IJP: Israel Journal of Psychiatry: Vol' 51, issue 3

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israel journal of

psychiatry

Vol. 51 - Number 3 2014

ISSN: 0333-7308

Special section Ethics and psychiatry 160

Editorial: Ethical Issues in Psychiatry Adiel Doron

162

Evil and the Punishment of Crime Azgad Gold and Paul S. Appelbaum

169

Voting Rights for Psychiatric Patients Adiel Doron et al.

175

Examining the Ethical Boundaries of Harm Reduction Shaul Lev-Ran et al.

182

Placebos in the Clinical Setting

Uri Nitzan, Yuval Bloch and Shmuel Fennig

188

Institutional Ethics Committees in Mental Health Care Tal Bergman-Levy et al.

193

Patient Suicide

David Greenberg and Gaby Shefler

199

Real-life decision making of Serious Mental Illness patients Amira Or et al.

204

Ethics and the Psychiatry Journal Editor: Responsibilities and Dilemmas David Greenberg and Rael D. Strous

Gender and psychiatry: Part 2

212

Psychiatric Outpatients’ Problems and Expectations Ora Nakash et al.

219

Negative Emotional Eating among Obese Individuals Sarah Roer et al.

226

Antenatal Group Therapy Angela Bowen et al.


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israel journal of

psychiatry

The Official Publication of the Israel Psychiatric Association Vol. 51 - Number 3 2014

and related sciences EDitor

David Greenberg DEPUTY EDITORS

199 > Real-life decision making of

Special section: Ethics and psychiatry

Serious Mental Illness patients: Opt-in and opt-out research participation

Doron Gothelf Yoav Kohn Ivonne Mansbach Ora Nakash Shaul Lev-Ran David Roe Rael Strous

160 > Editorial: Ethical Issues

Book reviews editor

162 > The Inclination to Evil and the

Yoram Barak PAst Editor

Eli L. Edelstein Founding Editor

Heinz Z. Winnik Editorial Board

Alean Al-Krenawi Alan Apter Omer Bonne Elliot Gershon Talma Hendler Ehud Klein Ilana Kremer ltzhak Levav Yuval Melamed Shlomo Mendlovic Ronnen Segman Eliezer Witztum Gil Zalsman Zvi Zemishlany International Advisory Board

Paul Appelbaum Dinesh Bhugra Yoram Bilu Boris Birmaher Aaron Bodenheimer Stephen Deutsch Carl Eisdorfer Michael First Helen Herrman Julian Leff Ellen Liebenluft John Mann Phyllis Palgi Soumitra Pathare Daniel Pine Bruce Pollock Dan Stein Robert Wallerstein Myrna Weissman

in Psychiatry

Adiel Doron

Punishment of Crime – from the Bible to Behavioral Genetics Azgad Gold and Paul S. Appelbaum

Amira Or, Yehuda Baruch, Shelly Tadger and Yoram Barak

204 > Ethics and the Psychiatry Journal Editor: Responsibilities and Dilemmas David Greenberg and Rael D. Strous

Special section: Gender and psychiatry: Part 2

169 > Voting Rights for Psychiatric

Patients: Compromise of the Integrity of Elections, or Empowerment and Integration into the Community?

Adiel Doron, Rena Kurs, Tali Stolovy, Aya Secker-Einbinder and Alla Raba

175 > Examining the Ethical Boundaries of Harm Reduction: From Addictions to General Psychiatry Shaul Lev-Ran, Uri Nitzan and Shmuel Fennig

182 > Using Placebo Medications in the Clinical Setting – An Intellectual Game or a Possible Reality? Uri Nitzan, Yuval Bloch and Shmuel Fennig

188 > Enhancing the Use of

Institutional Ethics Committees in Mental Health Care in Israel

212 > Presenting Problems and Treatment Expectations Among Service Users Accessing Psychiatric Outpatient Care: Are There Gender Differences? Ora Nakash, Maayan Nagar and Itzhak Levav

