Feasibility and efficacy of shared decision making for first-admission schizophrenia: a randomized clinical trial

Supported Decision-Making Interventions in Mental Healthcare: A Systematic Review of Evidence on the Outcomes for People With Mental Ill Health

BACKGROUND

Most people with mental ill health want to be involved in decision-making about their care, many mental health professionals now recognise the importance of this (at least in-principle) and the Convention on the Rights of Persons with Disabilities enshrines the ethical imperative to support people in making their own treatment decisions. Nonetheless, there are widespread reports of people with mental ill health being excluded from decision-making about their treatment in practice.

OBJECTIVES

We conducted a systematic review of quantitative, qualitative and mixed method research on interventions to improve opportunities for the involvement of mental healthcare service users in treatment planning. We sought to consolidate and understand the evidence on the outcomes of shared and supported decision-making for people with mental ill health.

METHODS

Seven databases were searched and 5137 articles were screened. Articles were included if they reported on an intervention for adult service users, were published between 2008 and October 2023 and were in English. Evidence in the 140 included articles was synthesised according to the JBI guidance on Mixed Methods Systematic Reviews.

RESULTS

There was evidence relating to the effects of these interventions on a range of outcomes for people with mental ill health, including on: suicidal crisis, symptoms, recovery, hospital admissions, treatment engagement and on the use of coercion by health professionals. There is favourable evidence for these types of interventions in improving some outcomes for people with mental ill health, more so than treatment-as-usual. For other outcomes, the evidence is preliminary but promising. Some areas for caution are also identified.

CONCLUSIONS

The review indicates that when the involvement of people with mental ill health in treatment planning is supported, there can be improved outcomes for their health and care. Areas for future research are highlighted.

PATIENT OR PUBLIC CONTRIBUTION

This systematic review has been guided at all stages by a researcher with experience of mental health service use, who does not wish to be identified at this point in time. The findings may inform organisations, researchers and practitioners on the benefits of implementing supported decision-making, for the greater involvement of people with mental ill health in their healthcare.

Shifting Perspectives on the Challenges of Shared Decision Making in Mental Health Care

Although shared decision making (SDM) has become the most preferable way in doctor-patient communication, it is not fully implemented in mental health care likely due to the complex nature of psychiatric syndromes and treatments. In this review we provide a systematic overview of all perceived and reported barriers to SDM in the literature, acknowledging field-specific challenges, and offering perspectives to promote its wider use. We conducted a systematic search of the wider literature in different databases and included all publications mentioning specified barriers to SDM in psychiatric care. Relevant data and opinions were categorised into micro-, meso- and macro-level themes and put into clinical perspective. We derived 20 barriers to SDM from 100 studies and reports. Eight were on micro-level care delivery, seven involved meso-level issues, five concerned macro-level themes. The multitude of perceived and actual barriers to SDM underline the challenges its implementation poses in mental health care, some of which can be resolved while others are inherent to the nature of the care, with its long-term relationships, complex dynamics, and social consequences, all requiring a flexible approach. We present four perspectives to help change views on the potential of SDM in mental health care.

Development and acceptability testing of a decision aid for considering whether to reduce antipsychotics in individuals with stable schizophrenia

AIM

Continued antipsychotic treatment is the key to preventing relapse. Maintenance antipsychotic monotherapy and optimal dose use are recommended for individuals with stable schizophrenia because of their undesirable effects. Decision aids (DAs) are clinical conversation tools that facilitate shared decision-making (SDM) between patients and health-care providers. This study aimed to describe the development process and results of acceptability testing of a DA for individuals with stable schizophrenia, considering (i) whether to continue high-dose antipsychotics or reduce to the standard dose and (ii) whether to continue two antipsychotics or shift to monotherapy.

METHODS

A DA was developed according to the guidelines for the appropriate use of psychotropic medications and International Patient Decision Aid Standards (IPDAS). First, a DA prototype was developed based on a previous systematic review and meta-analysis conducted for identifying the effects of continuing or reducing antipsychotic treatment. Second, mixed-method survey was performed among individuals with schizophrenia and health-care providers to modify and finalize the DA.

