Decisional conflict in mental health care: a cross-sectional study

The influence of health literacy, anxiety and education on shared decision making and decisional conflict in older adults, and the mediating role of patient participation: A video observational study

OBJECTIVE

To explore the relationship between personal characteristics of older adults with multiple chronic conditions (MCCs) and perceived shared decision making (SDM) resp. decisional conflict.

METHODS

In a video-observational study (N = 213) data were collected on personal characteristics. The main outcomes were perceived level of SDM and decisional conflict. The mediating variable was participation in the SDM process. A twostep mixed effect multilinear regression and a mediation analysis were performed to analyze the data.

RESULTS

The mean age of the patients was 77.3 years and 56.3% were female. Health literacy (β.01, p < .001) was significantly associated with participation in the SDM process. Education (β = -2.43, p = .05) and anxiety (β = -.26, p = .058) had a marginally significant direct effect on the patients' perceived level of SDM. Education (β = 12.12, p = .002), health literacy (β = -.70, p = .005) and anxiety (β = 1.19, p = .004) had a significant direct effect on decisional conflict. The effect of health literacy on decisional conflict was mediated by participation in SDM.

CONCLUSION

Health literacy, anxiety and education are associated with decisional conflict. Participation in SDM during consultations plays a mediating role in the relationship between health literacy and decisional conflict.

PRACTICE IMPLICATIONS

Tailoring SDM communication to health literacy levels is important for high quality SDM.

Assessing decisional conflict and challenges in decision-making among perinatal women using or considering using antidepressants during pregnancy-a mixed-methods study

This study aims to investigate decisional conflict and elucidate challenges in decision-making among perinatal women using or considering using antidepressant (AD) during pregnancy. A sequential, mixed-methods study was employed among pregnant and postnatal women in Norway who had been offered ADs in the last 5 years. Quantitative data were obtained through an electronic questionnaire. Decisional conflict in pregnancy was assessed using the Decisional Conflict Scale (DCS) defined as either low (< 25) or moderate-high ( ≥ 25) (evaluated retrospectively for postnatal women). Logistic regression was used to identify factors associated with moderate-high decisional conflict. Qualitative data were collected through focus groups with pregnant and postnatal women, and an inductive approach was used for data analysis. Among 174 pregnant and 102 postnatal women, 67.8% and 69.6%, respectively, reported moderate-high decisional conflict during pregnancy. Unsatisfactory doctor-patient relationship was associated with greater likelihood of having moderate-high decisional conflict in pregnancy, both in pregnant (aOR = 1.20, 95% CI: 1.00-1.44) and postnatal women (aOR = 1.40, 95% CI: 1.08-1.82). Reported barriers to decision-making regarding AD use in pregnancy encompassed five DCS subscales: uninformed knowledge following contradictory research and unfamiliarity with authorised resources, unclear values due to emotional blunting and fear associated with AD use, inadequate support, uncertainty in decisions and ineffective decisions due to difficulty in finding personalised treatment, and diverging recommendations by the healthcare providers (HCPs). The quality of the interaction with the HCP plays a crucial role in managing decisional conflict and supporting informed decisions in the management of perinatal mental illness. This study highlights the need for increased provision of clear, evidence-based information by HCPs to facilitate shared decision-making and create personalised treatments for perinatal women considering AD use during pregnancy.

Peer-Facilitated Decision Making in Mental Health: Promises, Pitfalls, and Recommendations for Research and Practice

Recognition has grown that peer support workers serve an important role in facilitating decision making about treatment and recovery among people with mental health conditions. This article provides examples of peer-facilitated decision support interventions in the literature, discusses promises and potential pitfalls associated with peers serving in decision support roles, and offers recommendations for research and practice. Examples were selected from the literature on decision support interventions for people with serious mental illnesses, such as schizophrenia, bipolar disorder, and major depression. Promises, pitfalls, and recommendations were informed by this research and by the literature on lived experience perspectives, the helper-therapy principle, and reported barriers to and facilitators of peers assisting with decision making. According to the included studies, peers may facilitate decision making in several ways (e.g., by asking service users about their goals or preferences, assisting them with using decision support tools, sharing stories, and facilitating access to information and resources). Peer-facilitated decision support may be associated with positive decision making and health outcomes for service users and peer support workers. However, providers need to carefully consider barriers to implementation of this support, such as inadequate resourcing, poor integration, and compromising of peer support values.

