Dissertations & Theses (Open Access)

Date of Award

Spring 5-2020

Degree Name

Doctor of Public Health (DrPH)


Melissa A Valerio-Shewmaker Phd

Second Advisor

Eric C. Jones, Phd

Third Advisor

Robert O Morgan Phd


Severe mental illness in adults refers to a group of mental health conditions including schizophrenia and schizoaffective, bipolar and major depressive disorders. These conditions are often characterized by recurring symptoms, multiple hospitalizations, and significant disability. The public health concern with these conditions is amplified because many individuals with severe mental illness fail to engage in outpatient treatment. Methods to support greater rates of participation in outpatient treatment are needed. Encouraging participation in medical decision making is viewed as one method to optimize patient empowerment, increase engagement in care and decrease the negative outcomes that often characterize this population. Shared Decision Making (SDM) is a collaborative and structured approach to patient-provider communication viewed as a negotiation between mutual experts with the goal of balancing empirical information with patient values and preferences. This was a cross-sectional mixed methods study examining SDM in a sample of individuals with severe mental illness who have recently been discharged from emergency rooms and inpatient psychiatric facilities. Extant data on decision-making preferences and a variety of clinical, demographic and communication variables were analyzed on 258 individuals with severe mental illness during a baseline visit at a transitional care clinic serving individuals immediately after hospital discharge. The association between clinical, demographic and communication characteristics and patients’ self-reported decision-making preference (active, collaborative, or passive) were examined using chi square and one-way analyses of covariance. In addition, we conducted semi-structured qualitative interviews with 15 individuals with serious mental illness a variety of clinical providers (n = 9). Results from the quantitative analyses indicated that race/ethnicity was significantly associated with the SDM preference group, with African American individuals desiring more active participation in decision making compared to their Hispanic counterparts. Other characteristics were not significantly associated with the patient’s baseline decision-making preferences in this context. Qualitative data were analyzed using latent thematic analysis and six themes were identified including: 1) Differences in the Use of SDM, 2) Consideration of Past Experiences, 3) Decisional Power Preferences, 4) Use of SDM in Psychiatry Versus Other Areas of Medicine, 5) Dignity and Disengagement, and 6) External Forces Impacting SDM. These findings indicate race/ethnicity may be an important factor when using a SDM approach. Implications for clinical practice and research using a SDM approach within this treatment setting are further discussed.