Existing programmes focussed on shared decision making in psychiatric medication management Amy Li and Dr. Nicola Moran

1. Existing programmes focussed on shared decision making in psychiatric medication managementAmy Li and Dr. Nicola Morant ShIMME (Shared Involvement in Medication Management Education)

2. Outline of the presentation • Introduction • Existing programmes focussed on shared decision making (SDM) in psychiatric medication management for service users • Existing programmes focussed on SDM in psychiatric medication management for professionals • Existing programmes focussed on SDM in psychiatric medication management for service users and professionals • Conclusion and Key Issues

3. Introduction • Little research has been done in the mental health field on the impact of preferences and processes on actual decisions. • Only a few studies have addressed shared decision making in relation to psychiatric medication management. • Decision support interventions and decision aids can help facilitate the process of shared decision making. • SDM intervention data provide good preliminary evidence of various effects including: • improvements in attendance and retention in treatment; satisfaction with health care; practitioner skills; patient involvement; concordance; clinicians’ understanding of clients; no extra time in consultations

4. Existing programmes focussed on shared decision making in psychiatric medication management for service users Deegan et al (2008) • Have carried out the most extensive work in the literature of shared decision making in psychiatric medication management. • http://www.patdeegan.com/commonground/tour/health-report Intervention: • Peer-specialist protocols, clients complete a one-page computer generated report, providing clients with access to health related information via the internet and providing informal peer support. • The internet based computer programme was user friendly, included written perspectives and a video vignettes regarding recovery from peers. • Clients were asked questions and competed a survey about their concerns and goals for meeting with the professionals. A decisional balance and trade off worksheet guide was then presented to the client listing the pros and cons of using medicine.

5. Patricia Deegan’s work Results • Medical staff members revealed that the one page report generated by the computer software helped to create efficiencies in the consultation, as it helped them to focus quickly on the clients concerns. • The report assisted professionals to develop a thorough understanding of the clients worries and consequently enabled them to come to an agreement on how to progress with treatment.

6. Ludman et al (2003) Randomised controlled trial of a primary care-based intervention to prevent depression relapse. Intervention: A low intensity 12 month intervention that combined education about depression, shared decision making regarding use of maintenance pharmacotherapy and cognitive behavioural strategies to promote self-management. Results Intervention clients had significantly greater self efficacy for managing depression, tracking of depression symptoms and early warning signs compared to usual care control clients.

7. Guy Holmes (2006) • Previously published a number of top tips for people coming off medication. Intervention: • Decision aids to help people think through pros and cons of coming off and staying on medication. • Peer support programmes and thinking about medication groups. • Participants in the peer support groups learnt from people who have gone through the process and were able to access support. Results: • Service users found it useful to reflect about medication and think through dilemmas. • Decision aids helped service users to access alternatives to medication.

8. Programmes focussed on SDM in psychiatric medication management for professionals Loh et al (2007) • Cluster randomised controlled intervention study in primary care settings of depression. Intervention: • Physicians completed modules on guideline-concordant depression care. • Modules included content on enhancing skills for involving clients in the decision making process, specialised lectures, facilitation practice, role-playing, and video exemplars of high quality shared decision making. • Physicians were given decision aids and information leaflets for dissemination to the clients. • The training: took place within 6 month time period which included 5 scheduled training programme events. Results: • The intervention was better than usual care for improving service user participation in treatment decision making and satisfaction with care, without increasing consultation time.

9. Bieber et al (2009) • Clinical trial implementing shared decision making training for German physicians in practice. Intervention: • 2 modules and each module was 4 hours in duration. • The agenda of the first training session covered service user preferences, the theoretical framework of the shared decision making concept. • The second training session embedded shared decision making skills into the broader concept of client-centeredness. Aspects such as partnership building with service users and techniques of good communication were covered. • Didactic methods intervention included interactive presentation, model films on shared decision making consultations, instructional videos, group discussions, practice exercises and role playing. Results: • The training highly improved physician’s confidence and knowledge in their shared decision making competencies. The intervention was attractive to practising physicians and greatly increased their self efficacy.

