Results Summary
What was the research about?
Shared decision making is a process in which patients work with their doctors to select tests and treatments based on what is most important to them. Shared decision making is uncommon in community mental health clinics.
In this study, the research team created a program to support shared decision making for patients with mental illness. The team wanted to learn if patients with mental illness who received treatment from community clinics that used the program
- Understood their treatment options
- Became more involved with treatment decision making
- Felt more satisfied with treatment decisions and with communication with their doctor
- Had improved progress in response to treatment, quality of life, and mental and physical health
- Felt more support during therapy
What were the results?
The study found no differences between patients in clinics that used the program and those in clinics that did not use the program in
- Satisfaction with treatment decisions
- Communication with doctors
- Involvement in decision making
- Treatment progress
- Quality of life
However, of patients who completed interviews after the study, 94 percent said they had some benefit from taking part in the program. These benefits included improved self-esteem and feeling more involved in their care.
Who was in the study?
The study included 240 patients from four community mental health clinics. Two of the clinics were in a city in California, and two were in rural New Mexico. Of the patients, 53 percent were female, 55 percent were white, and 26 percent were Hispanic. The average patient age was 58.
What did the research team do?
The team assigned the program to one of the urban clinics and one of the rural clinics by chance. Sixty patients at each clinic took part in the study.
All patients in the study received their usual mental health care. The patients took a survey at the start of the study and again every six months for two years. The survey asked about patients’ satisfaction with treatment decisions, communication with doctors, involvement in decision making, treatment progress, and quality of life. The research team also interviewed patients in the program at the end of the study or if they left the study early.
What were the limits of the study?
The mental health clinics that used the shared decision making program had challenges that affected the study. Staff did not always carry out the program, and many staff members left their jobs during the study. Patients at the clinics that did and didn’t use the program differed in age, race, ethnicity, and other social factors. The results may have been different if more and better matched clinics took part in the study.
Future research could compare the shared decision making program to regular care in larger studies with better matched clinics.
How can people use the results?
Patients said the program improved their self-esteem and made them feel more involved in their care. Community health clinics may be interested in further exploring shared decision making with their patients.
Professional Abstract
Objective
To compare the effectiveness of a community mental health-based shared decision making program called Moving Patient Outcomes toward Wellness and Recovery (mPOWR) to standard community-based mental health care.
Study Design
| Design Elements | Description |
|---|---|
| Design | Quasi-experimental |
| Population | 240 adults with mental illness |
| Interventions/ Comparators |
|
| Outcomes |
Primary: decision satisfaction, communication satisfaction, patient involvement in shared decision making, perceived therapeutic support Secondary: treatment progress, general quality of life, mental and physical health |
| Timeframe | 24-month follow-up for primary outcomes |
The research team conducted a quasi-experimental evaluation of a shared decision making program, called mPOWR, for patients with mental illness being treated in community clinics. In shared decision making, patients are active partners in deciding their treatment with their clinicians. mPOWR is a package of shared decision making approaches, decision aids, and implementation guidance for clinicians that aims to help patients communicate their preferences and values, identify available service options, and participate in informed decision making about their care. The study’s primary outcomes were decision satisfaction, communication satisfaction, patient involvement in shared decision making, and perceived therapeutic support. Secondary outcomes were treatment progress, general quality of life, and mental and physical health.
The research team compared one urban and one rural community mental health clinic with a similar urban and rural community mental health clinic that did not employ the intervention. Researchers recruited patients from two clinics in urban California and two in rural New Mexico. In this study, 53% of patients were female, 55% were white, and 26% were Hispanic. The average patient age was 58.
At the start of the study, the research team randomly assigned one urban clinic and one rural clinic to the intervention. From a pool of eligible patients, the team randomly selected 60 patients at each clinic to participate.
The research team administered questionnaires at the beginning of the study and every six months for two years. Patients at all clinics received their standard mental health care during the study. Those at the two intervention sites also received the mPOWR program. The team conducted exit interviews with 77 patients in the intervention groups.
Results
Patients at the intervention clinics did not show greater improvement in the study outcomes than those at the control clinics. However, 94% of patients who completed the qualitative exit interviews said they received some benefit from participating in mPOWR, including improved self-esteem and feeling more involved or connected.
Limitations
The study encountered several challenges, including difficulties with buy-in among staff and high staff turnover at the intervention clinics. Patients at control and intervention clinics differed substantially in age, race, ethnicity, and other social factors, which made it difficult to distinguish treatment effects from the effects of confounding factors.
Conclusions and Relevance
The mPOWR intervention did not lead to greater improvements in primary study outcomes compared with standard community-based mental health care. However, exit interview results suggest that patients at community mental health clinics may benefit from participating in shared decision making interventions like mPOWR.
Future Research Needs
Future research could investigate ways to successfully integrate shared decision making interventions like mPOWR into treatment practices at community mental health clinics and test their effectiveness.
Final Research Report
View this project's final research report.
Peer-Review Summary
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also confirms that the research has followed PCORI’s Methodology Standards. During peer review, experts who were not members of the research team read a draft report of the research. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. Reviewers do not have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve how the research team analyzed its results or reported its conclusions. Learn more about PCORI’s peer-review process here.
In response to peer review, the PI made changes including
- Describing how the decision aids evaluated in this study aligned with accepted standards established in the International Patient Decision Aids Standards. Reviewers noted that some components of the mPOWR intervention that focused on quality of life rather than medical decision making, but the researchers did indicate which standards were applicable to which parts of the decision aid.
- Specifying which of the many outcome measures were the primary outcomes on which the conclusions were based. The reviewers had found it difficult to determine which outcomes were most important in this research, and which should be considered more exploratory.
- Elaborating on the content of the shared decision making system and decision aids by including copies of the protocol and tools in an appendix. The draft report lacked specific information about these tools, making it difficult to evaluate the scientific quality of the intervention results.
- Expanding on study limitations to consider whether the intervention itself caused some barriers to uptake by clients. This was based on reviewer recommendations responding to the high rates of both incomplete implementation of the intervention, and high patient drop-out from the intervention.
Finally, while reviewers argued that the researchers could have used a simpler statistical approach given the small sample size and high dropout rate, they appreciated the clear presentation of study results, which showed that the decision aid did not improve primary or secondary outcomes relative to usual care.
Conflict of Interest Disclosures
Project Information
Key Dates
Study Registration Information
^Shobha Pais, MS, PhD, and Erika Van Buren, PhD, were the original principal investigators for this project.