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Abstract
Introduction Mental health disorders, particularly depression and anxiety, are widespread globally and necessitate effective solutions. The patient-centred approach has been identified as a viable and effective method for addressing these challenges. This paper synthesised the principles of patient-centred mental health services and provides a comprehensive review of the existing literature.
Materials and methods This is a qualitative content analysis study conducted in a systematic review framework in 2022. PubMed, Scopus, ProQuest and Cochrane databases were systematically searched, and by screening the titles, abstracts, and the texts of studies related to the purpose of the research, the data were extracted. Evaluation of the quality of the studies was done using the CASP checklist for qualitative studies. After selecting the final studies based on the entry and exit criteria, subsequently, a thematic analysis of findings was conducted on the data obtained from the systematic review.
Results The database search produced 6649 references. After screening, 11 studies met the inclusion criteria. The quality scores indicated the studies were of high level of quality with acceptable risk of bias. The thematic analysis identified six major principles of patient-centredness in mental health services: education, involvement and cooperation, access, effectiveness and safety, health and well-being, and ethics.
Conclusions Patient-centredness is a complex approach in mental health services. The principles and elements of patient-centredness foster positive patient outcomes, enhance healthcare quality and ensure compassionate and effective care. Upholding these principles is crucial for delivering patient-centred, ethical and effective mental health services. Furthermore, the study found that patient education can boost adherence and satisfaction, and decrease unnecessary hospitalisations. Patient involvement in decision-making is influenced by their age and the relationship with their psychologists. And, effective leadership and resource management can enhance clinical processes and patient-centredness in mental health services.
- Patient satisfaction
- Mental health
- Patient-centred care
- Healthcare quality improvement
- Health services research
Data availability statement
No data are available.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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- Patient satisfaction
- Mental health
- Patient-centred care
- Healthcare quality improvement
- Health services research
WHAT IS ALREADY KNOWN ON THIS TOPIC
Patient-centred care in mental health services has multiple principles and elements with numerous causal relationships which need to be probed and researched.
WHAT THIS STUDY ADDS
This paper accumulates the principles and elements of patient-centred care in mental health services and provides a report on the causal relationships of each principle with other issues in healthcare service delivery based on the existing evidence.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
The research provides some evidence on the causal relationships of each principle of patient-centred care for healthcare administers and policy-makers and underscores the need for future research to concentrate more on patients’ experiences during treatment (patient-reported experience measures) rather than solely on treatment outcomes (patient-reported outcome measures).
Introduction
Mental health disorders are a significant challenge for society, affecting a large number of individuals worldwide. According to the WHO, depression impacts over 264 million people while anxiety disorders affect 3.76% of the global population. Addressing mental health concerns and providing effective support is crucial.1 An international study estimated that 13.4% of children and youth worldwide had mental health problems; anxiety and disruptive behaviour disorders were the most common.2 Mental health is a condition of well-being that involves the biological, psychological and social aspects of an individual’s life. It can be defined by the lack of mental illness and the existence of positive mental states.3
It is shown using the patient-centred approach in the provision of mental health services can be a feasible and effective solution to address the challenges in mental health services, according to multiple studies.4–6 Patient-centredness is an approach to clinical services that considers and respects the wishes, preferences, values and essential needs of patients with the ultimate goal of enhancing their participation in their clinical care management, based on the conventional definition of patient-centred care in the literature.7
Multiple terms are frequently misapplied in scholarly discourse concerning patient-centred care, including the term ‘person-centred care’ while patient-centred and person-centred care have key differences. The former emphasises the individual’s values in clinical decisions. The latter, however, takes a holistic view, considering the individual’s context and broader role in health.8
Patient-centred care is characterised by an approach that underscores the importance of respecting and addressing the preferences, needs and values of each individual under care, thereby ensuring that the recipient’s values serve as the cornerstone for all clinical deliberations. Conversely, person-centred care places particular emphasis on comprehensively considering the entirety of an individual, recognising them as a unique entity with discernible objectives, requirements and preferences extending beyond mere medical concerns.9 Although both methodologies share commonalities such as empathy, respect, active engagement and collaborative decision-making, their principal disparity lies in their overarching objectives: patient-centred care endeavours to ensure that clinical decisions are congruent with the patient’s values, whereas person-centred care strives to facilitate a fulfilling existence for the individual.10
Our endeavour was to confine the research scope exclusively to patient-centred care within the study. This decision was made with the intention of distinguishing between the two terms and initiating a clear differentiation of the two concepts within the manuscript. Our aim was to enhance the precision of our paper and to enlighten future readers regarding the distinction between these concepts. By doing so, we aimed to prevent the perpetuation of misconceptions within the literature, fostering a clearer understanding for future scholars to discern between the two concepts.
