Shared Decision-Making (SDM) for People With Serious Mental Illness

Background: Shared decision-making (SDM) has become a central tenet of recovery and person-centered care delivery methods in mental health (SAMHSA, 2011). SDM is a mutual communication process in which health decisions are made jointly by health care providers and consumers (Legare et al, 2012). For consumers with serious mental illness, being involved in medication decisions (including not taking them) is important to recovery. Thus, providers should support an active role for consumers in relation to medication decisions (Baker et al, 2013). However, several concerns may interfere with active participation in decision-making (e.g., skepticism on consumers’ decisional capacity, psychiatric symptoms). Social workers who advocate for consumer involvement is critical. Understanding the characteristics of SDM can help social workers in this role.

Methods: We conducted a secondary data analysis using audio-recorded psychiatric visits (191 visits with 11 providers). The audio-recordings were transcribed, checked for accuracy, and coded by trained raters using the SDM coding system (Salyers et al, 2012), with good inter-rater reliability. The coding system rated nine elements of SDM (consumer’s role; consumer’s goal/context of decision; clinical issue or nature of the decision; alternative options; pros and cons; uncertainties associated with the decision; consumer’s understanding; desire for others’ input; and exploration of consumer preference) as absent (=0), partial (=1), or complete (=2). Factor analysis (a principal axis factoring method with promax rotation) using a polychoric correlation matrix was conducted to examine the underlying structures of the SDM coding system.

Results: The average age of consumers was 46.5±11.4, 119 (62%) were male, 112 (58.6%) were white, 74 (39%) had a schizophrenia diagnosis, and the average length of visit was 18.2±7.4 min. The analysis resulted in a two-factor model: “scientific discussion” (sharing and seeking scientific-based treatment options assuring consumer’s life goal/context and understandings) and “preference discussion” (consumer’s role in decision-making, preference, and alternative options). The two factors were correlated at .27. The scientific discussion (M=1.23±0.44) was observed more completely than preference discussion (M=1.13±0.47) [p<.01]. Initiation scores (indications of who initiated the elements in SDM) were strongly correlated with scientific discussion (r = .5[consumer] & .6 [provider]) but were weaker with preference discussion (r = .2 [consumer] & .4 [provider]). More complex decisions were associated with more scientific discussion (p<.001), but not for preference discussion. Non-white (p<.05) and people with schizophrenia diagnosis (p<.001) were more involved in preference discussion.

Conclusions and implications: SDM depends not only on scientific evidence, but on the potential impact on the consumer’s life, which is highly dependent on the consumer’s preferences. We found that preference discussion may be more difficult to elicit, regardless of who initiated the discussion (provider or consumer). SDM is deeply rooted in the context where consumers and providers meet. Support from significant others (including case managers, peers, social workers) before and after the psychiatric visits plays an important role for consumers to be activated in decision-making (Deegan et al, 2008). Understanding these factors seems to be important for social workers supporting consumers in SDM. Implications for social work practice in SDM will be discussed.