Schizophrenia Patients Should Be Asked to Share Care Decisions

If schizophrenia patients are motivated to become more involved in the medical decisions that their psychiatrists make in their regard, and given some guidance on how to do it, they might like the idea.

So suggests a study by German researchers published in the October Psychiatric Services.

Johannes Hamann, M.D., an assistant professor of psychiatry at the Technical University in Munich, and his colleagues conducted their study on 61 inpatients with schizophrenia or schizoaffective disorder in a Munich psychiatric hospital. The subjects were randomly assigned to receive either shared decision-making training or a control condition (cognitive training). The shared decision-making training included motivational aspects and role-playing exercises. The desire to participate in medical decisions was then compared between the two groups. Subjects in the training group wanted to become more involved in the medical decisions impacting them than subjects in the control group did.

Nonetheless, pressuring schizophrenia patients to participate more in their medical care could have a negative side, other results from this study suggested. The psychiatrists caring for the subjects after the subjects were discharged from the hospital were asked to rate the subjects on compliance. The subjects who had received the medical-decision-participation training were reported to be less trustful of their psychiatrists' judgment and more difficult to deal with than the control subjects.

Less trust and more cantankerousness might not necessarily be a bad thing, however, Hamann and his group wrote. "From the mental health care consumers' perspective, patients have a right to disagree with their physicians and to argue for treatment they believe to be the best."

A little over half of psychiatrists surveyed appear to be open to sharing medical decision making with their schizophrenia patients, Hamann and his colleagues found in another study, which was published in the August 2009 Psychiatric Services. In this study, 352 German psychiatrists were queried about whether they regularly involved their schizophrenia patients in the medical decisions that they made about them. Fifty-one percent said yes.

But even if schizophrenia patients want to be more involved in their medical care, and even if their psychiatrists are open to the idea, challenges remain, Hamann and his colleagues wrote in their 2009 paper. For example, should such participation be encouraged only for patients who have insight into their condition and who are well informed about their treatment? And under which circumstances should patient participation be furthered—where it concerns the types of antipsychotic medications used, the psychosocial treatments deployed, the need for hospitalization—undoubtedly an acute issue—or legal guardianship, which pertains to only a subset of all patients in terms of being competent to manage their affairs? And any decisions involving the use of restraints "have to be made only after discussion and shared decision making have failed," Hamann and colleagues concluded.

Psychiatric News asked Hamann whether he recommended, on the basis of his team's findings, that psychiatrists share decision making with all types of schizophrenia patients or only with certain types—say, those who have insight and are well informed.

"There are surely individual patients for whom shared decision making might not be appropriate," he said. "However, I believe it to be of potential danger if psychiatrists try to identify patients suitable or not suitable for shared decision making. In fact, they might choose the 'easy patients' for shared decision making and the more difficult ones for paternalistic treatment. [So] I recommend that psychiatrists should try to offer [patients] as much participation as soon as possible. Patients not motivated to engage actively should be motivated, and patients judged as not capable might be prepared to engage in important treatment decisions. In addition, some decisions can be postponed until the patient has improved."

The research was funded by the German-Israeli Foundation for Scientific Research and Development.