This paper explores a grey area of psychiatric practice and, as with other challenging practices, the law is called upon to navigate conflicting legal issues. In particular, this paper explores the covert administration of medication: the concealment of medication in food or drink so that it will be consumed undetected. Rights-based approaches support nuanced understanding of the practices. Few policies, protocols or guidelines govern the practice in Ontario's psychiatric settings. While covert medication is understood to have “something (...) to do” with rights, there is confusion about how those rights play out on the ground. Institutional silences underlie and reinforce the practice. Most pressing, the covert administration of medication warrants an overt discussion, including of its impact on the rights-experience of persons in psychiatric settings. (shrink)

The making and taking of psychotropic drugs, whether on medical prescription or as self-medication, whether marketed by pharmaceutical companies or clamoured for by an anxious population, has been an integral part of the twentieth century. In this modern era of speed, uncertainty, pleasure and anguish the boundaries between healing and enhancing the mind by chemical means have been redefined. Long before Prozac would become a household name for an ‘emotional aspirin’ did consumers embrace the idea and practice of (...) taking psychotropics not only to treat mental illness but also to make them feel better about living in a modern world. The Freudian promise that each individual can remake him- or herself in the pursuit of health and happiness was helpful in promoting and legitimizing the idea and practice of seeking wellness on prescription. We will argue that the modern consumer-driven political culture of medicine will continue to transverse the boundaries of therapy and enhancement of the mind into the largely unexplored territories of human cognition and behaviour. However exciting, this endeavour will come at the cost of further widening the problem of iatrogenic addiction in the age of happiness pills as ‘botox’ for the mind. (shrink)

This paper provides a brief visual history of the ways women patients, and specifically women patients whose marital status is identified in conjunction with their illness, have been constructed as abnormal in the images of advertisements designed to promote psychotropic medications to an audience of psychiatrists. The advertisements I discuss come from the two largest circulation American psychiatric journals, The American Journal of Psychiatry and Archives of General Psychiatry, between the years 1964 and 2001. I use the ads to (...) focus on two concomitant narratives. On one hand, I show how the advertisements situate the rise of wonder drugs in the context of an era described as the golden age of psychopharmacology, during which time drug treatments helped revolutionize the diagnosis and treatment of anxiety, depression, and other outpatient mental illnesses in the United States. On the other hand, the advertisements also illustrate the ways in which these new scientific treatments could not function free of the culture in which they were given meaning. In the space between drug and wonder drug, or between medication and metaphor, the images thus hint at the ways psychotropic treatments became imbricated with the same gendered assumptions at play in an American popular culture intimately concerned with connecting normal and heteronormal when it came to defining the role of women in civilization. (shrink)

The increasing use of pharmacotherapy raises specific ethical concerns for psychologists working with vulnerable populations. Due to a shortage of trained specialists, professionals without training in mental health, such as primary care providers, are increasingly prescribing and monitoring psychotropic medications. Vulnerable populations face additional barriers to mental health treatment and are at heightened risk when these factors intersect. Hence, these patients experience unique barriers to receiving optimal psychopharmacological care and are differentially vulnerable to deleterious outcomes associated with misdiagnosis and (...) overmedication. Taken together, these factors fuel inequities in the access, quality, and utilization of mental health care. Psychologists working with these patients are ethically mandated to protect patients from harm and ensure equitable care across patient populations. Specifically, psychologists must respond to the dilemma of how to effectively treat patients within these vulnerable populations who have been misdiagnosed or poorly medicated while remaining within the bounds of their competence. This article recommends pathways to address these dilemmas through education, training, research, and advocacy. (shrink)

Many children in the USA are prescribed psychotropic drugs that have not been fully investigated in paediatric clinical trials. The common practice of prescribing psychotropic drugs off-label poses unknown and potentially serious short- and long-term consequences for these children. This paper briefly reviews the factors associated with the lack of paediatric clinical trials. We advocate a shift toward increasing paediatric trials with psychotropic drugs through a combination of adequate safety controls, additional reimbursement/compensation, a more organised and large-scale (...) effort to collate results and outcomes across researchers and studies and additional public education about the importance of this research. In addition, we encourage the re-examination of the ethical standards for children's participation in phase 1 clinical trials as well as argue for longitudinal developmental studies on children who are prescribed off-label psychotropic drugs. (shrink)

BackgroundEnhancement involves the use of biomedical technologies to improve human capacities beyond therapeutic purposes. It has been well documented that enhancement is sometimes difficult to distinguish from treatment. As a subtype of enhancement, neuroenhancement aims to improve one’s cognitive or emotional capacities.Main bodyThis article proposes that the notion of neuroenhancement deserves special attention among enhancements in general, because apart from the notion of treatment, it also overlaps with other concepts such as prevention, pain relief, and pleasure seeking. Regarding prevention, patients’ (...) mental endurance can be enhanced when a patient is prescribed a selective serotonin reuptake inhibitor for the purpose of preventing the relapse of depression following a stressful situation. As for pain relief, psychiatrists use medication to alleviate distress in patients who experience various types of anxiety; the alleviation of distress is equal to psychological pain relief, but is also an enhancement of the patient’s temperamental traits. Regarding pleasure seeking, insidious transition exists between neuroenhancement and pleasure seeking when using psychotropic drugs. It is well known that people use psychostimulants for recreational purposes and to induce overconfidence in one’s performance. The polysemy of psychotropics derives from their effects on human sensibility. Therefore, when using psychotropic agents, psychiatrists should pay close attention to what the agent is used for on each patient in each situation, and explicitly share the continuity and overlap in the purpose of prescribing a medication with the patients to make a better clinical decision.ConclusionsThe notion of neuroenhancement overlaps not only with the notion of treatment, but also with other concepts of prevention, pain relief, and pleasure seeking. The continuity between those concepts makes the issues concerning the prescription of psychotropic drugs subtler. Psychiatrists should explicitly share the continuity with the patients to make a better clinical decision. (shrink)

Women are diagnosed with clinical depression at twice the rates as men. Treating depression through psychotherapy or medication both focus on changing an individual, rather than addressing socioecological influences or social roles. In the current study, participants read of systemic inequality contributing to differential rates of depression in either American men or women, or in two fictitious Australian First Nation groups. Participants then considered the acceptability and efficacy of treating depression through psychotherapy, medication, or social change. When socioecological (...) inequities and unequal social roles were presented through an unfamiliar foreign lens, participants were more likely to recognize the systemic unfairness, and endorsed social change more than psychotherapy or medication as a treatment strategy. However, when identical social inequities and social roles were presented through descriptions of American men and women, social intervention was less likely to be endorsed, and psychotherapy or medication gained in acceptability. Participants of color were also more likely to recognize and endorse social change as a strategy for treating depression, while those reporting a history of psychotropic medication for affective disorders rated medication as more effective and acceptable. (shrink)

