Ethical considerations for precision psychiatry: A roadmap for research and clinical practice

Fusar-Poli, P., Manchia, M., et al. (2022, October). 

European Neuropsychopharmacology, 63, 17–34.

https://doi.org/10.1016/j.euroneuro.2022.08.001

Abstract

Precision psychiatry is an emerging field with transformative opportunities for mental health. However, the use of clinical prediction models carries unprecedented ethical challenges, which must be addressed before accessing the potential benefits of precision psychiatry. This critical review covers multidisciplinary areas, including psychiatry, ethics, statistics and machine-learning, healthcare and academia, as well as input from people with lived experience of mental disorders, their family, and carers. We aimed to identify core ethical considerations for precision psychiatry and mitigate concerns by designing a roadmap for research and clinical practice. We identified priorities: learning from somatic medicine; identifying precision psychiatry use cases; enhancing transparency and generalizability; fostering implementation; promoting mental health literacy; communicating risk estimates; data protection and privacy; and fostering the equitable distribution of mental health care. We hope this blueprint will advance research and practice and enable people with mental health problems to benefit from precision psychiatry.

From the Results section

3.1. Ethics of precision psychiatry: Key concepts

Broadly speaking, ethical issues concern the development of ‘practical ought claims’ (Sheehan and Dunn, 2013) (i.e. normative claims that are practical in nature), which arise when we face ethical uncertainty in precision psychiatry. These practical claims come schematically like this: how should somebody or a group of people act in relation to a particular issue when they face certain circumstances? For example, how should researchers inform patients about their individualised risk estimates after running a novel clinical prediction model? To address these questions, four overarching ethical principles have been suggested (by Beauchamp and Childress) (Beauchamp and Childress, 2019), which include autonomy, beneficence, non-maleficence and justice. These can be applied to precision psychiatry, complemented by an extra principle of “explainability/interpretability” (Panel 1) which has been specifically introduced for artificial intelligence (Floridi et al., 2018) (for a more detailed discussion of ethical platforms for big data analytics see eSupplementary 1).

Although these four principles have become the cornerstones of biomedical ethics in healthcare practice, they have been criticised as they are often conflicting with no clear hierarchy and are not very specific (i.e. these principles are somewhat implicit, representing general moral values), leading to “imprecise ethics” that may not fit the needs of precision psychiatry (Table 1). Rather we should ask ourselves “why” a certain act may be harmful or beneficial. For example, let's imagine having a risk assessment; what would that mean for the individual, their family planning, workplace, choosing their studies, or their period of life? Alternatively, let's imagine that the risk assessment is not performed; what would be the results in a few years’ time? To address these sorts of questions, this study will consider ethical values in a broader sense, for example, by taking into account some of the different principles present in the charter of fundamental rights of the European Union – starting from dignity, freedom, equality, solidarity, citizens’ rights and justice (Table 1) (European Union, 2012; Hallinan, 2021). In particular, human dignity and human flourishing are the most crucial elements from an ethical point of view that are tightly linked to autonomy and self-determination (which is modulated by several factors such as physical health, psychological state, sociocultural environment, as well as values and beliefs). The loss of insight associated with some psychiatric disorders may incapacitate the individual to make autonomous decisions. For example, autonomy emerged as the driving decision component for undergoing risk prediction testing among young populations (Mantell et al., 2021a), regardless of whether a person would decide for or against risk profiling. Finally, it is important to highlight that unique ethical considerations may be associated with the historically complex socio-political perceptions and attitudes towards severe mental disorders and psychiatry (Ball et al., 2020a; Manchia et al., 2020a).

The info is here.

Implementing The 988 Hotline: A Critical Window To Decriminalize Mental Health

P. Krass, E. Dalton, M. Candon, S. Doupnik

Health Affairs

Originally posted 25 FEB 22

Here is an excerpt:

Decriminalization Of Mental Health

The 988 hotline holds incredible promise toward decriminalizing the response to mental health emergencies. Currently, if an individual is experiencing a mental health crisis, they, their caregivers, and bystanders have few options beyond calling 911. As a result, roughly one in 10 individuals with mental health disorders have interacted with law enforcement prior to receiving psychiatric care, and 10 percent of police calls are for mental health emergencies. When police arrive, if they determine an acute safety risk, they transport the individual in crisis for further psychiatric assessment, most commonly at a medical emergency department. This almost always takes place in a police vehicle, many times in handcuffs, a scenario that contradicts central tenets of trauma-informed mental health care. In the worst-case scenario, confrontation with police results in injury or death. Adverse outcomes during response to mental health emergencies are more than 10-fold more likely for individuals with mental health conditions than for individuals without, and are disproportionately experienced by people of color. This consequence was tragically highlighted by the death of Walter Wallace, Jr., who was killed by police while experiencing a mental health emergency in October 2021.