Community treatment orders and care planning: How is engagement and decision-making enacted?

Background

In many jurisdictions worldwide, individuals with a mental illness may be forced to receive care and treatment in the community. In Australia, legislation states that such care should be driven by a care plan that is recovery‐focussed. Key components in the care planning process include engagement and decision‐making about a person's support needs and care options, with trust being an essential component of care planning relationships.

Objective

This study examines how these components were enacted during service care contacts for individuals on community treatment orders.

Methods

The study was located at two community mental health teams in South Australia. Ethnographic observations of care planning discussions between consumers, their carers and clinicians, and interviews with individuals from these groups, were conducted over 18 months. Carspecken's critical ethnography provided a rigorous means for examining the data to identify underlying cultural themes that were informing day‐to‐day care interactions.

Results

Care planning was not occurring as it was intended, with service culture and structures impeding the development of trusting relationships. Clinicians striving to work collaboratively with consumers had to navigate a service bias and culture that emphasized a hierarchy of ‘knowing’, with consumers assumed to have less knowledge than clinicians.

Conclusions

Services and clinicians can challenge prejudicial ethical injustice and counter this through testimonial justice and implementation of tools and approaches that support genuine shared decision‐making.

Patient or Public Contribution

This study included individuals with lived experience of mental illness, their carers and clinicians as participants and researchers.

Effectiveness of patient decision aids in women considering psychotropic medication use during pregnancy: a literature review

Women face complicated decisions regarding psychotropic medication use during pregnancy. Patient decision aids (PDAs) could be a valuable tool to assist with decision-making. The objective of this review was to evaluate the effectiveness of PDAs in this population. A systematic search of the literature was conducted using PRISMA guidelines. Three major databases were searched to identify articles published between 2006 and June 2020. Studies were included if they evaluated use of a PDA for women considering medication for mental illness during pregnancy. A total of 4629 titles were returned from the search; however, only three studies met inclusion criteria and were selected for analysis. Two were pilot randomised controlled trials in women considering antidepressant use during pregnancy, and one was a non-randomised study in women considering medication for the treatment of opioid use disorder (OUD). The PDAs had good acceptability across all three studies. The randomised trials assessed knowledge, decisional conflict, depression, and anxiety, with non-significant trends towards reduced decisional conflict and anxiety in the PDA groups. PDAs have the potential to assist women with mental illnesses to make decisions regarding medication use during pregnancy; however, current evidence is too limited to evaluate the effectiveness of PDAs for this population.

Assessing patient information and decision-support needs in problematic alcohol use and co-occurring depression to inform shared decision-making interventions

The authors assessed the informational and decision-support needs of patients, families, and clinicians when deciding on treatment for problematic alcohol use and depression. Patients (n = 56), family members (n = 16), and clinicians (n = 65) with experience deciding on treatment for problematic alcohol use and depression were eligible. Participants completed an online decisional needs assessment survey. Stakeholder groups identified numerous difficult patient-level treatment decisions and elevated decisional conflict. Participants preferred patient-led or shared treatment decision-making (75%-95.4%). Patients (32.6%) reported not being as involved in treatment decision-making as preferred, a higher proportion than reported by clinicians (16.4%; p = .056). More patients (19.6%) than clinicians (3.6%) reported clinician-led treatment decision-making, with little or no patient involvement (p = .022). Stakeholder preferences for future decision-support resources included online information for use outside consultations.

Surgery decision conflict and its related factors among newly diagnosed early breast cancer patients in China: A cross-sectional study

Aim

The aim of this study was to explore surgery decision conflict and its related factors among newly diagnosed early breast cancer patients in China.

Design

A cross‐sectional survey study was conducted.

Methods

A total of 262 patients confronted with surgery decision‐making were enrolled. The related factors were assessed with a demographic questionnaire, the Chinese version of the Decision Conflict Scale (DCS‐C‐16) and the Patient Participation Competence Scale (PPCS).

