Re: Too much medicine in older people? Deprescribing through shared decision making
Dear Editor:
This was a very interesting article especially for persons like myself who are involved in providing care for the mentally ill. The title, “Too much medicine in older people? De-prescribing through shared decision making,” as presented by Jansen et al., 2016 captivated my attention. Yes, this is an initiative that needs to be examined and implemented, not just in older people, but especially for clients who are living with a mental illness!
As a primary care mental health practitioner I have seen multiple cases of poly-pharmacy. Similarly, one-third of the clients visiting outpatient psychiatric departments are being treated with three or more psychotropic drugs (Mojtabai & Olfson, 2010). Which leaves me asking the question; what is the role of the patient in decision making regarding medication management? Self-determination within mental health services is increasingly recognized as an ethical imperative, (Stanhope, Barrenger, Salzer & Marcus, 2013). Clients need to be invited to, and supported in expressing treatment preferences. Furthermore, this should take place within the context of a strong therapeutic relationship (Klingaman et al., 2013).
My interaction with clients has alerted me to adherence issues, as well as clients’ reluctance to be “dictated to”, and instead request to be “consulted” in the decision making process in relation to their medication management. There are, however, stereotyping and stigmatizing issues related to clients’ decision making and mental illness. As a result, when working with patients exhibiting poor insight, practitioners may use authoritative decision-making styles despite the patient's desire to participate (Grim, Rosenberg, Svedberg, & Schön, 2016). Krumholz (2010) posits that people want to be involved in understanding evidence and making decisions about their care.
I must agree, that forming a “…therapeutic alliance” towards reducing symptoms and improving functioning (Stanhope et al., 2013), while engaging clients in treatment decisions, not only provides clients’ with needed information and treatment options, but it allows them to feel actively involved in the treatment process thus increasing compliance rates (Klingaman et al., 2015).
While we seek to engage in shared decision making, there is one question that demands an answer. Are we as health practitioners treating the client, the disorder or the symptom (Kukreja, Kalra, Shah, & Shrivastava, 2013)?
References
Grim, K., Rosenberg, D., Svedberg, P., & Schön, U. (2016). 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. doi:http://dx.doi.org/10.3402/qhw.v11.30563
Jansen, J., Nagathan, V., Carter, S. M., McLachlan, A. J., Nickel, B., Irwig, L. et al. (2016). Too much medicine in older people? Deprescribing through shared decision making. British Medical Journal, 2016;353:i2893
Klingaman, E. A., Medoff, D. R., Park, S. G., Brown, C. H., Fang, L., Dixon, L. B., Hack, S. M., Tapscott, S. L., Walsh, M. B., Kreyenbuhl, J. A. (2015). Consumer satisfaction with psychiatric services: The role of shared decision making and the therapeutic relationship. Psychiatric Rehabilitation Journal, Vol 38(3), 242-248. http://dx.doi.org/10.1037/prj0000114
Krumholz, H. M. (2010). Informed Consent to Promote Patient-Centered Care.
The Journal of the American Medical Association, 303(12):1190-1191. doi:10.1001/jama.2010.309.
Kukreja, S., Kalra, G., Shah, N., & Shrivastava, A. (2013). Polypharmacy In Psychiatry: A Review. Mens Sana Monographs, 11(1), 82–99. http://doi.org/10.4103/0973-1229.104497
Mojtabai, R. & Olfson, M. (2010). National trends in psychotropic medication polypharmacy in office-based psychiatry. Archives of General Psychiatry, 67(1):26-36.
Stanhope, V., Barrenger, S. L., Salzer, M. S., Marcus, S. C. (2013). Examining the Relationship between Choice, Therapeutic Alliance and Outcomes in Mental Health Services. Journal of Personalized Medicine, 3, 191-202; doi:10.3390/jpm3030191
Rapid Response:
Re: Too much medicine in older people? Deprescribing through shared decision making
Dear Editor:
This was a very interesting article especially for persons like myself who are involved in providing care for the mentally ill. The title, “Too much medicine in older people? De-prescribing through shared decision making,” as presented by Jansen et al., 2016 captivated my attention. Yes, this is an initiative that needs to be examined and implemented, not just in older people, but especially for clients who are living with a mental illness!
As a primary care mental health practitioner I have seen multiple cases of poly-pharmacy. Similarly, one-third of the clients visiting outpatient psychiatric departments are being treated with three or more psychotropic drugs (Mojtabai & Olfson, 2010). Which leaves me asking the question; what is the role of the patient in decision making regarding medication management? Self-determination within mental health services is increasingly recognized as an ethical imperative, (Stanhope, Barrenger, Salzer & Marcus, 2013). Clients need to be invited to, and supported in expressing treatment preferences. Furthermore, this should take place within the context of a strong therapeutic relationship (Klingaman et al., 2013).
My interaction with clients has alerted me to adherence issues, as well as clients’ reluctance to be “dictated to”, and instead request to be “consulted” in the decision making process in relation to their medication management. There are, however, stereotyping and stigmatizing issues related to clients’ decision making and mental illness. As a result, when working with patients exhibiting poor insight, practitioners may use authoritative decision-making styles despite the patient's desire to participate (Grim, Rosenberg, Svedberg, & Schön, 2016). Krumholz (2010) posits that people want to be involved in understanding evidence and making decisions about their care.
I must agree, that forming a “…therapeutic alliance” towards reducing symptoms and improving functioning (Stanhope et al., 2013), while engaging clients in treatment decisions, not only provides clients’ with needed information and treatment options, but it allows them to feel actively involved in the treatment process thus increasing compliance rates (Klingaman et al., 2015).
While we seek to engage in shared decision making, there is one question that demands an answer. Are we as health practitioners treating the client, the disorder or the symptom (Kukreja, Kalra, Shah, & Shrivastava, 2013)?
References
Grim, K., Rosenberg, D., Svedberg, P., & Schön, U. (2016). 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. doi:http://dx.doi.org/10.3402/qhw.v11.30563
Jansen, J., Nagathan, V., Carter, S. M., McLachlan, A. J., Nickel, B., Irwig, L. et al. (2016). Too much medicine in older people? Deprescribing through shared decision making. British Medical Journal, 2016;353:i2893
Klingaman, E. A., Medoff, D. R., Park, S. G., Brown, C. H., Fang, L., Dixon, L. B., Hack, S. M., Tapscott, S. L., Walsh, M. B., Kreyenbuhl, J. A. (2015). Consumer satisfaction with psychiatric services: The role of shared decision making and the therapeutic relationship. Psychiatric Rehabilitation Journal, Vol 38(3), 242-248. http://dx.doi.org/10.1037/prj0000114
Krumholz, H. M. (2010). Informed Consent to Promote Patient-Centered Care.
The Journal of the American Medical Association, 303(12):1190-1191. doi:10.1001/jama.2010.309.
Kukreja, S., Kalra, G., Shah, N., & Shrivastava, A. (2013). Polypharmacy In Psychiatry: A Review. Mens Sana Monographs, 11(1), 82–99. http://doi.org/10.4103/0973-1229.104497
Mojtabai, R. & Olfson, M. (2010). National trends in psychotropic medication polypharmacy in office-based psychiatry. Archives of General Psychiatry, 67(1):26-36.
Stanhope, V., Barrenger, S. L., Salzer, M. S., Marcus, S. C. (2013). Examining the Relationship between Choice, Therapeutic Alliance and Outcomes in Mental Health Services. Journal of Personalized Medicine, 3, 191-202; doi:10.3390/jpm3030191
Competing interests: No competing interests