There’s a lot of talk about ‘shared decision making’ in the NHS right now. Many mental health patients say that they do not feel that they are properly listened to or that their expertise is not valued in the consultation, but it’s clear that many health professionals are quite evangelical about working in partnership with service users to determine the best approach to care.
Indeed, it’s a core principle of evidence-based medicine that clinicians should integrate the best research evidence with their own clinical expertise and the values and preferences of the patient. It’s impossible to do this properly without some degree of shared decision making.
The evidence-base around shared decision making in mental health remains fairly sparse. A Cochrane review from 2010 (ref 2) did not find much good quality evidence to speak of and concluded:
No firm conclusions can be drawn at present about the effects of shared decision making interventions for people with mental health conditions. There is no evidence of harm, but there is an urgent need for further research in this area.
Many other studies have explored clinical decision making in psychiatry more widely. A paper published in Nov 2011 (ref 3) interviewed 31 psychiatrists and found 7 main themes that influenced their decision making:
- Information gathering
- Training in psychiatry
- Intuition and experience
- Evidence-based practice
- Cognitive reasoning
- Uncontrollable factors
- Multidisciplinary team influences
Interesting to see no patients on that list ;-)
A new randomised controlled trial has been published by researchers from the Technische Universität in Munich, Germany. They studied 61 inpatients with schizophrenia and randomly assigned them to either standard cognitive training or shared decision-making training.
Here’s what they found:
- The patients who had the shared decision-making training were more engaged with treatment and had more interest in becoming responsible for their treatment decisions
- The patients who received the shared decision-making training were more skeptical of their treatment and perceived as more “difficult” by their psychiatrists
This is a very small study, so we shouldn’t read too much into the results, but it will be interesting to see further studies published in this area over the coming years.
The authors of this study certainly seem keen. They concluded by saying:
Training in shared decision making was highly accepted by patients and changed attitudes toward participation in decision making. There were some hints that it might generate beneficial long-term effects.
Links
- Hamann J, Mendel R, Meier A, Asani F, Pausch E, Leucht S, Kissling W. “How to speak to your psychiatrist”: shared decision-making training for inpatients with schizophrenia. Psychiatr Serv. 2011 Oct;62(10):1218-21. [PubMed abstract]
- Duncan E, Best C, Hagen S. Shared decision making interventions for people with mental health conditions. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD007297. DOI: 10.1002/14651858.CD007297.pub2.
- Bhugra D, Easter A, Mallaris Y, Gupta S. Clinical decision making in psychiatry by psychiatrists. Acta Psychiatr Scand. 2011 Nov;124(5):403-11. doi: 10.1111/j.1600-0447.2011.01737.x. Epub 2011 Jul 8. [PubMed abstract]
Very interesting blog and thanks once again for distilling this interesting research. As a follow-up to our Twitter exchange I wanted to try to lay out what I think can be inferred from the the discussion in the German study you mention. I don’t have access to the full text of the paper so my points are only about what is reported in the blog. It seems to me that if psychiatrists find patients who are skeptical ‘difficult’ and those who have had a shared decision making intervention (SDM) more engaged that we could then read SDM as a intervention with an underlying motive of ensuring compliance. I note the recent study by Quirk et al (2012 Sociology of Health and Illness 34(1): 95-113) showing how psychiatrists apply pressure to seek agreement in consultations and wonder if psychiatrists really want assertive knowledgeable patients who disagree with them? The concern then is that how truly shared is decision making in shared decision making and if it comes to be seen as a vehicle of compliance how will patients respond to that?
The right interaction sequence; the right questions and the right feedback: it’s all about the relationship and the content and the effect it has when it his the vulnerable person’s head (and not just triggering associations with all the worst power relationships which the patient can struggle to separate out – it’s about individualized sensitive negotiation – which is proper chivalry – not notional politeness and agreeing) – its not about all these white-coats peering in the pot and struggling to stir it nicely and dropping ingredients in! It’s not your stewpot!? The psychiatry is part of therapy
I believe the author(s) of this summary have misinterpreted the findings in reference 1. The abstract states “Patients in the intervention group became more skeptical of treatment and were perceived as more “difficult” by their psychiatrists.” It also states that subjects “were randomly assigned to receive shared decision-making training (N=32) or cognitive training (N=29, control condition)”. Thus the SDM group is the intervention group and the cognitive group are the controls. I remember reading this article in the past and being struck by the notion that once patients became more skeptical (less readily-accepting) of their prescribers, the prescribers found them to be more difficult. This seems congruent with the comments of other posters.
Thank you Elf.
This is a very important topic, and I think it’s essential that we all have a correct understanding of the scarce research that is available on the subject!
There’s an interesting related piece of research summarised on the Patient Information Forum website: http://www.pifonline.org.uk/research-do-physicians-recommendations-pull-patients-away-from-their-preferred-treatment-options/
“In the decision scenario, about 48% of patients with schizophrenia followed the advice of their physician and thus chose the treatment option that went against their initial preferences. Patients who followed their physician’s advice were less satisfied with their decision than patients not following their physician’s advice.”
Cheers,
The Mental Elf
Hello Mental Elf, and thanks Sharon for pointing that out, because I have now read it with the correction and it makes perfect sense.
All I can say on the subject is, I have seen 5 psychiatrists over time, and the one who worked with me over the first 7 years of my illness probably kept me alive. He prescribed very little meds, he gave me copies of letters and he discussed things with me equally. He tried his best, was person centred and at that time there were very little other options he could give me. However, two of the psychiatrists I saw were downright dangerous. One, cut me off an addictive drug, which is very difficult to come off (you need to taper it) which had been prescribed for me. I felt suicidal within weeks and had to beg him to put me back on it, to deal with the awful symptoms. At the same time I asked to be discharged and was. Another psychiatrist just kept asking me questions about what I could do, like whether I did the cleaning, housework, cooking, like a good little wife!!
How to talk to your psychiatrist indeed?
And, also they can say we have recovered, and not write discharge letters stating, we will be pleased to see her again should the need arise.
We are long past the time for shared decision making in mental health. I thought the patient was the centre of the process. I thought we were entitled to copy letters. I thought they wanted to cut down on prescribing drugs.
I think it is time that psychiatrists could actually discharge patients as cured. In other words that they no longer have that particular mental health issue which brought them into contact with the services in the first place.
Can we have an article about how to talk with your GP about your mental health too.