Psychiatric practice: caring for patients, collaborating with partners, or marketing to consumers?

Slade's paper1 usefully articulates the clinical and ethical arguments in support of shared decision making (SDM); emphasizes that, despite widespread superficial agreement that SDM is important, there is significant potential for contradiction between these arguments; and puts forward a number of approaches which may inform responses to the shift in the mental health system brought about by more empowered patients. Here I briefly comment on each of these components of Slade's review. While I admire his elegant synthesis of the literature and concur with the thrust of many of his arguments, I do also wish to express some cautions. First, Slade notes that – while there is a clinical argument that patients who are active decision makers will be more engaged, with consequent improved decision making, increased adherence, and superior outcomes – there are in fact limited data to support this view. One potentially important consideration is that, in psychiatry, the link between scientific knowledge and patient outcomes is not always as tight as we would ideally like; so that clinical decision making, whether shared or not, is unable to predict fully which individual will respond to which intervention. Furthermore, the data included in the Cochrane review of the clinical value of SDM for people with psychiatric disorders2 are from work done in Germany. It is theoretically possible that in other settings, where patients may have different expectations of the clinical encounter, the data may be even less supportive of the clinical argument for SDM. Second, Slade notes that, despite the ethical argument that SDM is a human right, clinical practice occurs in a range of different contexts, and it is less clear that SDM is the best approach to decision making in non-capacitous patients. Indeed, a potentially important issue is that, in medical and psychiatric practice, disorders range from more typical conditions (where, say, the disorder can be conceptualized as caused by an external agent that both clinician and patient are committed to eradicating) to more atypical ones (where, for example, it is harder to differentiate the self from the illness, which may itself impact negatively on decision making)3. It is also noteworthy that the desire to participate in SDM appears higher in some patient groups. Good ethical arguments can be put forward to support different sorts of decision-making models for different sorts of patients and different sorts of disorders. Third, Slade emphasizes that, although SDM is widely endorsed in official policies and by active clinicians, in theory it entails potential contradictions (for example, there is a potential for empowered patients to choose to be less adherent to treatment recommendations), and that in practice SDM is in fact often not implemented. Slade argues that data from the “Clinical decision making and outcome in routine care for people with severe mental illness” (CEDAR) study4 show that both patient outcomes and experiences are improved by SDM, so that there is an alignment between clinical and ethical justifications. However, although the CEDAR study is multi-national, it is based on a relatively restricted population (outpatients in Europe), and the statistical analysis cited by Slade does not focus on clinical symptoms (but rather on patient-rated unmet needs). Finally, Slade suggests that social marketing and the hospital industry provide potentially useful approaches for addressing the shift in the mental health system that will be brought about by more empowered patients. Metaphors play a crucial role in framing our views of physical and mental disorders, and of the clinician-patient relationship5. A collaborative model of the clinician-patient relationship has been particularly useful in cognitive behavioural therapy, for example. And viewing the patient as a consumer does have some advantages, perhaps particularly in the context of empowerment or activism6. However, we should be careful not to entirely jettison metaphors of the doctor-patient relationship that emphasize caring (rather than only collaborating or consuming). Caring is a core aspect of the work of mental health professionals, and one that is deserving of particular emphasis and pride. Dan J. Stein Department of Psychiatry and Mental Health, University of Cape Town and Medical Research Council Unit on Anxiety and Stress Disorders, Cape Town, South Africa