RESULTS

The DA consisted of an explanation of schizophrenia, options to continue high-dose antipsychotics or reduce to the standard dose, options to continue two antipsychotics or shift to monotherapy, pros and cons of each option, and a value-clarification worksheet for each option. The patients (n = 20) reported acceptable language use (75%), adequate information (75%), and well-balanced presentation (79%). Health-care providers (n = 20) also provided favorable overall feedback. The final DA covered six IPDAS qualifying criteria.

CONCLUSION

A DA was successfully developed for schizophrenia, considering whether to reduce antipsychotics, which can be used in the SDM process.

Trends, challenges, and priorities for shared decision making in mental health: The first umbrella review

BACKGROUND

Shared decision making (SDM) is a health communication model promoting patient-centered care that has not been routinely utilized in mental health. Inconsistent definitions, models, measurement tools, and lack of sufficient evidence for the effectiveness of SDM interventions are potential contributors to the limited use of SDM in mental health.

AIMS

(1) Provide the first systematic analysis of global development trends and challenges of SDM research; (2) clarify the meaning, role, and measurement of SDM in mental health; (3) create a theoretical framework for key effective SDM components to guide future development and implementation of SDM interventions.

METHODS

A comprehensive search strategy was conducted in CINAHL, PubMed, Scopus, MEDLINE, EMBASE, Cochrane Library, Web of Science, Scopus, and PsycInfo. Included reviews focused on SDM interventions for prevention and/or treatment of mental illness in adults. A narrative synthesis was performed to capture the range of interventions, populations, measurement tools, comparisons, and outcomes.

RESULTS

10 systematic reviews of SDM in mental health were included with 100 nested studies spanning from 2006 to 2020. All reviews focused on dyadic and psychopharmacological decision-making. Primary outcomes of SDM in mental health interventions include treatment satisfaction, medication adherence, symptom severity, quality of life, and hospital readmissions. Participant-related factors unique to SDM in mental health, such as stigma and mental capacity, were not reported.

CONCLUSIONS

The current landscape of SDM in mental health is overwhelmingly disconnected from the needs and experiences of potential end-users; clients, clinicians, and family members. Most SDM interventions and tools were adapted from physical health and are mainly geared to psychopharmacological decision-making. The SDM in Mental Health Framework (SDM-MH), developed here, expands the scope of decisions to non-psychopharmacological discussions, diversifies the pool of SDM participants and settings, and offers potential primary target outcomes of SDM in mental health to reduce heterogeneity across studies.

Shared decision making with schizophrenic patients: a randomized controlled clinical trial with booster sessions (DECIDE Study)

BACKGROUND

The treatment of schizophrenia requires a prolonged, multidimensional intervention that includes antipsychotic drugs. Treatment adherence is essential to effectively control the disorder. Shared decision-making (SDM) is a strategy, supported by numerous practical and ethical arguments, that seeks to involve patients in the therapeutic process to improve treatment adherence and satisfaction. The use of this model in mental health has been limited for many intrinsic and extrinsic reasons. The results of clinical trials conducted to date have largely been disappointing, potential due to study design-related limitations.

AIM/QUESTION

To evaluate the efficacy, in terms of treatment adherence and improvement in clinical variables, such as severity of symptoms, days of hospitalization or insight, of a carefully timed SDM model initiated immediately prior to hospital discharge in patients with schizophrenia.

METHODS

Single-blind, randomized clinical trial in an acute psychiatric care unit within the Andalusian Health Department to compare SDM (experimental group) to treatment as usual (TAU; control group) in a sample of patients hospitalized for an acute episode of schizophrenia or schizoaffective disorder. The study was performed between January 2014 and June 2017. The experimental group participated in SDM sessions prior to discharge with regular booster sessions over the one-year follow-up. The health care team responsible for SDM was predisposed to concordance (LatCon II scale) and received specific training in SDM. A hierarchical multiple linear regression analysis was performed to evaluate the factors independently associated with adherence, controlling for sociodemographic, clinical, and admission-related variables. Variables were assessed at admission, discharge and at 3, 6 and 12 months after discharge during the one year follow up. BARS, DAI, WAI-S, COMRADE and PANSS were used to evaluate adherence, attitude to treatment, therapeutic alliance, satisfaction and confidence with decision and clinical status, respectively.

