Rationale, aims and objectives Over the last years, traditional paternalistic model is being questioned. Shared Decision‐Making (SDM) model has been proposed as a way to improve patient‐physician interaction. Little is known to what extent people with severe mental illness want to be involved in decision‐making process. This study evaluates their preferences about making clinical decisions and which variables influence these desires. Method One hundred seven patients with DSM diagnoses of bipolar disorder or schizophrenia and 100 Non Psychiatric Comparison (NPC) subjects recruited from mental health and primary care departments completed a self‐reported questionnaire about preferences in decision‐making process. Demographic and clinical information was obtained through review of available records and the Brief Psychiatric Rating Scale (BPRS). Results Patients and NPCs differed as regards their preferences about their participation in medical decisions. NPCs were 18 times more likely to prefer options about their treatment and 2 times more likely to prefer to take medical decisions by their own than psychiatric patients. The best predictors of the preference of a SDM model were a lower BPRS global score and the absence of previous compulsory admissions. Conclusions Psychiatric patients more frequently preferred a passive role in the decision‐making process. Interventions to promote SDM should be tailored to the values and needs of each patient because not everyone wants to participate to the same degree. We found several factors to take into account in patient engagement in SDM as these populations may be more vulnerable.

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