Triadic shared decision making in emergency psychiatry: an explorative study

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C. Roselie van Asperen, A. I. Wierdsma, R. F. P. Winter, C. L. Mulder This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4467734/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 05 Mar, 2025 Read the published version in BMC Psychiatry → Version 1 posted 12 You are reading this latest preprint version Abstract Background This study aims to understand the complex triadic shared decision-making process in psychiatric emergency services, focusing on the choice between inpatient and outpatient care post-triage. It also identify scenarios where patient or significant others’ preferences override clinical judgment. Methods Conducted in the greater Rotterdam area, Netherlands, this explorative study surveyed patient and significant others’ preferences for voluntary or involuntary admission versus outpatient treatment, alongside professionals' clinical indications. Descriptive statistics were used to profile participants, and preference data were used to categorize groups, revealing patterns of agreement. Results Among 5680 assessments involving significant others, four groups emerged: agreement among the triad on in- or outpatient care (48.2%), patient disagrees (38.5%), significant others disagree (11.0%), and professionals disagree (2.3%). Professionals' recommendations were followed more frequently (57.0%) than patient (9.4%) or significant others’ preferences (11.0%). Conclusions We observed that consensus could often be reached among the members of the triad on inpatient or outpatient care following triage. Disagreements typically occurred when patients preferred outpatient care while others favoured inpatient care, or when significant others advocated for inpatient care while others preferred outpatient care. While professionals' recommendations held the most influence, they could be overridden in cases where valid criteria mandated involuntary care. triadic shared decision making emergency psychiatry acute mental health care inpatient care outpatient care Figures Figure 1 Figure 2 1. Background Shared decision-making (SDM) is a collaborative approach wherein healthcare professionals and patients engage in consensus-building to ascertain the treatment course and reach a treatment agreement ( 1 ). The aim of this approach, which regards the participation of individuals experiencing mental health conditions as an ethical imperative ( 2 ), is to improve treatment outcomes, for which is evidence ( 3 , 4 ). Involvement of family, friends, neighbours or other carers - i.e. 'significant others' – in triadic shared decision making, serves to establish SDM by providing supplementary information and comfort ( 5 ). Participation of significant others is defined as the acknowledgment of their contributions and the incorporation of their background information into the decision-making process ( 6 ). The transition from institution-based treatment to community-based care introduces shifts in the roles of significant others ( 7 ). Significant others take on responsibility in domains that may be inadequately addressed by healthcare professionals ( 8 ), potentially playing a pivotal role in managing various aspects of daily life, such as finances, housing, and social interactions ( 9 , 10 ). As patients receive care within their domestic environments, significant others often assume responsibility for the provision of support. However, these individuals frequently have feelings of blame for having caused mental health problems and are at higher risk of experiencing health-related, emotional, and financial burdens themselves ( 6 , 11 ). Consequently, the implementation of significant others' involvement in the care process can be challenging ( 12 , 13 ). The deployment of emergency psychiatry constitutes a particularly challenging setting for the participation of significant others in the SDM process. The focus on risk reduction and crisis management frequently leads in inpatient care, thereby complicating the engagement of significant others ( 14 ). One study found the will of significant others for inpatient care as the most important determinant in the decision between in- and outpatient care ( 15 ). In an observational study of a Crisis Resolution and Home Treatment Team (CRHT) in the Netherlands, the involvement of significant others was observed in two-thirds of cases, facilitated through the use of a structured motivational model ( 16 ). Notably, it was observed that treatment outcomes were similar, regardless of the in- or exclusion of significant others, even in instances where patients seem to be reluctant at first. A qualitative study described the needs of patients and significant others during psychiatric emergency services ( 17 ). Effective communication with both patients and significant others was found to be important to enhance cooperation. Healthcare professionals must be able at tailoring their approach. A conceptual review described the challenges professionals are confronted with in the course of involving significant others in psychiatric emergency services ( 18 ). The complexity of this involvement arises from the diverse expectations and needs of patients, significant others, and mental healthcare professionals, coupled with the delicate decision-making process regarding the choice between in- and outpatient care. The primary aim of this study is to disentangle the SDM process, primarily exploring the relative impact of the preferences of significant others, and the additional impact of patients and professionals, on the decision for in- or outpatient care after triage, taking the severity of the patients’ condition into account. As a secondary aim, this study describes the specific scenarios in which either patient or significant others’ preferences supersede the professionals’ clinical judgment. 2. Methods 2.1 Study design This was a retrospective and explorative study using data from the electronic health record (EHR) of the emergency psychiatric services. 2.2 Setting and participants This study was conducted within the greater Rotterdam area, situated in the southwestern region of the Netherlands. In this area, the emergency psychiatric services is responsible for the triage when confronted with individuals experiencing a mental health crisis. The primary sources of referrals to these services are family doctors, the police, general hospitals, and mental health services ( 18 , 19 ). A schematic representation of the referral process is provided in Fig. 1. The emergency psychiatric services are tasked with responding rapidly (at least within 24 hours) to sudden changes in patients' mental well-being or instances of behavioural loss of control, which may include suicidal crises. The initial triage consists of telephone consultation, and is performed by a trained mental healthcare professional to ascertain the necessity for a comprehensive face-to-face evaluation and crisis intervention. When after the telephone consultation it is decided that such a comprehensive evaluation and intervention is needed, a community psychiatric nurse and either a psychiatrist or a physician, the latter working under the supervision of a psychiatrist, go to visit the patient. The psychiatrist assumes responsibility for rendering a psychiatric diagnosis. The involvement of significant others is encouraged during this evaluation, and their perspectives and preferences are factored into the decision-making process. It is during this SDM process that the determination regarding in- or outpatient care is indicated. The study's participants comprised individuals aged 18 years and older who had undergone assessment by the emergency psychiatric services during the period spanning January 2015 to December 2019. A significant other had to be present during the assessment for the case to enter the study. 2.3 Data collection This study adhered to Dutch legislation, specifically the Medical Research Involving Human Subjects Acts (WMO) ( 20 ), which did not necessitate explicit approval from the regional medical ethical committee. Data were retrospectively gathered from the WebRAAP (Web-based Registration and Advisory system for Acute Psychiatry) EHR, designed for the documentation of the activities of the emergency psychiatric services ( 21 ). Prior to access by the authors, these data underwent complete anonymization, conducted by Myosotis IT services, a trusted data processing firm. The collected data encompassed various characteristics: patient characteristics such as age, gender, living situation and primary diagnosis, and the patient's as well as the significant others’ preference for either (in)voluntary admission to a psychiatric hospital, or outpatient treatment such as Intensive Home Treatment or other outpatient care services, and the professionals’ clinical indication for these services. In addition to this, the psychiatric nurse and medical doctor filled out the Severity of Psychiatric Illness (SPI) scale. The SPI is an observer rated scale, comprising of 14 dimensions, evaluating the severity of psychiatric illness, and employs a 4-point scale ranging from 0 (indicating no problems) to 3 (indicating severe problems) ( 22 , 23 ). The 14 dimensions assessed by the SPI scale encompass suicide potential, danger to others, severity of psychiatric symptoms, problems with self-care, substance abuse, medical complications, social complications, problems with professional functioning, problems with living conditions, problems with motivation for treatment, problems with compliance, problems with disease awareness, problems with family involvement, and persistence of problems. Due to the asymmetric distribution of the data, these variables were dichotomized into "no problem" and "small to severe problem." Note that in this study, the indicated level of care following the triage process was used for determining (dis)agreement within the SDM process, rather than the level of care that could actually be provided. The determination of the indicated level of care is determined mainly by clinical factors, because e.g. bed availability is not taken into account in this SDM process. Conversely, however, the level of care that could actually be provided was also determined by contextual factors such as bed availability( 18 ). This study will present the percentage of (dis)agreements within the triad on the indicated level of care to eliminate as much as possible the impact of contextual factors. 2.4 Data analysis Statistical analyses were performed using SPSS (Statistical Package for the Social Sciences) version 26.0 (SPSS Inc., Chicago,IL). Initially, descriptive statistics were computed to provide a profile of the study's participants. This analysis involved the examination of demographic variables, such as gender and age. Furthermore, the preferences for either in- or outpatient care stated by the parts of the triads were used to stratify groups, allowing for the exploration of distinct patterns of agreement among these groups. The SPI scale was used to assess the severity of psychiatric illness across 14 dimensions for the diverse subgroups. The SPI scale was used to describe its influence on care decisions, particularly in situations where patient or significant others’ preferences superseded the professionals’ preference based on clinical judgment. This analysis described the relationship between the SPI dimensions and the choice for in- or outpatient care. It sought to clarify the composition of cases and the severity of psychiatric symptoms to impact the selection of care options. To determine a difference between groups, exploration was conceptualized as different tests of the same hypothesis ( 24 ), and p-values were intentionally omitted in accordance with established methodology ( 25 ). 