Skip to main content


Supported Decision-Making for Persons with Mental Illness: A Review

Article metrics

  • 2513 Accesses

  • 23 Citations


Persons with mental illness (PWMI) are often not afforded the same opportunity to make decisions on a par with others in society. Article 12 of the International Convention on the Rights of Persons with Disabilities (CRPD) states that persons with disabilities should have equal recognition before the law and the right to exercise their legal capacity. Exercising legal capacity can mean making decisions about employment, medical or psychosocial treatment, property, finances, family, and participation in community activities. The aim of this paper is to comprehensively review the evidence on supported decision making for PWMI, both in legislation and research globally, with a focus on low- and middle-income countries (LMICs). Results reveal only a few countries have provisions for supported decision-making for PWMI, with a particular shortage of such provisions in legislation in LMICs There is also a general paucity of research evidence for supported decision-making, with the majority of research focusing on shared decision-making for treatment decisions. This review highlights the need for additional research in this area to better guide models, which can be utilised in domestic legislation, particularly in LMICs, to better implement the ideals of Article 12 of the CRPD.


  1. 1.

    Commissioner for Human Rights. Who gets to decide? Right to legal capacity for persons with intellectual and psychosocial disabilities. Strasbourg, France: CommDH/Issue Paper. Council of Europe; 20 February 2012.

  2. 2.

    Dhanda A. Legal capacity in the disability rights convention: stranglehold of the past or lodestar for the future? Syracuse J Int Law Commerce. 2007;34:429–62.

  3. 3.

    Bach M. Supported decision making under Article 12 of the UN Convention on the Rights of Persons with Disabilities: questions and challenges. Athlone, Ireland: Parents’ Committee of Inclusion Ireland; 3 November 2007.

  4. 4.

    Lawson A. The United Nations Convention on the Rights of Persons with Disabilities: new era or false dawn? Syracuse J Int Law Commerce. 2007;34:563–620.

  5. 5.

    McSherry B. Rethinking mental health laws: international trends. Samos Island, Greece: 12th Greek/Australian International Legal and Medical Conference; 4 June 2009.

  6. 6.

    Dinerstein RD. Implementing legal capacity under Article 12 of the UN Convention on the Rights of Persons with Disabilities: the difficult road from guardianship to supported decision-making. Human Rights Brief. 2012;19:8–12.

  7. 7.

    Srebnik D, Livingston J, Gordon L, King D. Housing choice and community success for individuals with serious and persistent mental illness. Community Ment Health J. 1995;31:139–52.

  8. 8.

    Rose S, Black B. Advocacy and Empowerment: Mental Health Care in the Community. Boston, MA: Routledge & Kegan Paul; 1985.

  9. 9.

    Law Commission of Ontario. Protecting autonomy and the equal right to legal capacity in the face of serious adverse effects. Chapter VI. Available from URL: (Accessed 3 December 2012).

  10. 10.

    Inclusion Europe. Legal Capacity. Available from URL: (Accessed 3 December 2012).

  11. 11.

    Inclusion International. Key elements of a system for supported decision-making: position paper of inclusion international, to be adopted at the General Assembly 2008.

  12. 12.

    Minkowitz T. Legal capacity in CRPD and its implications for older persons. Presentation at the Expert Group Meeting on the Human Rights of Older Persons. New York, NY: United Nations Headquarters (OHCHR and UNDESA); 29-31 May 2012. Available from URL: (Accessed 3 December 2012).

  13. 13.

    Quinn G. Rethinking personhood: new directions in legal capacity law and policy or how to put the ‘shift’ back into paradigm shift. Paper presented at ‘In from the margins’: New Foundations for Personhood and Legal Capacity in the 21st Century. Vancouver, Canada: University of British Columbia; 2011.

  14. 14.

    Convention on the Rights of Persons with Disabilities, 2006. Adopted 13 December 2006, UNGA Res. 61/106 and Optional Protocol to the Convention on the Rights of Persons with Disabilities. 13 December 2006, UNGA Res. 61/6 11.

