Priorities are what people value, and preferences show how they make trade-offs between one outcome and another. Both are important if we want to understand how people with schizophrenia make choices about treatment. Understanding patients’ views is vital if we want to encourage adherence. For patients, clarity of thought and minimizing symptoms are highly important outcomes.
When schizophrenia patients were asked about their priorities in achieving a successful outcome, 80% rated being able to think clearly as highly important. Not surprisingly, this was followed by minimization of symptoms and engaging in social activities. Unwanted side-effects of treatment, including weight gain and sexual problems, were relatively low on the list, a somewhat surprising finding, said John Bridges (Johns Hopkins University, Baltimore, USA). This may suggest that poor adherence to treatment may be due more to lack of focus on improving thinking and minimizing symptoms than it is to do with problems of tolerability.
People with schizophrenia are able to express their priorities and discuss trade-offs between outcomes
Discordance of view
Professor Bridges’ research has established a list of priorities that physicians undervalue when compared to patients. These include improved satisfaction, independence, physical health, activities of daily living and capacity for work. Many are tangible outcomes and relate to function.
Among the priorities that physicians overvalue relative to patients are decreased psychotic symptoms, improved self-confidence, improved capacity for communication and emotion, and decreased mistrust and hostility. To some extent these are “textbook” outcomes, explained John Bridges.
Patient priorities may be used to guide clinical trial design and inform regulatory decisions
Lack of concordance between patients and their physicians when setting goals can lead to poor compliance with therapy. The other side of the coin is that clinicians who can relate the potential impact of drug therapy to outcomes specifically valued by their patients may find better levels of adherence. It is also part of good, patient-tailored management.
Patient-focused drug development
Systematically eliciting the views of patients with schizophrenia is now seen as increasingly important in making treatment decisions, and in understanding patient response. Shared decision making can help achieve satisfactory outcomes.
But this approach may also be helpful in a wider context -- when selecting endpoints in clinical trials, when making regulatory decisions, and in the development of new treatments. Patient-focused drug development, for example, is an idea that is gaining ground.
People with schizophrenia are able to express their priorities and discuss trade-offs between outcomes; and these views can be elicited through stated-preference methodology. They also have opinions on the way mode of drug administration may influence their adherence. For example, patients with problems adhering to treatment place a higher value on an injectable – rather than oral -- formulation than those who are adherent.
Level of adherence affects formulation preferences
Physician preferences also change according to how adherent a patient is: as adherence declines, a longer-acting mode of administration comes to be viewed as more important.
This is a report of an Otsuka and Lundbeck-sponsored satellite symposium chaired by Professor Robin Emsley (Cape Town, South Africa), during ECNP 2017.
