ORIGINAL RESEARCH

 

Information on antidepressants for psychiatric inpatients: the divide between patient needs and professional practice

Información sobre antidepresivos para pacientes psiquiátricos hospitalizados: el espacio entre las necesidades del paciente y la práctica profesional

 

 

Franciska A. Desplenter¹, Gert J. Laekeman², Sandra De Coster³, VZA Psychiatry Research Group⁴, Steven R. Simoens⁵

¹PhD. Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven (Belgium).
²PhD. Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven (Belgium).
³PharmD. Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven (Belgium).
⁴VZA Psychiatry Research Group: Reyntens Johan (Psychiatric Hospital Sint Jan, Eeklo, Belgium), De Baere Sheila (Psychiatric Hospital Sleidinge, Sleidinge, Belgium), De Boever Willy (Psychiatric Hospital Sint Hiëronymus, Sint-Niklaas, Belgium), De Vos Marc (Psychiatric Hospital Sint Jan Baptist, Zelzate, Belgium), Vrijders Danny (Psychiatric Hospital Zoete Nood Gods, Lede, Belgium), De Fré Claudine (Psychiatric Hospital Sint Jan DeDeo, Gent, Belgium), De Keyster Cécile (Psychiatric Hospital Heilige Familie, Kortrijk, Belgium), De Meulemeester Katharina (Psychiatric Hospital Sint Camillus, Sint Denijs Westrem, Belgium), Heremans Marise (University Psychiatric Centre Sint Jozef, Kortenberg, Belgium), Rutgeerts Cathérine (Psychiatric Hospital Broeders Alexianen, Tienen, Belgium).
⁵MSc PhD. Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven (Belgium).

This research was supported by a grant of the Institute for the Promotion of Innovation through Science and Technology in Flanders (IWTVlaanderen).

 

 

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ABSTRACT

Background: Medicine information is an integral part of patient care and a patient right. In particular, patients with a mental health diagnosis have a need for information on medicines.
Objective: This study aims to describe the current practice on information provision on antidepressants to inpatients in psychiatric hospitals.
Methods: A qualitative study was conducted consisting of semi-structured interviews with health care professionals (n=46) and patients (n=17) in 11 Flemish psychiatric hospitals. Two topic guides were designed for conducting the interviews with these respective stakeholders. The issues addressed in the topic guides related to: organization of information provision in the hospital, information on demand of the patient, information provision by health care professionals, information for relatives, evaluation of provided information, interdisciplinary contacts on information provision and satisfaction on current practice of information provision. The interviews were analysed according to the five stages of the framework analysis.
Results: Psychiatrists and nurses are the key players to provide information on antidepressants. Their approach depends on patient characteristics and mental state. Information is provided mainly orally. Health care professionals consider non-verbal cues of patients to verify if information has been understood. Health care professionals reported lack of time and lack of interdisciplinary contacts as negative aspects. Patients indicated that health care professionals take too little initiative to provide medicine information.
Conclusions: Patients are informed about their antidepressants through various pathways. Although the awareness is present of the importance of the individual approach and efforts are done to tailor information to the individual patient, improvement is still possible. Tailoring communication; assessing patient needs and preferences; matching of health care professional style and patient needs; and achieving concordance, is a complex and challenging task for health care professionals in mental health care.

Key words: Drug Information Services; Antidepressive Agents; Depressive Disorder; Inpatients; Qualitative Research; Belgium.

