Skip to main content
NCBI home page
VA Author Manuscripts logoLink to VA Author Manuscripts
. Author manuscript; available in PMC: 2022 Nov 1.
Published in final edited form as: Adm Policy Ment Health. 2021 Feb 24;48(6):1046–1054. doi: 10.1007/s10488-021-01119-5

Provider Perspectives on Implementing Shared Decision Making for PTSD Treatment in VA Primary Care

Jessica A Chen a,b, Theresa E Matson c,d, Keren Lehavot a,b,c, Patrick J Raue b, Jessica P Young a, Molly C Silvestrini a,b, John C Fortney a,b, Emily C Williams a,c
PMCID: PMC8382773  NIHMSID: NIHMS1696683  PMID: 33625623

Abstract

Purpose.

Shared decision making is an important implementation “pull” strategy for increasing uptake of evidence-based mental health practices. In this qualitative study, we explored provider perspectives on implementing shared decision making at the point of mental health treatment initiation using a publicly available, patient-facing decision support tool for post-traumatic stress disorder (PTSD).

Methods.

We conducted semi-structured interviews with 22 mental health providers (psychiatrists, nurses, psychologists, and social workers) working in one of five VA primary care clinics. Interviewed were analyzed using thematic analysis.

Results.

Provider were enthusiastic about using decision aids as a source of high quality information that could improve patient experience and confidence in treatment. However, providers had concerns about decision aid accessibility, time constraints to conduct shared decision making in-session, and patient motivation to engage in shared decision making. Providers stated they would prefer to use shared decision making with patients that they felt were most likely to follow through with treatment.

Conclusions.

While providers believed that shared decision making could improve PTSD treatment planning, they thought it most appropriate for patients with the highest levels of motivation and fewest barriers to care. These beliefs may limit widespread adoption and reflect missed opportunities to reach difficult-to-engage patients.

Keywords: shared decision making, patient decision aids, PTSD, qualitative research, implementation, veteran care

Introduction

Shared decision making is defined as helping patients to achieve informed treatment preferences through a supportive discussion where providers share the best available evidence about treatment options and assist patients in identifying what matters most to them (Elwyn et al., 2012). Shared decision making in mental health promotes patient activation and improves treatment adherence (Joosten et al., 2008; Raue et al., 2019). It has been highlighted as a promising implementation “pull” strategy that increases patient demand for and engagement in evidence-based psychotherapies while reducing unwanted variation in provider treatment selection (Finley et al., 2020; Karlin & Brenner, 2020). Shared decision making requires clinician buy-in and skill, so that providers effectively engage patients in a conversation about treatment goals and preferences, and it also requires evidence-based tools that accurately reflect the best available knowledge about the risk and benefits of different treatment options (Sepucha et al., 2016), as informal, provider-driven descriptions of treatment options are unlikely to support evidence-based decision-making (Osei-Bonsu et al., 2016). Despite the many potential benefits, shared decision making has not been widely adopted in mental health settings (Slade, 2017).

Shared decision making is considered an ethical imperative in situations of where there is more than one reasonable treatment option (Elwyn et al., 2012). Many mental health conditions can be treated via multiple evidence-based psychotherapy and pharmacotherapy options. In the case of posttraumatic stress disorder (PTSD), evidence-based treatment options include cognitive behavioral psychotherapies, such as cognitive processing therapy or prolonged exposure, and pharmacotherapies, primarily selective serotonin reuptake inhibitors (SSRIs) such as sertraline and paroxetine (both FDA approved for PTSD) (VA/DoD, 2017).

The Department of Veterans Affairs (VA) recommends utilizing shared decision making in its Clinical Practice Guidelines for PTSD (VA/DoD, 2017), and VA’s National Center for PTSD created an online PTSD treatment decision aid (Department of Veterans Affairs & National Center for PTSD, n.d.) to support shared decision making. Decision aids are tools that are often used in shared decision making to concisely offer information about treatment options to patients (O’Connor et al., 2009). Observational and pilot studies of shared decision making in VA specialty PTSD settings suggest it improves initiation of and adherence to psychotherapy (Hessinger et al., 2018; Mott et al., 2014). One randomized trial found that providing a patient decision aid to VA primary care patients with PTSD resulted in higher treatment initiation and greater reductions in PTSD symptoms than a usual care control group (Watts et al., 2015). Despite promising preliminary results and clinical practice guideline recommendations, there is not yet a standardized process for shared decision making for PTSD treatment. One pilot study (Mott et al., 2014) incorporated a decision support tool into a 30-minute discussion between patients and their mental health providers, while the RCT (Watts et al., 2015) simply gave patients a paper decision aid but did not include provider discussion. In routine practice, providers are highly variable in how they approach PTSD treatment decision-making (Finley et al., 2020; Osei-Bonsu et al., 2016).

