Skip to main content
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2009 Nov 1.
Published in final edited form as: Curr Opin Psychiatry. 2008 Nov;21(6):606–612. doi: 10.1097/YCO.0b013e32830eb6b4

Recent Advances in Shared Decision Making for Mental Health

Sapana R Patel 1,*, Suzanne Bakken 2, Cornelia Ruland 3
PMCID: PMC2676935  NIHMSID: NIHMS94604  PMID: 18852569

Abstract

Purpose of review

To advance integration of shared decision making (SDM) into mental health care service delivery, researchers have outlined several priorities for future research [23]. These include: 1) SDM and its role in mental health care; 2) Patient and provider perspectives on SDM; 3) The degree to which SDM is practice in mental health settings; and 4) Outcomes of SDM in mental health populations. This article will review recent advances in these areas.

Recent findings

The current literature shows that 1) SDM can play a role in the mental health treatment process from entry into care to recovery; 2) Patients and providers find SDM acceptable and express a willingness to engage in SDM for reasons that are multifactorial; 3) Barriers to SDM exist in mental health decision making including patient preferences and provider level biases; and 4) Outcomes research provide encouraging preliminary evidence for feasibility and effectiveness of SDM during the mental health encounter.

Summary

Although there have not been a great number of SDM studies in mental health to date, the positive effects of SDM are comparable to those documented in general non-mental health patient groups, suggesting that future research is likely to be helpful for patients with psychiatric disorders.

Keywords: shared decision making, mental health, patient-provider relationship, communication

Introduction

Shared decision making (SDM) has received considerable attention as a communication method to improve the quality of health care delivery. Although a majority of the research evaluating SDM has been conducted in general health populations (e.g. cancer and cardiac patient groups) [1], patient participation in the mental health populations has received increasing interest [27]. Along with this interest, questions arise including: What is the role of SDM in mental health? Is SDM acceptable and feasible to mental health patients and providers? To what degree is SDM practiced in mental health settings? Finally, what are the outcomes associated with SDM? In this review, the authors summarize recent research findings to answer these questions.

Literature Search Strategy

For this review two systematic searches were performed. An exhaustive review of research on shared decision making for mental health was conducted for the time period 1990- January 2007 (search 1). To update the review for the purpose of this paper with the most recent publications, we performed an additional search (search 2) from January 2007 to April 2008. For both searches the following electronic databases were searched: MEDLINE, PsycINFO, and Cochrane Library. In each database every term was searched in the database thesaurus and as free text/key word. The following terms were the central search terms used, further synonyms were added: (‘mental health decision making’ OR ‘patient participation’ OR shared decision making’ AND psychiatr* OR schizophr* OR depress* OR patient decision aids AND psychiatry OR mental health.)

Inclusion criteria were publications restricted to the topic of decision making for treatment psychiatric disorders, English language articles, conceptual and theoretical articles, studies on patient, provider and mental health system perspectives of SDM, all types of research designs and qualitative research. Exclusion criteria included editorials and articles that the examined the effect of SDM on psychological parameters such as anxiety in general health (e.g. cancer and cardiac) patient groups. In search 2 the search strategy, the inclusion and exclusion criteria from the first search remained unchanged, however restricted to only research articles including all types of research designs, perspectives articles and qualitative research with at least 10 subjects.

The search in the online databases and cross referencing yielded 115 titles for search 1 and additional 11 for search 2. From the two searches combined, 102 were excluded after the abstract had been read, as they did not meet criteria. Twenty-four articles were retained for both searches 1 and 2 and will form the basis for discussion in this review.

Shared Decision Making

SDM is built upon the notion that there are two experts in the consultation room: the patient and the provider. Providers have expertise in the science-informed processes of medical diagnosis and treatment. Patients have the expertise by virtue of the lived experience of their disorder, and their intimate knowledge of what gives their life value, meaning, purpose and quality. Ideally both knowledge domains are bridged through the process of SDM, as both parties strive for agreement on what the problem is and what the outcomes of treatment should be [8]. SDM is seen as an intermediate stage between a traditional paternalistic model and an informed choice model. For the patient SDM offers some say without total responsibility, and for the provider an opportunity to go beyond a role of transferring information to also participate in, but not dominate, the decision-making process. Charles et al. [9] outline a three-stage model of decision-making consisting of: 1) bidirectional information exchange; 2) deliberation (e.g. expressing and discussing preferences and treatment options); and 3) selection of treatment to implement that is consistent with patients’ values and preferences.

