Time to Support Extensive Implementation of Shared Decision Making in Psychiatry

Abstract

Shared decision making (SDM) is a health communication approach focusing on patient-clinician interactions around treatment decisions, with the goals of improving clinical and functional outcomes and providing personalized care. 1 The fundamental principles of SDM involve (1) eliminating power asymmetries between clinician and patient; (2) acknowledging that there are at least 2 expert participants: a patient having livedexperience expertise, a clinician having professional expertise, and sometimes a family member 2 ; (3) eliciting patient preferences for their involvement in the decisionmaking (autonomously, conjointly with clinician input, letting clinician make decisions) and eliciting the patient's specific values that could guide the decision (eg, reducing medication adverse effects); (4) discussing at least 2 treatment options (eg, taking, tapering, or stopping antipsychotic medications); ( 5) making a decision that aligns with the patient's goals, preferences, and values that also makes clear the risks involved in particular decisions 3 ; and (6) accepting that the patient's choice of treatment plan may differ from the clinician's recommendation. SDM has been endorsed as the gold standard of patient-clinician interaction in preferencebased care by the National Academy of Medicine in the US and the National Institute for Health and Care Excellence in the UK. Studies in the last decade of individuals with serious mental illness (SMI) demonstrating the feasibility of using SDM, and showing the potential for improved outcomes, support the recent acknowledgment of SDM as an essential practice by the American Psychiatric Association 4 and the Substance Abuse and Mental Health Services Administration.Despite the potential contribution of SDM in mental health, it has yet to be successfully adopted for use in routine psychiatric care, especially for discussing treatment with individuals with SMI. Several patient-, clinician-, and system/policy-related barriers impeding SDM implementation among individuals with SMI have been identified 5 but only partly addressed. For example, a positive shift toward SDM has occurred at the system/ policy level, with greater acceptance of the notion of SDM in psychiatry by the American Psychiatric Association 4 and Substance Abuse and Mental Health Services Administration. At the patient level, recent systematic reviews indicate increased development and testing of patient decision aids and SDM interventions. Clinician-related barriers to SDM in psychiatry, however, have received far less empirical investigation. Because psychiatrists are an essential part of SDM, the purpose of this Viewpoint is to discuss critical, yet-tobe-addressed, clinician-related barriers that serve as the "elephant in the room," impeding extensive implementation of SDM in psychiatry.

Acceptability of Health Information Exchange and Patient Portal Use in Depression Care Among Underrepresented Patients

“… 5 , 6 2 , 3 7 In response to these challenges, efforts have largely focused on improving initial service linkages through systematic coordination within and across health and mental health care systems, 8 – 10 and encouraging sustained engagement in services by keeping individuals actively involved in their depression care. 11 – 14 …”

NICE shared decision making guidelines and mental health: challenges for research, practice and implementation

“…It dismisses a priori evidence for rich SDM research with individuals with SMI, 3,[6][7][8] and enhances stigmatic beliefs about the ability of individuals with SMI and other concerns regarding capacity to engage in an SDM process, an assumption that is not yet evidence-based. 9,10 As a result, the NICE recommendations for effectiveness approaches and activities to increase engagement in SDM (Evidence Document A) are based on only eight quantitative studies of SDM in mental health and ten qualitative studies. Of the included quantitative studies, only six [11][12][13][14][15][16] are relevant to SMI and addressed SDM in community mental health settings (the others focused on primary care or patients with behavioural health issues 17 or patients with dementia 18 ).…”

Digital Community Inclusion of Individuals With Serious Mental Illness: A National Survey to Map Digital Technology Use and Community Participation Patterns in the Digital Era

“…According to this traditional framework, the term "community participation" includes 3 main types of participation: social (eg, attending a community event, entertaining family or friends at home, or visiting family or friends), productive (going to school to earn a degree or certificate, working for pay, and participating in volunteer activities), and leisure (going to a museum, theater or cultural event, going to a park or recreating center, and going to a restaurant) [41]. Engaging with others in the community may also reduce public stigma toward people with SMI, which in turn can contribute to their recovery [55][56][57].…”