Abstract
BackgroundMental health policy makers encourage the development of electronic decision aids to increase patient participation in medical decision making. Evidence is needed to determine whether these decision aids are helpful in clinical practice and whether they lead to increased patient involvement and better outcomes.ObjectiveThis study reports the outcome of a randomized controlled trial and process evaluation of a Web-based intervention to facilitate shared decision making for people with psychotic disorders.MethodsThe study was carried out in a Dutch mental health institution. Patients were recruited from 2 outpatient teams for patients with psychosis (N=250). Patients in the intervention condition (n=124) were provided an account to access a Web-based information and decision tool aimed to support patients in acquiring an overview of their needs and appropriate treatment options provided by their mental health care organization. Patients were given the opportunity to use the Web-based tool either on their own (at their home computer or at a computer of the service) or with the support of an assistant. Patients in the control group received care as usual (n=126). Half of the patients in the sample were patients experiencing a first episode of psychosis; the other half were patients with a chronic psychosis. Primary outcome was patient-perceived involvement in medical decision making, measured with the Combined Outcome Measure for Risk Communication and Treatment Decision-making Effectiveness (COMRADE). Process evaluation consisted of questionnaire-based surveys, open interviews, and researcher observation.ResultsIn all, 73 patients completed the follow-up measurement and were included in the final analysis (response rate 29.2%). More than one-third (48/124, 38.7%) of the patients who were provided access to the Web-based decision aid used it, and most used its full functionality. No differences were found between the intervention and control conditions on perceived involvement in medical decision making (COMRADE satisfaction with communication: F1,68=0.422, P=.52; COMRADE confidence in decision: F1,67=0.086, P=.77). In addition, results of the process evaluation suggest that the intervention did not optimally fit in with routine practice of the participating teams.ConclusionsThe development of electronic decision aids to facilitate shared medical decision making is encouraged and many people with a psychotic disorder can work with them. This holds for both first-episode patients and long-term care patients, although the latter group might need more assistance. However, results of this paper could not support the assumption that the use of electronic decision aids increases patient involvement in medical decision making. This may be because of weak implementation of the study protocol and a low response rate.Trial RegistrationDutch Trial Register (NTR) trial number: 10340; http://www.trialregister.nl/trialreg/admin/rctsearch.asp?Term=10340 (Archived by WebCite at http://www.webcitation.org/6Jj5umAeS).
Highlights
Shared decision making in mental health care has been dubbed an ethical imperative [1]
Results of this paper could not support the assumption that the use of electronic decision aids increases patient involvement in medical decision making
The second question was: Do clinicians think there are too many hampering factors to realize a process of shared decision making? In addition, 18 clinicians reported that in processes of shared decision making, the following factors were often or almost always experienced as hampering decision making: patients receive contradictory advice from multiple clinicians (12/18, 67%), patients have difficulty accepting their diagnosis (12/18, 67%), and patients are indecisive (10/17, 59%)
Summary
Shared decision making in mental health care has been dubbed an ethical imperative [1]. Research has shown that people with severe and persistent mental disorders are no exception. People with psychotic disorders are able and willing to participate in medical decision making [2,3]. Most clinicians believe in the benefits of shared decision making, but time constraints and a large number of clinical responsibilities prevent them from practicing it [6,7]. Patients may not be used to actively participating in medical decision making and they can lack access to medical information that is intelligible [8]. Mental health policy makers encourage the development of electronic decision aids to increase patient participation in medical decision making. Evidence is needed to determine whether these decision aids are helpful in clinical practice and whether they lead to increased patient involvement and better outcomes
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