Results

Patients had a high level of decision conflict that was negatively correlated with the PPCS score. Age, marital status, living environment, education level, family income, cancer stage and the PPCS score were independent factors influencing decision conflict. Marital status, education level, cancer stage and participation competence were significant predictors of decision conflict. Patients who had higher participation competence were married, were well educated and had a lower cancer stage were likely to experience lower decision conflict.

Decision-making among the substitute decision makers in intensive care units: An investigation of decision control preferences and decisional conflicts

AIMS

To explore decision control preferences and decisional conflicts and to analyse their association among the surrogate decision makers in the intensive care unit.

DESIGN

The study carried out a cross-sectional survey among the surrogates.

METHODS

The participants were 115 surrogate decision makers of critical patients, from August to September 2019. A Chi-squared test and logistic regression were used to assess decision control preferences and decisional conflicts, and Spearman's rank correlation coefficient was employed to examine their association.

RESULTS

Of the 115 surrogate decision makers, 51.3% preferred a collaborative role, and 63.48% were somewhat unsure about making decisions. Logistic regression analysis identified decision control preferences was associated with surrogates' age, education level, and personality traits, while decisional conflicts was associated with surrogates' age, education level, character, medical expense burden, and Acute Physiology and Chronic Health Evaluation-II score. Cohen's kappa statistics showed a bad concordance of decision-making expectations and actuality, with kappa values of 0.158 (p < .05). Wherein surrogates who experienced discordance between their preferred and actual roles, have relatively higher decisional conflicts.

CONCLUSION

This study identified individual differences of surrogate decision makers in decision control preferences and decisional conflicts. These results imply that incorporation of the individual decision preferences and communication styles into care plans is an important first step to develop high quality decision support.

IMPACT

This research is a contribution to the limited study on decision control preferences and decisional conflicts among surrogate decision makers of critically ill patients. Moreover based on the investigation of understanding the status and related factors of decision preferences and decisional conflicts set the stage for developing effective decision support interventions.

Compulsory admissions and preferences in decision-making in patients with psychotic and bipolar disorders

PURPOSE

Participation in medical decisions and taking into account patients' values and preferences are especially important for psychiatric patients who may be treated against their will. The increasing rates of coercive measures and the underlying clinical, ethical, and legal issues highlight the need to examine their use in psychiatry. Although limited congruence in decision-making preferences may be on the basis of these coercive practices, this issue has not been adequately addressed. We explore the relationship between compulsory admissions and congruence in decision-making preferences in mental health settings.

METHODS

Cross-sectional study among 107 outpatients with DSM diagnoses of schizophrenia of bipolar disorder using the Control Preference Scale to assess congruence in decision-making experienced and preferred style. History of compulsory admissions was obtained through review of available records. Descriptive statistics and multivariate analyses were used.

RESULTS

70% of patients reported experiencing their preferred style of decision-making and 44% patients had history of compulsory admissions. These patients were more autonomous and preferred to take a more active role. The degree of congruence was lower in patients with previous compulsory admissions. The best predictors of compulsory admissions were not having a regular doctor and the unmatched participation preferences.

CONCLUSIONS

Patients who experienced a different level of participation in decision-making than desired more frequently had compulsory admissions. We propose to assess participation preferences each time a relevant treatment decision is about to be made and tailor care accordingly. We identified several factors leading to compulsory admissions that can be modified to prevent further coercive measures.

Quality of life, recovery and decision-making: a mixed methods study of mental health recovery in social care

PURPOSE

Mental health care is a complex system that includes social care organisations providing support for people with continuing needs. The relationship over time between decisional conflict, social support, quality of life and recovery outcomes across two time periods for people experiencing mental health problems in receipt of social care was investigated.

METHODS

This is a mixed methods study comprised of a quantitative survey at two time points using measures of decisional conflict, social support, recovery and quality of life in a random sample (n = 122) using social care services in Wales, UK. In addition, 16 qualitative case studies were developed from data collected from individuals, a supportive other and a care worker (n = 41) to investigate trajectories of care. Survey responses were statistically analysed using SPSS and case study data were thematically analysed.

