Being Kind to Your Future Self: Probability Discounting of Health Decision-Making

The Neural Response Process of Cognitive Decision Making: An ERP Study

Cognitive decision has the basic characteristics of risk avoidance and benefit seeking. To explore the neural response process of cognitive decision making, we asked 32 undergraduates to make a decision on whether to accept a specific treatment option with a certain cure rate and a certain risk rate while recording their electrical brain responses. The results showed that more participants chose the treatment option with a high cure rate and moderate or low risk. Compared with low and high risk, medium risk produced greater N1 and smaller P300. Low risk produced larger LPP than the moderate risk in the left hemisphere. The right prefrontal region appeared to have a smaller LPP for low risk than for high risk. The results suggest that individuals prioritize risk when making cognitive decisions. In addition, in medium-risk conditions, solution integration is more difficult. The effect of benefit size appears at the late stage of cognitive decision making and adjusts the effect of risk. These results support the satisfaction principle of decision making.

Reinforcer pathology, probabilistic choice, and medication adherence in patients with multiple sclerosis

The reinforcer pathology model posits that core behavioral economic mechanisms, including delay discounting and behavioral economic demand, underlie adverse health decisions and related clinical disorders. Extensions beyond substance use disorder and obesity, however, are limited. Using a reinforcer pathology framework, this study evaluates medical adherence decisions in patients with multiple sclerosis. Participants completed behavioral economic measures, including delay discounting, probability discounting, and a medication purchase task. A medical decision-making task was also used to evaluate how sensitivity to mild side effect risk and efficacy contributed to the likelihood of taking a hypothetical disease-modifying therapy. Less steep delay discounting and more intense (greater) medication demand were independently associated with greater adherence to the medication decision-making procedure. More generally, the pattern of interrelations between the medication-specific and general behavioral economic metrics was consistent with and contributes to the reinforcer pathology model. Additional research is warranted to expand these models to different populations and health behaviors, including those of a positive health orientation (i.e., medication adherence).

I'm wearing a mask, but are they?: Perceptions of self-other differences in COVID-19 health behaviors

As information about COVID-19 safety behavior changed, people had to judge how likely others were to protect themselves through mask-wearing and vaccination seeking. In a large, campus-wide survey, we assessed whether University of Kansas students viewed others' protective behaviors as different from their own, how much students assumed others shared their beliefs and behaviors, and which individual differences were associated with those estimations. Participants in our survey (N = 1, 704; 81.04% white, 64.08% female) estimated how likely they and others were to have worn masks on the University of Kansas campus, have worn masks off-campus, and to seek a vaccine. They also completed measures of political preference, numeracy, and preferences for risk in various contexts. We found that participants estimated that others were less likely to engage in health safety behaviors than themselves, but that their estimations of others were widely shared. While, in general, participants saw themselves as more unique in terms of practicing COVID-19 preventative behaviors, more liberal participants saw themselves as more unique, while those that were more conservative saw their own behavior as more similar to others. At least for masking, this uniqueness was false-estimates of others' health behavior were lower than their actual rates. Understanding this relationship could allow for more accurate norm-setting and normalization of mask-wearing and vaccination.

Patient-based benefit-risk assessment of medicines: development, refinement, and validation of a content search strategy to retrieve relevant studies

Introduction:

Poor indexing and inconsistent use of terms and keywords may prevent efficient retrieval of studies on the patient-based benefit-risk assessment (BRA) of medicines. We aimed to develop and validate an objectively derived content search strategy containing generic search terms that can be adapted for any search for evidence on patient-based BRA of medicines for any therapeutic area.

Methods:

We used a robust multistep process to develop and validate the content search strategy: (1) we developed a bank of search terms derived from screening studies on patient-based BRA of medicines in various therapeutic areas, (2) we refined the proposed content search strategy through an iterative process of testing sensitivity and precision of search terms, and (3) we validated the final search strategy in PubMed by firstly using multiple sclerosis as a case condition and secondly computing its relative performance versus a published systematic review on patient-based BRA of medicines in rheumatoid arthritis.

Results:

We conceptualized a final search strategy to retrieve studies on patient-based BRA containing generic search terms grouped into two domains, namely the patient and the BRA of medicines (sensitivity 84%, specificity 99.4%, precision 20.7%). The relative performance of the content search strategy was 85.7% compared with a search from a published systematic review of patient preferences in the treatment of rheumatoid arthritis. We also developed a more extended filter, with a relative performance of 93.3% when compared with a search from a published systematic review of patient preferences in lung cancer.

