Shared decision making interventions for people with mental health conditions

Mental health conditions are common and can have serious consequences for both affected individuals and society. Current clinical guidance encourages mental healthcare practitioners to involve patients in treatment decisions. This is advocated on the basis that people have a right to self-determination and also in the expectation that it will increase treatment adherence.

We conducted thorough searches for randomised controlled trials (RCTs), quasi-randomised controlled trials (q-RCTs), controlled before-and-after studies (CBAs); and interrupted time series (ITS) studies of interventions to increase shared decision making in people with mental health conditions. We found two studies that met the inclusion criteria. Both studies were of good quality and made attempts to reduce potential sources of bias.

We examined whether interventions to increase shared decision making affected patient satisfaction with treatment or care, led to better health outcomes or to patients being less likely to be readmitted to hospital. One of the studies indicated that the intervention increased patient satisfaction in the short term. One study indicated that doctor facilitation of consumer involvement in decision making was increased by the intervention, but no effects were found on the clinical or health service outcomes in either study. Neither study reported that shared decision making for people with mental health conditions is harmful. However, no firm conclusions can be drawn from these two studies on any of the outcomes measured and further research is needed.

Authors' conclusions: 

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.

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Background: 

One person in every four will suffer from a diagnosable mental health condition during their life course. Such conditions can have a devastating impact on the lives of the individual, their family and society. Increasingly partnership models of mental health care have been advocated and enshrined in international healthcare policy. Shared decision making is one such partnership approach. Shared decision making is a form of patient-provider communication where both parties are acknowledged to bring expertise to the process and work in partnership to make a decision. This is advocated on the basis that patients have a right to self-determination and also in the expectation that it will increase treatment adherence.

Objectives: 

To assess the effects of provider-, consumer- or carer-directed shared decision making interventions for people of all ages with mental health conditions, on a range of outcomes including: patient satisfaction, clinical outcomes, and health service outcomes.

Search strategy: 

We searched: the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2008, Issue 4), MEDLINE (1950 to November 2008), EMBASE (1980 to November 2008), PsycINFO (1967 to November 2008), CINAHL (1982 to November 2008), British Nursing Index and Archive (1985 to November 2008) and SIGLE (1890 to September 2005 (database end date)). We also searched online trial registers and the bibliographies of relevant papers, and contacted authors of included studies.

Selection criteria: 

Randomised controlled trials (RCTs), quasi-randomised controlled trials (q-RCTs), controlled before-and-after studies (CBAs); and interrupted time series (ITS) studies of interventions to increase shared decision making in people with mental health conditions (by DSM or ICD-10 criteria).

Data collection and analysis: 

Data on recruitment methods, eligibility criteria, sample characteristics, interventions, outcome measures, participant flow and outcome data from each study were extracted by one author and checked by another. Data are presented in a narrative synthesis.

Main results: 

We included two separate German studies involving a total of 518 participants. One study was undertaken in the inpatient treatment of schizophrenia and the other in the treatment of people newly diagnosed with depression in primary care. Regarding the primary outcomes, one study reported statistically significant increases in patient satisfaction, the other study did not. There was no evidence of effect on clinical outcomes or hospital readmission rates in either study. Regarding secondary outcomes, there was an indication that interventions to increase shared decision making increased doctor facilitation of patient involvement in decision making, and did not increase consultation times. Nor did the interventions increase patient compliance with treatment plans. Neither study reported any harms of the intervention. Definite conclusions cannot be drawn, however, on the basis of these two studies.

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