Research into Recovery and Wellbeing

A website about the work of the recovery research team at the Institute of Mental Health

The University of Nottingham

Clinical decision-making and outcome in routine care for people with severe mental illness (CEDAR)

CEDAR was a study of clinical decision-making which took place in Denmark, England (King's College London), Germany, Hungary, Italy and Switzerland from 2009 until 2012. The study was funded by a grant from the European Union (reference 223290).

We developed and evaluated three measures, each in five languages (Danish, English, German, Hungarian and Italian. Measures are available via the CEDAR website

CDMS assesses preference for decision-making style:

Puschner B, Neumann P, Jordan H, Slade M, Fiorillo A, Giacco D, Égerházi A, Ivánka T, Krogsgaard Bording M, Østermark Sørensen H, Bär A, Kawohl W, Loos S (2013) Development and psychometric properties of a five-language multiperspective instrument to assess clinical decision making style in the treatment of people with severe mental illness (CDMS), BMC Psychiatry, 13, 48.

CDIS assesses experience of involvement and satisfaction with decisions:

Slade M, Jordan H, Clarke E, Williams P, Kaliniecka H, Arnold K, Fiorillo A, Giacco D, Luciano M, Égerházi A, Nagy M, Krogsgaard Bording M, Østermark Sørensen H, Rössler W, Kawohl W, Puschner B, the CEDAR Study Group (2014) The development and evaluation of a five-language multi-perspective standardised measure: Clinical Decision-making Involvement and Satisfaction (CDIS), BMC Health Services Research, 14, 323.

CDRC assesses the content and implementation of decisions:

Konrad J, Loos S, Neumann P, Zentner N, Mayer B, Slade M, Jordan H, De Rosa C, Del Vecchio V, Égerházi A, Nagy M, Krogsgaard Bording M, Østermark Sørensen H, Kawohl W, Rössler W, Puschner B (2015) Content and implementation of clinical decisions in the routine care of people with severe mental illness, Journal of Mental Health, 24, 15-19.

We then evaluated the experience of clinical decison-making for 588 people using mental health services in the six countries.

The study protocol was published:

Puschner B, Steffen S, Slade M, Kaliniecka H, Maj M, Fiorillo A, Munk-Jørgensen P, Larsen J, Égerházi A, Nemes Z, Rössler W, Kawohl W, Becker T (2010) Clinical Decision Making and Outcome in Routine Care for People with Severe Mental Illness (CEDAR): Study protocol, BMC Psychiatry, 10, 90.

We showed that more active involvement in decision-making by the mental health service user was associated with…

…increased satisfaction:

Clarke E, Puschner B, Jordan H, Williams P, Konrad J, Kawohl W, Bär A, Rössler W, Del Vecchio V, Sampogna G, Nagy M, Süveges A, Krogsgaard Bording M, Slade M (2015) Empowerment and satisfaction in a multinational study of routine clinical practice, Acta Psychiatrica Scandinavica, 131, 369-378.

…and fewer unmet needs:

Puschner B, Becker T, Mayer B, Jordan H, Maj M, Fiorillo A, Égerházi A, Ivánka T, Munk-Jørgensen P, Krogsgaard Bording M, Rössler W, Kawohl W, Slade M, for the CEDAR study group (2016) Clinical decision making and outcome in the routine care of people with severe mental illness across Europe (CEDAR), Epidemiology and Psychiatric Sciences, 25, 69-79.

...but active involvement was associated with lower stage of recovery one year later:

Loos S, Clarke E, Jordan H, Puschner B, Fiorillo A, Luciano M, Ivánka T, Magyar E, Krogsgaard-Bording M, Østermark Sørensen H, Rössler W, Kawohl W, Mayer B, Slade M, CEDAR Study Group (2017) Recovery and decision-making involvement in people with severe mental illness from six countries: a prospective observational study, BMC Psychiatry, 17, 38.

Participants differed in their pattern of change in helping alliance:

Loos S, Arnold K, Slade M, Jordan H, Del Vecchio V, Sampogna G, Süvegese Á, Nagy M, Krogsgaard Bording M, Østermark Sørensen H, Rössler W, Kawohl W, Puschner B, CEDAR Study Group (2015) Courses of helping alliance in the treatment of people with severe mental illness in Europe: A latent class analytic approach, Social Psychiatry and Psychiatric Epidemiology, 50, 363-370.

and we found a causal relationship between improving helping alliance and reducing unmet needs:

Arnold K, Loos S, Mayer B, Clarke E, Slade M, Fiorillo A,  Del Veccio V, Egerhazi A, Ivanca T, Munk-Jørgensen P, Krogsgaard Bording M, Kawohl W, Rössler W, Puschner B (2017) Helping alliance and unmet needs in routine care of people with severe mental illness across Europe: a prospective longitudinal multicentre study, Journal of Nervous and Mental Disease, 205, 329-333.

Most participants had a high desire for information:

Giacco D, Luciano M, del Vecchio V, Sampogna G, Slade M, Clarke E, Glaub T, Nagy M, Munk-Jørgensen P, Krogsgaard Bording M, Kawohl W, Rössler W, Zentner N, Fiorillo A, Puschner B (2014) Desire for information of people with severe mental illness: results from the CEDAR study in six European countries, Social Psychiatry and Psychiatric Epidemiology, 49, 1883-1891.

Treatment-related decisions were associated with lower satisfaction, involvement and implementation:

Freidl M, Konrad J, Pesola F, De Rosa C, Fiorillo A, Kovacs A, Nagy M, Munk-Jørgensen P, Krogsgaard Bording M, Rössler W, Kawohl W, Puschner B, CEDAR Study Group, Slade M (2016) Effects of Clinical Decision Topic on Patients’ Involvement in and Satisfaction With Decisions and Their Subsequent Implementation, Psychiatric Services, 67, 658-663.

A preference for shared decision-making may reduce healthcare costs:

Cosh S, Zentner N, Ay E, Loos S, Slade M, Maj M, Salzano A, Berecz R, Glaub T, Munk-Jorgensen P, Krogsgaard Bording M, Rössler W, Kawohl W, Puschner B, CEDAR study group (2017) Clinical decision making and mental health service use in people with severe mental illness across Europe, Psychiatric Services, 68, 970-974.

Desire for involvement differed across countries:

Bär A, Hengartner M, Kawohl W, Konrad J, Puschner B, Clarke E, Slade M, Del Vecchio V, Sampogna G, Égerházi A, Süveges A, Krogsgaard Bording M, Munk-Jørgensen P, Rössler W, CEDAR study group Participation in medical decision-making across Europe: an international longitudinal multicenter study, European Psychiatry, in press.