219 > Negative Emotional Eating among Obese Individuals with and without Binge Eating Behavior and Night Eating Syndrome Sarah Roer, Yael Latzer and Allan Geliebter

226 > Antenatal Group Therapy Improves Worry and Depression Symptoms

Angela Bowen, Marilyn Baetz, Laura Schwartz, Lloyd Balbuena and Nazeem Muhajarine

Tal Bergman-Levy, Adiel Doron and Rael D. Strous

193 > Patient Suicide

Hebrew Section

David Greenberg and Gaby Shefler

234

> Abstracts

Associate editor

Rena Kurs

Assistant Editor

Joan Hooper

Marketing: MediaFarm Group +972-77-3219970 23 Zamenhoff st. Tel Aviv 64373, Israel   amir@mediafarm.co.il www.mediafarm.co.il

Meanwhile Autumn Michal Carmel Is the tree of the field a man? (Deuteronomy 20:19) For the tree I have chosen metallic, silver and gold colors as in an embalming; the tree is in a transitional state between death and renewal, while in the background is a storm (or blossoming); under the tree are fallen leaves, whose beauty and wealth of color are a positive end-product, at least until the next spring!


Isr J Psychiatry Relat Sci - Vol. 51 - No 3 (2014)

Editorial: Ethical Issues in Psychiatry This issue of the Israel Journal of Psychiatry, devoted to ethics, represents our belief that the topic of ethical dilemmas is playing an increasingly important role in psychiatric dialogue. As can be seen from the diversity of topics presented, ethical questions touch on many different areas. Roberts (1) has defined ethics as “ways of understanding what is good and right in human experience. It is the concrete expression of moral ideals in everyday life. Ethics is about meaning, and it is about action.” In the closing article, Greenberg and Strous share with readers the ethical questions that face them in preparing this journal: “An array of potential ethical stumbling blocks awaits the editors of scientific journals” (2). They address basic philosophical principles, the deontologic versus the utilitarian approach. Kant argued that to act in the morally right way, people must act from duty (deon). He argued that it was not the consequences of actions that make them right or wrong but the motives of the person who carries out the action. In utilitarianism, the moral worth of an action is determined mostly by its resulting outcome, a morally right act (or omission from acting) is one that will produce a good outcome, or consequence. Should we look at some basic moral axioms like “do not kill” and “tell the truth”, as Emanuel Kant says or look at the result of the action as John Stewart Mill thinks. The difference between those two principles is as relevant today as it was in the 18th century. Who decides what is the correct moral axiom, according to which should each of us pave his path? Typically in applied ethics, practitioners are guided to use their moral intuitions to determine which of the four principles of autonomy, beneficence, non-maleficence and justice are most important, given the particular facts of the situation (3). Some might say that it is fortunate while others believe that it complicates our problemsolving abilities, but there is no hierarchy between these four principles. Lev-Ran et al. (4) take this dilemma one step further. Is it moral to prescribe a drug to a drug addict which in turn can be legalized because it reduces the harm that a stronger drug causes? Kant and the deontologists would not allow it while Mill and the utilitarians would. Gold and Appelbaum (5) present an interesting perspective on the topic of violence and antisocial person160

ality disorder. How would new discoveries on the genetics of violence influence our attitude towards people with antisocial personalities. Would it make them more or less responsible in our eyes? The question of the psychiatric patient’s right to vote is a sensitive issue. Is it ethical to allow patients who are not responsible for their body and finances to be responsible for political decisions? (6). What of the ability of patients with severe mental disorders to give consent to participation in research? How much are they influenced by the policy of the hospital and the approach of the researcher? Or et al show us that neuropsychological impairments, as well as psychotic and severe affective symptoms and lack of insight, can affect patients’ abilities to make fully informed decisions about their own research participation. They recommend that attention to the process of informed consent as an ongoing dialogue strengthens the clinician-patient relationship and helps patients clarify preferences (7). The same issue applies to the question of placebo treatments. Ethically can they be used in clinical practice as an alternative to a standard therapy? Most centers nowadays do not allow placebo treatment as part of any research. Nitzan et al. question whether it is ethical to prevent patients from using placebo which has no side effects and is known to help a high percentage of the patients (8). Probably the most complicated question in psychiatric decision making deals with suicidal patients. Greenberg and Shefler discuss the difficulties therapists confront after losing a patient, recommending that we provide support for therapists (9). We may know the right way to help our patients but we do not always know how to help ourselves. The Patients Rights Acts of 1996 instituted statutory ethics committees. Bergman et al. (10), remind us that although institutional ethics committees were established and functioned in Israel prior to the application of the act, few health care workers consult these committees. As is evident from this journal issue, the range of topics that can be addressed at ethical committees is vast. In Tel Aviv medical school, at the psychotherapy program, we conduct every year a day devoted to ethics. The students bring many questions and it is difficult to choose which questions to select. Nevertheless, as


