***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: This column presents preliminary findings of an intervention to support shared decision making in psychopharmacology consultation . The waiting area in an urban psychiatric medication clinic was transformed into a peer-run Decision Support Center featuring a user-friendly , Internet-based software program with which clients could create a one-page computer-generated report for use in the medication consultation . The Decision Support Center was used 662 times by 189 unique users from a young-adult and general adult case management team from October 2006 to September 2007 . All clients had severe mental disorders . Only ten clients refused to use the intervention at some point during the pilot study . Focus groups with medical staff ( N=4 ) , clients ( N=16 ) , case managers ( N=14 ) , and peer-specialist staff ( N=3 ) reported that the intervention helped to create efficiencies in the consultation and empower clients to become more involved in treatment-related decision making . A r and omized controlled trial is currently in process We investigated associations between adult attachment , symptoms and interpersonal functioning , including therapeutic relationships in 96 patients with psychosis . Using a prospect i ve design , we also assessed changes in attachment in both psychiatrically unstable and stable groups . We measured  attachment  using the Psychosis Attachment Measure ( PAM ) and interpersonal problems and therapeutic relationships were assessed from both psychiatric staff and patient perspectives . Avoidant attachment was associated with positive symptoms , negative symptoms and paranoia . Attachment ratings were relatively stable over time , although changes in attachment anxiety were positively correlated with changes in symptoms . Predicted associations between high levels of attachment anxiety and avoidance and interpersonal problems were supported , and attachment avoidance was associated with difficulties in therapeutic relationships . Findings suggest that adult attachment style is a meaningful individual difference variable in people with psychosis and may be an important predictor of symptoms , interpersonal problems and difficulties in therapeutic relationships over and above severity of illness BACKGROUND A better therapeutic relationship predicts better outcomes . However , there is no trial-based evidence on how to improve therapeutic relationships in psychosis . AIMS To test the effectiveness of communication training for psychiatrists on improving shared underst and ing and the therapeutic relationship ( trial registration : IS RCT N94846422 ) . METHOD In a cluster r and omised controlled trial in the UK , 21 psychiatrists were r and omised . Ninety-seven ( 51 % of those approached ) out- patients with schizophrenia/schizoaffective disorder were recruited , and 64 ( 66 % of the sample recruited at baseline ) were followed up after 5 months . The intervention group received four group and one individualised session . The primary outcome , rated blind , was psychiatrist effort in establishing shared underst and ing ( self-repair ) . Secondary outcome was the therapeutic relationship . RESULTS Psychiatrists receiving the intervention used 44 % more self-repair than the control group ( adjusted difference in means 6.4 , 95 % CI 1.46 - 11.33 , P<0.011 , a large effect ) adjusting for baseline self-repair . Psychiatrists rated the therapeutic relationship more positively ( adjusted difference in means 0.20 , 95 % CI 0.03 - 0.37 , P = 0.022 , a medium effect ) , as did patients ( adjusted difference in means 0.21 , 95 % CI 0.01 - 0.41 , P = 0.043 , a medium effect ) . CONCLUSIONS Shared underst and ing can be successfully targeted in training and improves relationships in treating psychosis Background The quality of the therapeutic alliance ( TA ) has been invoked to explain the equal effectiveness of different psychotherapies , but prior research is correlational , and does not address the possibility that individuals who form good alliances may have good outcomes without therapy . Method We evaluated the causal effect of TA using instrumental variable ( structural equation ) modelling on data from a three-arm , r and omized controlled trial of 308 people in an acute first or second episode of a non-affective psychosis . The trial compared cognitive behavioural therapy ( CBT ) over 6 weeks plus routine care ( RC ) v. supportive counselling ( SC ) plus RC v. RC alone . We examined the effect of TA , as measured by the client-rated CALPAS , on the primary trial 18-month outcome of symptom severity ( PANSS ) , which was assessed blind to treatment allocation . Results Both adjunctive CBT and SC improved 18-month outcomes , compared to RC . We showed that , for both psychological treatments , improving TA improves symptomatic outcome . With a good TA , attending more sessions causes a significantly better outcome on PANSS total score [ effect size −2.91 , 95 % confidence