Decision-making ability in psychosis: a systematic review and meta-analysis of the magnitude, specificity and correlates of impaired performance on the Iowa and Cambridge Gambling Tasks

Abstract

AbstractTo identify factors which may help or hinder decision-making ability in people with psychosis, we did a systematic review and meta-analysis of their performance on the Iowa and Cambridge Gambling Tasks. Analysis of 47 samples found they had moderately poorer performance than healthy individuals (N= 4264,g= −0.57, 95% confidence interval (CI) −0.66 to −0.48). Few studies (k= 8) used non-psychotic clinical comparator groups, although very low-quality evidence (k= 3) found people with bipolar disorder may perform better. Negative symptoms (k= 13,N= 648,r= −0.17, 95% CI −0.26 to −0.07) and lower IQ (k= 11,N= 525,r= 0.20, 95% CI 0.29–0.10), but not positive symptoms (k= 10,N= 512,r= −0.01, 95% CI −0.11 to 0.08), each had small-moderate associations with poorer decision-making. Lower quality evidence suggested general symptoms, working memory, social functioning, awareness of emotional responses to information, and attentional bias towards gain are associated with decision-making, but not education, executive functioning or overall symptoms. Meta-regression suggested an inverse association between decision-making and depression severity (k= 6,Q= 6.41,R2100%,p= 0.01). Those taking first-generation (k= 6,N= 305,g= −0.17, 95% CI −0.40 to 0.06,p= 0.147) or low-dose antipsychotics (k= 5,N= 442,g= −0.19, 95% CI −0.44 to 0.06,p= 0.139) had unimpaired decision-making. Although meta-regression found no linear association between dose and performance, non-reporting of the dose was common and associated with larger impairments (k= 46,Q= 4.71,R214%,p= 0.03). Those supporting people with psychosis to make decisions, including treatment decisions, should consider the potential effect of these factors. Interventionist-causal trials are required to test whether reducing antipsychotic dose and treating anxiety and depression can improve decision-making in this group.