  15. 15.

    Quinn G. Personhood & legal capacity: perspectives on the paradigm shift of Article 12 CRPD. Concept Paper. Boston, MA: HPOD Conference, Harvard Law School; 20 February 2010.

  16. 16.

    Theytaz-Bergman L, Tromel S. Guidance document: effective use of international human rights monitoring mechanisms to protect the rights of persons with disabilities. Geneva, Switzerland: International Disability Alliance; 2010. Available from URL: (Accessed 3 December 2012).

  17. 17.

    Mental Disability Advocacy Center (MDAC). Supported decision-making: an alternative to guardianship. Policy Paper. Available from URL: (Accessed 3 December 2012).

  18. 18.

    Office of the United Nations High Commissioner for Human Rights. Legal capacity. August 2005. Background conference document. Available from URL: (Accessed 3 December 2012).

  19. 19.

    Fennell P, Khaliq U. Conflicting or complementary obligations? The UN Disability Rights Convention, the European Convention on the Human Rights and English law. European Human Rights Law Review. 2011;2:33–45.

  20. 20.

    Salzman L. Guardianship for persons with mental illness–a legal and appropriate alternative? St Louis University J Health Law Policy. 2011;4:279–329. Available from URL: (Accessed 3 December 2012).

  21. 21.

    Goins M, Good K, Harley C. Perceiving Others as Different: A discussion on the stigmatization of the mentally ill. Ann Health Law. 2010;19:441–7.

  22. 22.

    Wahl OF. Stigma as a barrier to recovery from mental illness. Trends Cogn Sci. 2012;16:9–10.

  23. 23.

    Bach M, Kerzner L. A new paradigm for protecting autonomy and the right to legal capacity. Ontario, Canada: Prepared for the Law Commission of Ontario; October 2010. Available from URL: (Accessed 3 December 2012).

  24. 24.

    World Health Organization. WHO Resource Book on mental health, human rights and legislation. Geneva, Switzerland: WHO; 2005.

  25. 25.

    Clayman ML, Makoul G. Conceptual variation and iteration in SDM: the need for clarity. In: Edwards A, Elwyn G, (editors). Shared Decision-Making in Health Care. Achieving Evidence-Based Patient Choice. 2nd Edition. Oxford, UK: Oxford University Press; 2009. p.109–16.

  26. 26.

    Duncan E, Best C, Hagen S. Shared decision making interventions for people with mental health conditions. Cochrane Database Syst Rev. 2010;1:C007297.

  27. 27.

    Charles C, Gafni A, Whelan T. Shared decision making in the medical encounter: what does it mean? (Or, it takes at least two to tango). Soc Sci Med. 1997;44:681–92.

  28. 28.

    Charles C, Gafni A, Whelan T. Decision-making in the physician-patient encounter: revisiting the shared treatment decision-making model. Soc Sci Med. 1999;49:651–61.

  29. 29.

    Coulter A. Partnerships with patients: the pros and cons of shared decision making. J Health Serv Res Policy. 1997;2:112–21.

  30. 30.

    Elwyn G, Edwards A, Gwyn R, Grol R. Towards a feasible model for shared decision making: Focus group study with general practice registrars. BMJ. 1999;319:753–6.

  31. 31.

    Elwyn G, Edwards A, Kinnersley P, Grol R. Shared decision making and the concept of equipoise: the competences of involving patients in healthcare choices. Br J Gen Pract. 2000;50:892–9.

  32. 32.

    Towle A, Godolphin W. Framework for teaching and learning informed shared decision-making. BMJ. 1999;319:766–71.

  33. 33.

    Trevene L, Barratt A. Integrated decision making: definitions for a new discipline. Patient Educ Couns. 2003;50:265–8.

  34. 34.

    Wills CE, Holmes-Rovner M. Integrating decision making and mental health interventions research: research directions. Clin Psychol (New York). 2006;13:9–25.

  35. 35.

    Patel SR, Bakken, S, Ruland C. Recent advances in shared decision making for mental health. Curr Opin Psychiatry. 2008;21:606–12.