interval ( CI ) −0.90 to −4.91 ] . With a poor TA , attending more sessions is detrimental ( effect size + 7.74 , 95 % CI + 1.03 to + 14.45 ) . Conclusions This is the first ever demonstration that TA has a causal effect on symptomatic outcome of a psychological treatment , and that poor TA is actively detrimental . These effects may extend to other therapeutic modalities and disorders Background Long acting injections ( LAI ) have been associated with perceptions of coercion in cross sectional studies but there have been no longitudinal studies of the effects on clinical relationships with newer depot medications . Method R and omized controlled trial with ( 50 ) participants with a diagnosis of schizophrenia r and omized to risperidone LAI or oral atypical antipsychotic medication .  The main outcome was the Working Alliance Inventory ( WAI ) with background variables ( symptoms , side effect , social functioning , quality of life ) measured before r and omization and at two years . Results At follow-up ( 14 risperidone LAI and 16 oral medication ) analyses including predictors of missing data and baseline score showed a trend for those on risperidone LAI to reduce WAI score and those on oral medication showing no change . Sensitivity analyses showed ( i ) a significant detrimental effect of LAI on WAI and ( ii ) the pattern of results was not affected by change in symptoms over the study . Conclusion This is the first study to show that the prescription of depot atypical depot medication is associated with detrimental effects on clinical relationships after 2 years of continual treatment BACKGROUND The CRIMSON ( CRisis plan IMpact : Subjective and Objective coercion and eNgagement ) study is an individual level , r and omised controlled trial that compared the effectiveness of Joint Crisis Plans ( JCPs ) with treatment as usual for people with severe mental illness . The JCP is a negotiated statement by a patient of treatment preferences for any future psychiatric emergency , when he or she might be unable to express clear views . We assessed whether the additional use of JCPs improved patient outcomes compared with treatment as usual . METHODS Patients were eligible if they had at least one psychiatric admission in the previous 2 years and were on the Enhanced Care Programme Approach register . The study was done with 64 generic and specialist community mental health teams in four English mental health care provider organisations ( trusts ) . Hypotheses tested were that , compared with the control group , the intervention group would experience : fewer compulsory admissions ( primary outcome ) ; fewer psychiatric admissions ; shorter psychiatric stays ; lower perceived coercion ; improved therapeutic relationships ; and improved engagement . We stratified participants by centre . The research team but not participants nor clinical staff were masked to allocation . This study is registered with Clinical Trials.gov , number IS RCT N11501328 . FINDINGS 569 participants were r and omly assigned ( 285 to the intervention group and 284 to the control group ) . No significant treatment effect was seen for the primary outcome ( 56 [ 20 % ] sectioned in the control group and 49 [ 18 % ] in the JCP group ; odds ratio 0·90 [ 95 % CI 0·58 - 1·39 , p=0·63 ] ) or any secondary outcomes , with the exception of an improved secondary outcome of therapeutic relationships ( 17·3 [ 7·6 ] vs 16·0 [ 7·1 ] ; adjusted difference -1·28 [ 95 % CI -2·56 to -0·01 , p=0·049 ] ) . Qualitative data supported this finding . INTERPRETATION Our findings are inconsistent with two earlier JCP studies , and show that the JCP is not significantly more effective than treatment as usual . There is evidence to suggest the JCPs were not fully implemented in all study sites , and were combined with routine clinical review meetings which did not actively incorporate patients ' preferences . The study therefore raises important questions about implementing new interventions in routine clinical practice . FUNDING Medical Research Council UK and the National Institute for Health Research Psychoeducation improves adherence and motivates patients to accept a maintenance therapy as recommended by the guidelines . This would mean a daily consumption of at least 300 chlorpromazine ( CPZ ) units in the long run and should lead to an increase of the antipsychotic dosage in comparison to patients with treatment as usual ( TAU ) . This raises 2 important questions : whether more side effects are provoked and do the patients have a corresponding benefit with a better outcome . A total of 41 patients with a diagnosis of schizophrenic or schizoaffective disorder were r and omized at study entry , either to bifocal psychoeducation ( 21 ) , or to st and ard treatment  ( 20 ) . They were compared concerning compliance , type of medication , dosage ( CPZ equivalents ) , motor side effects and number of days in hospital . The average daily antipsychotic medication  2 and 7 years after index discharge was 365 and 