RESULTS

A total of 227 schizophrenic patients hospitalized with acute decompensation were evaluated; of these, 102 met all inclusion criteria and were included in the study. Most patients (95%) had prior experience with antipsychotics and most (82%) had experienced related side effects. Despite randomization, psychopathologic severity was greater in the experimental group, with a mean (SD) PANSS score of 104.08 (80) vs. 93.45 (20.30) (p < 0.05). The final regression model to explain adherence was significant (adjusted R2 = 0.384; F [df= 6] = 4.386; p < 0.001), with a direct, significant and independent association with SDM mediated by the number of booster sessions.

DISCUSSION

Shared decision making with booster sessions appears to increase treatment adherence in patients with severe mental disorders.

IMPLICATION ON PRACTICE

Ethical, practical, and clinical reasons support the use of strategies designed promote the use of long-term, shared decision-making in psychiatric patients, especially in schizophrenia spectrum disorder.

How do patients and families evaluate attitude of psychiatrists in Japan?: quantitative content analysis of open-ended items of patient responses from a large-scale questionnaire survey

BACKGROUND

Patient and Public Involvement (PPI) has been widely advocated in psychiatric fields. In Japan, however, PPI has not been implemented in clinical practice. In order to improve quality of psychiatric service in Japan, it is essential to understand psychiatrists' attitudes from the patients' perspective as a first step in practicing PPI. This study aimed to investigate the patients' evaluation of psychiatrists' attitudes by illustrating themes appeared in the questionnaire survey.

METHODS

This study used the data obtained from the questionnaire survey responded by 2,683 patients with family members who belong to the family associations for psychiatric patients in Japan. Three open-ended question items in this survey, "criteria for selecting a psychiatrist (784 patient responses, response rate 29.2%)," "attitude of the psychiatrist in charge (929 patient responses, response rate 34.6%)," and "communication skills of the psychiatrist in charge (739 patient responses, response rate 27.5%)" were analyzed by co-occurrence network using KH Coder software.

RESULTS

The common theme observed in all three items was whether psychiatrist took sufficient consultation time. The criteria for selecting a psychiatrist were summarized whether psychiatrist provided appropriate advices for patients' problems, whether psychiatrist cared about patients' demands and whether psychiatrist informed to patients about diseases and medications. The attitudes of the psychiatrists in charge that patients had most wanted their psychiatrists to improve were: psychiatrists only watch the computer, make diagnosis according to the patients' individual condition, and try to build a relationship of trust with the patient. The patients' demands regarding communication skills of the psychiatrist in charge included: whether the psychiatrist communicated in a way that improves the patient's psychological state, whether the psychiatrist was attentive to the patients' family, and whether the psychiatrist could control his/her own mood during the consultation.

CONCLUSION

The results reflected the patients' demands that do not appear in closed-ended items. It was suggested that patients'open-ended responses to questionnaires and their involvement in the psychiatric research (PPI) may provide more insight into improving pshchiaric care in Japan.

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.

Factors influencing the outcome of integrated therapy approach in schizophrenia: A narrative review of the literature