Ideally, the new 988 number would activate an entirely different cascade of events. An individual in crisis, their family member, or even a bystander will be able to immediately reach a trained crisis counselor who can provide phone-based triage, support, and local resources. If needed, the counselor can activate a mobile mental health crisis team that will arrive on site to de-escalate; provide brief therapeutic interventions; either refer for close outpatient follow up or transport the individual for further psychiatric evaluation; and even offer food, drink, and hygiene supplies.

 

Rather than forcing families to call 911 for any type of help—regardless of criminal activity—the 988 line will allow individuals to access mental health crisis support without involving law enforcement. This approach can empower families to self-advocate for the right level of mental health care—including avoiding unnecessary medical emergency department visits, which are not typically designed to handle mental health crises and can further traumatize individuals and their families—and to initiate psychiatric assessment and treatment sooner. 911 dispatchers will also be able to re-route calls to 988 when appropriate, allowing law enforcement personnel to spend more time on their primary role of ensuring public safety. Finally, the 988 number will help offer a middle option for individuals who need rapid linkage to care, including rapid psychiatric evaluation and initiation of treatment, but do not yet meet criteria for crisis. This is a crucial service given current difficulties in accessing timely, in-network outpatient mental health care.

The info is here.

Voice-hearing across the continuum: a phenomenology of spiritual voices

Moseley, P., et al. (2021, November 16).

https://doi.org/10.31234/osf.io/7z2at

Abstract

Voice-hearing in clinical and non-clinical groups has previously been compared using standardized assessments of psychotic experiences. Findings from several studies suggest that non-clinical voice-hearing (NCVH) is distinguished by reduced distress and increased control. However, symptom-rating scales developed for clinical populations may be limited in their ability to elucidate subtle and unique aspects of non-clinical voices. Moreover, such experiences often occur within specific contexts and systems of belief, such as spiritualism. This makes direct comparisons difficult to interpret. Here we present findings from a comparative interdisciplinary study which administered a semi-structured interview to NCVH individuals and psychosis patients. The non-clinical group were specifically recruited from spiritualist communities. The findings were consistent with previous results regarding distress and control, but also documented multiple modalities that were often integrated into a single entity, high levels of associated visual imagery, and subtle differences in the location of voices relating to perceptual boundaries. Most spiritual voice-hearers reported voices before encountering spiritualism, suggesting that their onset was not solely due to deliberate practice. Future research should aim to understand how spiritual voice-hearers cultivate and control voice-hearing after its onset, which may inform interventions for people with distressing voices.

From the Discussion

As has been reported in previous studies, the ability to exhibit control over or influence voices seems to be an important difference between experiences reported by clinical and non-clinical groups.  A key distinction here is between volitional control (ability to bring on or stop voices intentionally), and the ability to influence voices (through other strategies such as engagement or distraction from voices), referred to elsewhere as direct and in direct control.  In the present study, the spiritual group reported substantially higher levels of control and influence over voices, compared to patients. Importantly, nearly three-quarters of the group reported a change in their ability to influence the voices over time –compared to 12.5% of psychosis patients–suggesting that this ability is not always present from the onset of voice-hearing in non-clinical populations, and instead can be actively developed. Indeed, our analysis indicated that 88.5% of the spiritual group described their voices starting spontaneously, with 69.2% reporting that this was before they had contact with spiritualism itself. Thus, while most of the group (96.2%) reported ongoing cultivation of the voices, and often reported developing influence over time, it seems that spiritual practices mostly do not elicit the actual initial onset of the voices, instead playing a role in honing the experience. 

The research is here.

Is It Ethical to Use Prognostic Estimates from Machine Learning to Treat Psychosis?

Nicole Martinez-Martin, Laura B. Dunn, and Laura Weiss Roberts
AMA J Ethics. 2018;20(9):E804-811.
doi: 10.1001/amajethics.2018.804.

Abstract

Machine learning is a method for predicting clinically relevant variables, such as opportunities for early intervention, potential treatment response, prognosis, and health outcomes. This commentary examines the following ethical questions about machine learning in a case of a patient with new onset psychosis: (1) When is clinical innovation ethically acceptable? (2) How should clinicians communicate with patients about the ethical issues raised by a machine learning predictive model?

(cut)

Conclusion

In order to implement the predictive tool in an ethical manner, Dr K will need to carefully consider how to give appropriate information—in an understandable manner—to patients and families regarding use of the predictive model. In order to maximize benefits from the predictive model and minimize risks, Dr K and the institution as a whole will need to formulate ethically appropriate procedures and protocols surrounding the instrument. For example, implementation of the predictive tool should consider the ability of a physician to override the predictive model in support of ethically or clinically important variables or values, such as beneficence. Such measures could help realize the clinical application potential of machine learning tools, such as this psychosis prediction model, to improve the lives of patients.