354 CPZ-units respectively in the intervention group ( IG ) , but 247 and 279 , respectively in the control group ( CG ) . The extent of motor side effects was slightly smaller in the IG , but they showed a small and statistically not significant increase in the rate of tardive dyskinesia ( TD ) after 7 years . At the 7-year follow-up the patients in the IG had spent 74.7 days in hospital compared to 243.4 days for the patients in the CG ( P < .05 ) . The course of illness was significantly better in the IG without increasing motor side-effects . Therefore , psychoeducation should be integrated more systematic ally into the routine treatment . These data are part of a previous study , published 2007 , with a sample size of 48 patients . Seven patients -3 of the IG and 4 of the CG-could not be included , because they were not able to complete the very complex " Computer-based kinematic analysis of motor performance . " In this article all conclusions are referred to the new sample size , therefore some results are slightly different in comparison to the previous data The importance of therapeutic alliance in predicting treatment outcomes is well established , but less is known about client characteristics that predict alliance . Clients with co-occurring psychosis and substance misuse ( n = 116 ) who received integrated motivational interviewing and cognitive behavior therapy in the context of a large r and omized controlled trial completed the Working Alliance Inventory . Their trial therapists also completed Working Alliance Inventories . Rating perspectives were compared , and in a cross-sectional study , client predictors of therapeutic alliance were examined . As hypothesized , clients ' negative attitudes to treatment , including lack of insight , were predictive of poorer alliance . Therapist-rated alliance was also predicted by the client 's attitude to medication , self-reported depression , and living situation . Symptom severity and substance use measures were unrelated to alliance . Consistent with previous studies , rating perspectives differed , with clients rating alliance more positive than therapists This study examined the relationship of the therapeutic alliance to the treatment course and outcome of 143 patients with nonchronic schizophrenia . Results showed that patients who formed good alliances with their therapists within the first 6 months of treatment were significantly more likely to remain in psychotherapy , comply with their prescribed medication regimens , and achieve better outcomes after 2 years , with less medication , than patients who did not . These results underscored the prognostic value of assessing the alliance and the need to identify factors that contribute to its development and maintenance with schizophrenic patients OBJECTIVES Outpatient and inpatient mental health service outcomes for out patients with schizophrenia or schizoaffective disorder who received psychoeducational multiple-family group treatment  were compared with outcomes for similar patients who received st and ard care . METHODS A total of 106 out patients with schizophrenia or schizoaffective disorder who were receiving services from a large community mental health center were r and omly assigned to receive st and ard care or st and ard care plus multiple-family group treatment . The two-year multiple-family intervention consisted of weekly group sessions design ed to educate patients and their family members about the biological basis of mental illness and treatment , to improve illness management and coping skills , and to provide social support . The group sessions were conducted by two clinicians using a st and ardized protocol . Each multiple-family group included five to eight families and consumers . Service records for the year before and after r and om assignment to the study groups were examined in an intent-to-treat analysis . RESULTS During the year after r and om assignment to study groups , multiple-family group treatment was associated with a lower rate of psychiatric hospitalization than st and ard care . It was only marginally associated with lower use of crisis services , and it was not associated with the amount of outpatient service time . CONCLUSIONS The findings suggest that implementation of multiple-family group treatment in a capitated community mental health setting improves hospitalization outcomes without increasing the overall volume of outpatient mental health services 
    Output:
    
The quality of therapeutic alliance correlates with clinical symptoms , insight , social and family support , the therapist 's qualities , the availability of shared therapeutic decision making , and the types of hospitalization .
Although current evidence needs to be completed with further studies , it is already clear that group and family psychoeducation , cognitive remediation , community-based psychiatric services , and shared therapeutic decision making are essential approaches in the management of patients with psychosis