Person-Centred Decision-Making in Mental Health: A Scoping Review

Figures & data

Figure 1. Screening flow chart.

Table 2. Quality assessment of each article.

No	Authors and year of publication	Type of study design	Quality assessment tool	Rated quality
1	Abate et al., 2023	Explanatory sequential mixed method study	Mixed Methods Appraisal Tool (MMAT), version 2018	Good
2	Alegria et al., 2018	Randomised clinical trial	JBI Critical Appraisal Checklist for randomised control trials (CACRCT)	Good
3	Aoki et al., 2019	Qualitative	JBI Critical Appraisal Checklist for qualitative research (CACQR)	Good
4	Farrelly et al., 2016	Qualitative	JBI Critical Appraisal Checklist for qualitative research (CACQR)	Fair
5	Giacco et al., 2018	Qualitative	JBI Critical Appraisal Checklist for qualitative research (CACQR)	Good
6	Grim et al., 2016	Qualitative	JBI Critical Appraisal Checklist for qualitative research (CACQR)	Good
7	Gurtner et al., 2022	Qualitative, ethnographic study	JBI Critical Appraisal Checklist for qualitative research (CACQR)	Good
8	Hamann et al., 2016	Qualitative	JBI Critical Appraisal Checklist for qualitative research (CACQR)	Good
9	Hamann et al., 2020	Randomised clinical trial	JBI Critical Appraisal Checklist for randomised control trials (CACRCT)	Good
10	Haugom et al., 2022	Qualitative descriptive exploratory	JBI Critical Appraisal Checklist for qualitative research (CACQR)	Good
11	Hines et al., 2018	Cross-sectional analysis from secondary data	JBI Critical Appraisal Checklist for analytical cross-sectional studies (CACACS)	Fair
12	Kokanović et al., 2018	Qualitative	JBI Critical Appraisal Checklist for qualitative research (CACQR)	Good
13	Lovell et al., 2018	Randomised clinical trial	JBI Critical Appraisal Checklist for randomised control trials (CACRCT)	Good
14	Matthias et al., 2012	Qualitative observational	JBI Critical Appraisal Checklist for qualitative research (CACQR)	Good
15	Matthias et al., 2014	Cross-sectional	JBI Critical Appraisal Checklist for analytical cross-sectional studies (CACACS)	Fair
16	Morán-Sánchez et al., 2020	Cross-sectional	JBI Critical Appraisal Checklist for analytical cross-sectional studies (CACACS)	Fair
17	Mundal et al., 2021	Cross-sectional	JBI Critical Appraisal Checklist for analytical cross-sectional studies (CACACS)	Fair
18	Myers et al., 2019	Qualitative	JBI Critical Appraisal Checklist for qualitative research (CACQR)	Fair
19	Park et al., 2014	Cross-sectional survey (secondary analysis)	JBI Critical Appraisal Checklist for analytical cross-sectional studies (CACACS)	Fair
20	Sather et al., 2019	Qualitative	JBI Critical Appraisal Checklist for qualitative research (CACQR)	Good
21	Thomas et al., 2022	Qualitative	JBI Critical Appraisal Checklist for qualitative research (CACQR)	Good

Table 1. Summary of the characteristics of the selected studies.

No.	Author(s), year	Country	Article title	Journal, volume, and issue	Design and purpose	Sample	Methods	Findings	Limitations
Therapeutic relationship and communication in decision-making
1	Giacco et al., 2018	United Kingdom	Shared decision-making with involuntary hospital patients: a qualitative study of barriers and facilitators.	BJPsych Open, 4(3).	Qualitative. To identify barriers and facilitators to shared decision-making with involuntary patients.	Focus groups: 24 patients, six of which required an interpreter (mean age = 38.4) and 16 clinicians. Individual interviews: six patients with interpreter (mean age = 37.7).	Randomised sampling of patients to preserve anonymity. Four focus groups and six individual interviews. Thematic analysis.	Obstacles for decision-making: Communication issues between patients and physicians. The busy and noisy environment of wards.	Recruitment limited to a specific area, East London. Sample based on ethnicity was not carried out. The main methodology used was focus groups, which may be less sensitive to individual experiences.