3. Results Over a period of 4 years (2016–2019), the emergency psychiatric services undertook 12,470 assessments of patients aged 18 and older. Significant others were present during almost half of these assessments (45.5%), leading to 5680 assessments meeting the inclusion criteria for this study. Table 1 shows the patient characteristics of the patients assessed by the psychiatric emergency services, divided into both groups. The groups exhibited comparability across most factors, with the primary distinguishing factor being the living situation. Notably, the presence of significant others was more prevalent among patients living with family in contrast to other living situations. Table 1 I Characteristics of patients assessed by the psychiatric emergency services Factors Significant others present Significant others not present Total Total n* 5680(45.5) 6790(54.5) 12470 (100) Age: mean (SD) 45.20(20.02) 41.85(16.32) 43.38 (18.17) Gender: n , female 2815(49.6) 2916(42.9) 5731 (46.0) Native language Dutch: n 3133(55.2) 3521(51.9) 6654 (53.4) Living situation Alone: n With family: n Institution: n Other/unknown: n Without residence: n 1556(27.4) 2776(48.9) 133(2.3) 1096(19.3) 119(2.1) 2616(38.5) 1588(23.4) 443(6.5) 1658(24.4) 485(7.2) 4172 (33.5) 4364 (35.0) 576 (4.6) 2754 (26.9) 604 (3.7) Primary diagnosis Depressive disorder: n Bipolar disorder: n Anxiety disorder: n Post traumatic stress syndrome: n Psychosocial problems: n Adjustment disorder: n Personality disorder: n Psychotic disorder: n Organic disorder: n Alcohol-related disorder: n Other substance-related disorder: n Other: n None/diagnoses deferred: n 981(17.3) 446(7.9) 206(3.6) 104(1.8) 105(1.8) 151(2.7) 379(6.7) 1820(32.0) 568(10.0) 253(4.5) 176(3.1) 443(7.8) 48(0.8) 1036(15.3) 351 (5.2) 203 (3.0) 208(3.1) 228(3.6) 291(4.3) 733(10.8) 2044(30.1) 260(3.8) 453(6.5) 320(4.7) 559(8.2) 114(1.7) 2017 (16.2) 797 (6.4) 409 (3.3) 312 (2.5) 333 (2.7) 442 (3.5) 1112 (8.9) 3864 (31.0) 828 (6.6) 696 (5.6) 496 (4.0) 1002 (8.0) 162 (1.3) *%, percentage of the total group. Figure 2 shows the distribution of the preferences of the patients and the indication of the professionals, divided by the wish of the significant others, whether they preferred in- or outpatient care. The figure consists of white boxes representing agreement and grey boxes representing disagreement in the triad. This distribution leads to 4 groups: agreement on in- or outpatient care, patient disagrees, significant others disagree or professionals disagree. Consensus is achieved in most cases when outpatient care is selected as the preferred level of care within the triad. Disagreements tend to emerge when a patient wants outpatient care while the remaining triad wants inpatient care (38.3%) or when significant others want inpatient care while the remaining triad wants outpatient care (10.5%). For additional details on the four groups, please refer to Table 2 . This table shows the distribution of the 4 groups on (dis)agreement with in- or outpatient care in the triad and the realization of in- or outpatient care. Table 2 I Distribution of (dis)agreement on the indication and realization of in- and outpatient care Group Total of 4882 (Dis)agreement with in- or outpatient care Realization of in- or outpatient care agreement on in- or outpatient care: n* 2351 (48.2) Inpatient care: 1189 (50.6) Outpatient care: 1162 (49.4) Outpatient care: 72 (6.1) Inpatient care: 1117 (93.9) Part involuntary: 174 (15.6) Outpatient care: 1160 (99.8) Inpatient care: 2 (0.2) Part involuntary: 1 (50.0) Patient disagrees with the other two components of the triad: n 1880 (38.5) Only the patient wants inpatient care: 9 (0.5) Only the patient wants outpatient care: 1871(99.5) Outpatient care: 9 (100) Inpatient care: 0 Outpatient care: 177 (9.5) Inpatient care: 1694 (90.5) Part involuntary: 1480 (87.4) Significant others disagree with the other two components of the triad: n 537 (11.0) Only the significant others want inpatient care: 514 (95.7) Only the significant others want outpatient care: 23 (4.3) Outpatient care: 465 (90.5) Inpatient care: 49 (9.5) Part involuntary: 35 (71.4) Outpatient care: 6 (26.1) Inpatient care: 17 (73.9) Part involuntary: 3 (17.6) Professionals disagree with the other two components of the triad: n 114 (2.3) Only the professionals indicate inpatient care: 67 (58.8) Only the professionals indicate outpatient care: 47 (41,2) Outpatient care: 34 (51.7) Inpatient care: 33 (49.3) Part involuntary: 25 (75.8) Outpatient care: 32 (68.1) Inpatient care: 15 (31.9) Part involuntary: 2(13.3) *%, percentage of the total group of patients. 3.1 Agreement on in- or outpatient care Agreement among the triad regarding in- or outpatient care is shown in the first and the last columns of Fig. 2 and was achieved in 2351 assessments, representing 48.2% of cases. When all three involved parties reached an agreement, the selected care level was nearly always implemented as decided. 3.2 Patient disagrees The patient held a different viewpoint from both the significant others and the professionals and stands alone advocating for either in- or outpatient care. The disagreement is shown in the second and second-to-last columns of Fig. 2, totalling 1880 assessments, amounting to 38.5% of cases. Predominantly, the patient favoured outpatient care (99.5%), while the other two components of the triad favoured inpatient care. In most of these cases (90.5%), inpatient care was realized despite the patient's preference for outpatient care. Disagreement on outpatient care in this group occurred scarcely (0.5%) and always resulted in outpatient care. In the group where the patient wants outpatient care and the other two components of the triad wanted inpatient care, we see the highest proportion of involuntary admissions (87.4%). Despite the disagreement, the patient's preference was granted in 9.4% of the assessments. This only occurred when the patient favoured outpatient care and the other two components of the triad favoured inpatient care. Exploring the particular subset where the patient's preference supersede both the significant others’ viewpoint and the professionals’ clinical assessment, the case mix characteristics quantified using the SPI showed few differences. For additional details on this group, see Table 3 . Within the group where the preference of the patient was granted, patients scored less on suicide potential (13.0% vs 19.9%) and less on danger to others (17.5% vs 34.2%) compared to the group where the preference of the patient was not granted. Table 3 I SPI of patients who disagree with the other two components of the triad Severity of psychiatric illness Preference of the patient was granted (outpatient) Preference of the patient was not granted (inpatient) Total N* 177 (9.4) 1703 (91.6) Suicide potential : n Danger to others : n Severity of psychiatric symptoms : n Problems with self-care : n Substance abuse : n Medical complications : n Social complications : n Problems with professional functioning : n Problems with living conditions : n Problems with motivation for treatment : n Problems with compliance : n Problems with disease awareness : n Problems with family involvement : n Persistence of problems : n 23 (13.0) 31 (17.5) 69 (39.0) 41 (23.2) 31 (17.5) 19 (10.7) 50 (28.2) 48 (27.1) 27 (15.3) 36 (20.3) 31 (17.5) 114 (64.4) 6 (3.4) 44 (24.9) 339 (19.9) 582 (34.2) 519 (30.5) 478 (28.1) 233 (13.7) 247 (14.5) 449 (26.4) 455 (26.7) 218 (12.8) 346 (20.3) 267 (15.7) 1187 (69.7) 27 (1.6) 324 (19) *%, percentage of the total group of patients. 3.3 Significant others disagree In 537 assessments, amounting to 11.0% of cases, the significant others held a different viewpoint from both the patient and the professionals and stand alone advocating for either in- or outpatient care. The disagreement is shown in the third and sixth columns of Fig. 2. Predominantly, the significant others favoured inpatient care (95.7%), while the other two components of the triad favoured outpatient care. In most of these cases (90.5%), outpatient care was realized despite the significant others’ preference. Disagreement on outpatient care in this group occurred scarcely (4.3%). Despite the disagreement, the significant others’ preference for inpatient care was granted in 9.5% of the assessments, the preference for outpatient care was granted in 26.1% of the assessments. This equates to a 11.0% allowance rate for the significant others’ preference in all assessments where the significant others express disagreement. Exploring the particular subset where the significant others’ preference supersede both the patient's viewpoint and the professionals’ clinical assessment, the case mix characteristics quantified using the SPI showed few differences. For additional details on this group, see Table 4 . Within the group where the preference of the significant others was granted, patients scored higher on suicide potential (21.8% vs 14.3%), higher on danger to others (20.0% vs 7.7%) and higher on problems with motivation (23.6% vs 12.7%) compared to the group where the preference of the significant others was not granted. Table 4 I SPI of patients from whom significant others disagree with the other two components of the triad Severity of psychiatric illness Preference of the significant others was granted Preference of the significant others was not granted Total N 55 (10.2) 482 (89.8) Suicide potential : n Danger to others : n Severity of psychiatric symptoms : n Problems with self-care : n Substance abuse : n Medical complications : n Social complications : n Problems with professional functioning : n Problems with living conditions : n Problems with motivation for treatment : n Problems with compliance : n Problems with disease awareness : n Problems with family involvement : n Persistence of problems : n 12 (21.8) 11 (20.0) 26 (47.3) 14 (25.5) 8 (14.5) 10 (18.2) 14 (25.5) 18 (32.7) 5 (9.1) 13 (23.6) 12 (21.8) 33 (60.0) 3 (5.5) 18 (32.7) 69 (14.3) 37 (7.7) 199 (41.3) 99 (20.5) 64 (13.3) 76 (15.8) 115 (23.9) 115 (23.9) 46 (9.5) 61 (12.7) 43 (8.9) 254 (52.7) 8 (1.7) 96 (19.9) *%, percentage of the total group of patients. 3.4 Professionals disagree Occasionally, the professionals held a different indication from both the patient and the significant others and stand alone advocating for either in- or outpatient care in 114 assessments, amounting to 2.3% of cases, with a nearly equal distribution between the indications for in- and outpatient care. This can be found in the fourth and fifth columns of Fig. 2. When only the professionals indicated inpatient care, the realization of both in- and outpatient care was almost equally distributed. However, in cases where only the professionals indicated outpatient care, outpatient care was realized in 67.4% of the assessments. Proportionally, the professionals’ indication was granted more frequently (57.0%) compared to the preference of both the significant others (11.0%) and the patient (9.4%). 