Johannes Hamann, M.D., and colleagues (1) addressed an important question about the desire of patients with schizophrenia to be involved in decisions regarding their treatment. Our field is still struggling to find a balance between substitute judgment or an authoritarian psychiatrist stance (e.g., in the case of a patient who, although not completely unable to give informed consent, does have deficits impairing his ability to test reality) and the principle of patient autonomy.
This is an important issue not only for patients with schizophrenia but, I would argue, for all psychiatric patients—regardless of their diagnoses. As such, it is unfortunate that the article by Dr. Hamann et al., by not including a control group of patients with psychiatric diagnoses other than schizophrenia, could not answer this important question: to what extent were the reported findings due to a specific effect of schizophrenia or to a nonspecific effect of mental illness in general?
Similarly, including an analysis of the correlation between scores on the Autonomy Preference Index (2) and schizophrenia types would have helped clarify to what extent the stated patient preference for being involved in the decision making correlates with the diagnosis of schizophrenia proper or only with some peculiar characteristic of the study subjects, e.g., paranoid ideation.
To illustrate these points, I can easily imagine that a paranoid patient would strongly prefer to be involved in the decision-making process, similar to a patient with paranoid personality disorder but possibly quite dissimilar from a schizophrenia patient with predominant negative or cognitive symptoms. Thus, because of a lack of appropriate controls or diagnostic type correlations, it is unclear if the findings of Dr. Hamann and colleagues characterized schizophrenia patients or may be, in fact, attributable to nonspecified confounders.
Hamann J, Cohen R, Leucht S, Busch R, Kissling W: Do patients with schizophrenia wish to be involved in decisions about their medical treatment? Am J Psychiatry 2005; 162:2382–2384
Ende J, Kazis L, Ash A, Moskowitz MA: Measuring patients’ desire for autonomy: decision-making and information-seeking preferences among medical patients. J Gen Intern Med 1989; 4:23–30