Measurement issues of shared decision making in mental health: challenges and opportunities

Publication Date11 September 2017
AuthorLilisbeth Perestelo-Perez,Amado Rivero-Santana,Yolanda Alvarez-Perez,Yaara Zisman-Ilani,Emma Kaminskiy,Pedro Serrano Aguilar
SubjectHealth & social care,Mental health
Measurement issues of shared decision
making in mental health: challenges
and opportunities
Lilisbeth Perestelo-Perez, Amado Rivero-Santana, Yolanda Alvarez-Perez,
Yaara Zisman-Ilani, Emma Kaminskiy and Pedro Serrano Aguilar
Purpose Shared decision making (SDM) is a model of health care in which patients are involved in the
decision-making process about their treatment, considering their preferences and concerns in a deliberative
process with the health care provider. Many existing instruments assess the antecedents, process,
or the outcomes of SDM. The purpose of this paper is to identify the SDM-related measures applied in a
mental health context.
Design/methodology/approach The authors performed a systematic review in several electronic
databases from 1990 to October 2016. Studies that assessed quantitatively one or more constructs related
to SDM (antecedents, process, and outcomes) in the field of mental health were included.
Findings The authors included 87 studies that applied 48 measures on distinct SDM constructs. A large
majority of them have been developed in the field of physical diseases and adapted or directly applied in the
mental health context. The most evaluated construct is the SDM process in consultation, mainly by patients
self-report but also by external observer measures, followed by the patientspreferences for involvement in
decision making. The most applied instrument was the Autonomy Preference Index, followed by the
Observing Patient Involvement in Decision Making (OPTION) and the Control Preferences Scale (CPS).
The psychometric validation in mental health samples of the instruments identified is scarce.
Research limitations/implications The bibliographic search is comprehensive, but could not be
completely exhaustive. Effort should be invested in the development of new SDM for mental health tools that
will reflect the complexity and specific features of mental health care.
Originality/value The authors highlight several limitations and challenges for the measurement of SDM in
mental health care.
Keywords Measurement, Patient involvement, Mental health, Outcomes, Shared decision making
Paper type General review
Health professionals are increasingly being encouraged to adopt a collaborative and deliberative
approach, shared decision making (SDM) to enhance patient-centered care (Elwyn et al., 2012).
In this sense, policy documents and clinical practice guidelines advocate for health professionals
to involve patients in decision-making processes and allow service userspreferences, along
with the scientific evidence, to guide decisions where possible (Van der Weijden et al., 2013;
NICE, 2016). Patient decision aids, risk calculators, and other tools can help to translate
information from evidence and incorporate the goals and subjective experiences of patients in
ways that are accessible in routine practice (Van Der Weijden et al., 2012).
The SDM approach aims to change the asymmetry between patients and their health professionals
regarding decisional power and decision-relevant information, as well a s to increase patient
autonomyand empower serviceusers in decisionsabout treatment(Charles et al., 1999). However,
while evidence suggesting its benefits is growing (Stacey et al.,2014), its application inthe area of
Received 18 January 2017
Revised 3 April 2017
7 June 2017
Accepted 23 June 2017
Conflict of interest: the authors
confirm that this paper content has
no conflict of interest.
Funding: the authors declare no
support from any organization for
the submitted work.
The authorsaffiliations can be
found at the end of this article.
VOL. 22 NO. 3 2017, pp. 214-232, © Emerald Publishing Limited, ISSN 1361-9322 DOI 10.1108/MHRJ-01-2017-0004
mental health is still in its infancy (Beitinger et al., 2014). There is a consensus about the importance
of patient-centered care when dealing with mental health problems. In this regard, the concept of
recovery (Duncan et al., 2010) goes beyond the simple cureof symptoms, emphasizing the
inclusion and continued participation within the community of people with mental health disorders.
Recovery implies to gain or retain control and responsibility over ones own life and to be able to
integrate in the community, overcoming the impact of symptoms although these have not
completely remitted. Interventions like assertive community treatment, supported employment or
family interventions promote this community integration of people with mental illnesses, and in this
sense SDM between services users and professionals seems an ineludible and core component of
the process of patientsinvolvement that could lead to recovery (Storm and Edwards, 2013).
Several barriers in adapting SDM to mental health exist have been discussed in this special issue,
including concerns regarding the patients decision-making capacity due to mental health
symptoms, and lack of interventions and methods for measuring and assessing SDM in mental
health (see Kaminskiy et al.; Zisman-Ilani et al., 2017). Measuring and assessing SDM is important
to understand the effect of interventions and to explore relationships between different constructs
(Scholl et al., 2011). Different constructs can be measured to provide insight into the decision-
making process: prerequisite skills for SDM (e.g. decision self-efficacy, health literacy of patients,
communication skills), decision-making elements (e.g. involvement and satisfaction in clinical
decision making, type of topics covered in the consultation, the amount and type of deliberation
on the part of patients and health professionals), and decision outcomes (e.g. objective
knowledge, concordance between values and choices, decisional conflict, adherence, and
utilization of the choice made) (Sepucha and Mulley, 2009; Barr, Scholl and de Silva, 2016).
Regarding the perspective assessed, SDM measures can be divided into three types: observer
measures, professional-report, and patient-report tools (Scholl et al., 2011). Observer measures
of SDM have been developed to assess observable aspects of SDM in clinical settings, typically
assessed via audio or video recordings of clinical encounters, which then are coded based on a
previously established system (Elwyn and Blaine, 2016); the perception of health care
professionals on SDM (Chong et al., 2013), and the patient-reported outcomes related to SDM
(Barr, Scholl and de Silva, 2016; Barr and Elwyn, 2016) are tools that assess the perspective from
health professionals or service users about the extent to which patients have been involved in the
decision-making process about their care. Assessments may measure a single consultation or to
the whole process of care. Further insight into SDM can be gained by the triangulation of methods
(e.g. observer, health professional, service users) and by using a dyadic data analysis approach
(Kenny et al., 2010).
Despite the importance of SDM for delivering patient-centered care in mental health, there is no
consensus on how to measure its process and outcomes (Perestelo-Perez et al., 2011). With the
growing interest among policymakers, researchers, clinicians, and patients in using SDM in
mental health routine care, there is a need for reliable measurement tools that will response to the
unique setting of mental health (Morant et al., 2015). The purpose of the present paper is the
review of measures of SDM-related constructs for mental health settings, describing their
psychometric properties evaluated in the identified mental health samples (the comparison of the
psychometric quality of the instruments falls beyond the scope of this review).
Review of key measurement instruments of SDM in mental health
In order to identify existing instruments, a systematic review was performed in the electronic
databases Medline, PsycINFO, Scopus, Web of Science, from January 1990 to October 2016
using a number of Medical Subject Headings (MeSH) and keywords in three domains: SDM,
mental health, and measures (see Appendix 1). A secondary search of the reference sections of
included papers and identified review articles was also conducted.
The study selection process consisted of several successive steps. First, the results obtained
from the databases were grouped into a single file. Duplicate records for a single study were
eliminated before starting the selection process. The study selection form was tested on ten
randomly drawn studies in order to ascertain selection criterion relevance and discrimination.
VOL. 22 NO. 3 2017

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