Schizophrenia: attitudes of patients and professional carers towards the illness and antipsychotic medication

Physician suicide demographics and the COVID-19 pandemic

Objective:

Methods:

Results:

Conclusions:

Where are all the psychologists? A review of factors impacting the underrepresentation of psychology in work with serious mental illness

Over the last few decades, clinical psychologists have played a key role in the development of empirically-validated psychosocial interventions for those with serious mental illness (SMI). However, in contrast to these substantial contributions, clinical psychologists in the United States are grossly underrepresented in treatment provision with this population (Roe, Yanos, & Lysaker, 2006; Rollins & Bond, 2001). This review aims to highlight various factors contributing to the establishment and perpetuation of this underrepresentation. First, we highlight systemic factors (e.g., the emergence of managed care) through an examination of the evolving role of the clinical psychologist. Next, we review training-based factors (e.g., limitations to SMI specific training) through a review of training in clinical psychology. Through an examination of training factors, the role of mental health stigma amongst clinicians toward individuals with SMI is identified as a potential perpetuating factor of this underrepresentation. Factors associated with clinician stigma are then reviewed and the relationship between clinical training and clinician stigma is considered. Lastly, important future directions to further investigate and address this underrepresentation are suggested - namely, investigating factors (training and individual) that may impact clinical psychology doctoral students' attitudes toward those with SMI.

Schizophrenia stigma in mental health professionals and associated factors: A systematic review

BACKGROUND

The consequences of schizophrenia stigma are numerous and highly damaging to individuals, their families, the health care system and society. Mental health professionals (MHP) are considered to be one of the main sources of stigmatization.

OBJECTIVES

To identify the characteristics of MHP stigma in schizophrenia in comparison with other psychiatric disorders, the specificities of MHP compared with other social groups, and associated factors.

METHODS

Following PRISMA guidelines, we systematically searched multiple electronic databases for articles: (i) reporting original data published in English in peer-reviewed journals, (ii) reporting quantitative data with statistical analysis, (iii) assessing stigma in a broad sense, and (iv) including samples composed only of MHP.

RESULTS

A total of 38 articles published from 1999 to 2019 and involving 10,926 MHP fulfilled our inclusion criteria. Studies showed that schizophrenia is the most stigmatized mental illnesses in MHP, despite recent results suggesting that borderline personality disorder and substance abuse may be more stigmatized. In comparison with other social groups, MHP reported less dangerousness beliefs and more positive beliefs regarding pharmacological treatment. Nevertheless, results were less consistent regarding prognosis and desire for social distance. Age, education level, type of mental health profession, or length of practice were associated factors that showed inconsistent relations with stigma. Work setting and biological causal beliefs were more clearly associated with MHP stigma.

CONCLUSION

These findings provide strong support for the need to conduct specific research on schizophrenia stigma in MHP and the importance of controlling for several variables to identify predictors of stigma.

Predictors of pharmacophobia

Recent studies estimate that between 30% to 50% of the population does not adhere to their prescribed therapies, and one of the reasons is pharmacophobia. Pharmacophobia is a fear of medication and a negative attitude toward drugs in general. The aim of this study was to determine predictors of pharmacophobia. 700 participants participated in the study, of which 80.9% were female. The age of the participants ranged from 19 to 62 years (M=26.5, SD=7.41). The instrument consisted of several questionnaires measuring attitudes toward drugs, beliefs about medicine, emotional disgust, medication form preference, tendency for alternative medical habits and the likelihood of believing in conspiracy theories. Also, the demographic data was collected. The research was conducted through an online survey. The results showed that out of the total number of participants, 20.3% evaluated themselves as pharmacophobic, and 79.7% as pharmacophilics. Given the goal of the study, the results obtained suggest that one of the predictors of pharmacophobia is the tendency to believe in conspiracy theories, where the higher inclination to believe in conspiracy theories leads to greater pharmacophobia. Furthermore, the preference for solid drug forms and drugs that are intended for usage through the body cavity also contribute to an explanation of pharmacophobia in a way that pharmacophobic persons do not have a preference toward said medication forms. The predictor that contributes the most in the explanation of pharmacophobia is a negative belief in drugs, suggesting that a person with an expressed negative attitude to medication will probably not adhere to prescribed therapies by doctors.

