MATERIALS AND METHODS

Study area: This study was performed at the University Clinic of Psychiatry and Psychotherapy/Department of Social Psychiatry, at Vienna General Hospital. The data was collected between October, 2016 and September, 2019.

Sample size: The study was performed on 100 patients (62.2% female, 35.1% male and 2.7% unspecified) and according to the ethical permit number 1809/2014 of the Medical University of Vienna.

Statistical analysis: A clinical assessment conducted at our clinic resulted in depression and anxiety disorder diagnosis according to the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10)²¹ On one hand, patients diagnosed with depression (57% of all patients) were suffering from light or moderate depression. On the other hand, the patients diagnosed with an anxiety disorder (66% of all patients) were mostly suffering from General Anxiety Disorder (GAD), social phobia, agoraphobia and Obsessive-Compulsive Disorder (OCD). Half of all participating patients were taking medications besides cognitive behavioral therapy. The most frequent drugs that have been used were sertraline (up to 100 mg/day) and escitalopram (up to 20 mg/day). The participants were recruited after receiving information about the study and giving their written consent. The participation included completion of the questionnaires prior to and after seven week-long treatments with CBT. The patients were interviewed using the following questionnaires (translated into German, of note, all participants were either native speakers or fluent in written and spoken German):

CDIS (Clinical decision-making involvement and satisfaction): Questionnaire about patient’s satisfaction regarding made decisions²². Illness perception questionnaire: Measures patients’ beliefs and feelings about their illnesses²³. It also measures patient personal control, self-efficacy (PSE) and self-management (PSM) (e.g. It is important for me to know all the side effects of my treatment, I should make my own decisions concerning I do everyday problems connected to my illness, I can determine whether my illness gets better or worse and I have the power to influence my illness, my actions will have no effect on the outcome of my illness. There is nothing which can help my condition, I have a clear picture or understanding of my condition my illness does (not) worry me.

Morisky medication adherence scale: Designed to estimate the risk of medication non-adherence²⁴.

In the t-test dropouts and completers were compared. Changes in quality of life-score, symptoms of depression, or symptoms of anxiety were collected and evaluated using regression analysis. Independent variables were social data, the severity of anxiety/depression at the beginning/admission, other psychiatric disorders and a few somatic symptoms.

Ethical approval
Institutional review board statements: This study was conducted in accordance with the Declaration of Helsinki. No experiments on human or animals were implemented. The work was authored according to Good Scientific Practice ethics in science and research guidelines of the Medical University of Vienna.

Statement of informed consent: Informed consent was obtained from the patient(s) for their anonymized information to be publish.

RESULTS

The study revealed that there was no significant association (p>0.05) between the way of clinical decision making, PSE, PSM and the characteristics age (rs = 0.01, p = 0.96), therapeutic relationship (rs = 0.21, p = 0.25) and the subjective cause of illness “y own behaviour” (rs = 0.01, p = 1.00).

Fig. 1:

Clinical decision making at the time of admission. Patients are divided based on their sex

Fig. 2:

Clinical decision making at the time of discharge

Of the sample, 66% have anxiety disorders and 57% have depressive disorders. Women tended to have more self-efficacy and sharing in clinical decision making (41% compared to 33% of men) or passive (24% compared to 17% of men) style of participation when admitted compared to men who chose half an active style of relationship (50% compared to 35% of women Fig. 1).

Female patients with AD (anxiety disorder) showed less PSE and PSM because they were more passive (25%) and shared decision-making (42%) participation style in clinical decision-making at admission, whereas female patients without AD showed better PSE and PSM because they were a predominantly active (53%) participation in decision making style. As shown in Fig. 2, at discharge, women tended to be more active (61% compared to 29% of men) (4% compared to 0% of men), compared to men. Of note, at discharge, patients with an AD showed a predominantly active (54%) participation style and patients without an AD showed a mutual (57%) participation style. The passive participation style was hardly present in patients with or without AD at discharge. No differences were made between patients with single (either DD or AD) or dual diagnosis.

Most patients without a DD (depressive disorder) showed better PSE and PSM because they were active in decision participation style at discharge (61%) compared to patients with a DD who predominantly (54%) showed a common participation style, there was no significant change since admission. The search for predictors showed that there was a tendency towards a mutual or active participation style at the time of admission among patients with a rather positive attitude towards medications. Half of our patients have been taking medications (62% sertraline and 38% escitalopram). There was also a tendency towards a common or active participation style at the time of admission and discharge if patients regarded “their personality” less strongly as the cause of the disease but other factors (genetics, environment). The tendency towards a common or active participation style in the clinical decision was further reported by patients with “greater satisfaction with the therapeutic relationship”.