  36. 36.

    Mueser K, Corrigan P, Hilton D, Tanzman B, Schaub A, Gingerich S, et al. Illness management and recovery for severe mental illness: a review of the research. Psychiatr Serv. 2002;53:1272–84.

  37. 37.

    Deegan PE, Drake RE. Shared decision making and medication management in the recovery process. Psychiatr Serv. 2006;57:1636–9.

  38. 38.

    Mistler LA, Drake RE. Shared decision making in antipsychotic management. J Psychiatr Pract. 2008;14:333–44.

  39. 39.

    Adams JR, Drake RE. Shared decision-making and evidence-based practice. Community Ment Health J. 2006;42:87–105.

  40. 40.

    Noble LM, Douglas BC. What users and relatives want from mental health services. Curr Opin Psychiatry. 2004;17:289–96.

  41. 41.

    Joosten EA, DeFuentes-Merillas L, de Weert GH, Sensky T, van der Staak CP, de Jong CA. Systematic review of the effects of shared decision-making on patient satisfaction, treatment adherence and health status. Psychother Psychosom. 2008;77:219–26.

  42. 42.

    Makoul G, Clayman ML. An integrative model of shared decision making in medical encounters. Patient Educ Couns. 2006;60:301–12.

  43. 43.

    Montori V, Gafni A, Charles C. A shared treatment decision making approach between patients with chronic conditions and their clinicians: the case of diabetes. Health Expect. 2006;9:25–36.

  44. 44.

    Adams JR, Drake RE, Wolford GL. Shared decision-making preferences of people with severe mental illness. Psychiatr Serv. 2007;58:1219–21.

  45. 45.

    Cooper LA. At the centre of decision making in mental health services and interventions research: patients, clinicians, or relationships? Clin Psychol: Society Practice. 2006:13:26–9.

  46. 46.

    Malm W, Ivarsson B, Allebeck P, Falloon, IRH. Integrated care in schizophrenia: a 2-year randomized controlled study of two community based treatment programs. Acta Psychiatr Scand. 2003;107:415–23.

  47. 47.

    Raue PJ, Schulberg HC, Heo M, Kilmstra S, Bruce ML. Patients’ depression treatment preferences and initiation, adherence and outcome: a randomized primary care study. Psychiatr Serv. 2009;60:337–43.

  48. 48.

    Raue PJ, Schulberg HC, Lewis-Fernandez R, Boutin-Foster C, Hoffman AS, Bruce ML. Shared decision-making in the primary car treatment of late life major depression: a needed new intervention? Int J Geriatr Psychiatry. 2010; 25:1101–11.

  49. 49.

    Campbell LA, Kisely, SR. Advanced treatment directives for people with severe mental illness. Cochrane Database Syst Rev. 2009;21:CD005963.

  50. 50.

    Sarin A, Murthy P, Chatterjee S. Psychiatric Advanced directives: Potential challenges in India. Indian J Med Ethics. 2012;9:104–7.

  51. 51.

    Honberg RS. Advance Directives. National Alliance on Mental Illness. Journal of NAMI California, Mental Illness and Law. Undated;11(3). Available from URL: (Accessed 3 December 2012).

  52. 52.

    Minkowitz T. The paradigm of supported decision making. Available from URL: (Accessed 3 December 2012).

  53. 53.

    Weller P. Developing law and ethics: The Convention on the Rights of Persons with Disabilities. Alternative Law J. 2010;35:8–12.

  54. 54.

    Mental Disability Advocacy Center. Czech Republic enacts legal capacity law reform. 21 February 2012. Available from URL: (Accessed 3 December 2012).

  55. 55.

    Mental Disability Advocacy Center. Hungary: Parliament reforms legal capacity laws. 22 September 2009. Available from URL: (Accessed 5 December 2012).

  56. 56.

    Mental Disability Advocacy Center. Constitutional court undermines legal status of Hungarians with disabilities. 27 April 2010. Available from URL: (Accessed 5 December 2012).

  57. 57.

