Shared Decision Making in the Treatment of Psychosis: Page 2 of 3

Shared Decision Making in the Treatment of Psychosis: Page 2 of 3

Challenges in implementing shared decision making

We hope this collaborative approach will catch on. However, apart from the fact that these are new recom­mendations and there is a predict-able lag between emerging best practices and standard care, psychiatrists face several hurdles in deciding whether to entertain discussion about the use of antipsychotics in early-episode psychosis and schizophrenia. Currently, for many psychiatrists, watchful waiting before starting antipsychotic therapy for patients expe­riencing psychotic symptoms is not a viable option. Unless the doctor can envision some legitimate benefit to the patient involving watchful wait-ing, medication delay, or minimization, it is understandable that he or she either offer no such option or inform the patient and family that he cannot in good conscience sanction such a clinical approach. Some of the barriers to envisioning such a clinical pathway are conceptual, some prac­tical. Some of these hurdles may be summarized as follows:

• A high degree of faith in the efficacy of antipsychotic agents, both to decrease positive symptoms in the short term and to bend the clinical course toward better long-term outcomes

• A concomitant pessimism about the natural course of psychotic illness, conceptualizing schizophrenia as a progressive neurodevel­opmental disease with a grim outcome, without sustained antipsychotic use7,8

• A belief that psychosis is inherently neurotoxic, akin to “kindling” in epilepsy, and that antipsychotic medications are neuroprotective9,10

• A corollary belief that the greater the duration of untreated psychosis (DUP), the greater the damage and the harder it will be to accomplish remission11

• A sense that many patients who are psychotic are ipso facto unable to engage in true shared decision making and that anosognosia blinds the patient to the true nature of the condition to be treated and to the dangers of nontreatment12

• A belief that it is too dangerous and/or impractical to delay treatment: trying to maintain a patient in the community who is acutely psychotic would be impossible for most office-based practitioners, and delaying treatment while the patient is hospitalized would not be supported by most insurers

Uncritical acceptance of these perspectives may cause psychiatrists to advocate for antipsychotics too zealously. Knowing that one of the greatest perceived obstacles to recovery is nonadherence, doctors may be less candid with patients at the beginning of their illness about the drawbacks and downsides of antipsychotic medications and not offer delaying or minimizing medications as a real option, for fear of reinforcing doubt and denial of illness.

Questioning our assumptions about antipsychotics

These are complex issues and defy brief exegesis. However, for pur-poses of framing the clinical problem of sharing decisions about the use of antipsychotic agents, the following ideas may be salient.

As helpful as antipsychotics can be for individual patients, there is no way to predict who will benefit or how much. Adherence to antipsychotic regimens does not guarantee recovery. While short-term use of antipsychotics poses little risk, long-term use poses significant risk of toxicity. These are powerful medications, with potential for great benefit and great harm. On the other hand, since there is no way to predict whom these medications will most benefit, the loss of opportunity for not trying them can be profound.


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