Applied Quantitative Analysis of Behavior: What It Is, and Why We Care-Introduction to the Special Section

Science evolves from prior approximations of its current form. Interest in changes in species over time was not a new concept when Darwin made his famous voyage to the Galapagos Islands; concern with speciation stretches back throughout the history of modern thought. Behavioral science also does and must evolve. Such change can be difficult, but it can also yield great dividends. The focus of the current special section is on a common mutation that appears to have emerged across these areas and the critical features that define an emerging research area-applied quantitative analysis of behavior (AQAB). In this introduction to the "Special Issue on Applications of Quantitative Methods," we will outline some of the common characteristics of research in this area, an exercise that will surely be outdated as the research area continues to progress. In doing so, we also describe how AQAB is relevant to theory, behavioral pharmacology, applied behavior analysis, and health behaviors. Finally, we provide a summary for the articles that appear in this special issue. The authors of these papers are all thinking outside the Skinner box, creating new tools and approaches, and testing them against relevant data. If we can keep up this evolution of methods and ideas, behavior analysis will regain its place at the head of the table!

"I Feel Therefore I Decide": Effect of Negative Emotions on Temporal Discounting and Probability Discounting

Temporal and probability discounting are considered two fundamental constructs in economic science, as they are associated with phenomena with major societal impact and a variety of sub-optimal behaviors and clinical conditions. Although it is well known that positive and negative affective states bear important cognitive/behavioral consequences, the effect of emotional experiences on decision-making remains unclear due to the existence of many conflicting results. Inspired by the need to understand if and to what extent the current COVID-19 pandemic has determined changes in our decision-making processes by means of the unusual, prolonged experience of negative feelings, in this study we investigate the effect of anger, fear, sadness, physical and moral disgust on intertemporal and risky choices. Results show that all emotions significantly increase subjects' preferences for immediate rewards over delayed ones, and for risky rewards over certain ones, in comparison to a "neutral emotion" condition, although the magnitude of the effect differs across emotions. In particular, we observed a more pronounced effect in the case of sadness and moral disgust. These findings contribute to the literature on emotions and decision-making by offering an alternative explanation to the traditional motivational appraisal theories. Specifically, we propose that the increased preference for immediate gratification and risky outcomes serves as a mechanism of self-reward aimed at down-regulating negative feelings and restore the individual's "emotional balance".

Effects of Amount on Probability Discounting: A Replication and Extension

We evaluated two quantitative models that attempt to account for the effects of amount on probability discounting. Sixty-four undergraduate psychology students completed four probability discounting tasks that differed in the amount of the probabilistic outcome ($20, $3,000, $50,000, and $500,000). In an amount-independent hyperboloid model, the exponent (s) systematically increased with reward amount. These systematic changes were not explained by the model. Myerson et al. (2011) reasoned that s increases as a power function of the amount of the probabilistic reward. We found support for the amount-dependent hyperboloid model at the aggregate and individual levels of analysis. The results replicate and extend previous research and suggest that the value function of a probabilistic outcome is weighted by, or depends on, its amount.

"I Will Respect the Autonomy of My Patient": A Scoping Review of Shared Decision Making in Multiple Sclerosis

Background

Patient autonomy is a bioethical principle that was strengthened in the revised Declaration of Geneva. Shared decision making (SDM) is particularly relevant in the management of multiple sclerosis (MS) because many preference-sensitive decisions have to be made during the disease course. We aimed to summarize the available evidence on SDM in the MS field and to inform future research and practice.

Methods

We performed a scoping review by searching MEDLINE (past 5 years). Studies were included if they reported primary/secondary research and focused on SDM related to people with MS. Data were grouped into topics, with results presented in narrative form.

Results

From 865 references, we included 55 studies conducted mostly in Europe. Half of the studies were observational, followed by qualitative (20%), mixed-methods (17%), randomized controlled trials (RCTs, 5%), quasi-experimental (5%), and reviews (4%). Most studies addressed people with relapsing-remitting MS (85%); the remaining addressed health care professionals, patients' significant others, or a combination. We identified five main topics: decisions on disease-modifying drugs, decisions on chronic cerebrospinal venous insufficiency treatment, information provision and patient education, health literacy, and risk knowledge.

Conclusions

The high proportion of included studies on SDM in MS in Europe suggests an earlier adoption of these concepts in this area. Decisions on disease-modifying drugs was the prevalent topic. Only 5% of studies were RCTs, indicating that more research is needed to study the effectiveness of SDM interventions. Studies addressing people with primary and secondary progressive MS are also needed.

