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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

  • Amanda Woodrow (a1), Sarah Sparks (a2), Valeria Bobrovskaia (a2), Charlotte Paterson (a1), Philip Murphy (a1) and Paul Hutton (a1)...

To 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, R2 100%, 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, R2 14%, 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.

Corresponding author
Author for correspondence: Paul Hutton, E-mail:
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Adan, A, Capella, MDM, Prat, G, Forero, DA, Lopez-Vera, S and Navarro, JF (2017) Executive functioning in men with schizophrenia and substance use disorders. Influence of lifetime suicide attempts. PLoS ONE 12, 1.
Bark, R, Dieckmann, S, Bogerts, B and Northoff, G (2005) Deficit in decision making in catatonic schizophrenia: an exploratory study. Psychiatry Research 134, 131141.
Bechara, A, Damasio, A, Damasio, H and Anderson, S (1994) Insensitivity to future consequences following damange to human prefrontal cortex. Cognition 50, 715.
Borenstein, M, Hedges, L, Higgins, JPT and Rothstein, H (2009) Introduction to Meta-Analysis. Chichester: Wiley.
Bradford, L (2015) The Effects of Atypical Antipsychotics on Implicit Reward Learning in Schizophrenia (Dissertation). Belfast, Northern Ireland: Queens University.
Bradford-Hill, A (1965) The enviroment and disease: association or causation? Proceedings of the Royal Society of Medicine 58, 295300.
Brambilla, P, Perlini, C, Bellani, M, Tomelleri, L, Ferro, A, Cerruti, S, Marinelli, V, Rambaldelli, G, Christodoulou, T, Jogia, J, Dima, D, Tansella, M, Balestrieri, M and Frangou, S (2012) Increased salience of gains versus decreased associative learning differentiate bipolar disorder from schizophrenia during incentive decision making. Psychological Medicine 43, 571580.
Brown, EC, Hack, SM, Gold, JM, Carpenter, WT, Fischer, BA, Prentice, KP and Waltz, JA (2015) Integrating frequency and magnitude information in decision-making in schizophrenia: an account of patient performance on the Iowa Gambling Task. Journal of Psychiatric Research 66–67, 1623.
Buelow, MT and Suhr, JA (2009) Construct validity of the Iowa Gambling Task. Neuropsychology Review 19, 102114.
Buseymeyer, JR and Stout, JC (2002) A contribution of cognitive decision models to clinical assessment: decomposing performance on the Bechara gambling task. Psychological Assessment 14, 253262.
Caletti, E, Paoli, RA, Fiorentini, A, Cigliobianco, M, Zugno, E, Serati, M, Orsenigo, G, Grillo, P, Zago, S, Caldiroli, A, Prunas, C, Giusti, F, Consonni, D and Altamura, AC (2013) Neuropsychology, social cognition and global functioning among bipolar, schizophrenic patients and healthy controls: preliminary data. Frontiers in Human Neuroscience 7, 661.
Capdevielle, D, Raffard, S, Bayard, S, Garcia, F, Baciu, O, Bouzigues, I and Boulenger, JP (2009) Competence to consent and insight in schizophrenia: is there an association? A pilot study. Schizophrenia Research 108, 272279.
Cavallaro, R, Cavedini, P, Mistretta, P, Bassi, T, Angelone, SM, Ubbiali, A and Bellodi, L (2003) Basal-corticofrontal circuits in schizophrenia and obsessive-compulsive disorder: a controlled double dissociation study. Biological Psychiatry 54, 437443.
Cella, M, Dymond, S, Cooper, A and Turnbull, OH (2012) Cognitive decision modelling of emotion-based learning impairment in schizophrenia: the role of awareness. Psychiatry Research 196, 1519.
Cella, M, Reeder, C and Wykes, T (2015) Lessons learnt? The importance of metacognition and its implications for cognitive remediation in schizophrenia. Frontiers in Psychology 6, 1259.
Cohen, J (1988) Statistical Power Analysis for the Behavioral Sciences, 2nd edition. Hillsdale, New Jersey: Lawrence Erlbaum Associates.
Crespo-Facorro, B, Rodríguez-Sánchez, JM, Pérez-Iglesias, R, Mata, I, Ayesa, R, Ramirez-Bonilla, M, Martínez-Garcia, O and Vázquez-Barquero, JL (2009) Neurocognitive effectiveness of haloperidol, risperidone and olanzapine in first-episode psychosis: a randomized controlled 1-year follow-up comparison. Journal of Clinical Psychiatry 70, 717729.
Da Silva, S (2017) Deconstructing Motivation Deficits in Schizophrenia and Beyond (Dissertation). Toronto, Canada: University of Toronto.
Damasio, AR, Everitt, BJ and Bishop, D (1996) The somatic marker hypothesis and the possible functions of the prefrontal Cortex (and Discussion). Philosophical Transactions of the Royal Society B: Biological Sciences 351, 14131420.
DerSimonian, R and Laird, N (1986) Meta-analysis in clinical trials. Controlled clinical trials 7, 177188.