4. Discussion Significant others were present in nearly half of all assessments conducted by emergency psychiatric services (45.5%). Our exploration of the triadic decision-making process during an assessment by the emergency psychiatric services revealed that consensus was reached in almost half of the assessments ( 48.2%). Nevertheless, even when unanimous agreement was achieved among the triad, the actual realization of the preferred form of care did not consistently align with the choice of the triad. Instances where outpatient care was realized instead of the previously chosen voluntary inpatient care could be attributed to the unavailability of hospital beds. Furthermore, despite the triad concurring on the necessity of inpatient care, 174 patients were admitted involuntarily. This discrepancy might be elucidated by varying expectations regarding the anticipated outcomes or the nature of the admitting hospital, leading to a contrast in the actual judicial status of the admissions despite agreement on the need for voluntary inpatient care. Disagreements on the indication of level of care tend to emerge when patients want outpatient care while the remaining part of the triad wants inpatient care (38.3%) or when significant others want inpatient care while the remaining triad wants outpatient care (10.5%). Patients tended to resist inpatient care when significant others requested it. This emphasizes the findings of a conceptual review, illustrating the diverse expectations and requirements among patients, significant others, and healthcare professionals in emergency psychiatric care ( 12 ). The patient holds the most vulnerable position within the triad, exhibiting the highest level of disagreement with the rest of the triad. The patient's preference was granted in 9.4% of the assessment when there was disagreement in the triad. In contrast, the significant others’ preference was granted in 11.0% of cases, while the professionals’ indication was granted in 57.0% of assessments when there was disagreement in the triad. These findings seemingly contradict an earlier study that identified the significant others' preference for inpatient care as the most important factor influencing the decision between in- and outpatient care ( 18 ). However, in this analysis the category “family or friends do not favour admission” included all cases with low problem severity and all cases where family or friends were not present. So, in many cases the variable “family or friends’ preference for admission” was not a predictor of inpatient care because the significant others were not present or opted for outpatient treatment in full agreement with the health care professionals. Our study's outcomes do align with a qualitative study examining the engagement of significant others of individuals diagnosed with serious mental illness (SMI) in SDM ( 26 ). This research revealed that the decision-making process is not democratic. While there is a growing recognition of the necessity to involve significant others, SDM has not been fully achieved or implemented in practice. The professionals hold the strongest position within the triad, which logically derives from their role in addressing crisis situations and possessing the expertise to navigate such circumstances. However, a review focusing on the involvement of significant others uncovered that they often perceived mental health professionals to have negative attitudes regarding their involvement ( 27 ). Consequently, it becomes important for professionals to recognize the significance of involving significant others and to handle this involvement with sensitivity, acknowledging the importance of the involvement in the overall care process. In certain scenarios, the professionals allow either the patient's or the significant others’ preferences to supersede their clinical judgment. This occurs when the patient expresses a preference for outpatient care against the wishes of the remaining triad. The professionals permit this preference to supersede their judgment if there is no immediate danger posed to the patient in terms of suicidal potential or danger to others. Similarly, the professionals allow for the preference of the significant others for inpatient care against the wishes of the rest of the triad in certain cases. This decision is made by the professionals when there is a presence of suicidal risk or danger to others, or when there are problems with motivation. An indication for outpatient care may be overridden if there are valid criteria for involuntary care. Previous research has highlighted that the integration of SDM practices is still in progress, resulting in a limited occurrence of wishes and needs of significant others ( 28 ). This observation aligns with the findings of this study, where the professionals are reticent in allowing the preferences of either the patient or the significant others, indicating a possible gap in meeting the desires of involved parties within the SDM process. Triadic SDM in emergency psychiatry is possible ( 16 ), a conclusion that is confirmed by the results of this study. However, this domain remains relatively underexplored ( 29 ) and the development of strategies are needed to address conflicts between the parts of the triad. A cross-sectional study examining the role of caregivers in psychiatric inpatient treatment ( 30 ) reported a low implementation of caregiver involvement, aligning with the findings of the present study. Earlier studies indicate that the degree of involvement of significant others is more difficult to implement than is commonly thought, and relies on the individual choices made by healthcare professionals ( 31 , 32 ). This understanding suggests that the frequency of significant others' presence during assessments could potentially increase if healthcare professionals prioritize on involving them in the assessments. 4.1 Limitations Our results must be interpreted with caution since our analyses relied on retrospective and routinely collected data. Consequently, specific data regarding the preferences of the individual components within the triad were unavailable, highlighting the need for future research to delve into these aspects in greater detail. The assessments were conducted by multiple professionals, a characteristic inherent in the structure of emergency psychiatric services, where various professionals perform their duties. This diversity in professionals involved could potentially result in varying outcomes for the same cases, posing a potential source of bias that might have influenced the results obtained. Schuster and colleagues ( 30 ) recommended a focus on interventions that prioritize involving caregivers in consultations. They proposed that a more comprehensive conceptualization of triadic SDM in mental health should be considered in a second step. The present study, aligning with these recommendations, also identifies a relatively low degree of involvement of significant others, thereby supporting this assertion. 5. Conclusions In our exploration of the triadic SDM process, we observed that consensus was achievable in almost half of the assessments. Disagreements commonly arose when the patient sought outpatient care while the rest of the triad preferred inpatient care, or when significant others advocated for inpatient care while the remaining triad favoured outpatient care. The professionals’ recommendation held the most influence in determining the outcome, yet this recommendation could be disregarded if there were valid criteria necessitating involuntary care. To effectively manage conflicts in the triad, strategies need to be devised to address conflicts between the parts of the triad. Declarations Ethics approval and consent to participate Prior to access by the authors, the data underwent complete anonymization, thereby allowing the waiver of consent. Consent for publication Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding The funding sources, namely the authors' institutions, had no involvement in the conduct of the research and the preparation of the article. Authors' contributions GA: Conceptualization, Methodology, Investigation, Writing- Original Draft, Visualization, Project administration. AW: Conceptualization, Methodology, Software, Formal analysis Validation, Data Curation, Writing - Review & Editing. 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Crisis: The Journal of Crisis Intervention and Suicide Prevention. 2020;.41(5):pp. Borst-Eilers E, Sorgdrager W. Wet medisch-wetenschappelijk onderzoek met mensen 1998 [updated 21-07-2021. Available from: https://wetten.overheid.nl/BWBR0009408/2021-07-01. ICT M. WebRAAP. Hèt EPD voor de spoedeisende psychiatrie 2021 [Available from: https://myosotis-ict.nl/home-webraap/. Lyons JS, Colletta J, Devens M, Finkel SI. Validity of the severity of psychiatric illness rating scale in a sample of inpatients on a psychogeriatric unit. International Psychogeriatrics. 1995;.7(3):pp. Lyons JS, Stutesman J, Neme J, Vessey JT, O'Mahoney MT, Camper J. Predicting psychiatric emergency admission and hospital outcome. Medical Care. 1997;.35(8):pp. Rubin M. Do p values lose their meaning in exploratory analyses? It depends how you define the familywise error rate. Review of General Psychology. 2017;21(3):269-75. Wagenmakers EJ, Wetzels R, Borsboom D, van der Maas HL, Kievit RA. An Agenda for Purely Confirmatory Research. Perspectives on Psychological Science : A Journal of the Association for Psychological Science. 2012;7(6):632-8. Bradley E, Green D. Involved, inputting or informing: "Shared" decision making in adult mental health care. Health Expectations. 2018;21(1):192-200. Doody O, Butler MP, Lyons R, Newman D. Families' experiences of involvement in care planning in mental health services: an integrative literature review. Journal of Psychiatric & Mental Health Nursing. 2017;24(6):412-30. Tambuyzer E, Van Audenhove C. Service user and family carer involvement in mental health care: divergent views. Community Mental Health Journal. 2013;49(6):675-85. Hamann J, Heres S. Why and How Family Caregivers Should Participate in Shared Decision Making in Mental Health. Psychiatric Services. 2019;70(5):418-21. Schuster F, Holzhuter F, Heres S, Hamann J. 'Triadic' shared decision making in mental health: Experiences and expectations of service users, caregivers and clinicians in Germany. Health Expectations. 2021;24(2):507-15. Schuster F, Holzhuter F, Heres S, Hamann J. Caregiver involvement in psychiatric inpatient treatment-A representative survey among triads of patients, caregivers and hospital psychiatrists. Epidemiology and Psychiatric Sciences Vol 29, 2020, ArtID e129.29. Kaselionyte J, Conneely M, Giacco D. "It's a matter of building bridges..." - feasibility of a carer involvement intervention for inpatients with severe mental illness. BMC Psychiatry. 2019;19(1):268. