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Decision-Making in Stepped Care for Common Mental Health Problems
[Thesis]. Manchester, UK: The University of Manchester; 2011.
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Abstract
Stepped care is designed to provide mental health treatment in the most effective and efficient way. It aims to provide patients with low intensity interventions in the first instance and only move onto high intensity treatments if outcome is not ‘successful’. However, there is a paucity of research about how health professionals make decisions about treatment and the experiences of patients within this decision-making process. Using a multi-method approach, this study aimed to explore health professional and patient decision-making in stepped care for anxiety and depression. 24 health professional interviews from three stepped care sites were conducted, which included the completion of an active information search (AIS) think-aloud task. In addition, 14 patients were interviewed about their experiences of decision-making whilst being managed within stepped care model. Qualitative interview data was analysed using the principles of Framework analysis, while some of the data collected in the AIS think-aloud task lent itself to quantitative analysis.This study revealed that three core tensions exist when making decisions within the stepped care model. These are 1. The notion of standardisation of outcomes versus the individual needs of patients; 2. The public health orientation of stepped care versus the therapeutic orientation of health professionals and; 3. The rhetoric about patient choices versus the realities of shared decision-making in a resource-limited system.The complexity of decision-making within the stepped care model was highlighted. The success of stepped care relies on ensuring that there is an adequate workforce to deliver the intended interventions, where this is not present health professionals are faced with difficult decisions and it is clear that those most affected are the less-experienced frontline workers. Scarcity of resources impacts heavily upon the decisions that are made. This can have a substantial impact upon variability in treatment decisions and on the ability to allow for patient choice to be incorporated. Decisions that are made for a patient are influenced by the need to provide them with the treatment that they want (which may not be regarded as what they need within the stepped care model nor necessarily by the health professional) and the capacity of the service. The problem that exists with primary care mental health is that the current demands exceed capacity. Optimal patient care is, in part, traded off by the need to meet the demands of the service. Improving the flexibility of the service may be one solution to the problem and adopting a stratified/stepped care approach might help to resolve some of the tensions and help to relieve some of the capacity issues.