Various international organisations, such as the G-20 summit, a prominent international forum, have acknowledged the necessity of patient-centred. They have highlighted the significance of this approach as a strategic policy for developing and implementing healthcare plans.11 Patient-centredness comprises various dimensions and components. These can be identified to improve the quality of healthcare services. This can be achieved by developing measures to assess patient-centredness and by providing feedback to healthcare providers.12
Patient-Reported Measures (PRMs) are standardised quantitative data collection tools that obtain reports from patients about their health status or experiences of receiving care services. They can capture content specific to the perspectives and experiences of patients, making them especially useful for promoting and evaluating patient-centred care.13 PRMs have two main categories: Patient-Reported Outcome Measures (PROMs) and Patient-Reported Experience Measures (PREMs). PROMs measure a patient’s health status at a specific point in time while PREMs include questions about patients’ experiences of receiving care.13
This paper aims to add on the literature by synthesising the existing principles and elements of patient-centredness of mental health services, by providing a comprehensive review of the existing reviews in the literature through conducting a review on multiple scientific databases.
Materials and methods
This paper presents a rigorous qualitative content analysis that was conducted in 2023 to systematically review the literature from 2000 to 2023. The main aim of this study was to determine elements of patient-centredness in mental health services.
Data collection and search method
To identify all the articles published on elements of patient-centredness in mental health services from 2000 to 2023, a comprehensive search was performed, exclusively in English on Searched on 28 August 2023. The search covered four databases: PubMed, Scopus, Cochrane and ProQuest. MeSH terms were used to group all the keywords into three categories: element, patient-centredness and mental health. The keywords within each category were combined using the logical operator ‘OR’. The three categories of keywords were then joined using the logical operator ‘AND’. The EndNote V.20.2.1 software was employed for reference management. Table 1 illustrates the search strategy.
Search strategy
Inclusion and exclusion standards
The inclusion criteria for this study encompassed articles published in English from 2000 to 2023 that concentrated on elements of patient-centredness in mental health services. Articles unrelated to the purpose of the research, and those whose text was not accessible, were excluded from the study. Moreover, articles that were assessed as low quality based on the quality assessment score using the respective checklists mentioned in the quality assessment section were eliminated. Furthermore, certain types of articles such as short communications, letters to the editor and other irrelevant publications were disregarded.
Screening and data retrieval
The article selection for the review followed the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart. Articles that were duplicated were removed, and the remaining ones were assessed based on their title and abstract. Articles that were not relevant to the research objective were discarded, and the full text of the remaining articles was carefully scrutinised. Only those that met the eligibility criteria were included in the final analysis. This entire process was independently carried out by two researchers. In cases of disagreement regarding the results of the procedure, consultation with other authors was sought to finalise the screening process. Data from the final articles that were consistent with the study objective were independently extracted by two authors. Microsoft Office Excel 2016 was used to create a data extraction form for the purpose of data collection. This form consisted of sections such as authors, title, year of publication, country of origin, type of study, purpose of the study and a summary of the results.
