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BACKGROUND: Salutogenesis focuses on understanding the factors that contribute to positive health outcomes. At the core of the model lies the sense of coherence (SOC), which plays a crucial role in promoting well-being and resilience. OBJECTIVE: Using the validscale Stata command, we aimed to assess the psychometric properties of the French version of the 3-dimension 13-item SOC questionnaire (SOC-13), encompassing the comprehensibility, manageability, and meaningfulness dimensions. We also aimed to determine if a refined scale, assessed through this method, exhibits superior psychometric properties compared to the SOC-13. METHODS: A sample of 880 consecutive primary care patients recruited from 35 French practices were asked to complete the SOC-13. We tested for internal consistency and scalability using the Cronbach α and Loevinger H coefficients, respectively, and we tested for construct validity using confirmatory factor analysis and goodness-of-fit indices (root mean square error of approximation [RMSEA] and comparative fit index [CFI]). RESULTS: Of the 880 eligible patients, 804 (91.4%) agreed to participate (n=527, 65.6% women; median age 51 years). Cronbach α and Loevinger H coefficients for the SOC-13 were all <0.70 and <0.30, respectively, indicating poor internal consistency and poor scalability (0.64 and 0.29 for comprehensibility, 0.56 and 0.26 for manageability, and 0.46 and 0.17 for meaningfulness, respectively). The RMSEA and CFI were >0.06 (0.09) and <0.90 (0.83), respectively, indicating a poor fit. By contrast, the psychometric properties of a unidimensional 8-item version of the SOC questionnaire (SOC-8) were excellent (Cronbach α=0.82, Loevinger H=0.38, RMSEA=0.05, and CFI=0.97). CONCLUSIONS: The psychometric properties of the 3-dimension SOC-13 were poor, unlike the unidimensional SOC-8. A questionnaire built only with these 8 items could be a good candidate to measure the SOC. However, further validation studies are needed before recommending its use in research.

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BACKGROUND: Loneliness is a significant public health challenge in the United States, especially among older adults. The epidemiology of loneliness among older adults in primary care is lacking, and specific research is needed on how loneliness impacts older primary patients' physical, mental, and cognitive health. A large sample of older primary care patients were recruited for a trial during the COVID-19 pandemic to measure the relationship between loneliness and physical and mental quality of life (QOL). METHODS: Baseline data come from the Caregiver Outcomes of Alzheimer's Disease Screening (COADS) study, an ongoing randomized controlled trial evaluating benefits and risks of Alzheimer's disease and related dementias screening among primary care patients ages 65 and older, collected April 2020 to September 2021. Loneliness was measured with the 5-item, Loneliness Fixed Form Ages 18+ from The NIH Toolbox Emotion Battery, physical and mental health-related QOL was measured with the SF-36v2, and depression and anxiety severity were measured with the PHQ-9 and GAD-7, respectively. RESULTS: Spearman correlation analyses revealed that loneliness was moderately correlated with mental health QOL (r[601] = -0.43, p < 0.001), anxiety severity (r[601] = 0.44, p < 0.001), and depression severity (r[601] = 0.42, p < 0.001), while weakly correlated with physical health QOL (r[601] = -0.15, p < 0.001). After conducting unadjusted and adjusted linear regression models, we found that loneliness was significantly associated with both lower mental (p < 0.001) and physical (p < 0.001) QOL. Furthermore, loneliness remained significantly associated with worse mental QOL after adjusting for age, gender, race, ethnicity, educational level, perceived income status, neighborhood disadvantage, severity of comorbidities, and comorbid depression and anxiety. CONCLUSION: Primary care providers should discuss loneliness with their older adult patients and provide resources to help patients develop and maintain meaningful social relationships.

