Shared Decision Making in Early Psychosis Care: A Nationwide Survey of Provider Practices and Training Needs
1. Catherine J. Leonard, Massachusetts General Hospital Center of Excellence for Psychosocial and Systemic Research
2. Lisa B. Dixon, Columbia University Medical Center; Center for Practice Innovations, Division of Behavioral Health Services and Policy Research, New York State Psychiatric Institute
3. Kim T. Mueser, Center for Psychosocial Rehabilitation, Departments of Occupational Therapy and Psychological & Brain Sciences, Boston University
4. Corinne Cather, Massachusetts General Hospital Center of Excellence for Psychosocial and Systemic Research; Harvard Medical School
5. Yaara Zisman-Ilani, Department of Social and Behavioral Sciences, Temple University's College of Public Health
Background: Shared decision making (SDM) is a recommended approach for enhancing patient-provider communication about psychiatric treatment and is embedded as a core principle in early psychosis coordinated specialty care (CSC) guidelines. Yet how providers apply SDM across early psychosis treatment decisions, and where their training gaps lie, remains unclear.
Methods: Providers working with people with early psychosis, recruited through nationwide early psychosis and EPINET hub listervs, completed a self-report online survey. On a 6-point scale, providers rated their likelihood of using SDM for 21 treatment decisions grouped into psychosocial intervention and recovery-oriented decisions (10 items), pharmacologic and medical decisions (8 items), and higher level of care and legal decisions (3 items; hospitalization, discharge planning, guardianship). Providers also rated perceived barriers and training and decision support tool needs. Ordinal mixed models with provider random intercepts tested SDM likelihood by decision type and provider role.
Results: Of 159 eligible providers across 29 states (75% in CSC; 41% individual therapists; 18% prescribers; 13% peer or family peer specialists), 69% described typically practicing SDM, 26% implementing client preferences, and 4% a paternalistic approach. While 92% involved care partners in treatment decisions, only 35% reported considering care partners’ own preferences. Within the same provider, SDM likelihood significantly differed by decision type (p<.001): relative to psychosocial decisions, odds of endorsing SDM were roughly halved for medication decisions (OR=0.55) and reduced 88% for hospitalization and guardianship decisions (OR=0.12). No role endorsed using SDM more than another overall, but prescribers and therapists reported being least likely to use SDM for higher-level-of-care decisions compared to other decisions, whereas peer/family peer specialists did not differ in SDM use across decision types. Limited client insight (72%) and insufficient medication knowledge (50%) were top barriers. Although 61% did not use decision support tools, 86% expected them to benefit care.
Conclusions: Early psychosis providers reported least likelihood of using SDM for hospitalization and guardianship decisions. Findings support whole-team SDM training addressing attitudinal and knowledge barriers and the balance of client autonomy and care partner involvement in higher-level-of-care decisions, alongside the development and use of decision aids for early psychosis care.