Quality appraisal of final studies using the CASP checklist
The quality of the studies and the risk of bias within them were assessed using the Critical Appraisal Checklist Programme (CASP) checklist for qualitative studies, comprising 10 questions.14 A scoring method of yes=2, can’t tell=1, no=0 was applied to the appropriate quality assessment checklist according to the study design. The scoring range percentage varied from 0 to 100, with higher scores indicating higher quality. The studies were divided into four quality levels: very low quality (0–25), low quality,15–39 medium quality (51–75) and high quality (76–100). Only studies that were rated as medium or high quality were considered eligible for research purposes.
Data analysis
A qualitative thematic analysis and an inductive approach were employed to examine the data obtained from the previous steps.40 The authors meticulously scrutinised the chosen articles, repeatedly examining the extractions to ensure a comprehensive understanding of the data. Initial codes were assigned to each pertinent extraction. These preliminary codes underwent a rigorous review process and were finalised before being categorised into subthemes and primary themes. Subelements, elements and principles were subsequently identified, defined and tabulated. To bolster the validity and reliability of the results and mitigate potential errors or biases, the authors diligently repeated the steps involved in the thematic analysis. Any disagreements that emerged during this process were addressed through discussions with the other authors.
Results
This section presents the findings of the systematic review, the quality assessment of the selected studies and the thematic analysis of the data extracted from the studies.
Systematic review
As delineated in figure 1, the database search yielded 6649 references, of which 387 were duplicates. After screening the titles, abstracts and full texts, 11 studies met the inclusion criteria and were selected for the study. The selected studies consisted of systematic reviews and scoping reviews that focused on specific topics such as adolescent depression, depression and anxiety. They examined the experiences and outcomes of mental health and well-being for children, adolescents and adults with mental health problems. They also reviewed various measures, such as self-report measures and PREMs, to inform practice and policy. Furthermore, the studies were retrieved from databases such as Scopus, PubMed, ProQuest and Cochrane. Moreover, the detailed information regarding the final studies is presented in online supplemental appendix 1 (bibliography of final studies).
Supplemental material
PRISMA diagram. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
Quality assessment of final studies
The quality assessment of the 11 studies using the CASP checklist is presented in table 2. The assessment revealed that all 11 studies had a clear focus and an appropriate design. However, the comprehensiveness of the literature search was unclear. The quality scores of the studies ranged from 12/16 to 14/16, with most studies scoring 14/16. This indicates that the majority of the studies were of high quality. Moreover, the risk of bias was within an acceptable level. Further detail is presented in online supplemental appendix 2 (quality assessment of final studies).
Supplemental material
Quality assessment of final studies included in the study using the CASP checklist.
Thematic analysis
As shown in table 3, the thematic analysis outlines the principles and elements of patient-centredness in mental health services. The data are organised into several principles, each comprising its own set of elements and subelements. These principles include education, involvement and cooperation, access, effectiveness and safety, health and well-being, and ethics.
Thematic analysis of data obtained from the final studies
Under the principle of education, elements such as disease information are present, which encompasses subelements such as information about mental health problems and treatment, information exchange, information on services and psychoeducation.
Under the principle of involvement and cooperation, elements such as family and friends are present, which includes the subelement involvement of family and friends. Additionally, there is the element of interpersonal relationships, which comprises subelements such as therapeutic alliance, therapist–patient alliance, staff-patient alliance, therapist attitude and behaviour, coordination of care, and communication.
Under the principle of access, there is the element of prompt access, which encompasses subelements such as access to care, prompt attention, access to services and service reception.
Under the principle of effectiveness and safety, elements such as drug therapy are present, which includes subelements such as effectiveness, side effects and convenience of drug therapy. Additionally, there is the element of psychological care, which comprises subelements such as psychological intervention, cognitive improvement, sharing of emotions and experiences.
Under the principle of health and well-being, elements such as emotional and psychological well-being are present which include subelements such as anxiety, depression, moods and emotions. Additionally, there is the element of behavioural well-being which includes subelements such as rule-breaking behaviour.
Under the principle of ethics, there is the element respect and dignity which includes subelements such as dignity and confidentiality.