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RESUMEN

Antecedentes: La información sobre medicamentos es parte integral de la atención al paciente y un derecho del paciente. En particular, los pacientes con diagnóstico de enfermedad mental necesitan información sobre los medicamentos.
Objetivo: Este estudio intenta describir la práctica actual de provisión de información sobre antidepresivos a pacientes psiquiátricos hospitalizados.
Métodos: Se realizó un estudio cualitativo consistente en entrevistas semi-estructuradas con profesionales de la salud (n=46) y pacientes (n=17) en 11 hospitales psiquiátricos flamencos. Se diseñaron dos guías de asuntos para realizar las entrevistas con los respectivos decisores. Los asuntos tratados en las guías estaban relacionados con: la organización de la provisión de información en el hospital, información a demanda del paciente, provisión de información por los profesionales de la salud, información para familiares, evaluación de la información proporcionada, contactos interdisciplinarios en la provisión de información, y satisfacción con la práctica actual de provisión de información. Las entrevistas se analizaron de acuerdo a los cinco etapas del análisis contextual.
Resultados: Los psiquiatras y enfermeras son los actores principales en la provisión de información sobre antidepresivos. Su abordaje depende de las características del paciente y de su estado mental. La información se proporciona fundamentalmente oral. Los profesionales de la salud tienen en cuenta señales no verbales para verificar si la información fue entendida. Los profesionales reportaron falta de tiempo y falta de contactos interdisciplinarios como aspectos negativos. Los pacientes indicaron que los profesionales de la salud tienen demasiado poca iniciativa en proporcionar información sobre medicamentos.
Conclusiones: Los pacientes están informados sobre sus antidepresivos por varios caminos. Aunque existe una conciencia de la importancia del abordaje individual y se realizan esfuerzos para adaptar la información a cada paciente, es posible mejorar. Adaptar la comunicación; evaluar las necesidades y las preferencias del paciente; alcanzar la concordancia son tareas complejas y desafiantes para los profesionales de la salud en cuidados de salud mental.

Palabras clave: Servicios de Información sobre Medicamentos; Antidepresivos; Trastorno Depresivo; Pacientes Internos; Investigación Cualitativa; Bélgica.

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Introduction

In Belgium, a law describing patient rights was approved on August 22^nd, 2002.¹ The law describes the commitments of health care professionals and the rights for patients, including the right for information. This comprises all information regarding the current health status as well as the prognosis. For patients to be able to give informed consent, information must be provided on the aim, nature, urgency, treatment plan (e.g. taking medicines), contraindications, side effects, relevant risks and financial implications.² Information should be provided according to the patient´s age, education, understanding and desire.³

As the provision of information to patients is important for several reasons, information should not only be given because it is a legal obligation. Information is an integral part of the caring for patients. Information provision may add to the quality of care and may also increase adherence rates associated with chronic disorders. Information is essential in any strategy to promote patient care, self-management, health literacy, shared-decision-making and medication adherence.^4,5

Patients have a clear demand for information on health-related topics.⁶ Information may be wanted on several topics such as diagnosis, examinations, treatment options, medicines, prognosis and duration. Suhonen et al. showed that patient information needs did not correspond to the information received in hospital.⁷ Duggan and Bates found that patients with certain diseases (e.g. endocrine and diabetes diagnoses) expressed a higher need for information than patients with other diseases (e.g. cardiovascular diseases).⁸ Through this, health care professionals (HCPs) have a challenging task to identify the needs of the individual patient and to tailor the information to patient needs.

In particular, patients with a mental health diagnosis have a need for information on medicines.^9-11 A literature review on educational interventions on medicines in a population of psychiatric patients showed that medication information positively impacts patient knowledge on and adherence to psychotropic pharmacotherapy.⁵ A review on the influence of communication on treatment outcomes in a psychiatric setting showed that there were associations between the physician´s communication skills and patient satisfaction, adherence to treatment recommendations and treatment outcomes.¹² Two reports on patient education in Flemish hospitals showed that a lot of effort is needed to increase and to improve patient education.^2,13 No specific information was available on the situation in Flemish psychiatric hospitals.

Communication is a prerequisite in psychiatry. Only by means of verbal communication and by observations of the behaviour of a patient, essential information for understanding the patient and for the diagnosis can be gathered. This depends also on the behaviour of the HCP to ask the right questions for clarifying facts and values. Creating an atmosphere of trust and openness in which such communication can take place is needed.¹⁴ Good communication is not only important to gather information but also to provide information to the patient on diagnosis and treatment.

The aim of this study is to explore current practices regarding the provision of information about antidepressants to patients with depression admitted to a psychiatric hospital. To this effect, this qualitative study will explore current practices of HCPs with respect to drug information provision and examine the experiences of patients using semi-structured interviews.

 

Methods

Semi-structured interviews

This study applied a qualitative approach as this was deemed most appropriate in order to investigate in-depth current practice of information provision on antidepressants in a psychiatric hospital setting.^15,16 Semi-structured interviews were selected as they give the possibility to ask each individual about his/her own views and experiences of current practice.