2	Grim et al., 2016	Sweden	Shared decision-making in mental health care—A user perspective on decisional needs in community-based services.	International Journal of Qualitative Studies on Health and Well-being, 11.	Qualitative descriptive. To investigate decisional and information needs among patients with mental illness as a prerequisite for the development of a decision support tool aimed at supporting shared decision-making in community-based mental health services in Sweden.	Twenty-two adult patients with mental illness aged 24 to 62 years old.	Three semi-structured focus group interviews. Directed content analysis of the interviews.	Inductive and deductive approach. Fostering decision-making: Conversations with healthcare provider characterised by trust, sincere interest, respect, clear guidance and equality. Involving family, partners, or friends during provider encounters. Early information sharing. Scheduled a follow-up and review visit.	Findings limited because of the small number of respondents. The needs of patients of community based mental health services are not totally represented.
3	Gurtner et al., 2022	Switzerland	Shared Decision Making in the Psychiatric Inpatient Setting: An Ethnographic Study about Interprofessional Psychiatric Consultations	International Journal of Environmental Research and Public Health, 19(6).	Qualitative, ethnographic study. To gain a better understanding of how psychiatric inpatients and the interprofessional care team interact during regular interprofessional psychiatric consultations.	Participants included patients and healthcare providers. Seventy-one interprofessional psychiatric consultations that differed in context (place and form) and culture (way of interacting).	Participant observation using a structured observation protocol. Conversations with the participants. Field notes.	The extent to which patients are involved in the discussion and decision making depended on individual factors: The communication style of health care professionals. The personal initiative of the patients to be engaged.	The ethnographic approach could also have biased the actions of both the health care professionals and the patients.
4	Haugom et al., 2022	Norway	Experiences of shared decision making among patients with psychotic disorders in Norway: a qualitative study.	BMC Psychiatry, 22(1).	Qualitative descriptive exploratory. To describe and explore experiences of shared decision-making among patients with psychotic disorders in mental health care.	Ten service patients of two community mental health centres with a psychotic disorder whose ages ranged between 32 to 72 years, mean age = 53 years.	Inductive approach: Individual interviews. Transcription of the interviews. Qualitative content analysis.	Obstacles for decision-making: Insufficient information about patients’ health situation and treatment options. Reluctance from health professionals to give patients the level of involvement they would like.	Transcripts not returned to the participants for comments and/or corrections. Participants did not provide feedback on the findings. Study conducted in a limited geographical area may only represent local practices. Half of the participants mainly received care and treatment from their psychiatrist. All interviewees were treated at a community mental health centre that implemented evidence based antipsychotic medications.
5	Kokanović et al., 2018	Australia	Supported decision-making from the perspectives of mental health service users, family members supporting them and mental health practitioners.	The Australian and New Zealand journal of psychiatry, 52(9).	Qualitative. To explore from several perspectives the barriers and facilitators to supported decision-making in an Australian context.	Twenty-nine mental health patients (aged between 18 to 65 years old) who were mostly female, aged over 40 years. Twenty-nine family members supporting them and 32 mental health practitioners, including psychiatrists.	Narrative interviews. Thematic analysis.	Communication skills from professionals and empathic relationships with health care professionals foster decision-making. Barriers for decision-making: Perception of impersonal interactions. Long wait periods for appointments. Impersonal care structures Stigma, with the assumption of decision-making incapacity.	Possible sampling bias because participants opted in. Supported decision-making is an emerging practice and participants had difficulty in drawing on current experience.
