A patient decision aid for bipolar disorder

Full title: MCDA-Based

Support in Clinical Decision-Making Throughout the

Patient Journey: The Use of ALBA in

Bipolar Disorder

Øystein Eiring, MD, specialist in psychiatry, cand. mag, PhDc. Editor Norwegian Electronic Library of Health/Mental Health

Head of Department of Knowledge Services, Innlandet Hospital Trust

My affiliation

The community developing

MCDA-based, Annalisa patient

decision aids

My affiliation

04/12/2023

4

The Norwegian Electronic Health

Library

04/12/2023

5

• Free access• for clinicians and

patients • nation-wide

GuidelinesJournals

DatabasesTextbooksNylenna M, Eiring Ø, Strand G, Røttingen JA.

Wiring a nation: Putting knowledge into action. Lancet 2010; 375: 1048–51

My affiliation

The University of Oslo (enhanced)

Menu

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Context

Three problems (and solutions)

Summary

Patient decision aids

• Tools for personalised decisions

• Many personalisation technologies

• Very limited use of technologies

Eiring Ø, Slaughter L. An Assessment of the Potential for Personalisation in Patient Decision Aids. Lecture Notes of The Institute for Computer Sciences, Social Informatics and Telecommunications Engineering Volume 91, 2012, pp 51 - 57

Bipolar disorder

• Singapore: 1,2 %

• Cross-national 0.3 – 1.5%

Chong SA, Abdin E, Vaingankar JA, Heng D, Sherbourne C, Yap M, Lim YW, Wong HB, Ghosh-Dastidar B, Kwok KW, Subramaniam M. A population-based survey of mental disorders in Singapore. Ann Acad Med Singapore 2012 Feb;41(2):49-18

Bipolar disorder I

• Chronic

• Suicide risk

• Relapses

• ”Never well”

• Impairment

• Medication mainstay in treatment

Outpatient psychiatry in Hamar, Norway

A challenging encounter

Why can´t I stop my medication?

It really bothers me. I would be much better

without!

With permission. iStockphoto. The person depicted has no relation to the subject and the picture is for illustrative purposes only.

You must continue taking it!If not, you will certainly have a

relapse again.You don´t remember how bad it

was, but I do

(Not shared decision-making)

New attempt!(shared decision-making)

Why can´t I stop my medication?

It really bothers me. I would be much better

without!

Ok, lets try to find the best decision together

What are the benefits and harms you care about?

And how likely are they, with and without medication?

Three patient roles

Doctor knows best

Consumer

Shared decision-making

Stubblefield C, Mutha S. Provider-patient roles in chronic disease management. J Allied Health. 2002 Summer;31(2):87-92.

The goal

• Find - together

• the best decision

• for you

And to achieve the goal…

• Find the:

• options

• attributes

• probabilities

• preferences

In example, hypothetical:

Options Suicide risk

Relapse risk

Nausea risk

Medicine A

2 % 25 % 10 %

Medicine B

1 % 35 % 1 %

Four sources of knowledge

Electronic medical record

All the research in the world

Problem 1

Knowledge not tailored to decisions

• All options not directly comparable

• Not personalised

• Not always reliable

• Not always readable

• Tells nothing in itself, without preferences

All the research in the world

A possible solution: Network meta-analysis

Top of the 6S model

High quality single studies

Single studies

Systematic reviews

Network m.a.

Summary

InEMR

ReadableRelevantReliable

Dicenso A, Bayley L, Haynes RB. Accessing pre-appraised evidence: fine-tuning the 5S model into a 6S model. Evid Based Nurs. 2009 Oct;12(4):99-101

A network of studies

Vergel YB, Dunn G, Palmer S, Beynon s, Woolacott N, Soares-Weiser K, Geddes J, Gilbody S. A Simultaneous Comparison of Multiple Treatments for Bipolar I: An Application of Bayesian Statistical Methods. Poster

Direct and indirect comparisons

Vergel YB, Dunn G, Palmer S, Beynon s, Woolacott N, Soares-Weiser K, Geddes J, Gilbody S. A Simultaneous Comparison of Multiple Treatments for Bipolar I: An Application of Bayesian Statistical Methods. Poster

Part 1 of the work

• Complete two network meta-analyses

Problem 2

Knowledge not operational

• Information about the effects of medicines taken is

• not systematic

• not quantified

• (Often lacking)

• not structured

• not available to the patient

Electronic medical record

A possible solution: An Annalisa decision aid

Enabling continuous registration of attributes

• Example: depressive symptoms

• Patient registers level of depression weekly

• Feeds into the decision aid

• Assessment of the effect of the medication

• continuously and in retrospect

Will visualise changes over time

Part 2 of the work

• Developing the Annalisa decision aid

Problem 3

How to evaluate a personalised intervention?

The problem with group designs

• Take considerable time and resources

• No improvement of intervention on-the-fly

• Do not establish causality in the individual

Kazdin AE. Single-Case Research Designs: Methods for Clinical and Applied Settings, 2nd Edition. New York, Oxford. 2009.

A possible solution: single-subject design

Single subject designs

• Extensive use within behavioural sciences

• Internal validity maintained

• Mimics and feasible within clinical practice

• Not the same as case studies!

Benefits• Assesses effect in the individual patient

• Identifies causal relationships

• External validity comparable to group designs

• Determines efficacy in novel interventions

• Helps optimalise the intervention

• Design and intervention can be adjusted on the fly

ABAB design

Non-concurrent, multiple baseline design

Combined

3 novelties in this work

Novelty 1:

Complete NMAs and feed the values into the desicion aid

Novelty 2:

• Continuous registration of attributes important to the patient

• in a decision aid

engineered for

distributed decisions

Novelty 3:

• Utilising a single subject research design…

• to evaluate a patient decision aid

Flexible yet rigorous

A personalisable:

• decision aid

• assessment tool

• study design

Thank you