Shared decision-making has a growing role in healthcare practice, particularly for chronic conditions. The concept is that treatment and medication decisions that impact a patient’s health and lifestyle can be made collaboratively between clinician and patient, rather than being a one-way doctor’s order that a patient accepts or rejects. The clinician and patient bring complementary expertise in designing treatment plans. The patient has the most detailed knowledge of their own situation, or years of lived experience, and how past interventions have helped or not. The clinician brings years of study, diagnostic training and experience with patients who may have similar conditions.
One practice area where adoption of shared decision-making has lagged is psychiatry. It’s a field that needs to get past tough barriers, including stigma and reluctance among psychiatrists, says Yaara Zisman-Ilani, assistant professor in the Department of Social and Behavioral Sciences. It’s necessary to find effective ways to employ shared decision-making in psychiatry to achieve better outcomes, Zisman-Ilani argues in “Time to Support Extensive Implementation of Shared Decision Making in Psychiatry,” a viewpoint paper published in JAMA Psychiatry.
“Shared decision-making works. We know it’s not always easy to engage patient, clinicians, and family members in shared decision-making in chronic conditions like cancer, diabetes or heart disease, and it can be much harder in psychiatry,” she says. It’s been a step in the right direction that the American Psychiatric Association and other mental health organizations have recently endorsed shared decision-making as an essential practice, she says, but “in practice, shared decision-making is not being done.”
Psychiatry’s unique barriers to shared decision-making stem from the stigma attached to mental health issues, says Zisman-Ilani, a psychologist with a PhD in community mental health who has spent 15 years researching and working to influence policy about shared decision-making in mental health. “When I started doing my research, people were asking me very bluntly, how can ‘crazy’ people make decisions? I hear it less often now, but I hear other excuses. They say people with schizophrenia, with psychosis, or people with addiction or with major depression, they don't have the capacity, or that they have cognitive impairments, and therefore they can't engage in a shared decision-making process.”
However, she points out, there is essentially no research examining a connection between cognitive impairments and capacity to succeed in shared decision-making. “People with schizophrenia, for example, still make many decisions in their lives. Why shouldn't they be engaging in decisions about their care?” she asks.
Even psychiatrists are susceptible to judging some patients as incapable of effective shared decision-making, Zisman-Ilani says. “That is the elephant in the room that nobody is talking about,” she says. Research has indicated that the main barrier preventing psychiatrists and other mental health clinicians from involving patients with serious mental illness in decision-making is a belief that the patients have low decisional capacity and cognitive and motivational deficits. That determination might be based on imperfect decision-making measurement tools that exist, or evaluations of competency administered to provide informed consent. “The presence of deficits based on such evaluations can lead psychiatrists and other psychiatric providers to erroneously assume that patients with serious mental illness cannot participate in shared decision-making,” her paper states.
Mental health providers also may hesitate to adopt the practice for fear of liability risk in straying from standard clinical treatment guidelines. If their decision about treatment is shared with a patient who might be viewed as lacking capacity to make sound judgments, what happens if something goes wrong?
“When there is a question regarding the ability of a person to make decisions, then everything is elevated,” she says. “It’s harder from the clinician perspective, from the patient perspective, from the research perspective, and from the policy perspective. I’ve even suggested that shared decision-making in psychiatry be called shared risk taking, because there are many risks involved in psychiatry.”
Another complicating factor unique to mental health care is the power of psychiatrists to initiate “coercive” treatment and involuntary hospitalization when they determine a patient is a potential risk to themselves or others. The psychiatrist’s power to admit a patient coercively contradicts the principle of symmetry and that of a “level playing field” between patient and clinician, that’s key to shared decision-making, Zisman-Ilani writes.
Patients may be hesitant to push back on a recommended treatment or medication as part of a collaborative treatment plan if they believe it will send a negative or uncooperative message. “Patient fear of sharing can be really strong, and it's unique to psychiatry,” Zisman-Ilani says. “If you talk to your primary care doctor, you don't have to be afraid that they will take your freedom from you.”
In her paper, Zisman-Ilani recommends that to integrate shared decision-making into routine psychiatric care, it should be part of psychiatrists’ medical education and training, and that patients should be made aware of their role in the process. This may include working with patients to create advance directives indicating their preference for care when they are incapacitated. Zisman-Ilani recommends further research to explore the association between shared decision-making’s success and outcomes in cognitive functioning, motivation and decision capacity. In addition, more work is needed, she says, to understand and address clinicians’ stigma about patients with SMI, and importantly, to develop interventions and tools to enhance shared decision-making in psychiatric care.