Decision-making In Mental Health Care Research Articles

What are the priorities of consumers and carers regarding measurement for evaluation in mental healthcare? Results from a Q-methodology study

BackgroundThe purpose of this study was to identify and describe common views of people with lived experience of mental health challenges – consumers and carers, families and supporters – of what they consider the most important measures to include in health economic evaluations which assess the incremental value of competing options in mental health care.MethodsParticipants (n = 111) were people living in the state of Victoria, Australia, who identified as consumers of mental healthcare (n = 38); carers, family members and/or supporters (n = 43); or both (n = 30). Factor analysis based on Q-Methodology was used to identify clusters of people who hold similar viewpoints. Common viewpoints were described in terms of the characteristics of the group, and a qualitative interpretation was conducted on the basis of distinguishing statements and quotes provided in participants’ own words.ResultsWe identified four common views: (1) safety before all else, prioritizing physical, sexual and psychological safety; (2) hope and partnership in processes of care; (3) physical and emotional health and wellbeing; and (4) care access, continuity and partnership with families. Although different priorities were identified for each viewpoint, key priority areas that were common to all views were having an environment in the health service that fosters respect and dignity, and that consumers feel heard and listened to. In sub-group and qualitative analyses, differences were observed regarding the likelihood of consumers and carers holding each of the views, as well as by age group.ConclusionsWhile some differences were noted between the views of consumers and carers and different age groups, there was also common ground regarding what outcomes are of most importance to measure. Including these measures in evaluation frameworks would provide a way of focussing mental healthcare decisions on the aspects of mental healthcare that are of most value to consumers and carers, thereby addressing an important shortcoming of current approaches to decision-making in mental healthcare.

Military culture and collaborative decision-making in mental healthcare: cultural, communication and policy considerations.

Military culture relies on hierarchy and obedience, which contradict the implementation and use of collaborative care models. In this commentary, a team of lived experience, clinical and research experts discuss, for the first time, cultural, communication and policy considerations for implementing collaborative care models in military mental healthcare settings.

No decision about me without me? Shared decision-making in mental healthcare

Is there really 'no decision about me without me'? This concept of shared decision-making is increasingly supported in the UK National Health Service and is to be welcomed. But the attempt to apply guidelines based on Western physical health settings to all psychiatric patients, across different cultural backgrounds, is problematic. Methodological difficulties when trying to apply the gold standard of randomised controlled trials to the real-life settings of mental health should be considered, especially when many patients with serious mental health problems are excluded, having been deemed to 'lack capacity'. Should guidelines originating in physical healthcare settings really be applied to mental health ones? Does one size really fit all?

Clinical decision-making style preferences of European psychiatrists: Results from the Ambassadors survey in 38 countries.

While shared clinical decision-making (SDM) is the preferred approach to decision-making in mental health care, its implementation in everyday clinical practice is still insufficient. The European Psychiatric Association undertook a study aiming to gather data on the clinical decision-making style preferences of psychiatrists working in Europe. We conducted a cross-sectional online survey involving a sample of 751 psychiatrists and psychiatry specialist trainees from 38 European countries in 2021, using the Clinical Decision-Making Style - Staff questionnaire and a set of questions regarding clinicians' expertise, training, and practice. SDM was the preferred decision-making style across all European regions ([central and eastern Europe, CEE], northern and western Europe [NWE], and southern Europe [SE]), with an average of 73% of clinical decisions being rated as SDM. However, we found significant differences in non-SDM decision-making styles: participants working in NWE countries more often prefer shared and active decision-making styles rather than passive styles when compared to other European regions, especially to the CEE. Additionally, psychiatry specialist trainees (compared to psychiatrists), those working mainly with outpatients (compared to those working mainly with inpatients) and those working in community mental health services/public services (compared to mixed and private settings) have a significantly lower preference for passive decision-making style. The preferences for SDM styles among European psychiatrists are generally similar. However, the identified differences in the preferences for non-SDM styles across the regions call for more dialogue and educational efforts to harmonize practice across Europe.

I'm not a diagnosis: Adolescents' perspectives on user participation and shared decision-making in mental healthcare.

