Identifying and Addressing Barriers to Treatment Decision‐making in Bipolar II Disorder: Clinicians’ Perspective

Objective

Treatment decision‐making in bipolar II disorder is complex due to limited evidence on treatment efficacy and potentially burdensome side‐effects of options. Thus, involving patients and negotiating treatment options with them is necessary to ensure that final treatment decisions balance both clinician and patient preferences. This study qualitatively explored clinician views on (a) effective treatment decision‐making, unmet patient needs for (b) decision‐support and (c) information.

Method

Qualitative semi‐structured interviews with 20 practising clinicians (n = 10 clinical psychologists, n = 6 general practitioners, n = 4 psychiatrists) with experience treating adult outpatients with bipolar II disorder were conducted. Interviews were audiotaped, transcribed verbatim and analysed thematically using framework methods. Self‐report professional experience, and clinician preferences for patient decision‐making involvement were also assessed.

Results

Qualitative analyses yielded two inter‐related themes: (a) challenges and barriers to decision‐making and (b) facilitators of clinician decision‐making. Symptom severity, negative family attitudes, system‐based factors, and information gaps were thought to pose challenges to decision‐making. By contrast, decision‐making was supported by patient information, family involvement and patient‐centredness, and a strong therapeutic relationship. Clinician views varied depending on their professional background (medical vs clinical psychologist), patient involvement preferences, and whether the clinician was a bipolar specialist.

Conclusions

Whilst clinicians uniformly recognise the importance of involving patients in informed treatment decision‐making, active patient participation is hampered by unmet informational and decision‐support needs. Current findings inform a number of bipolar II disorder‐specific, clinician‐endorsed strategies for facilitating patient decision‐making, which can inform the development of targeted patient decision‐support resources for use in this setting.     

The Default Position: Optimizing Pediatric Participation in Medical Decision Making

Inclusion of children in medical decision making, to the extent of their ability and interest in doing so, should be the default position, ensuring that children are routinely given a voice. However, optimizing the involvement of children in their health care decisions remains challenging for clinicians. Missing from the literature is a stepwise approach to assessing when and how a child should be included in medical decision making. We propose a systematic approach for doing so, and we apply this approach in a discussion of two challenging clinical cases. The approach is informed by a literature review, and is anchored by case studies of teenagers' refusal of clinical care, regulatory requirements for research assent, and the accepted approach to involving cognitively impaired adults in medical decisions.     

Levels of Desired, Actual, and Perceived Control of Employee Involvement in Decision Making: An Empirical Investigation

Using data obtained from 826 non-managers, this paper explores the effects of age, education and gender on the desired and actual levels of employee involvement in decision making. Analysis of five decision-making dimensions indicated that, though age and education appear to have an effect on desire for employee's involvement in decision-making processes, gender does not appear to be an influence. A discussion of this study's implications for human resource practice and suggestions for future research are presented.     

Integrating Cognitive Process and Descriptive Models of Attitudes and Preferences

Discrete choice experiments—selecting the best and/or worst from a set of options—are increasingly used to provide more efficient and valid measurement of attitudes or preferences than conventional methods such as Likert scales. Discrete choice data have traditionally been analyzed with random utility models that have good measurement properties but provide limited insight into cognitive processes. We extend a well‐established cognitive model, which has successfully explained both choices and response times for simple decision tasks, to complex, multi‐attribute discrete choice data. The fits, and parameters, of the extended model for two sets of choice data (involving patient preferences for dermatology appointments, and consumer attitudes toward mobile phones) agree with those of standard choice models. The extended model also accounts for choice and response time data in a perceptual judgment task designed in a manner analogous to best–worst discrete choice experiments. We conclude that several research fields might benefit from discrete choice experiments, and that the particular accumulator‐based models of decision making used in response time research can also provide process‐level instantiations for random utility models.     