Decision support interventions and decision aids can help facilitate the process of SDM [10]. In order to facilitate and standardize the shared decision-making process, decision aids have been developed for defined medical situations. Decision aids are evidence-based tools intended to assist the process of making informed values-based choices about screening, treatment options and disease management. They are designed to supplement rather than replace patient-provider interaction. A variety of media is used to present the information in an accessible form to patients, including pamphlets, audiotapes, interactive programs, websites, and decision boards [10]. In a Cochrane review, O’Connor et al. [11**] concluded that decision aids increased patient involvement in decision-making, knowledge, and the proportion of patients with realistic expectations of the chances of benefits and harms, and reduced decisional conflict.

What is the Role of SDM in Mental Health?

In recent years, mental health practice has become increasingly complex in terms of the available treatment options, use of new technologies, and consumer driven health care. SDM has received interest in mental health for reasons of empowerment, autonomy, and quality of life. With this interest, ethical concerns have also been cited in the literature with respect to patient participation in SDM for psychiatric disorders. Hamann et al. [12] conducted the first review of SDM in mental health and discussed the feasibility of SDM raising important concerns about competency to participate and reduced decisional capacity [13] among illness groups such as the acutely ill, those with dementia, and schizophrenia. The authors cite evidence of capacity to give informed consent in pharmaceutical studies to participation in therapeutic/educational interventions and conclude that successful inclusion of psychiatric patients in the therapeutic process could counteract existent prejudice about capacity to participate and may even lead to increased empowerment and quality of life.

In the psychiatric literature thus far, SDM has been cited as a method to enhance the patient-provider relationship that can be used throughout the evolving treatment process from facilitating entry into care to recovery and psychiatric rehabilitation [8,10]. Deegan and colleagues assert that people with psychiatric disabilities need support to resolve decisional conflict regarding the use of psychiatric medications. Much like other groups with long-term disorders such as hypertension, epilepsy and AIDS, people with psychiatric disabilities experience decisional conflict for reasons of stigma, symptom suppression, and delayed onset of consequences due to discontinuation of medicine. Furthermore decisional conflict may arise when patients are faced with decisions about treatment that have high risks (e.g. side effects such as tardive dyskinesia) and for which there are two or more alternatives to address the health problem, or low certainty [14]. SDM is appropriate for such types of decisions.

Is SDM Acceptable and Feasible to Patients and Providers?

For SDM to take place there is an assumption of two active participants willing to engage in SDM and find it acceptable and feasible within the constraints of a clinical encounter. To date there has been mounting evidence that those with severe mental illness and depression endorse positive attitudes towards SDM, desire to be involved in decisions, and are able to participate in decision making [15,16 17**, 18]. Four studies conducted in the past year (3 qualitative; 1 quantitative) reveal that patients’ motivations to participate are multifactorial and often explained by their past experiences in treatment (e.g. involuntary treatment) [19], types of treatment-related decisions to be made, and their desire for recovery.

In a pilot study of 30 patients with severe mental illness Adams et al. [20**] found that patients generally preferred greater participation than they are offered, and their preferences vary in relation to the type of decision being made with particular preference for involvement about decisions regarding medications.

Using qualitative focus group data, Tannenbaum et al. [21*] examined consumer perspectives on information and decision making with the severely mentally ill. Their qualitative data revealed that consumers very much want information about their illness, welcome scientific evidence and like to be kept up-to-date about illness and treatment related information as well as broader supports within the mental health system. Trust in one’s provider and recovery from illness was cited as especially important.

Hamann et al. [22**] examined the extent to which psychiatrists and patients agree on which events are considered to be decisions in treatment for schizophrenia, particularly decisions about medications, nonpharmacological treatments, hospital discharge or change in treatment setting.

