Editor’s note—This summary is based on Dr. Velligan’s presentation at the 2017 Psychiatric Congress on Saturday, September 16, at 9 am.
In the past several decades, clinical care has moved from a traditional provider-driven paternalistic model to one that values shared decision-making (SDM). SDM is a process in which both the provider and the patient are involved. The provider shares information about the alternatives, risks, and benefits of specific treatments and elicits input from the patient; the patient shares information about his or her preferences, values, and concerns and ask questions; and both parties work toward an agreement on the treatment to be implemented.
A focus on understanding preferences and values of the patient is particularly central to treatment outcomes in situations in which there is no clear “best” treatment and there are many choices with variable adverse-effect profiles. This is clearly the case in many areas of medical treatment including various cancers, diabetes, and psychiatric conditions.1-3 The Institute of Medicine calls for individuals’ values and preferences to guide all physical and mental health care.4
Empirical evidence indicates that involving patients in the treatment decision-making process leads to increased satisfaction with treatment, lower decision conflict arising from being better informed, better follow-through on treatment recommendations, and even improved outcomes for medical markers such as blood pressure and blood glucose.5,6
Despite its promise, it has been a slow process for SDM to be accepted in the mental health field relative to other areas of medicine. Provider-dominated decision-making characterizes many psychiatric consultations. This may reflect provider concerns about the effects of mental illness on patients’ ability to participate in SDM. Many individuals with serious mental illness suffer from cognitive impairments that may hinder their ability for complex cognitive processing. Moreover, some psychiatric conditions specifically affect judgment and decision-making. However, contradicting these apparent risks, many adults with serious mental illness frequently make competent and prudent treatment decisions.
To further complicate the picture, decision-making for doctors and patients is subject to multiple biases. Prescribers have biases based on habit (comfort or lack of comfort with a specific option) and perceived risk aversion. Patients as human beings are subject to appraisal biases including ignoring information that does not fit into preconceived ideas, giving more weight to negative information, and being affected by the context in which information is presented.1 Despite these pitfalls, patients routinely report wanting to be involved in decisions about their treatment.
Dr. Velligan is Director, Division of Community Recovery, Research and Training; and Henry B. Dielman Chair, Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX.
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