Development and pilot of a decision-aid for patients with bipolar II disorder and their families making decisions about treatment options to prevent relapse

Comparison of analog and digital patient decision aids for the treatment of depression: a scoping review

Introduction

Patient decision aids (PDAs) are important tools to empower patients and integrate their preferences and values in the decision-making process. Even though patients with mental health problems have a strong interest in being more involved in decision making about their treatment, research has mainly focused on PDAs for somatic conditions. In this scoping review, we focus on patients suffering from depression and the role of PDAs for this patient group. The review offers an overview of digital and analog PDAs, their advantages and disadvantages as well as recommendations for further research and development.

Methods

A systematic search of the existing literature guided by the Cochrane Handbook for Systematic Reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses - extension for scoping reviews (PRISMA-ScR) was conducted. Three electronic literature databases with the appropriate thematic focus were searched (PubMed, PsycInfo, and Web of Science). The search strategy used controlled and natural language to search for the key concepts decision aids and depression. The articles were selected in a two-step process guided by predefined inclusion and exclusion criteria. We narratively synthetized information extracted from 40 research articles.

Results

We included 40 articles in our review. Our review revealed that there is more focus on digital PDAs in research than in clinical practice. Digitalization can enhance the benefits of PDAs by developing tools that are more efficient, interactive, and personalized. The main disadvantages of both types of PDAs for the treatment of depression are related to time, dissemination, and capacity building for the health care providers. Digital PDAs need to be regularly updated, effective strategies for their dissemination and acceptance need to be identified, and clinicians need sufficient training on how to use digital PDAs. There is more research needed to study which forms of PDAs are most appropriate for various patient groups (e.g., older adults, or patients with comorbidities), and to identify the most effective ways of PDAs' integration in the clinical workflow. The findings from our review could be well aligned with the International Patient Decision Aids Standards.

Discussion

More research is needed regarding effective strategies for the implementation of digital PDAs into the clinical workflow, ethical issues raised by the digital format, and opportunities of tailoring PDAs for diverse patient groups.

Development and user testing of a patient decision aid for cancer patients considering treatment for anxiety or depression

BACKGROUND

Despite high rates of mental health disorders among cancer patients, uptake of referral to psycho-oncology services remains low. This study aims to develop and seek clinician and patient feedback on a patient decision aid (PDA) for cancer patients making decisions about treatment for anxiety and/or depression.

METHODS

Development was informed by the International Patient Decision Aid Standards and the Ottawa Decision Support Framework. Psycho-oncology professionals provided feedback on the clinical accuracy, acceptability, and usability of a prototype PDA. Cognitive interviews with 21 cancer patients/survivors assessed comprehensibility, acceptability, and usefulness. Interviews were thematically analysed using Framework Analysis.

RESULTS

Clinicians and patients strongly endorsed the PDA. Clinicians suggested minor amendments to improve clarity and increase engagement. Patient feedback focused on clarifying the purpose of the PDA and improving the clarity of the values clarification exercises (VCEs).

CONCLUSIONS

The PDA, the first of its kind for psycho-oncology, was acceptable to clinicians and patients. Valuable feedback was obtained for the revision of the PDA and VCEs.

Development and pilot of the Alcohol and Depression Decision-Aid for Psychological Treatments (ADDAPT)

Purpose

Evidence is lacking as to the superiority of dual-focused versus single-focused approaches in treating depression and alcohol use comorbidity. Different people may also value the different features of treatment options differently, necessitating a decision-support tool. This study aims to test the acceptability, feasibility, safety and potential usefulness of the Alcohol and Depression Decision-Aid for Psychological Treatments (ADDAPT).

Design/methodology/approach

ADDAPT was developed according to International Patient Decision-Aid Standards and in consultation with potential end users. Adults with depression and alcohol use comorbidity, who were considering/recently considered psychological treatments, were recruited via online advertisements. After clicking on the study URL, participants accessed the ADDAPT e-book and completed validated and purpose-designed questionnaires.

Findings

Of the 24 participants, most would recommend ADDAPT to others (79.2% agree) and endorsed it as easy-to-use (75%), useful in decision-making (79.2%), presenting balanced (87.5%), up-to-date (91.7%), easy-to-understand (79.2%) and trustworthy information (83.3%), which did not provoke anxiety (i.e. safety; 75%). Post-use, participants felt well prepared to decide on treatment (M = 3.48/5) and demonstrated good treatment knowledge (M = 65.83%). All but one participant indicated a treatment choice supported by best available evidence, and decisional conflict scores except for the uncertainty subscale were below the threshold for decisional delay (all M < 37.5/100).