Given that primary care is often the first point-of-contact for patients seeking PTSD care (Bohnert et al., 2016), it is an ideal setting for shared decision making to occur. Decisions about pharmacotherapy, treatment setting, and referrals often have to be made within primary care. In VA, only about half of patients with PTSD are successfully referred to specialty mental health settings (DeViva, 2014; Magruder et al., 2005; Spoont et al., 2010). Relying on primary care physicians to address yet another health condition in a brief visit is not always feasible (Friedberg et al., 2013). Interprofessional teams are a promising approach to delivering shared decision making in a coordinated fashion (Légaré et al., 2011). Integrated behavioral health teams in primary care are well-positioned to diagnose PTSD, engage in shared decision making around treatment options, and connect patients to appropriate care (Possemato et al., 2018). However, no studies have examined whether integrated behavioral health providers are willing to incorporate shared decision making into routine care for patients with PTSD.

Understanding provider perspectives is essential to improving the adoption of shared decision making (Elwyn et al., 2013). Therefore, utilizing a case study approach, we conducted semi-structured qualitative interviews with integrated behavioral health providers in VA’s Primary Care Mental Health Integration (PC-MHI) program to assess their perspectives on utilizing VA’s PTSD decision support tool as part of shared decision making. Our goal was to better understand how shared decision making may or may not fit into routine practice. To support the translation of research findings into implementation practice, we described and organized PC-MHI providers’ perspectives using domains from the Consolidated Framework for Implementation Research (CFIR) (Damschroder et al., 2009), a framework that provides a common language for describing determinants of implementation success, which is useful for comparing results across implementation studies. By situating the study findings within the five CFIR domains (intervention characteristics, outer setting, inner setting, characteristics of individuals, and process), the findings can be directly linked to barriers and facilitators likely to influence the adoption of shared decision making in integrated behavioral health settings.

Methods

Participants and Setting

The study was conducted in five primary care clinics associated with one large VA healthcare system located in Washington state. These clinics were chosen to represent a range of VA primary care settings with the goal of maximizing variation to achieve a sufficiently representative sample (Palinkas et al., 2015). Two clinics were located in major metropolitan areas, each serving approximately 20,000 primary care patients in the prior year and approximately 2,500 who received mental health services in primary care. Three of the clinics were VA-managed community-based outpatient clinics (CBOCs) that varied in size from small (~2,000 patients) to large (~7,000 patients) and primarily served rural patients. All clinics had well-established PC-MHI programs that had been operating for more than five years. PC-MHI providers (social workers, registered nurses, nurse practitioners, psychologists, and psychiatrists) who worked at least one half day per week were eligible. This study was approved by the local Institutional Review Board.

Recruitment

All eligible PC-MHI providers were contacted via email, sent a research information statement, and asked to reply if they were willing to schedule an interview. While on site at each clinic to conduct scheduled interviews, purposive snowball sampling was used to recruit additional participants. Providers who completed an interview were asked to refer potentially interested colleagues who might have unique perspectives, and we sought to maximize recruitment of providers across job classifications (e.g., psychiatrists, psychologists, nurse care managers, social workers) and clinic types (e.g., women’s health, rural CBOCs). Participants were asked to provide verbal consent and permission to audio record the interview.

Data Collection

This study uses a qualitative interview methodology to assess provider perceptions and practices because qualitative methods are ideal for eliciting participant perspectives and for understanding processes of care in-depth (Palinkas, 2014). Semi-structured interviews were conducted between November and December 2017 either in-person (primary method) or by phone when necessary (e.g., for off-site telehealth providers). Semi-structured interviews were used because open-ended interview questions and semi-structured probes allowed researchers to effectively assess provider perceptions of their patient population, ask them to describe their typical practices around discussing PTSD treatment options, and elicit feedback on the usability of the patient decision aid (both the online version and, if providers wished to see it, a printed version of a treatment comparison chart) and its fit into existing clinical workflow and practices. The interview guide (Supplementary Appendix 1) was informed by CFIR and an existing taxonomy of barriers and facilitators to implementing shared decision-making (Légaré et al., 2008). Interviewers included a master’s level researcher with a background in public health and a PhD-level clinical psychologist.

Although providers were sent the link to the online decision aid in advance, most did not review it until during the interview. During the interview, interviewers did not give explicit guidance as to how the decision aid should be used because the goal was to understand how providers would intuitively use it. Instead, interviewers asked participants for feedback on where, when, and how they would anticipate using or not using the tool. Interviewers were trained in qualitative methods and followed standardized protocols for prompting participants using a set of grounded prompts if necessary. Interviews lasted 15–45 minutes and were digitally recorded, professionally transcribed, and reviewed for accuracy by the first and second author. The team continued to interview until thematic saturation occurred, i.e., there was consensus that no new themes were identified with additional interviews.

