John W. Williams Jr., M.D.
Professor of Medicine and Psychiatry
Duke University School of Medicine

As a person living with a mental health condition, would you want your physician or other healthcare provider (HCP) making healthcare decisions on your behalf without any regard for your personal preferences, values, or needs? If you’re like most people, you’d prefer to be involved in choosing the care that’s right for you. After all, it’s your body, your mind, your financial resources, and your life.

Shared decision making, or SDM, is a process through which you and your HCP make decisions together, as partners. It’s a common sense concept: you discuss the things that matter to you, your HCP provides information and then works with you to choose the best treatment for you.

This idea is particularly important when it comes to mental health care. Conditions like depression can be treated in many ways, but people living with mood disorders are often unaware of different options and different stages of treatment. Using SDM, a person living with depression learns about which treatments are available and can make a choice that best suits them. Understanding this process and actively asking for this kind of personal attention from your healthcare providers will allow you to be more engaged and invested in your healthcare.

Why shared decision making matters
Healthcare providers can best understand a person’s priorities when they hear the person living with the mental health condition actively expresses their values, desires, and concerns. People get better care and doctors get better at their jobs. Everyone wins.

Shared decision making improves patients’ experience, knowledge, confidence, and ability to make decisions. They also have less decisional regret. It represents the future—patient-centric care—in which HCPs are respectful of and responsive to the preferences, needs, and values of each patient as an individual.

Patients know their own needs
Doctors may know a lot about medicine but, as the person seeking treatment, you’re the only expert on your personal values and needs. Your input matters most when it comes to deciding on how you should be treated.

When discussing treatment options for depression, your provider should be asking you a lot of questions. If medication is warranted, are you concerned about specific side effects? Are you willing to change your daily routine or lifestyle? What really matters to YOU when it comes to getting better? And how do you define your own wellness? These are crucial questions and only you can answer them.

Without having these important details about you, your provider is likely to prescribe a standard treatment that doesn’t take your individual situation into account. In current practice, many primary care physicians do not consider patient preferences when making treatment recommendations for depression. As a result, there may be a mismatch between the preferred and the prescribed treatment.

When should you expect shared decision making?
It’s not realistic to expect SDM to come into play in every medical situation. For example, if you come to the emergency department in the throes of a heart attack, the physician on duty will probably give you an aspirin to chew. The treatment risk from the aspirin is low, the potential benefits are high, the time window to take action is narrow, and almost all informed patients would want the aspirin. In that case, discussing your personal needs and values isn’t really necessary.

If you’re talking with your provider about Major Depressive Disorder, however, there are several possible care options, even for unremitting depression. Each treatment might potentially be effective alone or in combination, and each has other impacts on your life, whether due to side effects, inconvenience of frequency or geography, or time until treatment is effective.

In scenarios like this where there are many treatment choices and more time to consider these options, you deserve to have a provider who will walk you through the decision making process, enabling you to make a choice that aligns with your treatment goals, preferences, and priorities.

How patients can make shared decision making happen
If your doctor hasn’t engaged you in SDM, bring it up. Tell them that you’d like to be involved in understanding what your options are for making important healthcare decisions together. If a provider declines your request for SDM, consider how well your needs are being met overall before making any decision to change HCPs. Ask why she or he is opposed to including you in the process. Fortunately, more providers are learning about this process and putting it into practice.

The future is patient-centric care
SDM isn’t the norm. Things are improving, but there are many challenges ahead. The Comprehensive Primary Care (CPC) initiative—a multi-payer quality improvement initiative designed to deliver comprehensive primary care—offers bigger payments for doctors who engage in shared decision making. Financial incentives, recommendations for SDM from guideline panels, and increased training during medical school and residency should increasingly make this kind of care more available.

People seeking or undergoing treatment need to speak up. When it comes to your physical and/or mental health, you deserve nothing less than a provider who will educate you, listen to you, and offer suggestions responsive to your individual needs. As healthcare consumers, the more you ask for shared decision making, the faster it will happen.


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