Preliminary validation of the Satisfaction With Decision scale with depressed primary care patients

Abstract

Objective To conduct a preliminary validation of the Satisfaction With Decision (SWD) scale with depressed primary care patients.

Design  Cross‐sectional observational pilot study using a postal survey.

Setting and participants  Depressed primary care patients (n = 97) who recently had made a new decision about antidepressant medication use completed surveys regarding their treatment decisions.

Main variables  Measures included patient‐reported satisfaction with decision, decisional conflict, knowledge about depression and treatment, decision involvement, pain and health status, antidepressant medication efficacy, and satisfaction with health services.

Results  The SWD scale had good internal consistency reliability (α = 0.85). Evidence for construct validity was confirmed via a hypothesized pattern of relationships between the SWD scale and other measures. Decision satisfaction was associated with several issues of relevance for designing patient‐centred decision support interventions: (1) knowledge about depression and treatment; (2) involvement in health‐related decisions; and (3) aiding evaluation of trade‐offs among pros and cons of treatment.

Conclusions  The results of this pilot study show that the SWD scale appears to be a psychometrically sound and practical measure for research with this population. Additional research is needed on the theoretical nature of decision satisfaction and developing and testing patient‐centred decision support interventions for depression treatment.

Introduction

Depression is a serious worldwide health problem that is associated with substantial morbidity, mortality, diminished quality of life, and increased costs of health care. ¹ , ² , ³ In countries such as the US and the continent of Europe, healthy life year costs of unipolar major depression ($6.7 million in 1990 US dollars) were exceeded only by ischaemic heart disease ($8.9 million), as indexed by disability‐adjusted life years (DALYs). ⁴ In the general population, it is estimated that one in eight people will need depression treatment during their lifetimes, ¹ and depressive disorders affect more than 11 million Americans at any given time. ⁵ Depression is prevalent in primary care settings, affecting 15–30% of those seeking treatment for medical problems, ⁶ and is also most often treated in primary care settings. ¹ , ⁷ However, depression often goes inadequately detected and treated in primary care and other general health settings. ¹ US Public Health Service health risk reduction objectives emphasize increasing the number of people who obtain depression treatment, ⁸ and the under‐treatment of mental disorders has recently been underscored in the recent US Surgeon General's Report on Mental Health. ⁹ In light of the costs of under‐detection and under‐treatment of depression in primary care settings, the US Preventive Health Services Task Force has recently provided an updated recommendation for routine depression screening of adult age patients. ¹⁰

Primary care clinical practice guidelines include a recommendation of 4–9 months of antidepressant treatment for a single episode of major depression, ¹¹ but relatively few people receive pharmacotherapy that is consistent with clinical practice guidelines. Behaviours of both health care providers and patients affect the duration and adequacy of pharmacotherapy for depression. Audits of pharmacy records have shown that only about half of primary care antidepressant prescriptions met clinical guideline recommendations for a minimum adequate dose and duration of pharmacotherapy. ¹² Patient factors also play an important role in treatment adequacy. Most primary care patients decide to either refuse or discontinue antidepressant medication very soon after starting it, before potential benefits of the medication could be obtained. ¹³ , ¹⁴ , ¹⁵ About one in three people who receive antidepressant prescriptions from a primary care provider do not fill the prescription at all, and up to 50% have discontinued medication by within 3 months of starting it. ¹³ Medication discontinuation has been found to be most common during the first month of treatment. ¹⁵ Among other factors, patient satisfaction with various aspects of care, as well as the treatment decision itself, may affect the initiation and/or continuation of treatment.

Present study

This report focuses on one factor influencing the adequacy of depression treatment in primary care, patient decision‐making about use of antidepressant medication as related to satisfaction with the treatment decision. Research on health‐related patient decision‐making is a relatively new area of inquiry, and better understanding of patient perspectives for different treatment decision‐making situations is needed for health care improvement, especially because patient perspectives may differ from those of other stakeholders. ¹⁶ , ¹⁷ This information can inform the design of patient‐centred decision support interventions for specific treatment decision‐making contexts, as well as the development of standardized outcomes measures for evaluating effects of interventions. ¹⁸ Development of standardized measures of outcomes of decision support interventions has recently been proposed as a key priority for future research. ¹⁹

Within the goal of assessing the characteristics of decision‐making measures for use in future studies, the purpose of the present study was to assess the psychometric properties of a recently developed standardized outcome measure of patient decision‐making, the Satisfaction With Decision (SWD) scale for a sample of depressed primary care patients, against the original validation study results as reported in Holmes‐Rovner et al. ¹⁸ An additional goal was to explore relationships among several other recently developed measures of patient decision‐making and self‐reported antidepressant medication‐taking behaviour.