Delay discounting of compliance with containment measures during the COVID-19 outbreak: a survey of the Italian population

Aim

Unprecedented community containment measures were taken following the recent outbreak of COVID-19 in Italy. The aim of the study was to explore the self-reported future compliance of citizens with such measures and its relationship with potentially impactful psychological variables.

Subjects and methods

An online survey was completed by 931 people (18–76 years) distributed across the Italian territory. In addition to demographics, five dimensions were measured: self-reported compliance with containment measures over time (today, at 7, 14, 30, 60, 90, and 180 days from now) at three hypothetical risk levels (10, 50, 90% of likelihood of contracting the COVID-19), perceived risk, generalized anxiety, intolerance of uncertainty, and relevance of several psychological needs whose satisfaction is currently precluded.

Results

The mean compliance scores follow a hyperbolic-like curve, decreasing over time for the lowest level of risk (10%), whilst they tend to flatten for ≥ 50% risk (90%). Significantly higher levels of anxiety, intolerance of uncertainty, and perceived risk were reported by women compared to men (p < 0.001 for each variable). Outdoor sports was the only need associated with the discounting rate of compliance (r_s = − 0.08, p = 0.018).

Conclusion

The duration of containment measures plays a crucial role in tackling the spread of the disease as people will be less compliant over time. Psychological needs of citizens impacting on the compliance should be taken into account when planning an easing of the lockdown, along with interventions for protecting vulnerable groups from mental distress.

On the behavioral economics of medication choice: A research story

Behavioral economics has been consistently useful in describing a wide range of clinical phenomena, particularly in reference to behavioral excesses such as substance abuse, problematic gambling and obesity/overeating. Given an opportunity to explore these processes as they relate to treatment adherence in patients with multiple sclerosis (MS), our central thesis was that behavioral economic tools/processes that have been helpful in other areas of application (e.g., substance abuse, obesity) could be leveraged to help understand treatment non-adherence and hopefully lead to efforts to combat it. The current paper tells a story of how an interdisciplinary set of researchers came to combine their separate expertise in MS and behavioral economics to yield novel insights into the failures of treatment adherence often experienced in this clinical population.

Discontinuing Treatment Against Medical Advice: The Role of Perceived Autonomy Support From Providers in Relapsing-Remitting Multiple Sclerosis

BACKGROUND

Long-term medication adherence is problematic among patients with chronic medical conditions. To our knowledge, this was the first study to examine factors associated with nonadherence among patients with relapsing-remitting multiple sclerosis who discontinue disease-modifying treatments against medical advice.

PURPOSE

To examine differences in perceived provider autonomy support between disease-modifying treatment-adherent relapsing-remitting multiple sclerosis patients and relapsing-remitting multiple sclerosis patients who discontinued disease-modifying treatments against medical advice.

METHODS

Self-report questionnaires and a neurologic exam were administered to demographically matched adherent (n = 50) and nonadherent (n = 79) relapsing- remitting multiple sclerosis patients from the Midwest and Northeast USA.

RESULTS

Adherent patients reported greater perceived autonomy support from their treatment providers, F(1, 124) = 28.170, p < .001, partial η2 = .185. This difference persisted after controlling for current multiple sclerosis healthcare provider, education, disease duration, Expanded Disability Status Scale, perceived barriers to adherence, and prevalence of side effects, F(1, 121) = 9.61, p = .002, partial η2 = .074. Neither depressive symptoms, F(1, 124) = 1.001, p > .05, partial η2 = .009, nor the occurrence of a major depressive episode, χ2(1, N = 129) = .288, p > .05, differed between adherent and nonadherent patients.

CONCLUSIONS

Greater perceived autonomy support from treatment providers may increase adherence to disease-modifying treatments among patients who discontinue treatment against medical advice. Results may inform interventions for patients who discontinue treatment against medical advice.

Reasons for nonadherence and response to treatment in an adherence intervention trial for relapsing-remitting multiple sclerosis patients

OBJECTIVES

To explore whether patients in an adherence trial who appeared not to take disease modifying therapy (DMT) for avoidance reasons could be reliably identified, by observational coding, for their main reason of not taking DMT. To determine whether reason groups could be distinguished by clinical and self-report psychological characteristics and intervention outcomes.

METHOD

Participants were multiple sclerosis patients (N = 78, 88.5% female, mean age 45.64) demotivated to take DMT. Audio recordings of the sessions were coded for the main reason of not taking DMT. Reason groups were compared based on patient characteristics and intervention outcomes.

RESULTS

Avoidance and three other reasons for not taking DMT (side effects, cost, and mild course) were reliably identified (κ = 0.88). Patient characteristics failed to distinguish participants in the Avoidance group, which also had poorer outcomes (X² [2, n = 73] = 6.35, p = 0.036).