Discussion
The results of the thematic analysis revealed six major principles of patient-centredness in relation to mental health services. In this section, an initial analysis and discussion of each principle identified within the research will be conducted. Subsequently, an overarching examination of patient-centred care within mental health services will be provided.
Education
As reported by the findings of the study, the provision of education and information to patients has been identified as a key element of patient-centredness within mental health services. This includes providing information about mental health problems and their treatment, facilitating the exchange of information between patients and healthcare providers, and offering psychoeducation to support patients in managing their condition. These measures have been shown to be effective in promoting patient engagement and improving outcomes in mental healthcare.41 42 Roughly, 18% of the included studies reported such elements of patient-centred care within their manuscripts.
The provision of education and information regarding their ailments to patients within healthcare environments can yield numerous beneficial outcomes. Studies have demonstrated that such initiatives can foster enhanced participation in collaborative decision-making processes, bolster adherence to prescribed medications and treatments and elevate levels of patient satisfaction concerning the care they receive.16 17 Moreover, it has been observed to exert a positive influence on clinical results and contribute to a reduction in hospital admissions.18
Furthermore, the practice of educating patients about their diseases can lead to improvements in the effectiveness, efficiency and quality of health services. It can also enhance the quality of life for patients and promote the quality and accountability of health services.17 Thus, patient education and information dissemination are integral components of patient-centred healthcare delivery network.
Involvement and cooperation
As found in the results of the study, patient-centredness in mental health services entails engaging and collaborating with patients, their families and their friends; enabling patients to exercise autonomy and dignity; and fostering interpersonal relationships between healthcare personnel and patients.15 41–48 Approximately, 82% of the included studies referred to such elements of patient-centred care within their papers, which delineates the significant importance of the principle of ‘involvement and cooperation’ in the realm of patient-centred care in mental health services.
The active participation of patients in medical decision-making processes can profoundly influence both health outcomes and the degree of patient satisfaction. It has been observed that the active engagement of patients in medical decision-making processes can yield positive effects on psychosocial outcomes in the short term.19 Nevertheless, the extent of such involvement is subject to variation and is shaped by a multitude of factors. These include but are not limited to, the patient’s age, their level of education and the degree of trust they place in their therapists.20–23
Various strategies, such as tailored approaches and education programmes, have been proposed to address age-related challenges in patient involvement in healthcare services. Tailored approaches involve implementing age-specific strategies to enhance patient engagement, while education programmes empower patients of all ages to participate actively in their healthcare decisions.24 25 Meanwhile, health literacy initiatives, including educational campaigns and simplified communication by healthcare providers, can mitigate educational disparities among patients, enabling informed decision-making.24 25 Furthermore, it is indicated that the establishment of effective communication and a positive rapport between healthcare providers and patients can enhance the degree of trust and ultimately patient participation in decision-making processes.19 21
Access
As reported by the findings of the study, patient-centredness in mental health services requires timely access to healthcare services and attentive care from healthcare staff towards patients.41 43 Approximately, 27% of the included studies included within this review referred to the concept of ‘access’ as a principle of patient-centred care in mental health services.
Prompt access to healthcare services, coupled with diligent care, can yield numerous beneficial impacts. These include but are not limited to, improvements in health outcomes, heightened patient satisfaction and a reduction in healthcare-related costs.26–28 Furthermore, a particular study has highlighted a robust correlation between the possession of a consistent source of care and the timely acquisition of screening services. This relationship can subsequently contribute to the enhancement of health outcomes.28
Expectations of patients in the healthcare sector are on a continual rise. The effective management of these expectations can lead to the enhancement of outcomes and a reduction in instances of patient dissatisfaction.26 Furthermore, healthcare providers who are dedicated to serving uninsured clients have occasionally implemented specific interventions and programmes tailored for individuals with chronic illnesses. These initiatives aim to foster continuity of care and effective disease management, which can subsequently lead to a reduction in healthcare costs.28
Unwarranted delays and extended periods of waiting can not only lead to patient frustration but also pose potential risks to patients, particularly those with underlying medical conditions.27 In this regard, digital solutions are delineated to be instrumental in mitigating inefficiencies within the healthcare system. Through the integration of digital approaches within a hybrid healthcare framework, patients can seamlessly transition between virtual and physical care settings, resulting in notable reductions in delays and unnecessary treatments.29
Effectiveness and safety
As reported by the findings of the study, the effectiveness and safety of various aspects of care, including drug therapy, psychological care, the care environment and continuity of care, have been identified as important principles of patient-centrednesss in mental health services. Ensuring that these principles and elements of care are delivered in a manner that is both effective and safe is essential for promoting positive outcomes for patients and supporting their recovery.41–44 47 Approximately, 64% of the included papers within this study reported the principle of ‘effectiveness and safety’ within the realm of patient-centred care in mental health services.
