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Why Do Psychiatrists Select or Switch an Antipsychotic?

Why Do Psychiatrists Select or Switch an Antipsychotic?

The investigation of medical decision making, which includes drug selection and drug switching, is of high importance because it pertains to quality assurance, the development of treatment guidelines, and the understanding of treatment processes. The increase in diagnostic and therapeutic options has made the selection of the best medical strategy more complex. Physicians are often forced to work and make decisions under time pressure, which complicates matters.

The treatment decision is not only dependent on the type, severity, and course of the illness but also on the patient's preferences, his/her adherence to treatment regimens, and a variety of contextual factors, such as availability of treatments or possibilities of surveillance.1-6 Medical decision making can be understood as a problem-solving process. It aims at selecting the best of several alternatives while weighing advantages and disadvantages6-11 and making estimates on prognosis and therapy.8

For the description of complex decision-making processes, one can refer to the action theory that describes how everyday decisions are made.12-14 This theory can also be used as a theoretical framework for the analysis of drug selection and drug switching. It distinguishes several steps of action: (1) action planning, which is based on theoretical knowledge, experiential knowledge, assessment of the situation, and anticipations; (2) decision making, which includes the development of an intention, emotional assessment, and goal setting; and (3) operation, which refers to the implementation of action, effect control, and feedback.14


A method for examining action planning is to ask physicians for their reasons for selecting a particular treatment, which can be done using the Reasons for Treatment Selection Questionnaire (RTSQ) (Figure).8 The RTSQ allows a treating physician to investigate the reasons why he favors a certain drug, switches from one drug to another, or continues the present treatment. Based on the action theory, the questionnaire assesses:

  • Theoretical knowledge: awareness of recent empirical findings (eg, no. 2)
  • Experiential knowledge: personal experiences with a certain treatment (eg, no. 1)
  • Situational knowledge: knowing that a patient does not tolerate a specific treatment (eg, no. 5)
  • Attitudes and anticipations about the course of therapy (eg, no. 11)
  • Interactional knowledge: knowing what the patient prefers (eg, no. 4).

These categories are understood as latent constructs that have a combined influence on medical decisions. They contribute to the understanding of why a physician prescribes a certain drug in a certain case at a certain moment.8,14

Positive or negative expectations of a particular drug can be called "drug stereotype." This determines when a drug is prescribed.15

Knowledge of drug stereotypes is important in order to understand how medical decisions are made, to ensure quality of treatment, and to monitor advertisements and costs.16 Drug stereotypes that a physician has can be compared with his familiarity with pharmacological data and knowledge of prescribing trends. Discrepancies indicate a need for changes in how physicians are informed about a drug and/or the benefit of further studies to clarify whether practitioners have experience with the medication that has not been addressed in research.15 Drug stereotypes can be investigated in observational drug utilization studies.17-19


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