Setting

The members of the Flemish Hospital Pharmacists Association Psychiatry Group were contacted with a view to identifying which of their affiliated psychiatric hospitals would be willing to participate in our study. Out of this network, a convenience sample of eleven Flemish (Dutch-speaking part of Belgium) psychiatric hospitals consented to participate in this study, representing about one third of all psychiatric hospitals in Flanders. The sample included individual hospitals (n=3) and hospitals from different hospital networks: "Broeders van Liefde" (n=3), "Broeders Hiëronymieten" (n=3) and university hospitals (n=2). None of them were private hospitals. The hospitals were located in different geographical regions of Flanders. The number of beds per hospital ranged from 85 to 500 (mean: 214). This study was part of a larger study on the information provision on antidepressants for which approval was obtained by the Ethics Committee of University Hospitals Leuven.

Participants

HCPs working on mood disorders wards and having a role in providing information on antidepressants were invited to participate in a semi-structured interview. The selection of HCPs was made in collaboration with the hospital: a list of eligible HCPs was compiled for every hospital by the hospital management and hospital pharmacist to ensure to include all eligible staff. The listed HCPs were contacted by telephone by the main researcher to explain the purpose of the study and to invite them to participate. If the HCP consented to participate, an appointment was scheduled to perform the interview in the hospital. Different types of HCPs were included in the study to have the views of the different members of the multidisciplinary team of the hospital resulting in a comprehensive view of current practice.

Patients with a mood disorder were invited to participate in a one-to-one semi-structured interview on their experiences of information provision on antidepressants during their hospital stay. The head nurse of the ward for mood disorders selected patients with a diagnosis of depression and who were close to hospital discharge. These patients were selected as this study is part of a larger project examining information provision on antidepressants to patients with depression at hospital discharge. The head nurse informed the patients of the study and asked if they were interested to participate. When patients agreed to participate, an appointment to perform the interview in the hospital was scheduled.

Prior to the start of the interview, study procedures were explained and participants were asked for their consent to participate.

Data collection

The interviews were performed during the period April 2007 - July 2008. The interviews were performed by a trained master student in pharmacy or by a researcher. Training and reading materials were provided on performing semi-structured interviews.^16,17 A second person (i.c. another student or another researcher) acted as an observer and took notes during the interview.

A topic guide was designed for the interviews with the HCPs and a second one for patients. The two topic guides contained the same questions but were formulated according to the perspective of the interviewee. Topics were: organization of information provision in the hospital, information on demand of the patient, information provision by the HCPs, information for relatives, evaluation of provided information, interdisciplinary contacts on information provision and satisfaction on current practice of information provision. The topic guide was pilot tested in one hospital and refined for use in the remaining 10 hospitals.

Demographic characteristics were collected at the end of the interview. Gender, age, and education were registered for patients. Gender, the number of years of relevant experience in mental health care and the number of years of experience in the current position were registered for HCPs. All interviews were tape recorded and transcribed verbatim. Participants and all named persons were made anonymous.

Data analysis

The interviews were analyzed according to the five stages of the framework analysis: (I) familiarization, (II) identifying a framework, (III) indexing, (IV) charting and (V) mapping and interpreting.¹⁶ An inductive approach was used. The software QSR NVivo 7 was used to manage the analysis of the interviews. A thematic framework was built on consensus between the research fellow (SDC) and the main researcher (FD). This thematic framework was based on a priori issues as well as on issues emerging from the data. The interviews were indexed independently by two persons (SDC and FD), after which any discrepancies in the findings were discussed until consensus was reached. If needed a third reader assisted to consent on the indexing.

 

Results

In total, 17 patients and 46 HCPs (17 psychiatrists, 23 nurses, 2 pharmacists, 2 psychologists, 1 discharge manager and 1 patient care manager) consented to participate. The majority of the patients were female (n=14) with a mean age of 43 years (±10 years) and with up to secondary (n=9) or higher (n=8) education. Half (n=24) of the HCPs were female and had a mean of 17 years (±9 years) of experience in mental health care and a mean of 10 years (±8 years) in the current position. The mean duration of the interviews with patients was 16 minutes (range: 8-45 minutes). Interviews with HCPs had a duration of 38 minutes on average (range: 15-90 minutes). The number of participating patients and HCPs was evenly spread across hospitals (1-4 patients per hospital and 2-6 HCPs per hospital). In the following subsections, quotes are referenced to the hospital (hospital A-K), the kind of participant (D = psychiatrist, N = nurse, A = pharmacist, Y = psychologist, DM = discharge manager, PM = patient care manager, P = patient), and a number if more than one person of the same kind was interviewed within the same hospital.