The integration of pharmacotherapy with psychosocial interventions has an important role to play in the improvement of functional outcome of subjects with schizophrenia (SCZ), in all stages of the disorder. It is essential for the adequate management of unmet therapeutic needs, such as negative symptoms and cognitive dysfunctions which account for most of the functional impairment of subjects with SCZ and do not respond to available antipsychotics. Enhancing the knowledge on factors involved in the effectiveness of integrated treatment plans is an important step forward for SCZ care. This review aims to identify factors that might influence the impact of integrated treatments on functional outcome. Most studies on the impact of psychosocial treatments on functional outcome of subjects with SCZ did not control for the effect of prescribed antipsychotics or concomitant medications. However, several factors relevant to ongoing pharmacological treatment might influence the outcome of integrated therapy, with an impact on the adherence to treatment (e.g., therapeutic alliance and polypharmacotherapy) or on illness-related factors addressed by the psychosocial interventions (e.g., cognitive dysfunctions or motivational deficits). Indirect evidence suggests that treatment integration should consider the possible detrimental effects of different antipsychotics or concomitant medications on cognitive functions, as well as on secondary negative symptoms. Cognitive dysfunctions can interfere with participation to an integrated treatment plan and can be worsened by extrapyramidal or metabolic side effects of antipsychotics, or concomitant treatment with anticholinergics or benzodiazepines. Secondary negative symptoms, due to positive symptoms, sedation, extrapyramidal side effects or untreated depression, might cause early drop-out and poor adherence to treatment. Researchers and clinicians should examine all the above-mentioned factors and implement appropriate and personalized integrated treatments to improve the outcome of SCZ.

A Systematic Review of Shared Decision-Making Interventions for Service Users With Serious Mental Illnesses: State of the Science and Future Directions

OBJECTIVE

Shared decision making (SDM) is a health communication model that may be particularly appealing to service users with serious mental illnesses, who often want to be involved in making decisions about their mental health care. The purpose of this systematic review was to describe and evaluate participant, intervention, methodological, and outcome characteristics of SDM intervention studies conducted within this population.

METHODS

Systematic searches of the literature through April 2020 were conducted and supplemented by hand searching of reference lists of identified studies. A total of 53 independent studies of SDM interventions that were conducted with service users with serious mental illnesses and that included a quantitative or qualitative measure of the intervention were included in the review. Data were independently extracted by at least two authors.

RESULTS

Most studies were conducted with middle-age, male, White individuals from Western countries. Interventions fell into the following categories: decision support tools only, multicomponent interventions involving decision support tools, multicomponent interventions not involving decision support tools, and shared care planning and preference elicitation interventions. Most studies were randomized controlled trials with sufficient sample sizes. Outcomes assessed were diverse, spanning decision-making constructs, clinical and functional, treatment engagement or adherence, and other constructs.

CONCLUSIONS

Findings suggest important future directions for research, including the need to evaluate the impact of SDM in special populations (e.g., young adults and racial-ethnic minority groups); to expand interventions to a broader array of decisions, users, and contexts; and to establish consensus measures to assess intervention effectiveness.

NICE shared decision making guidelines and mental health: challenges for research, practice and implementation

The National Institute for Health and Care Excellence (NICE) initiated an ambitious effort to develop the first shared decision making guidelines. The purpose of this commentary is to identify three main concerns pertaining to the new published guidelines for shared decision making research, practice, implementation and cultural differences in mental health.

Conceptual understanding and applicability of shared decision-making in psychiatric care: An integrative review

WHAT IS KNOWN ON THE SUBJECT?: Shared decision-making is a concept originating in the medical field, and it is ideally based on a trustful relationship between the patient and the health professionals involved. Shared decision-making shows potential to strengthen patient autonomy and encourages patients to become involved in decisions regarding their treatment. WHAT DOES THE PAPER ADD TO EXISTING KNOWLEDGE?: A universal concept and understanding of shared decision-making with relevance specifically to psychiatric clinical practice could not be identified in the analysed literature. Shared decision-making refers to a process, and how and whether the patient wishes to participate in the decision-making process should be clarified from the very beginning. On the basis of this synthesizing review, a process model for psychiatric practice was specified and illustrated to help lead health professionals, patients and other supporters through the decision-making process. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The process of shared decision-making should be made visible to all persons involved, and it should be stated at the beginning that a decision must be made. Decisions regarding treatment are usually not limited to a single consultation. A collaborative approach including multiple health professionals and other supporters, such as peer workers and family members, is required. Psychiatric nurses could support patients during the process of decision-making and provide additional information, if requested.

ABSTRACT

INTRODUCTION: Patient involvement in decisions regarding treatment has increasingly been supported in health care, and therefore, shared decision-making (SDM), as an informative and participative approach, is promoted in the scientific literature.