Originality/value

ADDAPT is the first decision-aid of its kind, with pilot findings supporting its acceptability, feasibility, safety and potential usefulness for improving decision-making quality among people considering psychological treatment options for depression and alcohol use comorbidity.

The effectiveness and design of informed choice tools for people with severe mental illness: a systematic review

BACKGROUND

People with severe mental illness (SMI) report difficulty in making health-related decisions. Informed choice tools are designed to guide individuals through a decision-making process.

AIMS

To determine the effectiveness of these tools for people with SMI and to identify what methods and processes may contribute to effectiveness.

METHOD

A systematic electronic search was conducted for studies published between 1996 and January 2018. The search was updated in March 2020. Studies of any design reporting the development or evaluation of any informed choice tool for people with SMI were considered. A structured, narrative synthesis was conducted.

RESULTS

Ten articles describing four tools were identified. Tools were designed to assist with decision-making around bipolar treatment, smoking cessation and disclosure of mental illness in employment situations. Positive changes in decisional conflict, stage of change, knowledge and self-efficacy were reported for two tools, though insufficient data exists for definitive conclusions of effectiveness. Feedback from service users and attention to readability appeared key.

CONCLUSIONS

The evidence base for informed choice tools for people with SMI is limited. Such tools should be developed in stages and include the views of people with SMI at each phase; readability should be considered, and a theoretical framework should be used to facilitate process evaluation.

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 to family involvement in the care of patients with chronic mental illnesses: A qualitative study

INTRODUCTION

Caregivers are patients' family members or intimate friends who take care of individuals suffering from chronic mental illnesses without being paid. Evidence has supported the role of family-centered collaborative care in the treatment of patients with chronic mental illnesses. It has also been emphasized by national policies. However, carrying out this type of care is accompanied by challenges in Iran. Considering the importance of family participation in taking care of these patients as well as the necessity to determine its effective factors, the present study aimed to assess the barriers to family involvement in the care of patients with chronic mental illnesses.

METHOD

A conventional content analysis was used to conduct this qualitative study. Thirty four health care providers, patients, and caregivers were interviewed unstructured in-depth face-to-face using purposive sampling. Until saturation of data, sampling and data analysis were conducted simultaneously. Graneheim and Lundman's method was used to record, transcribe, and analyze the interviews.

RESULT

The results showed that there were many barriers to the collaboration of family in the care of patients with chronic mental illnesses. Accordingly, four main categories and twelve subcategories were extracted from the data as follows: "family-related barriers", "treatment-related factors", "disease nature threatening care", and "mental disease-associated stigma in the society".

CONCLUSION

The findings presented the barriers to family centers' collaborative care in patients with chronic mental illnesses and the necessary components of family involvement in the care to be used by healthcare managers and policymakers. The reported barriers emphasize the need for the development of structured approaches whose implementation is easy for health care providers, does not require a lot of time and resources, and can improve patient and family outcomes.

Effectiveness of a web-based decision aid for patients with generalised anxiety disorder: a protocol for a randomised controlled trial

INTRODUCTION

Patients with generalised anxiety disorder (GAD) have concerns and needs about their health and the healthcare they receive. Patient decision aids (PtDAs) are tools that assist patients in making health decisions, when there is uncertainty about treatment choice, incorporating their personal preferences and values about the available treatment options. PtDAs can improve shared decision-making and lead to better treatment outcomes. The aim of this study is to evaluate the effectiveness of a web-based PtDA for patients with GAD in primary care (PC).

METHODS AND ANALYSIS

The general study design is comprised of two stages: (1) development of a web-based PtDA for patients with GAD, derived from an evidence-based Clinical Practice Guideline and (2) assessment of the effectiveness of the PtDA in a randomised controlled trial (RCT) design, in PC centres in Tenerife (Spain). This RCT will be carried out with 124 patients with GAD, comparing the PtDA to a fact sheet with general information on mental health. Patients will review the PtDA in one session accompanied by a researcher. Post-intervention measures will be administered immediately after the intervention and at 3-month follow-up. The primary outcome will be decisional conflict. Secondary outcomes will include knowledge about GAD and its treatment, treatment preference, concordance between treatment preference and choice, and decision quality (knowledge ≥60% and concordant decision).