Organisation of medication information in hospital

Patients received information on antidepressants, firstly, through psychiatrists and, secondly, through nurses.

Psychiatrists reported that they had a duty to provide information on medicines, especially at first prescription.

Nurses were often described as contact persons to answer questions and to notice medicine related problems such as side effects. Other HCPs (psychologists and therapists) were not systematically considered having a role in medication information provision. When patients had questions regarding their medicines, HCPs said mostly to refer patients to their treating psychiatrist. Psychiatrists and nurses, and sometimes psychologists and pharmacists, were involved in organizing psycho-educational group sessions in which antidepressants were discussed. The role of the hospital pharmacist was described by HCPs as having a supporting role in the provision of medicine information towards other HCPs. Contact between hospital pharmacists and patients were reported to be uncommon. The organization of medicine information was mainly based on mutual understanding or on verbal arrangements between the different members of the multidisciplinary team. No specific procedures were reported in any of the hospitals.

"Euh, in the first place, this is actually the responsibility of the psychiatrist, I think heh. The provision of ... or to ensure that the information is provided well."(GD1)

"We are the ones who will see the side effects of the medication in the first place. And we will talk about it with the patient: does it cause you inconvenience? We have a bridging function towards the psychiatrist to report the observed topics or to ask for action."(DV2)

Medication information on demand of the patient

HCPs reported the following questions frequently asked by patients on antidepressants: (1) side effects; (2) instructions for medicine use; (3) indication; (4) therapeutic effectiveness and (5) the reason for changing the antidepressant pharmacotherapy. Four main approaches in dealing with questions were reported by HCPs: (1) only answering the question; (2) answering the question and taking this opportunity to provide additional information on the antidepressant; (3) referring to another HCP; (4) searching for additional information to provide an adequate and correct answer. Several HCPs said trying to identify underlying question or motivation: "why does this patient ask this question?".

Patients reported that they asked questions firstly to their psychiatrist and secondly to nurses. In the majority of the cases, patients reported to be satisfied with the answer provided: the answer was clear and they had no further questions. In half of the cases, patients did not feel that the HCP checked if they really understood the provided information.

"Yes euh, but not so often in fact. It happens that people ask for information, euh ... but there are also people with many questions who finally will not dare to ask them." (JD1)

"But let us say, a question concerning content. Then, first of all, we have a look at the question. Secondly, what is the underlying question? Because a question is never just a question. There is always a reason why something is asked."(ED1)

Medication information spontaneously provided by the HCP

HCPs, especially psychiatrists, but also nurses said that they were proactive in providing information on antidepressants to patients. Half of them reported that their approach in giving information depended on patient characteristics, his/her mental state or the type of medicine prescribed. They spontaneously provided information when the antidepressant was prescribed for the first time; when changes in antidepressant pharmacotherapy were made; when they experienced patients had a need for it (e.g. side effects or low compliance) or at discharge. Some HCPs said having difficulties in discussing side effects as patients may not want to take antidepressants any longer after discussing possible side effects.

HCPs reported that antidepressant information is provided mainly orally. Leaflets were not frequently used by HCPs but schemes of medications used by the patient and other hospital-related documents were. Some hospitals reported to organise psycho-educational group sessions in which patients can receive information on antidepressants. The package insert was not spontaneously used in any of the participating hospitals. The following information sources were reported to be available in hospitals: internet, leaflets or medicines compendia (with Summaries of Product Characteristics).

Half of the HCPs reported to repeat information provided on medicines as they experienced that a single information provision is often insufficient. The most cited topics that were repeated were compliance, therapeutic effectiveness and side effects.

"If someone asks for the package insert, I refer him/her to the psychiatrist because the psychiatrist preferably goes through the package insert with the patient. Then it is the psychiatrist who opens the medicines compendium and goes through it and explains. Unless, I mention during an interdisciplinary team meeting that a specific patient asks for the package insert. May I provide this to the patient? If they say yes, well that´s no problem. ... Then I ask the pharmacy for a package insert and I discuss this in a talk with the patient." (DV2)

Patients were rather satisfied with the provided information although the amount of provided information was reported to be limited. Information was mainly given spontaneously by psychiatrists. Several patients reported still having questions after the information was provided by the HCP. Group sessions were often rated by patients as too technical and too difficult. Information was said preferably not to be provided too soon as patients reported not yet being able to capture the provided information. Repetition of information was appreciated by patients.