Dudley, R, Taylor, P, Wickham, S and Hutton, P (2016) Psychosis delusions and the “jumping to conclusions” reasoning bias: a systematic review and meta-analysis. Schizophrenia Bulletin 42, 652665.
Duval, S, Tweedie, R, Taylor, S and Tweedie, R (2000) Trim and fill: a simple funnel plot based method of testing and adjusting for publication bias in meta-analysis. Biometrics 56, 455463.
Egger, M, Davey Smith, G, Schneider, M and Minder, C (1997) Bias in meta-analysis detected by a simple graphical test. British Medical Journal 315, 629634.
Evans, CEY, Bowman, CH and Turnbull, OH (2005) Subjective awareness on the Iowa Gambling Task: the key role of emotional experience in schizophrenia. Journal of Clinical and Experimental Neuropsychology 27, 656664.
Guillaume, S, Gorwood, P, Jollant, F, Van Den Eynde, F, Courtet, P and Richard-Devantoy, S (2015) Impaired decision-making in symptomatic anorexia and bulimia nervosa patients: a meta-analysis. Psychological Medicine 45, 33773391.
Guyatt, GH, Oxman, AD, Vist, GE, Kunz, R, Falck-Ytter, Y, Alonso-Coello, P and Schünemann, HJ and GRADE Working Group (2008) GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. British Medical Journal 336, 924926.
Higgins, JPT and Green, S (2011) Cochrane Handbook for Systematic Reviews of Interventions (Version 5.10). Chichester: Wiley and Sons.
Highet, K (2014) Thinking Matters: The Profile of Executive Functioning Associated with Cannabis Use in Schizophrenia and its Functional Outcome Correlates (Dissertation). Perth, Australia: Murdoch University.
Hori, H, Yoshimura, R, Katsuki, A, Atake, K and Nakamura, J (2014) Relationships between brain-derived neurotrophic factor clinical symptoms and decision-making in chronic schizophrenia: data from the Iowa Gambling Task. Frontiers In Behavioral Neuroscience 8, 417.
Howes, OD and Murray, RM (2014) Schizophrenia: an integrated sociodevelopmental-cognitive model. The Lancet 10, 16771687.
Kendler, KS and Campbell, J (2009) Interventionist causal models in psychiatry: repositioning the mind–body problem. Psychological Medicine 39, 881887.
Kovács, I, Richman, MJ, Janka, Z, Maraz, A and Andó, B (2017) Decision making measured by the Iowa Gambling Task in alcohol use disorder and gambling disorder: a systematic review and meta-analysis. Drug and Alcohol Dependence 181, 152161.
Larkin, A and Hutton, P (2017) Systematic review and meta-analysis of factors that help or hinder treatment decision-making capacity in psychosis. British Journal of Psychiatry 211, 205215.
Law, H and Morrison, AP (2014) Recovery in psychosis: a Delphi study with experts by experience. Schizophrenia Bulletin 40, 13471355.
Lee, SJ, Lee, HK, Kweon, YS, Lee, CT and Lee, KU (2009) The impact of executive function on emotion recognition and emotion experience in patients with schizophrenia. Psychiatry Investigation 6, 156162.
Leucht, S, Kane, JM, Kissling, W, Hamann, J, Etschel, E and Engel, RR (2005) What does the PANSS mean? Schizophrenia Research 79, 231238.
Leucht, S, Rothe, P, Davis, JM and Engel, RR (2013) Equipercentile linking of the BPRS and the PANSS. European Neuropsychopharmacology 23, 956959.
Martino, DJ and Strejilevich, SA (2014) A comparison of decision making in patients with bipolar i disorder and schizophrenia. Schizophrenia Research 156, 135136.
Matsuzawa, D, Shirayama, Y, Niitsu, T, Hashimoto, K and Iyo, M (2015) Deficits in emotion based decision-making in schizophrenia; a new insight based on the Iowa Gambling Task. Progress in Neuro-Psychopharmacology and Biological Psychiatry 57, 5259.
Mukherjee, D and Kable, JW (2014) Value-based decision making in mental illness: a meta-analysis. Clinical Psychological Science 2, 767782.
Must, A, Horvath, S, Nemeth, VL and Janka, Z (2013) The Iowa Gambling Task in depression – what have we learned about sub-optimal decision-making strategies? Frontiers in Psychology 4, 732.
National Institute for Health and Social Care Excellence (NICE) (2018) Decision Making and Mental Capacity (GID-NG10009): Draft Guidelines. London, UK: National Institute for Health and Social Care Excellence.
Newman, JM (2008) The Relationship between Risk Assessment and Victimization in Individuals with Schizophrenia (Dissertation). Hempstead, New York, USA: Hofstra University.
Premkumar, P, Fannon, D, Kuipers, E, Simmons, A, Frangou, S and Kumari, V (2008) Emotional decision-making and its dissociable components in schizophrenia and schizoaffective disorder: a behavioural and MRI investigation. Neuropsychologia 46, 20022012.
