The Role of Self-Determination: Examining the Relationship Between Choice, Adherence and Outcomes within Mental Health Services

Purpose:  Providing clients more choice about their treatment is a key aspect of mental health reform in the 21^st Century.  Driving this transformation is mental health recovery, which states that all people with severe mental illnesses can pursue meaningful lives and have a right to services that are oriented towards their individualized goals. Also, evidence based practice balances client preference and values with empirically supported treatments, demonstrating how choice must be integral to all aspects of service delivery. In order to promote self-determination within services, we need a greater understanding of the relationships between choice, adherence and clinical outcomes. Using a sample of people receiving services at community mental health clinics, this study addresses the following questions: 1) To what extent does choice lead to improved outcomes and 2) Does adherence to medication mediate the effect of choice on outcomes?

Methods:  This study was based on a secondary data analysis. The first source of data was from structured interviews conducted for a study set in four community mental health clinics. Participant data was then matched to Medicaid records of psychiatric medication prescriptions, the second source of data, yielding a final sample size of 129.  Choice was measured by Empowerment, Patient Perception of Patient Centeredness, and Patient Perception of Consultation Tasks scales from the baseline interview. Outcomes were measured by Recovery Assessment Scale, Quality of Life and the MHSHIP Outcomes Survey scales from the 12 month interview. Adherence to medication was measured by the number of months within the year that were covered by a prescription for anti-psychotic medication. Regression models examined the effects of the three choice variables on the three outcome variables controlling for demographics and severity of illness. A series of Sobel tests were then conducted to examine whether the effect of choice on outcomes was mediated by adherence to medication.

Results:  Significant relationships were found between the majority of choice and outcome variables and the R² for the three models ranged from .23 to .33.  Empowerment was positively related to recovery (B=.52, p<.01), quality of life (B=.65, p=.02) and service outcomes (B=.67, p<.01).  Perception of consultation tasks was positively related to recovery (B=.13, p=.03) and patient perception of centeredness was positively related to recovery (B=.15, p=.04) and outcomes (B=.21, p=.02).  However, according to the sobel tests, adherence to medication did not mediate the effect of choice and outcomes.  

Implications: This study provides empirical support for integrating a greater level of choice into mental health services by demonstrating a direct relationship between choice and improved client outcomes.  However, the study did not demonstrate that greater adherence to medication mediated the effect on choice and outcome. This suggests that the process of providing clients more autonomy leads to better outcomes independently from their adherence to medication.  Therefore, the manner in which services are delivered may have as much impact on outcomes as the specifics of the intervention.