6	Matthias et al., 2014	The United States	Consumer and Relationship Factors Associated With Shared Decision Making in Mental Health Consultations	Psychiatric Services, 65.	Cross-sectional. To explore the association between shared decision making and consumers’ illness management skills and consumer provider relationships.	79 consumers were audio recorded. Consumers’ ages ranged from 23 to 71 years (mean age = 53 years).	Audio recording of medication management appointments. Independent coding. Correlation analyses.	Adopting a shared decision-making approach could lead to a greater consumer-provider bond. A high level of shared decision-making is associated with a higher likelihood of taking medications as prescribed. Agreement was associated to shorter consumer-provider relationships, because longer relationships might lead participants to feel more comfortable expressing disagreement rather than keeping silent.	Only three providers were included, limiting the analysis of relevant factors like gender, years of experience and attitudes. Causality cannot be established due the cross-sectional nature of this study. The exclusion of consumers with symptom exacerbations may have limited the ability to examine a wider range of decision-making. Study conducted at a single setting.
Patient’s involvement in treatment decision-making
7	Abate et al., 2023	Ethiopia	Level of shared decision making and associated factors among patients with mental illness in Northwest Ethiopia: Explanatory sequential mixed method study	PloS one, 18(4).	Explanatory sequential mixed method study. To examine the level and factors associated with shared decision-making practice in Ethiopia.	Quantitative data: 423 patients from two specialised hospitals providing mental health services. Qualitative data: 10 participants were selected purposively for the in-depth interview. (Mean age = 33.02 years).	Quantitative data: Descriptive statistics analysis. Multivariate logistic regression. Qualitative data: Interviews. Thematic analysis. Triangulation with quantitative data.	Nearly half of participant’s had low level of shared decision-making involvement during treatment. Low shared decision-making was associated to poor perceived compassionate care, no community-based health insurance, and poor social support. From the patients, there are concerns related to service quality, psychosocial, and human resources.	Findings might be prone to a response bias due to the patients’ self-report. The questionnaire has some sensitive issues, which may suffer from social desirability. Patients who had admitted in inpatient and Emergency psychiatry ward were not included.
8	Hamann et al., 2016	Germany	What can patients do to facilitate shared decision making? A qualitative study of patients with depression or schizophrenia and psychiatrists	Social Psychiatry and Psychiatric Epidemiology, 51.	Qualitative. To explore both patients’ and psychiatrists’ views on how patients can facilitate shared decision making in acute mental health settings.	Seven focus groups were conducted: 3 with psychiatrists and 4 with patients with schizophrenia or depression (mean age = 41.8 years).	Seven focus groups. Independent transcription and coding by two researchers. Data analysed using content analysis.	The main factors involved in decision-making are: Honesty and openness with one’s psychiatrist and oneself. Trust in one’s psychiatrist and patience with the treatment. Respect and politeness. Informing the psychiatrist and giving feedback. Engagement/ active participation during the consultation. Gathering information/preparing for the consultation. Implementing decisions. Multiple Barriers (e.g. avolition, lack of decisional capacity, powerlessness during involuntary treatment).	Relatively small sample size. The inclusion of rather ill and chronic patients. Thinking about the shared decision-making requires abstraction, which may be affected in some of the interviewed patients.
9	Hines et al., 2018	The United States	Informed and patient-centred decision-making in the primary care visits of African Americans with depression.	Patient Education and Counselling, 101(2).	Cross-sectional analysis from secondary data. To examine the prevalence and extent of informed decision-making and patient centred decision-making in primary care visits of African Americans with depression.	Seventy-six African American research participants, mean age = 47.3 years.	Analysis of audiotaped clinical encounters and post-visit surveys. Patient-centeredness of visit dialogue was characterised.	Only 9% of the treatment choices for depression have satisfied the criteria for informed decision-making. Risks and benefits were only presented in less than 1 in 6 observed decisions. clinicians are aware of the significance of the patients’ social context.	The small sample size limits the reliability of the estimates. Participants may differ from those who chose not to participate. A single geographical region was included, and the results may not be generalisable to other regions. Patients interviewed up to two weeks after the clinical encounter.
