To the Editor: The Open Forum in the November issue by Patricia Deegan and Robert Drake (1)—"Shared Decision-Making and Medication Management in the Recovery Process"—is important. The authors state, "Mental health professionals commonly conceptualize medication management for people with severe mental illness in terms of strategies to increase compliance or adherence." They write that compliance interventions "are often designed to increase clients' behavioral conformity to a practitioner's view of optimal treatment." We hope that not all clinicians view compliance in this way. The authors state that "shared decision making assumes that two experts—the client and the practitioner—must share their respective information and determine collaboratively the optimal treatment." Who could argue against this approach, especially for persons with mental illness who are higher functioning?
There is deep truth here but also a deep problem. Medication compliance may diminish symptoms, but there is much more to recovery than symptom relief. Recovery goals today include the ability to work and to have relationships with family, friends, and coworkers. The pursuit of these goals may well require participating in psychoeducation and group and family work, learning interpersonal and occupational skills, and finding housing, medical care, and other support to achieve self-government and increase self-esteem and empowerment. Astute treating psychiatrists must listen to and work with their patients, not impose preconceived notions of their own—either by undue pessimism regarding the patient's recovery or by encouragement of unrealistic expectations. Working with patients always includes consideration of side effects and unwelcome consequences of even the most helpful medications.
The authors do not give us specifics, but both the devil and the deity are in the details. Disability and disempowerment of patients arise not just from the profession of psychiatry and society but, more importantly, from biopsychosocial pathology and patients' life stresses. The clinician must be experienced in understanding the interplay between patients' biopsychosocial vulnerability and their degree of stress.
"Paternalism" is given a pejorative connotation by the authors, but in psychic crisis, isn't someone in the parental role often what the troubled person needs and is looking for? Deegan and Drake use the word "client," which derives from a Latin word meaning "leaning on"—referring to "leaning on" a benevolent expert to help and who listens, understands, and works with another as much as and whenever possible. The two clearest examples of the need for so-called "paternalism" are in the case of co-occurring disorders (substance use disorders and other mental illnesses) and of acute psychosis with delusional thinking. Patients in the former group can often spend their disability check on alcohol and drugs before they pay for housing and food, and patients in the latter group are dangers to themselves or others if they stop taking medication.
Whenever possible, and certainly for patients with milder mental disorders, we strongly support" shared decision making with medication management." But for patients with co-occurring disorders and acute psychosis, shared decision making is not always possible because the disease can be serious, even dangerous. Such a client may not be able to be "an expert" and needs to be approached in a so-called "paternalistic manner."
Dr. Peyser is in private practice in New York City and on the faculty of Mt. Sinai Medical Center and St. Luke's-Roosevelt Hospital. Dr. Shadoan is in private practice in San Francisco and is clinical professor at the University of California, San Francisco.
1.Deegan PE, Drake RE: Shared decision making and medication management in the recovery process. Psychiatric Services 57:1636-1639, 2006