Background: Patients prescribed with medication that treats mental health conditions benefit the most compared to those prescribed with other types of medication. However, they are also the most difficult to adhere. The development of mobile health (mHealth) applications (‘apps’) to help patients monitor their adherence is fast growing but with limited evidence on their efficacy. There is no evidence on the content of these apps for patients taking psychotropic medication. The aim of this study is to (...) identify and evaluate the aims and functioning of available apps that are aiming to help and educate patients to adhere to medication that treats mental health conditions. Method: Three platform descriptions (Apple, Google and Microsoft) were searched between October 2015 and February 2016. Included apps need to focus on adherence to medication that treats mental health conditions and use at least a reinforcement strategy. Descriptive information was extracted and apps evaluated on a number of assessment criteria using content analysis. Results: Sixteen apps were identified. All apps included self-monitoring properties like reminders and psycho-educational properties like mood logs. It was unclear how the latter were used or how adherence was measured. Major barriers to medication adherence like patients’ illness and medication beliefs and attitudes were not considered nor where information to patients about mediation side effects. Very few apps were tailored and none was developed based on established theories explaining the processes for successful medication adherence like cognitions and beliefs. Reported information on app development and validation was poor. Discussion: A variety of apps with different properties that tackle both intentional and unintentional non-adherence from a different perspective are identified. An evidence-based approach and co-creation with patients is needed. This will ensure that the apps increase the possibility to impact on non-adherence. Theories like social cognition models can be useful in ensuring that patients’ education, motivation, skills, beliefs and type of adherence are taken into consideration when developing the apps. Findings from this study can help clinicians and patients make informed choices and pursue policy-makers to integrate evidence when developing future apps. Quality-assurance tools are needed to ensure the apps are systematically evaluated. (shrink)

Iam appreciative of the thoughtful comments and the diversity of the commentators’ perspectives and backgrounds. I take Hoffman’s original argument about psychotropic medications as risking ‘hyponarrativity’ as my starting point and my reply to her critique will naturally lead to a discussion of psychotherapeutic approach, importance of weighing Mr. A’s underlying autism and important bioethical considerations.It is important to imbed this case within the acuity of its clinical context: This individual presented for psychiatric hospitalization in the context of a...

The end of the 20th century became a milestone for the progress of Neurosciences and their contribution to a better understanding of the physiological mechanisms involved in cognition, mood and human behavior. Because of this, it was possible not only to intervene some of the aforementioned aspects with therapeutic purposes, but more recently they became objects of study in researches with a more pragmatic nature, such as clinical researches involving persons with no mental or physical disorders, but who require to (...) prove remarkable abilities for executive functions, e.g., soldiers, pilots, students, among others. On the other hand, there is an ethical and scientific debate over the interest to evaluate certain psychotropic medications due to its possible sideeffects as cognitive enhancers in healthy subjects that, because of their social status, might be benefited in their social, academic or work life by developing a better mental performance. Therefore, the article aims to present from the perspective of Bioethics and Psychopharmacology some aspects of the research in Neurosciences that might throw light upon the scientific debate oriented towards the social significance of such clinical studies and their possible consequences for the future. (shrink)

Failure to follow prescribed treatment has devastating consequences for those who are seriously and persistently mentally ill. Nurses, therefore, try to get clients to take psychotropic medication on a long-term basis. The goal is either compliance or adherence. Although current nursing literature has abandoned the term compliance because of its implications of coercion, in psychiatric nursing practice with patients suffering from serious long-term mental illness compliance and adherence are in fact different goals. The ideal goal is adherence, which (...) requires the patient to be an active participant in the team. This goal is consistent with nurses’ ethical values, but for such patients this is frequently unrealistic. If the person is severely psychotic, treatment may be involuntary and the goal compliance. Psychiatric nurses participate in involuntary treatment and thus should acknowledge the ethical implications of compliance as a goal and not obscure the issue by calling compliance adherence. (shrink)

In response to recent concerns about the overmedication of children, this paper considers ethical and conceptual issues that arise in the issue of when children who are diagnosed with attention deficit hyperactivity disorder should be given stimulants such as the psychotropic drug Ritalin as part of their treatment. There is considerable resistance and worry about the possibility of overmedication. This is linked to the worry that the diagnosis of ADHD is overused, and the paper considers some reasons to worry (...) about the overuse of the diagnosis itself. The paper then focuses on the resistance to the use of drugs, which is particularly strong for children in the gray area of diagnosis, where it is dubious whether the children really meet the strict diagnostic criteria. The reasons behind such resistance are often not well articulated, so part of the task of the paper is spell out what they might be. The reasons are given the following labels: side effects, unnaturalness, profit motives, thought control, competitiveness, and doctors' power. The paper ends in taking the polemical position that while there is some legitimate concern about possible short and long term side effects of children taking psychotropic drugs, the other reasons for resistance are not well‐founded. (shrink)

The discovery of psychoanalysis and of psychotropic medications represent two radical events in understanding and treatment of mental suffering. The growth of both disciplines together with the awareness of the impracticality of curing mental suffering only through pharmacological molecules – the collapse of the “Great Illusion” - and the experience of psychoanalysts using psychotropic medications along with depth psychotherapeutic treatment, have led to integrated therapies which are arguably more effective than either modality alone. The authors review studies on (...) the role of pharmacotherapy with psychoanalysis, and the role of the analyst as the prescriber. The psychotic disorders have specifically been considered from this perspective. (shrink)

Psychiatric disorders involve changes in how you feel, think, perceive, and/or act—and the same goes for psychotropic medication. How then do you know whether certain thoughts or feelings are genuine expressions of yourself, or whether they are colored by your psychiatric illness, or by the medication you take? Or, as Karp nicely sums up the problem: “if I experience X, is it because of the illness, the medication, or is it “just me’?” Such “self-illness ambiguity” seems (...) to be quite an ubiquitous problem in psychiatry. It is a very unsettling problem, moreover, and not easy to resolve.In their... (shrink)

_Manual of Regulation-Focused Psychotherapy for Children with Externalizing Behaviors: A Psychodynamic Approach_ offers a new, short term psychotherapeutic approach to working dynamically with children who suffer from irritability, oppositional defiance and disruptiveness. _RFP-C_ enables clinicians to help by addressing and detailing how the child’s externalizing behaviors have meaning which they can convey to the child. Using clinical examples throughout, Hoffman, Rice and Prout demonstrate that in many dysregulated children, _RFP-C_ can: Achieve symptomatic improvement and developmental maturation as a result of (...) gains in the ability to tolerate and metabolize painful emotions, by addressing the crucial underlying emotional component. Diminish the child’s use of aggression as the main coping device by allowing painful emotions to be mastered more effectively. Help to systematically address avoidance mechanisms, talking to the child about how their disruptive behavior helps them avoid painful emotions. Facilitate development of an awareness that painful emotions do not have to be so vigorously warded off, allowing the child to reach this implicit awareness within the relationship with the clinician, which can then be expanded to life situations at home and at school. This handbook is the first to provide a manualized, short-term dynamic approach to the externalizing behaviors of childhood, offering organizing framework and detailed descriptions of the processes involved in _RFP-C_. Supplying clinicians with a systematic individual psychotherapy as an alternative or complement to PMT, CBT and psychotropic medication, it also shifts focus away from simply helping parents manage their children’s misbehaviors. Significantly, the approach shows that clinical work with these children is compatible with understanding the children’s brain functioning, and posits that contemporary affect-oriented conceptualizations of defense mechanisms are theoretically similar to the neuroscience construct of implicit emotion regulation, promoting an interface between psychodynamics and contemporary academic psychiatry and psychology. Manual of Regulation-Focused Psychotherapy for Children with Externalizing Behaviors: A Psychodynamic Approach is a comprehensive tool capable of application at all levels of professional training, offering a new approach for psychoanalysts, child and adolescent counselors, psychotherapists and mental health clinicians in fields including social work, psychology and psychiatry. (shrink)

