psychiatric hospitals have lost about 50% of their beds and one psychiatric hospital has been closed. One hundred and sixty-five general hospital psychiatric units have been built up. Out-patient, community and residential services have been developed. There is a lack of diversified residential and rehabilitation services, particularly for the most severely ill. Co-ordination of care is not always ensured, transfer of patients to remote nursing homes has occurred in some places. Carers and service users articulate their views to an increasing degree. CONCLUSION: Political and professional enthusiasm have been important in implementation of the German reform. Evolving it further will require major efforts.     

Psychiatric opinion and antipsychotic selection in the management of schizophrenia

OBJECTIVES: This study examined psychiatrists' opinions regarding the use of second-generation antipsychotics for treatment-resistant schizophrenia. It then sought to identify factors associated with these opinions. METHODS: A national survey was conducted (September 2003-January 2004) of psychiatrists engaged in the management of patients with schizophrenia. RESULTS: Among survey respondents (N=431), most psychiatrists (88%) believed that one or more of the five currently available second-generation antipsychotics could improve treatment-resistant positive symptoms after a failed trial of optimal oral haloperidol treatment. Psychiatrists who reported familiarity with schizophrenia practice guidelines were more likely to have high levels of optimism that these medications improve positive symptoms (odds ratio [OR]=3.6, 95% confidence interval [CI]=1.4-9.3, p=.009). Psychiatrists who met with a pharmaceutical representative at least once a week were also more likely to have high levels of optimism toward second-generation antipsychotics (OR=2.3, CI=1.4-3.9, p=.001). CONCLUSIONS: Reported familiarity with treatment guidelines and frequent contact with pharmaceutical representatives appear to be associated with optimism toward second-generation antipsychotics.     

Variables affecting the decision making of a review panel

This study was designed to identify the variables that influence a review panel's decision to discharge or detain an involuntary patient. A group of fifty patients consecutively discharged by the review panel of a provincial mental hospital were compared according to thirty-five variables, with a group of forty-five patients consecutively detained by the panel. The variable set included information on the patient's psychiatric history, current hospitalization and treatment as well as ratings of dangerousness, insight and psychopathology, as reflected in the attending physician's case summary prepared for the review panel. The released and detained groups were found to be remarkably similar. They differed on ten of the thirty-five variables measured, but they did not differ on some variables that one would expect to form the basis of the panel's decision, including diagnosis and a history of suicide attempts. On the other hand, when the predictive value of the variable set as a whole was examined using discriminant analysis, the results indicated that there was a substantial amount of predictability to the review panel process. The group membership of 77.5% of the patients can be predicted from only nine variables that contribute to the discriminant function. The results will be of interest to clinicians who deal with review panels on a regular basis and the findings have implications for other practical issues including discharge planning and readiness for community living.     

Heuristic decision making in medicine

Can less information be more helpful when it comes to making medical decisions? Contrary to the common intuition that more information is always better, the use of heuristics can help both physicians and patients to make sound decisions. Heuristics are simple decision strategies that ignore part of the available information, basing decisions on only a few relevant predictors. We discuss: (i) how doctors and patients use heuristics; and (ii) when heuristics outperform information-greedy methods, such as regressions in medical diagnosis. Furthermore, we outline those features of heuristics that make them useful in health care settings. These features include their surprising accuracy, transparency, and wide accessibility, as well as the low costs and little time required to employ them. We close by explaining one of the statistical reasons why heuristics are accurate, and by pointing to psychiatry as one area for future research on heuristics in health care.     

Shared decision making in psychiatry

OBJECTIVE: In other medical fields, 'shared decision making' (a strategy for including patients in therapeutic decision processes) has been studied for several years now. This survey presents the potential of shared decision making for psychiatry. METHOD: Literature search. RESULTS: Research in other medical fields shows that shared decision making positively influences patients' satisfaction as well as health outcomes. The application of shared decision making to psychiatry is still in the initial stage. CONCLUSION: Evidence that shared decision making can be successfully practiced in psychiatry would contribute to an improved inclusion of psychiatric patients in therapeutic decisions and thereby help to implement basic rights of a group of patients who have not sufficiently benefited from consumer empowerment in other medical fields.     

The involvement of the striatum in decision making

Decision making has been extensively studied in the context of economics and from a group perspective, but still little is known on individual decision making. Here we discuss the different cognitive processes involved in decision making and its associated neural substrates. The putative conductors in decision making appear to be the prefrontal cortex and the striatum. Impaired decision-making skills in various clinical populations have been associated with activity in the prefrontal cortex and in the striatum. We highlight the importance of strengthening the degree of integration of both cognitive and neural substrates in order to further our understanding of decision-making skills. In terms of cognitive paradigms, there is a need to improve the ecological value of experimental tasks that assess decision making in various contexts and with rewards; this would help translate laboratory learnings into real-life benefits. In terms of neural substrates, the use of neuroimaging techniques helps characterize the neural networks associated with decision making; more recently, ways to modulate brain activity, such as in the prefrontal cortex and connected regions (eg, striatum), with noninvasive brain stimulation have also shed light on the neural and cognitive substrates of decision making. Together, these cognitive and neural approaches might be useful for patients with impaired decision-making skills. The drive behind this line of work is that decision-making abilities underlie important aspects of wellness, health, security, and financial and social choices in our daily lives.     

Basal ganglia play a crucial role in decision making

Many studies have suggested that the striatum, located at the interface of the cortico-basal ganglia-thalamic circuit, consists of separate circuits that serve distinct functions It plays an important role in motor planning, value processing, and decision making.     

Asynchronous decision making in a memorized paddle pressing task

This paper presents a method for asynchronous decision making using recorded neural data in a binary decision task. This is a demonstration of a technique for developing motor cortical neural prosthetics that do not rely on external cued timing information. The system presented in this paper uses support vector machines and leaky integrate-and-fire elements to predict directional paddle presses. In addition to the traditional metrics of accuracy, asynchronous systems must also optimize the time needed to make a decision. The system presented is able to predict paddle presses with a median accuracy of 88% and all decisions are made before the time of the actual paddle press. An alternative bit rate measure of performance is defined to show that the system proposed here is able to perform the task with the same efficiency as the rats.