Data Analysis

We analyzed transcripts in two stages guided by both deductive and inductive strategies (Fereday & Muir-Cochrane, 2006). The purpose of the first stage was to utilize templates (King, 2004), which were developed a priori to represent each section of the interview guide, to identify codes and develop a codebook. The first and second authors who conducted the interviews created templated interview summaries and used these to identify emergent codes for an initial codebook. The codebook was refined and informed by the existing literature on barriers and facilitators to implementing shared decision-making (Légaré et al., 2008). The purpose of the second stage was to conduct in-depth analysis to abstract core themes from the data. The first and second author independently coded three interview transcripts in ATLAS.ti 7 (Atlas.Ti, n.d.) to establish reliability in the content, breadth, and depth of data included in each code. Discrepancies were resolved through clarification and consensus building with two qualitative experts. Once consistency was reached, the two investigators divided the remaining transcripts for coding, iteratively refined the codebook, and reviewed the final codes and quotations together to generate initial themes. Themes were further refined through discussion with the senior author. Throughout the analysis process, full study team discussed the interpretations of findings.

Results

Sample

Twenty-two PC-MHI providers, 63% of eligible providers across these five clinics, were interviewed. They included 2 master’s-level social workers, 2 registered nurses, 6 prescribers (4 psychiatrists and 2 advanced registered nurse practitioners), and 12 doctoral-level psychologists. Providers had been working in their current clinics for a mean of 3.8 years (range = 1 month to 18 years). Half (n = 11) worked at a CBOC. Due to two audio recording errors and one participant declining to be recorded, we had a total of 19 transcripts available for coding. We utilized field notes from the remaining three interviews that were not transcribed to confirm thematic saturation and to inform development of the codebook.

Themes

We identified four qualitative themes that summarized the range of provider perspectives. Two of the themes were more specific to using decision aids in clinical practice, while the remaining two themes more broadly addressed concerns about shared decision making as a clinical process: 1) The decision aid provided high-quality information that could improve patient experience and confidence; 2) Providers were concerned about the accessibility and acceptability of the decision aid; 3) Shared decision making will take too much time; and 4) Providers expressed concerns regarding patient follow-through and motivation. We organized the presentation of themes according to CFIR domains (Damschroder et al., 2009). These four themes fit into two broad CFIR domains: 1) intervention characteristics, specifically intervention source, evidence strength, and quality (theme 1) and intervention complexity and adaptability (themes 2 and 3), and 2) characteristics of the individuals involved (theme 4) (see Figure 1).

Figure 1.

Figure 1.

Open in a new tab

Themes mapped onto the Consolidated Framework for Implementation Research domains (https://cfirguide.org/)

Theme 1: Providers Thought the Decision Aid Provided High-Quality Information that Could Improve Patient Experience and Confidence. (CFIR Domain: Intervention Characteristics, Namely Intervention Source, Evidence Strength, and Quality)

Providers valued having a professional decision aid that offered high quality, evidence-based information from a trustworthy source. One psychologist working in a rural CBOC said, “There’s so much bad information on the internet about PTSD, it’s nice to have something good out there…This all looks like it’s based on all of the research the VA has, and the educational PTSD information the VA has” (P8). Providers noted that a decision aid can provide comprehensive information to patients in a condensed format, perhaps more information than a provider has time to go over in the session itself. One CBOC psychologist said, “It’d be extremely helpful because it would mean that I wouldn’t have to explain so much of it” (P3).

Several providers noted that patients may be skeptical when they are first referred to a mental health provider, and that giving high quality information can change negative stereotypes or expectations of mental health providers. As one CBOC psychologist noted, “Sometimes they come in and they don’t expect us to know what we’re doing or to have any good solutions” but a “nice and organized” tool like a decision aid can facilitate “changing perceptions…that we know what we’re doing, we’ve preplanned these things, and we have these resources for you. I think it builds confidence in the overall process.” (P5). Others discussed how the information in the decision aid could support patient confidence in and readiness for treatment. One VAMC psychologist said, “I think that it’ll make veterans feel way more prepared. It will set them up for success because they actually know what they’re going into” (P18).

Theme 2: Providers Were Concerned About the Accessibility and Acceptability of VA’s PTSD Decision Aid. (CFIR Domain: Intervention Characteristics, Specifically Intervention Complexity and Adaptability)

Some providers expressed concerns that VA’s online decision aid tool not be usable for certain patient populations. Many concerns were technology-specific and centered around computer literacy, limited internet access for a subset of patients, and beliefs that the online format would not be accessible to older patients. One VAMC psychologist wondered if the decision aid could be challenging for “some of the older patients who maybe aren’t as computer savvy…I’m not confident that every patient is going to be savvy enough to get on the computer and access something like this” (P12). Providers also noted lack of internet access could be a concern in rural areas: “Some people, especially as you get further out on the [Olympic] peninsula, don’t have high speed internet.” (P5) and “We have a lot of remote areas and slow service” (P9).