10	Matthias et al., 2012	The United States	Decision Making in Recovery- Oriented Mental Health Care.	Psychiatric rehabilitation journal, 35(4).	Qualitative observational. To explore how consumers and providers make decisions in medication management consultations (shared decision-making).	Four providers and 40 consumers with severe mental illness (10 consumers per provider) from a community mental health centre (mean age = 43.5 years).	Observations were audio-taped and transcribed. Thematic Analysis.	Consumers’ preferences are not considered in the final choice. Outright disagreement led to a better representation of the consumer’s preference in the final decision.	Most participants were members of a support program and received person-centred care before the study. Only one visit per participant was observed. Interviewing both parties involved in the conversation was not possible. The development of the relationship over time could not be analysed. Findings were not intended to be generalisable.
11	Morán-Sánchez et al., 2020	Spain	Compulsory admissions and preferences in decision‑ making in patients with psychotic and bipolar disorders	Social Psychiatry and Psychiatric Epidemiology, 55(5).	Cross-sectional. To explore the relationship between compulsory admissions and congruence in decision-making preferences in mental health settings.	One-hundred and seven outpatients with diagnoses of schizophrenia or bipolar disorder with a history of compulsory admissions (mean age = 48.04 years).	Participants used the Control Preference Scale to assess congruence in decision-making experienced and preferred style. Descriptive statistics and multivariate analyses.	Patients a history of compulsory admission report a low incorporation of their preferences in decisional outcomes. Predictors of compulsory admission are: Unmatched participation preferences in shared decision-making. Having a regular psychiatrist. The severity of the psychiatric condition.	Research carried out in an urban setting with a small number of patients, limiting generalisation. Some predictors of compulsory admission might have not been included. Decisional conflict measured with a self-report questionnaire.
12	Mundal et al., 2021	Spain	Exploring patterns in psychiatric outpatients’ preferences for involvement in decision-making: a latent class analysis approach	BMC Psychiatry, 21(133).	Cross-sectional. To identify different latent class typologies of patient preferences for involvement in the shared decision-making process, and to investigate how patient characteristics predict these typologies in mental healthcare settings.	Three-hundred psychiatric outpatients aged 18 years and older, treated in two outpatient healthcare departments (mean age = 44.4 years).	Administration of questionnaires. Latent class analysis (LCA). Descriptive statistics.	Preference typologies varied according to gender, age group and educational level. Some groups showed reluctance to accept pharmacological treatment whereas others remained unconcerned. Young and middle-aged men tended to feel that they were in control of their disease contrasted by older women who attributed the control of their disease to their psychiatrists.	Results must be interpreted cautiously due to the cross-sectional nature of the study. Small patient samples. A convenience sample was used, limiting the generalisability of the findings. Information of those who refused to participate was not collected.
13	Myers et al., 2019	The United States	Decision Making About Pathways Through Care for Racially and Ethnically Diverse Young Adults With Early Psychosis	Psychiatric Services, 70(3).	Qualitative (Prospective longitudinal ethnographic). To elicit factors that shaped treatment decision making for young adults and their key supporters after an initial hospitalisation for psychosis to generate hypotheses about how to improve service engagement.	Eighteen young adults primarily from racial-ethnic minority groups and 19 of their self-identified key supporters (n = 37) as they made decisions about treatment (mean age = 21.9 years).	Home visits, interviews, and hospital-based fieldwork during the 12-week critical period after an initial hospitalisation for psychosis. Analysis conducted through inductive coding and constructivist grounded theory methods.	The main concerns were getting back to normal, the insufficient mental health care on offer, police involvement in their pathway to care, feeling worse, and needing help with repairing strained relationships. Further concerns were independent life in the future, paying for mental health care, distrusting mental health diagnoses, managing social pressure to use substances, feeling disempowered by hospitalisation experiences, and managing transportation challenges.	Difficulty retaining participants. Small sample size.