In addition to illness and diagnosis-specific characteristics and contextual characteristics (i.e. setting) there are other factors such as culture that may also influence preferences for decision making regarding mental health treatment. Charles and colleagues [23] discuss the influence of culture on the treatment decision-making process and challenge cultural assumptions underlying the development of decision-making interventions.

In the first study examining cultural variations, Cortes et al. [24*] examined qualitative data on Latino perspectives of a patient activation and empowerment program in community mental health care settings and found that some participants were reluctant to use some of the participation skills learned due to concens about offending their providers because they view them as friends or family members valuing the ‘personalismo’ (personalism) aspect of care, or their attitudes towards the provider as an all-knowing authority figure. Attitudes and customs of some cultures may represent facilitators or barriers to patient participation in decision making.

Provider perspectives on participation in SDM are characterized by a cautious willingness. In general most psychiatrists report advocacy of a cooperative therapeutic relationship yet particular obstacles exist. These include patient competence, the impact of unwanted side effects on motivation to participate in treatment, and honesty about adherence to medication [25].

Goossensen et al. [26**] measured the extent to which clinicians in a psychiatry department involve patients in decision making by using the Observing Patient Involvement in Treatment Choices instrument (OPTION). Results show that clinicians in the study are willing to engage in SDM with their patients however are not willing to ask their patients about preference for involvement in decision making and patients did not express great concern about this. Clinicians explained that they intuitively feel if a patient is capable and interested in participating in SDM.

To What Degree is SDM Practiced in Mental Health Settings?

Preferences for participation in SDM are multifactorial and it is important for providers to engage their patients prior to decision making and inquire about their preferences for participation. To what extent SDM is being practiced in settings where mental health needs are identified and treated has generated interest yet little research has been done in this area. Research has shown that SDM for mental health problems is being practiced at a low level in both psychiatric and primary care settings [26,27]. To date, research has shown that SDM for psychiatric disorders is being practiced at the level of information exchange (e.g. defining mental illness) and has not advanced beyond this first stage in the 3-stage model proposed by Charles et al. Several patient (i.e. culture), provider (i.e. biases) and system-level (i.e. time constraints) factors may be responsible for the low level of practice [27].

What Are the Outcomes Associated with SDM in Psychiatry?

Several researchers have taken initial steps towards understanding the effect of SDM by developing and testing SDM interventions. The focus of outcome research for SDM in mental health has ranged from feasibility of SDM in various settings, decision process outcomes (i.e. knowledge, perceived involvement in decision making), and satisfaction with care. Clinical outcome data are inconclusive to date and merit further research.

In a prospective, national cohort study of depressed primary care patients, the Quality Improvement for Depression (QID) Project, researchers found that higher involvement in decision-making was associated with a higher probability of reporting guideline-concordant care and recovering from depression over an 18-month period [28]. Using the same QID data Swanson and colleagues [29**] performed cross-sectional analyses to understand if SDM and/or receipt of mental health care was associated with satisfaction with overall and mental health care. Given these encouraging findings about interpersonal care, authors discuss policy implications including benefit of health plans to train existing and future providers in SDM and including SDM in practice guidelines for depression care.

Randmoized controlled trial research on the feasbility and effectiveness of shared decision making interventions both in severely mentally ill and depression show that compared to usual care the SDM interventions do not result in longer consulatation time and are associated with positive decision process outcomes. Hamann et al. [14] conducted the first controlled trial of SDM in a sample of acutely ill patients with schizophrenia and found that it was feasible for most patients to be involved in decisions about their care, patients had better knowledge about their illness and a higher level of perceived involvement in decision-making. In an RCT of a primary care–based intervention for prevention of depression relapse, Ludman and colleagues [30] tested a SDM approach for treatment of depression and found improvement in self-efficacy, tracking of depression symptoms, and planning for coping with high-risk situations.

Loh et al. [31**] conducted a cluster randomized controlled trial of a SDM intervention in primary care of depression and found that the intervention was better than usual care for improving patient participation in treatment decision making and satisfaction with care without increasing consultation time.

In an pre/post test comparison group evaluation of a patient self-reported activation and empowerment intervention, the Right-Question Project-Mental Health, Alegría et al. [32**] found that self-reported activation, attendance to scheduled visits and retention in treatment improved for minority patients seeking treatment in community mental health clinics.