Others reported concerns about the accessibility of the decision aid for individuals with cognitive impairment, learning disabilities, or sensory disabilities. A VAMC psychiatrist said, for “some vets who are having cognitive processing issues, have TBI or who are just easily frustrated, [the decision aid] was frustrating” (P13). Several providers perceived a mismatch between the decision aid and the health literacy of their typical patient. A psychologist in the women’s primary care clinic explained,

I think the treatment comparison chart is great for a provider, someone who has graduate school work, but think this would not be useful for one of my patients. There’s too much information and it’s assuming an understanding and knowledge. And if you didn’t have a framework, you just wouldn’t know what that meant. (P17) The same provider expressed an additional concern regarding the acceptability or

appropriateness of the tool for women veterans stating, “Well the picture in the front is a man. That might not seem like a big deal but I’m telling you, if it’s a woman, they are going to be triggered just by that picture” (P17).

Theme 3: Providers Thought That Shared Decision Making Will Take Too Much Time. (CFIR Domain: Intervention Characteristics, Specifically Intervention Complexity)

Several providers expressed concerns about the fit of shared decision making into the fast-paced nature of a primary care practice. One CBOC nurse described the many competing demands to be addressed within a short behavioral health appointment: “5 minutes of bureaucracy, 5 minutes of planning, so 10 minutes is all of the data gathering and conversation that we have” (P6). One VAMC psychologist noted that shared decision making is not currently a routine part of connecting a patient to PTSD treatment, and adding it in would require a large shift in practice:

A lot of my visits with people with PTSD are once. Or pretty brief and when I’m getting them connected to treatment. And I wouldn’t see myself having time to review something like this. I’m not typically, routinely doing something like that. It would require a change in practice for sure. (P16)

A CBOC psychologist noted that remembering to refer to the decision aid would be a challenge given the time constraints of the clinical visit: “Within the confines of a 30 minute Primary Care [Behavioral Health] interaction, I would have to remember to utilize this, that’s always the hard part with me, honestly. To remember to use new tools” (P3).

Theme 4: Providers Expressed Concerns Regarding Patient Follow-Through and Motivation. (CFIR Domain: Characteristics of the Individuals Involved, Specifically Provider Perceptions of Patients)

Perceived patient characteristics influenced providers’ confidence in offering decision aids to a patient and, more broadly, their willingness to adopt the shared decision making process. Due to concerns about lack of time to review or use a decision aid in the clinical encounter, several providers anticipated potentially asking patients to review a decision aid at home. However, the same providers expressed hesitancy to do so because they were concerned about patient follow-through. Providers gave statements such as: “I don’t know if they’d follow through” (P1, CBOC nurse) and, “I know for a fact they’re not going to do this at home” (P3, CBOC psychologist). Some providers felt that a characteristic of the patient population was to not be engaged with materials like patient decision aids: “Veterans with PTSD don’t tend to have a lot of patience for things like this” (P7, CBOC nurse). Some believed that putting a decision aid online would make it less likely to be used; one CBOC nurse said, “I would worry about giving them a web address, and then going home and maybe never looking it up” (P1).

A separate but related subtheme under perceived patient characteristics was the notion that only some patients are good candidates for shared decision making. Some providers suggested that shared decision making could be used with a subset of patients who were the most motivated and already trusting of the medical establishment. A VAMC psychiatrist described the ideal patient for shared decision making:

I think if someone buys in, somebody that’s educated and proactive…somebody that’s introspective who trusts the medical establishment and has a view that there’s something out there that can help them. I think they might go ahead and sort of buy into this…So for somebody that’s motivated, I think this could be useful. (P13)

As one women’s clinic psychologist said, “I think that I’d have the opportunity to select those that I thought it could be useful for. So I wouldn’t necessarily recommend it for everybody. Yeah. It would probably be…less than half” (P14).

Discussion

In this qualitative study, integrated behavioral health providers saw value in adopting shared decision making to help primary care patients navigate PTSD treatment options. When it came to using an evidence-based decision aid, providers liked having a decision aid that offered high quality information in a comprehensive format and believed that a decision aid could potentially improve patient experience and confidence in the overall process of initiating PTSD treatment. At the same time, providers had concerns regarding the accessibility of VA’s online decision aid for different patient subpopulations, such as older adults and those with limited digital or health literacy, and acceptability of the decision aid for women. When asked more broadly about adopting shared decision making as a clinical process, providers perceived shared decision making as potentially not a good fit for busy primary care settings due to time constraints. Providers expressed beliefs that they might reserve use of shared decision making for patients who already had strong motivation for treatment and trust in mental health providers.

