Development of Shared Decision Making
Interventions in Primary Care for Adults
with Depression
15th March 2013
Darren Flynn Senior Research Associate
Institute of Health and Society (Decision Making and Organisation of Care
Group), Newcastle University
Tel: 0191 222 5415
Email: [email protected]
Research Team
• Richard Thomson (Professor of Epidemiology & Public Health), IHS, Newcastle University
• Jan Scott (Professor of Psychological Medicine), Institute of Neuroscience, Newcastle University
• Mary-Jane Tacchi (Consultant Psychiatrist), Crisis Assessment & Treatment Service, NTW Foundation Trust
• Vera Araujo-Soares (Senior Lecturer in Health Psychology), IHS, Newcastle University
• Dave Tomson (GP), Collingwood Health Group, North Shields
• Luke Vale (Health Foundation Chair in Health Economics, Deputy Director), IHS, Newcastle University
• Jane Noble (Mental Health Service User Development Worker, North Tyneside PCT)
• Sandra Hutton (Patient Involvement Lead, Patient and Carer Engagement Team, NTW Foundation Trust
• Alison Chalmers (FMS, Engagement Support Co-ordinator)
• Alison Etherington (Administrative support)
What is Shared Decision Making (SDM)? SDM is a process in which people are:
1. involved as active partners with clinicians
2. in clarifying acceptable options for treatment
3. and choosing a preferred option that is consistent with their preferences and values
When is SDM Appropriate?
• ‘preference-sensitive’ healthcare decisions:
– More than one reasonable treatment option – Options have different ‘trade-offs’ between possible benefits, risk of
adverse effects and consequences
• When people with long-term conditions want to plan their care, adopt healthier lifestyles, and enhance their ability to self-manage their condition
• For the great majority of mental health
conditions
There are real choices between therapeutic
options, which are sensitive to individuals’
preferences and values in many ways:
• varying individual preferences for different medical
or psychological interventions (and self-
management strategies)
• different trade-offs between potential benefits,
unwanted side effects and consequences, which
individuals are likely to value differently
– e.g., several types of medication can help reduce anxiety, although there are
different trade-offs with risks of unwanted side-effects of different medications
• Only a third (34%) of service users who responded
to a survey were “definitely” involved as much as
they wanted to be in decisions about their care and
treatment
– Mental Health Acute Inpatient Service Users Survey
2009
• Around a quarter of service users who were
prescribed new medication said that they were not
told about the possible side effects.
– Community Mental Health Survey 2011
Potential Benefits of SDM in Mental Health
• Supporting empowerment and autonomy
• Enhancing adherence to treatment/care plans
SDM is a core component of service improvement
agenda for mental health
• New Horizons
• No Health Without Mental Health
• NICE Quality Statements: Service User Experience in Adult Mental Health
Compared with physical healthcare - little research on
SDM in mental health
More research needed to inform how best to support
implementation of SDM in mental healthcare
Developing Shared Decision Making Interventions in
Primary Care for Adults with Depression
Overview of Development Work
Development work packages (supported by joint RCF from NTW
and NHS North of Tyne) to inform a future research application to
the NIHR:
Focus on development and evaluation of interventions to:
1. enhance the capability/willingness of adults with depression, their
carers and clinicians to engage in SDM in primary care settings
2. support the implementation of SDM within the primary care pathway
for adults with depression that impact positively on recovery-focused
outcomes
• and are cost-effective to implement
Research Application to the NIHR
Exploratory Work
(engagement exercise with
public, service users, carers
and clinicians)
Public, Service
User/Carer Involvement
Strategy
Development of educational
DVD (and supplementary
material)
Scoping Review of Secondary Research
Advisory and reference
group
Development
Work Packages
• Scoping review of secondary research
– to develop a draft classification system (taxonomy) of
interventions targeting engagement of adults with depression in
decision making about available therapeutic options with clinicians
(once it has been established that presenting symptoms are
depression)
– Inform a protocol/search strategy for a review of primary research
evidence (future application for funding)
• Convening an advisory and reference group
– clinicians, representatives from service user/carer organisations,
service commissioners and other experts (national and
international)
– challenge forum for the preparatory work and critique application
to NIHR
Adult with Suspected Depression
1. Step one: Assessment and advice - development of a shared understanding of assessment, symptoms / severity / other co-
existing mental/physical health conditions, prior to discussing available therapeutic options
2. Initial Management
Step two: Therapeutic Options
• Supported self-management • choice of self-management option
• Low-intensity psychosocial interventions o Choice of LIPI; e.g., Guided self-help - based on Cognitive
Behavioural Therapy (CBT)
• Medication (where indicated) • choice of medication
Step three: Therapeutic Options
• Medication • choice of medication
• High-intensity psychosocial interventions o Choice of HIPI; e.g., CBT (individual or group-based)
• Combined medication and selected high-
intensity psychosocial interventions
Complex and severe depression;
significant risk of
self-harm / suicide
5. Step four: referral to secondary
care / specialist mental health
services (approx.’ 10% of people)
3. what are the therapeutic
options if initial
management is not
helping?
Access Point (GP, IAPT self-
referral, community)
4. what are the therapeutic
options if initial
management is helping?
Mild
to
mo
dera
te d
ep
ressio
n;
mo
dera
te a
nd
severe
dep
ressio
n (
ap
pro
x.’ 9
0%
of
peo
ple
)
NB: this is an ‘ideal’ primary care pathway based on NICE Guidelines
Decision points across the
care pathway (GP and IAPT
services), which are sensitive
to the preferences and values
of primary care service
users/carers
• Discussion Questions
– What are the key issues at each decision point across the
primary care pathway for depression?
– Where would involving primary care service users/carers
in decision making across the care pathway for
depression make a difference to recovery?
– What changes are needed to the primary care pathway for
depression to support shared decision making?
– What training / support would be needed for clinicians and
service users/carers in primary care to participate in
shared decision making?
– What order that should we develop interventions to
support shared decision making at specific points across
the primary care pathway?
Advisory and Steering Group
Public, Service User / Carer Steering Group
Service User Representatives
(supported by DF/AC)
Steering Group
Members
Research Team
OUTPUTS
Public, Service User / Carer
Steering Group
o Aims and objectives
o Meetings (location, frequency, ground
rules)
o Ways of working / support needs
o Training and development
o Reimbursement / expenses
• We are seeking
expressions of interest
Development of educational
DVD and other materials
Emergent roles: o Co-applicant on research application
to NIHR
o Service-user/carer researcher(s) /
trainer(s)
Public, Service User/Carer Involvement Strategy
Educational DVD and Supplementary Materials
• Short educational DVD (10 mins) and supplementary materials (posters and
leaflets) ideally public, service-user / carer led
• We are actively seeking expressions of interest
Aim:
• to inform the public / primary mental health service users with depression, their carers,
healthcare providers and commissioners on the existence, guiding principles and
potential benefits of implementing SDM in primary mental health care
• DVD could feature primary care mental health service user/carer narratives
• facilitating the development of knowledge and understanding on how they make
choices based on what is important to them - i.e., their preferences and values
Example of themes that could be included in the DVD:
• What is SDM, why it is important and what are the potential benefits?
• Importance of involving carers in the SDM process
• Information needs, including what is important to them when weighing up the pros and
cons of the available therapeutic options