Sample and procedures

All study procedures received approval from the Human Subjects Research Review committees of the University and participating health care organizations. A convenience sample of 97 depressed adult age primary care patients was recruited from throughout the State of Michigan via primary care providers, primary care office postings, and newspaper advertisements. Most study participants resided in the most urban and populated southernmost portion of Michigan. Study participants were offered their choice of a coffee mug or $10 in exchange for their time completing the survey. Potential study participants telephoned the investigator to indicate their interest in the study and, if eligible for the study, they were mailed the survey (which included all study measures) and a preaddressed stamped envelope in which to return their completed surveys. Patients were eligible for study participation if they were at least 18 years of age and reported making a new, at least initial, decision about use of antidepressant medication, as suggested or prescribed by a primary care provider (not a mental health specialist), within the 4‐month time period prior to their study participation. This time period was selected for two reasons: to assess if a less‐than‐minimally recommended duration of antidepressant pharmacotherapy ¹¹ had occurred, and to facilitate study participant recall of their own perceptions of treatment decision‐making.

Statistical analysis

Descriptive statistics were used to characterize the study sample. Cronbach's α was used to assess the internal consistency reliability of each standardized study scale (and subscales) as appropriate. Chi‐square and Fisher's exact test analyses were used for analyses of nominal level proportionate group differences. Construct validity of the SWD scale was assessed via correlations and logistic regression analyses to test hypothesized relationships of the SWD with other study measures. Independent sample t‐tests were used in the applicable context to compare the mean scores on measures for study participants who had declined, started and continued, or started and later discontinued antidepressant medication.

Satisfaction With Decision scale

The SWD scale contains six items that assess patient satisfaction with a health care decision, rated on a 1–5 scale (1 = strongly disagree; 5 = strongly agree). Higher scores indicate higher satisfaction with decision. The development and validation of this scale with a sample of women deciding about postmenopausal hormone‐replacement therapy is reported elsewhere. ¹⁸ The SWD is treated as a unidimensional scale. The wording of the SWD scale was adapted for this study for the antidepressant medication decision‐making context. The instructions for completing the SWD scale and the revised items are presented in the Appendix. A sum score was used in analyses.

Table Appendix.

Satisfaction With Decision (SWD) scale for antidepressant medication use decision. Please answer the following questions about your decision about taking antidepressant medication for your depression. Please indicate to what extent each statement is true for you AT THIS TIME (circle one number for each statement).

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
1. I was adequately informed about the different treatments available for my depression	1	2	3	4	5
2. The decision I made was the best decision possible for me personally	1	2	3	4	5
3. My decision was consistent with my personal values	1	2	3	4	5
4. I expect to successfully carry out (or continue to carry out) the decision I made	1	2	3	4	5
5. I had as much input as I wanted in the choice of treatment for my depression	1	2	3	4	5
6. I am satisfied with the decision that was made about treatment for my depression	1	2	3	4	5

Decision Conflict Scale (DCS)

The 1995 version of the DCS ²⁰ was used (the scale has been subsequently revised in wording and scoring), which is a 16‐item scale that assesses level of decisional conflict about health‐related decisions. The DCS has been validated for many health treatment decisions, including flu vaccination, hormone replacement therapy, breast cancer screening, schizophrenia treatment, and cystic fibrosis screening. It contains three subscales: (1) uncertainty about selection of alternatives; (2) specific factors contributing to uncertainty; and (3) perceived effectiveness of decision‐making. Each item is rated on a 1–5 scale (1 = strongly agree; 5 = strongly disagree). Scores can range from 16 to 80 points, with higher scores indicating relatively higher levels of decisional conflict. DCS items were revised for the antidepressant medication decision context. The sum score for the total scale and each of the three subscales was used in analyses. Internal consistency reliability was found to be adequate for the total scale and the subscales (α = 0.89 for total scale; α = 0.82, 0.83 and 0.87 for the subscales).

