ShIMME
(Shared Involvement in Medication Management
Education)
Existing programmes
focussed on shared decision
making in psychiatric
medication management
Amy Li and Dr. Nicola Morant
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
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
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.
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.
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 selfmanagement.
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.
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.
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.
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.
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.
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
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.
•
•
The results of the study showed 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.
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.
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:
1. 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;
2. Format
– Service users: group-work; peer support; first person accounts
– Practitioners: role-playing and feedback; patient testimony material
3. Specific decision aids:
– Medication diaries; preparation for consultations; values clarification