Integrating Client and Clinician Perspectives on Psychotropic Medication Decisions: Developing a Communication-Centered Epistemic Model of Shared Decision Making for Mental Health Contexts

Abstract

Shared decision making (SDM) interventions aim to improve client autonomy, information sharing and collaborative decision making, yet implementation of these interventions has been variably perceived. Using interviews and focus groups with clients and clinicians from mental health clinics, we explored experiences with and perceptions about decision support strategies aimed to promote SDM around psychotropic medication treatment. Using thematic analysis, we identified themes regarding beliefs about participant involvement, information management and participants' broader understanding of their epistemic expertise. Clients and clinicians highly valued clientcentered priorities such as autonomy and empowerment when making decisions.However, two frequently discussed themes revealed complex beliefs about what that involvement should look like in practice: 1) the role of communication and information exchange and 2) the value and stability of clinician and client epistemic expertise.Complex beliefs regarding these two themes suggested a dynamic and reflexive approach to information management. Situating these findings within the Theory of Motivated Information Management, we discuss implications for conceptualizing SDM in mental health services and adapt Siminoff and Step's Communication Model of Shared Decision Making (CMSDM) to propose a Communication-centered Epistemic Model of SharedDecision Making (CEM-SDM).3The quality of mental health care has been argued to be largely dependent on the quality of client-clinician communication (Priebe & McCabe, 2008), which is critical for accomplishing clinical tasks and improving health outcomes (Alegría et al., 2008;Wissow et al., 2008). The model of shared decision making (SDM) reconceptualizes client-clinician communication (Patel, Bakken & Ruland, 2008) by redefining the terms by which participants come together to make treatment decisions (Drake, Deegan & Rapp, 2010). In a SDM frame, neither clinicians (paternalistic model) nor clients (informed choice model) are singularly responsible for making decisions (Makoul & Clayman, 2006). Instead, decision making is characterized by the exchange of unbiased information (Drake et al., 2010), collaboration (Charles, Gafni & Whelan, 1999) and mutual respect for differing expertise (Deegan & Drake, 2006). Given the centrality of communication in mental health care, we believe the assumptions underlying SDM warrant critical examination.For instance, despite widespread support for SDM, its principles are not uniformly perceived or advocated. Not all clients desire high levels of autonomy (Levinson, Kao, Kuby & Thisted, 2005; Say, Murtagh & Thompson, 2006), and psychiatrists have been found to both value and criticize elements of SDM including the exchange of unbiased information (Seale, Chaplin, Lelliott & Quirk, 2006). To elucidate these discrepancies, we elicited perspectives from clients and mental health clinicians about their experiences making and facilitating medication decisions and about strategies that might suppo...

Patient participation in pro re nata medication in psychiatric inpatient settings: An integrative review

“…Our results agree with the existing knowledge of psychiatric patients' participation in regular medication, including the importance of their knowledge of medication, active role they play in medication decisions, and their partnership with professionals with regard to administering medications (Lorem et al 2014;Mikesell et al 2016;O'Sullivan & Rae 2014). However, we found that there are some special features of patient participation in PRN, as the need for PRN is often based on specific situations and the patients' risk being vulnerable because they depend on professionals' decision-making.…”

“…A statement of good practice highlighted patient participation and shared decision-making in PRN medication (Baker et al 2007b). However, patient participation can only be achieved if they are willing and competent to participate in decisions about PRN and have sufficient knowledge about their medication and health (Lorem et al 2014;Mikesell et al 2016;Stewart et al 2010). Participation means that patients play an active role when medication is planned (Mikesell et al 2016;Mullen & Drinkwater 2011), they are given choices, and they have a chance to make decisions.…”

“…Patient participation is described as a partnership between patient and professionals, with mutual respect for differing expertise. Patients will feel they are heard if they are included in a partnership that includes interaction and communication, and where their perspectives, needs, and preferences are taken into account (Lorem et al 2014;Mikesell et al 2016;O'Sullivan & Rae 2014). Furthermore, the cornerstones to successful patient participation in this area are that patients take the medication on a voluntary basis and receive support to help them comply (Lorem et al 2014).…”

Qualitative systematic review of barriers and facilitators to patient-involved antipsychotic prescribing

“…All study characteristics are detailed in the supplementary material (Tables DS2 and DS3). Of the 30 studies, 13 were conducted in the UK, 27 , 28 , 30 , 33 , 36 , 37 , 41 , 44 , 46 , 47 , 49 , 51 – 53 ten in the USA, 20 , 29 , 31 , 32 , 34 , 38 , 39 , 43 , 48 , 50 four in Canada, 35 , 40 , 42 , 55 and one each in Norway 45 and Sweden 54 . Sixteen studies examined data from only patients' perspectives, 28 , 29 , 32 , 33 , 37 , 39 – 43 , 45 , 46 , 49 , 50 , 53 , 55 six from only health professionals' perspectives, 30 , 34 , 35 , 47 , 51 , 52 , 54 and only one from carers' perspectives.…”

Attitudes towards shared decision making in mental health: a qualitative synthesis

“…the "SDM-PLUS"-model. These adapted models are seen by professionals as a way of making SDM more applicable to mental health settings, and allowing greater flexibility and considerations of the ways of overcoming challenges of implementing SDM in practice (Hamann & Heres, 2014;Mikesell et al, 2016).…”