Listening to patient preferences when making health care decisions is increasingly considered an essential element of evidence-based practice. Patient preferences refer to the specific activity, treatment and provider conditions that patients desire for their health care experience^{1, 2}. For example, patients may prefer medication or psychotherapy, have preferences for one type of medication over another based on side effects, or have preferences for one type of psychotherapy over another based on the focus of the treatment (e.g., present cognitions or past relational conflicts). As another example, patients may have preferences about their provider’s experience level, personal style (e.g., humor, personal examples), or demographics (e.g., age, gender, race, ethnicity, sexual orientation).

Two main arguments can be made for including patient preferences in the decision-making process in mental health care – one based on ethics and another based on outcomes.

First, attending to patient preferences is in line with ethical­ principles of respect for patients’ rights and dignity³. As the party whose life will be most affected by the treatment, patients should have a say in what that treatment will look like. Importantly though, ethical principles also require providers to ensure that patients receive adequate care. As such, ethical practice entails active participation from both providers and patients, which should include discussion and incorporation of patient preferences in treatment to the extent possible.

Second, the existing research on clinical outcomes supports accommodating patient preferences^{2, 4, 5}. Studies suggest that patients are more willing to initiate and engage in treatments that match their preferences. Evidence of this can be found in a meta-analysis including data from 187 randomized clinical trials comparing medication management strategies to psychotherapies⁴. Even though participants in these studies all agreed to be ran­domized to an intervention, 8.2% dropped out after learning of their assignment, and dropout rates were 1.76 times higher for the medication conditions than psychotherapy. Presumably, the assigned intervention did not match patient preferences in many of these cases. In another meta-analysis that directly tested the preference effect in clinical medicine, data from 32 studies indicated that preference accommodation resulted in greater treatment initiation, though only small improvements in treatment outcomes⁵.

More recently, we conducted a meta-analysis examining the preference effect in psychotherapy and medication management for mental and behavioral health concerns². This meta-analysis included data from 53 studies and over 16,000 patients. We found that patients whose preferences were accommodated were almost two times (odds ratio, OR=1.79) more likely to complete their treatment compared to patients who did not receive a preferred option. In addition, preference accommodation was associated with more positive treatment outcomes (d=0.28). The preference effects were consistent regardless of whether the choice was between two forms of psychotherapy or between psychotherapy and medication. Further, the preference effect was consistent across preference types (e.g., treatment, activity and provider) as well as patient demographics.

Taken together, this body of research suggests that accommodating patient preferences is linked with improvements in both treatment initiation and outcomes.

There are several possible explanations for the positive effect of preference accommodation in mental health care. First, patients may often be good judges of what treatments are best for them. Specifically, they know what they have already tried, what generally works or does not work for them, and what they are willing to engage in. Even the most effective treatment will have a 0% chance of success if the patient is unwilling to engage in it.

Second, allowing patients to have a choice may enhance motivation. Research shows that, when individuals are allowed to make choices, they are more invested to make sure that the choice they made is the “right” one⁶. Thus, patients who get to pick their treatment might be more likely to fully engage in it (i.e., more consistent in their follow through, exerting more effort to achieve recovery). Allowing patients to participate in the decision-making process also encourages an overall collaborative approach to treatment. In psychotherapy, in particular, collaboration is a key part of the therapeutic alliance, which is consistently linked with positive treatment outcomes⁷.

In addition, involvement in the decision-making process can build hope for patients, who often seek treatment in a demoralized state (e.g., low self-efficacy beliefs, low well-being). When “expert” providers express beliefs that patients can make good decisions by involving them in the decision-making process, this can lead patients to also believe in themselves and their decision-making capabilities. Increased hope and self-efficacy beliefs can in turn lead to improved treatment outcomes⁸.

Given ethical arguments and the existing research support, it is essential that mental health care providers work to include patient preferences. These can be accommodated in a variety of ways. First, providers can assess initial preferences by using a pre-treatment questionnaire or having a simple discussion at the start of the intake appointment. This discussion can focus on provider preferences, activity preferences, and broad treatment preferences (e.g., medication vs. psychotherapy). Second, after reviewing the patient’s presenting problems and background information, providers can share information about potential specific treatment options. This information should include a discussion of the nature of the treatments, their relative efficacy, side effects, and other potential pros and cons. Third, both parties (patient and provider) should discuss preferences and come to a collaborative decision⁹. This process can occur repeatedly throughout treatment, as patient preferences may change over time.

At times, providers may be unable to fulfill patients’ preferences in one area or another (e.g., patient asks for a specific type of provider that is unavailable, patient prefers a treatment approach that the provider is not competent in). When this happens, providers can seek to understand the reasons behind the specific preference and see if those reasons can be addressed through another option. Providers should also seek to provide those patients with several other choices in different areas (e.g., frequency of appointments, format of meetings), so the patients can still feel like they are participating in the decision-making process.

Listening to patient preferences and taking steps to accommodate them when making mental health care decisions can enhance treatment experiences and improve treatment outcomes. It should, therefore, become part of ordinary clinical practice.

