The Shared Decision-Making Process in the Pharmacological Management of Depression

Major depressive disorder (MDD) is a complex, heterogeneous, and potentially long-term condition that gives rise to serious handicaps and disabilities [1]. Following a stepped approach in depression care, the physician may start prescribing nonpharmacological therapies [2, 3] before proceeding to pharmacological treatments that can effectively mitigate the burden of depression, though this approach is sometimes subject to controversy [4, 5]. Treatment guidelines recommend continuous use of antidepressants for several months to reach and maintain remission, but this is far from being achieved in current practice [6]. In everyday medical practice, the efficacy of antidepressants is reduced by low patient adherence rates and premature discontinuation, which contribute to an increased risk of relapse [7‐10] and the chance of developing a chronic disease and increased morbidity and mortality. In fact, only a limited proportion of patients sufficiently adhere to their treatment [11, 12], which may be related to several factors. First, patients organize their drug intake around their own priorities, which may be very different from prescribers’ priorities, since most patients value their personal concerns and/or their social roles more than the benefits of a prescribed treatment. Second, factors associated with early discontinuation of antidepressant treatment include stigma and patient skepticism toward treatment [13, 14]. Patients are reluctant to start antidepressants because of the fear that it can be difficult to withdraw from every psychotropic drug [12]. Third, patients are generally aware of the side effects of antidepressant medications but do not necessarily distinguish the differences between drug classes [15]. Typically, there is a reluctance to start or continue antidepressants because patients have either developed side effects or believe they will. As long-term adherence to antidepressant treatment is primarily determined by the balance between the perceived necessity and perceived harmfulness of the medication [13, 14], tolerability becomes an increasingly important factor, with a longer duration of treatment as depressive symptoms recede [12]. It is important that clinicians present this information to patients in meaningful ways [16, 17]. Fourth, another factor is the absence of a perceived clinical benefit during the initial stages of treatment, as the efficacy of most antidepressant drugs against depressive symptoms generally builds over several weeks. Clinicians are advised to inform patients of the likely delayed onset of a perceived benefit of antidepressant drugs [18].

All these factors were reported in a clinical audit (TAILOR [Target Antidepressant Initiation choice to unLock positive patient Outcomes and Response]) involving 7650 patients and 1873 general practitioner clinics in Australia (data on file; results represent findings collected up to June 2018). Importantly, most patients had concerns about starting antidepressant treatment because of possible side effects, the most frequently mentioned being weight gain, sleep disturbance, and sexual dysfunction. This audit identified the importance of involving the patient in the decision-making process; once the treatment options were presented, the patient could share the decision on what management to follow. Clearly, targeted and tailored communication offers promise for fomenting discussion and reducing barriers to an appropriate initial treatment of depression.

A gap sometimes exists between patients’ views and professionals’ views, a gap mainly related to the patients’ health beliefs and the physicians’ attitudes. What depressed patients consider important in defining remission from depression may differ from what a physician sees as important [19, 20]. In a survey involving 535 psychiatric outpatients treated for MDD, the three items most frequently judged by the patients to be very important in determining remission were the presence of features of positive mental health, such as optimism and self-confidence, a return to their usual, normal self, and a return to their usual level of functioning. The patients endorsed a statement about absence of symptoms with nearly similar frequency [20].

It is critical to improve the process by which patients and clinicians together select and implement antidepressants; it should augment the proportion of patients who adhere to their antidepressant treatment for a duration that complies with the current recommendations.

The number of patients who discontinue drug therapy prematurely can be lowered when patients can decide which treatment they prefer [21]. Alternatively, the research has documented that lack of patient information, problems within the doctor–patient communication, and low patient participation in the medical decision-making process are key predictors of patient reluctance to engage in or continue with treatment [22, 23].

Models of shared decision making (SDM) have been developed as a strategy for involving patients in the decision-making process, which could result in improved clinical outcomes. SDM approaches emerged as a reaction to medicine’s traditional “paternalism,” wherein physicians exercise the dominant role in treatment decision making [24]. SDM is a collaborative process in which clinicians and patients work together to reach a consensus about treatment or diagnostic decisions; it is a process whereby clinicians present patients with technical information regarding the disease (diagnosis, etiology, prognosis) and the benefits and risks of the available treatment options and patients inform clinicians about their beliefs, values, goals, experiences, and preferences about the consequences of those treatment options. SDM involves the provision of evidence‐based information about options, outcomes, and uncertainties, together with decision-support counseling and a system for recording and implementing patients’ “informed preferences” [25]. Bringing these two types of expertise together should produce better decisions. SDM is especially relevant (1) when there is more than one reasonable option, (2) when the scientific evidence about the effectiveness or safety of available treatments is scarce, (3) when treatments show a similar balance between benefits and risks, or (4) when possible benefits and harms of each option affect patients differently.

Overall, there is international consensus across medicine about the importance of SDM, and it is widely supported [26]. Policy makers may perceive SDM as desirable because of its potential to (1) reduce overuse of options not clearly associated with benefits for all; (2) enhance the use of options clearly associated with benefits for the vast majority; (3) reduce unwarranted healthcare practice variations; and (4) promote the right of patients to be involved in decisions concerning their health.

SDM interventions have been successfully implemented when treating various illnesses, such as breast and prostate cancer [27]. Patients have shown reduced psychological distress and improved functioning [28, 29], and they have achieved better health outcomes when perceiving themselves as more involved in the decision-making process [30]. Better outcomes include increased compliance with decisions [31], reduced stigma, and increased involvement [32]. Of note, however, a systematic review of trials testing the impact of SDM on outcomes in physical health made a more skeptical conclusion, as only half of the reviewed trials indicated a positive effect [33].

Following beneficial applications of SDM in caring for physical illnesses [34], researchers have incorporated principles and elements of SDM for different mental health interventions. In this field, SDM is associated with enhanced patient satisfaction, adherence, empowerment, and guideline-concordant care [23, 35‐37].

SDM interventions have been developed for depressed individuals [31, 38‐42]. Loh et al. [23] found that, after an SDM intervention, depressed primary care patients displayed significantly greater participation in decision making and greater treatment satisfaction. A systematic review [43] identified 11 randomized controlled trials, including one focusing on depression [44]. Five trials, including the two mental health trials, showed positive outcomes associated with SDM, but the reviewers concluded that the overall evidence was encouraging but inconclusive. SDM can lead to reduced substance use and improved quality of life [45], and is associated with increased patient autonomy [46]. In a systematic literature review, Samalin et al. [47] identified three 6-month studies demonstrating that SDM interventions using decision aids effectively improved depressed patients’ satisfaction and engagement in the decision-making process. Regarding treatment adherence or reduced depression severity, results remain inconclusive [23], but the clinician–patient alliance and communication can be associated with improved antidepressant treatment adherence [48, 49]. Studies comparing the effects of SDM with usual care on patient adherence in mental disorders are ongoing [50].