Shared decision-making interventions or care as usual: which works better for people with mental health conditions?
What are mental health conditions?
There are many mental health conditions. They are generally characterised by a combination of abnormal thoughts, perceptions, emotions, behaviour, and relationships with others. Access to health care and social services capable of providing treatment and social support is key.
What did we want to find out?
Shared decision-making is an approach to consumer-professional communication where both parties (e.g. patients or their carers, or both, together with their clinician) are acknowledged to bring equally important experience and expertise to the process. In this approach, both parties work in partnership to make treatment recommendations and decisions.
This approach is considered part of a broader recovery and person-centred movement within the behavioural health field. The focus on recovery and individual responsibility for understanding and managing symptoms in collaboration with professionals, caregivers, peers, and family members is also fundamental to this approach.
Sometimes it also involves a 'decision aid', such as videos, booklets, or online tools, presenting information about treatments, benefits and risks of different options, and identifying ways to make the decision that reflects what is most important to the person. The process of shared decision-making may often also involve decision coaching by someone who is non-directive and provides decision support that aims to prepare people for discussion and the decision in the encounter with their practitioner.
We wanted to find out if shared decision-making interventions were better than care as usual for people with mental health conditions to improve:
• clinical outcomes, such as psychotic symptoms, depression, anxiety, and readmission;
• participation or level of involvement in the decision-making process.
We also wanted to find out if shared decision-making interventions were associated with any unwanted (harmful) effects.
What did we do?
We searched for studies that examined shared decision-making interventions compared with care as usual in people with mental health conditions. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes.
What did we find?
We found 15 studies involving 3141 adults, from seven countries: Germany, Italy, Japan, Saudi Arabia, the Netherlands, the UK, and the USA.
Care settings included primary care, community mental health services, outpatient psychiatric services, specialised outpatient services such as post-traumatic stress disorder clinics, forensic psychiatric services, and nursing home wards.
The mental health conditions studied were schizophrenia, depression, bipolar disorder, post-traumatic stress disorder, dementia, substance-related disorders and multiple clinical conditions, including personality disorder. Care providers included family carers, clinicians, case managers, nurses, pharmacists, and peer supporters. Three studies used an interprofessional collaboration.
When people with mental health conditions receive shared decision-making interventions, we do not know if their clinical conditions change. They may feel that they participated more in decision-making processes compared with those receiving usual care, although we are uncertain about this when participation was measured in other ways or at later time points after the consultation.
People who take this approach probably improve some, but not all, aspects of their satisfaction with received information compared with those receiving usual care.
Although it is often suggested that shared decision-making takes a lot of time, we found that there is probably little or no difference compared with usual care in the length of consultation.
We are uncertain about whether shared decision making-interventions change outcomes such as recovery, carer satisfaction, healthcare professional satisfaction, knowledge, treatment/medication continuation, carer participation, relationship with healthcare professionals, length of hospital stay, or possible harmful effects.
Further research is needed in this area. Longer term follow-up is also needed to better determine the impact of shared decision-making on: perceptions of quality of life; impact on frequency and severity of crises, hospitalisations, or both; stability of key functions of life, work, housing and overall health; and satisfaction with decision-making.
The review is up to date as of January 2020.
This review update suggests that people exposed to SDM interventions may perceive greater levels of involvement immediately after an encounter compared with those in control groups. Moreover, SDM interventions probably have little or no effect on the length of consultations.
Overall we found that most evidence was of low or very low certainty, meaning there is a generally low level of certainty about the effects of SDM interventions based on the studies assembled thus far. There is a need for further research in this area.
One person in every four will suffer from a diagnosable mental health condition during their life. Such conditions can have a devastating impact on the lives of the individual and their family, as well as society.
International healthcare policy makers have increasingly advocated and enshrined partnership models of mental health care. Shared decision-making (SDM) is one such partnership approach. Shared decision-making is a form of service user-provider communication where both parties are acknowledged to bring expertise to the process and work in partnership to make a decision.
This review assesses whether SDM interventions improve a range of outcomes. This is the first update of this Cochrane Review, first published in 2010.
To assess the effects of SDM interventions for people of all ages with mental health conditions, directed at people with mental health conditions, carers, or healthcare professionals, on a range of outcomes including: clinical outcomes, participation/involvement in decision-making process (observations on the process of SDM; user-reported, SDM-specific outcomes of encounters), recovery, satisfaction, knowledge, treatment/medication continuation, health service outcomes, and adverse outcomes.
We ran searches in January 2020 in CENTRAL, MEDLINE, Embase, and PsycINFO (2009 to January 2020). We also searched trial registers and the bibliographies of relevant papers, and contacted authors of included studies.
We updated the searches in February 2022. When we identified studies as potentially relevant, we labelled these as studies awaiting classification.
Randomised controlled trials (RCTs), including cluster-randomised controlled trials, of SDM interventions in people with mental health conditions (by Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD) criteria).
We used standard methodological procedures expected by Cochrane. Two review authors independently screened citations for inclusion, extracted data, and assessed risk of bias. We used GRADE to assess the certainty of the evidence.
This updated review included 13 new studies, for a total of 15 RCTs. Most participants were adults with severe mental illnesses such as schizophrenia, depression, and bipolar disorder, in higher-income countries. None of the studies included children or adolescents.
Primary outcomes
We are uncertain whether SDM interventions improve clinical outcomes, such as psychiatric symptoms, depression, anxiety, and readmission, compared with control due to very low-certainty evidence.
For readmission, we conducted subgroup analysis between studies that used usual care and those that used cognitive training in the control group. There were no subgroup differences.
Regarding participation (by the person with the mental health condition) or level of involvement in the decision-making process, we are uncertain if SDM interventions improve observations on the process of SDM compared with no intervention due to very low-certainty evidence. On the other hand, SDM interventions may improve SDM-specific user-reported outcomes from encounters immediately after intervention compared with no intervention (standardised mean difference (SMD) 0.63, 95% confidence interval (CI) 0.26 to 1.01; 3 studies, 534 participants; low-certainty evidence). However, there was insufficient evidence for sustained participation or involvement in the decision-making processes.
Secondary outcomes
We are uncertain whether SDM interventions improve recovery compared with no intervention due to very low-certainty evidence.
We are uncertain if SDM interventions improve users' overall satisfaction. However, one study (241 participants) showed that SDM interventions probably improve some aspects of users' satisfaction with received information compared with no intervention: information given was rated as helpful (risk ratio (RR) 1.33, 95% CI 1.08 to 1.65); participants expressed a strong desire to receive information this way for other treatment decisions (RR 1.35, 95% CI 1.08 to 1.68); and strongly recommended the information be shared with others in this way (RR 1.32, 95% CI 1.11 to 1.58). The evidence was of moderate certainty for these outcomes. However, this same study reported there may be little or no effect on amount or clarity of information, while another small study reported there may be little or no change in carer satisfaction with the SDM intervention. The effects of healthcare professional satisfaction were mixed: SDM interventions may have little or no effect on healthcare professional satisfaction when measured continuously, but probably improve healthcare professional satisfaction when assessed categorically.
We are uncertain whether SDM interventions improve knowledge, treatment continuation assessed through clinic visits, medication continuation, carer participation, and the relationship between users and healthcare professionals because of very low-certainty evidence.
Regarding length of consultation, SDM interventions probably have little or no effect compared with no intervention (SDM 0.09, 95% CI -0.24 to 0.41; 2 studies, 282 participants; moderate-certainty evidence). On the other hand, we are uncertain whether SDM interventions improve length of hospital stay due to very low-certainty evidence.
There were no adverse effects on health outcomes and no other adverse events reported.