Conclusion

Since the review by Hamman et al. [12] five years ago, there has been considerable advancement in research on SDM and its applications in mental health. Recent evidence points favorably towards the inclusion of SDM in mental health decision making given that majority of patients with mental illness prefer to be involved in the process and desire information about their illness. It is important to remain mindful that preferences for participation can vary by demographics and treatment experiences. Studies examining the degree of SDM being practiced in mental health decision making indicate low levels of SDM practice. Providers express a willingness to engage patients however several barriers are noted in the literature including: competence to participate, preference to rely on intuition regarding patient interest in SDM, and concerns about patient medication use. Shared decision making intervention data provide good preliminary evidence for SDM as a method to improve mental health services including receipt of guideline-concordant care, attendance and retention in treatment, and satisfaction with health care. There is evidence that SDM is feasible and time comparable to usual care in psychiatric and primary care settings. Patients perceive greater involvement in the treatment process and increased knowledge about illness.

In summary, although there have not been a great number of SDM studies in mental health to date, the positive effects of SDM are comparable to those documented in general non-mental health patient groups, suggesting that future research is likely to be helpful for patients with psychiatric disorders. Future directions for SDM research in mental health include: assessment of preferences for participation, what participation means and how acceptable it is among diverse psychiatric and cultural populations, research on clinical outcomes of SDM, the development of decision aids and interventions that are in accordance with quality criteria [33], the development of multimedia decision support interventions [34**, 35**], and a better understanding of barriers and facilitators for integrating SDM in mental health decision making at the provider and system level.

Table 1.

Studies of SDM for mental health from January 2007 to April 2008

Authors Participants and clinical scenario N Study question and brief description Outcome measures Results
Adams et al. [8••], USA Adults with severe mental illness in community mental health center 30 Pilot study of perceived role and preferences for shared decision making Autonomy Preference Index-Decision Making Scale (API-D) Control Preferences Scale (CPS) Participants preferred greater participation than they experienced. Participants preferred SDM particularly with respect to their mental health care and medications
Alegría et al. [9••], USA Latino outpatients from community mental health clinics, mood disorders 231 patients Evaluation of Right-Question Project-Mental Heath (RQP-MH: patient activation/empowerment intervention) using pre/posttest comparison group Self-reported patient activation/empowerment Intervention participants were two times more likely to be retained in treatment, three times more likely to have scheduled at least one visit during 6-month follow-up and had 29% more attendance to scheduled visits
Treatment attendance Significant increase in patient activation for intervention group
Retention in treatment
Cortes et al. [10•], USA See Alegría et al. [9••] 141 patients Qualitative data from RQP-MH to describe patient activation process in intervention group Thematic analysis of open-ended questions from interviews Patient activation and patient empowerment are interdependent processes
Cultural (reluctance to ask questions given values of ‘respecto’ and ‘personalismo’) and contextual factors (navigating the mental health system) influence experience of Latinos’ participation in care
Goosensen et al. [11••], The Netherlands Clinicians and patients in outpatient psychiatry clinic, mood disorders 61 patients, 8 clinicians Measurement of SDM in consultations, patient satisfaction with clinician communication behaviors Observing Patient Involvement in Treatment Choices (OPTION) Scale Clinicians scored low on overall shared decision making