The Impact of Mental Illness Stigma on Psychiatric Emergencies

Psychiatric emergencies are severe behavioral changes secondary to worsening mental illness. Such situations present a risk to the patient and other people, so they need immediate therapeutic intervention. They are associated with feelings of fear, anger, prejudice, and even exclusion. The attitudes of professionals and factors related to the workplace culture in health can help to perpetuate stereotypes and interfere with the quality of care. Stigma has undesirable consequences in patients with mental disorders. Certain measures can reduce stigma and provide a more dignified way for patients to recover from the crisis. This article aims to discuss the causes of stigma, ways of dealing with it, and achievements that have been made in psychiatric emergency care settings.

Attitude of undergraduate medical students toward psychiatry: A cross-sectional comparative study

CONTEXT

Both psychiatry as a specialty and mental illnesses carry a lot of stigmatizing attitudes. Even medical professionals are not immune to prevailing stigma. Psychiatrists are perceived to have less scientific attitude, earn less money, to be less respected, and to have less prestige.

AIMS

The present study was designed to know the attitude of medical students with different years of exposure to medical education, toward psychiatry as a specialty.

SETTINGS AND DESIGN

The study was conducted at JLN medical College, Ajmer. The participants were divided into two groups, undergraduate and interns, respectively. It was a cross-sectional descriptive study.

MATERIALS AND METHODS

Self-administered sociodemographic and Attitude Toward Psychiatry-30 items questionnaires were given to the second-year and medical intern and the scores were analyzed using appropriate statistical tools.

STATISTICAL ANALYSIS USED

Student's t-test and Chi-square test using SPSS version 21.

RESULTS

Nearly 84% of second-year medical students and 52% of interns had positive attitude toward psychiatry (P = 0.001). Only five second-year (5%) and two intern (1.8%) students affirmatively indicated to choose psychiatry as a career choice, while 73% denied choosing psychiatry as a specialty.

CONCLUSIONS

Second-year medical students showed more positive attitude than the intern group. Increasing negative attitude in higher classes might be due to poor teaching of psychiatry in under graduate training, ridiculous stereotypic comments and remarks by medical teachers and practitioners belonging to other specialty branches.

The least worst option: user experiences of antipsychotic medication and lack of involvement in medication decisions in a UK community sample

BACKGROUND

Treatment decision-making that fully involves service users is an aim across medicine, including mental health.

AIM

To explore service users experiences of taking antipsychotic medication for psychotic disorders and their perceptions of decision-making about this.

METHOD

Semi-structured interviews with 20 users of community mental health services, conducted by service user researchers and analysed using thematic analysis.

RESULTS

Antipsychotic medication was perceived to have beneficial effects on symptoms and relapse risk, but adverse effects were prominent, including a global state of lethargy and demotivation. Weighing these up, the majority viewed antipsychotics as the least worst option. Participants were split between positions of "willing acceptance", "resigned acceptance" and "non-acceptance" of taking antipsychotics. Many felt their choices about medication were limited, due to the nature of their illness or pressure from other people. They commonly experienced their prescribing psychiatrist as not sufficiently acknowledging the negative impacts of medication on life quality and physical health concerns and described feeling powerless to influence decisions about their medication.

CONCLUSION

The study highlights the complexity of agendas surrounding antipsychotic medication, including the pervasive influence of coercive processes and the challenges of implementing collaborative decision-making for people with serious mental health problems.

Treatment outcomes in schizophrenia: qualitative study of the views of family carers

BACKGROUND

Schizophrenia is a complex, heterogeneous disorder, with highly variable treatment outcomes, and relatively little is known about what is important to patients. The aim of the study was to understand treatment outcomes informal carers perceive to be important to people with schizophrenia.

METHOD

Qualitative interview study with 34 individuals and 8 couples who care for a person with schizophrenia/schizoaffective disorder. Interviews were transcribed verbatim and analysed by a thematic framework based approach.

RESULTS

Carers described well-recognised outcomes of importance, alongside more novel outcomes relating to: Safety (of the patient/others); insight (e.g. into non-reality of psychotic phenomena); respite from fear, distress or pain; socially acceptable behaviour; getting out of the house; attainment of life milestones; changes in personality and/or temperament; reduction of vulnerability to stress; and several aspects of physical health.

CONCLUSIONS

These findings have the potential to inform the development of patient- or carer- focused outcome measures that take into account the full range of domains that carers feel are important for patients.