ETHICS AND DISSEMINATION

The project received ethics approval from the local committee at Nuestra Señora de la Candelaria (HUNSC) University Hospital in Santa Cruz de Tenerife (code: CHUNSC_2019_58). Informed consent will be obtained from each participant before randomisation. Results from the trial will be submitted for publication in international peer-reviewed scientific journals and will be disseminated through workshops and local and international conferences.

TRIAL REGISTRATION NUMBER

NCT04364958.

Improving treatment decision-making in bipolar II disorder: a phase II randomised controlled trial of an online patient decision-aid

BACKGROUND

Many patients with bipolar II disorder (BPII) prefer to be more informed and involved in their treatment decision-making than they currently are. Limited knowledge and involvement in one's treatment is also likely to compromise optimal BPII management. This Phase II RCT aimed to evaluate the acceptability, feasibility, and safety of a world-first patient decision-aid website (e-DA) to improve treatment decision-making regarding options for relapse prevention in BPII. The e-DA's potential efficacy in terms of improving quality of the decision-making process and quality of the decision made was also explored.

METHODS

The e-DA was based on International Patient Decision-Aid Standards and developed via an iterative co-design process. Adults with BPII diagnosis (n = 352) were recruited through a specialist outpatient clinical service and the social media of leading mental health organisations. Participants were randomised (1:1) to receive standard information with/without the e-DA (Intervention versus Control). At baseline (T0), post-treatment decision (T1) and at 3 months' post-decision follow-up (T2), participants completed a series of validated and purpose-designed questionnaires. Self-report and analytics data assessed the acceptability (e.g., perceived ease-of-use, usefulness; completed by Intervention participants only), safety (i.e., self-reported bipolar and/or anxiety symptoms), and feasibility of using the e-DA (% accessed). For all participants, questionnaires assessed constructs related to quality of the decision-making process (e.g., decisional conflict) and quality of the decision made (e.g., knowledge of treatment options and outcomes).

RESULTS

Intervention participants endorsed the e-DA as acceptable and feasible to use (82.1-94.6% item agreement); most self-reported using the e-DA either selectively (51.8%; relevant sections only) or thoroughly (34%). Exploratory analyses indicated the e-DA's potential efficacy to improve decision-making quality; most between-group standardised mean differences (SMD) were small-to-moderate. The largest potential effects were detected for objective treatment knowledge (- 0.69, 95% CIs - 1.04, - 0.33 at T1; and - 0.57, 95% CIs - 0.99,-0.14 at T2), decisional regret at T2 (0.42, 95% CIs 0.01, 0.84), preparation for decision-making at T1 (- 0.44, 95% CIs - 0.81, - 0.07), and the Decisional Conflict Scale Uncertainty subscale (0.42, 95% CIs 0.08, 0.08) and Total (0.36, 95% CIs 0.30, 0.69) scores, with all SMDs favouring the Intervention over the Control conditions. Regarding safety, e-DA use was not associated with worse bipolar symptoms or anxiety.

CONCLUSION

The e-DA appears to be acceptable, feasible, safe and potentially efficacious at improving patients' decision-making about BPII treatment. Findings also support the future adoption of the e-DA into patient care for BPII to foster treatment decisions based on the best available evidence and patient preferences.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12617000840381 (prospectively registered 07/06/2017).

Giving Patients Choices During Involuntary Admission: A New Intervention

Background: People who receive involuntary treatment are some of the most vulnerable in psychiatric services. They are more likely to have poorer social and clinical outcomes and to be disillusioned with and disengaged from care. Research indicates that patients' experience in the first week of involuntary treatment is a critical period: a better experience of care in the first week predicts better quality of life and reduced readmission 1 year later. Patients have identified involvement in clinical decisions as key to improving their experience of care. The aim of this study was to test the feasibility and acceptability of an intervention to facilitate involvement in decision making for involuntary inpatients called OPeNS (Options, Preferences, Negotiate, and Summarise). Methods: This was a mixed method study. The OPeNS intervention was developed based on previous research carried out by a multidisciplinary team. Clinicians were trained to deliver it to involuntary inpatients. Feasibility indices (rates of participation in the intervention and time required to deliver it) were collected. Patients (N = 14) and clinicians (N = 5) provided qualitative data on their experience of the intervention in semi-structured interviews which were analysed using thematic analysis. Results: The OPeNS intervention was found to be acceptable by both patients and clinicians and feasible to conduct within the first week of involuntary treatment. Patients' and clinicians' experiences of the intervention fall into two themes: 'Enabling a different dynamic' and 'Clashing with usual practices and priorities'. Conclusion: The OPeNS intervention provides a structure that can be used by clinicians across disciplines to facilitate involving involuntary patients in decision making. Although challenges related to changing usual practices were identified, the intervention was received positively and was feasible to conduct in the first week of involuntary treatment.