Clinicians were not willing to ask patients about preferences for participation in decision making and preferred to rely on intuition
Patient satisfaction scores of 29 patients did not reflect concern about low scores in SDM
Hamann et al. [12••], Germany Psychiatric state hospitals and university clinic, schizophrenia 60 patients, 30 psychiatrists Qualitative study of perceptions of clinical decision during treatment for schizophrenia Semistructured interviews Good correspondence between patients and psychiatrists regarding decisional topics
Poor correspondence regarding individual decisions such as medications, leave from ward, change in treatment, and nonpharmacological therapies.
Hamann et al. [13••], Germany Psychiatric state hospital inpatients, schizophrenia 107 patients Examination of long-term compliance/rehospitalization rates after a cluster RCT of an SDM program Symptoms High rates of noncompliance and rehospitalization
Therapeutic alliance Intervention showed a positive trend but no clear beneficial effect on long-term outcomes
Autonomy Communication/decision-making effectiveness
Satisfaction Adherence
Jeste et al. [14••] Literature search of Medline, PsycINFO, and CINAHL, mental and nonmental health populations 37 randomized controlled trials (33 nonmental health RCTs) Review of studies that compared the effects of multimedia educational aids versus routine procedures Scale for Assessing Scientific Quality of Investigations (SASQI) Two-thirds of studies in diverse patient populations reported that multimedia educational aids produced better understanding of information than routine methods
It is likely that multimedia educational aids could become an effective supplement to the clinician–patient interaction in the near future
Loh et al. [15••], Germany Primary care clinics in university setting 405 patients, 23 primary care clinicians Cluster RCT to examine the effect of an SDM intervention in primary care of depression Patient involvement and satisfaction Intervention was better than usual care for improving patient participation in treatment decision making and patient satisfaction without increasing consultation time
Treatment adherence There was no intervention effect for depression severity
Depression severity/remission
O’Connor et al. [16••] Literature search of Medline, PsycINFO, EMBASE, Cochrane Review, and CINAHL 55 RCTs of patient decision aids To describe the extent to which patient decision aids meet effectiveness standards of the International Patient Decision Aid Standards (IPDAS) IPDAS criteria for establishing a decision aid is effective Among 55 RCTs, 38 studies used at least one criterion that mapped on to IPDAS effectiveness criteria
Patient decision aids improve decision quality (knowledge, accurate risk perception, and values congruence with chosen option) compared with usual care
Detailed decision aids were more effective than simpler ones
Swanson et al. [17••], USA Primary care clinics, quality improvement for depression study 1317 patients To assess if SDM and or receipt of mental health care was associated with patient satisfaction for patients with depression and if gender modified this relationship Satisfaction with overall and mental health care Mental health care and shared decision making were important independent predictors of patient satisfaction for depressed primary care patients
SDM Gender was not a moderator of health care or SDM on satisfaction
Social support Positive association between SDM and satisfaction
Health status
Depression symptomatology
Alcohol use
Tanenbaum [18•], USA Mental health consumers within a suburban/rural community, severely mentally ill 38 patients Qualitative study of mental health consumers’ perspectives on information and decision making Thematic analysis of focus group data Consumers desire and seek information about their illness and the mental health system
Consumers identify scientific studies as information with special and welcome properties
Trust in one’s provider and recovery are other important inputs into treatment decision making