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Enfermedad de Alzheimer , Soledad , Humanos , Anciano , Soledad/psicología , Calidad de Vida/psicología , Pandemias , Atención Primaria de Salud , Depresión/psicología

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Background: Psychosomatic internal medicine (PSIM) assesses psychosocial factors and provides holistic consideration. In Japan, PSIM physicians seem to be recognized as providers of mental health services, but family medicine did not so. When family physicians confront with psychological problems, high dropout rate is reported so it is needed to reveal factors related to dropouts, The purpose of this study is to describe characteristics of patients, treatment dropouts and its related factors in PSIM practice by family physician. Methods: This cross-sectional study used data from the medical records of the Kitaibaraki Center of Family Medicine located in Kitaibaraki City, Ibaraki, Japan. The study included all new patients who made an appointment and visited the PSIM in this clinic from January 2020 to December 2022.Chief complaints and diagnoses were coded based on the International Classification of Primary Care, version 2 (ICPC-2). Results: In total, 377 new patients were included in this study. The mean age was 39.9 ± 20.2 years. We found that 69.2% of patients who visited the clinic had a psychological chief complaint and 84.1% of primary diagnoses consisted of a psychological problem. One hundred sixty-five patients (43.8%) were still receiving treatment 6 months after the initial visit. Of the patients who ended treatment within 6 months after the initial visit, 84 patients (39.2%) dropped out. In multivariate analysis, the dropouts were less likely to occur patients with primary diagnosis of psychological problem (odds ratio (OR): 0.35, 95% confidence interval (CI): 0.19 - 0.67). Conclusions: Patients who visited a PSIM wanted consultation about psychological problems. Patients with a diagnosis of a psychological problem at the initial visit were less likely to drop out.

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INTRODUCTION: The approaches to cope with the challenges of providing medical care to patients with symptoms of long COVID are multidisciplinary and involve primary care worldwide. The aim of this study was to explore the experiences and ideas for continued development of medical care of long COVID from the patients' (PAT) and primary care practitioners' (PCP) perspective. METHODS: Between the third and fourth COVID-19 wave in Germany (July to September 2021), a mixed methods study was conducted by inviting patients and PCPs in two neighboring districts (urban and rural) in Baden-Wuerttemberg to a paper-based questionnaire with both closed and open questions. On the part of the PCPs a written, anonymized, complete survey was conducted, on the part of symptomatic COVID long-haulers an anonymized online survey with announcement of the study by multiple recruiting processes. Qualitative content analysis was applied to free text entries. The quantitative results were analyzed mainly descriptively. RESULTS: The responses of n = 72 PCPs (response rate 12%) and n = 126 PAT showed a heterogeneous assessment regarding the satisfaction with medical care for long COVID as well as the perception of the attitude towards patients and their disease in both groups. Uncertainty and dealing with it played a relevant role in both groups as well. The professional medical knowledge was assessed by 3,1 (self-assessment PCPs) and 3,2 (PAT) on average using a five-point Likert scale (1 = not applicable; 5 = applicable). The request for a structured overall concept with competent contact points and coordination of medical care for long COVID patients emerged out of the statements of both groups. CONCLUSION: The results support an interdisciplinary, intersectoral and interprofessional stepped-care concept for long COVID in Germany with PCPs as the first contact persons, integration of specialized contact points and knowledge transfer. Therefore, it appears to be both reasonable and appropriate to establish regional networks with links between regional outpatient medical care structures and the university medical sector.

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COVID-19 , Atención Ambulatoria , Actitud del Personal de Salud , COVID-19/complicaciones , COVID-19/terapia , Alemania , Humanos , Atención Primaria de Salud , Síndrome Post Agudo de COVID-19

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INTRODUCTION/OBJECTIVES: COVID-19 vaccination is important to stop the pandemic. It has been reported that willingness to be vaccinated is associated with system factors as well as individual attitudes and beliefs. Primary care patients include individuals at increased risk of poor outcomes after COVID-19 infection, such as elderly people and those with comorbidities. This study investigated attitudes in this population toward COVID-19 and COVID-19 vaccination, including willingness to be vaccinated and associated factors. This study was conducted in Japan, where the population has low vaccine confidence, during the initial phase of COVID-19 vaccination. METHODS: Patients from 1 primary care clinic in Kitaibaraki City, Ibaraki, Japan, participated in this study from March to April 2021. They were administered a self-reported questionnaire exploring factors such as willingness to undergo COVID-19 vaccination, perceived susceptibility, and perceived vaccine efficacy. Multivariable logistic regression analysis was conducted to identify factors associated with vaccination. RESULTS: Of the 717 patients (response rate, 88.3%), 512 (70.0%) reported they were willing to be vaccinated for COVID-19. Multivariate analysis revealed that vaccination willingness was associated with older age (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01-1.05), male gender (OR 1.95, 95% CI 1.15-3.30), influenza vaccination in in the 2020/2021 season (OR 2.54, 95% CI 1.49-4.32), recommendation from others (OR 3.11, 95% CI 1.58-6.18), high perceived susceptibility (OR 2.51, 95% CI 1.45-4.33), belief in vaccine efficacy (OR 3.83, 95% CI 1.54-9.56), high perceived susceptibility to vaccine-related adverse events (OR 0.37, 95% CI 0.22-0.64), and high espousal of social norms (OR 8.00, 95% CI 2.78-23.0). CONCLUSIONS: COVID-19 vaccination was widely acceptable to Japanese primary care patients. In addition to factors such as vaccine efficacy, and past influenza vaccination, social norms may be important in determining COVID-19 vaccination willingness.