To our knowledge, only one recently published study has examined provider perspectives on shared decision making for PTSD treatment (Etingen et al., 2020). This study conducted a survey among 12 mental health providers working in a VA PTSD specialty clinic after they underwent a one-hour training in shared decision making. The authors found that all providers believed shared decision making to be a valuable addition to clinical care, but they perceived time constraints to be a major barrier to adoption (even within standard 60-minute appointments in specialty care), very few knew how to integrate an evidence-based decision aid into the process, and almost all discussed non-evidence-based PTSD treatment options with their patients. Other mental health research suggests that mental health providers are generally supportive of using shared decision making, but unequal power dynamics and having negative perceptions of patients decrease the likelihood that shared decision making will occur with a given patient (Matthias et al., 2017). Qualitative studies of shared decision making for serious mental illness have identified similar themes to our theme 4, in which providers perceive only a subset of patients as well-suited to participate in shared decision making (Brooks et al., 2017; Fisher et al., 2017). When taken together with the findings of the present study, existing literature suggests a strong need to standardize provider presentation of treatment options, particularly balancing the promotion evidence-based treatments with providing a range of treatment options and ensuring that shared decision making is delivered equitably, rather than being driven by provider perceptions of patient characteristics.

This study’s findings suggest multiple avenues that may improve the adoption of shared decision making in integrated behavioral health settings based on the identified CFIR domains, such as intervention characteristics and individual characteristics. For intervention characteristics, reducing the complexity of existing decision aids through simplifying content, offering multiple media versions (e.g., online, smartphone, and paper), and/or offering coaching to patients on how to use decision aids to participate in shared decision making could help enhance accessibility. Decision aid images and content should reflect a range of patient experiences and ensure representation of minority groups—for instance, including images of women for veteran-centric materials. Simplifying the shared decision making process so that it fits easily into a brief integrated care appointment, e.g., using design-focused adaptation to increase intervention usability (Lyon et al., 2019), could help address provider acceptability and the concern about lack of time. In design-focused adaptation, it is particularly important to consider the implementation targets, such as the types of providers who would be implementing shared decision making and the types of appointments that would need to accommodate shared decision making. Within the primary care setting, it is likely that integrated care psychologists, social workers, and prescribers are best suited to lead shared decision making for PTSD treatment with patients, rather than nurses or primary care providers who have less familiarity with PTSD treatment. Within the trajectory of mental health care, shared decision making sessions may work best as a stand-alone, 30-minute follow-up appointment after the initial triage or intake, which is often used to establish preliminary diagnoses and assess for acute risk concerns.

With regards to characteristics of the individuals involved, provider beliefs about patients may be a significant barrier to address, given that the patient-provider relationship is the bedrock of shared decision making (Eliacin et al., 2015). Because shared decision making may improve patients’ perceptions of care (Alegria et al., 2018), providers who limit shared decision making to patients who demonstrate high motivation and trust may miss opportunities to improve relationships with their patients. The belief that shared decision making would be appropriate or effective for only motivated patients is similar to provider beliefs that only a subset of patients with PTSD are ready to participate in PTSD psychotherapies (Cook et al., 2017). Being selective about which patients should engage in shared decision making has the potential to limit patient knowledge and access to a range of PTSD treatment options (Osei-Bonsu et al., 2016). Some have advocated for direct-to-consumer marketing to directly inform patients about PTSD treatment options and to increase patient demand for evidence-based psychotherapies rather than relying on providers to effectively “sell” these treatments (Kehle-Forbes et al., 2020). Future research should explore the relative benefits of improving providers’ skill in engaging patients in PTSD care (such as training in shared decision making) versus direct-to-consumer marketing of PTSD treatments to patients and their families. Although we did not identify any themes related to the outer setting domain of the CFIR, interventions to change the organizational climate may also be needed to address provider attitudes and behavior (Kimberly & Cook, 2008; Sayer et al., 2017).

This study has several limitations. Our sample was recruited from a single VA healthcare system, and while we aimed to obtain a representative sample, these results may not be generalizable to other VA facilities or non-VA healthcare systems. We do not know if the factors that we identified as potential determinants to adopting shared decision making are associated with actual provider behavior. Provider attitudes are only one factor of many that influence successful implementation of new clinical practices. Providers in this study also offered several ideas that reflected their perceptions of patients and perceived patient barriers, but we do not know to what degree these provider perceptions match actual patient barriers to shared decision making. To our knowledge, there have been no studies of patient perspectives on shared decision making for PTSD treatment. There is limited existing information on the accessibility or acceptability of PTSD decision support tools. The one prior study of a decision support tool for PTSD that also reported patient demographics had a sample comprised primarily of white men (88%) (Watts et al., 2015), suggesting that future research should obtain the perspectives of a diverse group of patients.

In conclusion, providers believed that shared decision making and the use of a patient decision aid could help them provide high quality information to empower primary care patients with PTSD. However, it may be necessary to address barriers related to patient accessibility, time constraints, and provider perceptions of which patients are appropriate for different PTSD interventions before more routine adoption of shared decision making is possible.