"Because if you do not ask anything, well you do not know a thing about the medication." (JP4)

"Actually, that is hard to say because the day you enter here, you are so impressed. That is something different from a usual hospital. ... You are having a hard time the first days. Really, you are not busy with the things the doctor told you. He prescribes you a medicine and you just take it because you plunged and you want to go for it. ... There are things you do not hear because you are not focused on it. That has more to do with the patient than the doctor."(FP2)

Medication information for relatives

HCPs reported to provide information on antidepressants to patients´ relatives (=partner or first degree family members) but mainly on their demand. HCPs described meetings with relatives as a general talk in which medicines are one of the topics discussed. The most frequently asked topics by relatives related to antidepressants were compliance, general information on antidepressants, instructions for use, indication and side effects. All HCPs said to ask patient´s approval before discussing any information with relatives in order not to violate patient privacy. In most cases, the patient was asked to be present. If this was not possible, the content of the discussion was reported to the patient afterwards.

"Some people are very involved. Some people are even taking up a caring partner role, also for the use of medicines. When patients are at home, they will keep an eye on and follow up medication use. It is possible people get such a role ... Exactly then it is important to provide them with more information."(CY1)

"Generally this is in the presence of the patient. If this is not the case, then we do report back to the patient because we will never see and talk to relatives without the patient´s approval." (DD3)

Evaluation of provided medication information

To verify if information was well understood, HCPs said they asked questions to the patients and considered their non-verbal cues. Some HCPs said they had no real method. Evaluation was not systematically performed.

When information was not clear for patients, HCPs said they repeated the information, further clarification was given or the patient was referred to another HCP to elaborate on the unclear topics.

"Hm, we explain it once more ... euh, if they still don´t understand it, then we can print it if desired ... yes, print it on paper or ... or try to explain it in an easier way ..."(BV1)

Interdisciplinary contacts on provided medication information

There were no systematic interdisciplinary contacts reported with regard to the provision of information on medicines. HCPs said this was only done for a particular patient when it was deemed important for all involved HCPs (e.g. in case of non-compliance) or when follow-up was needed. This was performed via regular interdisciplinary meetings. Patient files and one-to-one correspondence were said to be used as alternative communication ways in absence of meetings.

"Oh, if these are regular questions, I don´t think we report them. But if these questions do have an impact on the treatment or the further process, then I will. Then it is said on the team meeting: I provided the patient or the family with information on these medicines. So we won´t do the same job twice."(EH2)

"Actually, what is registered usually, are the topics regarding the medicine intake and the problems a patient is having with that. So, if a patient says: I don´t take this; then this is reported. This will be discussed." (ID1)

General topics concerning the provision of medication information

Providing information or answering questions was often said to be adapted to the individual patient in several ways: (1) according to the personal characteristics of the patient: age, education level, level of understanding, suspicious or anxious nature of the patient; (2) according to the health condition of the patient: crisis situation, acute phase, kind of symptoms (depressive, manic, psychotic or anxious), severity of symptoms or ability to concentrate; (3) taking into account the attitude towards medicines: need of pharmacotherapy, motivation to take medicines, duration of pharmacotherapy, distrust or resistance towards medicines, fear of side effects, past negative experience or addictive character of medicines; (4) according to the information desire of patients: a high need for information and search for more information versus trust in the medical team and not asking questions about their medicines. Patients and HCPs reported that information was sometimes searched outside the hospital (package inserts, internet, general practitioner or pharmacist).

"We always try ... we should obviously talk according to the patient´s level but you don´t have only problems of intelligence. You have problems of personality: the beliefs are not always optimal. But we still try to provide tailored care."(KD)

"A first kind of bias is that some patients will search for information, for example on internet. Nurses do not consult the internet together with the patient. A second kind of bias is that information is received through other HCPs like for example the general practitioner. By saying this, I want to make clear that it is naïve to think that patients do not search information on their own and that we are the only source of information." (AH)

HCPs and patients identified several barriers in the provision of medicine information. 1) Too little initiative by HCPs to provide spontaneously medicine information. 2) Insufficient time for HCPs to perform this task apart from all other medical and non-medical tasks. 3) Provided information often unclear or not understandable by patients. 4) HCPs not always aware of the medication information provided by each member of the HCP team. 5) Patients not asking questions because they considered it to be too big a step to ask a question to a HCP. 6) A limited number of patient-psychiatrist consultations in some cases.