在做出医疗保健决定时倾听患者的偏好越来越被认为是循证实践的一个基本要素。患者偏好是指患者希望获得医疗保健体验^{1, 2}的特定活动、治疗和提供者条件。例如，患者可能更喜欢药物治疗或心理治疗，基于副作用更喜欢一种类型的药物治疗，或者基于治疗的重点（例如，目前的认知或过去的关系冲突）偏好一种类型的心理治疗而不是另一种）。作为另一个例子，患者可能对他们的提供者的经验水平、个人风格（例如，幽默、个人例子）或人口统计（例如，年龄、性别、种族、民族、性取向）有偏好。

可以提出两个主要论点，将患者偏好纳入精神卫生保健的决策过程——一个基于伦理，另一个基于结果。

首先，关注患者的喜好符合尊重患者权利和尊严的伦理原则³。作为生活受治疗影响最大的一方，患者应该对治疗方式有发言权。但重要的是，道德原则还要求提供者确保患者得到足够的护理。因此，伦理实践需要提供者和患者的积极参与，其中应包括讨论和尽可能将患者偏好纳入治疗。

其次，现有的临床结果研究支持适应患者的偏好^{2, 4, 5}。研究表明，患者更愿意开始和参与符合他们偏好的治疗。可以在荟萃分析中找到这方面的证据，其中包括来自 187 项比较药物管理策略与心理治疗的随机临床试验的数据⁴. 尽管这些研究的参与者都同意随机接受干预，但 8.2% 的人在得知他们的任务后退出，药物治疗的退出率是心理治疗的 1.76 倍。据推测，在许多这些情况下，分配的干预措施与患者的偏好不匹配。在另一项直接测试临床医学中偏好效应的荟萃分析中，来自 32 项研究的数据表明偏好调节导致了更大的治疗开始，尽管治疗结果只有很小的改善⁵。

最近，我们进行了一项荟萃分析，研究了心理治疗和药物管理对心理和行为健康问题的偏好效应². 这项荟萃分析包括来自 53 项研究和超过 16,000 名患者的数据。我们发现，与未接受首选治疗的患者相比，接受偏好治疗的患者完成治疗的可能性几乎是其两倍（比值比，OR=1.79）。此外，偏好调节与更积极的治疗结果相关（d=0.28）。无论选择是在两种形式的心理治疗之间还是在心理治疗和药物治疗之间进行选择，偏好效应都是一致的。此外，偏好效应在偏好类型（例如，治疗、活动和提供者）以及患者人口统计数据中是一致的。

综上所述，这项研究表明，适应患者的偏好与治疗开始和结果的改善有关。

对于偏好调节在精神卫生保健中的积极影响，有几种可能的解释。首先，患者通常可以很好地判断哪种治疗最适合他们。具体来说，他们知道他们已经尝试过什么，什么对他们通常有效或无效，以及他们愿意从事什么。 如果患者不愿意从事，即使最有效的治疗也有 0% 的成功机会它。

其次，让患者有选择权可以增强动力。研究表明，当个人被允许做出选择时，他们会投入更多精力来确保他们做出的选择是“正确的” ⁶。因此，选择治疗的患者可能更有可能完全参与其中（即，在后续行动中更加一致，付出更多努力以实现康复）。允许患者参与决策过程也鼓励了整体协作的治疗方法。特别是在心理治疗中，合作是治疗联盟的关键部分，它始终与积极的治疗结果相关⁷。

此外，参与决策过程可以为患者带来希望，他们经常在士气低落的状态下寻求治疗（例如，自我效能感低、幸福感低）。当“专家”提供者表示相信患者可以通过让他们参与决策过程来做出正确的决定时，这可能会导致患者也相信自己和他们的决策能力。增加的希望和自我效能信念可以反过来导致改善的治疗结果⁸。

鉴于伦理争论和现有的研究支持，精神卫生保健提供者必须努力考虑患者的偏好。这些可以以多种方式容纳。首先，提供者可以通过使用治疗前问卷或在开始预约时进行简单讨论来评估初始偏好。该讨论可以集中于提供者偏好、活动偏好和广泛的治疗偏好（例如，药物治疗与心理治疗）。其次，在审查了患者提出的问题和背景信息后，提供者可以共享有关潜在的特定治疗方案的信息。该信息应包括对治疗性质、其相对疗效、副作用和其他潜在利弊的讨论。第三，⁹ . 这个过程可以在整个治疗过程中反复发生，因为患者的偏好可能会随着时间的推移而改变。

有时，提供者可能无法满足患者在一个或另一个领域的偏好（例如，患者要求无法获得特定类型的提供者，患者更喜欢提供者无法胜任的治疗方法）。发生这种情况时，提供者可以寻求了解特定偏好背后的原因，并查看是否可以通过其他选项解决这些原因。提供者还应设法为这些患者提供不同领域的其他几种选择（例如，约会的频率、会议的形式），这样患者仍然可以感觉到他们正在参与决策过程。

在做出心理健康护理决定时，倾听患者的偏好并采取措施适应他们，可以增强治疗体验并改善治疗结果。因此，它应该成为普通临床实践的一部分。