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 05 Mar, 2025 Read the published version in BMC Psychiatry → Version 1 posted Editorial decision: Revision requested 08 Nov, 2024 Reviews received at journal 09 Sep, 2024 Reviews received at journal 09 Sep, 2024 Reviews received at journal 04 Sep, 2024 Reviewers agreed at journal 04 Sep, 2024 Reviewers agreed at journal 03 Sep, 2024 Reviewers agreed at journal 03 Sep, 2024 Reviewers invited by journal 03 Sep, 2024 Editor invited by journal 02 Jul, 2024 Editor assigned by journal 28 Jun, 2024 Submission checks completed at journal 28 Jun, 2024 First submitted to journal 23 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4467734","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":311971805,"identity":"9f11ff80-47a6-4000-b888-2973e81346ae","order_by":0,"name":"G. C. Roselie van Asperen","email":"data:image/png;base64,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","orcid":"","institution":"Parnassia Psychiatric Institute","correspondingAuthor":true,"prefix":"","firstName":"G.","middleName":"C. Roselie van","lastName":"Asperen","suffix":""},{"id":311971806,"identity":"3becae39-0600-4183-8647-4886fabc9044","order_by":1,"name":"A. I. Wierdsma","email":"","orcid":"","institution":"Erasmus University Medical Center","correspondingAuthor":false,"prefix":"","firstName":"A.","middleName":"I.","lastName":"Wierdsma","suffix":""},{"id":311971807,"identity":"4b991d0a-41c2-4c91-86dc-37fef920c79c","order_by":2,"name":"R. F. P. Winter","email":"","orcid":"","institution":"Mental Health Institute Rivierduinen","correspondingAuthor":false,"prefix":"","firstName":"R.","middleName":"F. P.","lastName":"Winter","suffix":""},{"id":311971808,"identity":"b30d4927-34db-4da9-9183-32ecee5eb869","order_by":3,"name":"C. L. Mulder","email":"","orcid":"","institution":"Parnassia Psychiatric Institute","correspondingAuthor":false,"prefix":"","firstName":"C.","middleName":"L.","lastName":"Mulder","suffix":""}],"badges":[],"createdAt":"2024-05-23 15:06:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4467734/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4467734/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12888-025-06640-7","type":"published","date":"2025-03-05T15:58:21+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":58222798,"identity":"893c94a6-b78a-4508-8768-7ea4060a685f","added_by":"auto","created_at":"2024-06-12 17:08:42","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":32643,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"Figure1ReferralprocessoftheemergencypsychiatricservicesinRotterdam.png","url":"https://assets-eu.researchsquare.com/files/rs-4467734/v1/1f78fe956828b84fd8f92471.png"},{"id":58222800,"identity":"cb4574bc-b934-4573-940b-20f7de55360a","added_by":"auto","created_at":"2024-06-12 17:08:42","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":49698,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"Figure2Thedistributionofthe4groupsondisagreementinthetriad.png","url":"https://assets-eu.researchsquare.com/files/rs-4467734/v1/5a7f9749cbccc92a03661867.png"},{"id":78190694,"identity":"24227889-a78c-4820-a8aa-3d1fb1b56bb9","added_by":"auto","created_at":"2025-03-10 19:50:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1254743,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4467734/v1/c2598f71-94d8-450f-a15b-2d6056cff79e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Triadic shared decision making in emergency psychiatry: an explorative study","fulltext":[{"header":"1. Background","content":"\u003cp\u003eShared decision-making (SDM) is a collaborative approach wherein healthcare professionals and patients engage in consensus-building to ascertain the treatment course and reach a treatment agreement (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The aim of this approach, which regards the participation of individuals experiencing mental health conditions as an ethical imperative (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), is to improve treatment outcomes, for which is evidence (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Involvement of family, friends, neighbours or other carers - i.e. 'significant others' \u0026ndash; in triadic shared decision making, serves to establish SDM by providing supplementary information and comfort (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Participation of significant others is defined as the acknowledgment of their contributions and the incorporation of their background information into the decision-making process (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe transition from institution-based treatment to community-based care introduces shifts in the roles of significant others (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Significant others take on responsibility in domains that may be inadequately addressed by healthcare professionals (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), potentially playing a pivotal role in managing various aspects of daily life, such as finances, housing, and social interactions (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). As patients receive care within their domestic environments, significant others often assume responsibility for the provision of support. However, these individuals frequently have feelings of blame for having caused mental health problems and are at higher risk of experiencing health-related, emotional, and financial burdens themselves (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Consequently, the implementation of significant others' involvement in the care process can be challenging (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe deployment of emergency psychiatry constitutes a particularly challenging setting for the participation of significant others in the SDM process. The focus on risk reduction and crisis management frequently leads in inpatient care, thereby complicating the engagement of significant others (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). One study found the will of significant others for inpatient care as the most important determinant in the decision between in- and outpatient care (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). In an observational study of a Crisis Resolution and Home Treatment Team (CRHT) in the Netherlands, the involvement of significant others was observed in two-thirds of cases, facilitated through the use of a structured motivational model (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Notably, it was observed that treatment outcomes were similar, regardless of the in- or exclusion of significant others, even in instances where patients seem to be reluctant at first. A qualitative study described the needs of patients and significant others during psychiatric emergency services (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Effective communication with both patients and significant others was found to be important to enhance cooperation. Healthcare professionals must be able at tailoring their approach. A conceptual review described the challenges professionals are confronted with in the course of involving significant others in psychiatric emergency services (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). The complexity of this involvement arises from the diverse expectations and needs of patients, significant others, and mental healthcare professionals, coupled with the delicate decision-making process regarding the choice between in- and outpatient care.\u003c/p\u003e \u003cp\u003eThe primary aim of this study is to disentangle the SDM process, primarily exploring the relative impact of the preferences of significant others, and the additional impact of patients and professionals, on the decision for in- or outpatient care after triage, taking the severity of the patients\u0026rsquo; condition into account. As a secondary aim, this study describes the specific scenarios in which either patient or significant others\u0026rsquo; preferences supersede the professionals\u0026rsquo; clinical judgment.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study design\u003c/h2\u003e \u003cp\u003eThis was a retrospective and explorative study using data from the electronic health record (EHR) of the emergency psychiatric services.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Setting and participants\u003c/h2\u003e \u003cp\u003eThis study was conducted within the greater Rotterdam area, situated in the southwestern region of the Netherlands. In this area, the emergency psychiatric services is responsible for the triage when confronted with individuals experiencing a mental health crisis. The primary sources of referrals to these services are family doctors, the police, general hospitals, and mental health services (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). A schematic representation of the referral process is provided in Fig.\u0026nbsp;1. The emergency psychiatric services are tasked with responding rapidly (at least within 24 hours) to sudden changes in patients' mental well-being or instances of behavioural loss of control, which may include suicidal crises. The initial triage consists of telephone consultation, and is performed by a trained mental healthcare professional to ascertain the necessity for a comprehensive face-to-face evaluation and crisis intervention. When after the telephone consultation it is decided that such a comprehensive evaluation and intervention is needed, a community psychiatric nurse and either a psychiatrist or a physician, the latter working under the supervision of a psychiatrist, go to visit the patient. The psychiatrist assumes responsibility for rendering a psychiatric diagnosis. The involvement of significant others is encouraged during this evaluation, and their perspectives and preferences are factored into the decision-making process. It is during this SDM process that the determination regarding in- or outpatient care is indicated.\u003c/p\u003e \u003cp\u003eThe study's participants comprised individuals aged 18 years and older who had undergone assessment by the emergency psychiatric services during the period spanning January 2015 to December 2019. A significant other had to be present during the assessment for the case to enter the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Data collection\u003c/h2\u003e \u003cp\u003eThis study adhered to Dutch legislation, specifically the Medical Research Involving Human Subjects Acts (WMO) (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), which did not necessitate explicit approval from the regional medical ethical committee. Data were retrospectively gathered from the WebRAAP (Web-based Registration and Advisory system for Acute Psychiatry) EHR, designed for the documentation of the activities of the emergency psychiatric services (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Prior to access by the authors, these data underwent complete anonymization, conducted by Myosotis IT services, a trusted data processing firm. The collected data encompassed various characteristics: patient characteristics such as age, gender, living situation and primary diagnosis, and the patient's as well as the significant others\u0026rsquo; preference for either (in)voluntary admission to a psychiatric hospital, or outpatient treatment such as Intensive Home Treatment or other outpatient care services, and the professionals\u0026rsquo; clinical indication for these services. In addition to this, the psychiatric nurse and medical doctor filled out the Severity of Psychiatric Illness (SPI) scale. The SPI is an observer rated scale, comprising of 14 dimensions, evaluating the severity of psychiatric illness, and employs a 4-point scale ranging from 0 (indicating no problems) to 3 (indicating severe problems) (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). The 14 dimensions assessed by the SPI scale encompass suicide potential, danger to others, severity of psychiatric symptoms, problems with self-care, substance abuse, medical complications, social complications, problems with professional functioning, problems with living conditions, problems with motivation for treatment, problems with compliance, problems with disease awareness, problems with family involvement, and persistence of problems. Due to the asymmetric distribution of the data, these variables were dichotomized into \"no problem\" and \"small to severe problem.\"\u003c/p\u003e \u003cp\u003eNote that in this study, the indicated level of care following the triage process was used for determining (dis)agreement within the SDM process, rather than the level of care that could actually be provided. The determination of the indicated level of care is determined mainly by clinical factors, because e.g. bed availability is not taken into account in this SDM process. Conversely, however, the level of care that could actually be provided was also determined by contextual factors such as bed availability(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). This study will present the percentage of (dis)agreements within the triad on the indicated level of care to eliminate as much as possible the impact of contextual factors.