CONCLUSIONS

Patients not taking DMT for avoidance reasons may need novel methods to identify them and encourage (re-)initiation.

Probability discounting of treatment decisions in multiple sclerosis: associations with disease knowledge, neuropsychiatric status, and adherence

RATIONALE

Patients weigh risks and benefits when making treatment decisions. Despite this, relatively few studies examine the behavioral patterns underpinning these decisions. Moreover, individual differences in these patterns remain largely unexplored.

OBJECTIVES

The purpose of this study was to test a probability discounting model to explain the independent influences of risks and benefits when patients make hypothetical treatment decisions. Furthermore, we examine how individual differences in this probability discounting function are associated with patient demographics, clinical characteristics, disease knowledge, neuropsychiatric status, and adherence.

METHODS

Two hundred eight participants with relapsing-remitting multiple sclerosis (MS) indicated their likelihood (0-100%) of taking a hypothetical medication as the probability of mild side effects (11 values from .1 to 99.9%) and reported medication efficacies (11 values from .1 to 99.9%) varied systematically. They also completed a series of questionnaires and cognitive tests.

RESULTS

Individual components of medication treatment decision making were successfully described with a probability discounting model. High rates of discounting based on risks were associated with poor treatment adherence and less disease-specific knowledge. In contrast, high rates of discounting of benefits was associated with poorer cognitive functioning. Regression models indicated that risk discounting predicted unique variance in treatment adherence.

CONCLUSIONS

Insights gained from the present study represent an important early step in understanding individual differences associated with medical decision making in MS. Future research may wish to use this knowledge to inform the development of empirically supported adherence interventions.

Impairment in delay discounting in schizophrenia and schizoaffective disorder but not primary mood disorders

A measure of planning and impulse control, the delay-discounting (DD) task estimates the extent to which an individual decreases the perceived value of a reward as the reward is delayed. We examined cross-disorder performance between healthy controls (n = 88), individuals with bipolar disorder (n = 23), major depressive disorder (n = 43), and primary psychotic disorders (schizophrenia and schizoaffective disorder; n = 51) on the DD task (using a $10 delayed larger reward), as well as the interaction of DD scores with other symptom domains (cognition, psychosis, and affect). We found that individuals with schizophrenia and schizoaffective disorder display significantly greater rates of discounting compared to healthy controls, while individuals with a primary mood disorder do not differ from healthy controls after adjustment for IQ. Further, impairment in working memory is associated with higher discounting rates among individuals with schizophrenia and schizoaffective disorder, but cognitive dysfunction alone does not account for the extent of impairment in DD. Taken together, these results suggest an impaired ability to plan for the future and make adaptive decisions that are specific to individuals with psychotic disorders, and likely related to adverse functional outcomes. More generally, this work demonstrates the presence of variation in impulsivity across major psychiatric illnesses, supporting the use of a trans-diagnostic perspective.

Patients with schizophrenia find it harder to delay gratification compared with patients diagnosed with other psychiatric disorders. Hannah Brown and colleagues in Roy Perlis’ lab at the Center for Quantitative Health at Massachusetts General Hospital, Boston, compared the performance of patients with bipolar disorder, major depressive disorder, schizophrenia, and healthy controls on a task that measures impulsivity. The delay discounting (DD) task assesses individuals’ ability to put off immediate pleasures for greater enjoyments later and is indicative of decision-making and planning behaviors. They found that certain aspects of cognitive dysfunction were associated with an increased preference for immediate rewards and that, even after adjusting for IQ, patients with schizophrenia showed significantly greater discounting rates compared with the other study participants. This variation in a specific measure of impulsivity suggests that the DD task could be used to better define aspects of impulsive behaviors across psychiatric disorders.

Neural mechanisms associated with treatment decision making: An fMRI study

Great progress has been made in understanding how people make financial decisions. However, there is little research on how people make health and treatment choices. Our study aimed to examine how participants weigh benefits (reduction in disease progression) and probability of risk (medications' side effects) when making hypothetical treatment decisions, and to identify the neural networks implicated in this process. Fourteen healthy participants were recruited to perform a treatment decision probability discounting task using MRI. Behavioral responses and skin conductance responses (SCRs) were measured. A whole brain analysis were performed to compare activity changes between "mild" and "severe" medications' side effects conditions. Then, orbitofrontal cortex (OFC), ventral striatum (VS), amygdala and insula were chosen for effective connectivity analysis. Behavioral data showed that participants are more likely to refuse medication when side effects are high and efficacy is low. SCRs values were significantly higher when people made medication decisions in the severe compared to mild condition. Functionally, OFC and VS were activated in the mild condition and were associated with increased likehood of choosing to take medication (higher area under the curve "AUC" side effects/efficacy). These regions also demonstrated an increased effective connectivity when participants valued treatment benefits. By contrast, the OFC, insula and amygdala were activated in the severe condition and were associated with and increased likelihood to refuse treatment. These regions showed enhanced effective connectivity when participants were confronted with increased side effects severity. This is the first study to examine the behavioral and neural bases of medical decision making.

