Medication Management in Schizophrenia

Medication Management in Schizophrenia

Principal Investigator: Mark Olfson, M.D. Ethnographic Consultants: Kim Hopper, Ph.D., Norma Ware, Ph.D.

PROJECT GOALS

This is a study of clinical decision making in the medication management of schizophrenia. Preparatory to the construction of a survey instrument, exploratory ethnographic interviews were commissioned to elicit the everyday clinical decisions of working psychiatrists in a variety of practice venues – as they inherit, correct, contest, adjust, research, or otherwise deliberate, alone or with others, over medication decisions for patients diagnosed with schizophrenia.

RESEARCH ACTIVITIES AND RESULTS

Method: Over a period of three months, eleven psychiatrists were interviewed in practice settings in Boston and Washington, D.C., usually by both anthropologists. Average length of the interviews was an hour. The interviews were taped and selectively transcribed. For a provisional report, we independently reviewed our interview notes and/or transcripts and classified observations, accounts, and direct responses into types of “influence” taken into consideration when actually making medication decisions. The two lists were then synthesized, through an iterative process of integration and editing, into a single version. All comments – with the exception of ideas about reasons for “bad” medication decisions – were elicited in the course of descriptions of actual decision-making and real, not hypothetical, cases. Most prominent among such themes were the influence of pragmatic concerns – what is feasible for this patient with these symptoms, given the side-effect profiles of these candidate drugs, their costs and likelihood of reliable administration, available of adjunctive care or surveillance, impact of potential failure and ease of correction, and considering both the patient and any implicated others (e.g., other patients on a locked ward).

Results: Reports of findings were made to the collective research staff, and proved instrumental in focusing the surveys on a variety of aspects of the clinical encounter and symbolic ones (expectations, stigma, trust) that had not been previously represented. A series of pilot studies were conducted, aimed chiefly at improving survey response rates from the APA practice-network of working psychiatrists.

SIGNIFICANCE OF FINDINGS/ POLICY IMPLICATIONS

Initial impressions suggest that any survey instrument will need to assess contingencies of everyday practice as key determinants of medication decisions.

PLANS

Participate in the final construction of the survey instrument; consider possibility of blinded ethnographic interviews with a specified number of survey participants. We will also consult on new research (with Drs. Olfson and Carole Boyer) designed to investigate reasons for non-compliance - or uneven, imperfect compliance - from the standpoint of medication users.

Entered: 09/23/2002
Updated: 7/8/03