The effectiveness and safety of care are influenced by individual, organisational and environmental factors. These include supportive leadership, proper planning, education, training and resource management, which enhance medical service quality.30 The availability of resources and differences in internal and external factors also impact service quality and patient outcomes.30 Access to care, including its availability, timeliness, convenience and affordability, affects healthcare utilisation.31 Technical quality which is the care’s effectiveness in achieving health gains while interpersonal quality which is patient satisfaction.30 Patient safety principles which aim to create a reliable healthcare system that minimises adverse events.32 Lastly, a culture of quality and safety which is a crucial domain of healthcare effectiveness and safety.27
Health and well-being
As reported by the findings of the study, the health and well-being of individuals, encompassing emotional and psychological, behavioural, social and interpersonal, physical, and self-concept and personal aspects of life, has been identified as an important pillar of patient-centredness in mental health services. Ensuring that these aspects of an individual’s well-being are addressed and supported through the provision of care is essential for promoting positive outcomes and supporting recovery.15 41–45 48–50 About 91% of the studies incorporated in this paper delved into the principle of ‘health and well-being’ as an integral component of patient-centred care in mental health services.
Numerous factors contribute to an individual’s overall health and well-being. These include the social environment, encompassing socioeconomic status, education and social support.33 34 Lifestyle choices, particularly unhealthy ones such as poor diet, sedentary behaviour and excessive technology use, can negatively affect both physical and mental health.35 Behavioural and biological responses, including how individuals react to symptoms or diagnoses, their ability to engage in work, family, and community activities, and their overall well-being, can also influence health outcomes.33 Safety, a crucial determinant of health, protects against illness, injury or death.36 Psychological factors such as social gradient, stress and social exclusion can impact health and well-being. Lastly, community infrastructure elements such as food and transportation availability can also affect health outcomes.36
Ethics
As reported by the findings of the study, ensuring respect and dignity for patients, as well as maintaining the confidentiality of their personal data, have been identified as major pillars of patient-centredness in mental health services. These principles are essential for building trust and promoting positive relationships between patients and healthcare providers and are fundamental to the provision of compassionate and effective care.41 Roughly, 1% of the papers included in this study referenced the principle of ‘ethics’ concerning patient-centred care in mental health services within their manuscripts.