Preferences of Information Dissemination on Treatment for Bipolar Disorder: Patient-Centered Focus Group Study

BACKGROUND

Patient education has taken center stage in successfully shared decision making between patients and health care providers. However, little is known about how patients with bipolar disorder typically obtain information on their illness and the treatment options available to them.

OBJECTIVE

This study aimed to obtain the perspectives of patients with bipolar disorder and their family members on the preferred and most effectively used information channels on bipolar disorder and the available treatment options.

METHODS

We conducted nine focus groups in Montana, New Mexico, and California, in which we surveyed 84 individuals including patients with bipolar disorder and family members of patients with bipolar disorder. The participants were recruited using National Alliance on Mental Illness mailing lists and websites. Written verbatim responses to semistructured questionnaires were analyzed using summative content analysis based on grounded theory. Two annotators coded and analyzed the data on the sentence or phrase level to create themes. Relationships between demographics and information channel were also examined using the Chi-square and Fisher exact tests.

RESULTS

The focus group participants mentioned a broad range of information channels that were successfully used in the past and could be recommended for future information dissemination. The majority of participants used providers (74%) and internet-based resources (75%) as their main information sources. There was no association between internet use and basic demographics such as age or geographical region of the focus groups. Patients considered time constraints and the fast pace in which an overwhelming amount of information is often presented by the provider as major barriers to successful provider-patient interactions. If Web-based channels were used, the participants perceived information obtained through Web-based channels as more helpful than information received in the provider's office (P<.05).

CONCLUSIONS

Web-based resources are increasingly used by patients with bipolar disorder and their family members to educate themselves about the disease and its treatment. Although provider-patient interactions are frequently perceived to be burdened with time constraints, Web-based information sources are considered reliable and helpful. Future research should explore how high-quality websites could be used to empower patients and improve provider-patient interactions with the goal of enhancing shared decision making between patients and providers.

Phase II Randomised Controlled Trial of a patient decision-aid website to improve treatment decision-making for young adults with bipolar II disorder: A feasibility study protocol

BACKGROUND/AIMS

This paper describes the protocol for a feasibility study for a parallel Phase II randomised control trial (RCT) aiming to evaluate a novel decision-aid website (e-DA) to support young adults with bipolar II disorder (BPII), and their families.

MATERIAL AND METHODS

The e-DA was developed according to the International Patient Decision-Aid Standards (IPDAS). Participants will be 40 young adults (18-30 years) referred to a specialist outpatient clinical facility, who have a confirmed clinical diagnosis of BPII. Participants will be randomised (1:1) to receive access to the clinic's online factsheets/website with (Intervention) or without (Control) the e-DA. A series of validated and purpose-designed questionnaires will be administered at baseline (T0), immediately post-decision (T1), and 3 months post-decision (T2). Questionnaires assess key decision-making constructs related to decision-making quality, including: decisional conflict, subjective and objective treatment knowledge, values-based informed choice, concordance between preferred/actual decision-making involvement, preparation for decision-making, and decisional regret. Self-report symptom severity and anxiety will ascertain the safety of e-DA use. The focus of analyses will be to assess effect sizes, in order to guide a future RCT.

DISCUSSION

This feasibility study will evaluate a world first, evidence-based online decision-support resource, a DA website, for young adults with BPII and their families who are deciding on treatment options for relapse prevention. Findings will determine the e-DA's feasibility in RCT procedures (i.e., outpatient clinical setting) and provide estimates of effect sizes on outcomes related to improving treatment decision-making and patient outcomes in a sample of potential end-users, compared to usual care.

TRIAL REGISTRATION

This trial is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) - ACTRN12617000840381.