Supplementary Material

1696683_SupAppendix

ACKNOWLEDGEMENTS

We would like to thank Dr. Juliette Harik at the National Center for PTSD for her input on study design and the providers and leadership at our participating sites for their contributions to this project.

Funding

This study was funded by a grant from the VA Puget Sound Research & Development Seed Grant Program (co-PIs: Chen & Williams) and additional support was provided by an NIMH R03 (co-PIs: Chen & Williams) from the University of Washington ALACRITY Center (P50 MH115837; PI: Areán). Dr. Chen is supported by a VA Health Services Research & Development Career Development Award (CDA 18–186).

Sources of support for this work had no involvement in or restrictions regarding publication. The content is solely the responsibility of the authors and does not necessarily represent the official views of Department of Veterans Affairs, the University of Washington, the National Institutes of Health, or Kaiser Permanente Washington Health Research Institute.

Footnotes

DECLARATIONS

Guidelines

This manuscript follows the qualitative guidelines (Standards for Reporting Qual Research) hosted by the EQUATOR Network.

Compliance with Ethical Standards

The authors have no conflicts of interest to disclose. Human subjects in this study were asked to provide verbal consent and permission to audio record the interview. This study is in compliance with ethical standards of research and was approved by the Institutional Review Board of VA Puget Sound. This study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Conflict of Interest

The authors declare that they have no conflict of interest.

Prior presentations

A preliminary version of these analyses was presented as a poster at the 2018 AcademyHealth Annual Research Meeting in Seattle, WA.

