Shared decision making for psychiatric medication management: beyond the micro‐social

Abstract

BackgroundMental health care has lagged behind other health‐care domains in developing and applying shared decision making (SDM) for treatment decisions. This is despite compatibilities with ideals of modern mental health care such as self‐management and recovery‐oriented practice, and growing policy‐level interest. Psychiatric medication is a mainstay of mental health treatment, but there are known problems with prescribing practices, and service users report feeling uninvolved in medication decisions and concerned about adverse effects. SDM has potential to produce better tailoring of psychiatric medication to individuals' needs.ObjectivesThis conceptual review argues that several aspects of mental health care that differ from other health‐care contexts (e.g. forms of coercion, questions about service users' insight and disempowerment) may impact on processes and possibilities for SDM. It is therefore problematic to uncritically import models of SDM developed in other health‐care contexts. We argue that decision making for psychiatric medication is better understood in a broader way that moves beyond the micro‐social focus of a medical consultation. Contextualizing specific medication‐related consultations within longer term relationships, and broader service systems enables recognition of the multiple processes, actors and agendas that shape how psychiatric medication is prescribed, managed and used, and which may facilitate or impede SDM.ConclusionA broad conceptualization of decision making for psychiatric medication that moves beyond the micro‐social can account for why SDM in this domain remains a rarity. It has both conceptual and practical utility for evaluating research evidence, identifying future research priorities and highlighting fruitful ways of developing and implementing SDM in mental health care.

Psychiatric service staff perceptions of implementing a shared decision-making tool: a process evaluation study

“…This finding mirrors international implementation studies on SDM which illustrate that the desire for participation is still greater than the degree of actual participation in practice. In existing research, a number of barriers are outlined related to a successful implementation of SDM, including time constraints, excessive workload of staff, lack of training to staff and users, and lack of access to medical information and decision support to users (Duncan et al, 2010; Morant et al, 2015; Stovell et al, 2016). In the actual implementation, the first training day was initially conceived of as an attempt to lift theories and principles related to participation, to a level that could be discussed and that would lay the groundwork for a shared approach in relation to values, knowledge and required structural changes.…”

“…SDM diverges radically from compliance, which is often a primary focus in treatment planning, since it assumes that two experts—the user and the practitioner—must share their respective knowledge, experience and viewpoints and collaboratively agree upon the choice of treatment. Despite these potential benefits, research on SDM and its implementation in practice in psychiatric care is still at a formative stage (Morant, Kaminskiy, & Ramon, 2015; Stovell et al, 2016). Attempts to describe and measure the benefits of SDM in psychiatric care have often been compromised by poor implementation (Morant et al, 2015; Ramon et al, 2017; Slade, 2017; Stovell et al, 2016).…”

“…Despite these potential benefits, research on SDM and its implementation in practice in psychiatric care is still at a formative stage (Morant, Kaminskiy, & Ramon, 2015; Stovell et al, 2016). Attempts to describe and measure the benefits of SDM in psychiatric care have often been compromised by poor implementation (Morant et al, 2015; Ramon et al, 2017; Slade, 2017; Stovell et al, 2016). In the field of somatic care, SDM has been described as a process of supportive collaboration between users and staff, drawing on user’s preferences and values, and the best available evidence to discuss multiple options and reach a consensus in care (Duncan, Best, & Hagen, 2010; O’Connor et al, 2007).…”

Recovery-oriented Medical Training: An Informational Rapid Literature Review for the University of Recovery as a New Concept of Co-learning between Patients and (Future) Healthcare Providers

“…In effect, even though several aspects of mental health care differ from other health-care contexts (e.g. forms of coercion, questions about service users' insight and disempowerment, stigma against the mentally ill) [35], we postulate that there is no objective a priori reasons to exclude that such phenomena might also exist with chronic physical illness; they may be simply less readily observable.…”

Title: Playing Telephone: Understanding the state of medication decision making in growing healthcare teams in the time of electronic health records (Preprint)

“…21 The notion of "cautious willingness" also applies to healthcare professional collaboration. 22 Physicians are cautious about giving up a perceived ownership of a patient's care, and pharmacists are equally cautious about making physicians feel like they are trying to take over care. The reluctance of pharmacists to embrace a full scope of practice also reflects serious concerns about missing information.…”