Abbreviations

SDM

Shared decision making

Contributor Information

Sapana R. Patel, Columbia University, Department of Psychiatry, College of Physicians and Surgeons, New York State Psychiatric Institute, New York, NY, USA.

Suzanne Bakken, School of Nursing and Department of Biomedical Informatics, Columbia University, New York, NY, USA.

Cornelia Ruland, Center for Shared Decision Making and Nursing Research, Rikshospitalet-Radiumhospitalet HF, Forskningsvn. 2b, N-0027 Oslo, Norway.

References

  • 1.Benbassat J, Pilpel D, Tidhar M. Patients’ preferences for participation in clinical decision making: A review of published surveys. Behav Med. 1998;24:81–88. doi: 10.1080/08964289809596384. [DOI] [PubMed] [Google Scholar]
  • 2.Cooper LA. At the center of the decision-making in mental health services and interventions research: Patients, clinicians, or relationships? (Commentary) Clin Psychol- Sci Pr. 2006;15:26–29. [Google Scholar]
  • 3.Wills CE, Holmes-Rovner M. Integrating decision-making and mental health interventions research: Research directions. Clin Psychol-Sci Pr. 2006;13:9–25. doi: 10.1111/j.1468-2850.2006.00002.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Institute of Medicine. Improving the quality of health care for mental and substance use conditions: Quality chasm series. Washington, DC: National Academies Press; 2005. [PubMed] [Google Scholar]
  • 5.Institute of Medicine: Committee on Quality of Health Care in America. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press; 2001. [Google Scholar]
  • 6.National Consensus Conference on Mental Health Recovery and Mental Health Systems Transformation. 2006 Retrieved 02 07 2008 from http://www.mentalhealth.samhsa.gOv/media/ken/pdf/SMAo5-4i29/trifold.pdf.
  • 7.New Freedom Commission on Mental Health. Achieving the promise: Transforming mental health care in America. Final report. Rockville, MD: 2003. DHHS Pub. No. SMA- 03-3832. [Google Scholar]
  • 8.Deegan PE, Drake RE. Shared decision making and medication management in the recovery process. Psychiatr Serv. 2006;57:1636–1639. doi: 10.1176/ps.2006.57.11.1636. [DOI] [PubMed] [Google Scholar]
  • 9.Charles C, Gafni A, Whelan T. Shared decision-making in the medical encounter: what does it mean? (Or, it takes at least two to tango. Soc Sci Med. 1997;44:681–692. doi: 10.1016/s0277-9536(96)00221-3. [DOI] [PubMed] [Google Scholar]
  • 10.O’Connor AM, Rostom A, Fiset V, et al. Decision aids for patients facing health treatment or screening decisions: A Cochrane systematic review. BMJ. 1999;519:731–740. doi: 10.1136/bmj.319.7212.731. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.**.O’Connor A, Bennett C, Stacey D, et al. Do Patient Decision Aids Meet Effectiveness Criteria of the International Patient Decision Aid Standards Collaboration? A Systematic Review and Meta-analysis. Med Decis Making. 2007:554–574. doi: 10.1177/0272989X07307319. [DOI] [PubMed] [Google Scholar]
  • 12.Hamann J, Leucht S, Kissling W. Shared decision-making in psychiatry. Acta Psychiat Scand. 2003;107:403–409. doi: 10.1034/j.1600-0447.2003.00130.x. [DOI] [PubMed] [Google Scholar]
  • 13.Appelbaum PS, Redlich A. Impact of decisional capacity on the use of leverage to encourage treatment adherence. Comm Ment Hlt J. 2006;42:121–130. doi: 10.1007/s10597-005-9015-6. [DOI] [PubMed] [Google Scholar]
  • 14.Whitney SN, McGuire AL, McCullough LB. A typology of shared decision making, informed consent and simple consent. Ann Intern Med. 2004;140:54–59. doi: 10.7326/0003-4819-140-1-200401060-00012. [DOI] [PubMed] [Google Scholar]
  • 15.Hamann J, Langer B, Winkler V, et al. Shared decision-making for in-patients with schizophrenia. Acta Psychiat Scand. 2006;11:265–273. doi: 10.1111/j.1600-0447.2006.00798.x. [DOI] [PubMed] [Google Scholar]
  • 16.Bunn MH, O’Connor AM, Tansey MS, et al. Characteristics of clients with schizophrenia who express certainty or uncertainty about continuing treatment with depot neuroleptic medication. Arch Psychiat Nurs. 1997;11:238–248. doi: 10.1016/s0883-9417(97)80014-3. [DOI] [PubMed] [Google Scholar]
  • 17.**.Hamann J, Cohen R, Leucht S, et al. Shared decision making and long term outcome in schizophrenia. J Clin Psychiat. 2007;68:992–997. doi: 10.4088/jcp.v68n0703. [DOI] [PubMed] [Google Scholar]