RESULTS

Participants reported increasing decisional conflict and decreasing social support, recovery and quality of life over the two time points. Linear regression indicated that higher recovery scores predict better quality of life ratings and as ratings for social support decline this is associated with lower quality of life. Correlational analysis indicated that lower decisional conflict is associated with higher quality of life. Thematic analysis indicated that 'connectedness and recovery' is a product of 'navigating the system of care' and the experience of 'choice and involvement' achieved by individuals seeking help.

CONCLUSIONS

These results indicate that quality of life for people experiencing mental health difficulties is positively associated with social support and recovery and negatively associated with decisional delay.

Shared decision-making in mental health care using routine outcome monitoring: results of a cluster randomised-controlled trial

PURPOSE

To investigate the effects of Shared Decision-Making (SDM) using Routine Outcome Monitoring (ROM) primary on patients' perception of Decisional Conflict (DC), which measures patients' engagement in and satisfaction with clinical decisions, and secondary on working alliance and treatment outcomes.

METHOD

Multi-centre two-arm matched-paired cluster randomised-controlled trial in Dutch specialist mental health care. SDM using ROM (SDMR) was compared with Decision-Making As Usual (DMAU). Outcomes were measured at baseline (T0) and 6 months (T1). Multilevel regression and intention-to-treat analyses were used. Post hoc analyses were performed on influence of subgroups and application of SDMR on DC.

RESULTS

Seven teams were randomised to each arm. T0 was completed by 186 patients (51% intervention; 49% control) and T1 by 158 patients (51% intervention, 49% control). DC, working alliance, and treatment outcomes reported by patients did not differ significantly between two arms. Post hoc analyses revealed that SDMR led to less DC among depressed patients (p = 0.047, d =- 0.69). If SDMR was applied well, patients reported less DC (SDM: p = 0.000, d = - 0.45; ROM: p = 0.021, d = - 0.32), which was associated with better treatment outcomes.

CONCLUSION

Except for patients with mood disorders, we found no difference between the arms for patient-reported DC. This might be explained by the less than optimal uptake of this generic intervention, which did not support patients directly. Regarding the positive influence of a higher level of applying SDM and ROM on less DC and better treatment outcomes, the results are encouraging for further investments in patient-oriented development and implementation of SDMR.

Effectiveness of a multi-facetted blended eHealth intervention during intake supporting patients and clinicians in Shared Decision Making: A cluster randomised controlled trial in a specialist mental health outpatient setting

OBJECTIVE

To investigate the effectiveness of a multi-facetted blended eHealth intervention, called SDM-Digital Intake (SDM-DI), in which patients and clinicians are supported in Shared Decision Making during the intake process.

METHODS

The study is a two-arm matched-paired cluster Randomised Controlled Trial in a specialist mental health outpatient setting with two conditions: SDM-DI and Intake As Usual (IAU). Four intake teams were allocated to each arm. All patients who followed an intake, were asked to participate if they were capable to complete questionnaires. Decisional Conflict (DC), referring to patients' engagement and satisfaction with clinical decisions, was the primary outcome. Secondary outcomes were patient participation, applying Shared Decision Making (SDM), working alliance, treatment adherence and symptom severity. Effects were measured at two weeks (T1) and two months (T2) after intake. Multilevel regression and intention-to-treat analyses were used. Additionally, the influence of subgroups and intervention adherence on DC were explored.

RESULTS

At T1, 200 patients participated (47% intervention, 53% control), and at T2 175 patients (47% intervention, 53% control). At T1 and T2, no differences were found between conditions on DC. Subgroup analyses showed that effects of SDM-DI on DC were not modified by primary diagnoses mood, anxiety and personality disorders. Compared to IAU, at T2, patients reported positive effects of SDM-DI on SDM (β 7.553, p = 0.038, 95%CI:0.403-14.703, d = 0.32) and reduction of symptoms (β -7.276, p = 0.0497, 95%CI:-14.544--0.008, d = -0.43). No effects were found on patient participation, working alliance and treatment adherence. Exploratory analyses demonstrated that if SDM was applied well, patients reported less DC (β = -0.457, p = 0.000, 95%CI:-0.518--0.396, d = -1.31), which was associated with better treatment outcomes.

CONCLUSION

Although, this trial fails to demonstrate that SDM-DI by itself is sufficient to reduce DC, the results are encouraging for further efforts in improving and implementing the SDM intervention.