Centre for Epidemiological Studies Depression (CESD) scale

The CESD ²¹ is a self‐report measure of depression that has been extensively validated with community‐based samples, including depressed populations. The standard 20‐item version of the scale was used in this study. Each item is rated relative to how frequently a specific symptom of depression occurred (0 = rarely or none of the time; 3 = most or all of the time). Scale items assess somatic, affective, interpersonal and cognitive dimensions of depression. A score of 0–60 points is possible, with higher scores indicating greater depression severity. In adult populations, a score of ≥16 is indicative of clinically significant depression. The sum score for the total scale was used in analyses. The internal reliability consistency for the CESD in this study was high (α = 0.94).

Single item measures

Six single‐item measures were included for construct validation analyses of the SWD scale. Three items were developed by the investigator (perceived antidepressant medication efficacy, satisfaction with clinic, satisfaction with primary health care provider), two items (amount body pain, degree of overall health) were used from the Medical Outcomes Short Form Health Status scale, ²² and one item assessing patient preference for decision participation was adapted from an existing question previously described in the literature. ²³ Each item was rated on a 5‐point scale and the scores for individual items were used in analyses.

Physician Participatory Decision‐Making (PDM) Style scale

The three‐item PDM scale ²⁴ measures patient perceptions of being included by the physician in decision‐making in the health care encounter. Each statement about involvement of the patient by the health care provider is rated by the patient on a 1–5 scale (1 = strongly agree; 5 = strongly disagree) regarding the extent of involvement. Lower scores indicate higher inclusion of the patient in decision‐making. The internal consistency reliability for this scale in this study was adequate (α = 0.85).

Knowledge about depression and its treatment

This 20‐item scale was developed by the investigator on the basis of the Agency for Health Care Policy and Research (AHCPR) ‘Patient Guide to Depression’ booklet. Participants rated each item about depression or its treatment as ‘true’ or ‘false.’ A sum score of correctly answered items was used in analyses, with higher scores indicating higher level of knowledge.

Sample characteristics

The average participant in this study was a relatively young, well‐educated, white female who was significantly depressed. Mean level of depression, as measured by the CESD scale, was 28.3 (SD = 13.7). The sample ranged in age from 18 to 61 years, with a mean age of 31.9 years (SD = 11.3), and was 79% female and 94% white. Compared with white participants, non‐white participants were more likely to have refused or discontinued antidepressant medication, 67% (n = 4 of 6 non‐white participants) vs. 20% (n = 18 of 91 white participants), Fisher's exact test, P < 0.05. Thirty‐eight per cent of the sample was enrolled in college (undergraduate or graduate level), and 39% reported employment outside of the home. Ninety‐three per cent of the sample reported having at least some college level education.

Internal consistency reliability

The internal consistency reliability of the adapted SWD scale was assessed through calculation of Cronbach's α. The results indicated that the revised scale had an adequate level of reliability (α = 0.85) that was not improved by the deletion of any of the scale items. This result is virtually identical to the original study reporting validation of the scale for women making decisions about hormone replacement therapy, in which α = 0.86.

Construct validity

Evidence for construct validity was found in a hypothesized pattern of statistically significant relationships that occurred between the SWD scale and other measures. Table 1 presents the bivariate correlations of the SWD scale with other measures included in the survey. Where applicable, results of the original SWD scale validation study are reported for purposes of comparison. Lower satisfaction with decision was associated with less physician involvement of the patient in treatment decision‐making, more severe pain, poorer overall health, higher decisional conflict, lower perceived antidepressant medication effectiveness, less satisfaction with the primary care treatment setting and health care provider, and lower knowledge about depression and its treatment. A series of logistic regression analyses were performed to test relationships between SWD and knowledge scale items. SWD was associated with responses to several knowledge scale items concerning the aetiology of depression and pharmacotherapy for depression (see Table 1). SWD was not significantly associated with level of depression in the present study, but the relationship was inverse in a way that might be intuitively expected based on the negative life view that is often associated with depressive states; i.e. higher depression was associated with lower SWD.

Table 1.

Correlations of Satisfaction With Decision (SWD) and other measures: present and original SWD validation studies