The aims of this study were to examine the effectiveness of a range of smartphone apps for managing symptoms of anxiety and depression and to assess the utility of a single-case research design for enhancing the evidence base for this mode of treatment delivery. The study was serendipitously impacted by the COVID-19 pandemic, which allowed for effectiveness to be additionally observed in the context of significant community distress. A pilot study was initially conducted using theSuperBetter app to evaluate the proposed (...) methodology, which proved successful with the four finishing participants. In the main study, 39 participants commenced, with 29 finishing the intervention phase and completing post-intervention measures. At 6-month follow-up, a further three participants could not be contacted. This study used a digitally enhanced, multiple baseline across-individuals single-case research design. Participants were randomly assigned to the following apps:SuperBetter,Smiling Mind,MoodMission,MindShift, andDestressify. Symptomatology and life functioning were measured at five different time points: pre-baseline/screening, baseline, intervention, 3-week post-intervention, and 6-month follow-up. Detailed individual perceptions and subjective ratings of the apps were also obtained from participants following the study’s completion. Data were analyzed using visual inspection, time-series analysis, and methods of statistical and clinical significance. Positive results were observed for all apps. Overall, more favorable outcomes were achieved by younger participants, those concurrently undertaking psychotherapy and/or psychotropic medication, those with anxiety and mixed anxiety and depression rather than stand-alone depression, and those with a shorter history of mental illness. Outcomes were generally maintained at 6-month follow-up. It was concluded that a diverse range of evidence-based therapies offered via apps can be effective in managing mental health and improving life functioning even during times of significant global unrest and, like all psychotherapies, are influenced by client features. Additionally, this single-case research design is a low-cost/high value means of assessing the effectiveness of mental health apps.Clinical Trial Registration: The study is registered with the Australian and New Zealand Clinical Trials Registry, which is a primary registry in the World Health Organization Registry Network, registration number ACTRN12619001302145p. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:ADOLESCENCE, INDIFFERENTIATION, AND THE ONSET OF PSYCHOSIS Henri Grivois Hôtel-Dieu, Paris The onset of psychosis happens, by definition, only once. The first psychotic episode is unforeseeable and risks being overlooked. Left to itself its future is uncertain, and the prognosis is potentially unfavorable. The variety of its manifestations as well as its thymic and cognitive instability explains why so little is written on this subject. The psychiatric literature, by (...) its almost exclusive reference to evolved psychoses, has not distinguished the qualities peculiar to the onset of psychosis (nascent psychosis). Yet recent research reflects an interest in early diagnosis of psychosis to secure qualitative improvements and the chance ofa favorable outcome for patients. A special approach must be used for patients during the stage of nascent psychosis. Something must be done, but early treatment is not enough. Psychotropic medication has no more than a sedative effect and there are few specifics at this stage (Swain 175). Further, one risks obliterating the patient's lived experience. The entire battery of interventions, above all the first consultations, must follow from a rigorously organized and intensive strategy to directly engage with this subjective experience. For many years at l'Hôtel-Dieu, a general hospital situated in the center of Paris, we have harnessed ourselves to this task. First I shall describe the existence of centrality. It constitutes the most characteristic and permanent trait of the onset of psychosis. From the concept of concernment, I propose a phenomenological morphogenesis of the initial sequence of psychosis. Next I turn to the state of indifferentiation that overcomes the subject, and then to the vulnerability peculiar to adolescents. I shall end with some fundamental epidemiological data. Henri Grivois1 05 Centrality To be mad is not only the feeling of being uniquely in contact with all humanity, whether as alienated from it or as uniting all of it in oneself conceived as the only member of the species. It is this certainly but also more than this. It is to infer that one occupies a unique place in the human world. It is the feeling of being encircled by everyone. Without being responsible, the patient is placed in the forefront of some grandiose project. His centrality, whatever the mode ofexpression, orients him towards a form of mental disorder. As a general rule, at the beginning, centrality is never explicit and passes unnoticed. The physical and verbal behavior of the patient suffice to accuse him, without any further investigation, of unintelligibility and incoherence. Centrality is above all an emotion about which we should admit that we know almost nothing. People with nascent psychosis are the prey of intuitions impossible to comprehend. Like Rimbaud's drunken boat, they flee, drifting or hiding themselves, coming back and taking offagain. They are therefore incapable, wherever they go, of living an instant of unconcern. Incapable of expressing their singular rapport with the world, they keep silent. Very soon nevertheless centrality engenders a torrent of questions. Silently, voicelessly, patients apprehend in an almost automatic manner the responses to these questions in the verbal and gestural behavior of others. Since Esquirol (Gauchet and Swain 464) identified hallucinatory phenomena as the cause of psychosis, they have occupied a disproportionate place in mental science for 200 years. This construction of the concept of hallucination in psychiatry, key to the orthodox vision of psychosis, assures a watchful vigilance to rule out every non-symptomatic treatment ofpatients. Hours or perhaps days later, no longer capable of abstaining from interpretation, patients begin to sketch out an explanation ofthe prodigious situation which they have experienced. They interrogate their relation to others and the intentions and the degree of unanimity of people towards them. Invoking demons and monsters often gives their explanations a first coherence which is in harmony with the scale of their experience. On their side the psychiatrists, to facilitate verbalizing the experience, suggest paraphrases of a general order: influence, mental automatism, exterior action, xenopathia, etc. To mask centrality, to get away from it, or in response to the gravity of the event, the patients, in search of some responsibility, envisage more elaborate scenarios: mission, conspiracy, trial, condemnation. A political vocabulary, more plausible but less universal than a... (shrink)

When mental suffering and distress are diagnosed as so-called “mental illnesses” it locates the cause as within the afflicted person. A close examination of the life situation of the distressed person will most times show the cause as originating external to the sufferer. Mental distress can arise with any number of troubling life situations such as financial or relationship problems, illness or death in the family, ethical dilemmas and so on. But diagnosing the person as having a biological brain problem (...) allows the prescription of psychotropic medications that can cost thousands of dollars over their lifetime. Of course, this adds to the profit margins of the corporations that produce them. These medications not only cause harmful side-effects, they add to the suffering of the person taking them. Philosophical counselling doesn’t cause any side effects, and is often much more effective at mitigating mental distress. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Incorporating Religion into Psychiatry:Evidenced–Based Practice, Not a Bioethical DilemmaMary D. MollerFor over sixteen years I was the owner and clinical director of an advanced practice nurse–managed outpatient rural psychiatric clinic staffed by APNs, a social worker, a licensed counselor and several graduate students. Many of our patients were victims of severe and often brutal trauma and abuse suffered at the hands of family, friends, and various professionals including spiritual (...) leaders. We also uncovered sources of abuse suffered from those involved in occult practices ranging from seemingly innocent white witchcraft (Wicca, Paganism, New Age) that includes such activities as astral projection and remote viewing to the darkest possible black witchcraft (perpetrating evil, incanting evil spirits, casting spells and hexes, creating dissociative identities) such as occurs in ritual abuse and satanic rites. Both types of witchcraft also typically involved family, friends, various professionals, and spiritual leaders. Recognizing the controversy surrounding the reality of witchcraft I am sharing a story that I hope will help break down the barriers that prevent many patients from receiving the treatment that would provide the most benefit to recovery.Seeking services for these patients led me on an intense personal and professional journey that included a profound Christian born–again experience at almost 50 years of age. My professional career grew in nearly indescribable terms as a result of the incorporation of prayer and deliverance ministry as part of the services we selectively provided. Today I always include assessment of spiritual experiences a patient has as well as spiritual supports that are available with every new patient intake. For patients who indicate that prayer is one of their supports, I ask if they would like prayer at the conclusion of the session. The gratitude that is expressed by individuals who appreciate being able to pray with a psychiatric provider is often profound.In the field of psychiatry there has been a long–standing and distinct taboo regarding incorporating religious and spiritual aspects of life experience into treatment unless it is to frame most of these discussions within the context of psychosis. This stems from the advent of psychoanalysis in which religion was deemed a neurosis and atheism became the goal. Some still hold to that belief and there certainly remains controversy regarding the incorporation of prayer into routine outpatient or inpatient care. The essential starting point is the determination of accurate differential diagnosis, which can often be a lengthy process. The clinician must be careful about distinguishing between religious experiences and religious delusions, and often this takes time to sort out. The determination of the etiology of hearing the voice of God or the devil or demons must be carefully parsed and framed within the context of the situation and culture the patient describes. If the clinician denies the existence of God or the devil or demons or the practice of witchcraft, the patient’s descriptions of such experiences will be quickly [End Page 206] labeled psychotic. The patient may then experience a lengthy hospitalization and treatment with psychotropic medications that can have an extremely negative effect on the possibility of recovery. Once I witnessed the level of healing that occurs with carefully administered spiritual interventions that are related to specific spiritual experiences that are based on the patient’s belief system, there was no going back to using only allopathic medication and non–spiritual psychosocial interventions, even in spite of the criticisms from others. The key is to understand and respect the patient’s belief system, if this is not congruent with the practitioner’s belief system, then practitioner must refer out.In the United States, an increasing persecution of Christianity and a devaluing of the Judeo–Christian heritage of our Constitution are creating a climate of intolerance to the expression of religious values resulting in an expectation that Christians should compromise their beliefs for the sake of political correctness. As a doctorally prepared psychiatric–mental health advanced practice nurse I experienced a profound born–again Christian experience that ultimately led to study of the Hebrew roots of Christianity and I now worship in a Messianic Jewish synagogue. It is impossible for me to not include the concept of spirituality into... (shrink)