Adiel Doron

with the hospital ethics committees, students seldom approach the school ethical committee. Another significant issue is the difference between law and ethics. Greenberg and Strous (2) point out a few dilemmas indicating the difficulties in differentiating those two areas. Ethical behavior is above maintaining the law. When the law gives us an answer to the appropriate way of behavior, we have no dilemma, ethical questions make our decision making difficult but more interesting. One of the main recommendations when dealing with an ethical dilemma is to consult with your colleagues or supervisors. If you are not ashamed of what you have done and can consult your coworkers, many would state that most likely the extent of the act and potential damage are limited. The main purpose of this issue is to remind us again and again to think about ethics, to teach ethics and to live an ethical life.

3. Beauchamp TL & Childress J F , Principles of Biomedical Ethics, 5th (ed). Oxford University Press, NY, 2001. 4. Lev-Ran S, Nitzan U, Fennig S. Examining the ethical boundaries of harm reduction from addictions to general psychiatry. Isr J Psychiatry Relat Sci 2014;51:175-181. 5. Gold A, Appelbaum PS. The inclination to evil and the punishment of crime – from the Bible to medical genetics. Isr J Psychiatry Relat Sci 2014;51:162-168. 6. Doron A, Kurs R, Stolovy A, Secker-Einbinder T, Raba A. Voting rights for psychiatric patients: compromise of the integrity of elections or empowerment and integration into the community? Isr J Psychiatry Relat Sci 2014;51:169-174. 7. Or A, Baruch Y, Tadger S, Barak Y. Real-life decision making of serious mental illness patients: opt-in and opt-out research participation. Isr J Psychiatry Relat Sci 2014;51:199-203. 8. Nitzan U, Bloch U, Fennig S. Using placebo in the clinical setting – an intellectual game or a possible reality?. Isr J Psychiatry Relat Sci 2014;51:182-187. 9. Greenberg D, Shefler G. Patient suicide. Isr J Psychiatry Relat Sci 2014; 51:193-198: 10. Bergman-Levy T, Doron A, Strous RD. Enhancing the use of institutional ethical committees in mental health care in Israel. Isr J Psychiatry Relat Sci 2014;51:188-192.

References

Adiel Doron

1. Roberts LW. Ethics as endeavor in psychiatry: principles, skills, and knowledge. Psychiatric Times 2002. 12:19. 2. Greenberg D, Strous R. Ethics and the psychiatry journal editor: responsibilities and dilemmas. Isr J Psychiatry Relat Sci 2014;51:204-211.

Lev Hasharon Mental Health Center, Netanya   adoron@lev-hasharon.co.il

Guest editor

161


Isr J Psychiatry Relat Sci - Vol. 51 - No 3 (2014)

The Inclination to Evil and the Punishment of Crime – from the Bible to Behavioral Genetics Azgad Gold, MD, PhD,1 and Paul S. Appelbaum, MD1,2 1

Division of Law, Ethics, & Psychiatry, Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, New York, U.S.A. 2 New York State Psychiatric Institute, New York, New York, U.S.A.

