Using Decision Aids in Depression Treatment: An Update

Susan Weinstein, Editor in Chief
Care for Your Mind

Shared decision making (SDM) is a process requiring accurate information, communication skills, and flexibility. Providers can use decision aids to inform and engage patients and their families. Are they helping?

In October 2016, Dr. Juan Brito Campana and Dr. Annie LeBlanc from the Mayo Clinic Knowledge and Evaluation Research Unit made the case on Care for Your Mind that “decision aids” helped providers to engage in meaningful conversation with patients’ to choose the treatment that best matches their preferences, priorities, and goals. In other words, decision aids – basically, communication facilitation tools – help providers, patients, and families (where appropriate) succeed in shared decision making.

SDM doesn’t happen by itself, but can easily enough (and should) become a part of everyday practice. As noted in the earlier post, “decision aids are not sufficient … to promote SDM, but effective ones could really help SDM become more feasible.” In the case of depression, the Mayo Clinic’s aid is depression medication choice. What has happened since that post? Here we provide an update.

From the previous post:

[I]f we want SDM to become the norm in exam rooms nationwide, we have to support clinicians by giving them the means to make it happen. We can do this by providing tools that allow physicians to communicate effectively and engage in meaningful conversations about their patients’ preferences, needs, and values.

… If the clinicians use the decision aids and the conversation flows, we generally consider the aid a success. … Overall, we look for signs of engagement: body language, patient response, length of conversation, etc. … A key marker is the ability of the patient to try the treatment options on for size and fit, like clothes at a shop. Patients may ask questions or make statements to that effect: “So if I do X now, I may be able to do Y later?”

The quality of the decision making process has significant consequences with regard to treatment experience and treatment outcomes. What is happening in the field?

Less than a month ago, the clinical trials database posted a study being undertaken in Quebec by Dr. LeBlanc and others, continuing to evaluate the potential impact of health professionals and patients using the Depression Medication Choice decision aid during clinical encounters as it relates to the quality of the decisional process and health issues important to the patient and health professional. We look forward to continued progress on this study.

Another decision aid, “decision making in depression,” available through PyDeSalud.com (Spanish language), has been tested in Spain. There, the research team led by Lilisbeth Perestelo‐Perez found the decision aid to be helpful in decreasing uncertainty in decision making (also known as “decisional conflict”) and increasing the patients’ knowledge of treatment options. Although the decision aid improved the process of shared decision making, it is not yet clear that the decision aid or the process actually result in agreement between patients’ goals and their choice of treatment.

From the previous post:

Certainly it takes more time to implement SDM in an initial visit but, following that, the doctor and patient may have laid the groundwork for quicker follow-up care. With depression, for example, once a patient has seen the decision aid, he or she will be educated on the different medication options. From there, a follow-up visit to solve the problem of intolerance or inefficacy of a drug could be quickly addressed by revisiting the tool. We don’t have enough data — yet — to say for sure that aids increase efficiency, but we suspect the evidence will bear that out.

Does use of a decision aid increase the consultation appointment time? From the studies so far, the answer appears to be that it does not.

A study regarding use of a decision aid for depression patients in primary practice in Germany concluded that the decision aid supported physician facilitation of patient participation. There, they found improvement only in the intervention group (i.e., not the control group) with regard to

  • doctor facilitation of patient participation
  • patient-rated involvement
  • physician assessment of adherence.

They also found that patient satisfaction at post-intervention yielded a higher level of improvement in the intervention group. Importantly, the consultation time did not differ between the intervention and control groups.

A review of research studies in 2018 found that “Decision aids can improve clinicians’ satisfaction with medical decision making and provide helpful information without affecting length of consultation time.”

From the previous post:

In terms of clinical outcomes, it’s challenging to measure the value of these aids. We don’t expect depression severity to decrease with the use of a medication decision aid, for example, but it can help a patient find the best drug for their personal circumstance—and feel more confident about their choice. It may follow (although the evidence is not yet in) that when patients select their approach, it is more likely to fit their context and preferences, thereby enhancing adherence, and therefore effectiveness. This, of course, would not be a benefit of the patient using the decision aid, but of the SDM conversation supported by that tool.

The March 2018 review by Ludovic Samalin et al., noted that the studies that they reviewed strongly indicate that use of decision aids had positive effects in patient satisfaction and engagement in the decision-making process and that all of those studies showed significant improvement in depression outcomes or medication adherence.

From the previous post:

In all, we have to continue advocating for patient-centered care, training of clinicians and patients for mutual engagement, development of evidence-based and effective decision aids, and systematically removing policy and health care organizational barriers that interfere with meaningful doctor-patient conversations. Only then will we see shared decision making become the standard of care.

We couldn’t agree more!

What do you think?

What has been your experience in using decision aids with regard to depression treatment?

What do you believe will help improve the decision-making process for people living with depression and their families? How do you believe this will impact treatment outcomes?

Editor’s Note: The previous post was developed in collaboration with National Network of Depression Centers.

ADDITIONAL READING AND RESOURCES

On Care for Your Mind (Depression Treatment series)

Mayo Clinic, Depression Medication Choice and Shared Decision Making National Resource Center

Comparing Talk Therapy and Other Depression Treatments with Antidepressant Medicines (Consumer Summary), based on findings in Gartlehner, G., et al., Nonpharmacological Versus Pharmacological Treatment for Patients With Major Depressive Disorder: Current State of the Evidence (Clinician’s Summary) (Editor’s Note: CFYM takes issue with the authors ignoring SDM in the section about what to discuss with your patients and their caregivers, saying “That it is important for patients to comply with the treatment that has been recommended to them.”)

Samalin, L., Shared Decision-Making: A Systematic Review Focusing on Mood Disorders

Dobler, C.C., Impact of decision aids used during clinical encounters on clinician outcomes and consultation length: a systematic review

Loh, A., et al., The effects of a shared decision-making intervention in primary care of depression: A cluster-randomized controlled trial

Simon, D., Effectiveness of a web-based, individually tailored decision aid for depression or acute low back pain: A randomized controlled trial

LeBlanc, A., et al., Translating comparative effectiveness of depression medications into practice by comparing the depression medication choice decision aid to usual care: study protocol for a randomized controlled trial

Perestelo-Perez, L., et al., Effectiveness of a decision aid for patients with depression: A randomized controlled trial

Depression-related studies and publications from the Agency for Healthcare Research and Quality

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