Communication of Potential Benefits and Harm to Patients and Payers in Psychiatry: A Review and Commentary

BackgroundCommunicating potential benefits and harm to patients and payers is essential for high-quality care. However, there are no published guidelines or consensuses on how to communicate potential benefits and harm to patients and payers.ObjectiveThe goal of this review was to identify key elements for communication between clinicians, patients, and payers to achieve maximal benefits and minimal risk.MethodsLiterature published from January 1980 to July 2011 and cited on MEDLINE was searched using the terms communication, benefit, harm, effectiveness, cost, cost-effectiveness, psychiatry, bipolar disorder, schizophrenia, and major depressive disorder. Elements related to communicating benefits and/or harm to patients and payers were identified, with only key elements discussed in detail here.ResultsEvidence-based medicine, number needed to treat to benefit (NNTB) or harm (NNTH), and the likelihood of being helped or harmed (LHH) have been advocated as the basis for communication in all specialties of medicine. Phase-dependent communication of benefits and harm is novel, especially in patients with different phases of illness, such as bipolar disorder. Duration-dependent (short-term versus long-term) communication is essential for all psychiatric disorders to reduce the burden of relapse and adverse events with long-term treatment. For drugs with multiple therapeutic indications, a disease-dependent approach is crucial to maximize benefits and minimize harm. The exclusion of comorbid psychiatric disorders in pivotal efficacy trials affects their generalizability. Communicating cost (direct versus indirect) is an essential component in reducing health care expenditures. The results of available cost-effectiveness analyses of psychiatric pharmacotherapy have been inconsistent and/or contradictory.ConclusionsEvidence-based communication of potential benefits and harm to patients and payers, using NNTB, NNTH, and LHH, should be the key principle that guides decision making. Phase-, duration-, and disease-dependent communication and evidence-based cost-saving principles can maximize benefit and reduce harm.