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Data analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed using SPSS (Statistical Package for the Social Sciences) version 26.0 (SPSS Inc., Chicago,IL). Initially, descriptive statistics were computed to provide a profile of the study's participants. This analysis involved the examination of demographic variables, such as gender and age. Furthermore, the preferences for either in- or outpatient care stated by the parts of the triads were used to stratify groups, allowing for the exploration of distinct patterns of agreement among these groups. The SPI scale was used to assess the severity of psychiatric illness across 14 dimensions for the diverse subgroups.\u003c/p\u003e \u003cp\u003eThe SPI scale was used to describe its influence on care decisions, particularly in situations where patient or significant others\u0026rsquo; preferences superseded the professionals\u0026rsquo; preference based on clinical judgment. This analysis described the relationship between the SPI dimensions and the choice for in- or outpatient care. It sought to clarify the composition of cases and the severity of psychiatric symptoms to impact the selection of care options. To determine a difference between groups, exploration was conceptualized as different tests of the same hypothesis (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), and p-values were intentionally omitted in accordance with established methodology (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eOver a period of 4 years (2016\u0026ndash;2019), the emergency psychiatric services undertook 12,470 assessments of patients aged 18 and older. Significant others were present during almost half of these assessments (45.5%), leading to 5680 assessments meeting the inclusion criteria for this study. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the patient characteristics of the patients assessed by the psychiatric emergency services, divided into both groups. The groups exhibited comparability across most factors, with the primary distinguishing factor being the living situation. Notably, the presence of significant others was more prevalent among patients living with family in contrast to other living situations.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eI Characteristics of patients assessed by the psychiatric emergency services\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSignificant others present\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSignificant others\u003c/p\u003e \u003cp\u003enot present\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal \u003cem\u003en*\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5680(45.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6790(54.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12470 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge: mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45.20(20.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41.85(16.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43.38 (18.17)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender: \u003cem\u003en\u003c/em\u003e, female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2815(49.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2916(42.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5731 (46.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNative language Dutch: \u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3133(55.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3521(51.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6654 (53.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiving situation\u003c/p\u003e \u003cp\u003eAlone: \u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003cp\u003eWith family: \u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003cp\u003eInstitution: \u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003cp\u003eOther/unknown: \u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003cp\u003eWithout residence: \u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1556(27.4)\u003c/p\u003e \u003cp\u003e2776(48.9)\u003c/p\u003e \u003cp\u003e133(2.3)\u003c/p\u003e \u003cp\u003e1096(19.3)\u003c/p\u003e \u003cp\u003e119(2.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2616(38.5)\u003c/p\u003e \u003cp\u003e1588(23.4)\u003c/p\u003e \u003cp\u003e443(6.5)\u003c/p\u003e \u003cp\u003e1658(24.4)\u003c/p\u003e \u003cp\u003e485(7.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4172 (33.5)\u003c/p\u003e \u003cp\u003e4364 (35.0)\u003c/p\u003e \u003cp\u003e576 (4.6)\u003c/p\u003e \u003cp\u003e2754 (26.9)\u003c/p\u003e \u003cp\u003e604 (3.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary diagnosis\u003c/p\u003e \u003cp\u003eDepressive disorder: \u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003cp\u003eBipolar disorder: \u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003cp\u003eAnxiety disorder: \u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003cp\u003ePost traumatic stress syndrome: \u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003cp\u003ePsychosocial problems: \u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003cp\u003eAdjustment disorder: \u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003cp\u003ePersonality disorder: \u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003cp\u003ePsychotic disorder: \u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003cp\u003eOrganic disorder: \u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003cp\u003eAlcohol-related disorder: \u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003cp\u003eOther substance-related disorder: \u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003cp\u003eOther: \u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003cp\u003eNone/diagnoses deferred: \u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e981(17.3)\u003c/p\u003e \u003cp\u003e446(7.9)\u003c/p\u003e \u003cp\u003e206(3.6)\u003c/p\u003e \u003cp\u003e104(1.8)\u003c/p\u003e \u003cp\u003e105(1.8)\u003c/p\u003e \u003cp\u003e151(2.7)\u003c/p\u003e \u003cp\u003e379(6.7)\u003c/p\u003e \u003cp\u003e1820(32.0)\u003c/p\u003e \u003cp\u003e568(10.0)\u003c/p\u003e \u003cp\u003e253(4.5)\u003c/p\u003e \u003cp\u003e176(3.1)\u003c/p\u003e \u003cp\u003e443(7.8)\u003c/p\u003e \u003cp\u003e48(0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1036(15.3)\u003c/p\u003e \u003cp\u003e351 (5.2)\u003c/p\u003e \u003cp\u003e203 (3.0)\u003c/p\u003e \u003cp\u003e208(3.1)\u003c/p\u003e \u003cp\u003e228(3.6)\u003c/p\u003e \u003cp\u003e291(4.3)\u003c/p\u003e \u003cp\u003e733(10.8)\u003c/p\u003e \u003cp\u003e2044(30.1)\u003c/p\u003e \u003cp\u003e260(3.8)\u003c/p\u003e \u003cp\u003e453(6.5)\u003c/p\u003e \u003cp\u003e320(4.7)\u003c/p\u003e \u003cp\u003e559(8.2)\u003c/p\u003e \u003cp\u003e114(1.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2017 (16.2)\u003c/p\u003e \u003cp\u003e797 (6.4)\u003c/p\u003e \u003cp\u003e409 (3.3)\u003c/p\u003e \u003cp\u003e312 (2.5)\u003c/p\u003e \u003cp\u003e333 (2.7)\u003c/p\u003e \u003cp\u003e442 (3.5)\u003c/p\u003e \u003cp\u003e1112 (8.9)\u003c/p\u003e \u003cp\u003e3864 (31.0)\u003c/p\u003e \u003cp\u003e828 (6.6)\u003c/p\u003e \u003cp\u003e696 (5.6)\u003c/p\u003e \u003cp\u003e496 (4.0)\u003c/p\u003e \u003cp\u003e1002 (8.0)\u003c/p\u003e \u003cp\u003e162 (1.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e*%, percentage of the total group.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFigure 2 shows the distribution of the preferences of the patients and the indication of the professionals, divided by the wish of the significant others, whether they preferred in- or outpatient care. The figure consists of white boxes representing agreement and grey boxes representing disagreement in the triad. This distribution leads to 4 groups: agreement on in- or outpatient care, patient disagrees, significant others disagree or professionals disagree. Consensus is achieved in most cases when outpatient care is selected as the preferred level of care within the triad. Disagreements tend to emerge when a patient wants outpatient care while the remaining triad wants inpatient care (38.3%) or when significant others want inpatient care while the remaining triad wants outpatient care (10.5%).\u003c/p\u003e \u003cp\u003eFor additional details on the four groups, please refer to Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. This table shows the distribution of the 4 groups on (dis)agreement with in- or outpatient care in the triad and the realization of in- or outpatient care.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eI Distribution of (dis)agreement on the indication and realization of in- and outpatient care\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003eof 4882\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(Dis)agreement with \u003c/p\u003e \u003cp\u003ein- or outpatient care\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRealization of\u003c/p\u003e \u003cp\u003ein- or outpatient care\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eagreement on in- or outpatient care: \u003cem\u003en*\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2351 (48.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInpatient care:\u003c/p\u003e \u003cp\u003e1189 (50.6)\u003c/p\u003e \u003cp\u003eOutpatient care:\u003c/p\u003e \u003cp\u003e1162 (49.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOutpatient care: 72 (6.1)\u003c/p\u003e \u003cp\u003eInpatient care: 1117 (93.9)\u003c/p\u003e \u003cp\u003e\u003cem\u003ePart involuntary: 174 (15.6)\u003c/em\u003e\u003c/p\u003e \u003cp\u003eOutpatient care: 1160 (99.8)\u003c/p\u003e \u003cp\u003eInpatient care: 2 (0.2)\u003c/p\u003e \u003cp\u003e\u003cem\u003ePart involuntary: 1 (50.0)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient disagrees with the other two components of the triad: \u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1880 (38.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOnly the patient wants\u003c/p\u003e \u003cp\u003einpatient care:\u003c/p\u003e \u003cp\u003e9 (0.5)\u003c/p\u003e \u003cp\u003eOnly the patient wants\u003c/p\u003e \u003cp\u003eoutpatient care:\u003c/p\u003e \u003cp\u003e1871(99.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOutpatient care: 9 (100)\u003c/p\u003e \u003cp\u003eInpatient care: 0\u003c/p\u003e \u003cp\u003eOutpatient care: 177 (9.5)\u003c/p\u003e \u003cp\u003eInpatient care: 1694 (90.5)\u003c/p\u003e \u003cp\u003e\u003cem\u003ePart involuntary: 1480 (87.4)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSignificant others disagree with the other two components of the triad: \u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e537 (11.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOnly the significant others want inpatient care:\u003c/p\u003e \u003cp\u003e514 (95.7)\u003c/p\u003e \u003cp\u003eOnly the significant others want outpatient care:\u003c/p\u003e \u003cp\u003e23 (4.