A systematic review of shared decision making interventions in child and youth mental health: synthesising the use of theory, intervention functions, and behaviour change techniques

Youth Perspectives on 'Highly Personalised and Measurement-Based Care': Qualitative Co-Design of Education Materials

OBJECTIVES

Despite high levels of mental ill-health amongst young people (aged 15-30), this group demonstrates low help-seeking and high drop-out from mental health services (MHS). Whilst shared decision-making can assist people in receiving appropriate and effective health care, young people frequently report that they do not feel involved in treatment decisions. The current study focused on co-design of a clinical education and participant information programme for the Brain and Mind Centre Youth Model of Care. This model, which articulates a youth-focused form of highly personalised and measurement-based care, is designed to promote shared decision-making between young people and clinical service providers.

METHODS

We conducted workshops with 24 young people (16-31; MAge = 21.5) who had accessed mental health services. Participants were asked what advice they would give to young people entering services, before giving advice on existing materials. Workshops were conducted and transcripts were coded using thematic analysis by two lived experience researchers and a clinical researcher.

RESULTS

Young people found it empowering to be educated on transdiagnostic models of mental illness, namely clinical staging, which gives them a better understanding of why certain treatments may be inappropriate and ineffective, and thus reduce self-blame. Similarly, young people had limited knowledge of links between mental health and other life domains and found it helpful to be educated on multidisciplinary treatment options. Measurement-based care was seen as an important method of improving shared decision-making between young people and health professionals; however, to facilitate shared decision-making, young people also wanted better information on their rights in care and more support to share their expertise in their own needs, values and treatment preferences.

CONCLUSIONS

These findings will inform the delivery of the further development and implementation of a youth-specific clinical education and participant information programme for the BMC Youth Model.

PATIENT OR PUBLIC CONTRIBUTION

Workshops were facilitated by researchers with lived expertise in mental ill-health (A.H. and/or C.G.) and a clinical researcher (who has expertise as an academic and a clinical psychologist). A.H. and C.G. were also involved in conceptualisation, analysis, interpretation, review and editing of this paper.

A systematic review of the effectiveness of decision making interventions on increasing perceptions of shared decision making occurring in advanced cancer consultations

OBJECTIVE

To determine how decision making interventions for use in advanced cancer treatment consultations function and whether they increase perceptions of shared decision making (SDM) behaviours within consultations.

METHODS

A systematic search of five literature databases was conducted. Evaluations of decision making interventions where participants faced active treatment decisions for stage 4 or otherwise incurable cancer were included. Intervention descriptions were coded using Behaviour Change Techniques (BCTs) to provide a narrative of how the interventions function. A narrative synthesis of interventions effect on perceptions of SDM behaviours compared to usual care was conducted.

RESULTS

Four studies presenting different interventions were included. Education, training, modelling and enablement intervention functions were identified. Oncologist SDM training alone and combined with a patient communication aid demonstrated the only significant effect (p < 0.05) on SDM behaviours in advanced cancer consultations.

CONCLUSION

Healthcare professional (HCP) SDM training which includes modelling and enablement functions may be effective in increasing clinician motivation, capability and opportunity to facilitate SDM in advanced cancer consultations.

PRACTICE IMPLICATIONS

Implementing HCP SDM training into practice may encourage greater uptake of SDM which may lead to treatment decisions concordant with the goals of care of people with advanced cancer.

Educating for supported decision making and shared decision making: a scoping review of educational design and outcomes for education and training interventions

PURPOSE

To characterise existing knowledge about the design and learning outcomes of education and training programs for supported or shared decision making.

MATERIALS AND METHODS

A scoping review was performed to identify academic and grey literature, published between January 2006 and February 2022, that reported on the design and/or learning outcomes of supported or shared decision making education or training programs. Eligible literature was mapped across domains of educational design and Kirkpatrick's hierarchy of learning effectiveness, and then qualitatively synthesised using cross-case analysis.

RESULTS

A total of 33 articles were identified (n = 7 for supported decision making and n = 26 for shared decision making) that provided education or training to supporters of persons with mental illness or substance use disorders (n = 14), dementia or neurocognitive disorders (n = 6), cognitive disability (n = 5), mixed populations (n = 1), and those receiving end-of-life care (n = 7). In their design, most programs sought specific changes in practice (behaviour) via experiential learning. Reported educational outcomes also focused on supporter behaviour, with limited evidence for how changes in learner attitudes, skills, or knowledge might be contributing to changes in supporter behaviour.

CONCLUSIONS

Future education and training would benefit from a closer engagement with theories of teaching and learning, particularly those oriented towards co-design.

Patient Involvement in Shared Decision-Making: Do Patients Rate Physicians and Nurses Differently?

BACKGROUND

Shared decision-making implies that patients and healthcare professionals make decisions together about clinical exams, available treatments, choice of options, and the benefit or downside of every choice. Patients involved in the shared decision-making process are more compliant with treatments and have a reduced risk of complications related to the pathology. In Italy, patient involvement in caring processes is still barely investigated.

AIM

To investigate patients' perceptions about shared decision-making with physicians and nurses, respectively, and to examine the relationship between shared decision-making and patient satisfaction and perceived quality of care/treatment.

METHODS

The study was performed between March and June 2019 in two wards of one Italian hospital. A questionnaire was administered to inpatients at the time of admission and again at discharge, including demographic information and measurement scales regarding patient involvement in shared decision-making, patient satisfaction, and perceived quality of treatment/care.