Background: Treatment of psychotic disorders in pregnancy is often ethically and clinically challenging, especially when psychotic symptoms impair decision-making capacity. There are several competing ethical obligations to consider: the ethical obligation to maternal autonomy, the maternal and fetal beneficence-based obligations to treat peripartum psychosis, and the fetal beneficence-based obligation to minimize teratogenic exposure. Objective: This article outlines an ethical framework for clinical decision-making for the management of chronic psychosis in pregnancy, with an emphasis on special considerations in the previable and (...) periviable period. Case Presentation: A 31-year-old gravida 2, para 1 with intrauterine pregnancy at 12 weeks and 4 days gestation was brought to the emergency department by her husband seven months after delivering her first child, due to sudden onset of behavioral changes that included self-isolation, not eating, and not taking care of her child. Her past medical history included hypothyroidism and inflammatory bowel disease, but no prior psychiatric illness. After being admitted to the psychiatric hospital, she continued to have poor oral intake and weight loss despite initial inpatient treatment with antipsychotics, levothyroxine, and discontinuation of corticosteroids. Her pregnancy was also complicated by the diagnosis of multiple fetal anomalies at 20 weeks gestation, when the fetus was periviable. Conclusions: For previable or periviable pregnancies, the patient and/or surrogate should decide whether to pursue prenatal genetic screening and invasive diagnostic testing, as well as whether to continue or terminate the pregnancy. When the choice is made to continue the pregnancy, initiation of long-term psychiatric treatment (including medications with potential adverse fetal effects) should be based on shared decision-making between the physician and the patient and/or surrogate. Although some pharmacologic interventions may have potential adverse effects on the developing fetus, the use of psychotropic medications can be ethically justified, even if the patient herself does not have the capacity to consent and requires a surrogate, when the goal is to restore maternal autonomy and minimize the risks of maternal and fetal harm from untreated psychiatric illness. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 10.3 (2003) 227-231 [Access article in PDF] World Traveling as a Clinical Methodology for Psychiatric Care Suzanne M. Jaeger Keywords embodiment, dialogical consciousness, interpersonal communication, epistemic responsibility, self-knowledge, understanding IN HER ARTICLE "Moral Tourists and World Travelers," Nancy Potter suggests a way in which psychiatrists and psychologists could gain a better understanding of their mentally ill patients' experiences. Rather than assuming that hallucinations and incoherent (...) speech and behavior are merely senseless disconnections from reality, Potter argues that mental health care clinicians ought to spend time engaging patients on their own terms. Even when mental illness is a result of brain disease, much can be learned about the patient's experiences of their disease by temporarily setting aside the scientific frameworks of diagnosis and medical treatment. Potter uses Maria Lugones' concept of world traveling and recommends playfully accepting, and even entering into the patient's world (Lugones 1990). She calls world traveling a methodology and explains it in some detail. Moreover, at the close of her essay, Potter suggests that clinicians have a moral obligation to understand the mentally ill patient's world from the patient's perspective. This obligation is based on an appeal to our sense of what it is to be a responsible knower who attends to issues of trust and truth. Relying on arguments made by Lorraine Code (1987), Potter asserts that to try to understand the other's perspective is the responsible thing to do.My discussion focuses on the notion of play to which Potter appeals, as well as on what she sees as the moral obligation of clinicians to communicate with their mentally ill patients in extra-professional ways. This moral obligation arises because (a) the theoretical and professional frameworks of medical science are seen as inadequate, and (b) playfulness opens up mutually respectful, authentic interaction between persons. I generally agree with Potter's claims, and I want to situate them in the wider framework of an epistemological debate about the status of our knowledge of others. A broader context will help to elucidate the strengths of Potter's analysis as well as some points for critical discussion. I begin with the relationship of trust between clinicians and patients.Few people would disagree with the claim that patients need to be able to trust that their physicians are not harming them, but helping them to get better. If patients feel misunderstood, they will not trust their caretakers. This is probably even truer for psychiatric patients, whose conditions and loss of autonomy make establishing trust even more challenging. Psychiatric patients [End Page 227] often have their own ways of compensating for the symptoms of their mental illness. If either their will to survive or their compensatory strategies go unrecognized or misinterpreted, patients may respond by rejecting the well-intentioned efforts of caretakers to restore them to a degree of ease, measured as it must be by the standards of the professionals under whose care the patient remains. 1 Despite the fact that these standards are established through scientific testing procedures for the treatment of diseases, they may be experienced by patients as indifferent to the particular and unique features of their condition. Nestled within the issue of trust is thus a question of truth.Although current scientific knowledge of the human brain, and of human behavior, has made available a range of sophisticated therapies and psychotropic drugs, there are still many mental illnesses that leave families and clinicians wondering whether the treatment plans are providing any help. Alzheimer's disease and schizophrenia are two examples. There is a difference between, on the one hand, containing the patient's behavior by admitting the patient to a psychiatric ward and managing symptoms with psychotropic medications, and, on the other hand, understanding what is happening for the patient, from his or her perspective. Although psychiatric patients may not have a realistic sense of either their abilities or the extent and nature of their disease, there may be much about their experiences that ought to be known and understood by the professionals caring for them... (shrink)