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOutpatient care: 465 (90.5)\u003c/p\u003e \u003cp\u003eInpatient care: 49 (9.5)\u003c/p\u003e \u003cp\u003e\u003cem\u003ePart involuntary: 35 (71.4)\u003c/em\u003e\u003c/p\u003e \u003cp\u003eOutpatient care: 6 (26.1)\u003c/p\u003e \u003cp\u003eInpatient care: 17 (73.9)\u003c/p\u003e \u003cp\u003e\u003cem\u003ePart involuntary: 3 (17.6)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProfessionals disagree with the other two components of the triad: \u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e114 (2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOnly the professionals indicate inpatient care:\u003c/p\u003e \u003cp\u003e67 (58.8)\u003c/p\u003e \u003cp\u003eOnly the professionals indicate outpatient care:\u003c/p\u003e \u003cp\u003e47 (41,2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOutpatient care: 34 (51.7)\u003c/p\u003e \u003cp\u003eInpatient care: 33 (49.3)\u003c/p\u003e \u003cp\u003e\u003cem\u003ePart involuntary: 25 (75.8)\u003c/em\u003e\u003c/p\u003e \u003cp\u003eOutpatient care: 32 (68.1)\u003c/p\u003e \u003cp\u003eInpatient care: 15 (31.9)\u003c/p\u003e \u003cp\u003e\u003cem\u003ePart involuntary: 2(13.3)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e*%, percentage of the total group of patients.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Agreement on in- or outpatient care\u003c/h2\u003e \u003cp\u003eAgreement among the triad regarding in- or outpatient care is shown in the first and the last columns of Fig.\u0026nbsp;2 and was achieved in 2351 assessments, representing 48.2% of cases. When all three involved parties reached an agreement, the selected care level was nearly always implemented as decided.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Patient disagrees\u003c/h2\u003e \u003cp\u003eThe patient held a different viewpoint from both the significant others and the professionals and stands alone advocating for either in- or outpatient care. The disagreement is shown in the second and second-to-last columns of Fig.\u0026nbsp;2, totalling 1880 assessments, amounting to 38.5% of cases. Predominantly, the patient favoured outpatient care (99.5%), while the other two components of the triad favoured inpatient care. In most of these cases (90.5%), inpatient care was realized despite the patient's preference for outpatient care. Disagreement on outpatient care in this group occurred scarcely (0.5%) and always resulted in outpatient care.\u003c/p\u003e \u003cp\u003eIn the group where the patient wants outpatient care and the other two components of the triad wanted inpatient care, we see the highest proportion of involuntary admissions (87.4%).\u003c/p\u003e \u003cp\u003eDespite the disagreement, the patient's preference was granted in 9.4% of the assessments. This only occurred when the patient favoured outpatient care and the other two components of the triad favoured inpatient care.\u003c/p\u003e \u003cp\u003eExploring the particular subset where the patient's preference supersede both the significant others\u0026rsquo; viewpoint and the professionals\u0026rsquo; clinical assessment, the case mix characteristics quantified using the SPI showed few differences. For additional details on this group, see Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Within the group where the preference of the patient was granted, patients scored less on suicide potential (13.0% vs 19.9%) and less on danger to others (17.5% vs 34.2%) compared to the group where the preference of the patient was not granted.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3 I SPI of patients who disagree with the other two components of the triad\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"649\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.83204930662558%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeverity of psychiatric illness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.58397534668721%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreference of the patient\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ewas granted (outpatient)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.58397534668721%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreference of the patient\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ewas not granted (inpatient)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.83204930662558%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal N*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.58397534668721%\" valign=\"top\"\u003e\n \u003cp\u003e177 \u0026nbsp;(9.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.58397534668721%\" valign=\"top\"\u003e\n \u003cp\u003e1703 \u0026nbsp; \u0026nbsp; (91.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.83204930662558%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuicide potential\u003c/strong\u003e: \u003cem\u003en\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDanger to others\u003c/strong\u003e: \u003cem\u003en\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSeverity of psychiatric symptoms\u003c/strong\u003e: \u003cem\u003en\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eProblems with self-care\u003c/strong\u003e: \u003cem\u003en\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSubstance abuse\u003c/strong\u003e: \u003cem\u003en\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMedical complications\u003c/strong\u003e: \u003cem\u003en\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSocial complications\u003c/strong\u003e: \u003cem\u003en\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eProblems with professional functioning\u003c/strong\u003e: \u003cem\u003en\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eProblems with living conditions\u003c/strong\u003e: \u003cem\u003en\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eProblems with motivation for treatment\u003c/strong\u003e: \u003cem\u003en\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eProblems with compliance\u003c/strong\u003e: \u003cem\u003en\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eProblems with disease awareness\u003c/strong\u003e: \u003cem\u003en\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eProblems with family involvement\u003c/strong\u003e: \u003cem\u003en\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePersistence of problems\u003c/strong\u003e: \u003cem\u003en\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.58397534668721%\" valign=\"top\"\u003e\n \u003cp\u003e23 \u0026nbsp; (13.0)\u003c/p\u003e\n \u003cp\u003e31 \u0026nbsp; (17.5)\u003c/p\u003e\n \u003cp\u003e69 \u0026nbsp; (39.0)\u003c/p\u003e\n \u003cp\u003e41 \u0026nbsp; (23.2)\u003c/p\u003e\n \u003cp\u003e31 \u0026nbsp; (17.5)\u003c/p\u003e\n \u003cp\u003e19 \u0026nbsp; (10.7)\u003c/p\u003e\n \u003cp\u003e50 \u0026nbsp; (28.2)\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e48 \u0026nbsp; (27.1)\u003c/p\u003e\n \u003cp\u003e27 \u0026nbsp; (15.3)\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e36 \u0026nbsp; (20.3)\u003c/p\u003e\n \u003cp\u003e31 \u0026nbsp; (17.5)\u003c/p\u003e\n \u003cp\u003e114 \u0026nbsp;(64.4)\u003c/p\u003e\n \u003cp\u003e6 \u0026nbsp; \u0026nbsp; (3.4)\u003c/p\u003e\n \u003cp\u003e44 \u0026nbsp; (24.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.58397534668721%\" valign=\"top\"\u003e\n \u003cp\u003e339 \u0026nbsp;(19.9)\u003c/p\u003e\n \u003cp\u003e582 \u0026nbsp;(34.2)\u003c/p\u003e\n \u003cp\u003e519 \u0026nbsp;(30.5)\u003c/p\u003e\n \u003cp\u003e478 \u0026nbsp;(28.1)\u003c/p\u003e\n \u003cp\u003e233 \u0026nbsp;(13.7)\u003c/p\u003e\n \u003cp\u003e247 \u0026nbsp;(14.5)\u003c/p\u003e\n \u003cp\u003e449 \u0026nbsp;(26.4)\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e455 \u0026nbsp;(26.7)\u003c/p\u003e\n \u003cp\u003e218 \u0026nbsp;(12.8)\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e346 \u0026nbsp;(20.3)\u003c/p\u003e\n \u003cp\u003e267 \u0026nbsp;(15.7)\u003c/p\u003e\n \u003cp\u003e1187 \u0026nbsp; \u0026nbsp; (69.7)\u003c/p\u003e\n \u003cp\u003e27 \u0026nbsp; (1.6)\u003c/p\u003e\n \u003cp\u003e324 \u0026nbsp;(19)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*%, percentage of the total group of patients.\u003c/p\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Significant others disagree\u003c/h2\u003e \u003cp\u003eIn 537 assessments, amounting to 11.0% of cases, the significant others held a different viewpoint from both the patient and the professionals and stand alone advocating for either in- or outpatient care. The disagreement is shown in the third and sixth columns of Fig.\u0026nbsp;2. Predominantly, the significant others favoured inpatient care (95.7%), while the other two components of the triad favoured outpatient care. In most of these cases (90.5%), outpatient care was realized despite the significant others\u0026rsquo; preference. Disagreement on outpatient care in this group occurred scarcely (4.3%).\u003c/p\u003e \u003cp\u003eDespite the disagreement, the significant others\u0026rsquo; preference for inpatient care was granted in 9.5% of the assessments, the preference for outpatient care was granted in 26.1% of the assessments. This equates to a 11.0% allowance rate for the significant others\u0026rsquo; preference in all assessments where the significant others express disagreement.\u003c/p\u003e \u003cp\u003eExploring the particular subset where the significant others\u0026rsquo; preference supersede both the patient's viewpoint and the professionals\u0026rsquo; clinical assessment, the case mix characteristics quantified using the SPI showed few differences. For additional details on this group, see Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Within the group where the preference of the significant others was granted, patients scored higher on suicide potential (21.8% vs 14.3%), higher on danger to others (20.0% vs 7.7%) and higher on problems with motivation (23.6% vs 12.7%) compared to the group where the preference of the significant others was not granted.\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eTable 4 I SPI of patients from whom significant others disagree with the other two components of the triad\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"640\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.906103286384976%\" valign=\"top\" style=\"width: 43.5156%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeverity of psychiatric illness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.046948356807512%\" valign=\"top\" style=\"width: 26.3282%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreference of the significant others was granted\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.046948356807512%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreference of the significant others was not granted\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.906103286384976%\" valign=\"top\" style=\"width: 43.5156%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal N\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.046948356807512%\" valign=\"top\" style=\"width: 26.3282%;\"\u003e\n \u003cp\u003e55 \u0026nbsp; (10.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.046948356807512%\" valign=\"top\"\u003e\n \u003cp\u003e482 \u0026nbsp;(89.