Background:Adolescents have the right to be involved in decisions affecting their healthcare. More knowledge is needed to provide quality healthcare services that is both suitable for adolescents and in line with policy. Shared decision-making has the potential to combine user participation and evidence-based treatment. Research and governmental policies emphasize shared decision-making as key for high quality mental healthcare services.Objective:To explore adolescents’ experiences with user participation and shared decision-making in mental healthcare inpatient units.Method:We carried out ten in-depth interviews with adolescents (16-18 years old) in this qualitative study. The participants were admitted to four mental healthcare inpatient clinics in Norway. Transcribed interviews were subjected to qualitative content analysis.Results:Five themes were identified, representing the adolescents’ view of gaining trust, getting help, being understood, being diagnosed and labeled, being pushed, and making a customized treatment plan. Psychoeducational information, mutual trust, and a therapeutic relationship between patients and therapists were considered prerequisites for shared decision-making. For adolescents to be labeled with a diagnosis or forced into a treatment regimen that they did not initiate or control tended to elicit strong resistance. User involvement at admission, participation in the treatment plan, individualized treatment, and collaboration among healthcare professionals were emphasized.Conclusions:Routines for participation and involvement of adolescents prior to inpatient admission is recommended. Shared decision-making has the potential to increase adolescents’ engagement and reduce the incidence of involuntary treatment and re-admission to inpatient clinics. In this study, shared decision-making is linked to empowerment and less to standardized decision tools. To be labeled and dominated by healthcare professionals can be a barrier to adolescents’ participation in treatment. We suggest placing less emphasis on diagnoses and more on individualized treatment.

Decision-Making in Mental Health Care: Measuring Provider and Supervisor Use of Evidence.

Use of evidence to inform clinical decisions has been shown to improve the quality and effectiveness of services. This study piloted an observational coding system for understanding providers and supervisors' use of evidence in their clinical decision-making. The Action Cycle and Use of Evidence Behavioral Observation Coding System (ACE-BOCS) is based on Graham et al. (Contin Educ Health Prof 26:13-24, 2006) conceptual framework for knowledge management, which articulates a sequence relevant to integrating evidence into decisions and actions, including identifying and selecting a problem and choosing, planning, and rehearsing a solution or action. Using the ACE-BOCS, two coders rated the extensiveness with which evidence was used to inform decisions made in clinical supervision sessions. In these clinical supervision sessions, supervisor-provider dyads discussed cases (N = 30; age range 8-19years; 80% Latino/a or Hispanic ethnicity) that were identified as potentially being at risk for low treatment engagement in school mental health services. Results indicated that the ACE-BOCS can reliably and validly measure use of evidence and distinguish between strategic and indiscriminate use of evidence. The ACE-BOCS has value and utility for studying use of evidence, as it incorporates multiple actions related to service delivery and has the potential to be adapted for other aspects of mental healthcare decision-making beyond clinical supervision, as well as decision making within fields outside of mental health.

An end to coercion: rights and decision-making in mental health care.

The United Nations Convention on the Rights of Persons with Disabilities requires a paradigm shift from a medical model of disability to a social model that emphasizes overcoming the barriers to equality created by attitudes, laws, government policies and the social, economic and political environment. The approach adopted by the social model recognizes that people with psychosocial disabilities have the same right to take decisions and make choices as other people, particularly regarding treatment, and have the right to equal recognition before the law. Consequently, direct or supported decision-making should be the norm and there should be no substitute decision-making. Although recent mental health laws in some countries have attempted to realize a rights-based approach to decision-making by reducing coercion, implementing the Convention on the Rights of Persons with Disabilities can be challenging because it requires continuous refinement and the development of alternatives to coercion. This article reviews the impact historical trends and current mental health frameworks have had on the rights affected by the practice of involuntary treatment and describes some legal and organizational initiatives that have been undertaken to promote noncoercive services and supported decision-making. The evidence and examples presented could provide the foundation for developing a context-appropriate approach to implementing supported decision-making in mental health care.

Practitioners' positive attitudes promote shared decision-making in mental health care.

There is a growing expectation of implementing shared decision making (SDM) in today's health care service, including mental health care. Traditional understanding of SDM may be too narrow to capture the complexity of treatments of mental health problems. Although the patients' contribution to SDM is well described, the contribution from the health care practitioners is less explored. Therefore, our aim was to explore the attitudes of practitioners in mental health care and the associations between practitioners' attitudes and SDM. We performed a cross-sectional study where practitioners reported their sharing and caring attitudes on the Patient-Practitioner Orientation Scale (PPOS) and age, gender, profession, and clinical working site. The patients reported SDM using the CollaboRate tool. We used a mixed effect model linking the data from each practitioner to one or more patients. We presented the findings and used them as background for a more philosophic reflection. We included 312 practitioners with mean age 46.1years. Of the practitioners, 60 held a medical doctors degree, 97 were psychologists, and 127 held a college degree in nursing, social science, or pedagogy. Female practitioners reported higher sharing (4.79 vs 4.67 [range 1-6], P=.04) and caring scores (4.77 vs 4.65 [range 1-6], P=.02) than males. The regression model contained 206 practitioners and 772 patients. We found a higher probability for the patient to report high SDM score if the practitioner reported higher sharing scores, and lower probability if the practitioner worked in ambulatory care. SDM in mental health care is complex and demands multifaceted preparations from practitioners as well as patients. The practitioners' attitudes are not sufficiently explored using one instrument. The positive association between practitioners' patient-centred attitudes and SDM found in this study implies a relevance of the practitioners' attitudes for accomplishment of SDM processes in mental health care.

