Shared Decision-Making (SDM) in healthcare prioritizes collaborative treatment choices between patients, clinicians, and families. While SDM offers numerous benefits in mental health, its implementation lags significantly behind physical health. This disparity stems from several key factors: the pervasive stigma surrounding mental illness and decision-making capacity, clinicians' concerns about liability, and the absence of a comprehensive, mental health-specific SDM model. Existing SDM frameworks in mental health suffer from inconsistent definitions, inadequate measurement tools, and a limited understanding of effective intervention components. This umbrella review addresses these shortcomings by systematically synthesizing evidence from existing systematic reviews and meta-analyses to define effective SDM practices in mental health and to pinpoint crucial elements for its successful implementation. The study aims to guide future research and improve SDM utilization within mental health settings, ultimately enhancing patient outcomes and promoting person-centered care.

The introduction highlights a scarcity of mental health-specific SDM models, leading to inconsistent definitions and measurement tools. The existing literature points to challenges in SDM implementation due to stigma, clinician liability concerns, and a lack of understanding of effective interventions. Several SDM models from physical health are cited (e.g., Charles et al., Integrative model, Three Talk Model, SDM 3 Circle model), but none are specifically designed for the nuances of mental health decision-making. The review emphasizes the need for a mental health-driven SDM model that accounts for factors such as fluctuating decision-making capacity and the involvement of family members and carers.

This study employed an umbrella review design, systematically synthesizing findings from multiple systematic reviews and meta-analyses. Nine electronic databases (CINAHL, PubMed, Scopus, MEDLINE, EMBASE, Cochrane Library, Web of Science, Scopus, and PsycInfo) were searched using keywords related to shared decision-making. Inclusion criteria focused on systematic and scoping reviews published between 2010 and 2021 that evaluated SDM interventions across various mental health settings and professional roles, targeting patients, healthcare professionals, or both. Reviews had to include primary research using quantitative, qualitative, or mixed-methods methodologies. The AMSTAR 2 tool assessed the methodological quality of included reviews, and GRADE ratings evaluated the quality of evidence. Data extraction included review characteristics, objectives, PICO elements, setting, methodology, SDM taxonomy, quality assessment, and results. The corrected covered area (CCA) index addressed potential overlap between primary studies across reviews. A narrative synthesis summarized the findings due to heterogeneity across the included reviews, preventing meta-analysis.

The literature search yielded 7,383 records, resulting in 10 eligible systematic reviews and 100 non-overlapping primary studies (47,846 participants). The included studies spanned 16 high-income countries. The methodological quality of the included reviews was generally poor (60% critically low, 30% low, 10% high). All reviews reflected a medical perspective, emphasizing decision aids (DAs) for psychopharmacological decision-making within patient-clinician dyads. Only three reviews adopted broader psycho-educational perspectives. Key SDM components mentioned included providing decision support (10/10 reviews), while others like clarifying understanding (1/10 reviews) were less frequently cited. Crucially, essential components for mental health interactions like building trust and addressing recovery were missing from the models. The primary studies were spread across various settings (mental health hospitals, general hospitals, community mental health settings, community health settings) and addressed a range of mental health conditions (schizophrenia-spectrum disorders, SMI-related disorders, depressive disorders). SDM interventions included decision support tools (DSTs) only, multicomponent interventions with or without DSTs, and shared care planning interventions. The CCA indicated a low degree of overlap (4%) between primary studies across the reviews. The majority of studies (43%) were published between 2015 and 2020. The identified measurement tools lacked validation for people with mental illness. There was also a notable lack of consensus on primary outcomes, with a bias towards clinical outcomes (hospitalizations, symptoms) rather than recovery-oriented outcomes (empowerment, self-efficacy).

This umbrella review offers a novel perspective on SDM in mental health, moving beyond the traditional dyadic model (patient-clinician) to advocate for a polyadic approach, involving family members, peer support workers, and non-psychiatric healthcare professionals. Decision aids, while useful, only address information exchange and neglect crucial aspects like deliberation and building rapport. The recovery model necessitates a holistic approach to SDM, encompassing diverse decisions (social prescribing, therapy choices) and addressing issues such as stigma. The review highlights the inadequate use of recovery-oriented outcomes in existing SDM research. Current SDM interventions lack a person-centered approach, failing to incorporate personal values, preferences, and cultural contexts. Addressing these gaps requires developing new measurement tools and interventions collaboratively with patients, clinicians, and family members, ensuring cultural sensitivity and incorporating sociocultural backgrounds and experiences. The focus should shift to person-driven measurement approaches and participatory research methods to improve service quality and impact, aligning clinical outcomes with patient-valued recovery-oriented outcomes.

This umbrella review provides a comprehensive overview of SDM in mental health, advocating for a paradigm shift toward polyadic SDM that incorporates diverse stakeholders, embraces recovery-oriented outcomes, and prioritizes person-centered care and participatory research methods. The findings highlight the critical need for new SDM measures, interventions, and decision aids developed and validated specifically for people with mental illness, considering diverse populations and sociocultural factors. Future research should focus on the development of collaborative measures and interventions, ensuring a genuine, inclusive, and effective SDM process within mental healthcare.

The study's limitations include the heterogeneity of the included reviews, preventing meta-analysis. The narrative synthesis relied on detecting statistically significant differences in outcomes, not accounting for effect sizes. The review excluded non-English studies and studies involving children under 18. The bias towards high-income countries limits the generalizability of the findings to diverse populations and healthcare systems.