ABSTRACT The evolving field of behavioral genetics is gradually elucidating the complex interplay between genes and environment. Scientific data pertaining to the behavioral genetics of violent behavior provides a new context for an old dilemma regarding criminal responsibility and punishment: if the inclination to violent behavior is inherent in someone's nature, how should it affect punishment for crime? Should it be considered as a mitigating or an aggravating factor? Given psychiatrists’ increasing involvement in providing testimony on behavioral genetics in the criminal justice system, this paper first provides the necessary background required for understanding how this question arises and reviews the relevant literature. Then, we address this question from the perspective of the Bible and its commentators, in the belief that their insights may enrich the contemporary discussion of this question.

Introduction Genes play a major role in the development of both our bodies and our minds. The evolving field of behavioral genetics is gradually elucidating the complex interplay between genes and environment that contributes to the behavioral differences between individuals (1). One area of behavioral genetics that has attracted a great deal of This work was supported in part by funding from the National Human Genome Research Institute (1P20HG005535-01). Address for Correspondence:   atg2119@columbia.edu

162

attention is the exploration of the roots of violent behavior (2-4). Researchers hope someday to have the ability to detect accurately persons at high risk of violence and to develop effective “anti-violence” interventions for use with this population. Although such innovative technologies appear to be beyond our reach today, the societal implications of behavioral genetics research may require our consideration much sooner than might be thought. In fact, behavioral genetics may be the next frontier for the world of criminal justice. The scientific data that suggest that the inclination to evil may be embedded – at least in part – in our genes provide a new context for an old ethical and legal question regarding criminal responsibility and punishment: if the inclination to violent behavior is inherent in someone’s nature, how should it affect punishment for crime? Should it be considered a mitigating factor that lessens the degree of punishment, or should it serve as an aggravating factor justifying a more severe sanction? In this article we address this question from a biblical perspective, relying primarily but not exclusively on the classical rabbinic commentators. We suggest that although the context of behavioral genetics is relatively new, the question pertaining to the relationship between the inclination to evil and the punishment of crime is not. The issue is addressed in the Old Testament and discussed by its commentators; their insights may enrich the contemporary discussion of this question. The Genetic Contribution to Violent Behavior The possibility that hereditary factors play a causal role in the genesis of criminal behavior was raised during the efflorescence of interest in genetics and heredity in the

Dr. Azgad Gold, NY State Psychiatric Institute, 1051 Riverside Drive, Box #122, New York, NY 10032, U.S.A.


Azgad Gold and Paul S. Appelbaum

late 19th century. Francis Galton, who dedicated much of his extensive corpus of work to issues of heredity (3), noted, “The perpetuation of the criminal class by heredity is a question difficult to grapple with on many accounts. Their vagrant habits, their illegitimate unions, and extreme untruthfulness, are among the difficulties of the investigation. It is, however, easy to show that the criminal nature tends to be inherited” (5). In 1876, Italian psychologist and physician Cesare Lombroso argued in his essay The Criminal Man that criminality is inborn, not acquired from the environment and therefore could be identified by characteristic physical traits (6, 7). Several scientifically oriented articles began to appear in the following years (8), but the empirical basis for such conclusions remained weak. In the 1960s and 1970s men who carried an extra Y chromosome – the so-called XYY syndrome – were thought to be at increased risk of violence, a subsequently disproven contention (9). A different and more promising connection between genetic predispositions and violent crime was reported in 1993. Brunner et al. described the case of a Dutch kindred, in which several males exhibited borderline mental retardation and “abnormal behavior, including disturbed regulation of impulsive aggression” (10). They were found to have a complete absence of activity of the enzyme monoamine oxidase A (MAOA), which metabolizes several key monoamine neurotransmitters. Genetic analysis revealed that the affected men carried a mutation on their X chromosome in the gene that codes for MAOA that rendered the enzyme inactive. The authors suggested that genetic defects in neurotransmitter metabolism may affect aggressive behavior. In 2002, another paper was published that extended the scope of the MAOA findings (11). Although complete absence of MAOA activity is extremely rare, a group of researchers postulated that reductions in activity, known to be related to mutations in the promoter region of the MAOA gene, might also increase the risk of violent and other antisocial behaviors, especially when paired with adverse environmental circumstances. Thus, as part of a major longitudinal study of a birth cohort of 1,037 children in Dunedin, New Zealand (reporting data from the most recent follow-up interviews at age 26), the researchers examined 442 males in the group for differences in the promoter region of the gene. Exploring the interactions of the participants’ genetic endowments with their environmental circumstances, the researchers looked at the impact of maltreatment between the ages of three and 11 on later antisocial pro-

