It Does Take Two to Tango: An Applied Conversation Analysis of Interactions between a Psychiatrist and Service-Users Discussing Medication

Codesigning a systemic discharge intervention for inpatient mental health settings (MINDS): a protocol for integrating realist evaluation and an engineering-based systems approach

INTRODUCTION

Transition following discharge from mental health hospital is high risk in terms of relapse, readmission and suicide. Discharge planning supports transition and reduces risk. It is a complex activity involving interacting systemic elements. The codesigning a systemic discharge intervention for inpatient mental health settings (MINDS) study aims to improve the process for people being discharged, their carers/supporters and staff who work in mental health services, by understanding, co-designing and evaluating implementation of a systemic approach to discharge planning.

METHODS AND ANALYSIS

The MINDS study integrates realist research and an engineering-informed systems approach across three stages. Stage 1 applies realist review and evaluation using a systems approach to develop programme theories of discharge planning. Stage 2 uses an Engineering Better Care framework to codesign a novel systemic discharge intervention, which will be subjected to process and economic evaluation in stage 3. The programme theories and resulting care planning approach will be refined throughout the study ready for a future clinical trial. MINDS is co-led by an expert by experience, with researchers with lived experience co-leading each stage.

ETHICS AND DISSEMINATION

MINDS stage 1 has received ethical approval from Yorkshire & The Humber-Bradford Leeds (Research Ethics Committee (22/YH/0122). Findings from MINDS will be disseminated via high-impact journal publications and conference presentations, including those with service user and mental health professional audiences. We will establish routes to engage with public and service user communities and National Health Service professionals including blogs, podcasts and short videos.

TRIAL REGISTRATION NUMBER

MINDS is funded by the National Institute of Health Research (NIHR 133013) https://fundingawards.nihr.ac.uk/award/NIHR133013. The realist review protocol is registered on PROSPERO.

PROSPERO REGISTRATION NUMBER

CRD42021293255.

Peer support and shared decision making in Open Dialogue: Opportunities and recommendations

Open dialogue (OD) is a person-centred social network model of crisis and continuing mental healthcare, which promotes agency and long-term recovery in mental illness. Peer support workers who have lived experience of mental illness play a key role in OD in the UK, as they enhance shared understanding of mental health crisis as part of the OD model and provide a sense of belonging and social inclusion. These elements are in alignment with the shared decision making (SDM) approach in mental health, which focuses on person-centred communication in treatment decision-making. The previously documented benefits of peer-led SDM include increased engagement with services, symptom reduction, increased employment opportunities, and reduced utilization of mental and general health services. While the contribution of peer support and SDM principles to OD has been acknowledged, there is only a small body of literature surrounding this development, and little guidance on how peer support can enhance treatment decision-making and other aspects of OD. This viewpoint, which was co-authored by people with lived experience of mental illness, clinicians, and researchers, discusses practical implications and recommendations for research and training for the provision of a co-produced OD model grounded in peer support and SDM.

Shared decision-making interventions for people with mental health conditions

BACKGROUND

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.

OBJECTIVES

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.

SEARCH METHODS

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.

SELECTION CRITERIA

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).

DATA COLLECTION AND ANALYSIS

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.

MAIN RESULTS

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.

AUTHORS' CONCLUSIONS

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.

Barriers and Enablers to Shared Decision Making in Psychiatric Medication Management: A Qualitative Investigation of Clinician and Service Users' Views

Shared decisionmaking (SDM) is a recommended health communication approach in mental health settings. Yet, implementation of SDM in psychiatric consultations discussing medication management is challenging. Insufficient attention has been given to examine the views of both clinicians and service users together about the experiences of SDM in psychiatric medication management. The purpose of this paper is to examine the views of service users, community psychiatric nurses, and psychiatrists about enablers and barriers of SDM. A thematic analysis of 30 semi structured interviews with service users, psychiatrists, and community psychiatric nurses, in a community mental health team in the UK, was conducted. A service user advisory group was involved in all phases of the research cycle, including data collection, analysis, and dissemination. The results offer a detailed contextualized account of how medication decisions are made. For psychiatrists and service user participants SDM is seen as a way of enhancing service users' engagement in and control over treatment decisions. While psychiatrists value the transactional benefits of SDM, service user participants and psychiatric nurses conceptualize SDM as a long-term endeavor embedded within therapeutic partnerships. For service users these partnerships mitigate acknowledged problems of feeling unable to be fully involved during times of crisis. This study identified a range of barriers and facilitators to SDM concerning psychiatric medications from the lived experience of service users and the professional experience of clinicians. Furthermore, it indicates new potential intervention points to support SDM in psychiatric medication decisions.