Accounting for Time Preference in Management Decisions: An Application to Invasive Species

Managers of invasive species seek to prevent and mitigate their impact, which vary in the time horizon over which they are realized. Likewise, stakeholders vary in the time horizons they consider relevant. Agricultural impacts might reasonably be considered over two or three decades, although ecologists typically consider environmental impacts over much longer time frames. Although time preference plays a critical role in decision making, it has largely been ignored in multicriteria analyses. In this study, we examine how time has been treated in previous decision analyses of invasive species management, focusing on the differences between multicriteria and economic cost–benefit analyses. We then outline a method for incorporating time preference information into multicriteria decision analyses to ensure that criteria weights remain a faithful representation of the decision maker's preferences. To illustrate how time preference can be elicited for invasive species problems involving both monetary and nonmonetary consequences, we describe a small empirical study we conducted with a small group of experts and managers. By outlining a way to consider time preference information in multicriteria analyses of invasive species management, we hope to facilitate better decision making that is reflective of the decision maker's true preferences. Copyright © 2013 John Wiley & Sons, Ltd.     

Older adults prefer less choice than young adults

Previous research has demonstrated that older adults prefer less autonomy and seek less information when making decisions on their own relative to young adults (for a review, see M. Mather, 2006). Would older adults also prefer fewer options from which to choose? The authors tested this hypothesis in the context of different decision domains. Participants completed a choice preferences survey in which they indicated their desired number of choices across 6 domains of health care and everyday decisions. The hypothesis was confirmed across all decision domains. The authors discuss implications from these results as they relate to theories of aging and health care policy.     

An outcomes model of medical decision making

In the traditional fix-it model of medical decision making, the identified problem is typically characterized by a diagnosis that indicates a deviation from normalcy. When a medical problem is multifaceted and the available interventions are only partially effective, a broader vision of the health care endeavor is needed. What matters to the patient, and what should matter to the practitioner, is the patient's future possibilities. More specifically, what is important is the character of the alternative futures that the patient could have and choosing among them so as to achieve the best future possible, with the ranking of outcomes determined by the patient's preferences. This paper describes the fix-it model, presents and defends the outcomes-based model, and demonstrates that the latter is useful in developing normative conceptions of informed consent and decision making and in establishing a basis for societal involvement in the decision making process. Finally, several shortcomings of the model will be acknowledged.     

Doc, what would you do if you were me? On self-other discrepancies in medical decision making

Doctors often make decisions for their patients and predict their patients' preferences and decisions to customize advice to their particular situation. We investigated how doctors make decisions about medical treatments for their patients and themselves and how they predict their patients' decisions. We also studied whether these decisions and predictions coincide with the decisions that the patients make for themselves. We document 3 important findings. First, doctors made more conservative decisions for their patients than for themselves (i.e., they more often selected a safer medical treatment). Second, doctors did so even if they accurately predicted that their patients would want a riskier treatment than the one they selected. Doctors, therefore, showed substantial self-other discrepancies in medical decision making and did not make decisions that accurately reflected their patients' preferences. Finally, patients were not aware of these discrepancies and thought that the decisions their doctors made for themselves would be similar to the decisions they made for their patients. We explain these results in light of 2 current theories of self-other discrepancies in judgment and decision making: the risk-as-feelings hypothesis and the cognitive hypothesis. Our results have important implications for research on expert decision making and for medical practice, and shed some light on the process underlying self-other discrepancies in decision making.     

Biased memory for prior decision making: Evidence from a longitudinal field study

This research reveals systematic effects of outcome and behavior knowledge on memory for prior decision making in a three-wave longitudinal study of retrospective predictions and intentions involving the 1999–2000-millennium change. We demonstrate a pervasive consistency bias in memory for prior decision making, such that not only are remembered predictions more consistent with experienced outcomes than actual predictions, but also that remembered intentions are more consistent with behavior than actual intentions. These new findings reveal how outcome and behavior knowledge jointly influence memory reconstruction, reflecting multiple cue usage, and they identify the contribution of reconstruction processes in memory for prior decision making. Implications for research and theories on memory and decision making are discussed.     