Premkumar, P, Peters, ER, Fannon, D, Anilkumar, AP, Kuipers, E and Kumari, V (2011) Coping styles predict responsiveness to cognitive behaviour therapy in psychosis. Psychiatry Research 187, 354362.
Raffard, S, Capdevielle, D, Gely-Nargeot, MC, Attal, J, Baillard, A, Del-Monte, J, Mimoun, N, Boulenger, JP and Bayard, S (2011) Insight is not associated with insensitivity to future consequences in schizophrenia. Psychiatry Research 187, 307309.
Raffard, S, Fond, G, Brittner, M, Bortolon, C, Macgregor, A, Boulenger, JP, Gely-Nargeot, MC and Capdevielle, D (2013) Cognitive insight as an indicator of competence to consent to treatment in schizophrenia. Schizophrenia Research 144, 118121.
Richard-Devantoy, S, Berlim, MT and Jollant, F (2014) A meta-analysis of neuropsychological markers of vulnerability to suicidal behavior in mood disorders. Psychological Medicine 44, 16631673.
Riley, RD, Higgins, JPT and Deeks, JJ (2011) Interpretation of random effects meta-analyses. British Medical Journal 342, 549549.
Rogers, RD, Everitt, BJ, Baldacchino, A, Blackshaw, AJ, Swainson, R, Wynne, K, Baker, NB, Hunter, J, Carthy, T, Booker, E, London, M, Deakin, JF, Sahakian, BJ and Robbins, TW (1999) Dissociable deficits in the decision-making cognition of chronic amphetamine abusers opiate abusers patients with focal damage to prefrontal cortex and tryptophan-depleted normal volunteers: evidence for monoaminergic mechanisms. Neuropsychopharmacology 20, 322339.
Rotge, JY, Poitou, C, Fossati, P, Aron-Wisnewsky, J and Oppert, JM (2017) Decision-making in obesity without eating disorders: a systematic review and meta-analysis of Iowa Gambling Task performances. Obesity Reviews 18, 936942.
Samara, MT, Engel, RR, Millier, A, Kandenwein, J, Toumi, M and Leucht, S (2014) Equipercentile linking of scales measuring functioning and symptoms: examining the GAF, SOFAS, CGI-S, and PANSS. European Neuropsychopharmacology 24, 17671772.
Sedgwick, OL (2016) The Contribution of Dissocial Personality Disorder to Cognition Emotion Processing and Clinical Outcome in Violent Men with Psychosis (Dissertation). London, UK: Kings College London.
Starcke, K and Brand, M (2016) Effects of stress on decisions under uncertainty: a meta-analysis. Psychological Bulletin 142, 909933.
Stewart, L, Moher, D and Shekelle, P (2012) Why prospective registration of systematic reviews makes sense. Systematic Reviews 1, 7.
Stovell, D, Wearden, A, Morrison, AP and Hutton, P (2016) Service users experiences of the treatment decision-making process in psychosis: a phenomenological analysis. Psychosis: Psychological Social and Integrative Approaches 8, 311323.
Taylor, PJ, Hutton, P and Wood, L (2015) Are people at risk of psychosis also at risk of suicide and self-harm? A systematic review and meta-analysis. Psychological Medicine 45, 911926.
Thompson, SG and Higgins, JPT (2002) How should meta-regression analyses be undertaken and interpreted? Statistics in Medicine 21, 15591573.
Turnbull, OH, Evans, CEY, Kemish, K, Park, S and Bowman, CH (2006) A novel set-shifting modification of the Iowa Gambling Task: Flexible emotion-based learning in schizophrenia. Neuropsychology 20, 290298.
Wang, SB, Wang, YY, Ungvari, GS, Ng, CH, Wu, RR, Wang, J and Xiang, YT (2017) The MacArthur competence assessment tools for assessing decision-making capacity in schizophrenia: a meta-analysis. Schizophrenia Research 183, 5663.
Wells, A and Matthews, G (1996) Modelling cognition in emotional disorder: the S-REF model. Behaviour Research and Therapy 34, 881888.
Whitney, KA, Fastenau, PS, Evans, JD and Lysaker, PH (2004) Comparative neuropsychological function in obsessive-compulsive disorder and schizophrenia with and without obsessive-compulsive symptoms. Schizophrenia Research 69, 7583.
Yechiam, E, Busemeyer, JR, Stout, JC and Bechara, A (2005) Using cognitive models to map relations between neuropsychological disorders and human decision-making deficits. Psychological Science 16, 973978.
Yip, SW, Sacco, KA, George, TP and Potenza, MN (2009) Risk/reward decision-making in schizophrenia: a preliminary examination of the influence of tobacco smoking and relationship to Wisconsin Card Sorting Task performance. Schizophrenia Research 110, 156164.
Zhang, L, Tang, J, Dong, Y, Ji, Y, Tao, R, Liang, Z, Chen, J, Wu, Y and Wang, K (2015) Similarities and differences in decision-making impairments between autism spectrum disorder and schizophrenia. Frontiers in Behavioral Neuroscience 9, 259.
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