Measure	Present study			Original study
	r	d.f.	P	r	P	Measure
Centre for Epidemiological Studies Depression (CESD) scale	−0.13	92	NS	–	–	–
Physician Participatory Decision‐Making (PDM) Style scale	−0.58	95	<0.001	–	–	–
Body pain (Medical Outcomes Study Short Form‐20)	−0.26	94	<0.01	−0.27	<0.05	Health Status Restrictions Scale
Overall health (Medical Outcomes Study	0.24	94	<0.05	–	–	–
Short Form‐20)
Decisional Conflict Scale (DCS)	−0.59	94	<0.001	–		–
• Uncertainty subscale	−0.29	94	<0.01	−0.54	<0.05	Uncertainty subscale
• Decision factors subscale	−0.52	95	<0.001	–		–
• Perceived effectiveness of decision subscale	−0.72	95	<0.001	–		–
Desire to participate	0.01	90	NS	−0.18	<0.05	Desire to participate
Perceived medication efficacy	0.32	76	<0.01	–	–	–
Satisfaction with clinic	0.33	89	<0.01	–	–	–
Satisfaction with primary health care provider	0.31	94	<0.01	0.23	<0.05	Satisfaction With Provider scale
Knowledge about depression and its treatment*	0.29	85	<0.01	0.21	<0.05	Knowledge of menopause scale

^* SWD was associated with responses to the following knowledge scale items: (1) certain kinds of physical health problems can cause depression, r = 0.24, P < 0.05; (2) research has shown that medicines for depression help only a small number of people who try them, r = −0.21, P < 0.05; and (3) most people have a lot of trouble with side‐effects from antidepressant medicines, r = −0.13, P < 0.05.

Overall, the pattern of relationships between SWD and similar measures used in the present and original validation studies of the SWD scale is quite similar, except for preference for decision participation. In this study, SWD was not significantly associated with decision participation preference. The reason for this difference in findings between the two studies is not clear on the basis of the present study, but may be the result of lack of response variance. Less than 14% of participants (n = 12) endorsed a wish for the health care provider to make the decision about antidepressant medication use, compared with over 86% who endorsed a wish to either make the decision themselves (n = 49) or to share decision‐making equally with their health care provider (n = 30).

SWD was also associated with self‐reported antidepressant medication use. The sample was classified by participant responses to survey questions about antidepressant medication use, as to whether or not participants had: (1) initially declined medication; (2) started medication and later discontinued it; or (3) started medication and were still taking it at time of completing the survey for the reported study. Of the 97 participants, 11 participants reported initially declining medication, 11 reported starting medication but later discontinuing it, and 75 participants reported starting medication and were still taking it at time of survey completion. The subsample of participants who discontinued medication after starting it reported significantly lower satisfaction with their medication use decision compared with participants who started and continued taking medication, t ₍₈₂₎ = −4.57, P < 0.001. A logistic regression was performed to test if group membership for antidepressant medication use behaviour was predictable from SWD score. Participants who reported they had started and continued medication were classified into one group, and were compared with participants who reported they had either initially refused medication or who had discontinued medication after starting it. SWD was a significant predictor of self‐reported medication use behaviour, r ₍₁₎ = −0.27, P < 0.01. The classification was 80% correct overall. Participants who started and continued medication were 97.3% correctly classified, and participants who either refused or discontinued medication were 19.05% correctly classified.

The results of this analysis show how a specific perception (SWD) is related to a self‐reported behaviour (antidepressant medication use). However, the logistic model performed better for the prediction of starting and continuing antidepressant medication (97.3% correct classification) as compared with refusing or discontinuing antidepressant medication (19.05% correct classification). The interpretation of this finding is speculative as a result of the small number of participants who had refused or discontinued medication at the time of study participation. However, further research might focus on describing the characteristics of those patients who may be relatively satisfied with a ‘negative’ decision (to decline or discontinue antidepressant medication). Clinical interventions would be different for individuals who are relatively unsatisfied with their decision to decline or discontinue antidepressant medication, vs. those who are relatively satisfied with their decision.

Relationships between decision‐making measures and medication use behaviour

An additional goal was to explore relationships among several other recently developed measures of patient decision‐making and self‐reported antidepressant medication‐taking behaviour. For these analyses, groups of participants who: (1) initially declined medication; (2) started medication and later discontinued it; or (3) started medication and were still taking it at time of completing the survey for the reported study were compared to each other, on other decision‐making measures included in the survey. Table 2 presents tests of mean differences on measures for patients who declined medication (n = 11) vs. those patients ever starting medication (n = 86), and for patients who discontinued medication (n = 11) vs. those patients who started and continued medication (n = 75), together with effect sizes for the mean differences. The results show that patients who refused antidepressant medication had significantly lower satisfaction with their primary health care provider, higher decisional conflict, and reported a preference for relatively more control of decision‐making about medication, compared with patients who ever started medication. Also, patients who discontinued medication reported significantly higher levels of decisional conflict about their antidepressant medication decision‐making. The effect sizes show that the mean differences between groups are generally moderate in size.

Table 2.

