Introduction
At least one in four people in the UK will experience a mental health problem and up to two percent of the population will be diagnosed with a serious mental illness (SMI) during their lifetime [
1]. For the purposes of this research SMI is considered to include diagnoses that are treated with antipsychotics, typically schizophrenia and bipolar affective disorder [
2]. The adverse effects of antipsychotics can decrease adherence rates [
3].
Adherence, the currently accepted term used for medication-taking behaviour, is defined ‘as the extent to which the patient’s action matches the agreed recommendations’ [
4]. Adherence presumes agreement about the proposed medication, between the prescriber and the person taking the medicine, emphasising the importance of shared decision-making (SDM; [
4]). A third to a half of all medications for long-term conditions are not taken as recommended, and treatment adherence is one of the biggest challenges in mental health [
4,
5]. Adherence in SMI is very poor; estimated non-adherence rates for people diagnosed with schizophrenia range from 40 to 75 % [
6,
7]. Studies have found that 75 % of people with chronic schizophrenia discontinue their medication within 18 months [
8] and non-adherence rates in bipolar disorder range between 20 and 60 % with a mean of 41 % [
9,
10]. Antipsychotic prescribing lends itself to SDM, because the adverse event profile is the main factor in the choice of antipsychotics [
11].
SDM is defined by the NHS as ‘the conversation that happens between a patient and their healthcare professional to reach a healthcare choice together’, where both parties consider what is important to the other when selecting treatment. There are ethical, clinical and economic arguments for SDM [
12]; it represents a method of healthcare communication that promotes patient-centred care and sharing expertise between clinicians and service users [
13,
14]. The most accepted model is that of Charles and colleagues, which emphasises patient autonomy, informed consent and empowerment [
15]. SDM is founded on partnership and opposed to a paternalistic model of healthcare [
16]. A recent Department of Health White Paper stated that ‘care should be personalised to reflect peoples’ needs, not those of the professional or the system’ and patients should be involved in treatment decisions [
17]. People diagnosed with SMI can be fully engaged with making decisions and seek a more collaborative approach, thus treatment decisions should be made by the service user and the healthcare professional working together and considering both the likely benefits and possible adverse effects of the medication [
11,
18].
SDM has been linked to improved quality of care and service user satisfaction [
19,
20]. However, the evidence base supporting the use of SDM for chronic conditions, notably mental health [
21] and the use of SDM for decisions made on multiple occasions over the longer-term is limited. Hamann [
22] found that SDM increased knowledge and perceived involvement in treatment in inpatients with schizophrenia. However, SDM failed to show long-term benefits in the same study [
23]. A Cochrane review found that no conclusions could be drawn regarding the effectiveness of SDM interventions for people with mental health problems and highlighted the urgent need for more research [
13]. A more recent study found that although a pharmacist intervention based on SDM significantly improved adherence, treatment satisfaction and beliefs about medication in people with depression, it had no significant effect on depressive symptoms [
24].
Both service users and clinicians appear to support SDM [
25]. However, only 32 % of service users report that their views about treatment were considered ‘to some extent’ and less than half (43 %) were informed about adverse effects, suggesting clinicians are not engaging in SDM [
26]. The lack of a multi-disciplinary approach and the perceived difficulty of implementing SDM with service users who may lack insight are barriers to SDM across mental healthcare [
21,
27]. In addition, there are structural obstacles to collaborative care in psychiatry which include timely access to relevant, reliable clinical information, and therefore research is vital to understand the practicalities of SDM in practice [
21,
28,
29].
Whilst experiences of and attitudes of consultant psychiatrists towards shared decision making in antipsychotic prescribing have been studied, qualitative data on the views of other key groups of healthcare professionals involved in medication management across mental health services, including pharmacists, is lacking [
21]. This study aimed to understand the views and opinions of mental health pharmacists in the UK who are increasingly developing clinical roles. These clinical roles include; advising prescribers and clinicians on the most appropriate medication after interviewing patients; patient education and advocacy; attending and directly inputting into multi-disciplinary meetings. These roles are generally independent from the prescribing process although a limited number of pharmacists may have a caseload with a prescribing role.
Discussion
Pharmacist participants were supportive in principle for SDM, particularly when considering the use of antipsychotic medication, and believed that practising SDM was a key part of stigma-free clinical care. Like previous research, the pharmacists felt SDM increased service user satisfaction, which in turn improved the therapeutic relationship and was key to achieving long term treatment success and positive outcomes by improving adherence to medication [
19,
45‐
50].
The pharmacists perceived that attitudes of both services users and prescribers to SDM varied. Some pharmacists felt that a minority of service users were happy with the clinician making treatment decisions on their behalf. Other research has also identified this group who believe ‘the doctor knows best’; perhaps because they undervalue their expertise in relation to clinicians and want to be ‘a good patient’ [
47,
51]. Most service users, however, particularly those in younger age groups, were said by the pharmacists to increasingly crave involvement, which is in line with previous research [
27,
46,
52]. This change may reflect an increasingly consumerist society, where choice is expected [
53‐
55].