HCPs expressed during the interview their views and attitudes towards information provision on antidepressants to hospitalized patients with depression. These views are grouped in seven categories. The first one relates to the quantity of information to be provided: looking for the right balance; no overload of information as this may result in resistance towards taking the medicines; repetition of information is important and necessary and package inserts have a frighteningly complete overview of information. The second one relates to the quality and the format of information: written materials should be accompanied with verbal explanation; use of clear and understandable words are necessary; some sources of information could be biased (internet sites or leaflet of a pharmaceutical company); information must be situated within the correct perspective; package inserts are considered as unreadable, not understandable, impersonal and frightening and therefore HCPs often discourage patients to read them. The third one relates to the timing of the intervention: information should be dosed according to the need of the patient at that specific moment and considering the presence and severity of symptoms; sometimes certain information is given on a preventive basis (e.g. pregnancy) or because of practical reasons (e.g. patient goes home at the weekend). The fourth one describes the attitude of the patient: critical attitude or questions related to therapy and pharmacotherapy; priorities of the patient and the underlying question when questions are asked. The fifth one concerns the relationship between the patient and the HCP: openness and respect were often cited as important; HCP wants to act with the patient´s knowledge and approval, respecting his/her privacy and taking into account previous experiences with medicines; motivation of patients facilitates a positive relationship, patients must have the feeling the HCPs are ready if they have any questions or problems; and sometimes a HCP refers a patient to another HCP in order not to interfere or to cause tension in their relationship. The sixth one discusses the individual approach: every patient has his/her own story; his/her own problems and his/her own situation. HCPs report to take these individual differences (as mentioned before: personality, health condition, information desire, attitudes and beliefs, and motivation) into account when talking to patients. And the seventh one is on the position of medication information within the context of the treatment plan: treatment of a major depressive episode in hospital is more than prescribing antidepressants and informing about them. Other support such as psychotherapy, occupational and music therapy are available for patients. The position of pharmacotherapy within the whole treatment process should be situated.

"I really dislike the fact that people need to collect information from a package insert which is totally impersonal. It frightens people more than anything else." (BD1)

"Well, as I said, timing is important. You have to do it when the patient is mentally ready for it. You have to consider education level, the mental condition of the patient. One explanation is nearly never satisfying. Nearly always a number of topics need to be repeated." (ID1)

Satisfaction on current practice of medication information provision

HCPs reported to be satisfied with current practice on information provision, being aware that it could always be improved. HCPs reported lack of time, lack of interdisciplinary contacts and absence of a systematic approach as negative aspects. Some of them were aware that they could provide more information than they currently did.

Some HCPs, mainly nurses, reported not to have sufficient knowledge on medicines to have an in-depth discussion about antidepressants with patients. Patients indicated that HCPs take too little initiative to give information about medicines and that this information was limited in amount. Some patients reported that information was not clear or insufficiently comprehensible.

Suggestions for improving practice reported by the interviewees were: providing more medication information to patients, in particular on side-effects; enhancing the availability of easy readable information; providing medication information more systematically; and organizing continuing education for nurses on medicines.

"The fact is that we are always there to provide information and to consider a question seriously. Referring to the psychiatrist if we cannot answer ourselves." (IV2)

"I think it is still too depending on the person. There is still not enough structure. You see ... you heard that psychiatrists as well as nurses have a very crucial role. Much is depending on the motivation, the efforts and the professionalism of the HCP in question. There is possibly not enough structure in the care delivery."(DD1)

 

Discussion

Several information pathways on medicines are available in psychiatric hospitals. Psychiatrists and nurses are the key persons in the provision of information on antidepressants. Pharmacists are generally not directly involved, which is also reflected in the selection of HCPs eligible for this study as only two pharmacists were selected by the hospital team. Patients asking questions were a trigger for HCPs to provide information. Medication information was provided ad hoc rather than on a systematic basis. In every hospital, there was someone available to deal with questions of patients, but not in a structured way. The provision of medication information was reported to be particularly important to achieve compliance.