    Gordon RM. The emergence of assisted (supported) decision-making in the Canadian law of adult guardianship and substitute decision-making. Int J Law Psychiatry. 2000;23:61–77.

  58. 58.

    David MS. Legal guardianship of individuals incapacitated by mental illness: where do we draw the line? Suffolk U Law Rev. 2012;45:465–96.

  59. 59.

    Marson DC, Savage R, Phillips J. Financial capacity in persons with schizophrenia and serious mental illness: Clinical and research ethics aspects. Schizophr Bull. 2006;32:81–91.

  60. 60.

    Office of the Public Advocate. South Australian Supported Decision Making Project: October 2012 update. Australia. Available from URL: (Accessed 5 December 2012).

  61. 61.

    Carter B. Supported decision-making: Background and discussion paper. Victoria, Australia: Office of the Public Advocate; November 2009. Available from URL: (Accessed 5 December 2012).

  62. 62.

    Amnesty International. Decision-making capacity in mental health: exploratory research into the views of people with personal experience. Ireland: Amnesty International Ireland; December 2009.

  63. 63.

    McDaid S, Delaney S. A social approach to decision-making capacity: exploratory research with people with experience of mental health treatment. Disability Society. 2011:26;729–42.

  64. 64.

    Joosten EA, de Jong CA, de Weet-van Oene GH, Sensky T, van der Staak CP. Shared decision-making reduces drug use and psychiatric severity in substance-dependent patients. Psychother Psychosom. 2009;78:245–53.

  65. 65.

    Mahone I. Shared decision making and serious mental illness. Arch Psychiatr Nurs. 2008;22:334–43.

  66. 66.

    Hamera E, Pallikkthayil L, Baker D, White D. Descriptive study of shared decision making about lifestyle modifications with individuals who have psychiatric disabilities. J Am Psychiatr Nurses Assoc. 2010;16:280–7.

  67. 67.

    Hamann J, Mendel, R, Meier A, Asani F, Pausch, E, et al. How to speak to your psychiatrist: shared decision-making training for inpatients with schizophrenia. Psychiatr Serv. 2011;62:1218–21.

  68. 68.

    Stein BD, Kogan JN, Mihalyo MJ, Schuster J, Deegan PE, et al. Use of a computerized medication shared decision-making tool in community mental health settings: impact on psychotropic medication adherence. Community Men Health J. July 2012: epub ahead of print.

  69. 69.

    Hamann J, Cohen R, Leucht S, Busch R, Kissling W. Do patients with schizophrenia wish to be involved in decisions about their medical treatment? Am J Psychiatry. 2005;162:2382–4.

  70. 70.

    O’Neal EK, Adams JR, McHugo, GJ, Van Citters AD, Drake RE, Bartels SJ. Preferences of older and younger adults with serious mental illness for involvement in decision-making in medical and psychiatric settings. Am J Geriatr Psychiatry. 2008;16:826–33.

  71. 71.

    Patel SR, Bakken S. Preferences for participation in decision making among ethnically diverse patients with anxiety and depression. Community Ment Health J. 2010; 46:466–73.

  72. 72.

    Woltmann E, Whitley R. Shared decision making in public mental health care: perspectives form consumers living with severe mental illness. Psychiatr Rehabil J. 2010;34:29–36.

  73. 73.

    Stacey D, Menard P, Gaboury I, Jacobsen M, Sharif F, et al. Decision-making needs of patients with depression: a descriptive study. J Psychiatr Ment Health Nurs. 2008;15:287–95.

  74. 74.

    Simon D, Loh A, Wills CE, Harter M. Depressed patient’s perceptions of depression treatment decision-making. Health Expectations. 2006;10:62–74.

  75. 75.

    Campbell SM, Gately C, Gask L. Identifying the patient perspective of the quality of mental healthcare for common chronic problems: a qualitative study. Chronic Illn. 2007;3:46–65.

  76. 76.

