You're on the Team: Why Providers Should Use It

Shared decision-making in medical treatment is a fairly new development. It was initially proposed to address disparities in the quality of general medical care first identified in the 1970's.[1],[2] Research showed unwarranted variations in healthcare around the United States, including variations in the use of standard procedures, underuse of preventive procedures known to be effective, and overuse of discretionary surgeries that should reflect patient preference. Proponents suggested that patients needed better information and more say to reduce these disparities. They advanced shared decision-making as a way to:

• introduce evidence about efficacy,
• reduce unnecessary procedures,
• get patients more involved in learning about treatment options and understanding trade-offs,
• help patients work through a decision process, and
• promote decisions that reflect the preferences of the patient as well as those of the provider.

The movement to streamline and improve healthcare, culminating in the Patient Protection and Affordable Care Act (health care reform) gives added justification for wider use of shared decision-making. It can be helpful in reducing unneeded care, bolstering evidence-based medicine, making care more patient-centered and collaborative, and increasing consumer satisfaction.

Interest in adapting shared decision-making to mental health treatment is recent. Its use was pioneered by Patricia E. Deegan, PhD, who developed CommonGround, a web-based application to support shared decision-making in medication consultations. Once trained in its use by peers, mental health consumers arrive early for clinic appointments and fill out a computerized questionnaire on their health status and concerns, as well as their own suggestions for self-care. They can consult videos to learn more about conditions and treatment options. A peer specialist is present to help out. During the appointment, clinician and client use the report as the starting point for shared decision-making. The consumer leaves with a printout for follow-up, and the clinic retains a record.

In 2007, the Center for Mental Health Services of the Substance Abuse and Mental Health Services Administration convened a meeting of researchers, providers in general and mental health care, policymakers, and mental health consumers to review the science and research on shared decision-making in mental health treatment and make recommendations for advancing its use.[3] Barriers to adaption and ethical issues were explored. Shared decision-making was recommended as a tool to further the transformation of the mental health care system called for by the President's New Freedom Commission on Mental Health, help individuals achieve recovery and reduce "decisional conflict" associated with treatment.

Advantages in Mental Health Treatment

Shared decision-making can help patients cope with the uncertainties of mental health treatment. Mental health treatment is often a process of tentative diagnosis, trial and discovery. It is hard to predict how a given treatment will work for each patient, and what side-effects will result. 

This approach promotes the active engagement of patients, which is essential throughout the course of treatment. It helps patients share their lifestyle, self-care, and attitudes, all of which affect their mental health and the success of treatment.

Shared decision-making offers a number of potential advantages that can result in better care and outcomes:

• Patients can provide a fuller picture of functioning, concerns and the impact of their condition on their lives, assisting with diagnosis and treatment.
• Shared decision-making improves mutual trust and communication.
• Valuing the patient’s input and participation can lead to greater honesty, more willing engagement, and more willingness to stick with treatment.
• Reservations about treatment options can be surfaced and addressed.
•  Disagreements about treatment—including unwillingness to take medication or acknowledge a mental health condition—can be discussed and negotiated.
• Because patients have more say in deciding, they have more investment in the chosen treatment.
• Treatment can be better targeted to the symptoms that matter most to the patient.
• Treating patients as partners in the process encourages them to take more responsibility for themselves.
• Helping patients to understand, accept and manage their disorder is a key aspect of treatment.

Shared decision-making validates the non-medical approaches patients take to manage and recover from their mental illness, such as exercise, jobs, spiritual practices and peer support. 

The goal of medical treatment is to restore health and help people heal. For a person with a mental health condition, the goal is to recover not only health, but a full and meaningful life. This often involves gaining new skills and recovering relationships, work and independence that were lost during illness. Shared decision-making allows the patient to validate these needs and factor them into treatment choices.

[1] The Dartmouth Institute for Health Quality and Clinical Practice: History of the Dartmouth Institute. http://tdi.dartmouth.edu/about/history/
[2] Perspective: Practice Variations And Health Care Reform: Connecting The Dots. John E. Wennberg. Health Affairs, October 2004; published ahead of print October 7, 2004, doi:10.1377/hlthaff.var.140
[3] Shared Decision-Making in Mental Health Care: Practice, Research and Future Directions. Substance Abuse and Mental Health Services Administration, 2007