Taken together, results showed that participation in integrated clinical behavior therapy (ICBT) had an effect of “empowerment”, an active and mutual style of participation was significantly more frequent at discharge than at admission. Women were more likely to show a passive and mutual participation style at admission, but almost exclusively an active or mutual participation style at discharge.

The opposite was for male participants, who predominantly reported an active participation style at the time of admission, but a majority mutual participation style at discharge. Patients with anxiety disorders, regardless of gender, reported a more passive and mutual participation style at the time of admission but after completing the cognitive behavioral therapy program, most of these patients actively participated in the clinical decision. Patients with DD showed a rather passive style at the time of admission but exhibited a shared style at the time of discharge.

DISCUSSION

According to the results, at the time of the discharge active and shared decision-making styles occurred on significantly more occasions in comparison to the time of admission. The study assumed that such an outcome is a consequence of increased confidence between patients and staff during the treatment period. Additionally, female patients are even more prone to active and shared decision making, than male patients. Such discrepancy between genders could be explained with the fact that staff at the healthcare setting were predominantly female. This could impact the patients decision-making preferences. This result was constant with Schuttner et al.¹⁸ arguing that many physicians consider patient values, health priorities and preferences influential during clinical decision-making. Also, healthcare sittings staff values can affect patient health priorities, goals and decision making before, during and aftercare planning¹⁶.

Integrated cognitive behavioral therapy (ICBT) with patient’s self-efficacy (PSE) and patient self-management (PSM) can be as effective as medication in treating anxiety and depression disorder and might aid in cases where medication alone is ineffective. Skills that patients acquire in ICBT are useful, practical and helpful strategies that can be incorporated into everyday life to help them cope better with future stressors and difficulties, even after the treatment ends. This was consistent with what Zineldin¹⁹ found that too much control by others on one’s own life, such as solely making decision for the patients can be a significant factor correlating with depression. Internal control over own personal life and health such as PSE, PSM and sharing the clinical decision making was a significant factor to ameliorate or control some of the negative symptoms of anxiety. Self-efficacy is also vital factors in ICBT. Some previous studies argue that patient quality of life could be improved by effective self-efficacy training and management^16,17,25,26. Thus, enhanced performance and patient self-management (PSM) and performance in personal life is a shared positive impact to adjust both depression (DEP) and anxiety (XITY)²⁷. His study shows that DEPXITY is associated with negative life quality. In contrast to the previous studies describing the correlation between CDM and race, emotions, nursing, etc. Our study is innovative and describes the phenomenon that was previously overlooked by scholars.

Limitations and future recommendation: Discomfort and nervousness could be felt at the beginning of CBT/ICBT, because it consists of facing the root of problems.

Staff at the healthcare setting were predominantly female. This could impact the patients’ decision-making preferences.

One of the main recommendations of this study is to provide patients with DADs with a patient self-efficacy training (PST) and knowledge to increase their ability to be active participant in the clinical decision-making process at both of the admission when possible and at the discharge. Having trained psychiatrists and the patient’s will to collaborate will help overcome the limitation of discomfort and nervousness, thus this type of therapy can be very successful and useful for further life.

CONCLUSION

Participating in an integrated clinical behavior therapy (ICBT) lead to “empowerment”, an active and mutual style of participation was significantly more frequent at discharge than at admission. Active style in making decisions is very important for the patients, because they have the feeling of influence on their quality of life. Besides medications, cognitive behavioral therapy has shown positive influence in patients with anxiety and/or depression disorder and their willing to participate in clinical decision making. We always have to be aware that people with mental illness are indeed among the most stigmatized, marginalized and vulnerable members of the society. According to current observation this type of therapy is generally effective not only for the healing process but also in clinical decision making. To benefit from the CBT program and ICBT patients need to collaborate with doctors and other medical staff. It is very important to encourage more medical students to start a career in psychiatry, as previous studies have shown lack of interest in the past years worldwide. Well trained psychiatrists are crucial part for the further developing of this program. The psychiatrists and all other medical staff working with patients suffering from depression and/or anxiety disorder should be confident about this program.

SIGNIFICANCE STATEMENT

This study was done to investigate the effects of Integrated cognitive behavioral therapy (ICBT) on clinical decision-making (CDM). Taken together, results showed that participation in integrated clinical behavior therapy (ICBT) had an effect of “empowerment”, an active and mutual style of participation was significantly more frequent at discharge than at admission. Besides medications, ICBT has shown a more positive influence on patients with anxiety and/or depression disorder and their willing to participate in clinical decision making. According to our ICBT type of therapy is comprehensive effective then CBT, not only for the healing process, but also in the case of clinical decision making.