Estranged relations: coercion and care in narratives of supported decision-making in mental healthcare

Supported decision-making has become popular among policymakers and mental health advocates as a means of reducing coercion in mental healthcare. Nevertheless, users of psychiatric services often seem equivocal about the...

Shared decision-making in mental health care using routine outcome monitoring: results of a cluster randomised-controlled trial

PurposeTo investigate the effects of Shared Decision-Making (SDM) using Routine Outcome Monitoring (ROM) primary on patients’ perception of Decisional Conflict (DC), which measures patients’ engagement in and satisfaction with clinical decisions, and secondary on working alliance and treatment outcomes.MethodMulti-centre two-arm matched-paired cluster randomised-controlled trial in Dutch specialist mental health care. SDM using ROM (SDMR) was compared with Decision-Making As Usual (DMAU). Outcomes were measured at baseline (T0) and 6 months (T1). Multilevel regression and intention-to-treat analyses were used. Post hoc analyses were performed on influence of subgroups and application of SDMR on DC.ResultsSeven teams were randomised to each arm. T0 was completed by 186 patients (51% intervention; 49% control) and T1 by 158 patients (51% intervention, 49% control). DC, working alliance, and treatment outcomes reported by patients did not differ significantly between two arms. Post hoc analyses revealed that SDMR led to less DC among depressed patients (p = 0.047, d =− 0.69). If SDMR was applied well, patients reported less DC (SDM: p = 0.000, d = − 0.45; ROM: p = 0.021, d = − 0.32), which was associated with better treatment outcomes.ConclusionExcept for patients with mood disorders, we found no difference between the arms for patient-reported DC. This might be explained by the less than optimal uptake of this generic intervention, which did not support patients directly. Regarding the positive influence of a higher level of applying SDM and ROM on less DC and better treatment outcomes, the results are encouraging for further investments in patient-oriented development and implementation of SDMR.

Sensing Technologies for Monitoring Serious Mental Illnesses

Mental health is an urgent global issue. Around 450 million people suffer from serious mental illnesses worldwide, which results in devastating personal outcomes and huge societal burden. Effective symptom monitoring and personalized interventions can significantly improve mental health care across different populations. However, traditional clinical methods often fall short when it comes to real-time monitoring of symptoms. Sensing technologies can address these issues by enabling granular tracking of behavioral, physiological, and social signals relevant to mental health. In this article, we describe how sensing technologies can be used to diagnose and monitor patient states for numerous serious mental illnesses. We also identify current limitations and potential future directions. We believe that the multimedia community can build on sensing technologies to enable efficient clinical decision-making in mental health care. Specifically, innovative multimedia systems can help identify and visualize personalized early-warning signs from complex multimodal signals, which could lead to effective intervention strategies and better preemptive care.

Using the RAI-MH to support shared decision-making in mental healthcare.

Persons with mental illness often struggle to meaningfully participate in decisions about their services. This study engaged persons with mental illness to understand how health information could empower them. Participants reported wanting information on diagnoses, medications, symptoms, and strengths as well as clinician notes and rationale. The Resident Assessment Instrument for Mental Health contains this information and is mandated in in-patient psychiatry. Its findings could be summarized and shared with individuals to promote and facilitate shared decision-making.

Factors influencing patients’ preferences and perceived involvement in shared decision-making in mental health care

Background: Although research has suggested that patients desire to participate in shared decision-making, recent studies show that most patients take a passive role in their treatment decisions. The discrepancy between patients’ expressed desire and actual behaviors underscores the need to better understand how patients perceive shared decision-making and what factors influence their participation.Aims: To investigate patients’ preferences and appraisals of their involvement in treatment decisions.Methods: Fifty-four qualitative interviews were conducted with veterans receiving outpatient mental health care at a U.S. Veterans Affairs Medical Center. Interviews were analyzed using thematic analysis.Results: Participants outlined several factors that influence their preferences and involvement in treatment decisions. These include the patient–provider relationship, fear of being judged, perceived inadequacy, and a history of substance abuse.Conclusion: Patients’ preferences and willingness to engage in shared decision-making fluctuate over time and are context dependent. A better understanding of these factors and a strong patient–provider relationship will facilitate better measurement and implementation of shared decision-making.

Decision-making in mental healthcare: A phenomenological investigation of service user perspectives.