  • 18.Arora NK, Mchorney CA. Patient preferences for medical decision making: who really wants to participate? Med Care. 2000;38:335–341. doi: 10.1097/00005650-200003000-00010. [DOI] [PubMed] [Google Scholar]
  • 19.Hamann J, Cohen R, Leucht S, et al. Do patients with schizophrenia wish to be involved in decisions about their medical treatment? Am J Psychiat. 2005;162:2382–2384. doi: 10.1176/appi.ajp.162.12.2382. [DOI] [PubMed] [Google Scholar]
  • 20.**.Adams JR, Drake RE, Wolford GL. Shared Decision-Making Preferences of People With Severe Mental Illness. Psychiatr Serv. 2007;58:1219–1221. doi: 10.1176/ps.2007.58.9.1219. [DOI] [PubMed] [Google Scholar]
  • 21.*.Tannenbaum SJ. Consumer perspectives on information and other inputs to decision making: Implications for evidence-based practice. Comm Ment Hlt J. 2008 doi: 10.1007/s 10597-008-9134-y. [DOI] [PubMed] [Google Scholar]
  • 22.**.Hamann J, Mendel RT, Fink B, et al. Patients’ and Psychiatrists’ perceptions of clinical decisions during schizophrenia treatment. J Nerv Ment Dis. 2008;196:329–332. doi: 10.1097/NMD.0b013e31816a62a0. [DOI] [PubMed] [Google Scholar]
  • 23.Charles CA, Gafni A, Whelan T, et al. Cultural influences on the physician-patient encounter: the case of shared treatment decision-making. Patient Educ Couns. 2006;63:262–267. doi: 10.1016/j.pec.2006.06.018. [DOI] [PubMed] [Google Scholar]
  • 24.*.Cortes DE, Mulvaney-Day N, Fortuna L, et al. Patient-provider communication: Understadning the role of patients activation for Latinos in metal health treatment. Health Educ Behav. 2008:1–17. doi: 10.1177/1090198108314618. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25.Seale C, Chaplin R, Lelliott P, et al. Sharing decisions in consultations involving antipsychotic medication: A qualitative study of psychiatrists’ experiences. Soc Sci Med. 2006;62:2861–2873. doi: 10.1016/j.socscimed.2005.11.002. [DOI] [PubMed] [Google Scholar]
  • 26.**.Goosensen A, Zijlstra P, Koopmanschap M. Measuring shared decision making processes in psychiatry: Skills versus patient satisfaction. Patient Educ Couns. 2007;67:50–56. doi: 10.1016/j.pec.2007.01.017. [DOI] [PubMed] [Google Scholar]
  • 27.Loh A, Simon D, Henning K, et al. The assessment of depressive patients’ involvement in decision making in audio-taped primary care consultations. Patient Educ Couns. 2006;63:314–318. doi: 10.1016/j.pec.2006.04.006. [DOI] [PubMed] [Google Scholar]
  • 28.Clever SL, Ford DE, Rubenstein LV, et al. Primary care patients’ involvement in decision making is associated with improvement in depression. Med Care. 2006;44:398–403. doi: 10.1097/01.mlr.0000208117.15531.da. [DOI] [PubMed] [Google Scholar]
  • 29.**.Swanson KA, Bastani R, Rubenstein LV, et al. Effect of mental health care and shared decision making in patient satisfaction in a community sample of patients with depression. Med Care Res Rev. 2007;64:416–430. doi: 10.1177/1077558707299479. [DOI] [PubMed] [Google Scholar]
  • 30.Ludman E, Katon W, Bush T, et al. Behavioural factors associated with symptom outcomes in a primary care-based depression prevention intervention trial. Psychol Med. 2003;33:1061–1070. doi: 10.1017/s003329170300816x. [DOI] [PubMed] [Google Scholar]
  • 31.**.Loh A, Simon D, Wills CE, et al. The effects of a shared decision making intervention in primary care of depression: A cluster-randomized controlled trial. Pat Educ Couns. 2007;67:324–332. doi: 10.1016/j.pec.2007.03.023. [DOI] [PubMed] [Google Scholar]
  • 32.Alegría M, Polo A, Gao S, et al. Evaluation of a patient activation and empowerment intervention in mental health care. Med Care. 2008;46:247–256. doi: 10.1097/MLR.0b013e318158af52. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 33.Elwyn G, O’Connor A, Stacey D, et al. Developing a quality criteria framework for patient decision aids: online international Delphi consensus process. BMJ. 2006 doi: 10.1136/bmj.38926.629329.AE. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34.**.Jeste DV, Bunn LB, Folsom DP, et al. Multimedia educational aids for improving consumer knowledge about illness management and treatment decisions: A review of randomized controlled trials. J Psychiat Res. 2008;42:1–21. doi: 10.1016/j.jpsychires.2006.10.004. [DOI] [PubMed] [Google Scholar]
  • 35.**.Deegan P. The lived experience of using psychiatric medication in the recovery process, and a program to support it. Psychiat Rehab J. 2007;31:62–69. doi: 10.2975/31.1.2007.62.69. [DOI] [PubMed] [Google Scholar]

RESOURCES