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COVID-19 , Vacunas contra la Influenza , Gripe Humana , Anciano , COVID-19/prevención & control , Vacunas contra la COVID-19/uso terapéutico , Estudios Transversales , Conocimientos, Actitudes y Práctica en Salud , Humanos , Vacunas contra la Influenza/uso terapéutico , Gripe Humana/prevención & control , Japón , Masculino , Atención Primaria de Salud , Vacunación

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Diabetes mellitus type 2 (DM2) is a complex disease associated with chronic inflammation, end-organ damage, and multiple comorbidities. Initiatives are emerging for a more personalized approach in managing DM2 patients. We hypothesized that by clustering inflammatory markers with variables indicating the sociodemographic and clinical contexts of patients with DM2, we could gain insights into the hidden phenotypes and the underlying pathophysiological backgrounds thereof. We applied the k-means algorithm and a total of 30 variables in a group of 174 primary care (PC) patients with DM2 aged 50 years and above and of both genders. We included some emerging markers of inflammation, specifically, neutrophil-to-lymphocyte ratio (NLR) and the cytokines IL-17A and IL-37. Multiple regression models were used to assess associations of inflammatory markers with other variables. Overall, we observed that the cytokines were more variable than the marker NLR. The set of inflammatory markers was needed to indicate the capacity of patients in the clusters for inflammatory cell recruitment from the circulation to the tissues, and subsequently for the progression of end-organ damage and vascular complications. The hypothalamus-pituitary-thyroid hormonal axis, in addition to the cytokine IL-37, may have a suppressive, inflammation-regulatory role. These results can help PC physicians with their clinical reasoning by reducing the complexity of diabetic patients.

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BACKGROUND: Embedding patient accommodation need in the electronic health record (EHR) has been proposed as one means to improve health care delivery to patients with disabilities. Accommodation need is not a standard field in commercial EHR software. However, some medical practices ask about accommodation need and store it in the EHR. Little is known about how the information is used, or barriers to its use. This exploratory-descriptive study examines whether and how information about patients' disability-related accommodation needs stored in patient records is used in a primary health care center to plan for care. METHODS: Four focus groups (n = 35) were conducted with staff of a Federally Qualified Health Center that asks four accommodation questions at intake for the EHR. Respondents were asked how they learned about patient accommodation need, whether and how they used the information in the EHR, barriers to its use, and recommendations for where accommodation information should reside. A brief semi-structured interview was conducted with patients who had indicated an accommodation need (n = 12) to learn their experience at their most recent appointment. The qualitative data were coded using structural coding and themes extracted. RESULTS: Five themes were identified from the focus groups: (1) staff often do not know accommodation needs before the patient's arrival; (2) electronic patient information systems offer helpful information, but their structure creates challenges and information gaps; (3) accommodations for a patient's disability occur, but are developed at the time of visit; (4) provider knowledge of a regular patient is often the basis for accommodation preparation; and (5) staff recognize benefits to advance knowledge of accommodation needs and are supportive of methods to enable it. Most patients did not recall indicating accommodation need on the intake form. However, they expected to be accommodated based upon the medical practice's knowledge of them. CONCLUSIONS: Patient accommodation information in the EHR can be useful for visit planning. However, the structure must enable transfer of information between scheduling and direct care and be updatable as needs change. Flexibility to record a variety of needs, visibility to differentiate accommodation need from other alerts, and staff education about needs were recommended.