BackgroundBurnout is a syndrome that results from stressors in the work environment that have not been successfully managed. The prevalence of burnout among schoolteachers was always controversial. COVID-19 pandemic added more stressors to teachers since they had to change their working styles in response to the pandemic lockdowns or curfews. In Saudi Arabia, the prevalence and determinants of burnout among school teachers were not measured by any other group during the COVID-19 pandemic stressors.MethodsA cross-sectional survey was conducted among 879 teachers (...) in the Jazan region, Saudi Arabia, using the Maslach Burnout Inventory, during April 2021. Multistage cluster random sampling was used.ResultsThe mean age of the participants was 41.4 years. Male teachers represented 52.6% of the participants while females represented 47.4%. Most teachers showed burnout symptoms. Consequences of burnout were observed, such as using psychotropic medications, absenteeism, lack of job satisfaction, and changing schools. Using the MBI scale, most teachers showed medium or high emotional exhaustion, low depersonalization, and low personal accomplishment.ConclusionMost teachers showed symptoms of burnout during the COVID-19 pandemic. Being an expert and ability to adapt to technology during the COVID-19 pandemic proved to effectively reduce burnout symptoms. Increasing incentives, early detection, and improving the work environment is recommended to diminish burnout consequences. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Underplayed Ethics and the Dilemmas of Psychiatric CareChong Siow Ann and Tamra LysaghtThe practice of psychiatry is fraught with uncertainty. The exact causes and the biological substrates underlying mental disorders remain to be elucidated; even the diagnosis of these disorders is descriptive and not based on an etiological understanding and no biological diagnostic markers have been validated. The manifestation of almost all mental disorders results from a complex interaction (...) of biological and environmental factors which encompasses the patient’s unique life history, experiences and relationship with others and the community. In the face of such uncertainties — at times extending to the types of treatment (psychiatry is generally acknowledged not be an exact science) — it has been argued that adopting a pragmatic approach is necessary.1 Accordingly, this approach necessitates high ethical standards among mental health practitioners.Some mental illnesses are associated with varying degrees and types of cognitive impairments. Others have certain symptoms like auditory hallucinations and delusions that might severely compromise the patients’ autonomy, distort their sense of reality, increase the risk of harm to themselves or others and render them incapable of making informed decisions in their treatment and participation in research.Consequently, there are issues that are particular to the provision of mental healthcare. These include the need for enforced involuntary treatment with the corollary of depriving a patient of his personal liberty even [End Page 173] though it is often justified on the grounds that it is in the patient’s best interests. However, at times, it is the legal and societal obligation of mental health practitioners to protect those who might be harmed from the patient’s action that might seem to be more pressing. In this situation of double agency, lies the tension of providing confidential care for patients and acting as “an agent of the state” where that patient’s confidentiality might be breached and his liberty infringed upon. This situation is further aggravated by the stigma that clings ever so tenaciously to those who suffer from mental disorders and where it is the norm to stereotype them as dangerous and unpredictable.Consideration of a patient’s autonomy is also challenged by characteristics that are unique to the practice of psychiatry. The prescription of certain psychotropic medications can alter how people think and feel, while psychotherapy works towards changing the patient’s views and values. The philosopher, Jennifer Radden, describes this process as “re-forming the patient’s whole self or character … akin to the responsibilities of raising children”.2 The psychotherapeutic relationship is thus particularly personal and intimate because patients are asked to provide information that often reveals their innermost feelings, fears and fantasies. This information is provided on the basis of trust and assurance of confidentiality, and with expectation of being helped.Jeremy Holmes and Gwen Adshead have elaborated on the vulnerability of patients seeking psychotherapy: they might be particularly susceptible to exploitation because their past experiences of being exploited have led to their distress and help seeking — their dependency and the extreme privacy of the therapeutic relationship make any transgression difficult to be uncovered.3 There is a calamitous combination of the “unconscious wish in the patient to be used” with the complicity of an unethical therapist seeking to fulfil his own interests.4As in any other doctor-patient relationship, the relationship between the mental healthcare practitioner and the patient is one of unequal power where the former is ascendant. While that power should be exercised to heal and to relieve suffering, it also gives the practitioner tremendous power “to harm, reject, misunderstand, or exploit patients who struggle with the experience of mental illness, which itself may generate helplessness, despair, distress, and exceptional dependence on the clinician”.5 Given the potential of doing good and harm coupled with the likelihood of being so significant in the life of the patient,6 providing care for those with mental disorders and distress is necessarily ethically exacting — arguably more so than in other medical practice settings. [End Page 174]This precariousness has led to the suggestion that ethics in psychiatry should have a special status and that the more general principles of biomedical ethics are too limited in scope to... (shrink)

This chapter evaluates the multiple roles of technology in psychiatry, drawing on philosophical resources and mindful of psychiatry's need to benefit from technology without reducing itself to nothing but a technology. It approaches the topic of technology and psychiatry from three perspectives. First, it addresses technology as a way of thinking-technical or instrumental reason-and how technical reason informs psychiatric theory and practice. For this analysis it invokes a philosophical tradition that stretches from Aristotle to Toulmin and Gadamer. Second, it takes (...) up technology as achievement, the most obvious example of which is psychotropic medications. For this dimension of technology in psychiatry it recruits philosopher Albert Borgmann, who has analyzed the tendency of technological products, analyzed as device paradigms, to transmute into commodities. Finally, the chapter takes up technology as instrument of investigation. Philosopher Don Ihde is the guide in this investigation into how the psychiatrically real can become what is revealed through the technological instrument. The final section addresses the overarching question of how to set the right balance between the technological and the non-technological in psychiatry-how psychiatry can make use of technology without losing its humanistic core. It notes that the binary of the technological and non-technology in psychiatry can be mapped onto other binaries: biology and psychology, mind and brain, medication and psychotherapy, diagnosis and patient, theory and instance, general and individual, technical and practical reason. These binaries are not precisely isomorphic with each other, but all contribute to evaluating the role of technology in psychiatry, both in the present and in the desired future. (shrink)

Benzodiazepines and antidepressants have been shown to change responses to unfairness; however, the effects of their combined use on unfairness evaluation are unknown. This study examines the effects of concomitant benzodiazepines and antidepressants long-term use on the evaluation of fair and unfair offers. To analyze behavioral changes on responses to unfairness, we compared the performance of medicated participants and healthy controls in the Ultimatum Game, both in the proposer and in the respondent role. The results showed that long-term psychotropic (...) users had the worse economic strategy by accepting less offers than control subjects. However, in the proposer role, the unfair offers made by participants were similar between groups. The present results suggest that long-term use of psychotropic medication, specifically the combination of benzodiazepines and antidepressants, may increase the sensitivity to unfairness, resulting in higher rejection rates in conditions where this strategy is the most disadvantageous. (shrink)

In this essay, I use the theological anthropology of the apostle Paul as a diagnostic lens in order to bring into focus some implicit assumptions about human personhood in the goals and methods of treatment with psychotropic medications. I argue that Paul views the body as a mode of participation in larger relational matrices in both vulnerable and vital ways. He thus sees the self as constituted relationally rather than as fundamentally isolated and self-determining. Such an understanding of personhood (...) yields an account of human agency as co-constituted and freedom as interpersonally mediated and sustained. From this perspective, the proper goal for psychiatric medication is the removal of barriers to life-giving human connections; methods of care for persons in psychological distress may include medication, but they also require embodied personal encounter. (shrink)

Pediatric psychopharmacology is a relatively new science. Although the use of psychotropic medications in children has risen in the past decade, there are few standard treatments for serious psychiatric or developmental disorders of childhood. The relative absence of standard treatments is further complicated by the fact that many of the agents used in pediatric psychopharmacology have been adapted from other fields. Therefore, investigators have a responsibility to make incremental progress from concept through pilot studies and large-scale, multisite efficacy and (...) safety trials. Thus, although there is a pressing need to conduct medication trials that can guide clinical practice, there are scientific and ethical considerations to bear in mind when designing clinical trials in pediatric psychopharmacology. This article reviews essential ethical and scientific issues that are relevant to designing clinical trials in children with psychiatric and developmental disorders. Using examples from recently published literature, the article describes the challenges and pitfalls of various clinical trial study designs. The application of sound ethical and scientific principles is necessary to ensure that clinical trials are properly conducted and to guard against ambiguous results that can not guide practice. (shrink)