As Victorian asylums closed down in the United Kingdom, community mental health services were set up to support patients in exercising choice and freedom; in finding a place in society. The success of these services has been questioned, so further policies have been introduced in an effort to protect rights and improve social inclusion. However, capacity to make decisions has been interpreted as no more than a process of rational mental calculation. This article reports on a phenomenological study that explores the decision-making experiences of three men who have endured psychosis. It is not only associated with choice and freedom but also with responsibility, blame, and social exclusion. These men appear to have faced common existential dilemmas, but have sought to express emotional will in conflict with other people and have, perhaps, been placed under more social pressure and become more isolated as individuals, while enduring experiences that are difficult to make meaningful for others. It seems that...

Paramedic clinical decision-making in mental health care: a new theoretical approach

This article aims to present a new theoretical approach for examining paramedic clinical decision-making in relation to mental health care. Recent theorizing has begun exploring key clinical decision-making approaches that are particularly relevant to paramedic practice. These approaches have also revealed some important factors that influence clinical decision-making behaviours among paramedics such as prior experience and clinical and tacit knowledge. The literature, however, provides very little insight into the clinical decision-making strategies paramedics draw on and use when dealing with mental health patients, in particular, those patients who are dealt with under involuntary provisions of mental health legislation. In addition, the literature provides limited coverage to account for how paramedics deal with and mitigate risk factors relating to patients experiencing a mental health emergency. Following these shortcomings, this article will propose the use of hermeneutic phenomenological methods as a suitable and innovative interpretive research approach for examining paramedic clinical decision-making in relation to prehospital mental health care. It is argued that this approach is well suited for exploring how paramedics make sense of their experience providing emergency mental health care, how they perceive their role within the clinician-patient relationship, and the particular circumstances in which paramedics exercise their legislative responsibilities under mental health legislation.

Paramedic clinical decision-making in mental health care: a new theoretical approach

This article aims to present a new theoretical approach for examining paramedic clinical decision-making in relation to mental health care. Recent theorizing has begun exploring key clinical decision-making approaches that are particularly relevant to paramedic practice. These approaches have also revealed some important factors that influence clinical decision-making behaviours among paramedics such as prior experience and clinical and tacit knowledge. The literature, however, provides very little insight into the clinical decision-making strategies paramedics draw on and use when dealing with mental health patients, in particular, those patients who are dealt with under involuntary provisions of mental health legislation. In addition, the literature provides limited coverage to account for how paramedics deal with and mitigate risk factors relating to patients experiencing a mental health emergency. Following these shortcomings, this article will propose the use of hermeneutic phenomenological methods as a suitable and innovative interpretive research approach for examining paramedic clinical decisionmaking in relation to prehospital mental health care. It is argued that this approach is well suited for exploring how paramedics make sense of their experience providing emergency mental health care, how they perceive their role within the clinician-patient relationship, and the particular circumstances in which paramedics exercise their legislative responsibilities under mental health legislation.

Patient Involvement and Shared Decision-Making in Mental Health Care

There is growing interest in shared decision-making (SDM) in which the provider and patient go through each phase of the decision-making process together, share treatment preferences, and reach an agreement on treatment choice. Although a majority of the research evaluating SDM has been conducted under "physical" health conditions, patients' participation and SDM for mental health conditions has received increasing interest since the mid 1990s. SDM in mental health care can be more complex than in general health care because that several patient characteristics, health care provider, and system level factors may hinder normalization and implementation of this model into clinical practice. To date, in comparison with other health problems, there are few studies which have assessed SDM in this context. In spite of that, evidence points favorably towards the inclusion of SDM in mental health treatment decisions, given that the majority of patients with mental illness prefer to be involved in the process and wish to have information. However, more studies are needed to provide evidence about the impact of SDM on treatment compliance and health care outcomes. In this overview, the authors present the current state and the future perspectives of SDM in mental health.

Promoting the value and practice of shared decision-making in mental health care.

Active consumer participation is critical in contemporary mental health care and treatment planning and has been a staple of the field of psychiatric rehabilitation for the last three decades. Providing the opportunity for consumers to chose interventions that fit personal preferences and recovery increase the likelihood that these interventions will enhance personal meaning, satisfaction and quality of life (Improving the Quality of Health Care for Mental and Substance Use Conditions, 2006). Similarly, self-determination and shared decision-making are critical components of recovery. As stated in the President's New Freedom Commission on Mental Health Final Report, recovery from mental illnesses should be the expectation in mental health care with services and treatments that are consumer and family-driven. Mental health care should be planned and delivered to ensure that consumers and families with children with mental health problems receive real and meaningful choices about treatment options and providers. The purpose of this paper is to explore the value and use of shared decision-making in health and mental health care, briefly examine the advantages and disadvantages of shared decision making and propose next steps in advancing use of shared decision-making in mental health care.