The role of the affective temperament in the treatment adherence in psychiatry

Introduction

Adherence to psychotropic medications is affected by factors related to the treatment, to the physician, to the environment and to the patient himself. The purpose of the present study was to investigate the influence of affective temperaments on treatment adherence.

Methods

Thirty six stabilized outpatients were recruited from the aftercare consultation of Psychiatry to perform Temperament Evaluation of Memphis, Pisa, Paris and San Diego Auto questionnaire version (TEMPS-A) for affective temperaments and the Medication Adherence Rating Scale (MARS) for treatment adherence.

Results

The total MARS score was negatively correlated with the irritable temperament score. The MARS’s score relative to the attitude of patients to psychotropic medications and their negative side effects was negatively correlated with the cyclothymic, the irritable and anxious temperaments. Patients having a diagnosis of psychotic disorder had a significantly greater medication adherence and behaviour toward medication score compared to those having a diagnosis of affective disorder. A greater MARS’s score for the negative side effects and attitudes to psychotropic medication was associated with medication by neuroleptics with prolonged action.

Conclusion

The results of the present study suggest that patients with irritable temperament may have more difficult to follow psychotropic medications, and that patients with cyclothymic, irritable and anxious temperaments may be more attentive and sensitive toward psychotropic medications and their negative side effects.

Assessment of impact of pharmacophilia and pharmacophobia on medication adherence in patients with psychiatric disorders: A cross-sectional study

AIMS

To investigate the impact of pharmacophilia and pharmacophobia on medication adherence among patients with psychiatric disorders.

MATERIALS AND METHODS

A cross-sectional, observational study was conducted in the Department of Psychiatry over a period of 2 months. Patients above 18 years of age with a psychiatric diagnosis as per the International Classification of Diseases 10 and receiving at least one psychotropic medication (any medication capable of affecting the mind, emotions, and behavior) for >1 month were enrolled in the study. Patients who were critically ill, on magico-religious treatment (beliefs prevalent in a particular culture concerning various supernatural influences operating in the environment), diagnosis of dementia, or mental retardation and patients from whom reliable history of illness cannot be obtained were excluded from the study. Drug attitude inventory scale was used to classify patients into pharmacophilic and pharmacophobic groups. Medication adherence rating scale was used to identify the extent of medication adherence.

RESULTS

Among 176 patients included, 110 were found to be pharmacophilic and 54 were pharmacophobic. The number of hospitalizations (P < 0.03) and adverse drug reactions (P < 0.001) were found to be higher in pharmacophobic group as compared to pharmacophilic group. Antipsychotics were found to be most commonly prescribed medications among pharmacophobic group (P < 0.001). In this study, patients who had pharmacophilia were found to be have higher adherence score (mean score: 6.98) than patients with pharmacophobia (mean score: 2.9), with P< 0.001.

CONCLUSIONS

This study concluded that pharmacophobia toward psychopharmacological agents can significantly reduce the medication adherence among patients with psychiatric disorders.

Attitudes toward metabolic adverse events among patients with schizophrenia in Japan

BACKGROUND

Metabolic syndrome is a growing concern among patients with schizophrenia because metabolic abnormalities are widely regarded as a major risk factor for cardiovascular disease and premature death. The current study assessed attitudes toward metabolic adverse events among patients with schizophrenia.

METHODS

A brief questionnaire was constructed to investigate patient recognition of the following broad areas: dietary habits, lifestyle, self-monitoring, knowledge, and medical practice. Between January 2012 and June 2013, questionnaires were sent to patients associated with 520 outpatient facilities and 247 inpatient facilities belonging to the Japan Psychiatric Hospital Association. All of the participants (n=22,072; inpatients =15,170, outpatients =6,902) were diagnosed with schizophrenia based on the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, or the International Classification of Diseases, tenth revision.

RESULTS

Approximately 55.0% (8,069/14,669) of inpatients and 44.8% of outpatients (2,978/6,649) reported that they did not exercise at all. Although 60.9% (4,116/6,760) of outpatients reported that they felt obese, only 35.6% (5,261/14,794) of inpatients felt obese. More than half of the inpatients (51.2%; 7,514/14,690) and outpatients (60.8%; 4,086/6,721) hoped to receive regular blood tests to prevent weight gain and diseases such as diabetes.

