Shared decision making in mental health: Myths, barriers, and benefits

Sirs,

Shared decision making consists of an interactive clinical relationship process in which the professional helps their patients to choose the best treatment considering their values, preferences and clinical circumstances. Many myths have been considered about this type of healthcare relationship (the patient finally decides himself or herself, or they even let the professional make the decision, they do not want to get involved, etc.).¹ In addition, barriers have been found in the professionals that make applying it difficult, such as the concern that psychiatric patients might not be competent to decide for themselves.² However, perhaps the most significant problem is that of insight.³ Such difficulties can also be seen in the patients: passive patients, ones not interested in the decision or those who think that their negative response constitutes in itself an active attitude.⁴ At any rate, all of this can represent a paternalistic stance.⁵

In spite of this, reality shows that applying shared decision making in the sphere of mental health leads to an increase in the patients’ quality of life, better communication with the professionals and, consequently, better therapeutic alliance and even greater drug adherence.⁶

But it is important not to think that the process stops with merely giving information about the various treatments and their adverse reactions. Deep down, patients want to be heard and to have their desires incorporated in the decision. That means that the professionals need to have communication skills to improve this shared decision: motivational interviews, negotiation processes, etc.⁶ Although this is not an easy task, a tool to make it possible to ascertain and evaluate how the decision was taken has been created and validated in Spanish.⁷ It consists of a 9-question test given to the patient about the experience he or she has had in the consultation with the professional.

It is understandable that there are clear situations in which a paternalistic model is justified, such as “life or death” decisions or those in which the “best interest” may be applicable.⁶ However, the objective has to be promoting decision making shared with the patients. A valuable way to encourage them to decide is by anticipation of the decisions, such as (for example) an advanced directives document, which has also been shown to have positive effects (both clinical and ethical).⁸

Consequently, we have to urge the professionals to carry out aware psychiatry⁹ that goes beyond the biomedical, biological reductionist paradigm and centres on the individual, their needs and their wishes. Shared decisions, whether advance or not, will aid this type of psychiatry, which must be based on both technical values and moral values.¹⁰ This focus will make a change of direction possible in the basis of the healthcare relationship, given that we will go from examining solely the aim of doing good and doing no harm, even without patient consent, to a perspective whose main focus is autonomy and dignity. In this way, the patients’ autonomy is increased without leaving them alone in the face of the decision. But this has to be a task performed jointly between the professionals and the patients.