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Personas con Discapacidad , Registros Electrónicos de Salud , Necesidades y Demandas de Servicios de Salud , Atención Primaria de Salud/organización & administración , Adulto , Personas con Discapacidad/estadística & datos numéricos , Femenino , Grupos Focales , Humanos , Masculino , Investigación Cualitativa

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OBJECTIVES: To characterize deep skin and soft tissue infections (dSSTI) caused by Panton-Valentine leukocidin (PVL)-positive versus PVL-negative Staphylococcus aureus isolates. METHODS: We performed a retrospective analysis of patients' records including S. aureus isolates from outpatients with dSSTI. Samples had been submitted by primary care physicians, i.e. general practitioners, surgeons, dermatologists and paediatricians, located in Berlin, Germany, in 2007-2017. Bacterial isolates were identified and tested for antimicrobial susceptibility by VITEK 2; PVL was detected by PCR. RESULTS: In total, 1199 S. aureus isolates from 1074 patients with dSSTI were identified, and 613 (51.1%) of 1199 samples were PVL+. The median age of patients with PVL+S. aureus was lower than in patients with PVL- S. aureus (34 years, range 0-88 years, vs. 44 years, range 0-98 years; p < 0.0001). PVL was associated with repeated/multiple samples compared to single sample submission (69/92, 75% vs. 448/982, 45.6%, p < 0.0001; odds ratio (OR), 3.6; 95% confidence interval (CI), 2.2-5.8). Interestingly, the highest PVL positivity rate was found in isolates from gluteal (82/108, 75.9%; OR, 3.6; 95% CI, 2-5) or axillary (76/123, 61.8%; OR, 2; 95% CI, 1.1-3.3) localizations compared to isolates from the arm. The PVL positivity rate did not increase over time. Yet we noticed an increase in the trimethoprim/sulfamethoxazole (SXT) resistance rate in PVL+ isolates, mainly methicillin-sensitive S. aureus, when considering SXT resistance rates of 2007-2012 versus 2013-2017 (35/226, 15.5% vs. 74/289, 25.6%; p 0.01). CONCLUSIONS: In outpatients, gluteal and axillary dSSTI are indicative of PVL+S. aureus. Providing SXT as a complementary treatment for dSSTI should be based on susceptibility testing.

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Toxinas Bacterianas/metabolismo , Exotoxinas/metabolismo , Leucocidinas/metabolismo , Infecciones de los Tejidos Blandos/patología , Infecciones Cutáneas Estafilocócicas/patología , Staphylococcus aureus/metabolismo , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Antibacterianos/uso terapéutico , Proteínas Bacterianas/metabolismo , Niño , Preescolar , Humanos , Lactante , Pruebas de Sensibilidad Microbiana , Persona de Mediana Edad , Proteínas de Unión a las Penicilinas/metabolismo , Atención Primaria de Salud , Estudios Retrospectivos , Infecciones de los Tejidos Blandos/tratamiento farmacológico , Infecciones de los Tejidos Blandos/microbiología , Infecciones Cutáneas Estafilocócicas/tratamiento farmacológico , Infecciones Cutáneas Estafilocócicas/microbiología , Staphylococcus aureus/aislamiento & purificación , Combinación Trimetoprim y Sulfametoxazol/uso terapéutico , Adulto Joven

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OBJECTIVES: This study aims to analyze the accuracy and predictive ability of the Risk Instrument for Screening in the Community (RISC) scored by general practitioners (GPs) in a sample of primary care patients aged 80+ with perceived mental health concerns. METHOD: GPs ranked the perceived risk of the three adverse outcomes (hospitalization, institutionalization and death) at 1 year in a five Likert scale (RISC score), where 1 is the lowest risk and 5 is the highest. Follow up contacts were conducted after 1 year of assessment in order to collect data on the three outcomes. RESULTS: The 1-year proportion of institutionalization, hospitalization and death were 12.1 %, 25.2 % and 19.0 % respectively. Based upon the sensitivity and specificity from the Receiver Operating Characteristic (ROC) curves, we found an optimal cut-off point of ≥4 for the RISC. The RISC had fair accuracy for 1-year risk of institutionalization (Area Under the ROC curve (AUC) = 0.75, 95% CI 0.43-0.68) and hospitalization (AUC = 0.65, 95% CI 0.52-0.78), but not for death (AUC = 0.55, 95% CI 0.43-0.68). CONCLUSIONS: The RISC as a short global subjective assessment is to be considered a reliable tool for use by GPs. Our results showed that RISC seems to be a good instrument to triage very old people at risk for institutionalization but with poor accuracy at predicting hospitalization and limited predictive ability for death, suggesting further research and caution on this instrument's use.

