Mental health is an integral component of overall well-being; as Saxena (2013) stated, "there is no health without mental health." However, mental health conditions are often stigmatized and lack adequate support for treatment or care (Rehm 2019). This can lead to significant personal, social, and economic burdens for individuals and families. Addressing these challenges requires innovative approaches to mental healthcare, with a growing emphasis on shared decision-making (SDM).
The Imperative of Mental Health
Mental health problems are a global concern, affecting individuals across the life course (Kessler 2007). The repercussions of mental illness extend to various aspects of life, impacting one's ability to function at home and in the workplace. Families are also affected, and the economic costs to society rise (WHO 2011). Despite the prevalence and impact of mental health conditions, many countries invest less than 1% of their health budgets in mental health services (WHO 2015). This disparity highlights the urgent need for increased attention and resources to address mental health needs effectively.
Understanding Shared Decision-Making (SDM)
Shared decision-making (SDM) represents a paradigm shift from traditional, paternalistic approaches in healthcare, where physicians drive the decision-making process (Charles 1997). SDM emphasizes a collaborative partnership between the clinical team and the patient (Montori 2017). In this model, all parties acknowledge equally important experience and expertise to the process (Charles 1997).
Defining SDM
SDM involves a process where patients and healthcare professionals work together to make informed decisions about treatment and care. It's a partnership between the clinical team (not just the clinician) and the patient (Montori 2017). This partnership approach is distributed over a range of people and times or episodes (Rapley 2008).
Makoul (2006) addressed SDM in healthcare to determine the range of conceptual definitions and characteristics. Trevena (2003) highlighted the importance of exchanging information, considering patient preferences, and clarifying practitioner responsibilities. Unsurprisingly, SDM does not mean the same thing in all cases.
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The Core Principles of SDM
At its core, SDM is about empowering individuals to take an active role in managing their health. It involves:
- Information Exchange: Ensuring patients have access to comprehensive and understandable information about their condition, treatment options, and potential outcomes.
- Preference Elicitation: Understanding and respecting patients' values, beliefs, and preferences regarding their health and treatment.
- Collaborative Deliberation: Engaging in open and honest dialogue between patients and healthcare providers to weigh the pros and cons of different options and arrive at a mutually agreed-upon decision.
SDM in Mental Health: A Recovery-Oriented Approach
Within the behavioral health field, SDM aligns with the principles of recovery, which emphasizes hope, finding meaning in life, empowerment, and taking responsibility for recovery (Van Eck 2018). Recovery from mental illness involves accepting and overcoming the challenge of the disability (Deegan 1988; Anthony 1993). It also means control being placed in the hands of the individual and not the professional (Jacobson 2001). SDM supports this by promoting person-centered care.
Evidence-Based Assessment of SDM Interventions
Given the increasing interest in SDM, it is crucial to evaluate the effectiveness of SDM interventions in improving outcomes for individuals with mental health conditions. A Cochrane review assessed whether SDM interventions improve a range of outcomes. The review included 15 RCTs and used standard methodological procedures expected by Cochrane.
Study Characteristics
The review included studies enrolling individuals of all ages with various mental health conditions, including schizophrenia, depression, and bipolar disorder, in higher‐income countries. The studies took place in Europe or the USA, and three studies were in Japan. The 15 studies recruited a total of 3141 people with mental health conditions.
Interventions varied across studies, including decision coaching sessions, decision aids, and the use of decision boards during consultation with physicians (Loh 2007). Comparators included usual care, treatment as usual, or control groups, which do not explicitly intend to involve patients.
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Key Findings
The review's findings were based on low- or very low-certainty evidence, leaving uncertainty about the effects of SDM interventions on various outcomes.
- Primary Outcomes: There was little or no difference between groups regarding mental health symptoms (e.g. depression, anxiety) and social functioning.
- Service User Satisfaction: We are uncertain if SDM interventions improve users' overall satisfaction.
- Secondary Outcomes: Moderate-certainty evidence suggests that people in the SDM group were more likely to have the information shared with others in this way (RR 1.32, 95% CI 1.11 to 1.58).
Limitations and Considerations
Several factors limit the strength of the conclusions that can be drawn from the available evidence:
- Heterogeneity: The meta-analyses showed considerable heterogeneity for almost all outcomes, which could be attributed to variations in study populations, interventions, and measurement in use.
- Risk of Bias: Several studies were judged to have a high risk of bias due to issues such as inadequate blinding, missing data, and small sample sizes.
- Underpowered Studies: Many studies were underpowered to detect important differences in outcomes.
- Variability in Interventions: The components of the SDM interventions adopted by the included studies varied (e.g. physician versus those involved an interprofessional team).
Implications for Practice and Research
Despite the limitations, this review highlights potential benefits of SDM in mental health settings. SDM interventions may prolong the consultation duration.
Further research is needed to strengthen the evidence base for SDM in mental health. Future studies should:
- Employ rigorous methodologies to minimize bias and ensure adequate statistical power.
- Standardize outcome measures to reduce heterogeneity and facilitate comparisons across studies.
- Investigate the specific components of SDM interventions that contribute to positive outcomes.
- Explore the cost-effectiveness of SDM interventions in mental health settings.
Practical Applications of SDM
Implementing SDM in mental health settings requires a multifaceted approach that addresses organizational, provider, and patient-level factors.
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Organizational Support
Healthcare organizations can foster a culture of SDM by:
- Providing training and resources to support healthcare professionals in implementing SDM.
- Integrating SDM into clinical guidelines and protocols.
- Creating patient-friendly materials and decision aids to facilitate informed decision-making.
- Establishing mechanisms for monitoring and evaluating the implementation of SDM.
Provider Engagement
Healthcare professionals can promote SDM by:
- Building rapport and trust with patients.
- Actively listening to patients' concerns and preferences.
- Providing clear and unbiased information about treatment options.
- Encouraging patients to ask questions and express their opinions.
- Collaborating with patients to develop individualized treatment plans.
Patient Empowerment
Patients can take an active role in SDM by:
- Educating themselves about their condition and treatment options.
- Reflecting on their values, beliefs, and preferences regarding their health.
- Communicating openly and honestly with their healthcare providers.
- Asking questions and seeking clarification when needed.
- Participating in shared decision-making tools and resources.