Cognitive functioning as a contraindication to organ transplant surgery: Dilemmas encountered in medical decision making

A case is presented to illustrate some of the difficulties encountered when providing psychological consultation to evaluate the readiness of patients for pediatric heart-lung transplantation. The outcome of complex medical decision making can often hinge on information provided by the psychological consultant who is attempting to simultaneously serve the needs of the patient as well as the transplant team. Ethical dilemmas frequently arise when medical decision making is driven by limited health care resources and cost constraints. The utility of cognitive functioning as a variable in pediatric transplant decision making is discussed. Recommendations are made for further work in this area on both conceptual and empirical grounds to guide the integration of psychological information into transplant decision making as health care delivery continues to evolve in the future.     

Do you look to the future or focus on today? The impact of life experience on intertemporal decisions

In this research, we investigate the impact of significant life experiences on intertemporal decisions among young adults. A series of experiments focus specifically on the impact of experiencing the death of a close other by cancer. We show that such an experience, which bears information about time, is associated with making decisions that favor the long-term future over short-term interests (Studies 1 and 2). Underlying this effect appears to be increased salience and concreteness regarding one’s future life course, shifting focus away from the present toward the long run (Studies 3 and 4). Finally, we explore the shift caused by a cancer death of a public figure and examine its stability over time (Study 5). Implications for research on intertemporal decision making and the impact of life events on perceptions and preferences are discussed.     

Racial/ethnic matching of clients and therapists in mental health services: a meta-analytic review of preferences, perceptions, and outcomes

Across several decades the effects of matching clients with therapists of the same race/ethnicity have been explored using a variety of approaches. We conducted a meta-analysis of 3 variables frequently used in research on racial/ethnic matching: individuals' preferences for a therapist of their own race/ethnicity, clients' perceptions of therapists across racial/ethnic match, and therapeutic outcomes across racial/ethnic match. Across 52 studies of preferences, the average effect size (Cohen's d) was 0.63, indicating a moderately strong preference for a therapist of one's own race/ethnicity. Across 81 studies of individuals' perceptions of therapists, the average effect size was 0.32, indicating a tendency to perceive therapists of one's own race/ethnicity somewhat more positively than other therapists. Across 53 studies of client outcomes in mental health treatment, the average effect size was 0.09, indicating almost no benefit to treatment outcomes from racial/ethnic matching of clients with therapists. These 3 averaged effect sizes were characterized by substantial heterogeneity: The effects of racial/ethnic matching are highly variable. Studies involving African American participants demonstrated the highest effect sizes across all 3 types of evaluations: preferences, perceptions, and outcomes.     

What variety of attention is automatically captured by peripheral cues?

Previous studies have shown that the voluntary allocation of attention to a location in space can influence accuracy in two ways. First, additional processing resources can be allocated to the attended location, leading to an improvement in perceptual quality for objects presented at that location. Second, decision processes can be restricted to information arising from the attended location, which improves accuracy without influencing the perceptual representation. The present study examined the operation of these two attentional mechanisms when nonpredictive peripheral cues were used to capture attention automatically. Experiment 1 showed that, like predictive cues, nonpredictive cues influence accuracy by summoning perceptual resources and also by influencing decision processes. However, both the cues and the targets in this experiment were defined by luminance increments, making it possible that the cuing effects were mediated by a task-controlled attentional set rather than being fully automatic. Experiments 2 and 3 examined this possibility by using luminance-defined cues and color-defined targets; evidence was again obtained for both perceptual-level and decision-level attention effects. The capture of attention by a nonpredictive peripheral cue thus appears to influence both perceptual resource allocation and postperceptual decision processes.     

A constructive process view of decision making: Multiple strategies in judgment and choice

A viewpoint that has recently emerged in decision research is that preferences for objects of any complexity are often constructed — not merely revealed — in generating a response to a judgement or choice task. This paper reviews a program of research that traces the constructiveness of preferences to the use of multiple strategies in decision making, contingent on task demands. It is argued that individuals often build strategies opportunistically, changing their processing on the spot depending upon the information they encounter during the course of solving the decision problem.     

What else could I have done? Patients' responses to failed treatment decisions

Successful and failed renal transplant patients were compared concerning their perceptions of the initial decision to undergo transplantation. Results suggest that, relative to successful transplant patients, failed transplant patients recalled the circumstances of the initial decision in a manner that lessened personal responsibility for that decision. In essence, they indicated that they had had little choice but to make the decision they had made. There was slight evidence that failed transplant patients diffused responsibility for the decision or its outcome onto others. Implications for patient involvement in medical decision making and for the informed consent procedure are discussed. It is concluded that cognitive factors may play a role in undermining possible self-recrimination following failed treatment decisions in which a patient has been involved.     

