How to speak to your psychiatrist: are we ready for shared decision making in mental health?

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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:

  1. Information gathering
  2. Training in psychiatry
  3. Intuition and experience
  4. Evidence-based practice
  5. Cognitive reasoning
  6. Uncontrollable factors
  7. 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

  1. 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]
  2. 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.
  3. 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]
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