When interpreting the results of the interviews from the perspective of health communication models, our results suggest that the medical model seems to preponderate shared-decision making and empowerment.^18,19 Traditionally, the medical model or paternalistic approach sees the patient as a passive recipient. Paternalism implies that the HCPs know what´s best for the patient´s wellbeing and take the responsibility.¹⁸ Traditional medical education sees "communication" as a way of collecting data from and providing factual information to the patient in an efficient and rational way without considering how illness affects mental well-being or how implicit aspects of dialogues with HCPs influence patients.²⁰ This medical model was particularly observed for discussion of side effects. Most HCPs found it difficult to discuss side effects with their patients, especially when these were severe side effects, e.g. weight gain. Sometimes, HCPs preferred not to tell these side effects as they feared the patient would no longer want to take the antidepressant.

Instead of openly discussing this matter with the patient and seeing how they could deal with this possible side effect, the HCP decided not to talk about it. Additionally, the fact that patients reported not to receive much information and had to ask about it, is an indication for the more paternalistic approach even at times of first prescription.

HCPs found the provision of information important within the context of compliance. HCPs and patients should participate as partners to reach an agreement on when, how and why to use medicines, drawing on the expertise of the HCP as well as the experiences, beliefs and wishes of the patient. A review on the communication between patients and HCPs about medicines showed that despite the belief that patients should participate in discussions on medicines, HCP behavior can impede as well as enhance patient involvement.²¹ Patient concerns, beliefs and attitudes towards psychotropic medicines have to be discussed in order to achieve a concordant pharmacotherapy. Even for the treatment of severe mental problems, psychotropic medicines are not well accepted compared to e.g. cardiac medicines. Psychotropic medicines are believed to cause significantly more severe side effects and provoke more fear of losing control in comparison with cardiac medicines.²² The continuous use of these psychotropic medicines has shaped the opinion of users toward a more beneficial perception, while the opinion of the general population is more negative towards them.²³ A study showed that physician initial communication style positively influenced patient knowledge and initial beliefs about the medication during treatment for depression.²⁴

Tailored communication is intended to reach one specific individual, based on characteristics that are unique to that person, and that are related to the specific outcome of interest and have been derived from an individual assessment.²⁵ Advantages of tailored communication of materials might be: greater attention, greater comprehension, greater intention to change the behaviors addressed by the content and greater likelihood of behavior change.²⁶ Three strategies can be used in tailoring communication about health, separately or in combination with each other: personalization, feedback and content matching.²⁷ This approach has proven its effectiveness.²⁸ The interviewed HCPs reported to keep in mind patient personality, disease-related aspects, information desire and attitudes and beliefs towards antidepressants. However, this individual approach did not always match patient needs. There appeared to be a mismatch between HCPs´ attitude towards providing drug information and patients´ rights and needs for information. Mismatches were seen in terms of the amount of provided information, the clearness and comprehensibility of the information and the barrier to ask questions. How can these mismatches be explained? Was the HCP fully aware of the exact needs of the patient? Was the communication not adapted to the patient? Which communication style was preferred by the patient? Future research to explore the strategies of tailoring the information to the patient and to match patient preferences for medical information, decision-making and interpersonal behaviour is needed to answer these questions.

There are some methodological limitations in our approach. The number of patients interviewed is limited (n=17). However, saturation of data was achieved which is in line with the theoretical saturation reached after 20-60 interviews given the number of interviewees (n=63).¹⁵ Sampling of interviewees was performed in cooperation with the hospital staff causing potential selection bias. This approach was chosen to ensure that HCPs and patients were appropriately included in the study. The interviews were performed by different researchers due to organisational reasons. Generalisation of these qualitative results is not appropriate. Therefore, the results must be seen within the context of the eleven participating psychiatric hospitals in Flanders.

 

Conclusions

Psychiatric inpatients are informed about their antidepressants through various pathways. Although the awareness is present of the importance of the individual approach and efforts are done to tailor information to the individual patient, improvement is still possible. In particular, attention should be given to the improvement of the amount and the quality of information provided; to search for a way to provide or to embed this information provision systematically in the care for patients; and education should be considered to enhance competencies needed to perform the provision of medication information according to a patient-focused approach.

 

Acknowledgements

We would like to thank all members of the staff of the 11 psychiatric hospitals and all participating patients for their kind cooperation. We would like to thank Annelies Buekers, Inne Depree, Ellen De Smet and Anne Vervoort who performed the interviews in eight hospitals. We would like to thank Veerle Foulon for her feedback on the topic guide and Valérie De Vriese for her assistance during the interviews.

 

Conflict of interest

The authors declare no conflict of interest.

 

References

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Received (first version): 23.10.12
Accepted: 01.04.13