Commentary: Shared Decision Making Must Be Adopted, Not Adapted

In their Open Forum, Dr. Hamann and Dr. Heres (1) discuss limited adoption of shared decision making in psychiatric services. They propose SDM-PLUS, a platform that might help speed adoption. In their model, three types of decisions are delineated: life-and-death decisions, best-choice decisions, and preference-sensitive decisions. According to the model, preference-sensitive decisions require classic shared decisions, whereas life-and-death decisions fall outside the purview of shared decision making. The third category—best-choice decisions—is for people who clinicians anticipate will resist medication treatment, such as those with psychotic disorders or those who lack insight. In these situations, the authors believe clinicians should choose the best option for the individual. Furthermore, the authors suggest that motivational interviewing and other interventions that support behavior change can be used to help achieve adherence.

I would argue that we do not need an adaptation of shared decision making for behavioral health care. Legal statutes already exist to guide proxy decision making in situations of decision incapacity and psychiatric emergencies. Similarly, introducing a category of best-choice decisions brings us back to the paternalism that shared decision making seeks to avoid. It also reintroduces a familiar form of circular clinical reasoning. That is, if the client is compliant, then shared decision making is a virtue; but when there is disagreement about the course of treatment, the person lacks insight and shared decision making is risky. SDM-PLUS also confounds decision support interventions (shared decision making and decision aids) with behavior change support interventions, such as motivational interviewing. These are two distinct classes of interventions with different aims and should not be merged (2,3).

Rather than adapting shared decision making, we must focus on helping our field adopt it. Learning to use psychiatric medications to support recovery is a journey that often takes time. Along the way, people face many preference-sensitive decisions, including the decision to have electroconvulsive therapy or psychosurgery, the decision to use psychiatric medication during pregnancy, the decision to return to work or school, and the decision to use psychiatric medications. These are not just medical decisions. They are also personal decisions that have a profound impact on individuals’ lives. Psychiatric medications can be effective. However, they also can be harmful and ineffective for some people. Using antipsychotics is not always a best-choice decision. Individuals must have a voice and a choice in such decisions.

As we learned in the CATIE study, decision incapacity is the exception rather than the rule, even among people with psychotic conditions (4). We should, therefore, expect that when faced with preference-sensitive decisions in behavioral health care, most people will participate in shared decision making if the care pathway is carefully designed to support it.

Designing the infrastructure to support routine use of shared decision making holds promise for more widespread adoption of the practice. Training alone is usually not sufficient to achieve adoption of a new practice. More significant adoption results when training is reinforced through on-site coaching, determined leadership, and alignment of funding resources (5). Might it be possible for clinicians who engage in shared decision making to bill at higher rates on the basis of the complexity of the visit? In addition, technology and other decision support strategies should be easily accessible, with some used during the consultation and others used prior to it or even from home. Finally, brief measures of shared decision making are becoming available that can help leadership teams gauge the success of their adoption efforts and make adjustments as needed.