RESULTS

A total of 151 out of 301 patients completed questionnaires at both admission and discharge. Patients' scores for shared decision-making (information, patient needs, treatment planning) were significantly different for physicians and nurses. At both admission and discharge, patients rated shared decision-making significantly higher for physicians compared to nurses, while there were no differences in their satisfaction ratings. Patient ratings of physicians did not change from admission (information: mean (M) = 3.50, standard deviation (SD) = 0.81; patient need: M = 3.05, SD = 1.05; treatment planning: M = 2.75, SD = 1.23) to discharge (information: M = 3.50, SD = 0.79; patient need: M = 3.17, SD = 1.02; treatment planning: M = 2.66, SD = 1.23) (p = 0.924, p = 0.098, p = 0.293, respectively), but patients' ratings of nurses' behavior increased significantly from admission (information: M = 2.44, SD = 1.23; patient need: M = 2.27, SD = 1.17; treatment planning: M = 2.12, SD = 1.19) to discharge (information: M = 2.62, SD = 1.22; patient need: M = 2.53, SD = 1.24; treatment planning: M = 2.35, SD = 1.21) (p = 0.019, p = 0.001, p = 0.003, respectively). Attention to patients' needs was the key determinant of both satisfaction with nurses (OR = 3.65, 95% CI = 1.31-10.14, p = 0.013) and perceived quality of care (OR = 3.97, 95% CI = 1.49-10.55, p = 0.006). Providing appropriate information about disease progress and treatments was a key determinant of both satisfaction with physicians (OR = 19.75, 95% CI = 7.29-53.55, p < 0.001) and perceived quality of treatment (OR = 8.03, 95% CI = 3.25-19.81, p < 0.001).

DISCUSSION

Nurses should be sensitized to involving patients in the decision-making process, especially upon hospital admission. Specific training about effective communication techniques can be implemented to manage relationships with patients in different caring situations. Practical implications and future directions are discussed.

Predictors, Moderators, and Mediators Associated With Treatment Outcome in Randomized Clinical Trials Among Adolescents With Depression: A Scoping Review

Importance

The application of precision medicine principles for the treatment of depressive disorders in adolescents requires an examination of the variables associated with depression outcomes in randomized clinical trials (RCTs).

Objective

To describe predictors, moderators, and mediators associated with outcomes in RCTs for the treatment of depressive disorders in adolescents.

Evidence Review

A scoping review of RCTs for the treatment of depression in adolescents was conducted. Databases searched included MEDLINE, Embase, APA PsycInfo, and CINAHL. Included publications tested predictors, moderators, and/or mediators associated with depression symptom outcomes (eg, symptom reduction, response, remission) in RCTs pertaining to the treatment of adolescents, ages 13 to 17 years. Predictors were defined as variables that were associated with depression outcomes, independent of treatment group. Moderators were defined as baseline variables that were associated with differential outcomes between treatment groups. Mediators were defined by a formal mediation analysis. In duplicate, variables were extracted and coded with respect to analysis type (univariable or multivariable), statistical significance, direction of effect size, reporting of a priori hypotheses, and adjustment for multiple comparisons. Aggregated results were summarized by variable domain and RCT sample.

Findings

Eighty-one articles reporting on variables associated with outcomes across 33 RCTs were identified, including studies of biological (10 RCTs), psychosocial (18 RCTs), and combined (4 RCTs) treatments as well as a service delivery model (1 RCT). Fifty-three variable domains were tested as baseline predictors of depression outcome, 41 as moderators, 19 as postbaseline predictors, and 5 as mediators. Variable domains that were reported as significant in at least 3 RCTs included age, sex/gender, baseline depression severity, early response to treatment, sleep changes, parent-child conflict, overall psychopathology, suicidal ideation, hopelessness, functional impairment, attendance at therapy sessions, and history of trauma. Two publications reported a priori hypotheses and adjustment for multiple comparisons, both finding that baseline depression severity and family conflict were associated with poorer outcomes.

Conclusions and Relevance

This review identified commonly researched variables requiring more scrutiny as well as underresearched variables to inform future study designs. Further efforts to discover predictors, moderators, and mediators associated with treatment response have great potential to optimize care for adolescents with depression.

Conflicted Anger as a Central Dynamic in Depression in Adolescents-A Double Case Study

The incidence of depression in teenagers has increased for many years and is one of the most common diagnosis in adolescent psychiatry. Effective and accessible psychotherapy methods need sustained attention since psychopharmaceutic treatment might be less effective in younger people than in adults. The First Experimental Study of Transference-In Teenagers (FEST-IT) is a Randomized Controlled Study (RCT) with a dismantling design. The main intention in this study was to illustrate a way to address parts of a case formulation by focusing a psychodynamic feature in two different therapies with a good outcome suffering from depression. We present two representative patients from the FEST-IT with case formulations revealing conflicted anger. The patients were different in many aspects, as were the therapeutic methods. Therapies with and without transference interpretations may help to understand what is helpful in therapy in general. It may also show how a more individualized approach can guide the therapy beyond diagnosis and to make it more effective for the specific patient. Looking into individual cases with good outcomes can help us address dynamic features in therapy and give some ideas about what works for whom. The use of nested qualitative double case studies may together add more knowledge about working aspects in successful therapies.