10. Priebe et al (2007) • Cluster randomised controlled trial to test a computer-mediated intervention structuring client-clinician dialogue (DIALOG) focusing on clients’ quality of life and needs for care. Intervention: • Clinicians used a maunulised computer-mediated procedure to discuss 11 domains with their clients. • Clients were asked whether they wanted any additional or different help in the given domain and explicit response was required before participants could proceed in the meetings. • The intervention therefore ensured the 11 life and treatment domains were consistently addressed and clients’ views and priorities were always considered. • Clinicians were trained to take a more client-centred approach in their consultations. Intervention was applied every 2 months in meeting that had been arranged as part of routine care. Results: • After 12 months, the intervention had a significant positive effect on the quality of life, unmet needs or care and treatment satisfaction of clients.

11. Professional competencies for SDM: work in general medicine • Much more work on SDM in general health care than mental health • What skills do professionals need to encourage SDM? • Godolphin (2009): develop partnership; establish patient’s preferences and concerns; identify choices; help pt evaluate choices and their implications; negotiate decision / resolve conflict; agree follow-up plan • Lots of work by Glyn Elwyn (eg. Elwyn, Edwards, Kinnersley & Grol (2000) • Skills development interventions: Elwyn et al (2004) • Randomised trial with 20 GPs: training in SDM vs. risk communication • SDM training = 2 workshops: presentations, discussion and participation in simulated consultation • SDM training increased patient involvement more; risk communication training increased treatment agreement and pt satisfaction more

12. Existing programmes focussed on SDM in psychiatric medication management for service users and professionals Hamann et al (2006) • Randomised controlled trial of shared decision making in a sample of acutely ill service users with schizophrenia. • Intervention: 16 page booklet covering pros and cons of oral vs. depot formulation, first vs. second generation antipsychotic and psychoeducation for service users. • Clients took 30-60 minutes working through the booklet and were asked to write down their experiences with previous medication and highlight their preferential choice regarding antipsychotic medication. • Clients met with their prescribers 24 hours after working through the decision aid with their nurse. The aim of the meeting / planning tasks were to reach an agreement according to the preferences highlighted in the booklet • Training: Nurses were trained in assisting clients to work through the booklets, dealing with queries and encouraging participation. Physicians were trained by attending information sessions on shared decision making and communication skills. Service users were trained in communication skills to encourage them to be more assertive during consultations by asking more questions and by introducing their point of view into the discussion.

13. The results of the studyshowed the clients had better knowledge about their illness and treatment. Clients also had a higher level of perceived involvement in decision making. • The study found that shared decision making did not take up more of the professionals time than usual care.

14. Conclusion • Many psychiatric treatment decisions are preference sensitive, and the involvement of service users and professionals in the decision making process can result in benefits for both parties. • Studies testing the feasibility and effectiveness of shared decision making programmes for depression and schizophrenia have been promising. • Although research in the mental health field is behind other areas of medicine, several randomised trials supports its effectiveness. These studies show that SDM increases the quality of decisions, participation and is congruent with underlying values. • There is evidence that shared decision making is feasible and time comparable to usual care in psychiatric and primary care setting. • Current researchers and developers explicitly include shared decision making about psychiatric medications as critical to the recovery process in mental health (Deegan & Drake, 2006). • Different decision aids and techniques are used in managing psychiatric medication.

15. Key Issues and Messages • Focus is on how to change decision-making processes • Service users’ preferences for levels of involvement are important and may not be fixed • One size SDM may not fit all! • ShiMME intervention needs to be evidence-based • Consultations groups; previous research and interventions • Literature and previous research tells us quite a lot about: • Content: • Service users: information provision and access; clarifying values; support and confidence building; becoming active participants; self-management • Practitioners: interactive skills; professional competencies assoc. with SDM; • Format • Service users: group-work; peer support; first person accounts • Practitioners: role-playing and feedback; patient testimony material • Specific decision aids: • Medication diaries; preparation for consultations; values clarification