Is there ‘parity of esteem’ in shared decision making between physical and mental health?

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Current health and social care policies determine that people who use services should have choice and control over their care and support. This is particularly important for people with mental health problems who are managing their mental health and designing support in preventative ways to avoid crisis. One way for mental health service practitioners to enable this approach is to share decision making about treatment and support with mental health service users.

The aim of this study was to compare and measure the extent to which shared decision making with people with mental health problems takes place in primary care and in psychiatric outpatient settings. The researchers focused on the patient’s perspective on shared decision making between them and the clinician. While the study was conducted in the Canary Islands, the topic is of relevance to the UK where a core mental health policy theme is ‘parity of esteem’ between physical and mental health. This piece of research compares how shared decision making can happen for physical health in primary care and for mental health in psychiatric outpatient settings and sheds light on an aspect of parity between physical and mental health.

Methods

A total of 1,477 patients were recruited from one community mental health centre and two primary care centres in the Canary Islands Health Service. 571 people using psychiatric outpatient services finally agreed to participate along with 540 people who were using primary care services. Primary care patients who were also receiving mental health services were excluded.

Participants completed an anonymous, self-administered nine item Shared Decision Making Questionnaire (SDM-Q-9 PDF) immediately after they had seen their clinician. The SDM-Q-9 is a valid, reliable and brief self-report questionnaire that is used to assess the patients’ view of decision making processes during consultations.

Participants were asked to think about their last consultation for the questionnaire rating.

Two appointment types were considered:

  • New and follow-up scheduled appointments to monitor the condition or review treatment
  • Non-scheduled consultation if condition is worsening or there is an emergency

Treatment decisions were categorised as follows:

  • Prescription of a new treatment
  • Maintenance of previous treatment
  • Modification of previous treatment by altering dosage

Statistical tests were used to assess the relationship and differences between the questionnaire scores in the groups of patients in primary care and psychiatric outpatients.

Patients completed questionnaires, which means that the research may suffer from recall and response bias

Patients completed questionnaires, which means that the research may suffer from recall and response bias

Results

The researchers reported that:

No disparity was found for total [questionnaire] score [but] specific items showed statistically significant differences between the two groups of patients…While most primary care patients agreed with each and every one of the questionnaire items, most psychiatric outpatients disagreed with five of the items

The five items that participants using psychiatric outpatient services most commonly disagreed with, related to making informed decisions about different treatment options and their advantages and disadvantages. Most said they were helped to understand the information but:

  • They were not asked about which treatment option they preferred
  • There was no negotiation
  • The selection of treatment was not a consensus decision
  • They were not asked about arranging a follow-up
Psychiatric outpatients did not always feel involved in the decision making process

Psychiatric outpatients did not always feel involved in the decision making process

Conclusion

Overall the researchers concluded that:

Our results show no differences in final SDM between patients’ perceptions, but when a contrast was made step by step in SDM (as items), several differences were found. These differences support the fact that regardless of the final results, the process to come to a shared decision has a distinctive profile, depending on the type of medical care.

According to patient experience, psychiatric outpatient services emphasise shared decision making in the initial steps of a consultation while primary care emphasises decision making in the final steps. The researchers say that:

Psychiatric outpatients considered that during their agreement at initial steps (when a decision must be made), they report their disagreement with the subsequent (successive) steps of the decision making process, including sharing decisions. On the other hand, most primary care patients reported having taken part in each step of the decision making process.

Summing up

This study suggests that people who use community mental health services may be less likely to be involved in making shared decisions about treatment and support than people using primary care services for physical conditions. Because treatment adherence is an important feature of mental health management, it is very important that people with mental health problems participate in informed, shared decision making about treatment. More broadly, shared decision making is part of personalised care and support and will become a key feature of practice as personal health budgets are introduced for mental health.

Although the authors note limitations about self-report instruments (particularly in terms of recall and response bias), the research suggests that the SDM-Q-9 questionnaire could be a useful way of helping patients to report back on experiences of shared decision making to improve clinical practice, particularly in mental health.

Even though the research was carried out in the Canary Islands with a particular population and health system which means generalising the findings is problematic, it nonetheless suggests some interesting disparities in shared decision making between physical and mental health services. In the UK context where ‘parity of esteem’ with physical health is a focus for mental health policy, it may be useful to replicate the study to explore the shared decision making in UK clinical practice.

This study suggests that people who use community mental health services may be less likely to be involved in making shared decisions about treatment and support than people using primary care services for physical conditions

People who use community mental health services may be less likely to be involved in making shared decisions than people using primary care services for physical conditions

Links

De Las Cuevas C, Peñate W, Perestelo-Pérez L, Serrano-Aguilar P. Shared decision making in psychiatric practice and the primary care setting is unique, as measured using a 9-item Shared Decision Making Questionnaire (SDM-Q-9). Neuropsychiatr Dis Treat. 2013;9:1045-52. doi: 10.2147/NDT.S49021. Epub 2013 Jul 30.

Kriston, L., Scholl, I., Hölzel, L., Simon, D., Loh, A. & Härter, M. (2010). The 9-item Shared Decision Making Questionnaire (SDM-Q-9) (PDF). Development and psychometric properties in a primary care sample. Patient Education and Counseling, 80 (1), 94-99.

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Sarah Carr

Sarah Carr

Sarah is Associate Professor of Mental Health Research at Middlesex University. Sarah also runs an independent mental health and social care knowledge consultancy. She has a background as a senior research and policy analyst in mental health and social care, with a focus on service user participation, personalisation and equality issues, having formerly worked for the Social Care Institute for Excellence (SCIE). She is an Honorary Senior Lecturer at Institute for Applied Social Science at the University of Birmingham, an Honorary Visiting Fellow, Social Policy and Social Work at the University of York and a Fellow of the Royal Society of Arts. Co-chair of the National Survivor and User Network (NSUN) and a member of the editorial boards of the journals Disability and Society and Lancet Psychiatry, Sarah has a particular interest in social care and mental health issues and is a long term user of services.

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