(a) Differences on measures for patients declining vs. starting medication. (b) Differences on measures for patients discontinuing vs. starting and continuing medication

Measure	Mean differences (SD)		d.f.	t	P	ES (γ)
	Declining	Starting
(a)
Satisfaction with provider	1.8 (1.55)	3.1 (1.01)	93	−3.72	<0.001	0.39
Decisional conflict (DCS)	46.2 (9.53)	37.0 (9.83)	93	2.91	<0.01	0.30
Decision participation desire	1.7 (0.71)	2.6 (0.94)	89	−2.83	<0.01	0.30
Uncertainty subscale (DCS)	10.8 (2.89)	8.2 (3.13)	93	2.68	<0.01	0.28
Decision factors subscale (DCS)	26.5 (7.97)	21.0 (5.77)	94	2.86	<0.01	0.30
(b)	Discontinuing	Starting and continuing
Decisional conflict (DCS)	46.7 (8.25)	35.6 (9.24)	82	3.78	<0.01	0.42
Uncertainty subscale (DCS)	10.0 (3.03)	7.9 (3.07)	82	2.14	<0.05	0.24
Decision factors subscale (DCS)	26.4 (3.78)	20.2 (5.60)	83	3.52	<0.001	0.39
Perceived effectiveness of decision subscale (DCS)	10.4 (2.87)	7.35 (2.41)	83	3.78	<0.001	0.41

Discussion

There are three main findings of this study. First, this study provides preliminary evidence of reliability and construct validity of the SWD scale to support its use in research with depressed primary care patients. The reliability and validity findings are largely consistent with the patterns of findings in original report of the development of the SWD scale. This provides additional evidence in support of decision satisfaction as a generic concept occurring across a variety of treatment decision‐making contexts.

Secondly, SWD is shown in this study to be associated with patient education, decision participation, and depression treatment issues that are potential targets for decision support interventions to improve depression treatment. Specifically, the results of this study are suggestive of the need to intervene with the following constellation of treatment issues among a subset of patients: (1) lack of knowledge about depression and its treatment; (2) patient perceptions of not being involved in treatment decision‐making; (3) perceived lack of antidepressant medication effectiveness; and (4) decisional conflict. For example, SWD was significantly associated with beliefs that antidepressant medications have low efficacy and frequent side‐effects. Sources of decisional conflict include a lack of information about risks, side‐effects, benefits and choices. A number of patients in this study who were recently prescribed antidepressant medication may have needed information about the length of time needed for the medication to start working, vs. how to tell if the medication should be stopped, as well as information about other options if the prescribed medication did not work. They may also have needed information about how to structure visits with their primary care providers, in order to be involved as they preferred in decision‐making about depression treatment. On the other hand, it is interesting to note that satisfaction with decision, as measured by the SWD and the Barry et al. scale ²⁵ is sensitive to changes in information in trials of decision aids. In this study, as well as the O'Connor et al. study of immunization decision‐making, ²⁶ the SWD predicted uptake of therapy following the decision. Clearly future research needs to further elucidate the role of SWD in predicting behaviour, whether or not it is amenable to direct intervention. Thirdly, the results of this study provide important information about the patient perspective in decision‐making as it is related to medication use behaviour. SWD was associated with self‐reported medication use behaviour. Also, significant differences on other measures assessing the patient perspective also occurred between groups that were classified based on their self‐reported medication use behaviours. In brief, patients who were classified as initially refusing or discontinuing their medication early on experienced substantially higher levels of decisional conflict, had preferences for control of decision‐making, and may have perceived a need for an improved relationship with their primary health care providers, as revealed by lower satisfaction ratings for their primary care providers. These issues would be important to address in treatment, as they may be predictors of a potentially less‐than‐optimal treatment decision by the patient, with the associated potential to adversely affect the outcomes of depression care.