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Evaluación Geriátrica/métodos , Hospitalización/estadística & datos numéricos , Institucionalización/estadística & datos numéricos , Atención Primaria de Salud , Anciano de 80 o más Años , Muerte , Femenino , Humanos , Masculino , Riesgo

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The present study examined the role of vitality as a mediator of the association between dispositional hope and quality of life (QoL) (namely, physical health, psychological health, social relationships, and environment) in a sample of 101 adult primary care patients. Vitality was found to fully mediate the relationship between hope and physical health, social relationships, and environment. In addition, vitality was found to partially mediate the association between hope and psychological health. The present findings are consistent with a model in which vitality represents an important mechanism through which hope affects QoL in adults. Accordingly, these findings point to the importance of fostering both hope and vitality in efforts to promote positive QoL in adults.

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Esperanza , Satisfacción Personal , Aptitud Física , Atención Primaria de Salud , Calidad de Vida/psicología , Autoimagen , Adolescente , Adulto , Correlación de Datos , Femenino , Humanos , Relaciones Interpersonales , Masculino , Persona de Mediana Edad , Medio Social , Adulto Joven

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OBJECTIVES: To estimate the 6-month prevalence of generalized anxiety disorder (GAD) in primary care patients aged 70 years and above and to describe their clinical profile, including types of worries. METHODS/DESIGN: Participants (N = 1193) came from the Étude sur la Santé des Aînés (ESA) services study conducted in Quebec, Canada. An in-person structured interview was used to identify GAD and other anxiety/depressive disorders as well as to identify types of worries. Three groups were created (ie, patients with GAD, patients with another anxiety disorder, and patients without anxiety disorders) and compared on several sociodemographic and clinical characteristics using multinomial logistic regression analyses. RESULTS: The 6-month prevalence of GAD was 2.7%. Findings also indicated that the most common types of worries were about health, being a burden for loved ones, and losing autonomy. Compared with respondents without anxiety disorders, older patients with GAD were more likely to be women, be more educated, suffer from depression, use antidepressants, be unsatisfied with their lives, and use health services. In comparison with respondents with another anxiety disorder, those with GAD were 4.5 times more likely to suffer from minor depression. CONCLUSIONS: GAD has a high prevalence in primary care patients aged 70 years and above. Clinicians working in primary care settings should screen for GAD, since it remains underdiagnosed. In addition, it may be associated with depression and life dissatisfaction. Screening tools for late-life GAD should include worry themes that are specific to aging.

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Trastornos de Ansiedad/epidemiología , Atención Primaria de Salud/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Trastorno Depresivo/epidemiología , Femenino , Servicios de Salud , Humanos , Masculino , Prevalencia , Quebec/epidemiología

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There is a large gap between life expectancy and healthy life years at age 65. To reduce this gap, it is necessary that people with medical concerns perceived at higher risk of adverse outcomes are readily identified and treated. The same goes for the need to implement prevention plans. The main objectives of this study are to, in a first step, (a) estimate the percentage of medical concerns, (b) identify factors associated with this concern; in a second step, (c) estimate the perceived risk of death, and (d) evaluate the ability of medical concerns to predict this risk. Results show that the existence and severity of medical concerns are crucial in the prediction of perceived risk of death. Early identification of severity of medical concerns and the availability and adequacy of informal caregiving should allow healthcare professionals to promptly initiate an appropriate assessment and treatment of older patients.

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Muerte , Estado de Salud , Atención Primaria de Salud/métodos , Medición de Riesgo/métodos , Índice de Severidad de la Enfermedad , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Atención Primaria de Salud/normas , Pronóstico , Medición de Riesgo/normas