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.906103286384976%\" valign=\"top\" style=\"width: 43.5156%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuicide potential\u003c/strong\u003e: \u003cem\u003en\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDanger to others\u003c/strong\u003e: \u003cem\u003en\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSeverity of psychiatric symptoms\u003c/strong\u003e: \u003cem\u003en\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eProblems with self-care\u003c/strong\u003e: \u003cem\u003en\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSubstance abuse\u003c/strong\u003e: \u003cem\u003en\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMedical complications\u003c/strong\u003e: \u003cem\u003en\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSocial complications\u003c/strong\u003e: \u003cem\u003en\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eProblems with professional functioning\u003c/strong\u003e: \u003cem\u003en\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eProblems with living conditions\u003c/strong\u003e: \u003cem\u003en\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eProblems with motivation for treatment\u003c/strong\u003e: \u003cem\u003en\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eProblems with compliance\u003c/strong\u003e: \u003cem\u003en\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eProblems with disease awareness\u003c/strong\u003e: \u003cem\u003en\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eProblems with family involvement\u003c/strong\u003e: \u003cem\u003en\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePersistence of problems\u003c/strong\u003e: \u003cem\u003en\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.046948356807512%\" valign=\"top\" style=\"width: 26.3282%;\"\u003e\n \u003cp\u003e12 \u0026nbsp; (21.8)\u003c/p\u003e\n \u003cp\u003e11 \u0026nbsp; (20.0)\u003c/p\u003e\n \u003cp\u003e26 \u0026nbsp; (47.3)\u003c/p\u003e\n \u003cp\u003e14 \u0026nbsp; (25.5)\u003c/p\u003e\n \u003cp\u003e8 \u0026nbsp; \u0026nbsp; (14.5)\u003c/p\u003e\n \u003cp\u003e10 \u0026nbsp; (18.2)\u003c/p\u003e\n \u003cp\u003e14 \u0026nbsp; (25.5)\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e18 \u0026nbsp; (32.7)\u003c/p\u003e\n \u003cp\u003e5 \u0026nbsp; \u0026nbsp; (9.1)\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e13 \u0026nbsp; (23.6)\u003c/p\u003e\n \u003cp\u003e12 \u0026nbsp; (21.8)\u003c/p\u003e\n \u003cp\u003e33 \u0026nbsp; (60.0)\u003c/p\u003e\n \u003cp\u003e3 \u0026nbsp; \u0026nbsp; (5.5)\u003c/p\u003e\n \u003cp\u003e18 \u0026nbsp; (32.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.046948356807512%\" valign=\"top\"\u003e\n \u003cp\u003e69 \u0026nbsp; (14.3)\u003c/p\u003e\n \u003cp\u003e37 \u0026nbsp; (7.7)\u003c/p\u003e\n \u003cp\u003e199 \u0026nbsp;(41.3)\u003c/p\u003e\n \u003cp\u003e99 \u0026nbsp; (20.5)\u003c/p\u003e\n \u003cp\u003e64 \u0026nbsp; (13.3)\u003c/p\u003e\n \u003cp\u003e76 \u0026nbsp; (15.8)\u003c/p\u003e\n \u003cp\u003e115 \u0026nbsp;(23.9)\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e115 \u0026nbsp;(23.9)\u003c/p\u003e\n \u003cp\u003e46 \u0026nbsp; (9.5)\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e61 \u0026nbsp; (12.7)\u003c/p\u003e\n \u003cp\u003e43 \u0026nbsp; (8.9)\u003c/p\u003e\n \u003cp\u003e254 \u0026nbsp;(52.7)\u003c/p\u003e\n \u003cp\u003e8 \u0026nbsp; \u0026nbsp; (1.7)\u003c/p\u003e\n \u003cp\u003e96 \u0026nbsp; (19.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*%, percentage of the total group of patients.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Professionals disagree\u003c/h2\u003e \u003cp\u003eOccasionally, the professionals held a different indication from both the patient and the significant others and stand alone advocating for either in- or outpatient care in 114 assessments, amounting to 2.3% of cases, with a nearly equal distribution between the indications for in- and outpatient care. This can be found in the fourth and fifth columns of Fig.\u0026nbsp;2.\u003c/p\u003e \u003cp\u003eWhen only the professionals indicated inpatient care, the realization of both in- and outpatient care was almost equally distributed. However, in cases where only the professionals indicated outpatient care, outpatient care was realized in 67.4% of the assessments.\u003c/p\u003e \u003cp\u003eProportionally, the professionals\u0026rsquo; indication was granted more frequently (57.0%) compared to the preference of both the significant others (11.0%) and the patient (9.4%).\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eSignificant others were present in nearly half of all assessments conducted by emergency psychiatric services (45.5%). Our exploration of the triadic decision-making process during an assessment by the emergency psychiatric services revealed that consensus was reached in almost half of the assessments ( 48.2%). Nevertheless, even when unanimous agreement was achieved among the triad, the actual realization of the preferred form of care did not consistently align with the choice of the triad. Instances where outpatient care was realized instead of the previously chosen voluntary inpatient care could be attributed to the unavailability of hospital beds. Furthermore, despite the triad concurring on the necessity of inpatient care, 174 patients were admitted involuntarily. This discrepancy might be elucidated by varying expectations regarding the anticipated outcomes or the nature of the admitting hospital, leading to a contrast in the actual judicial status of the admissions despite agreement on the need for voluntary inpatient care.\u003c/p\u003e \u003cp\u003eDisagreements on the indication of level of care tend to emerge when patients want outpatient care while the remaining part of the triad wants inpatient care (38.3%) or when significant others want inpatient care while the remaining triad wants outpatient care (10.5%). Patients tended to resist inpatient care when significant others requested it. This emphasizes the findings of a conceptual review, illustrating the diverse expectations and requirements among patients, significant others, and healthcare professionals in emergency psychiatric care (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe patient holds the most vulnerable position within the triad, exhibiting the highest level of disagreement with the rest of the triad. The patient's preference was granted in 9.4% of the assessment when there was disagreement in the triad. In contrast, the significant others\u0026rsquo; preference was granted in 11.0% of cases, while the professionals\u0026rsquo; indication was granted in 57.0% of assessments when there was disagreement in the triad. These findings seemingly contradict an earlier study that identified the significant others' preference for inpatient care as the most important factor influencing the decision between in- and outpatient care (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). However, in this analysis the category \u0026ldquo;family or friends do not favour admission\u0026rdquo; included all cases with low problem severity and all cases where family or friends were not present. So, in many cases the variable \u0026ldquo;family or friends\u0026rsquo; preference for admission\u0026rdquo; was not a predictor of inpatient care because the significant others were not present or opted for outpatient treatment in full agreement with the health care professionals.\u003c/p\u003e \u003cp\u003eOur study's outcomes do align with a qualitative study examining the engagement of significant others of individuals diagnosed with serious mental illness (SMI) in SDM (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). This research revealed that the decision-making process is not democratic. While there is a growing recognition of the necessity to involve significant others, SDM has not been fully achieved or implemented in practice. The professionals hold the strongest position within the triad, which logically derives from their role in addressing crisis situations and possessing the expertise to navigate such circumstances. However, a review focusing on the involvement of significant others uncovered that they often perceived mental health professionals to have negative attitudes regarding their involvement (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Consequently, it becomes important for professionals to recognize the significance of involving significant others and to handle this involvement with sensitivity, acknowledging the importance of the involvement in the overall care process.\u003c/p\u003e \u003cp\u003eIn certain scenarios, the professionals allow either the patient's or the significant others\u0026rsquo; preferences to supersede their clinical judgment. This occurs when the patient expresses a preference for outpatient care against the wishes of the remaining triad. The professionals permit this preference to supersede their judgment if there is no immediate danger posed to the patient in terms of suicidal potential or danger to others. Similarly, the professionals allow for the preference of the significant others for inpatient care against the wishes of the rest of the triad in certain cases. This decision is made by the professionals when there is a presence of suicidal risk or danger to others, or when there are problems with motivation. An indication for outpatient care may be overridden if there are valid criteria for involuntary care.\u003c/p\u003e \u003cp\u003ePrevious research has highlighted that the integration of SDM practices is still in progress, resulting in a limited occurrence of wishes and needs of significant others (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). This observation aligns with the findings of this study, where the professionals are reticent in allowing the preferences of either the patient or the significant others, indicating a possible gap in meeting the desires of involved parties within the SDM process. Triadic SDM in emergency psychiatry is possible (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), a conclusion that is confirmed by the results of this study. However, this domain remains relatively underexplored (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) and the development of strategies are needed to address conflicts between the parts of the triad.\u003c/p\u003e \u003cp\u003eA cross-sectional study examining the role of caregivers in psychiatric inpatient treatment (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) reported a low implementation of caregiver involvement, aligning with the findings of the present study. Earlier studies indicate that the degree of involvement of significant others is more difficult to implement than is commonly thought, and relies on the individual choices made by healthcare professionals (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). This understanding suggests that the frequency of significant others' presence during assessments could potentially increase if healthcare professionals prioritize on involving them in the assessments.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Limitations\u003c/h2\u003e \u003cp\u003eOur results must be interpreted with caution since our analyses relied on retrospective and routinely collected data. Consequently, specific data regarding the preferences of the individual components within the triad were unavailable, highlighting the need for future research to delve into these aspects in greater detail.\u003c/p\u003e \u003cp\u003eThe assessments were conducted by multiple professionals, a characteristic inherent in the structure of emergency psychiatric services, where various professionals perform their duties. This diversity in professionals involved could potentially result in varying outcomes for the same cases, posing a potential source of bias that might have influenced the results obtained.\u003c/p\u003e \u003cp\u003eSchuster and colleagues (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) recommended a focus on interventions that prioritize involving caregivers in consultations. They proposed that a more comprehensive conceptualization of triadic SDM in mental health should be considered in a second step. The present study, aligning with these recommendations, also identifies a relatively low degree of involvement of significant others, thereby supporting this assertion.