We followed 201 patients remitted from a first episode psychosis, participating in the HAMLETT study for a period of one year, during which 82.4% together with their psychiatrist decided to reduce the dose of their antipsychotic medication and another 10.6% changed the type of antipsychotic drug. We demonstrated that psychiatrists were associated with patients’ outcome expressed as psychotic symptom severity and daily functioning after one year, which attenuated but remained significant when corrected for baseline severity, antipsychotic dose and type, treatment site, years of education, and number of visits. The gender of the psychiatrist in relation to that of the patient was not related to outcome, nor did his/her education. These findings support the idea that not only patient-related factors like age, gender, and education, but also psychiatrist-related factors are important for outcome after a FEP.
The current study is the first to show the association between psychiatrists and long-term outcomes in pharmacotherapy after a FEP. Psychiatrists accounted for 9.1% variance in psychotic symptom severity scores, and 10.1% variance in daily functioning during the study period. This study is also the first to show a psychiatrist effect of prescribed dose on clinical outcomes, which could explain an additional 2.4% of the variance in symptom severity and 4.3% in daily functioning. Controlling for prescribed dose hardly affected the explained variance of the psychiatrist effect (it lowered from 9.1–9.0% for symptoms severity and from 10.1–9.2% for daily functioning), indicating that the relationship between the psychiatrist and their patient’s outcome goes well beyond the dosing of antipsychotic medication. We explored only the psychiatrist-related factor of gender, but this was not significantly associated with symptom outcome or daily functioning. While the gender of the doctor in relation to that of the patient related to clinical outcomes in a previous study across medical disciplines,30 we did not find this effect on positive symptom severity or daily functioning in FEP patients during the study period. Also, we found similar prescription behaviours in male and female psychiatrists.
Several previous studies6,31 showed that increased alliance is associated with better therapy adherence. This alliance might be even more important during the tapering of medication and in finding the lowest possible effective dose. We need to emphasize that this study was not designed to specifically address quality of shared decision-making or therapeutic alliance and hence important factors that might underly the psychiatrist aspect could not be revealed, nor were we able to test the impact of individual psychiatrist characteristics.
Our results suggest that the psychiatrist effect may be partially related to patients’ baseline symptom severity, as the variance related to the psychiatrist dropped from 9.1–2.3% in positive symptom severity and from 10.1–3.9% in daily functioning after controlling for baseline severity or functioning. However, the exact relationship between the psychiatrist effect and baseline severity and functioning remains unknown and might actually consist of two different effects. First, some psychiatrists may treat more severe patients than others, which could be related to their position in a treatment centre. Second, psychotherapeutic studies showed that the therapist effect was largest in the most severe patient, as effective therapeutic bonding may be more demanding with severely psychotic patients. Likewise, psychiatrists might have a greater influence on treatment outcomes during pharmacotherapy in patients with higher dysfunction and severity of psychosis.
The association we observed between psychiatrist and clinical and functional outcomes for pharmacotherapeutic contacts in psychosis is in line with the study of McKay et al. (2006) who found that psychiatrists explained 6.7% of the variance in symptom severity assessed with the Hamilton Rating Scale for Depression (HAMD). Their finding was not replicated by Strunk and colleagues (2010). The present study differs from these two studies in several aspects. First, the present study included nearly twice as many patients and psychiatrists. Second, while the results of McKay et al. (2006) were only corrected for baseline severity, and Strunk et al. (2010) only adjusted for treatment type, our analyses were corrected for baseline severity, dose and type of antipsychotic drugs, years of education, treatment site, and number of visits to the psychiatrist. The fact that the psychiatrist association remained significant, confirms McKay’s conclusion that the person of the psychiatrist is an important factor for patients’ outcome during pharmacotherapy. The most important difference, of course, is that we investigated the outcome of people who had experienced psychosis, while the previous two studies investigated outcome of depressive patients. Given the occurrence of a paranoid tendency in some people with psychosis, the effect of psychiatrist could be even more important in this group, as a solid therapeutic relationship with someone with a paranoid tendency may demand specific skills and dedication of the psychiatrist. Indeed, the psychotherapeutic alliance was found to be weaker in patients with more paranoia.18 This is in line with our findings, that the association between psychiatrists and psychotic symptom severity and daily functioning in FEP patients was partially related to baseline severity.
Several limitations of the present study should be mentioned. As the study was not initially designed to assess the psychiatrist effect, we did not study the shared decision-making process, nor the therapeutic alliance, which are expected to explain part of the psychiatrist association. The limited available sample size did not allow for more detailed analysis of the psychiatrist effects, for example by determining whether it is different for patients with mild, moderate or severe symptom severity. Due to the nearly 1:1 ratio of the 18 psychiatrist and 14 treatment centres, the individual effects of psychiatrists and treatment centres could not be adequately investigated. Yet, Fig. 1 which displays the psychiatrist-effect colour-coded for treatment centre does not suggest that centre was an important confounder, as the effects of psychiatrists of the same centre (colour) can run in quite different directions. The analyses did not include whether the patient was randomized to the continuation or discontinuation group, because the HAMLETT study protocol is flexible regarding the timing and speed of antipsychotic tapering and some patients chose to switch from the continuation to the discontinuation group. Therefore, we included the actually prescribed dose of antipsychotic medication in the analyses. We studied the effect of the psychiatrists, who are the chief practitioners and together with the patients determine medication prescription. While the frequency of visits to psychologists or nurses did not affect the association between psychiatrist and clinical and functional outcomes, we did not assess the possible effects of the combination of other therapists involved in the treatment of FEP patients, such as social workers, physiotherapists, and job coaches. Patients in the present sample often received treatments from specialized early psychosis teams, which include various care professionals. Still, given the central role of the psychiatrist in treatment teams, we cautiously propose that it is likely that a psychiatrist’s treatment approach is to some extent also reflected in that of other team members. Previously, the physician-nurse relationship in hospitals has been shown predictive of work satisfaction, nurses’ health, and even patients’ outcomes and satisfaction.32 Future research may also include effects of other relevant care professionals on the outcome of pharmacotherapy.
The present study highlights the association between the psychiatrist who provides pharmacotherapy and clinical and functional outcomes in remitted first episode psychosis patients. Although the current study does not shed light on which characteristics of the interaction between psychiatrist and patients may drive this effect, interventions for psychiatrists may be particularly effective in improving the therapeutic relationship, shared decision making, and prescription behaviour. For instance, even a brief intervention on simulating communication showed improved alliance between psychiatrists and psychosis patients.33
Our results emphasize the importance of psychiatrist-related factors to patients’ outcomes after FEP. Hence detailed identification of potential drivers of these effects could improve psychiatrists’ training, inform optimal psychosis treatment and ultimately lead to better outcomes for those who experience a first psychotic episode.