CONCLUSION

Although more than half of patients hoped to prevent weight gain and diabetes, only a minority of patients were mindful of eating balanced meals and having physical exercise. Educational efforts and the promotion of the best pharmacotherapy and monitoring practices are needed for patients with schizophrenia.

EPA guidance on how to improve the image of psychiatry and of the psychiatrist

Stigma against mental illness and the mentally ill is well known. However, stigma against psychiatrists and mental health professionals is known but not discussed widely. Public attitudes and also those of other professionals affect recruitment into psychiatry and mental health services. The reasons for this discriminatory attitude are many and often not dissimilar to those held against mentally ill individuals. In this Guidance paper we present some of the factors affecting the image of psychiatry and psychiatrists which is perceived by the public at large. We look at the portrayal of psychiatry, psychiatrists in the media and literature which may affect attitudes. We also explore potential causes and explanations and propose some strategies in dealing with negative attitudes. Reduction in negative attitudes will improve recruitment and retention in psychiatry. We recommend that national psychiatric societies and other stakeholders, including patients, their families and carers, have a major and significant role to play in dealing with stigma, discrimination and prejudice against psychiatry and psychiatrists.

Does pharmacogenetic testing for CYP450 2D6 and 2C19 among patients with diagnoses within the schizophrenic spectrum reduce treatment costs?

The effect of pharmacogenetic testing for CYP450 2D6 and 2C19 on treatment costs have not yet been documented. This study used Danish patient registers to calculate healthcare costs of treating patients with diagnoses within the schizophrenic spectrum for 1 year with or without pharmacogenetic testing for polymorphisms in the genes for the CYP2D6 and CYP2C19 enzymes. In a randomized, controlled trial, stratified with respect to metabolizer genotype, 104 patients were assigned to treatment based on pharmacogenetic testing and 103 patients to treatment as usual. Random exclusion of extensive and intermediate metabolizers was used to increase the frequency of extreme metabolizers (poor metabolizers and ultrarapid metabolizers for CYP2D6) to 20% in both groups. Cost differences were analysed at several levels including (i) overall healthcare expenditure, (ii) psychiatric hospital cost (iii) nonpsychiatric hospital cost, (iv) primary care spending and (v) pharmaceuticals. Statistically significant differences in costs of psychiatric care dependent on metabolizer status were found between intervention groups. Pharmacogenetic testing significantly reduced costs among the extreme metabolizers (poor metabolizers and ultrarapid metabolizers) to 28%. Use of primary care services and pharmaceuticals was also affected by the intervention.This study confirms earlier findings that extreme metabolizers (poor and ultrarapid metabolizers) incur higher costs than similar patients with a normal metabolizer genotype. However, this study shows that these excess costs can be reduced by pharmacogenetic testing. Pharmacogenetic testing for CYP2D6 and CYP2C19 could thus be considered as a means of curtailing high psychiatric treatment costs among extreme metabolizers.

Do guidelines recommending pharmacogenetic testing of psychiatric patients affect treatment costs and the use of healthcare services?

Aim: To identify the effects of local recommendations of pharmacogenetic testing in psychiatry with respect to treatment costs. Methods: Based on Danish patient registers, individual treatment costs within a 365-day period at three psychiatric hospitals recommending and using pharmacogenetic testing is compared retrospectively with treatment costs at other Danish psychiatric hospitals using alternate treatment strategies. Primary outcome of interest is total direct costs analyzed by multilevel modelling. Secondary outcome measures are healthcare consumption within specific sectors analyzed by Tobitregressions. Results: Costs among patients treated at hospitals recommending and using pharmacogenetic testing were not found to be statistically significantly different from costs among patients treated at sites using alternate treatment strategies. In spite of recommendations to test all patients the uptake of the test was, however, low (26—31 %). Treatment practice using routine therapeutic drug monitoring (in Ãrhus) shows a trend towards lower costs. Conclusions: Based on this natural experiment we were not able to document statistically significant differences in total costs between treatment sites that had guidelines recommending pharmacogenetic testing, relative to sites without such guidelines, over a period of one year. However, guidelines of pharmacogenetic testing and possibly also therapeutic drug monitoring seem to lead to reductions in costs for primary care services. In the case of the former, reductions do, however, seem to be outweighed by increases in costs for psychiatric and non-psychiatric inpatient stays. In conclusion, no statistically significant differences in total direct costs across sites with different treatment strategies were found.