    Mahone IH, Farrell S, Hinton I, Johnson R, Moody D, et al. Shared decision making in mental health treatment: qualitative findings from stakeholder focus groups. Arch Psychiatr Nurs. 2011;25:e27–36.

  77. 77.

    Lester H, Tait L, England E, Tritter J. Patient involvement in primary care mental health: a focus group study. Br J Gen Pract. 2006;56:415–22.

  78. 78.

    Loh A, Simon D, Wills CE, Kriston L, Niebling W, Harter M. The effects of shared decision-making intervention in primary care of depression: A cluster-randomized controlled trial. Patient Educ Couns. 2007;67:324–32.

  79. 79.

    Hamann J, Langer B, Winkler V, Busch R, Cohen R, et al. Shared decision making for in-patients with schizophrenia. Acta Psychiatr Scand. 2006;114:265–73.

  80. 80.

    McMullen LM. Discourses of influence and autonomy in physicians’ accounts of treatment decision making for depression. Qual Health Res. 2012;22:238–49.

  81. 81.

    Young HN, Bell RA, Epstein, RM, Feldman, MD, Kravitz RL. Physicians’ shared decision-making behaviours in depression care. Arch Intern Med. 2008;168:1404–8.

  82. 82.

    Loh A, Simon D, Hennig K, Hennig B, Harter M, Elwyn G. The assessment of depressive patients’ involvement in decision making in audio-taped primary care consultation. Patient Educ Couns. 2006;63:314–8.

  83. 83.

    Hamann J, Cohen R, Leucht S, Busch R, Kissling W. Shared decision making and long-term outcome in schizophrenia treatment. J Clin Psychiatry. 2007;68:992–7.

  84. 84.

    Woltmann EM, Wilkniss SM, Teachout A, McHugo GJ, Drake RE. Trial of an electronic decision support system to facilitate shared decision-making in community mental health. Psychiatr Serv. 2011;62:54–60.

  85. 85.

    Jonikas JA, Gret DD, Copeland ME, Razzano LA, Hamilton MM, et al. Improving propensity for patient self-advocacy through wellness recovery action planning: results of a randomized controlled trial. Community Ment Health J. December 2011: epub ahead of print.

  86. 86.

    Deegan PE. A web application to support recovery and shared decision making in psychiatric medication clinics. Psychiatr Rehabil J. 2010;34:23–8.

  87. 87.

    Kumar TC, John S, Gopal S, Mohan G, Joseph J, Rangaswamy T. PAS study group. Psychiatric advance statements: an Indian experience. Int J Soc Psychiatry. April 2012: epub ahead of print.

  88. 88.

    Department of Health. Independence, choice and risk: a guide to best practice in supported decision-making. London, England: DHUK; May 2007. Available from URL: (Accessed 5 December 2012).

  89. 89.

    United Nations Enable. Chapter Six: From provisions to practice: implementing the Convention. 2012. Available from URL: (Accessed 5 December 2012).

  90. 90.

    Legare F, Politi MC, Drolen R, Desroches S, Stacey D, et al. Training health professionals in shared decision-making: an international environmental scan. Patient Educ Couns. 2012;88:159–69.

  91. 91.

    Bartlett P, Hamzic V. Reforming mental disability law in Africa: practical tips and suggestions. Prepared for the Nuffield Foundation. Human Rights law Centre, University of Nottingham, England. 2010.

  92. 92.

    International Guardianship Network. Resource for Second World Congress on Adult Guardianship. Available from URL: (Accessed 3 December 2012).

  93. 93.

    Brandstätter A. Personal decision making: towards a paradigm-shift in Austria. Lebensilfe Osterreich; undated. [In German]

  94. 94.

    Brayley J. Supported Decision making in Australia. Presentation notes. Presented in Melbourne, 14 December 2009. Presentation delivered at the Victoria Office of the Public Advocate, Australia.

  95. 95.

    Government of Victoria. Exposure Draft Mental Health Bill 2010. Information sheet 1: supported decision-making, improving patient participation and carer involvement. Department of Health, State Government of Victoria, Australia.

  96. 96.

