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Two Experts Weigh In: Principles of Shared Decision-Making

Leslie Citrome, MD, MPH

Clinical Professor
Department of Psychiatry and Behavioral Sciences
New York Medical College
Valhalla, New York

Leslie Citrome, MD, MPH: consultant: AbbVie/Allergan, Acadia, Adamas, Alkermes, Angelini, Astellas, Avanir, Axsome, BioXcel, Boehringer Ingelheim, Cadent Therapeutics, Cerevel, Clinilabs, COMPASS, Eisai, Enteris BioPharma, HLS Therapeutics, Idorsia, INmune Bio, Impel, Intra-Cellular Therapies, Janssen, Karuna, Lundbeck, Lyndra, Medavante-ProPhase, Marvin, Merck, Mitsubishi-Tanabe Pharma, Neurocrine, Neurelis, Novartis, Noven, Otsuka, Ovid, Praxis, Recordati, Relmada, Reviva, Sage, Sunovion, Supernus, Teva; speaker: AbbVie/Allergan, Acadia, Alkermes, Angelini, Axsome, BioXcel, Eisai, Idorsia, Intra-Cellular Therapies, Janssen, Lundbeck, Neurocrine, Noven, Otsuka, Recordati, Sage, Sunovion, Takeda; individual publicly traded stocks and stock options: Bristol-Myers Squibb, Johnson & Johnson, Lilly, Merck, Pfizer.

View ClinicalThoughts from this Author

Released: December 30, 2022

Key Takeaways

  • Medication nonadherence is a common problem that prevents optimal patient outcomes.
  • Long-acting injectable (LAI) antipsychotics, while a convenient way to address nonadherence, can be perceived as stigmatizing by patients and providers.
  • Engaging patients using shared decision-making and motivational interviewing can help inform about LAI antipsychotic options and enhance treatment outcomes.

Long-acting injectable (LAI) antipsychotics offer a convenient way for patients to receive their medication, but they are not always offered as a standard of practice. Perhaps this is because the intervention has been stigmatized by the myth that injectable options are a “last resort.” Perhaps we assume that no patient will want to receive an injection when they can take a pill. This misperception is unfortunate because treatment with a LAI antipsychotic improves the chances that someone will remain relapse-free.

Adherence is a problem with many chronic disorders, psychiatric or otherwise, including hypertension, diabetes, asthma, bipolar disorder, and schizophrenia. Failure to recognize nonadherence makes healthcare professionals quick to assume that lack of adequate response is “treatment resistance” and that the medication lacks efficacy for that patient. We need to be more vigilant about considering treatment nonadherence in the setting of poor treatment response: The bottom line is that poor adherence to antipsychotic medication is common, likely exists in your practice, and can lead to suboptimal outcomes.

Shared decision-making is a good first step in engaging patients in their treatment, especially when a stigmatized option such as LAI antipsychotics comes into play. This technique acknowledges that there are 2 experts in the room—the patient is the expert regarding their lived experience with their disorder, and the healthcare provider is the expert in what treatments are available. Patients want to share their experience with treatments and can express preferences when it comes to medications (and new options).

Effective shared decision-making involves the use of motivational interviewing, defined as a style of dialogue between 2 parties, which is intended to motivate one party into making positive changes by compassionately challenging the status quo and helping them explore alternatives. The basic premise of motivational interviewing is that a patient’s ambivalence to change is normal and that all patients vary in their readiness to change. Thus, the most important technique when using shared decision-making to discuss treatment options is to use open-ended questions and reflective listening. When conversing with patients, try to make sure your question cannot be answered by a simple yes or no. Remember the acronym “RULE”:

  • Resist making too many suggestions
  • Understand the patient’s motivation
  • Listen with a patient-centered empathic approach
  • Empower the patient

In an observational study conducted at 10 community mental health centers, 33 recorded conversations in which a psychiatrist offered an LAI antipsychotic to a patient with schizophrenia were analyzed. Based on an examination of the content of the conversations, it was found that psychiatrists presented LAI therapy in a suboptimal way, and consequently, only 11 of 33 recommendations (33%) to take an LAI were accepted during the discussion. However, in the post-visit interview, where closer attention was paid to phrasing and presentation of LAI antipsychotic information, 27 of 28 patients (96%) who seemed to decline the initial recommendation said they actually would be willing to try LAI treatment. Words do matter! The study also pointed out that psychiatrists' ambivalence regarding the value of LAIs may play a significant role in the perceived difficulty of patient acceptance of this recommendation.

What about patients in their first episode of schizophrenia? A study was done to examine LAI vs Usual Care in patients with schizophrenia, aged 18-35 years old, with first-episode schizophrenia and <5 years of lifetime antipsychotic use. For this study, there was an in-person 2-day training for LAI site staff. This included teaching about the role of nonadherence in patient outcomes, rationale for LAI use in patients with early psychosis, shared decision-making, frequently asked questions about LAIs, roleplaying, solutions to overcoming logistical barriers, and prescribing guidelines. This staff training led to 76.6% of first-episode and early-phase schizophrenia patients receiving at least one LAI injection.

Studies have consistently demonstrated that continuous pharmacotherapy treatment is of utmost importance to minimize risk of relapse, but there are substantial adherence challenges for patients with chronic disorders. We know about the superior overall effectiveness of LAIs vs oral antipsychotics as demonstrated time after time in multiple studies. We also know that once offered, caregivers and patients may prefer LAIs. The key word here is “offer”—we should do that more often.

Your Thoughts?
Patient nonadherence is a major barrier to optimal treatment outcomes. For patients with bipolar disorder or schizophrenia, LAI antipsychotics can be a way to overcome that barrier…if offered in an informative, nonjudgmental way. Have you discussed LAI antipsychotics as an option with your patients? Answer the polling question and join in the discussion in the comments section below.

For more information on LAI antipsychotics and shared decision-making, watch the on-demand presentation “Changing Minds, Changing Lives: Elucidating the Role of LAI Antipsychotics.”

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