WPA guidance on how to combat stigmatization of psychiatry and psychiatrists

In 2009 the WPA President established a Task Force that was to examine available evidence about the stigmatization of psychiatry and psychiatrists and to make recommendations about action that national psychiatric societies and psychiatrists as professionals could do to reduce or prevent the stigmatization of their discipline as well as to prevent its nefarious consequences. This paper presents a summary of the Task Force's findings and recommendations. The Task Force reviewed the literature concerning the image of psychiatry and psychiatrists in the media and the opinions about psychiatry and psychiatrists of the general public, of students of medicine, of health professionals other than psychiatrists and of persons with mental illness and their families. It also reviewed the evidence about the interventions that have been undertaken to combat stigma and consequent discrimination and made a series of recommendations to the national psychiatric societies and to individual psychiatrists. The Task Force laid emphasis on the formulation of best practices of psychiatry and their application in health services and on the revision of curricula for the training of health personnel. It also recommended that national psychiatric societies establish links with other professional associations, with organizations of patients and their relatives and with the media in order to approach the problems of stigma on a broad front. The Task Force also underlined the role that psychiatrists can play in the prevention of stigmatization of psychiatry, stressing the need to develop a respectful relationship with patients, to strictly observe ethical rules in the practice of psychiatry and to maintain professional competence.

Differential diagnoses and management strategies in patients with schizophrenia and bipolar disorder

Successful treatment of psychiatric disorders, including bipolar disorder and schizophrenia, is complicated and is affected by a broad range of factors associated with the diagnosis, choice of treatment and social factors. In these patients, treatment management must focus on accurate and early diagnosis, to ensure that correct treatment is administered as soon as possible. In both disorders, the treatment of the disease in the acute phase must be maintained long term to provide continuous relief and normal function; the treatment choice in the early stages of the disease may impact on long-term outcomes. In schizophrenia, treatment non-compliance is an important issue, with up to 50% of patients discontinuing treatment for reasons as diverse as efficacy failure, social barriers, and more commonly, adverse events. Treatment non-compliance also remains an issue in bipolar disorder, as tolerability of mood stabilizers, especially lithium, is not always good, and combination treatments are frequent. In order to achieve an optimal outcome in which the patient continues with their medication life-long, treatment should be tailored to each individual, taking into account treatment and family history, and balancing efficacy with tolerability to maximize patient benefit and minimize the risk of discontinuation. These case studies illustrate how treatment should be monitored, tailored and often changed over time to meet these needs.

Antipsychotic medication, sedation and mental clouding: an observational study of psychiatric consultations

Sedation and mental clouding are of concern to people on antipsychotic medication and are implicated in social withdrawal but their severity may be underestimated by psychiatrists. Existing studies of communication about adverse effects of medication are based on reports made by doctors or patients. This study is based on audiotapes of 92 outpatient consultations in two UK mental health trusts involving nine consultant psychiatrists where antipsychotic medication was discussed. When interviewed, these doctors and their colleagues had expressed a commitment to 'patient-centred' practice as well as recording concerns about the difficulties involved in the discussion of medication side effects. The study focuses on the ways in which sedation and mental clouding are presented and engaged with. Analysis of audiotape transcripts showed that patients raise these issues more often than doctors, contrasting with other adverse effects (such as blood changes) where doctors are more frequently the initiators of discussion. Sleepiness is sometimes presented by both patients and doctors as a part of normal experience and therefore to be welcomed. When presented as troublesome, patients' reports were sometimes met by doctors offering no response, changing the subject, or disagreeing with the patient's interpretation of the experience. Equally, there were some attempts by doctors to engage with patients' troubles and seek solutions. These could be unsuccessful where they involved challenges to the patients' medication-taking rationale, or more successful where they involved sympathetic and supportive listening. We speculate that the capacity to avoid addressing these problems is linked to the informal conversational style of these consultations, which means that concerns raised by one party can remain unaddressed without offending conversational norms. Doctors in these consultations are able to exercise considerable discretion over whether to define reports of sedation and mental clouding as medication-related problems.

