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The promotion of shared decision-making is a central policy initiative in the Patient Protection and Affordable Care Act and a key component of person-centered medicine. Yet, as interest increases, disturbing distortions of shared decision-making have occurred. Fueled by a desire to reduce healthcare costs, reduce litigation and improve cost-effectiveness, the underlying rationale for shared decision-making risks being overshadowed. Some portray shared decision-making as a method to bend the cost curve, but opponents claim it is a ploy to ration care to patients [1]. Both these positions misrepresent the underpinning principles.The imperative for shared decision-making rests on the principles of good clinical practice, respecting patients' right to know that their informed preferences should be the basis for professional actions. Technologic advances have led to the proliferation of multiple treatment options while evidence-based medicine has contributed to our understanding that many therapies have marginal benefits. Shared decision-making aims to make the trade-offs between harms and benefits evident to patients rather than ration care. Overutilization arguably arises out of undue corporate influence on the promotion of marginally efficacious therapies with distorted claims of benefit. Other methods should be used to tackle these wider challenges, while the practice of shared decision-making would help medical professionals re-align themselves with patients' informed preferences and, in so doing, place patients, not making or saving money, at the center of care.

Bechdolf A, Thompson A, Nelson B, Cotton S, Simmons MB, Amminger GP, Leicester S, Francey SM, McNab C, Krstev H, Sidis A, McGorry PD, Yung AR. Experience of trauma and conversion to psychosis in an ultra‐high‐risk (prodromal) group. Objective:  We aimed to replicate a recent finding of high prevalence of trauma history in patients at ‘ultra‐high risk’ (UHR) of psychotic disorder and to investigate whether trauma predicts conversion to psychosis in this population. Method:  A consecutive sample of UHR patients was assessed. History of trauma was accessed with the General Trauma Questionnaire. Cox regression models were used to explore relationship between conversion to psychosis and trauma. Results:  Of 92 UHR patients nearly 70% had experienced a traumatic event and 21.7% developed psychosis during follow‐up (mean 615 days). Patients who had experienced a sexual trauma (36%) were significantly more likely to convert to first‐episode psychosis (OR 2.96) after controlling for meeting multiple UHR intake groups. Conclusion:  UHR patients have a high prevalence of history of trauma. Previous sexual trauma may be a predictor of onset of psychotic disorder in this population.

BackgroundEffective treatment of depression in young people is critical, given its prevalence, impacts, and link to suicide. Clinical practice guidelines point to the need for regular monitoring of depression symptom severity and the emergence of suicidal ideation to track treatment progress and guide intervention delivery. Yet, this is seldom integrated in clinical practice.ObjectiveThe objective of this study was to address the gap between guidelines about monitoring and real-world practice by codesigning an app with young people that allows for self-monitoring of mood and communication of this monitoring with a clinician.MethodsWe engaged young people aged 18 to 25 years who had experienced depression, suicidal ideation including those who self-harm, as well as clinicians in a codesign process. We used a human-centered codesign design studio methodology where young people designed the features of the app first individually and then as a group. This resulted in a minimal viable product design, represented through low-fidelity hand-drawn wireframes. Clinicians were engaged throughout the process via focus groups.ResultsThe app incorporated a mood monitoring feature with innovative design aspects that allowed customization, and was named a “well-being tracker” in response to the need for a positive approach to this function. Brief personalized interventions designed to support young people in the intervals between face-to-face appointments were embedded in the app and were immediately available via pop-ups generated by a back-end algorithm within the well-being tracker. Issues regarding the safe incorporation of alerts generated by the app into face-to-face clinical services were raised by clinicians (ie, responding in a timely manner) and will need to be addressed during the full implementation of the app into clinical services.ConclusionsThe potential to improve outcomes for young people via technology-based enhancement to interventions is enormous. Enhancing communication between young people and their clinicians about symptoms and treatment progress and increasing access to timely and evidence-based interventions are desirable outcomes. To achieve positive outcomes for young people using technology- (app) based interventions, it is critical to understand and incorporate, in a meaningful way, the expectations and motivations of both young people and clinicians.

http://www.anzctr.org.au Identifier: ACTRN012605000247673.

Background Depressive disorders are common in young people and are associated with significant negative impacts. Newer generation antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs), are often used, however evidence of their effectiveness in children and adolescents is not clear. Furthermore, there have been warnings against their use in this population due to concerns about increased risk of suicidal ideation and behaviour. Objectives To determine the efficacy and adverse outcomes, including definitive suicidal behaviour and suicidal ideation, of newer generation antidepressants compared with placebo in the treatment of depressive disorders in children and adolescents. Search methods For this update of the review, we searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) to October 2011. The CCDANCTR includes relevant randomised controlled trials from the following bibliographic databases: CENTRAL (the Cochrane Central Register of Controlled Trials) (all years), EMBASE (1974-), MEDLINE (1950-) and PsycINFO (1967-). We searched clinical trial registries and pharmaceutical company websites. We checked reference lists of included trials and other reviews, and sent letters to key researchers and the pharmaceutical companies of included trials from January to August 2011. Selection criteria Published and unpublished randomised controlled trials (RCTs), cross-over trials and cluster trials comparing a newer generation antidepressant with a placebo in children and adolescents aged 6 to 18 years old and diagnosed with a depressive disorder were eligible for inclusion. In this update, we amended the selection criteria to include newer generation antidepressants rather than SSRIs only. Newer generation antidepressants for depressive disorders in children and adolescents (Review)

BackgroundClinical guidelines advocate for the inclusion of young people experiencing depression as well as their caregivers in making decisions about their treatment. Little is known, however, about the degree to which these groups are involved, and whether they want to be. This study sought to explore the experiences and desires of young people and their caregivers in relation to being involved in treatment decision making for depressive disorders.MethodsSemi-structured interviews were carried out with ten young people and five caregivers from one primary care and one specialist mental health service about their experiences and beliefs about treatment decision making. Interviews were audio taped, transcribed verbatim and analysed using thematic analysis.ResultsExperiences of involvement for clients varied and were influenced by clients themselves, clinicians and service settings. For caregivers, experiences of involvement were more homogenous. Desire for involvement varied across clients, and within clients over time; however, most clients wanted to be involved at least some of the time. Both clients and caregivers identified barriers to involvement.ConclusionsThis study supports clinical guidelines that advocate for young people diagnosed with depressive disorders to be involved in treatment decision making. In order to maximise engagement, involvement in treatment decision making should be offered to all clients. Involvement should be negotiated explicitly and repeatedly, as desire for involvement may change over time. Caregiver involvement should be negotiated on an individual basis; however, all caregivers should be supported with information about mental disorders and treatment options.