Ethical considerations in healthcare services can differ based on the setting, but common issues include confidentiality, which involves protecting patients’ personal information, especially in the era of electronic health records.37 Informed consent is another crucial aspect, requiring patients to be informed about their medical condition and the risks and benefits of proposed treatments, with their consent obtained before treatment.38 Meanwhile, dignity and respect are paramount, with providers obligated to treat patients with dignity and respect, irrespective of their race, ethnicity, gender or socioeconomic status, and to respect their cultural and religious beliefs.39 Interestingly, resource allocation can present ethical dilemmas, particularly when resources are scarce, such as organs for transplant or vaccines during a pandemic.51 Finally, end-of-life care can also pose ethical dilemmas, such as deciding whether to continue life-sustaining treatment for a terminally ill patient.52
Various strategies have been proposed to enhance respect for patients’ cultural and religious beliefs. These include providing cultural competence training to healthcare professionals, integrating culture-specific values into health promotion efforts and offering cultural awareness training to increase understanding of diverse cultures and their impact on healthcare.53–56 Furthermore, several strategies have been proposed to navigate ethical dilemmas in resource allocation. These strategies include seeking accurate information through fact-finding, fostering objectivity by stepping back to assess situations, consulting with colleagues or ethical committees for guidance and prioritising patient well-being by advocating for fair resource allocation.57
An overall look at patient-centred care in mental health services
As delineated in the previous sections of the study, patient-centred care within mental health services embodies a clinical approach that emphasises patient education and empowerment regarding their conditions and treatment processes. It entails actively involving patients in the decision-making process concerning their care, granting them autonomy while collaborating with various professionals and experts across multidisciplinary fields to ensure the delivery of comprehensive, holistic and evidence-based treatment. Additionally, it involves removing existing barriers to access clinical services, thereby facilitating patient engagement and acquisition of necessary care. Furthermore, it prioritises the provision of effective, outcome-based interventions while mitigating risks of adverse effects across diverse care domains. Central to this approach is the prioritisation of patient health and well-being, upheld within the framework of ethical norms and standards.
Although our findings were consistent with previous literature, which indicated that patient-centred care transcends the conventional emphasis on clinical outcomes to tackle the intricacies of the healthcare system by involving families and communities in care provision and adapting service structures to promote patient-centredness.5 Our results underscored the continued significance of clinical outcomes as a fundamental principle of patient-centred care in mental health services. This divergent finding may be attributed to our objective of distinguishing between the concepts of patient-centred and person-centred care within the study.
Figure 2 delineates the interconnectivity and causal relationships between each of the principles and the issues within the process of healthcare service delivery within healthcare systems as addressed and discussed throughout the previous sections of the study.
Principles and elements of patient-centredness in mental health services and their corresponding casual effects.
Limitations and implications
This study was subject to certain limitations. First, it incorporated only 11 studies due to a dearth of research within the context, suggesting an opportunity for future researchers to conduct original investigations on the principles and measures of patient-centred care within mental health services, with an emphasis on deriving measures from them. Second, as the study’s results indicated, the majority of the included studies were centred on the outcomes of mental health services (PROMs), as opposed to the experiences of patients during the treatment process (PREMs). This observation underscores the need for future research to concentrate more on patients’ experiences during treatment (PREMs) rather than solely on treatment outcomes (PROMs). Due to the differentiation between patient-centred care and person-centred care, as well as the constrained scope of the study, our research solely encompassed papers pertaining to patient-centred care, thereby excluding those related to person-centred care. In this regard, the methodology employed in our study to differentiate between the concepts of patient-centred and person-centred care may serve as a valuable implication for future researchers to follow. Lastly, the findings of this paper can serve as a valuable resource for healthcare policy-makers and administrators in their efforts to devise plans and initiatives that promote patient-centred care within their respective organisations.
Conclusions
Patient-centredness in mental health services involves key principles such as patient education, engagement, timely healthcare access and quality care. These contribute to improved health outcomes and reduced costs. Respect and confidentiality are crucial in building trust. Moreover, patient education enhances adherence and satisfaction and reduces hospital admissions. While, effective leadership improves clinical processes, leading to enhanced patient-centredness. Further research is needed to concentrate more on patients’ experiences during treatment (PREMs) rather than solely on treatment outcomes (PROMs).
Data availability statement
No data are available.
Ethics statements
Patient consent for publication
Acknowledgments
Here, we acknowledge the contribution of Bing AI chatbot in rewriting the text of the manuscript to adjust it in terms of English language nativity and grammar.
References
Supplementary materials
Supplementary Data
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Footnotes
Contributors MK conducted the search within the databases; MK and RI extracted the data and conducted the analysis; MK wrote the introduction, results and discussion sections; RI wrote the methods section. GA cooperated in writing the discussion section and consulted with the authors during each phase of the study. MK is the guaranteer of the overall content published within study.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.