Anwendung - Effektivität - Aufrechterhaltung

Zusammenfassung. Hintergrund: Die “Effektivität“ psychotherapeutischer Interventionen, für die “Wirksamkeit“ in kontrollierten Studien belegt wurde, hängt in der Versorgungspraxis von zahlreichen Faktoren ab, die bisher meist isoliert diskutiert wurden. Fragestellung: Es soll geklärt werden, ob Fragen zur Wirkung psychotherapeutischer Interventionen heuristisch fruchtbar in formalen Modellen integriert werden können. Methoden: Zur Modellbildung wird dabei die Boolesche Logik verwendet. Die Möglichkeiten dieses Ansatzes werden anhand von Beispielen zur Therapie psychischer Störungen aufgezeigt. Ergebnisse: Die beispielhaften Modelle hilfreicher Interventionen setzen voraus, dass 1. die Intervention aktiviert wird, wenn eine therapeutische Veränderung notwendig ist (Anwendung), dass 2. die Intervention die intendierte Veränderung herbeiführen kann (Effektivität) und dass 3. die erreichte Veränderung nachhaltig ist (Aufrechterhaltung). Schlussfolgerungen: Die vorgestellten “Booleschen Interventionsmodelle“ postulieren spezifische zeitliche Muster (“Attraktoren“) und erlauben eine neuartige vergleichende Analyse von Interventionsformen und Versorgungssystemen.

Advances in psychotropic formulations

BACKGROUND

Successful pharmacotherapy is dependent on several factors. While efficacy is obviously important, other factors that are often overlooked include the availability of optimal dosage forms, treatment compliance and reduction in side effects. A number of innovative delivery systems have been developed to address suboptimal therapy outcomes by enhancing drug delivery, assuring efficacy of treatment, reducing side effects, and improving compliance.

OBJECTIVE

The purpose of this review is to discuss the advances in formulations for various psychotropic agents that have been developed for the treatment of psychiatric illnesses such as depression, attention deficit hyperactivity disorder, schizophrenia and other psychotic disorders.

METHODS

Information was identified via a MEDLINE and EMBASE search of data published between 2002 and 2005 with keywords 'psychotropic', 'atypical antipsychotic', 'antidepressant' or 'anxiolytic' in combination with 'new/novel/advanced formulation/delivery/technology', or 'controlled release/extended release', or 'fast-acting/fast-dissolving/orodispensible', or 'intramuscular/inject'.

RESULTS

In antidepressant therapy, formulations that allow extended release for once-daily and even once-weekly administration, orally disintegrating tablets, and transdermal systems have all been introduced. Long-acting central nervous system stimulants for the treatment of attention deficit hyperactivity disorder eliminate the need for multiple dosing. A number of new formulations of atypical antipsychotic agents have become available, offering important alternatives in certain patient groups. These include rapid-acting intramuscular injections, liquid formulations, and fast-dissolving tablets, all of which are useful options in the acute treatment setting as well as for geriatric and/or pediatric populations. Furthermore, formulations that deliver sustained levels of medications, including a long-acting antipsychotic and a new extended-release oral formulation, are important new developments that may improve compliance and offer efficacy and safety benefits in long-term management.

CONCLUSIONS

New formulations of psychotropics can offer advantages over older formulations in terms of convenience, side-effect profiles, efficacy, and/or a fast onset of action. Treatment-related factors can help to enhance patient's satisfaction with treatment and compliance, thereby improving patient prognosis and outcomes in both acute and outpatient management.

Sharing decisions in consultations involving anti-psychotic medication: a qualitative study of psychiatrists' experiences

In psychiatry, and in treating people with a diagnosis of schizophrenia in particular, there are obstacles to achieving concordant, shared decision making and in building a co-operative therapeutic alliance where mutual honesty is the norm. Studies of people with a diagnosis of schizophrenia have revealed critical views of medical authority, particularly over the issue of enforced compliance with antipsychotic medication. Psychiatrists are known to place particular value on such medication. This qualitative study reports the views of 21 general adult psychiatrists working in UK about their experiences of consultations involving discussion of antipsychotic medication. Interviewees reported a general commitment to achieving concordant relationships with patients and described a number of strategies they used to promote this. In this respect, their self-perception differs from the picture of authoritarian practice painted by critics of psychiatry, and by some studies reporting patients' views. Interviewees also described obstacles to achieving concordance, including adverse judgements of patients' competence and honesty about their medication use. Explaining the adverse effects of medication was perceived to discourage some patients from accepting this treatment. Moments of strategic dishonesty were reported. Psychiatrists perceived that trust could be damaged by episodes of coercion, or by patients' perception of coercive powers. We conclude that a self-perception of patient-centredness may not preclude psychiatrists from fulfilling a social control function.