Treichler Emily B H, Rabin Borsika A, Cohen Amy N, Light Gregory A
From the Departments of Psychiatry (Drs. Treichler and Light) and Family Medicine and Public Health (Dr. Rabin), and Dissemination and Implementation Science Center, Altman Translational Research Institute (Dr. Rabin), University of California San Diego; VA Desert Pacific Mental Illness Research, Education, and Clinical Center (MIRECC), San Diego, CA (Drs. Treichler and Light); Center of Excellence in Stress and Mental Health, San Diego VA, La Jolla, CA (Dr. Rabin); American Psychiatric Association, Los Angeles, CA (Dr. Cohen).
Harv Rev Psychiatry. 2021;29(5):361-369. doi: 10.1097/HRP.0000000000000304.
Shared decision making in mental health is a priority for stakeholders, but faces significant implementation barriers, particularly in settings intended to serve people with serious mental illnesses (SMI). As a result, current levels of shared decision making are low. We highlight these barriers and propose that a novel paradigm, collaborative decision making, will offer conceptual and practical solutions at the systemic and patient/clinician level. Collaborative decision making is tailored for populations like people with SMI and other groups who experience chronic and complex symptoms, along with power imbalances within health systems. Advancing from shared decision making to collaborative decision making clarifies the mission of the model: to facilitate an empowering and recovery-oriented decision-making process that assigns equal power and responsibility to patients and clinicians; to improve alignment of treatment decisions with patient values and priorities; to increase patient trust and confidence in clinicians and the treatment process; and, in the end, to improve treatment engagement, satisfaction, and outcomes. The primary purpose of collaborative decision making is to increase values-aligned care, therefore prioritizing inclusion of patient values, including cultural values and quality of life-related outcomes. Given the broad and constantly changing context of treatment and care for many people with SMI (and also other groups), this model is dynamic and continuously evolving, ready for use across diverse contexts. Implementation of collaborative decision making includes increasing patient knowledge but also patient power, comfort, and confidence. It is one tool to reshape patient-clinician and patient-system relationships and to increase access to value-aligned care for people with SMI and other groups.
心理健康领域的共同决策是利益相关者的优先事项，但面临重大的实施障碍，尤其是在旨在为严重精神疾病（SMI）患者提供服务的环境中。因此，当前共同决策的水平较低。我们强调这些障碍，并提出一种新的模式——协作决策，将在系统层面以及患者/临床医生层面提供概念性和实用性的解决方案。协作决策是为患有严重精神疾病的人群以及其他经历慢性和复杂症状的群体量身定制的，同时也考虑到卫生系统内部的权力不平衡问题。从共同决策推进到协作决策，明确了该模式的使命：促进一个赋权且以康复为导向的决策过程，赋予患者和临床医生平等的权力和责任；使治疗决策与患者的价值观和优先事项更加契合；增强患者对临床医生和治疗过程的信任与信心；最终改善治疗参与度、满意度和治疗效果。协作决策的主要目的是增加符合价值观的护理，因此将纳入患者价值观作为优先事项，包括文化价值观和与生活质量相关的结果。鉴于许多患有严重精神疾病的人（以及其他群体）的治疗和护理背景广泛且不断变化，这种模式是动态的且不断发展，随时可在不同背景下使用。协作决策的实施包括增加患者的知识，同时也包括增强患者的权力、舒适度和信心。它是重塑患者与临床医生以及患者与系统关系的一种工具，可增加患有严重精神疾病的人和其他群体获得符合价值观护理的机会。