A shocking number of mentally ill Americans end up in prison instead of treatment

By Ana Swanson
The Washington Post
Originally published April 30, 2015

Here is an excerpt:

For various reasons, these community treatment plans proved inadequate, leaving many of the mentally ill homeless or in jail. According to the Department of Justice, about 15 percent of state prisoners and 24 percent of jail inmates report symptoms meet the criteria for a psychotic disorder.

In its survey of individual states, the Treatment Advocacy Center found that in 44 of the 50 states and the District of Columbia, the largest prison or jail held more people with serious mental illness than the largest state psychiatric hospital (see map below). The only exceptions were Kansas, New Jersey, North Dakota, South Dakota, Washington and Wyoming. "Indeed, the Polk County Jail in Iowa, the Cook County Jail in Illinois, and the Shelby County Jail in Tennessee each have more seriously mentally ill inmates than all the remaining state psychiatric hospitals in that state combined," the report says.

The entire article is here.

Judge wants back on bench after insanity ruling

By Steve Schmadeke
Chicago Tribune
Originally published March 28, 2014

Can a suspended Cook County judge return to the bench after being declared legally insane at the time she shoved a sheriff’s deputy in 2012?

For the first time in Illinois, attorneys on the case say, a judicial disciplinary panel has begun tackling the question of whether a judge whose psychotic episodes can apparently be controlled through medication should be allowed to return to the bench.

The entire article is here.

The reality show: The Truman Show Delusion

Schizophrenics used to see demons and spirits. Now they talk about actors and hidden cameras – and make a lot of sense

By Mike Jay
Aeon Magazine

Here is an excerpt:

The Gold brothers’ interpretation of the Truman Show delusion runs along similar lines. It might appear to be a new phenomenon that has emerged in response to our hypermodern media culture, but is in fact a familiar condition given a modern makeover. They make a primary distinction between the content of delusions, which is spectacularly varied and imaginative, and the basic forms of delusion, which they characterise as ‘both universal and rather small in number’.

Persecutory delusions, for example, can be found throughout history and across cultures; but within this category a desert nomad is more likely to believe that he is being buried alive in sand by a djinn, and an urban American that he has been implanted with a microchip and is being monitored by the CIA. ‘For an illness that is often characterised as a break with reality,’ they observe, ‘psychosis keeps remarkably up to date.’ Rather than being estranged from the culture around them, psychotic subjects can be seen as consumed by it: unable to establish the boundaries of the self, they are at the mercy of their often heightened sensitivity to social threats.

The entire article is here.

Norway: Insanity Defense Not Likely

AP Exclusive

It's unlikely that the right-wing extremist who admitted killing dozens in Norway last week will be declared legally insane because he appears to have been in control of his actions, the head of the panel that will review his psychiatric evaluation told The Associated Press.

The decision on Anders Behring Breivik's mental state will determine whether he can be held criminally liable and punished with a prison sentence or sent to a psychiatric ward for treatment.

The July 22 attacks were so carefully planned and executed that it would be difficult to argue they were the work of a delusional madman, said Dr. Tarjei Rygnestad, who heads the Norwegian Board of Forensic Medicine.

In Norway, an insanity defense requires that a defendant be in a state of psychosis while committing the crime with which he or she is charged. That means the defendant has lost contact with reality to the point that he's no longer in control of his own actions.

"It's not very likely he was psychotic," Rygnestad told the AP.

The forensic board must review and approve the examination by two court-appointed psychiatrists before the report goes to the judge hearing the case. The judge will then decide whether Breivik can be held criminally liable.

Rygnestad told the AP a psychotic person can only perform simple tasks. Even driving from downtown Oslo to the lake northwest of the capital, where Breivik opened fire at a political youth camp, would be too complicated.

"If you have voices in your head telling you to do this and that, it will disturb everything, and driving a car is very complex," Rygnestad said.

"How he prepared" for the rampage — meticulously acquiring the materials and skills he needed to carry out his attack while maintaining silence to avoid detection — argues against psychosis, Rygnestad added.

By his own account, the 32-year-old Norwegian spent years plotting the attack. On July 22, he set off a car bomb that killed eight people in downtown Oslo's government district, then drove north to a youth camp on Utoya, a small lake island set amid a quiet countryside of pines and spruces.

There, he spent 90 minutes executing 69 people, mostly teenage members of the youth wing of Norway's governing Labor Party.

The entire story can be found here.