Making decisions about treatment for young people diagnosed with depressive disorders: a qualitative study of clinicians’ experiences

Abstract

BackgroundThe imperative to provide effective treatment for young people diagnosed with depressive disorders is complicated by several factors including the unclear effectiveness of treatment options. Within this context, little is known about how treatment decisions are made for this population.MethodsIn order to explore the experiences and beliefs of clinicians about treatment decision making for this population, semi-structured, qualitative interviews were conducted with 22 psychiatrists, general practitioners and allied health professionals from health care settings including specialist mental health services and primary health care. Interviews were audio taped, transcribed verbatim and analysed using thematic analysis.ResultsClinicians largely reported and endorsed a collaborative model of treatment decision making for youth depression, although several exceptions to this approach were also described (e.g. when risk issues were present), highlighting a need to adapt the decision-making style to the characteristics and needs of the client. A differentiation was made between the decision-making processes (e.g. sharing of information) and who makes the decision. Caregiver involvement was seen as optional, especially in situations where no caregivers were involved, but ideal and useful if the caregivers were supportive. Gaps between the type and amount of information clinicians wanted to give their clients and what they actually gave them were reported (e.g. having fact sheets on hand). A broad range of barriers to involving clients and caregivers in decision-making processes were described relating to four levels (client and caregiver, clinician, service and broader levels) and suggestions were given to help overcome these barriers, including up-to-date, accessible and relevant information.ConclusionsThe current data support a collaborative model of treatment decision making for youth depression which: 1) focuses on the decision-making processes rather than who actually makes the decision; 2) is flexible to the individual needs and characteristics of the client; and 3) where caregiver involvement is optional. Shared decision making interventions and the use of decision aids should be considered for this area.

Qualitative and Mixed Methods in Mental Health Services and Implementation Research

“…As in other fields of inquiry, they have often been used in mental health services research to provide a “thick description” (Geertz, 1970) of phenomena by providing a depth of understanding to complement the breadth of understanding afforded by quantitative methods, aiding in the interpretation of results obtained from quantitative methods, and contextualizing phenomena of interest. Examples of the use of qualitative methods in mental health services research for this purpose include Rhodes' (1991) ethnography of an emergency psychiatric unit; a descriptive account of the way in which clinicians reported making treatment decisions, their beliefs about how decisions should be made, and barriers to making treatment decisions (Simmons, Hetrick & Jorm, 2013); use of qualitative data to contextualize the outcomes evaluation of a quality improvement approach for implementing evidence-based employment services in specialty mental health clinics (Hamilton et al, 2013); and an examination of the context and intervening mechanisms of an RCT evaluating an intervention for shared care in mental health (Byng, Norman, Redfern & Jones, 2008). In the papers included in this special series, Rodriguez, Southam-Gerow and O'Connor (in press) use qualitative methods to “localize” evidence-based practices by providing the necessary insight into the local context in which practices that have been evaluated for their “global” generalizability must be applied.…”

“…Such analysis often involves a rigorous process of reviewing transcripts and other documents line by line and assigning codes based on a priori and/or emergent topics or themes, and the construction of themes (Miles & Huberman, 1994; Strauss & Corbin, 1998). Coding also occurs in stages in which initial preliminary codes are followed by secondary or focused coding (e.g., Green et al, 2008; Simmons et al, 2013), or in which open codes are followed by axial codes (e.g., Hamilton et al, 2013). The papers by Rodriguez and colleagues (in press), Lyon and colleagues (2013), and Dorsey and colleagues (in press) provide an illustration of the inductive process or content or thematic analysis.…”

Identifying and Addressing Barriers to Treatment Decision‐making in Bipolar II Disorder: Clinicians’ Perspective

“…Given that family rarely attend consultations (Drapalski, Leith, & Dixon, 2009), involving family during post-consultation discussions gives them the opportunity to contribute to treatment preferences prior to reaching a final treatment decision. Finally, structuring decisionmaking over multiple consultations may compensate for short consultation times, a common systemic barrier (Morant, Kaminskiy, & Ramon, 2015;Simmons et al, 2013) that was associated with poorer decision quality in this study (i.e., more clinician-led, "prescriptive" decision-making and potentially/reportedly lower patient satisfaction with decision-making). Finally, structuring decisionmaking over multiple consultations may compensate for short consultation times, a common systemic barrier (Morant, Kaminskiy, & Ramon, 2015;Simmons et al, 2013) that was associated with poorer decision quality in this study (i.e., more clinician-led, "prescriptive" decision-making and potentially/reportedly lower patient satisfaction with decision-making).…”

“…Second, having family attend consultations and serve as "a second pair of ears" (Laidsaar-Powell, Butow, Bu, Fisher, & Juraskova, 2016b;Laidsaar-Powell et al, 2016a) may foster better continuity of care through improved communication of information between clinicians. These clinician-related factors have not been systematically explored within other qualitative studies of clinician views in depression (McMullen, 2012;Simmons et al, 2013) and schizophrenia (Farrelly et al, 2016;Seale et al, 2006). Given that clinicians linked family involvement to BPII patient outcomes, both positive (e.g., improved treatment adherence) and negative (e.g., premature discontinuation of medication), ensuring family are informed and involved, to the extent desired by patients, is important.…”

“…This study identified patient-related barriers, such as symptoms, communicative difficulties, as well as clinician-related barriers, such as poor empathy and listening, and discounting patient concerns. In fact, no existing studies have explored the views and experiences of clinicians on the process of treatment decision-making in bipolar disorder , in contrast to several studies on depression (McMullen, 2012;Simmons, Hetrick, & Jorm, 2013) and schizophrenia (Farrelly et al, 2016;Hamann et al, 2015;Seale, Chaplin, Lelliott, & Quirk, 2006). However, this study did not ask specifically about treatment decision-making, and included only patient perspectives.…”