    Wolstenholme M. Current trends in mental health legislation. Department of Health, Mental Health Commission, Government of Western Australia.

  97. 97.

    Quinn M. Mental health and human rights in Victoria. Right Now, Human Rights in Australia. 20 May 2011. Available from URL: (Accessed 5 December 2012).

  98. 98.

    Victorian government. Chapter 9: Co-decision making. Victorian Government of Australia Law Reform. Guardianship Report. Available from URL: (Accessed 5 December 2012).

  99. 99.

    Office of the Public Advocate, South Australia. Supported decision-making. Available from URL: (Accessed 5 December 2012).

  100. 100.

    Friday S. Vancouver/Richmond mental health network society representation agreements and supported decision-making. Ontario, Canada: Canadian Coalition of Alternative Mental Health Resources; May 2005. Available from URL: (Accessed 5 December 2012).

  101. 101.

    Surtees D. The evolution of co-decision-making in Saskatchewan. Saskatchewan Law Rev. 2010;73:75–92.

  102. 102.

    Government of Alberta. The Mental Health Act and Adult Guardianship and Trusteeship Act. Fact Sheet. 2009/2010. OPG5632. Available from URL: (Accessed 5 December 2012).

  103. 103.

    Kerzner L. Paving the way to full realization of the CRPD’s rights to legal capacity and supported decision-making: a Canadian perspective. Canada: April 2011. Available from URL: (Accessed 5 December 2012).

  104. 104.

    Burningham S. Developments in Canadian adult guardianship and co-decision-making law. Dalhousie J Legal Studies. 2009;18:119.

  105. 105.

    Handicap International. Making it work: Colombia. Making it work: good practices for disability inclusive development. Available from URL: (Accessed 5 December 2012).

  106. 106.

    Blankman K. Guardianship models in the Netherlands and Western Europe. Int J Law Psychiatry. 1997;20:47–57.

  107. 107.

    European Court of Human Rights. Amicus Brief. Application No. 13469/06. D.D. v. Lithuania. Written comments by the European Group of National Human Rights Institutions. Pursuant to Article 35 2 of the European Convention on Human Rights and Rule 44 2 of the Rules of the European Court of Human Rights; 22 April 2008.

  108. 108.

    Boyle G. The Mental Capacity Act 2005: promoting the citizenship of people with dementia? Health Soc Care Community. 2008;16:529–37.

  109. 109.

    Fulton K, Woodley K, Sanderson H. Supported decision making: a guide for supporters. United Kingdom: Paradigm; 2008. Available from URL: (Accessed 5 December 2012).

  110. 110.

    Ministry of Health and Family Welfare, Government of India. Draft Mental Health Care Bill. 2011. National Mental Health Programme, Government of India, Delhi, India. Available from URL: (Accessed 5 December 2012).

  111. 111.

    Patrick H. Assisted decision-making: a legal response. Association of Law Reform Agencies of Eastern and Southern Africa (Alraesa) Alraesa law Reform Conference: March 2005.

  112. 112.

    PO-Skåne. Sweden. Available from URL: (Accessed 5 December 2012). [In Swedish]

  113. 113.

    Alzheimer Europe. Switzerland: legal capacity and proxy decision-making: Issues surrounding loss of legal capacity. Available from URL: (Accessed 5 December 2012).

  114. 114.

    Federal Department of Justice and Police. Bills still under discussion, Revision of guardianship legislation. Confederation of Switzerland. Available from URL: (Accessed 5 December 2012).

  115. 115.

    National Resource Center on Psychiatric Advance Directives (NRC-PAD). Available from URL: (Accessed 5 December 2012).

  116. 116.

    Henderson C, Swanson JW, Szmukler G, Thornicroft G, Zinkler M. A typology of advance statements in mental health care. Psychiatr Serv. 2008;59:63–71.

Download references

Author information

Correspondence to Dr. Soumitra Pathare MD.

Rights and permissions

Reprints and Permissions

About this article

Key Words

  • Supported decision-making
  • mental illness
  • human rights
  • CRPD
  • legal capacity