Is the Consumer Always Right?

A century ago,retailers popularized the slogan “The customer is always right.” Many customers have surely felt the erosion of this maxim in our impersonal era of e-marketing and robot-voice menus. But has the mental health care “consumer,” or psychiatric patient, also perceived a lack of appreciation of his or her wishes on the part of providers? Research suggests that many patients with major depression have better outcomes when they receive the treatment they want. Aside from the fact that they are getting what they choose, these patients may also feel that their therapists are listening to them, respecting their opinion. This perception may cement the therapeutic alliance , itself a predictor of treatment outcome. Thus, patient treatment preference is generally considered a predictor of antidepressant treatment outcome.

Whether the same holds true for treatment preference among patients with posttraumatic stress disorder (PTSD) had never really been studied. As the article by my colleagues and me in The Journal of Clinical Psychiatry documented, much of the sparse literature on patient preference in PTSD has consisted of artificial mind games, asking psychology students, “Suppose you had PTSD and you had a choice of treatments, which would you pick?” Our study was the first to assess pre-treatment patient choice among 3 time-limited psychotherapies for PTSD. We then randomly assigned participants to treatment (having noted but not always followed their choices) and assessed the outcomes.

The biggest differences in patient preference are generally between discrepant treatment types such as psychotherapy and antidepressant medication. Patients generally favor talking over taking pills. Although my colleagues and I were comparing 3 talking therapies, their methods differed sufficiently that I expected that we would find preference differences anyway. Our findings showed that most patients preferred treatment other than prolonged exposure therapy, the best tested of the 3 therapies, probably because it requires facing one’s fears, and avoidance is a prime symptom of PTSD. Instead, patients favored receiving interpersonal psychotherapy, a relatively untested but non–exposure-based approach.

Interestingly, patient treatment preference did not make much difference in predicting PTSD outcome in this study. The presence of comorbid depression turned out to be at least as important to outcomes as receipt of undesired treatment. And the 20% of patients who reported no preference actually did best—perhaps feeling desperate enough for treatment that they didn’t care what they got, as long as they got something that might help.

No study tells you everything you want to know or is definitive. We don’t know whether patient preference would matter more in comparing a PTSD psychotherapy with medication. We don’t know whether patients might be more willing to accept exposure therapy as part of combined treatment with medication—and whether combined treatment might provide better outcomes as has been shown in the depression treatment literature. But this study opens the door a crack for what I hope will be a stampede of further research, assuming that researchers can conduct further clinical trials in which to assess this potential outcomes moderator. Although the National Institute of Mental Health (NIMH) funded our study, the current NIMH funding situation largely dispenses with clinical treatment trials, favoring instead an almost all-neuroscience, Research Domain Criteria approach to understanding mental illnesses. This hardly suits the preference of clinical researchers like me, and it may not meet the needs of patients (and their therapists) who might benefit from having more evidence on potentially effective treatments.

Financial disclosure:Dr Markowitz has received grant/research support from Mack Foundation, New York-Presbyterian Hospital, and National Institute of Mental Health; has received an editorial stipend from Elsevier Press; and has received book royalties from American Psychiatric Press, Basic Books, and Oxford University Press. ​