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Special Articles   |    
Toward an Understanding of Decision Making in Severe Mental Illness
Ricardo Cáceda, M.D., Ph.D.; Charles B. Nemeroff, M.D., Ph.D.; Philip D. Harvey, Ph.D.
The Journal of Neuropsychiatry and Clinical Neurosciences 2014;26:196-213. doi:10.1176/appi.neuropsych.12110268
View Author and Article Information

Dr. Cáceda receives funding from the Arsht Foundation, the Community Alliance Against AIDS, the National Institute on Alcohol Abuse and Alcoholism, the National Institute on Drug Abuse, and NIMH. Dr. Nemeroff receives research/grant support from the Agency for Healthcare Research and Quality and NIH; he has served as a consultant to Allergan, Lilly, Roche, Shire, SK Pharma, Takeda, and Xhale; he is a shareholder with CeNeRx BioPharma, NovaDel Pharma, PharmaNeuroBoost, Reevax Pharma, and Xhale; he holds patents for a method and devices for transdermal delivery of lithium and for a method of assessing antidepressant drug therapy through transport inhibition of monoamine neurotransmitters by ex vivo assay; he has served on the scientific advisory boards of the American Foundation for Suicide Prevention, the Anxiety Disorders Association of America; AstraZeneca, CeNeRx BioPharma, NARSAD, PharmaNeuroBoost, Skyland Trail, and Xhale; he has served on the board of directors for the American Foundation for Suicide Prevention, the Anxiety and Depression Association of America, Gratitude America, Mt. Cook Pharma, NovaDel, and Skyland Trail; he has received royalties from American Psychiatric Publishing; and he has received other financial support from AstraZeneca, BioPharma, CeNeRx, NovaDel Pharma, PharmaNeuroBoost, Reevax Pharma, and Xhale. Dr. Harvey has received consulting fees from Abbott Laboratories, Amgen, Bristol-Myers Squibb, Genentech, Johnson and Johnson, PharmaNeuroBoost, Sunovion Pharma, and Takeda Pharma.

From the Brain Imaging Research Center, Psychiatric Research Institute, University of Arkansas for Medical Sciences, Little Rock, AR (RC), and the Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL (CBN, PDH).

Send correspondence to Ricardo Cáceda, M.D., Ph.D.; e-mail: rcaceda@uams.edu

Copyright © 2014 by the American Psychiatric Association

Received November 12, 2012; Revised March 05, 2013; Accepted April 17, 2013.

Abstract

A commonality of patients with major psychiatric disorders is their propensity to make poor decisions, which is intimately related to poor real-life outcomes. The authors reviewed the literature on decision making as applied to severe psychiatric disorders, with particular focus on advances in cognitive neuroscience. Deficits in reward sensitivity, avoidance learning, and temporal discounting are reported in depression. Besides abnormalities in hedonic capacity, other cognitive distortions required for flexible control of behavior occur in patients with bipolar disorder and schizophrenia. A conceptual framework of abnormal decision making in mental illness could generate targeted interventions to improve quality of life and clinical outcomes.

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FIGURE 1. Decision Making Classified According to the Risk and Context Available Information

A) Stable environment; B) changing environment; C) stochastic environment; D) unknown environment; and E) interactive environment (Adapted From13)

FIGURE 2. Neuroanatomy of Decision Making

The bottom highlighted area shows the brain reward valuation system: ventral tegmental area (VTA) projections, ventral striatum (VS), and orbitofrontal cortex (OFC). The top highlighted area shows the substrates of executive function: dorsolateral prefrontal cortex (DLPFC) and posterior parietal cortex. The middle highlighted area shows two brain regions involved in emotion and intuition processing: amygdala and insula.

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TABLE 1.Paradigms Used to Study Decision Making
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TABLE 2.Decision Making Concepts and Their Neural Substrates
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TABLE 3.Insight Brought to Mental Illness Through Decision-Making Research
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