Study limitations and future research

The data presented in this paper represent a preliminary validation of the SWD scale with a depressed primary care sample. The use of a small, non‐diverse convenience sample and the retrospective cross‐sectional survey design limits the generalizability of the study findings, the ability to make causal inferences about observed correlations between variables such as SWD and medication use, and limits the ability to do more substantive subgroup analyses. Future research could extend the reported findings by collecting data about the specific types of depression experienced by the study participants and the use of alternative and complementary therapies, as well as medical records data about medication prescribing patterns. In addition, there is a need for additional research on the SWD with diverse populations of patients and health decision‐making contexts. Depressed primary care patients are known to represent a heterogeneous group of depressive disorders and range of severity of depressive symptoms. Primary care patients who are depressed but who do not meet diagnostic criteria for major depression may be two to three times more prevalent than those meeting criteria for major depression, ⁷ and may not necessarily require treatment with antidepressant medication. ¹² , ^{27 , 28} Also, a number of primary care patients who receive ‘inadequate’ pharmacotherapy for depression actually may have good short‐term outcomes, ²⁹ but outcomes for pharmacotherapy for depression in primary care also may be less than optimal; i.e. recovery rates are documented to be as low as 22% at 8 months following treatment initiation for the ‘usual’ treatment of depression in primary care. ³⁰ In addition, many patients prefer to use non‐pharmacological remedies for depression ³¹ , ³² , ³³ including alternative or complementary therapies. ³⁴ The finding that non‐white study participants were more likely to have refused or discontinued their antidepressant medication should be explored in future research with larger samples, particularly in light of recent research documenting the effects of race and gender on relationship with health care providers. ³⁵ Decision satisfaction (a measure of patient perceptions) should not be considered to be synonymous with the actual quality of health care that patients may or may not have received. However, satisfaction with decision is an important outcome, insofar as patients ultimately make their own decisions about initiating and continuing depression treatments.

Theoretical issues

The development of measures to assess the outcomes of decision‐making, including patient satisfaction with decisions, is currently of heightened interest, and much additional research on the theoretical nature of the satisfaction concept remains to be done. For example, Sainfort et al. ³⁶ in a recent report of the development of decision‐attitude scale to assess post‐decision satisfaction, concluded that satisfaction with an (at least) initial decision is multidimensional, and includes, ‘…at least three generic dimensions: satisfaction with choice, usability of information, and adequacy of information’ (p. 60), and possibly includes a fourth dimension of decision responsibility/self‐efficacy. The decision‐attitude scale was developed independently and concurrently with the SWD scale, but appears to have two‐third overlap (four of six items) with the SWD scale. In the Sainfort et al. analysis, both the SWD and decision‐attitude scales appear to have items that tap into satisfaction with choice and adequacy of information dimensions of satisfaction. Also, in the Sainfort et al. analysis, one of the SWD items seems to come close to tapping the possible fourth dimension of responsibility/self‐efficacy.

As proposed by Sainfort et al., additional instrument development research should be done to develop a more complete but feasible to use measure that taps each of the key dimensions of post‐decision satisfaction. In addition, it may also be fruitful to explore other related concepts, such as post‐decision regret, noting that these concepts may sometimes be better related with the process aspects of decision‐making as opposed to the actual outcomes of decisions. Our work here suggests that SWD is a valid construct. It was developed initially to measure satisfaction immediately following the decision. When the outcomes of the decision are actually experienced, regret may overwhelm satisfaction with the decision at the time it was made. It is important to distinguish satisfaction with the decision as construct from its ability to predict behaviour. Attempts to improve decision‐making and behaviour are both important. It is important to understand the attributes of each. Finally, future research should be done on patient decision‐making for a variety of treatment decision‐making contexts, to replicate and refine existing findings, and to in turn further refine theoretical formulations of the decision satisfaction construct.

Conclusions

In summary, this preliminary validation of the SWD scale with depressed primary care patients provides evidence in support of its reliability and validity for this population. This study makes a small but important contribution to the growing body of literature concerning the measurement of patient decision satisfaction, by testing the SWD scale with a different population of patients and a different treatment decision‐making context. Additional research is needed to replicate the study findings and to test newly developing ideas about the multidimensional nature of post‐decision satisfaction. In addition, there is a need to develop and test decision support interventions for depressed primary care populations, which incorporate the decision support needs identified in this and other research. Measures such as the SWD can be useful and feasible measures of outcomes, insofar as they are associated with specific patient decision support needs, such as information needs, values clarification, and strategies for effective communication and involvement with health care providers.

Acknowledgements

Portions of this paper were presented as a poster at the Twentieth Annual Meeting of the Society for Medical Decision Making, Cambridge, Massachusetts, USA, October 1998. Financial support for this study was provided by a Michigan State University College of Nursing Research Initiation Grant awarded to the first author. The funding agreement guaranteed the authors' independence in designing the study, interpreting the data, and writing and publishing the report. The first author is currently a recipient of a Mentored Clinical Scientist Career Development (K08) Award (MH01721) from the US National Institute of Mental Health focusing on patient decision‐making about depression treatment. The data reported in this paper were collected as pilot data in support of the K08 grant proposal.