Choice Overload in Systemic Psoriasis Therapy

Over the past ten years, the number of highly effective systemic medications available to our patients has dramatically increased. Patients overwhelmingly benefit from the increased number of medications as new medications have new targets and fewer adverse effects. However, with each additional systemic medication added to the possible treatment regimen, there is the possibility that in attempting to decide which medication would be best to treat psoriasis, patients or even physicians could suffer from choice overload, thereby potentially decreasing the patient security and satisfaction in their choice.

Choice overload is defined as the difficulty with decision-making when presented with an abundance of options. While this concept commonly appears in psychology, marketing, and behavioral economics, it is rarely mentioned in medicine. Originally introduced in the 1970’s with the book Future Shock, the idea of choice overload gained popularity in 2000 with the Jam Study (1).

Iyengar and Lepper investigated how increasing the number of choices (in this case, jam flavor options) affected a customer’s decision to make a purchase. The researchers divided customers into two groups: in the first group, they offered customers six different flavors to sample; in the second group, they offered twenty-four different flavors. Outcome measures included how many customers stopped to sample the different jams, and how many customers purchased a jar of jam.

The six flavor display attracted fewer shoppers, with 40% of customers stopping to sample compared to 60% stopping at the twenty-four flavor display. However, customers were more likely to purchase the jam when selecting among fewer choices. 30% of customers offered the six-flavor display purchased one of the jams, compared to only 3% of those offered the twenty-four flavor display (Figure 1). While more flavors initially attracted more customers, the abundance of options seemed to hinder customers from deciding which jam flavor to buy (2). The insignificance of the purchasing decision the customers may have affected the results. However, when researchers investigated workers making a far more critical decision, choosing a retirement savings plan among different investment options, workers were more likely to save for retirement when provided with fewer, rather than more, investment options (3).

Figure 1. Jam Sampling Versus Jam Purchase in Minimal Versus Extensive Choice Options

Source: Iyengar and Lepper (2000)

Choice overload may impact our patients when considering a large number of treatment options as they now do for psoriasis. When presented with this abundance of choices, patients may find choosing a preferred treatment difficult. Alternatively, even if patients do choose one treatment from among the many available, patients may feel less satisfied with their choice. As the number of options increases, patients may be at greater risk of thinking they made the wrong choice.

There are over a dozen good systemic medications for psoriasis. If providers present all available psoriasis medications to patients, the information about the different targets, benefits, adverse effects, and cost of each medication could be overwhelming.

A few strategies that have been suggested to mitigate the problem of choice overload include:

1. Decreasing the number of choices that are presented to patients

2. More clearly defining the consequences associated with each choice option, thereby making the decision and consequences more real to the person making the decision.

3. Divide options into a smaller number of categories

4. Start with simple decisions and gradually increase the complexity of subsequent decisions.(4)

Decision researchers have proposed other strategies for reducing choice overload including an articulated ideal point (5). This strategy reduces choice overload by having the decision maker identify specific qualities of the hypothetical ideal product for which they are searching. By first identifying their optimal hypothetical choice, consumers are more able to easily sort through many options and identify a product that most closely correlates to their ideal.

When presenting medication options, providers could limit the options presented to patients, concretize or contextualize the implications of taking each of the medications, present medications in terms of groups (for example, TNF, IL-23, or IL-17 targeted treatments), or possibly even suggest that the patient imagine their ideal psoriasis medication and then present the options for treatment. Theoretically, reducing choice overload could increase patient satisfaction, and, since patient satisfaction may affect patient adherence, reducing choice overload has the potential to improve patients’ adherence to their treatment choice (6).

Between oral medications and biologics, psoriasis patients these days may be spoiled for choice when it comes to their treatment. While it is important for providers to offer patients a choice about their medication, it may help for providers to be mindful about lightening the (choice) overload.

Disclosure statement

Steven Feldman has received research, speaking and/or consulting support from a variety of companies including Galderma, GSK/Stiefel, Almirall, Leo Pharma, Boehringer Ingelheim, Mylan, Celgene, Pfizer, Valeant, Abbvie, Samsung, Janssen, Lilly, Menlo, Merck, Novartis, Regeneron, Sanofi, Novan, Qurient, National Biological Corporation, Caremark, Advance Medical, Sun Pharma, Suncare Research, Informa, UpToDate and National Psoriasis Foundation. He is founder and majority owner of www.DrScore.com and founder and part owner of Causa Research, a company dedicated to enhancing patients’ adherence to treatment.

Patrick Whitman and Abigail Cline have no conflicts to disclose.