Singh's study of 150 UK and US children diagnosed with attention deficit hyperactivity disorder and prescribed psychotropic medication concludes on the basis of interviews with the children that ‘stimulants improve their capacity for moral agency … an ability to meet normative expectations’.1 Reinterpreted in lay language, she finds that, when taking Ritalin, the children conform to the wishes and expectations of their parents and teachers. They get better grades at school and show less ‘oppositional-defiance’. This is not surprising (...) as it is precisely what Ritalin is supposed to do. However, it begs a number of crucial questions. Might it not be that the failure of the child to conform to the expected norms in the non-medicated state is a legitimate expression of the child's own moral agency, rebelling against what he/she experiences as inappropriate …. (shrink)

Current research suggests that stressful life experiences and situations create a substantive effect in the development of the initial manifestations of psychotic disorders and may influence temporo-limbic epileptic-like activity manifesting as cognitive and affective seizure-like symptoms in non-epileptic conditions. The current study assessed trauma history, hair cortisol levels, epileptic-like manifestations and other psychopathological symptoms in 56 drug naive adult young women experiencing their initial occurrence of psychosis. Hair cortisol levels among patients experiencing their initial episode of psychosis, were significantly correlated (...) with stress symptoms measured by Trauma Symptom Checklist-40, and complex partial seizure-like symptoms measured by the Complex Partial Seizure-Like Symptoms Inventory and LSCL-33. Hair cortisol levels were not found to be significantly correlated with symptoms of anxiety and depression measured by Beck depression Inventory and Zung Anxiety Scale. These findings suggest a significant relationship between epileptic-like symptoms and stress responses demonstrated by patients in their first psychotic episode. These findings may suggest the potential for research to explore usefulness of anticonvulsant treatment in patients who do not respond to usual psychotropic medication. (shrink)

The vignette described in the introduction of this symposium raises a number of ethical and legal problems for physicians who work for correctional institutions and death row inmates. They are not confined to correctional physicians, however, as states have requested aid from practicing physicians in the community, and even from other states, when conflicts have arisen in the treatment of death row inmates as they near the date of execution. As outlined, the case involves a 48-year-old man with a long (...) history of schizophrenia, initially diagnosed at age 19. Compliant with medication, he remained generally free from positive symptoms-delusions and hallucinations. Nonetheless, he committed two murders during a robbery and was sentenced to death. Since his incarceration, the defendant has consistently refused psychotropic medications and has been forcibly medicated on several occasions when he exhibited violent outbursts and was overtly psychotic. (shrink)

A grounded theory study of psychiatric nurses’ experiences of administering medication to involuntary psychiatric patients revealed a basic social process of justifying coercion. Although the 17 nurses interviewed all reported success at avoiding the use of coercion, each had an individual approach to using the nurse-patient relationship to do this. However, all the nurses used the same process to reconcile themselves to using coercion when it became necessary. This has three stages: assessment of need; negotiation; and justifying and taking (...) coercive action. Two critical junctures - decision to engage and impasse - determine the progression from one stage to the next. The process of justifying coercion allows a nurse to engage in behavior generally disapproved of while retaining a self-image of a ‘good’ nurse. (shrink)

BackgroundSelf-prescribing and prescribing to personal contacts is explicitly discouraged by General Medical Council guidelines.AimsThis study examines how widespread the practice of self-prescribing and prescribing to personal contacts is.MethodsA 16-item questionnaire was distributed via an online forum comprising 4445 young medical doctors (representing 20% of all Irish registered doctors), which asked respondents about previous prescribing to themselves, their families, friends and colleagues, including the class of medication prescribed. Demographic details were collected including medical grade and specialty.ResultsA total of 729 responses (...) were obtained, the majority of which were from young non-consultant hospital doctors from a range of specialties. Two-thirds of respondents had self-prescribed, over 70% had prescribed to family, and nearly 60% had prescribed to a friend or colleague. Older doctors were more likely to self-prescribe (χ2=17.51, p<0.001). Interns being less likely to self-prescribe was not unexpected (χ2=69.55, p<0.001), while general practitioners (GPs) and paediatricians were more likely to self-prescribe (χ2=13.33, p<0.001;χ2=11.35, p<0.001). GPs, paediatricians and hospital medicine specialties were more likely to prescribe to family (χ2=5.19, p<0.05;χ2=8.38, p<0.05;χ2=6.17, p<0.05) and surgeons were more likely to prescribe to friends (χ2=15.87, p<0.001). Some 3% to 7% who had self-prescribed had prescribed an opiate, benzodiazepine or psychotropic medication. Male doctors, anaesthetists and surgeons were more likely to self-prescribe opioids (χ2=7.82, p<0.01;χ2=7.31, p<0.01;χ2=4.91, p<0.05), while those in hospital medicine were more likely to self-prescribe psychotropic medications (χ2=5.47, p<0.05).ConclusionPrescribing outside the traditional doctor-patient relationship is widespread despite clear professional guidance advising against it. (shrink)

Weight-gain in psychiatric populations is a common clinical challenge. Many patients suffering from mental disorders, when exposed to psychotropic medications, gain significant weight with or without other side-effects. In addition to reducing the patients' willingness to comply with treatment, this weight-gain may create added psychological or physiological problems that need to be addressed. Thus, it is critical that clinicians take precautions to monitor and control weight-gain and take into account and treat all problems facing an individual. In this review, (...) we examine some of the key issues surrounding weight-gain in individuals suffering from mental disorders for contemporary practitioners in community clinics. We describe some factors known to make certain patients more susceptible to treatment-induced weight-gain and mechanisms implicated in this process. We also highlight a few psychological and pharmacological interventions that have proven effective in weight management. Importantly, we provide critical steps for management and prevention of weight-gain and related issues in the clinical practice of psychopharmacology. (shrink)

Die Komplexität ethischer Fragen und Alltagskonflikte in Einrichtungen der stationären Altenpflege verlangen Gesprächsforen für Ethikberatung und Fortbildung zur ethischen Entscheidungsfindung. Noch ist in Deutschland die Einrichtung von Ethikkomitees in Altenpflegeheimen in den Anfängen. Es kommt nun vordringlich darauf an, bei der Institutionalisierung die spezifischen strukturellen und personellen Bedingungen eines Altenpflegeheims zu berücksichtigen, um zum Wohle aller Betroffenen mit der erforderlichen Kontextsensitivität zu einer verbesserten ethischen Entscheidungskultur beizutragen. Wesentliche Merkmale eines Altenpflegeheims werden dargestellt und anhand der Psychopharmakaversorgung einige typische ethische Probleme (...) diskutiert. (shrink)

Antipsychotic medications are sometimes imposed on psychiatric patients deemed dangerous to themselves and others. This is based on the assumption that treatment is safe and effective, and that recovery depends on biological adjustment. Under new laws, patients can be required to remain on these medications after leaving hospitals. However, survivors attest that forced treatment used as a restraint can feel like torture, while the consequences of withdrawal can also be severe.

