Embracing patient choice

Morrison and colleagues ¹ highlight the important issue of patient choice in relation to the prescription of antipsychotic medication. They argue that patient choice should be considered because of the uncertainty regarding potential benefits and increasing awareness of potential risks of both older and newer types of antipsychotic medication. I agree that patient choice, along with consideration of the evidence, should be an essential part of the decision-making process and believe that shared decision-making is an ideal way in which to do this.

Shared decision-making involves a collaborative approach to treatment decision-making whereby the clinician presents information about suitable treatment options along with details about the potential risks and benefits of each option. ² In return, the patient provides information about their personal values and preferences, so that a decision can be made on both evidence and patient preferences and values.

In areas where evidence is limited or ambiguous, shared decision-making offers an opportunity to be explicit about what is known about likely treatment outcomes and therefore encourages realistic expectations. Having frank and collaborative discussions as part of the decision-making process may also encourage patients to be more open about sources of decisional conflict and lead to greater knowledge, adherence and satisfaction, whatever the chosen treatment option may be.

Decision-making tools called decision aids (usually online or paper-based tools) can facilitate shared decision-making. A systematic review of decision aids across all health areas found that they: increase patients’ knowledge of treatment options; give patients more realistic expectations about the potential risks and benefits of these treatment options; help patients to make a decision that is more in line with their personal values and to be more involved in the decision-making process. ³

There has been a growing interest in shared decision-making for mental disorders. ⁴ Shared decision-making interventions, usually involving decision aids, for treatment decision-making in areas of mental health have shown promising preliminary results and include one study for adult in-patients diagnosed with schizophrenia faced with a decision about treatment with antipsychotic medication. ⁵ The shared decision-making intervention was feasible for this population and significantly increased patients’ knowledge about schizophrenia, uptake of psychoeducation and feelings of involvement in consultations, without increasing consultation time.

In areas where there is uncertainty or ambiguity in the available evidence for treatment options, it is imperative to inform patients of the potential risks and benefits and support them to explore their preferences and values around these outcomes. Shared decision-making is one way in which to do this and is well suited to the provision of antipsychotic medication for psychotic (and other) disorders.