AIM

To review the current state of research regarding the conceptual understanding and implementation of SDM in psychiatric clinical practice.

METHOD

An integrative review that included empirical, theoretical and conceptual research published between 1997 and 2019 was conducted. For this, five health-related databases were searched.

RESULTS

Fourteen articles were included in the synthesis. No universal conceptual understanding of SDM regarding psychiatric care could be identified, although several articles highlighted the link with other concepts, such as autonomy and patient-centeredness. Furthermore, four additional key themes with relevance for the successful implementation of SDM in clinical practice were determined.

DISCUSSION

SDM refers to a process and is usually not limited to a single consultation. SDM shows the potential to enhance patient-centred and recovery-oriented care. A collaborative approach including multiple health professionals, peer workers and family members is required.

IMPLICATIONS FOR PRACTICE

The process of SDM should be made visible for all parties involved. Nurses in particular could play a key role by collecting information regarding patient's preferences and by providing support.

Relationship between satisfaction with mental health services, personal recovery and quality of life among service users with psychosis: a cross-sectional study

Background

Mental health policy internationally emphasizes patient centredness and personal recovery. This study investigated the relationship between satisfaction with mental health services among service users with psychosis in Norway, and personal recovery, perceived support for personal recovery, and quality of life.

Methods

Cross-sectional data were collected from 292 service users diagnosed with psychosis from 39 clinical sites across Norway. Satisfaction with services was assessed using the Client Satisfaction Questionnaire-8. A linear mixed model was estimated to explore the relationship between satisfaction with services and preselected covariates, and to control for confounding factors.

Results

A large majority of participants (89%) reported moderate-to-high levels of satisfaction. Satisfaction with services was positively associated with perceived support for personal recovery, but not with personal recovery or quality of life. In addition, service users under a Community Treatment Order (CTO) were significantly less satisfied than those who were not.

Conclusions

Satisfaction levels among service users were higher compared with similar, international studies. Those who feel supported in their personal recovery were more satisfied with the care they receive, which support the need for implementation of recovery-oriented practices for service users with psychosis. However, satisfaction with services was not related to service user-rated quality of life or level of personal recovery; thus, more follow-up studies are needed. The lower satisfaction of service users placed under CTOs shows the importance of targeted interventions to improve satisfaction with services among this group.

Trial registration

NCT03271242, date of registration: 5 sept. 2017.

Shared decision making for adults with severe mental illness: A concept analysis

AIM

Shared decision making for adults with severe mental illness has increasingly attracted attention. However, this concept has not been comprehensively clarified. This review aimed to clarify a concept of shared decision making for adults with severe mental illness such as schizophrenia, depression, and bipolar disorder, and propose an adequate definition.

METHODS

Rodgers' evolutionary concept analysis was used. MEDLINE, PsychINFO, and CINAHL were searched for articles written in English and published between 2010 and November 2019. The search terms were "psychiatr*" or "mental" or "schizophren*" or "depression" or "bipolar disorder", combined with "shared decision making". In total, 70 articles met the inclusion criteria. An inductive approach was used to identify themes and sub-themes related to shared decision making for adults with severe mental illness. Surrogate terms and a definition of the concept were also described.

RESULTS

Four key attributes were identified: user-professional relationship, communication process, user-friendly visualization, and broader stakeholder approach. Communication process was the densest attribute, which consisted of five phases: goal sharing, information sharing, deliberation, mutual agreement, and follow-up. The antecedents as prominent predisposing factors were long-term complex illness, power imbalance, global trend, users' desire, concerns, and stigma. The consequences included decision-related outcomes, users' changes, professionals' changes, and enhanced relationship.

CONCLUSIONS

Shared decision making for adults with severe mental illness is a communication process, involving both user-friendly visualization techniques and broader stakeholders. The process may overcome traditional power imbalance and encourage changes among both users and professionals that could enhance the dyadic relationship.