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BACKGROUNDS: The quality of life and survival of elderly depend not only on their age but on many social and health factors. In the present study, comprehensive geriatric assessment (CGA) was made in elderly patients on regular hemodialysis (HD) and those without chronic kidney disease recruited in primary health care in order to compare their sociodemographic characteristics, physical health, functional ability and social support. METHOD: The 106 HD patients and 300 primary care patients aged 70 years and more were studied. Data on sociodemographic characteristics, neurosensory deficits, pain, falls, polypharmacy, basic activities of daily living (ADL) questionnaire, instrumental activities of daily living (IADL) questionnaire were obtained during interview. The Timed Up and Go, Nutritional Health Checklist, Two Question Instrument for depression and Charlson comorbidity index (CCI) were applied. RESULTS: No significant differences were found for age, gender, education level and dwelling between the two groups. A lower percentage of HD patients lived alone when compared with controls. BMI >25 kg/m(2) had 43.4% of HD patients and 49.3% of controls. CCI differed significantly between HD and primary care patients (median: 6 vs. 4) and significantly more HD patients reported depression. No significant difference was found between groups for cognitive dysfunction and ADL, but HD patients had significantly lower IADL scores than controls. The mobility of HD patients was worse; 45.7% of them reported falls in the previous year but only 9.7% from the controls. CONCLUSIONS: CGA revealed that HD patients had significantly higher CCI, worse IADL score, mobility and reported more frequent falls, depression and impaired vision than primary care patients.

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Depresión/diagnóstico , Evaluación Geriátrica/métodos , Atención Primaria de Salud/organización & administración , Calidad de Vida/psicología , Diálisis Renal/psicología , Accidentes por Caídas , Actividades Cotidianas , Anciano , Anciano de 80 o más Años , Cognición , Estudios Transversales , Femenino , Humanos , Masculino , Escalas de Valoración Psiquiátrica , Factores de Riesgo , Encuestas y Cuestionarios

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OBJECTIVES: The study examines the difference in characteristics between primary care patients who turn to "religious resources for medical purposes" (RRMP) and those who turn to "complementary or alternative medicine" (CAM) services to cope with a physical or mental health problem. DESIGN AND SETTING: Data were collected from eight primary care clinics in Israel and included 905 Jewish patients aged 25-75. MAIN OUTCOME MEASURE: A self-report questionnaire with a battery of validated mental health assessment instruments and two questionnaires regarding use of unconventional therapies (RRMP and CAM services) were administered to the participants. The association of various variables with type of 'service use' was examined through logistic regression analysis. RESULTS: Primary care patients suffering from emotional problems have a propensity to utilize unconventional therapies in addition to conventional medical treatment. However, differences exist between patients who turn to RRMP and to CAM. The risk factors for turning to RRMP are North African, Middle Eastern or Israeli origin, low SES, religious observance, and high use of primary care clinics. For using CAM services the risk factor is high SES. CONCLUSIONS: In the present study, a quarter of primary care patients also use additional resources for their medical problems. While all segments of the population use unconventional resources, our study reveals that two types of unconventional therapies - RRMP and CAM - tend to be used by two different population sectors. It is noteworthy that those suffering from mental health problems are more likely to utilize unconventional resources.

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Terapias Complementarias/estadística & datos numéricos , Pacientes/estadística & datos numéricos , Atención Primaria de Salud/métodos , Terapias Espirituales/estadística & datos numéricos , Adulto , Anciano , Femenino , Humanos , Israel , Modelos Logísticos , Masculino , Persona de Mediana Edad , Atención Primaria de Salud/estadística & datos numéricos , Religión , Encuestas y Cuestionarios

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BACKGROUND: To measure and compare the extent to which shared a decision making (SDM) process is implemented both in psychiatric outpatient clinical encounters and in the primary care setting from the patient's perspective. METHODS: A total of 1,477 patients recruited from the Canary Islands Health Service mental health and primary care departments were invited to complete the nine-item Shared Decision Making Questionnaire (SDM-Q-9) immediately after their consultation. MANCOVA, Student's t-test, and Pearson correlations were used to assess the relationship and differences between SDM-Q-9 scores in patient samples. RESULTS: No differences were found in SDM-Q-9 total scores between the two patient samples, but there were relevant differences when item by item analysis was applied; differences were observed according to the different steps of the SDM process. SDM is present to a very limited extent in the routine psychiatric setting compared to primary care. Patients' age, education, type of appointment, and treatment decision all play a specific role in predicting SDM. CONCLUSION: The study provides evidence that SDM is a complex process that needs to be analyzed according to its different steps. SDM patterns were different in the primary care and psychiatric outpatient care settings and reflect quite a different perspective of the decision making process.