References

  1. Alegria M, Nakash O, Johnson K, Ault-Brutus A, Carson N, Fillbrunn M, Wang Y, Cheng A, Harris T, Polo A, Lincoln A, Freeman E, Bostdorf B, Rosenbaum M, Epelbaum C, LaRoche M, Okpokwasili-Johnson E, Carrasco M, & Shrout PE (2018). Effectiveness of the DECIDE Interventions on Shared Decision Making and Perceived Quality of Care in Behavioral Health With Multicultural Patients: A Randomized Clinical Trial. JAMA Psychiatry, 75(4), 325. 10.1001/jamapsychiatry.2017.4585 [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Atlas.ti (7.5.18). (n.d.). [Computer software]. GmBH.
  3. Bohnert KM, Sripada RK, Mach J, & McCarthy JF (2016). Same-Day Integrated Mental Health Care and PTSD Diagnosis and Treatment Among VHA Primary Care Patients With Positive PTSD Screens. Psychiatric Services, 67(1), 94–100. 10.1176/appi.ps.201500035 [DOI] [PubMed] [Google Scholar]
  4. Brooks H, Harris K, Bee P, Lovell K, Rogers A, & Drake R (2017). Exploring the potential implementation of a tool to enhance shared decision making (SDM) in mental health services in the United Kingdom: A qualitative exploration of the views of service users, carers and professionals. International Journal of Mental Health Systems, 11(1), 42. 10.1186/s13033-017-0149-z [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Cook JM, Simiola V, Hamblen JL, Bernardy N, & Schnurr PP (2017). The influence of patient readiness on implementation of evidence-based PTSD treatments in Veterans Affairs residential programs. Psychological Trauma: Theory, Research, Practice, and Policy, 9(Suppl 1), 51–58. pdh. 10.1037/tra0000162 [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, & Lowery JC (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science, 4, 50. 10.1186/1748-5908-4-50 [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Department of Veterans Affairs, & National Center for PTSD. (n.d.). PTSD Treatment Decision Aid. https://www.ptsd.va.gov/apps/decisionaid/
  8. DeViva JC (2014). Treatment utilization among OEF/OIF veterans referred for psychotherapy for PTSD. Psychological Services, 11(2), 179. 10.1037/a0035077 [DOI] [PubMed] [Google Scholar]
  9. Eliacin J, Salyers MP, Kukla M, & Matthias MS (2015). Patients’ understanding of shared decision making in a mental health setting. Qualitative Health Research, 25(5), 668–678. [DOI] [PubMed] [Google Scholar]
  10. Elwyn G, Frosch D, Thomson R, Joseph-Williams N, Lloyd A, Kinnersley P, Cording E, Tomson D, Dodd C, Rollnick S, Edwards A, & Barry M (2012). Shared decision making: A model for clinical practice. Journal of General Internal Medicine, 27(10), 1361–1367. 10.1007/s11606-012-2077-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Elwyn G, Scholl I, Tietbohl C, Mann M, Edwards AGK, Clay C, Légaré F, van der Weijden T, Lewis CL, Wexler RM, & Frosch DL (2013). “Many miles to go …”: A systematic review of the implementation of patient decision support interventions into routine clinical practice. BMC Medical Informatics and Decision Making, 13 Suppl 2(Suppl 2), S14. 10.1186/1472-6947-13-S2-S14 [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Etingen B, Hessinger JD, & Hunley HA (2020). Training providers in shared decision making for trauma treatment planning. Psychological Services. 10.1037/ser0000511 [DOI] [PubMed]
  13. Fereday J, & Muir-Cochrane E (2006). Demonstrating Rigor Using Thematic Analysis: A Hybrid Approach of Inductive and Deductive Coding and Theme Development. International Journal of Qualitative Methods, 5(1), 80–92. 10.1177/160940690600500107 [DOI] [Google Scholar]
  14. Finley EP, Garcia HA, Ramirez VA, Haro EK, Mignogna J, DeBeer B, & Wiltsey-Stirman S (2020). Treatment selection among posttraumatic stress disorder (PTSD) specialty care providers in the Veterans Health Administration: A thematic analysis. Psychological Trauma: Theory, Research, Practice, and Policy, 12(3), 251–259. 10.1037/tra0000477 [DOI] [PubMed] [Google Scholar]
  15. Fisher A, Manicavasagar V, Sharpe L, Laidsaar-Powell R, & Juraskova I (2017). A Qualitative Exploration of Clinician Views and Experiences of Treatment Decision-Making in Bipolar II Disorder. Community Mental Health Journal, 53(8), 958–971. 10.1007/s10597-016-0077-4 [DOI] [PubMed] [Google Scholar]
  16. Friedberg MW, Van Busum K, Wexler R, Bowen M, & Schneider EC (2013). A Demonstration Of Shared Decision Making In Primary Care Highlights Barriers To Adoption And Potential Remedies. Health Affairs, 32(2), 268–275. 10.1377/hlthaff.2012.1084 [DOI] [PubMed] [Google Scholar]
  17. Hessinger JD, London MJ, & Baer SM (2018). Evaluation of a Shared Decision-Making Intervention on the Utilization of Evidence-Based Psychotherapy in a VA Outpatient PTSD Clinic. Psychological Services, 15(4), 437–441. psyh. 10.1037/ser0000141 [DOI] [PubMed] [Google Scholar]
  18. Joosten EA, DeFuentes-Merillas L, De Weert G, Sensky T, Van Der Staak C, & de Jong CA (2008). Systematic review of the effects of shared decision-making on patient satisfaction, treatment adherence and health status. Psychotherapy and Psychosomatics, 77(4), 219–226. [DOI] [PubMed] [Google Scholar]
  19. Karlin BE, & Brenner LA (2020). Improving engagement in evidence-based psychological treatments among Veterans: Direct-to-consumer outreach and pretreatment shared decision-making. Clinical Psychology: Science and Practice. 10.1111/cpsp.12344 [DOI]
  20. Kehle-Forbes SM, Gerould H, Polusny MA, Sayer NA, & Partin MR (2020). “It leaves me very skeptical” messaging in marketing prolonged exposure and cognitive processing therapy to veterans with PTSD. Psychological Trauma: Theory, Research, Practice, and Policy. 10.1037/tra0000550 [DOI] [PMC free article] [PubMed]
  21. Kimberly J, & Cook JM (2008). Organizational Measurement and the Implementation of Innovations in Mental Health Services. Administration and Policy in Mental Health and Mental Health Services Research, 35(1–2), 11–20. 10.1007/s10488-007-0143-x [DOI] [PubMed] [Google Scholar]