pensities of participants with either high or low MAOA activity. They found that manifestations of antisocial behavior were significantly increased in the group that had both low MAOA activity and a history of severe maltreatment. In contrast, for participants with high levels of MAOA, even in the presence of maltreatment, the increase in antisocial activity was much less significant. The overall impact of this gene-environment interaction is evidenced by the fact that the 12% of the cohort that had both low MAOA and maltreatment accounted for 44% of the convictions for violent crime. Eighty-five percent of the males with both risk factors developed some form of antisocial behavior. Several attempts have been made to replicate the Dunedin findings, most successful but some not, though meta-analyses suggest that the effect is real; this literature has been extensively reviewed elsewhere (3, 4). The discrepancy among studies may be explained, in part, by differences in subject populations and in the definitions of maltreatment or aggression (12). This highlights the need to better define and objectively quantify environmental factors in future empirical investigation of gene-environment interactions (13). In addition, it calls attention to the possible variation introduced to the data by different degrees of early trauma (14). Given that differences in the expression of MAO-A protein in human subjects have been shown to account for greater than 30% of the variability in trait aggression (15), several studies have been conducted with the aim of finding an underlying mechanism. One group proposed that hormonal activity (high testosterone levels) may be responsible for both low MAO-A activity and violence (16). Another study showed that functional connectivity between the ventromedial prefrontal cortex (vmPFC) and the amygdalae was increased only in males with the low MAO-A gene (17). In addition, that study found that when performing an emotional face matching task, low MAO-A activity males showed increased activation of the amygdalae and decreased activation of the vmPFC compared to control subjects. Given that this pattern had previously been correlated with antisocial behavior, conviction for violent crimes, and self-reported violence, it was hypothesized that increased activation of the emotion centers in the amygdalae and decreased activation of inhibitory input from the prefrontal cortex may foster aggressive behavior. Low MAO-A activity subjects show greater activation of the anterior cingulate in response to being excluded from a virtual “ball-passing” game (18), and higher 163


The Inclination the Punishment of Crime – from the Bible to Behavioral Genetics Isr J Psychiatry Relat Sci - Vol.to 51 Evil - No 3and (2014)

levels and intensity of aggression in response to provocation as compared to high MAO-A activity subjects. None of these mechanistic studies took into account the potential effects of environmental influences on the development of aggressive behavior, a methodological limitation that needs to be addressed in future work (ַ6). In spite of the ongoing uncertainty regarding the exact role of monoamines and their genetic underpinnings in aggressive and antisocial behavior (19), and the controversy regarding the current applicability of this knowledge to determinations made by the courts (20), it seems likely that with continued advances in behavioral genetics, if we cannot already do it, we will at some point be able to identify genes that, combined with environmental stimuli, predispose persons to increased rates of criminality (21). These anticipated findings will pose a challenge for the criminal justice system with regard to their implications for determining criminal culpability and punishment. In legal systems in which some mental disorders negate culpability, commentators are already beginning to ask why genetic determinants such as low MAO-A activity should not have the same effect (20, 21). A recent review of the role of MAO-A in aggressive behavior highlighted two cases in which MAO-A levels were introduced as evidence in court and appeared to influence the verdict in favor of the defendants (6). In a case from the U.S., the defendant was charged with murder (a capital offense) of his estranged wife’s friend, attempted murder of his wife, and two counts of kidnapping. The defense argued that he was both abused as a child and possessed the low activity MAO-A variant. Based on this evidence, among other considerations, the defendant was found guilty of voluntary manslaughter instead of murder. Nevertheless, he was sentenced to 32 years in prison (22). An Italian case involved a defendant who had been assaulted by a group of youths and bought a knife as a result. Spotting someone whom he thought had been one of his assailants, he followed his victim down the street and stabbed him to death. Although the defendant may have been delusional at the time of the crime, the judge deemed the evidence not strong enough to support an insanity defense. However, an Italian appeals court reduced the defendant’s sentence from 9 to 8 years, on the grounds that he tested positive for a low activity variant of MAO-A, which made him genetically predisposed towards violence (23). In both cases, it is hard to estimate the exact contribution of the genetic evidence to the final legal outcome. That being said, it is remarkable 164