A strong, trusting relationship, with health care professionals and service users both accepting an active role, is essential to the success, or otherwise of SDM [
47]. Yet service users often describe mixed feelings, that they are both helped and misunderstood by healthcare professionals, and commonly report experiencing discrimination [
56,
57]. SDM involves the clinician respecting the right of service users to make treatment decisions, even if they disagree with this decision [
58]. However, like other research, we found a mixed picture; the pharmacists perceived that some prescribers adopted an authoritative approach, dominating consultations and failing to take into account the views of service users [
26,
59‐
62].
The participants perceived a lack of service user insight as the main barrier to SDM. Service users suffering from acute illness were said to lack capacity precisely when medication was most likely to be initiated or changed and, therefore, when SDM was important. However, when the illness being treated was well controlled, and the service user may be more likely to be able to be engaged in SDM, the pharmacists perceived that clinicians would be reluctant to change medication due to concerns about the illness becoming less well-controlled.
Generally the pharmacists reported that SDM was not possible with service users treated under the mental health act without their consent [
63]. This act is designed to protect the rights, health and safety of people with a mental health disorder and the safety of others; it covers the circumstances in which someone can be detained for treatment [
63]. Unlike some other studies, some pharmacists in this study did not view capacity in absolute terms [
21]. They felt more should be done to engage service users and that SDM should be attempted with all service users to varying degrees depending on the level of insight and capacity. This echoes other research, which has found that service users with SMI value the opportunity to collaborate with those providing their care and are prepared to engage with SDM within the current patient-professional relationship [
47]. SDM can also improve treatment knowledge amongst service users with schizophrenia potentially reducing the risk of medication errors [
18,
64‐
66].
However, rather than focus on individual barriers, it may be more relevant to consider structural barriers to SDM in mental health practice such as a lack of time, poor communication between clinicians and service users, and limited access to evidence-based information [
28,
58]. SDM can be seen to be a time consuming activity to undertake [
22,
27]. In this research pharmacists reported the lack of time of both pharmacists and prescribers to be a barrier, with pharmacists identifying that other duties were seen to override SDM; other research has found that lack of time is a commonly reported barrier by both health professionals and service users [
27,
51,
59,
60].
The pharmacists felt they were able to play a vital role in SDM partly because their independence from the prescribing process enabled them to engage in SDM. Previous research has identified the need for an inter-disciplinary approach involving autonomous clinicians to engage service users in SDM [
67‐
70]. However, many of the pharmacists felt that they did not always get the opportunity to be involved in the SDM process due to the lack of a structured referral system and multi-disciplinary approach or resources issues within pharmacy departments.
Implications of study
Services should be structured to support SDM with a more inter-disciplinary approach. This could include a formal referral system to pharmacists or implementation of pharmacist clinics. Training for pharmacists (and potentially other clinicians) should highlight that SDM should be adapted depending on the state of illness at the time, but not abandoned.
Further study
Further qualitative research on SDM, and more specifically the potential role of pharmacy, involving pharmacists, other clinicians and service users is required. Research is also required on the impact of SDM on outcomes including adherence to medication [
19,
48‐
50,
71]. Future research should investigate whether clinicians use SDM differentially depending on various characteristics including how long they have known the service user for and what the medication is being utilized for. It could also cover service users’ views on the role of family members as advocates. Previous research has identified a role for healthcare professional ‘coaches’ not involved in treatment to actively support service users in engaging in SDM [
58]. Therefore, future research could investigate the impact of ‘pharmacy medication management coaches’ on key outcomes.
Limitations
All the participants recruited for the study came from the Midlands region and may not be broadly representative of attitudes and experiences of mental health pharmacists nationally and internationally. Moreover, we cannot be sure how long the participants had worked in mental health for (other than more than 1 year), whether they have a formal mental health qualification or their area of practice. We relied on convenience and snowballing sampling and relatively small sample sizes; however we found data saturation with consistent themes identified and no new themes identified in the last set of interviews. Additionally, identifying participants via known contacts may have influenced the interview responses in relation to socially desirable responses.
This research project only sought the views of mental health pharmacists; a future project should triangulate the data collection methods and also interview other clinicians and more importantly service users. Pharmacists are increasingly becoming prescribers and therefore future research should also compare and contrast the views and experiences of prescribing and non-prescribing (who are independent from the prescribing process) pharmacists.
Conclusion
In keeping with previous research in this area, SDM was seen as a positive concept by the mental health pharmacists interviewed. SDM should take into consideration the service user’s ability to tolerate adverse effects and their preferences regarding medication. The pharmacists believed that such an approach could improve service users’ satisfaction with medication management services and ultimately adherence to medication. The pharmacists perceived that the attitudes of prescribers and service users, although noted as variable, to be increasingly in favour of SDM.
The pharmacists identified that the use of SDM was limited by barriers, particularly the difficulties perceived by clinicians of engaging people with SMI who lack insight and mental capacity in the process. Greater effort is seen to be needed to work around these issues and try to engage service users as much as possible. Structural issues, such as time pressures may also limit the use of SDM.
Pharmacists clearly feel they can play a vital role in SDM but their skills and knowledge in this area are being underutilised, limiting their opportunity to contribute. SDM is clearly seen as one way to improve outcomes, and more research on how it can be effectively implemented in mental health is required.