Our lives are dominated by technology. We live with and through the achievements of technology. What is true of the rest of life is of course true of medicine. Many of us owe our existence and our continued vigour to some achievement of medical technology. And what is true in a major way of general medicine is to a significant degree true of psychiatry. Prozac has long since arrived, and in its wake an ever-growing armamentarium of new psychotropics; beyond that, (...) neuroscience promises ever more technological advances for the field. -/- However, the effect of technology on the field of psychiatry remains highly ambiguous. On the one hand there are the achievements, both in the science and practice of psychiatry; on the other hand technology's influence on the field threatens its identity as a humanistic practice. In this ambiguity psychiatry is not unique - major thinkers have for a long time been highly ambivalent and concerned about the technological order that now defines modern society. For the future, the danger is that the psychiatrically real becomes that which can be seen, the symptom, and especially that which can be measured. Disorders and treatments might become reduced to what can be defined by diagnostic criteria and what can be mapped out on a scale. -/- This book exams how technology has come to influence and drive psychiatry forward, and considers at just what cost these developments have been made. It includes a range of stimulating and thought-provoking chapters from a range of psychiatrists and philosophers. (shrink)

In this article, I examine children's reported experiences with stimulant drug treatments for attention deficit hyperactivity disorder in light of bioethical arguments about the potential threats of psychotropic drugs to authenticity and moral agency. Drawing on a study that involved over 150 families in the USA and the UK, I show that children are able to report threats to authenticity, but that the majority of children are not concerned with such threats. On balance, children report that stimulants improve their (...) capacity for moral agency, and they associate this capacity with an ability to meet normative expectations. I argue that although under certain conditions stimulant drug treatment may increase the risk of a threat to authenticity, there are ways to minimise this risk and to maximise the benefits of stimulant drug treatment. Medical professionals in particular should help children to flourish with stimulant drug treatments, in good and in bad conditions. (shrink)

The availability of a range of new psychotropic agents raises the possibility that these will be used for enhancement purposes (smart pills, happy pills, and pep pills). The enhancement debate soon raises questions in philosophy of medicine and psychiatry (eg, what is a disorder?), and this debate in turn raises fundament questions in philosophy of language, science, and ethics. In this paper, a naturalistic conceptual framework is proposed for addressing these issues. This framework begins by contrasting classical and critical (...) concepts of categories, and then puts forward an integrative position that is based on cognitive-affective research. This position can in turn be used to consider the debate between pharmacological Calvinism (which may adopt a moral metaphor of disorder) and psychotropic utopianism (which may emphasize a medical metaphor of disorder). I argue that psychiatric treatment of serious psychiatric disorders is justified, and that psychotropics are an acceptable kind of intervention. The use of psychotropics for sub-threshold phenomena requires a judicious weighing of the relevant facts (which are often sparse) and values. (shrink)

BackgroundDespite five decades of increasingly elegant studies aimed at advancing the pathophysiology and treatment of mental illness, the results have not met expectations. Diagnoses are still based on observation, the clinical history, and an outmoded diagnostic system that stresses the historic goal of disease specificity. Psychotropic drugs are still based on molecular targets developed decades ago, with no increase in efficacy. Numerous biomarkers have been proposed, but none have the requisite degree of sensitivity and specificity, and therefore have no (...) usefulness in the clinic. The obvious lack of progress in psychiatry needs exploration.MethodsThe historical goals of psychiatry are reviewed, including parity with medicine, a focus on diagnostic reliability rather than validity, and an emphasis on reductionism at the expense of socioeconomic issues. Data are used from Thomas Picketty and others to argue that our failure to advance clinical care may rest in part on the rise in social and economic inequality that began in the 1970s, and in part on our inability to move beyond the medical model of specificity of disease and treatment.ResultsIt is demonstrated herein that the historical goal of specificity of disease and treatment has not only impeded the advance of diagnosis and treatment of mental illness, but, in combination with a rapid increase in socioeconomic inequality, has led to poorer outcomes and rising mortality rates in a number of disorders, including schizophrenia, anxiety, and depression.ConclusionsIt is proposed that Psychiatry should recognize the fact of socioeconomic inequality and its effects on mental disorders. The medical model, with its emphasis on diagnostic and treatment specificity, may not be appropriate for investigation of the brain, given its complexity. The rise of scientific inequality, with billions allocated to connectomics and genetics, may shift attention away from the need for improvements in clinical care. Unfortunately, the future prospects of those suffering from mental illness appear dim. (shrink)

This paper examines the culture, the dynamics and the financial underpinnings that determine how medical research is being conducted on children in the United States. Children have increasingly become the subject of experiments that offer them no potential direct benefit but expose them to risks of harm and pain. A wide range of such experiments will be examined, including a lethal heartburn drug test, the experimental insertion of a pacemaker, an invasive insulin infusion experiment, and a fenfluramine "violence prediction" experiment. (...) Emphasis, however, is given to psychoactive drug tests because of the inherent ethical and diagnostic problems involved in the absence of any objective, verifiable diagnostic tool. Effort is made to provide readers comprehensive reference sources to evidence-based reports about the serious risks these drugs pose for adults and children so that the reader may judge whether the benefits (if any) outweigh the risks for children. The first ethical issue raised by these experiments is: did the severity of illness in these children justify their exposure to short and long-term risks? The ethics of the experiments will be evaluated by referring to existing codes of medical research ethics-the Nuremberg Code, the Declaration of Helsinki, and the federal Code of Regulations. The thirteen cases presented will demonstrate that children are being used in ever more speculative experiments, often in the absence of a therapeutic intent, but a significant chance for causing harm and / or discomfort. Some of the experiments were designed to explore the mechanisms of pathology and pharmacological interventions, or the response of neurological brain receptors to chemical provocation ("challenge"). Others were designed to test the safety or efficacy of new drugs, even to test these drugs on healthy children who were hypothesized to be "at risk." Children and adolescents have been subjected to "forced dose titration" experiments that induced a spectrum of severe adverse effects, including insomnia, extreme restlessness, agitation, (akathisia) and self-injurious behavior. FDA reports show that suicide is a significant issue in psychotropic drug trials-in pediatric trials the problem is even greater. The paper aims to demonstrate how the enactment of the Better Pharmaceuticals for Children Act (incorporated into the Food and Drug Administration Modernization Act, FDAMA), set in motion a radical shift in public policy by providing huge financial incentives to pharmaceutical companies to test new or patented drugs in children. Federal policy shifted from one aimed at protecting children by setting limits on permissible research risks, to a policy aimed at broadening the inclusion of children as test subjects. It will be shown how the FDA and the Department of Health and Human Services lifted regulatory restrictions to permit research involving greater than minimal risk to be conducted on healthy children, claiming that all children are potentially "at risk" of a future condition. Children were in this way deprived of regulatory protections. An argument will be made that the approval of nontherapeutic, harmful experiments-such as exposure of toddlers to lead poison-under the current gate keeping system raises serious doubts about the sustainability of institutional review boards (IRBs) as protectors of human research subjects. Children, who are precluded from exercising the adult human's right to informed consent, are being exploited as commodities for commercial ends. It is the position of the author that nothing less than the enactment of a federal law mandating a radical overhaul of the current research review system, with independent checks and balances, will provide children the legal protections they need. Ten specific recommendations are offered to protect children from harmful experiments. (shrink)