that in spite of the primordial phase of scientific knowledge regarding the significance of low MAO-A activity’s impact on violent behavior, some courts have accepted such evidence and adjusted their verdicts and sentences accordingly. The difficulty linking genetic predispositions to the commission of particular criminal acts may make it difficult to demonstrate the prerequisites for a finding of non-responsibility. Thus, it seems more likely that the initial dilemmas faced by the criminal justice system in light of behavioral genetics findings will relate to sentencing rather than to exculpation (21), as already appears to be the case. Indeed, an examination of the early use of behavioral genetics in court reveals that “the majority of criminal defendants to have introduced expert testimony regarding their behavioural predisposition in U.S. criminal cases have done so in an attempt to mitigate their sentence, rather than to excuse or justify criminal conduct”. Although it is clear that such evidence can have a mitigating effect (witness the Italian case noted above), it can resemble the proverbial double-edged sword. As one U.S. appellate court noted in rejecting a prisoner’s appeal from a murder conviction on the grounds that he had not had the chance to introduce evidence of his MAO-A status: “[We find it] highly doubtful that the sentencing court would have been moved by information that Landrigan was a remorseless, violent killer because he was genetically programmed to be violent…Although Landrigan’s new evidence can be called mitigating in some slight sense, it would also have shown the court that it could anticipate that he would continue to be violent…On this record, assuring the court that genetics made him the way he is could not have been very helpful.” (Landrigan v. Stewart, 272 F.3d 1221 (9th Cir. 2001) From a theoretical as well as practical perspective, therefore, the impact that behavioral genetic data should have on punishment remains in question. Philosophical Considerations Two contrasting approaches to criminal sentencing exist in tension with each other. The retributive approach ascribes the degree of culpability and hence the extent of just punishment retrospectively. Retributivists look back at the criminal act and base their determination of appropriate sanctions on the nature of the mens rea, i.e., guilty mind, involved in the offence. When determining punishment, the retributive approach asks what kind of punishment the offender deserves, based on the extent


Azgad Gold and Paul S. Appelbaum

of the person’s responsibility for his or her actions. As a result, proponents of the retributive approach may be reluctant to find a person fully blameworthy for an action that evolved, at least in part, from powers that were beyond his or her control (e.g., due to low MAOA activity). Hence, since one cannot be blamed for having genes that, combined with early life experiences, contribute to some degree to criminal behavior, it would be unjustified to punish an offender as severely as in a case in which someone has full control over his actions. On the other hand, the utilitarian approach to sentencing is forward-looking, focusing on which punishment will be most effective in terms of preventing future crimes. For the utilitarian, the aspiration to protect society from a potentially dangerous criminal seems to be more important than the meticulous retributive effort to find the perfectly justified degree of retaliation for past criminal action. Thus, if a defendant is found to have an innate propensity to criminal behavior, whether genetic or otherwise, and there is no effective treatment for that condition, it might be reasonable from a utilitarian point of view to increase his or her sentence. In practice, however, sentencing may rely more on different moral intuitions than reflective moral arguments. According to some scholars, real-life moral judgments are made intuitively and spontaneously according to what “feels right” (24). For example, the culpable control model posits that “relatively unconscious, spontaneous evaluations… [which] are affective reactions to the harmful event and the people involved” drive judgments of blame (25, p. 558). Under this view, in which reason is subordinate to emotion, either retributive or utilitarian rational justifications are a posteriori phenomena, functioning only as intellectual defenses for a priori, intuitive moral decisions. Indeed, ample research suggests that people tend to have intuitive “biases” when making moral and legal decisions regarding criminal culpability (26). Factors such as offenders’ personality traits affect people’s legal intuitions regarding legal responsibility (27), and given the known positive correlations between perceived freedom and aggressiveness and attributions of responsibility and punishment of offenders (28), it is reasonable to assume that genetic information would have a similar effect on sentencing judges’ moral and legal intuitions. The primacy of intuitive responses in moral decision making makes sense from a phylogenetic perspective. During the development of the human species, it seems probable that our distant ancestors based their “moral”