14	Park et al., 2014	The United States	Factors Associated with Shared Decision– Making Preferences Among Veterans With Serious Mental Illness	Psychiatric Services, 65(12).	Cross-sectional survey (secondary analysis). To evaluate preferences for shared decision making with respect to mental health treatment in a sample of veterans who were diagnosed as having serious mental illness.	Two-hundred and thirty-nine outpatients aged between 18 and 70 years old, receiving care from the Department of Veterans Affairs (mean age = 54.3 years).	Completion of a self-reported questionnaire. Analysis through multivariate linear regression.	Most participants preferred to be offered options and to be asked their opinions about mental health treatment. More than half of participants preferred to rely on their providers’ knowledge and let their providers to make final treatment decisions. Greater preferences for participation were found among those: African American clients. Working for pay. College or higher education Other than a schizophrenia spectrum diagnosis. Poorer therapeutic relationship with their prescribers.	Sample composed mostly of older men. Only participants receiving a second-generation antipsychotic were considered. Data about the length of time that participants had been seeing their provider was not available for analysis. The assessment of participation in shared decision-making has not been validated in a psychiatric setting. Unclear degree of representation of shared decision-making due to the self-reported data. Replication is necessary to confirm the study findings due to the exploratory nature of the study.
15	Sather et al., 2019	Norway	Patients’ perspectives on care pathways and informed shared decision making in the transition between psychiatric hospitalisation and the community	Journal of Evaluation in Clinical Practice, 25.	Qualitative descriptive. To explore former patients’ views of pathways in transition between district psychiatric hospital centres and community mental health services.	Ten informants, three men and seven women with a mean age at 40 years, from five different communities.	Three focus group interviews. Transcription and analyses of findings. Thematic analysis.	Participants feel they have the knowledge to actively participate in decision-making, but they are not always given the chance to be more active. Individuals see their opinions are neglected, invalidating their autonomy. An individual care plan is seen as important to switch the power imbalance between practitioners and patients.	The findings are non-generalisable because the focus was the health planning system in a region of Norway. Small sample size.
Interventions for improving patients’ decision-making involvement
16	Alegria et al., 2018	The United States	Effectiveness of the DECIDE Interventions on Shared Decision Making and Perceived Quality of Care in Behavioural Health with Multicultural Patients. A Randomised Clinical Trial.	JAMA Psychiatry, 75(4).	Cross-level 2 × 2 randomised clinical trial. To test the effectiveness of patient and clinician interventions to improve SDM and quality of care among an ethnically/racially diverse sample.	Seventy-four clinicians at level 2 and 312 patients (nested within clinicians) at level 1 from 13 Massachusetts behavioural health clinics. 49% aged between 18-34 5% aged 65 and older	Random selection of participants. Intervention: six coaching telephone calls to promote communication and therapeutic alliance. Assessment by a blinded coder.	An intervention is effective to improve shared decision-making when the patient and clinician have different primary languages.	Causality cannot be established with cross-sectional data. Low intervention participation rate of clinicians. Assessment of multiple measures of shared decision-making and testing both interventions simultaneously.
17	Aoki et al., 2019	Japan	Psychiatric outpatients’ experiences with shared decision-making: a qualitative descriptive study	Journal of Communication in Healthcare, 12(2).	Qualitative. To explore patients’ experiences of a shared decision-making program developed for psychiatric outpatients who faced new treatment decisions.	Ten psychiatric outpatients aged 25–72 years with a range of psychiatric conditions (e.g. bipolar disorder, depression).	Individual semi-structured interviews. Thematic analysis.	Anticipatory anxiety and becoming involved in decision-making in the first consultation. Less decisional conflict with the psychiatrist after the second consultation. Facing mental illness, involving others, and deepening knowledge are relevant while at home.	Small sample size with restricted recruitment. Findings not generalisable to other populations. Control groups were not incorporated due to the qualitative nature of the analysis.