Within the broad field of human enhancement, pediatric cognitive neuro-enhancement appears to arouse particular interest. The increasing importance of cognitive capacities in our contemporary and cultural context appears to be the main reason for the focus on cognition as the preferred trait of enhancement, while the choice of pharmacological means is based on factors of feasibility, accessibility, and cost. While the ethical issues arising in the adult context have already been extensively covered in the literature, pediatric neuro-enhancement brings with it (...) additional ethical challenges requiring further attention. Although there are numerous important ethical considerations, the focus of this chapter is on the pursuit of normalcy as the goal in pediatric neuro-enhancement. Parental attempts to shape children are not new, and the resources available for them to do so include widespread and mostly uncontroversial tools, such as education. The increasing use of psychotropic drugs, however, reveals the significant impact of the concept of normalcy, which has resulted in a trend to medicalize what used to be considered “normal” behavior. In this context, special challenges are posed by psychiatric disorders, where the familiar treatment-enhancement distinction continues to be relied upon to justify interventions in children. Drawing on the examples of attention deficit/hyperactivity disorder and autism spectrum disorder, it will be argued that children are already being enhanced within psychiatric practice and that this is incompatible with an understanding of disability under a mixed model. (shrink)

Developments in neuroscience have raised the possibility that pharmaceuticals may be used to enhance memory, mood, and attention in people who do not have an illness or disorder, a practice known as “cognitive enhancement.” We describe historical experiences with two medicinal drugs for which similar enhancement claims were made, cocaine in the late 19th and early 20th centuries, and amphetamines in the mid 20th century. These drugs were initially introduced as medicinal agents in Europe and North America before becoming more (...) widely used for a variety of purposes, including what would nowadays be considered cognitive enhancement. Their trajectory of use conformed to the typical use cycle of psychotropic drugs. There was an initial steep rise in prescribing for medical use, followed by expanded nonmedical use that was fueled by enthusiasm for the drugs’ effects. As the number of regular users increased, problems related to use (such as addiction) became apparent, societal concern increased, and laws were passed banning nonmedical use and eventually, medical use. This historical experience draws attention to the adverse side effects of enhancement use that only become apparent with regular, wide-scale use of a drug. We highlight the similarities between the enthusiasms for cocaine and amphetamines and the current enthusiasms for using prescription stimulants for cognitive enhancement. We argue bioethicists should not encourage the cognitive enhancement use of drugs such as methylphenidate in the absence of evidence on the efficacy and safety of their use for cognitive enhancement purposes. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Concurrent Contents: Recent and Classic References at the Interface of Philosophy, Psychiatry, and PsychologyArticlesAntonak, R. J., C. R. Fielder, and J. A. Mulick. 1993. A scale of attitudes toward the application of eugenics to the treatment of people with mental retardation. Journal of Intellect Disabilities Research 37:75–83.Arens, K. 1996. Commentary on “Lumps and bumps.” Philosophy, Psychiatry, & Psychology 3:15–16.Bavidge, M. 1996. Commentary on “Minds, memes, and multiples.” Philosophy, Psychiatry, (...) & Psychology 3:29–30.Blashfield, R. K. 1973. Evaluation of the DSM-II classification of schizophrenia as a nomenclature. Journal of Abnormal Psychology 85(2):140–150.Braude, S. E. 1996. Multiple personality and moral responsibility. Philosophy, Psychiatry, & Psychology 3:37–54.Broverman, I. K., S. R. Vogel, D. M. Broverman et al. 1972. Sex-role stereotypes: a current appraisal. Journal of Social Issues 28:59–78.Broverman, I. K., D. M. Broverman, P. E. Clarkson et al. 1975. Sex-role stereotypes and clinical judgments of mental health. Journal of Consulting and Clinical Psychology 34:1–7.Checkland, D., and M. Silberfeld. 1996. Mental competence and the question of beneficient intervention. Theoretical Medicine 17(2):121–134.Clark, S. R. L. 1996. Commentary on “Multiple personality and moral responsibility.” Philosophy, Psychiatry, & Psychology 3:55–57.Clark, S. R. L. 1996. Minds, memes, and multiples. Philosophy, Psychiatry, & Psychology 3:21–28.Dickenson, D., and D. Jones. 1995. True wishes: The philosophy and developmental psychology of children’s informed consent. Philosophy, Psychiatry, & Psychology 2:287–303.Donaldson, T. 1978. Psychoanalyzing the practical inference model. Philosophical Research Archives 4:1215.Eekelaar, J. 1995. Commentary on “True wishes.” Philosophy, Psychiatry, & Psychology 2:305–307.Fisher, S., and R. P. Greenberg. 1993. How sound is the double-blind design for evaluating psychotropic drugs? Journal of Nervous and Mental Disease 181:345–350.Fulwiler, C., and M. F. Folstein. 1995. Commentary on “Chris Walker’s interpretation of Karl Jaspers’ phenomenology.” Philosophy, Psychiatry, & Psychology 2:345–346.Heinze, M. 1995. Commentary on “Moralist or therapist?” Philosophy, Psychiatry, & Psychology 2:31–32.Iturrate, M. 1977. Man’s freedom: Freud’s therapeutic goal. Review of Existential Psychology and Psychiatry 15:32–45.Littlewood, R. 1991. From diseae to illness and back again. Lancet 337:1013–1015.Maddox, J. 1993. New genetics means no new ethics. Nature 364:97.McCormick, S. 1995. Commentary on “True wishes.” Philosophy, Psychiatry, & Psychology 2:309–310.Murray, T. H. 1995. Commentary on “True wishes.” Philosophy, Psychiatry, & Psychology 2:311–312.Muzika, E. G. 1989. Object relations theory, Buddhism, and the self-synthesis of eastern and western approaches. International Philosophical Quarterly 30(1):59–74.Parker, M. 1995. Commentary on “True wishes.” Philosophy, Psychiatry, & Psychology 2:313–314.Phillips, J. 1996. Key concepts: Hermeneutics. Philosophy, Psychiatry, & Psychology 3:61–69.Pole, D. 1970. Self and personality. The Journal of the British Society for Phenomenology 1:30–36.Priebe, S. 1989. On the subjectivity of psychiatric diagnosis. Psychiatric Praxis 16:86–89.Radden, J. 1996. Lumps and bumps: Kantian faculty psychology, phrenology, and twentieth-century psychiatric classification. Philosophy, Psychiatry, & Psychology 3:1–14.Sampson, E. E. 1981. Cognitive psychology as ideology. American Psychologist 36:730–743.Sarbin, T. R. 1976. Contextualism: A worldview for modern psychology. Nebraska Symposium on Motivation 24:1–41.Senft, P. A. 1975. The self-contradictions (antinomies) of psychotherapy: Is a solution in social action possible? The Human Context 7:367–372.Shuman, D. W. 1996. Commentary on “Multiple personality and moral responsibility.” Philosophy, Psychiatry, & Psychology 3:59–60.Sprigge, T. 1996. Commentary on “Minds, memes, and multiples.” Philosophy, Psychiatry, & Psychology 3:31–36.Wallace, K. 1996. Commentary on “Lumps and bumps.” Philosophy, Psychiatry, & Psychology 3:17–20.Wells, L. A. 1995. Commentary on “True wishes.” Philosophy, Psychiatry, & Psychology 2:315–317.Wiggins, O. P., and M. A. Schwartz. 1995. Chris Walker’s interpretation of Karl Jaspers’ phenomenology: a critique. Philosophy, Psychiatry, & Psychology 2:319–343.BooksAmerican Hospital Association. 1994. Values in conflict: Resolving ethical issues in health care. 2nd ed. Chicago: American Hospital Association.American Medical Association. 1992. Code of medical ethics: Annotated current opinions of the council on ethical and judicial affairs. Chicago: American Medical Association.———. 1994. Council on ethical and judicial affairs... (shrink)