decisions on their pro-social intuitions prior to being able to offer rational justifications for their choices. As Rousseau suggested, “Men would have never been better than monsters, had not nature bestowed on them a sense of compassion, to aid their reason… what is generosity, clemency or humanity but compassion applied to the weak, to the guilty, or to mankind in general?... It is this compassion that hurries us without reflection to the relief of those who are in distress…” (29). Contemporary scholars have proposed modern, empirically based versions of Rousseau’s theory, according to which our tendency to make moral judgments is innate, having evolved out of “pro-social” emotions (30). Based on these theories, it might be reasonable to assume that only as humankind’s cognitive capacities developed and language became established did reflective conceptualizations of morality and rational justifications of moral decisions appear. A Biblical Perspective One of the earliest systematized moral codes can be found in the Old Testament. The Hebrew Bible’s moral philosophy cannot be reduced to a single moral theory (31) as, for example, both deontological and utilitarian voices can be found in it (32). Similarly, since the Bible presents various justifications for punishment (such as deterrence, revenge, rehabilitation, etc.) in different cases, it would be inaccurate to ascribe to its authors a univocal theory of punishment. In fact, the multidimensional character of the Bible with regard to morality has preserved its capacity to serve as an inspirational source of reference for proponents of a range of moral views. The contradictory nature of the Bible with regard to moral questions can be exemplified by the examination of two early biblical references to the dilemma at hand, namely whether an innate propensity to misbehavior should be considered as a mitigating or aggravating factor. A thorough exploration of the biblical approach to this dilemma is beyond the scope of this paper, therefore our inquiry will be limited to the example offered by two references pertinent to this question at the beginning of the book of Genesis. The context in which the Bible refers to the question of the propensity to evil and punishment is woven in the story about Noah. After the Flood, the Bible suggests God’s less-than-favorable opinion regarding human nature: “the imagination of man’s heart is evil from his youth” (Genesis 8:21). The Bible ascribes to God the 165


The Inclination the Punishment of Crime – from the Bible to Behavioral Genetics Isr J Psychiatry Relat Sci - Vol.to 51 Evil - No 3and (2014)

notion that humans are inherently evil from a very early stage of development. This biblical notion was shared by some more recent scholars, albeit on varying theoretical grounds, such as Thomas Hobbes and Sigmund Freud. Hobbes developed a political theory based on the assumption that human nature is evil and hostile (33), while Freud’s psychological theory – and its cultural ramifications – are rooted in the contention that infant behavior derives, in part, from innate aggression (34). How early can one find the manifestations of this wickedness in a child? According to early Christian and Jewish traditions (200-450 AD), badness is attributed to a man even in infancy. Saint Augustine believed that “there is none free from sin, not even the infant who has lived but a day upon this earth… the infant’s innocence lies in the weakness of his body and not in the infant mind… I have myself observed a baby to be jealous, though it could not speak; it was livid as it watched another infant at the breast” (35). Jewish scholars at that time also shared the notion that badness is embedded in man since the time he “awakens” to the world. The challenge that biblical commentators and translators have confronted in understanding the passage from the story of Noah comes later in the account, when God indicates that he will not again destroy all life on earth: “[T]he LORD said in his heart, I will not again curse the ground any more for man’s sake… neither will I again smite any more everything living, as I have done” (Genesis 8:21). Although seemingly a promise only to refrain from collective punishment, God’s declaration was understood by the classic Jewish commentators as applying to individual chastisement as well. Moreover, by linking this promise to the earlier statement about humankind’s innate inclination to evil, they interpreted it as reflecting leniency based on a view that uncontrollable impulses diminish moral culpability. Rabbi Moses ben Nachman Girondi (Nachmanides; 1194-1270), a prominent medieval Jewish physician and scholar, held on the basis of these verses that the innate inclination to evil serves as a mitigating factor. Rabbi Hezekiah ben Manoah (13th century), another Jewish commentator, explained that given the fact that a man’s sin derives from immaturity and in addition a man’s heart is evil, it is not justified to “take revenge” on human beings by such an extreme measure as a flood. A meticulous reading of Rabbi Hezekiah ben Manoah’s opinion illustrates the connection between a retributive orientation and a tendency to perceive the innate inclination to evil as a mitigating factor. His use of the words “take revenge” gives us 166