18	Farrelly et al., 2016	United Kingdom	Barriers to shared decision making in mental health care: qualitative study of the Joint Crisis Plan for psychosis	Health Expectations, 19.	Qualitative. To understand how stakeholders perceived the intervention and the barriers to shared decision-making in the form of a joint crisis plan.	Fifty service users (mean age = 39 years) with psychotic disorders and 45 clinicians.	Focus group and interviews. Analyses through grounded theory methods.	The main barriers for shared decision-making are ambivalence about care planning, perceptions that shared decision-making was already done, concerns of clinicians about the appropriateness of patient’s choices, and limited availability of choices. The intervention of a joint crisis plan effectively addressed these barriers.	Limitations not reported by the authors.
19	Hamann et al., 2020	Germany	Implementing shared decision-making on acute psychiatric wards: a cluster-randomised trial with inpatients suffering from schizophrenia (SDM-PLUS).	Epidemiology and Psychiatric Sciences, 29.	Randomised clinical trial. To examine whether shared decision-making (SDM) is facilitated by an approach which is specifically adapted to the needs of acutely ill patients (SDM-PLUS).	A total of 257 patients from 12 acute psychiatric wards of five psychiatric hospitals.	Participants were recruited at their admission. Treatment teams and patients of intervention wards were trained. Staff and patients of the control wards continued in usual conditions.	The SDM-PLUS approach led to higher perceived involvement in decision-making. Intervention group patients showed better therapeutic alliance, treatment satisfaction and self-rated medication compliance. The adoption of behavioural approaches (e.g. motivational interviewing) for SDM may yield a successful application to mental health.	Potential bias of the results due to lower participation of patients in the intervention group. Unknown extent to which the proposed strategies were implemented by health care staff. Low number of questionnaires returned by patients during follow-up.
20	Lovell et al., 2018	United Kingdom	Embedding shared decision-making in the care of patients with severe and enduring mental health problems: The EQUIP pragmatic cluster randomised trial	PLoS ONE, 13(8).	Randomised clinical trial. To test whether we could deliver a practical and feasible intervention in routine community mental health services to embed shared decision-making for patients with severe mental illness, by improving patient and carer involvement in care planning.	A total of 604 patients and 90 carers.	Cluster randomised community mental health teams to the training intervention or usual care. Primary and secondary outcomes were collected by self-report, six months after allocation. Analysis completed using Stata 13.	Results showed no statistically significant difference in the primary outcome between the intervention and usual care at 6 months. Significant effects on only one secondary outcome, service satisfaction, were found. The intervention had no significant effects on patient perceptions of autonomy support, or other outcomes.	The volunteer sites may not be fully representative of the general population. Measures of service use and contact with professionals were based on self-report. It is possible that telephone administration of follow-up assessments might impact on patient responses.
21	Thomas et al., 2022	The United States	Treatment decision-making needs among emerging adults with early psychosis	Early Intervention in Psychiatry, 16.	Qualitative. To identify the range of treatment decisions that emerging adults face during their initial engagement in an early intervention in psychosis program and elucidate barriers and facilitators to decision-making.	Twenty emerging adults with early psychosis (mean age = 20.20 years). They were interviewed during the first six months after enrolment in an early intervention in psychosis program.	Semi structured interviews. Integrated thematic analysis approach. Data analysis facilitated by NVivo 12 Plus.	Emerging adults in an early intervention in psychosis program may benefit from interventions designed to reduce decisional conflict. Decisions pertaining to life and treatment goals and to starting and continuing psychiatric medication were selected as the most difficult/ complicated. Decision-making barriers included: not having the right amount or type of information/ knowledge Social factors Lacking internal resources Unappealing options. Facilitators are obtaining information/knowledge, social supports, considering personal values, and time were decision-making facilitators.	Relatively homogeneous participant demographic makeup limits generalisability. Adults with barriers to autonomous decision making and those who chose not to enrol into the program were not included. Interview probe questions may have artificially inflated the frequencies of reported decision points, barriers and facilitators.

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