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eIn our exploration of the triadic SDM process, we observed that consensus was achievable in almost half of the assessments. Disagreements commonly arose when the patient sought outpatient care while the rest of the triad preferred inpatient care, or when significant others advocated for inpatient care while the remaining triad favoured outpatient care. The professionals\u0026rsquo; recommendation held the most influence in determining the outcome, yet this recommendation could be disregarded if there were valid criteria necessitating involuntary care. To effectively manage conflicts in the triad, strategies need to be devised to address conflicts between the parts of the triad.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePrior to access by the authors, the data underwent complete anonymization, thereby allowing the waiver of consent.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe funding sources, namely the authors\u0026apos; institutions, \u0026nbsp;had no involvement in the conduct of the research and the preparation of the article.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors\u0026apos; contributions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eGA:\u0026nbsp;Conceptualization,\u0026nbsp;Methodology, Investigation, Writing- Original Draft, Visualization, Project administration.\u0026nbsp;AW:\u0026nbsp;Conceptualization,\u0026nbsp;Methodology, Software, Formal analysis Validation, Data Curation, Writing - Review \u0026amp; Editing.\u0026nbsp;RW: Validation, Writing - Review \u0026amp; Editing.\u0026nbsp;CM: Validation, Writing - Review \u0026amp; Editing, Supervision, Funding acquisition.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCharles 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(5):681-92.\u003c/li\u003e\n\u003cli\u003eDrake RE, Deegan PE. Shared decision making is an ethical imperative. (8):1007.\u003c/li\u003e\n\u003cli\u003eBeitinger R, Kissling W, Hamann J. Trends and perspectives of shared decision-making in schizophrenia and related disorders. Current Opinion in Psychiatry. 2014;27(3):222-9.\u003c/li\u003e\n\u003cli\u003eHopwood M. The Shared Decision-Making Process in the Pharmacological Management of Depression. The Patient: Patient-Centered Outcomes Research. 2020;13(1):23-30.\u003c/li\u003e\n\u003cli\u003eGiacco D, Mavromara L, Gamblen J, Conneely M, Priebe S. Shared decision-making with involuntary hospital patients: A qualitative study of barriers and facilitators. BJPsych Open. 2018;4(3):113-8.\u003c/li\u003e\n\u003cli\u003eWorthington A, Rooney P, Hannan R. The Triangle of Care Carers Included: A Guide to Best Practice in Mental Health Care in England. . London: Carers Trust; 2013. Available from: https://carers.org/downloads/resources-pdfs/triangle-of-care-england/the-triangle-of-care-carers-included-second-edition.pdf.\u003c/li\u003e\n\u003cli\u003eKroon H, Knispel A, Hulsbosch L, Lange dA. Landelijke Monitor Ambulantisering en Hervorming Langdurige GGZ 2020.2021. Available from: https://www.trimbos.nl/docs/6a82d78c-de54-4613-aa9f-6c09fdf21d07.pdf.\u003c/li\u003e\n\u003cli\u003eJungbauer J, Stelling K, Dietrich S, Angermeyer MC. Schizophrenia: problems of separation in families. Journal of Advanced Nursing. 2004;47(6):605-13.\u003c/li\u003e\n\u003cli\u003eLester H, Marshall M, Jones P, Fowler D, Amos T, Khan N, et al. Views of young people in early intervention services for first-episode psychosis in England. Psychiatric Services. 2011;62(8):882-7.\u003c/li\u003e\n\u003cli\u003eLavis A, Lester H, Everard L, Freemantle N, Amos T, Fowler D, et al. Layers of listening: qualitative analysis of the impact of early intervention services for first-episode psychosis on carers\u0026apos; experiences. Br J Psychiatry. 2015;207(2):135-42.\u003c/li\u003e\n\u003cli\u003eSmith L, Onwumere J, Craig T, McManus S, Bebbington P, Kuipers E. Mental and physical illness in caregivers: results from an English national survey sample. Br J Psychiatry. 2014;205(3):197-203.\u003c/li\u003e\n\u003cli\u003eEassom E, Giacco D, Dirik A, Priebe S. Implementing family involvement in the treatment of patients with psychosis: a systematic review of facilitating and hindering factors. BMJ Open. 2014;4(10):e006108.\u003c/li\u003e\n\u003cli\u003eHuang C, Plummer V, Lam L, Cross W. Perceptions of shared decision-making in severe mental illness: An integrative review. 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Perspectives in psychiatric care. 2018;54(4):462-8.\u003c/li\u003e\n\u003cli\u003eDirik A, Sandhu S, Giacco D, Barrett K, Bennison G, Collinson S, et al. Why involve families in acute mental healthcare? A collaborative conceptual review. BMJ Open. 2017;7(9):e017680.\u003c/li\u003e\n\u003cli\u003ede Winter RFP, Hazewinkel MC, van de Sande R, de Beurs DP, de Groot MH. Outreach psychiatric emergency service: Characteristics of patients with suicidal behavior and subsequent policy. Crisis: The Journal of Crisis Intervention and Suicide Prevention. 2020;.41(5):pp.\u003c/li\u003e\n\u003cli\u003eBorst-Eilers E, Sorgdrager W. Wet medisch-wetenschappelijk onderzoek met mensen 1998 [updated 21-07-2021. Available from: https://wetten.overheid.nl/BWBR0009408/2021-07-01.\u003c/li\u003e\n\u003cli\u003eICT M. WebRAAP. H\u0026egrave;t EPD voor de spoedeisende psychiatrie 2021 [Available from: https://myosotis-ict.nl/home-webraap/.\u003c/li\u003e\n\u003cli\u003eLyons JS, Colletta J, Devens M, Finkel SI. Validity of the severity of psychiatric illness rating scale in a sample of inpatients on a psychogeriatric unit. International Psychogeriatrics. 1995;.7(3):pp.\u003c/li\u003e\n\u003cli\u003eLyons JS, Stutesman J, Neme J, Vessey JT, O\u0026apos;Mahoney MT, Camper J. Predicting psychiatric emergency admission and hospital outcome. Medical Care. 1997;.35(8):pp.\u003c/li\u003e\n\u003cli\u003eRubin M. Do p values lose their meaning in exploratory analyses? It depends how you define the familywise error rate. Review of General Psychology. 2017;21(3):269-75.\u003c/li\u003e\n\u003cli\u003eWagenmakers EJ, Wetzels R, Borsboom D, van der Maas HL, Kievit RA. An Agenda for Purely Confirmatory Research. Perspectives on Psychological Science : A Journal of the Association for Psychological Science. 2012;7(6):632-8.\u003c/li\u003e\n\u003cli\u003eBradley E, Green D. Involved, inputting or informing: \u0026quot;Shared\u0026quot; decision making in adult mental health care. Health Expectations. 2018;21(1):192-200.\u003c/li\u003e\n\u003cli\u003eDoody O, Butler MP, Lyons R, Newman D. Families\u0026apos; experiences of involvement in care planning in mental health services: an integrative literature review. Journal of Psychiatric \u0026amp; Mental Health Nursing. 2017;24(6):412-30.\u003c/li\u003e\n\u003cli\u003eTambuyzer E, Van Audenhove C. Service user and family carer involvement in mental health care: divergent views. Community Mental Health Journal. 2013;49(6):675-85.\u003c/li\u003e\n\u003cli\u003eHamann J, Heres S. Why and How Family Caregivers Should Participate in Shared Decision Making in Mental Health. Psychiatric Services. 2019;70(5):418-21.\u003c/li\u003e\n\u003cli\u003eSchuster F, Holzhuter F, Heres S, Hamann J. \u0026apos;Triadic\u0026apos; shared decision making in mental health: Experiences and expectations of service users, caregivers and clinicians in Germany. Health Expectations. 2021;24(2):507-15.\u003c/li\u003e\n\u003cli\u003eSchuster F, Holzhuter F, Heres S, Hamann J. Caregiver involvement in psychiatric inpatient treatment-A representative survey among triads of patients, caregivers and hospital psychiatrists. Epidemiology and Psychiatric Sciences Vol 29, 2020, ArtID e129.29.\u003c/li\u003e\n\u003cli\u003eKaselionyte J, Conneely M, Giacco D. \u0026quot;It\u0026apos;s a matter of building bridges...\u0026quot; - feasibility of a carer involvement intervention for inpatients with severe mental illness. BMC Psychiatry. 2019;19(1):268.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"triadic shared decision making, emergency psychiatry, acute mental health care, inpatient care, outpatient care","lastPublishedDoi":"10.21203/rs.3.rs-4467734/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4467734/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThis study aims to understand the complex triadic shared decision-making process in psychiatric emergency services, focusing on the choice between inpatient and outpatient care post-triage. It also identify scenarios where patient or significant others\u0026rsquo; preferences override clinical judgment.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eConducted in the greater Rotterdam area, Netherlands, this explorative study surveyed patient and significant others\u0026rsquo; preferences for voluntary or involuntary admission versus outpatient treatment, alongside professionals' clinical indications. Descriptive statistics were used to profile participants, and preference data were used to categorize groups, revealing patterns of agreement.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAmong 5680 assessments involving significant others, four groups emerged: agreement among the triad on in- or outpatient care (48.2%), patient disagrees (38.5%), significant others disagree (11.0%), and professionals disagree (2.3%). Professionals' recommendations were followed more frequently (57.0%) than patient (9.4%) or significant others\u0026rsquo; preferences (11.0%).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eWe observed that consensus could often be reached among the members of the triad on inpatient or outpatient care following triage. Disagreements typically occurred when patients preferred outpatient care while others favoured inpatient care, or when significant others advocated for inpatient care while others preferred outpatient care. While professionals' recommendations held the most influence, they could be overridden in cases where valid criteria mandated involuntary care.\u003c/p\u003e","manuscriptTitle":"Triadic shared decision making in emergency psychiatry: an explorative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-12 17:08:37","doi":"10.21203/rs.3.rs-4467734/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-08T09:54:54+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-09T15:25:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-09T10:42:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-04T06:37:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"26850454300013985097721318140729617021","date":"2024-09-04T05:45:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"272243152062637773977221925777926308973","date":"2024-09-03T20:52:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"100073570848401745993483094563246774096","date":"2024-09-03T13:00:01+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-09-03T10:12:38+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-07-02T08:58:27+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-29T02:19:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-29T02:18:12+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychiatry","date":"2024-05-23T15:03:35+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"baaba384-dc74-4677-bcc5-6357d79b9c41","owner":[],"postedDate":"June 12th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-03-10T19:46:58+00:00","versionOfRecord":{"articleIdentity":"rs-4467734","link":"https://doi.org/10.1186/s12888-025-06640-7","journal":{"identity":"bmc-psychiatry","isVorOnly":false,"title":"BMC Psychiatry"},"publishedOn":"2025-03-05 15:58:21","publishedOnDateReadable":"March 5th, 2025"},"versionCreatedAt":"2024-06-12 17:08:37","video":"","vorDoi":"10.1186/s12888-025-06640-7","vorDoiUrl":"https://doi.org/10.1186/s12888-025-06640-7","workflowStages":[]},"version":"v1","identity":"rs-4467734","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4467734","identity":"rs-4467734","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}