Shared Decision-Making in Mental Health Care - SAMHSA Store ...

75consumers to engage with their providers in making a choice that is consistent withthe evidence and with their personal values. DAs are used most often for what havebeen called preference-sensitive health decisions—decisions for which the benefitharmratio is uncertain. These so-called “gray-zone” decisions involve more than onealternative that is reasonable from the standpoint of efficacy, yet the outcomes maybe valued differently by different people. This definition has been used most for situationswhere surgical and medical options, as well as wait-and-see options, are allreasonable. In mental health, DAs are useful for problems such as depression, wheremedical therapy, talk therapy, and a wait-and-see approach may all be reasonable.DAs are particularly helpful in clinical problems for which there is a small risk of agrave outcome, or when people attach very different levels of importance to a certainoutcome. Some DAs include an explicit strategy to clarify values for outcomes orelicit preliminary treatment preferences prior to talking with a clinician. Many DAsalso provide structured guides for decision-making, as well as examples of otherpeople’s decisions, opinions, and experiences.Role of DAs in Health Service ReformDAs are designed to improve clinical decision-making, which has frequently beenshown to be suboptimal (Braddock, Fihn, Levinson, Jonsen, & Pearlman, 1997). Inparticular, consumers are often not well informed about treatment options and thebenefits and downsides of each option. Providers rarely assess patient values explicitly,and infrequently involve patients in SDM. The focus on patients, rather thanproviders, emerged from at least two sources. The health services argument madeby Wennberg, Barnes, and Zubkoff (1982) was that patient self-interest would balanceprovider self-interest, expressed as supplier-induced demand. This argumentwas the logical extension of Wennberg’s work documenting practice variation thatclearly was not a function of patient or disease characteristics. At the same time, anethical argument was made by many, proposing that SDM was a higher ethical standardthan simple informed consent (President’s Commission, 1981; Siegler, 1981).Taken together, these two parallel threads of inquiry, combined with a deep interestin supporting patient choice, led researchers and developers to create tools to supportpatient participation in treatment decision-making. From the health servicesperspective, it was hoped that patient participation would improve the quality of decisions,and thereby improve care, cost, and satisfaction. It was anticipated that patientself-interest in avoiding unnecessary intervention would eliminate unwarrantedvariation. The ethical rationale focused on SDM as the appropriate moral principle.The goal of DAs is not to suggest “mandatory autonomy,” but rather to encourageinformed patients to share in decision-making as they like, or to defer to their providers(Schneider, 1998). A systematic review of DAs assessed the efficacy of 55 clinicaltrials for a variety of clinical conditions. Results show that when they are used,DAs appear to modestly increase the utilization of services in situations of underuseof services and decrease utilization in cases of overuse (O’Connor et al., 2007).Shared Decision-Making in Mental Health Care: Practice, Research, and Future Directions