A Novel Communication Value Task Demonstrates Evidence of Response Bias in Cases with Presbyacusis

Decision-making about the expected value of an experience or behavior can explain hearing health behaviors in older adults with hearing loss. Forty-four middle-aged to older adults (68.45 ± 7.73 years) performed a task in which they were asked to decide whether information from a surgeon or an administrative assistant would be important to their health in hypothetical communication scenarios across visual signal-to-noise ratios (SNR). Participants also could choose to view the briefly presented sentences multiple times. The number of these effortful attempts to read the stimuli served as a measure of demand for information to make a health importance decision. Participants with poorer high frequency hearing more frequently decided that information was important to their health compared to participants with better high frequency hearing. This appeared to reflect a response bias because participants with high frequency hearing loss demonstrated shorter response latencies when they rated the sentences as important to their health. However, elevated high frequency hearing thresholds did not predict demand for information to make a health importance decision. The results highlight the utility of a performance-based measure to characterize effort and expected value from performing tasks in older adults with hearing loss.

Using EP50 to forecast treatment adherence in individuals with multiple sclerosis

Much like delay discounting, probability discounting may be related to a host of pro-health behaviors. In a recent report, a Medical Decision Making Questionnaire (MDMQ) was developed that leveraged this insights of probability discounting to both describe ways that multiple sclerosis (MS) patients weigh costs and benefits when making adherence choices, and predicted their self-reported treatment adherence. The current re-analysis of those data use a novel EP50 measure as a framework of a model that predicted the cost/benefit ratios necessary for the choices of typically non-adherent patients to become indistinguishable from those of typically adherent patients (and vice versa). These analytic tools may aid in the development/evaluation of both novel therapeutics and treatment adherence strategies for chronic conditions.

Syntax for calculation of discounting indices from the monetary choice questionnaire and probability discounting questionnaire

The 27-item Monetary Choice Questionnaire (MCQ; Kirby, Petry, & Bickel, 1999) and 30-item Probability Discounting Questionnaire (PDQ; Madden, Petry, & Johnson, 2009) are widely used, validated measures of preferences for immediate versus delayed rewards and guaranteed versus risky rewards, respectively. The MCQ measures delayed discounting by asking individuals to choose between rewards available immediately and larger rewards available after a delay. The PDQ measures probability discounting by asking individuals to choose between guaranteed rewards and a chance at winning larger rewards. Numerous studies have implicated these measures in addiction and other health behaviors. Unlike typical self-report measures, the MCQ and PDQ generate inferred hyperbolic temporal and probability discounting functions by comparing choice preferences to arrays of functions to which the individual items are preconfigured. This article provides R and SPSS syntax for processing the MCQ and PDQ. Specifically, for the MCQ, the syntax generates k values, consistency of the inferred k, and immediate choice ratios; for the PDQ, the syntax generates h indices, consistency of the inferred h, and risky choice ratios. The syntax is intended to increase the accessibility of these measures, expedite the data processing, and reduce risk for error.

Effects of delay and probability combinations on discounting in humans

To determine discount rates, researchers typically adjust the amount of an immediate or certain option relative to a delayed or uncertain option. Because this adjusting amount method can be relatively time consuming, researchers have developed more efficient procedures. One such procedure is a 5-trial adjusting delay procedure, which measures the delay at which an amount of money loses half of its value (e.g., $1000 is valued at $500 with a 10-year delay to its receipt). Experiment 1 (n=212) used 5-trial adjusting delay or probability tasks to measure delay discounting of losses, probabilistic gains, and probabilistic losses. Experiment 2 (n=98) assessed combined probabilistic and delayed alternatives. In both experiments, we compared results from 5-trial adjusting delay or probability tasks to traditional adjusting amount procedures. Results suggest both procedures produced similar rates of probability and delay discounting in six out of seven comparisons. A magnitude effect consistent with previous research was observed for probabilistic gains and losses, but not for delayed losses. Results also suggest that delay and probability interact to determine the value of money. Five-trial methods may allow researchers to assess discounting more efficiently as well as study more complex choice scenarios.