Treating Schizophrenia: Open Conversations and Stronger Relationships Through Psychoeducation and Shared Decision-Making

Integrated pharmacological and psychosocial treatments, such as psychoeducation (PE) and shared decision-making (SDM), have been shown to significantly improve outcomes for people living with schizophrenia (PLWS). Underpinning the success of these interventions is a strong therapeutic relationship between PLWS, their carers, and their healthcare team. While many recognize the value of this relationship, implementation of the interventions necessary to facilitate its construction remain low. In this article, we identify the barriers to developing productive therapeutic relationships and explain how PE and SDM, taking into account cultural difference, can improve adherence to treatment, strengthen therapeutic relationships, and ultimately equip patients to achieve better functional outcomes.

The role of shared decision-making in improving adherence to pharmacological treatments in patients with schizophrenia: a clinical review

Shared decision-making (SDM) is a process in which the doctor provides clear and complete medical information to patients about their treatment, and patients provide information on his/her preferences. Patients and clinicians bring different, but equally important, knowledge to the decision-making process. Through the adoption of SDM, it should be possible to overcome the barriers that hinder the acceptance of long-acting injectable antipsychotics (LAIs) by patients, and often also by psychiatrists. The present paper is a critical appraisal of recent literature on the impact of SDM in improving adherence to pharmacological treatments and in implementing the use of LAIs in the treatment of patients with schizophrenia. SDM is recognized as a promising strategy to improve collaboration between clinicians and patients in achieving recovery. When considering drug treatments, clinicians must evaluate the patient's preferences, expectations and concerns towards the development of a personalized treatment strategy. Moreover, an active involvement in the decision process could reduce the patient's perception of being coerced into the use of LAIs. Involving patients in the choice of therapy is not sufficient to increase pharmacological adherence if, at the same time, there is no constant work of comparison and communication with the reference psychiatric team. SDM can be particularly effective for LAI prescription, since patient can have prejudices and unjustified fears related to the LAI formulation, which the doctor must resolve.

The Momentum trial: the efficacy of using a smartphone application to promote patient activation and support shared decision making in people with a diagnosis of schizophrenia in outpatient treatment settings: a randomized controlled single-blind trial

BACKGROUND

Shared decision making (SDM) is often defined as an interactive process that ensures that both patient and practitioner are actively involved in the treatment and that they share all relevant information to arrive at a mental health decision. Previous SDM interventions have found improvements in outcomes such as personal recovery, higher perceived involvement in treatment decisions and knowledge about one's disease. Still, SDM occurs less frequently in mental health care than in primary care. Electronic aids developed to support patient activation and SDM could be a promising mean to engage patients in their mental healthcare. The aim of this trial is to investigate the effects of using a smartphone app to promote patient activation and support SDM for people with schizophrenia-spectrum disorders in an outpatient treatment setting.

METHODS

This randomised controlled trial will allocate participants to one of two groups: (1) Intervention group: smartphone app and TAU (treatment as usual) or (2) Control group: TAU without the smartphone app. A total sample size of 260 people with a diagnosis of schizophrenia, schizotypal or delusional disorder will be recruited from five OPUS teams (a specialized early intervention program) in Denmark between 2019 and 2020. The intervention will last for 6 months with data collection at baseline, and at 3 and 6 months. Primary outcome will be self-perceived patient activation. Secondary outcomes will be feeling of being prepared for SDM; self-efficacy; working alliance; treatment satisfaction; positive and negative symptoms; level of functioning; hope; and perceived efficacy in patient-provider interaction. Patients' and health providers' preferences in clinical decision making will be assessed. Patients' usage and perceived usefulness of the app will be explored.

DISCUSSION

This study will investigate the efficacy of using the smartphone app to support people with severe mental illness in engaging in their own healthcare management. The study may provide evidence to the idea that linking client and practitioner in digital solutions can have advantages in facilitating SDM in mental health. The trial will provide new knowledge of whether a digital healthcare solution can improve patient activation and support SDM for people with severe mental illness.

TRIAL REGISTRATION

ClinicalTrials.gov number: NCT03554655 Registered on: June 13, 2018.