  22. King N (2004). Chapter 21: Using templates in the thematic analysis of text. In Cassell C & Symon G (Eds.), Essential guide to qualitative methods in organizational research (pp. 256–287). SAGE Publications. [Google Scholar]
  23. Légaré F, Ratté S, Gravel K, & Graham ID (2008). Barriers and facilitators to implementing shared decision-making in clinical practice: Update of a systematic review of health professionals’ perceptions. Patient Education and Counseling, 73(3), 526–535. 10.1016/j.pec.2008.07.018 [DOI] [PubMed] [Google Scholar]
  24. Légaré F, Stacey D, Pouliot S, Gauvin F-P, Desroches S, Kryworuchko J, Dunn S, Elwyn G, Frosch D, Gagnon M-P, Harrison MB, Pluye P, & Graham ID (2011). Interprofessionalism and shared decision-making in primary care: A stepwise approach towards a new model. Journal of Interprofessional Care, 25(1), 18–25. 10.3109/13561820.2010.490502 [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Lyon AR, Munson SA, Renn BN, Atkins DC, Pullmann MD, Friedman E, & Areán PA (2019). Use of Human-Centered Design to Improve Implementation of Evidence-Based Psychotherapies in Low-Resource Communities: Protocol for Studies Applying a Framework to Assess Usability. JMIR Research Protocols, 8(10), e14990. 10.2196/14990 [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Magruder KM, Frueh BC, Knapp RG, Davis L, Hamner MB, Martin RH, Gold PB, & Arana GW (2005). Prevalence of posttraumatic stress disorder in Veterans Affairs primary care clinics. General Hospital Psychiatry, 27(3), 169–179. [DOI] [PubMed] [Google Scholar]
  27. Matthias MS, Fukui S, & Salyers MP (2017). What Factors are Associated with Consumer Initiation of Shared Decision Making in Mental Health Visits? Administration and Policy in Mental Health and Mental Health Services Research, 44(1), 133–140. 10.1007/s10488-015-0688-z [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Mott JM, Stanley MA, Street RL, Grady RH, & Teng EJ (2014). Increasing engagement in evidence-based PTSD treatment through shared decision-making: A pilot study. Military Medicine, 179(2), 143. 10.7205/MILMED-D-13-00363 [DOI] [PubMed] [Google Scholar]
  29. O’Connor AM, Bennett CL, Stacey D, Barry M, Col NF, Eden KB, Entwistle VA, Fiset V, Holmes-Rovner M, Khangura S, & others. (2009). Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews, 3. 10.1002/14651858.CD001431.pub2 [DOI] [PubMed]
  30. Osei-Bonsu PE, Bolton RE, Wiltsey Stirman S, Eisen SV, Herz L, & Pellowe ME (2016). Mental health providers’ decision-making around the implementation of evidence-based treatment for PTSD. The Journal of Behavioral Health Services & Research, 44(2), 213–223. psyh. 10.1007/s11414-015-9489-0 [DOI] [PubMed] [Google Scholar]
  31. Palinkas LA (2014). Qualitative and Mixed Methods in Mental Health Services and Implementation Research. Journal of Clinical Child & Adolescent Psychology, 43(6), 851–861. 10.1080/15374416.2014.910791 [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Palinkas LA, Horwitz SM, Green CA, Wisdom JP, Duan N, & Hoagwood K (2015). Purposeful Sampling for Qualitative Data Collection and Analysis in Mixed Method Implementation Research. Administration and Policy in Mental Health and Mental Health Services Research, 42(5), 533–544. 10.1007/s10488-013-0528-y [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Possemato K, Shepardson RL, & Funderburk JS (2018). The Role of Integrated Primary Care in Increasing Access to Effective Psychotherapies in the Veterans Health Administration. FOCUS, 16(4), 384–392. 10.1176/appi.focus.20180024 [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Raue PJ, Schulberg HC, Bruce ML, Banerjee S, Artis A, Espejo M, Catalan I, & Romero S (2019). Effectiveness of Shared Decision-Making for Elderly Depressed Minority Primary Care Patients. The American Journal of Geriatric Psychiatry, 27(8), 883–893. 10.1016/j.jagp.2019.02.016 [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Sayer NA, Rosen CS, Bernardy NC, Cook JM, Orazem RJ, Chard KM, Mohr DC, Kehle-Forbes SM, Eftekhari A, Crowley J, Ruzek JI, Smith BN, & Schnurr PP (2017). Context Matters: Team and Organizational Factors Associated with Reach of Evidence-Based Psychotherapies for PTSD in the Veterans Health Administration. Administration and Policy in Mental Health and Mental Health Services Research, 44(6), 904–918. 10.1007/s10488-017-0809-y [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Sepucha KR, Simmons LH, Barry MJ, Edgman-Levitan S, Licurse AM, & Chaguturu SK (2016). Ten Years, Forty Decision Aids, And Thousands Of Patient Uses: Shared Decision Making At Massachusetts General Hospital. Health Affairs, 35(4), 630–636. 10.1377/hlthaff.2015.1376 [DOI] [PubMed] [Google Scholar]
  37. Slade M (2017). Implementing shared decision making in routine mental health care. World Psychiatry, 16(2), 146–153. 10.1002/wps.20412 [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Spoont MR, Murdoch M, Hodges J, & Nugent S (2010). Treatment Receipt by Veterans After a PTSD Diagnosis in PTSD, Mental Health, or General Medical Clinics. Psychiatric Services, 61(1), 58–63. 10.1176/ps.2010.61.1.58 [DOI] [PubMed] [Google Scholar]
  39. VA/DoD, (Department of Veterans Affairs/Department of Defense). (2017). VA/DoD Clinical practice guideline for the management of posttraumatic stress and acute stress disorder. Washington, DC: Veterans Health Administration, Department of Defense. http://www.healthquality.va.gov/guidelines/MH/ptsd/cpgPTSDFULL201011612c.pdf [Google Scholar]
  40. Watts BV, Schnurr PP, Zayed M, Young-Xu Y, Stender P, & Llewellyn-Thomas H (2015). A randomized controlled clinical trial of a patient decision aid for posttraumatic stress disorder. Psychiatric Services, 66(2), 149–154. 10.1176/appi.ps.201400062 [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

1696683_SupAppendix
NIHMS1696683-supplement-1696683_SupAppendix.docx (16KB, docx)

RESOURCES