Shared decision-making interventions or care as usual: which works better for people with mental health conditions?
What are mental health conditions?
There are many mental health conditions. They are generally characterised by a combination of abnormal thoughts, perceptions, emotions, behaviour, and relationships with others. Access to health care and social services capable of providing treatment and social support is key.
What did we want to find out?
Shared decision-making is an approach to consumer-professional communication where both parties (e.g. patients or their carers, or both, together with their clinician) are acknowledged to bring equally important experience and expertise to the process. In this approach, both parties work in partnership to make treatment recommendations and decisions.
This approach is considered part of a broader recovery and person-centred movement within the behavioural health field. The focus on recovery and individual responsibility for understanding and managing symptoms in collaboration with professionals, caregivers, peers, and family members is also fundamental to this approach.
Sometimes it also involves a 'decision aid', such as videos, booklets, or online tools, presenting information about treatments, benefits and risks of different options, and identifying ways to make the decision that reflects what is most important to the person. The process of shared decision-making may often also involve decision coaching by someone who is non-directive and provides decision support that aims to prepare people for discussion and the decision in the encounter with their practitioner.
We wanted to find out if shared decision-making interventions were better than care as usual for people with mental health conditions to improve:
• clinical outcomes, such as psychotic symptoms, depression, anxiety, and readmission;
• participation or level of involvement in the decision-making process.
We also wanted to find out if shared decision-making interventions were associated with any unwanted (harmful) effects.
What did we do?
We searched for studies that examined shared decision-making interventions compared with care as usual in people with mental health conditions. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes.
What did we find?
We found 15 studies involving 3141 adults, from seven countries: Germany, Italy, Japan, Saudi Arabia, the Netherlands, the UK, and the USA.
Care settings included primary care, community mental health services, outpatient psychiatric services, specialised outpatient services such as post-traumatic stress disorder clinics, forensic psychiatric services, and nursing home wards.
The mental health conditions studied were schizophrenia, depression, bipolar disorder, post-traumatic stress disorder, dementia, substance-related disorders and multiple clinical conditions, including personality disorder. Care providers included family carers, clinicians, case managers, nurses, pharmacists, and peer supporters. Three studies used an interprofessional collaboration.
When people with mental health conditions receive shared decision-making interventions, we do not know if their clinical conditions change. They may feel that they participated more in decision-making processes compared with those receiving usual care, although we are uncertain about this when participation was measured in other ways or at later time points after the consultation.
People who take this approach probably improve some, but not all, aspects of their satisfaction with received information compared with those receiving usual care.
Although it is often suggested that shared decision-making takes a lot of time, we found that there is probably little or no difference compared with usual care in the length of consultation.
We are uncertain about whether shared decision making-interventions change outcomes such as recovery, carer satisfaction, healthcare professional satisfaction, knowledge, treatment/medication continuation, carer participation, relationship with healthcare professionals, length of hospital stay, or possible harmful effects.
Further research is needed in this area. Longer term follow-up is also needed to better determine the impact of shared decision-making on: perceptions of quality of life; impact on frequency and severity of crises, hospitalisations, or both; stability of key functions of life, work, housing and overall health; and satisfaction with decision-making.
The review is up to date as of January 2020.