Biased information search in group decision making

Research has shown that people prefer supporting to conflicting information when making decisions. Whether this biased information search also occurs in group decision making was examined in three experiments. Experiment 1 indicated that groups as well as individuals prefer supporting information and that the strength of this bias depends on the distribution of the group members' initial decision preferences. The more group members had chosen the same alternative prior to the group discussion (group homogeneity), the more strongly the group preferred information supporting that alternative. Experiment 2 replicated these results with managers. Experiment 3 showed that the differences between homogeneous and heterogeneous groups reflect group-level processes. Higher commitment and confidence in homogeneous groups mediated this effect. Functional and dysfunctional aspects of biased information seeking in group decision making are discussed.     

Counselor Ethical Reasoning: Decision‐Making Practice Versus Theory

Counselors’ decision‐making processes have received little attention in the literature. The purpose of this study was to ascertain the ethical decision‐making practices of counselors working in the field. The results of a phenomenological study indicate that linear models and an orientation to professional ethical guidelines learned in graduate training serve as a foundation, yet not a practical guide, in professional ethical decision making. The authors found that 4 themes guide counselors’ ethical decision making: personal values, clients’ best interest, transparency in decision making, and perceptions of formal training and practice. Implications for practice and counselor education are provided, with recommendations for future research.     

Vocational choice: A decision making perspective

We propose a model of vocational choice that can be used for analyzing and guiding the decision processes underlying career and job choices. Our model is based on research in behavioral decision making (BDM), in particular the choice goals framework developed by Bettman, Luce, and Payne (1998). The basic model involves two major processes. First, the selection of a decision strategy according to four choice goals: maximizing decision accuracy, minimizing cognitive effort, minimizing negative emotion, and maximizing justifiability of the decision. Second, the construction of situation-specific preferences, which can reflect irrelevant task and context factors such as the evaluation mode. This basic model is extended to account for social influences and the long decision time typical of most career and job decisions. We review research on vocational choice in light of this model, discuss normative implications for counseling, and outline a research agenda for studying vocational choice from a behavioral decision making perspective.     

Self‐regulation principles underlying risk perception and decision making within the context of genomic testing

Advances in theory and research on self‐regulation and decision‐making processes have yielded important insights into how cognitive, emotional, and social processes shape risk perceptions and risk‐related decisions. We examine how self‐regulation theory can be applied to inform our understanding of decision‐making processes within the context of genomic testing, a clinical arena in which individuals face complex risk information and potentially life‐altering decisions. After presenting key principles of self‐regulation, we present a genomic testing case example to illustrate how principles related to risk representations, approach and avoidance motivations, emotion regulation, defensive responses, temporal construals, and capacities such as numeric abilities can shape decisions and psychological responses during the genomic testing process. We conclude with implications for using self‐regulation theory to advance science within genomic testing and opportunities for how this research can inform further developments in self‐regulation theory.     

Why older adults make more immediate treatment decisions about cancer than younger adults

Literature relevant to medical decision making was reviewed, and a model was outlined for testing. Two studies examined whether older adults make more immediate decisions than younger adults about treatments for prostate or breast cancer in authentic scenarios. Findings clearly showed that older adults were more likely to make immediate decisions than younger adults. The research is important because it not only demonstrates the consistency of this age-related effect across disease domains, gender, ethnic groups, and prevalent education levels but begins to investigate a model to explain the effect. Major reasons for the effect focus on treatment knowledge, interest and engagement, and cognitive resources. Treatment knowledge, general cancer knowledge, interest, and cognitive resources relate to different ways of processing treatment information and preferences for immediate versus delayed decision making. Adults with high knowledge of treatments on a reliable test tended to make immediate treatment decisions, which supports the knowledge explanation. Adults with more cognitive resources and more interest tended to delay their treatment decisions. Little support was found for a cohort explanation for the relationship between age and preference for immediate medical decision making.