a hint regarding his implicit perception of punishment and its purpose. Justifying the reduction in punishment due to an innate predisposition to evil in terms of the grounds for retaliation signifies that from a retributive point of view human beings do not deserve harsh punishment, such as a universal flood. Rabbi Chaim ben Moses ibn Attar (1696-1743) acknowledged in his analysis that a person’s disposition toward misbehavior is not compelling enough to exculpate him or her from punishment. Nevertheless, he argued, it should be taken into consideration at the sentencing phase. God decided to reduce the severity of future punishments – especially capital punishments – but not to abolish punishment completely, since humans still have the capability to overcome evil. The interpretation of the first biblical phrase examined above in a way that contemplates the innate inclination to evil as a mitigating factor seems correct from a purely literal perspective. The Hebrew word kee (‫)כי‬ that connects the statement regarding a man’s inclination to evil with mitigation of future punishments usually means “because.” Thus, according to this more common translation of kee, the meaning of the biblical phrase is that God will reduce the severity of the punishment because a man’s heart is evil from his youth. However, although this mitigating interpretation seems more appealing from a literal perspective, it confronts some difficulties when God’s “mitigating approach” is compared to a somewhat different view expressed a few chapters earlier (Genesis 6:5-7): And God saw that the wickedness of man was great in the earth, and that every imagination of the thoughts of his heart was only evil continually…And the LORD said, I will destroy man whom I have created from the face of the earth… It is clear from this text that, as opposed to the “mitigating approach,” the human disposition to evil plays a crucial role in God’s decision to punish humankind. Here, the innate inclination to evil is perceived as an aggravating factor that justifies capital punishment. The Bible’s commentators noticed this contradiction. Rabbi Isaac ben Judah Abrabanel (1437-1508), a Jewish statesman, philosopher and Bible commentator, asked, “Why is the justification for not cursing the ground again that ’the imagination of a man’s heart is evil from youth?!’ [It does not make sense]; on the contrary, this is a worthy reason for a cursed and total destruction!... In addition, in chapter 6:5-7, God considered man’s impetus to evil as a reason for bringing a curse of annihila-


Azgad Gold and Paul S. Appelbaum

tion and here (Genesis 8:21) he considered man’s impetus to evil as a justification for not cursing the ground. How can the same claim serve as a justification for two contradictory conclusions?” Several answers have been suggested by the classical biblical commentators. One suggestion – consisting of only two-words - is highly relevant to our discussion. Rabbi Sa’adia Gaon (10th century) proposed that the interpretation of the word kee should be “even though” rather than “because”. The modification in the interpretation of this one word changes significantly the relationship between the inclination to evil and punishment. Instead of understanding the disposition to evil as a justification for a reduction in the severity of punishment, according to the alternate interpretation the inclination to evil should serve as an aggravating factor. There is no contradiction, according to this interpretation, between the two texts referring to God’s different mindsets. When God’s contemplates the future of humanity – a perspective that is characteristic of the utilitarian approach – it seems futile to demonstrate clemency. What is the benefit of mitigation if the defendant will commit the same crime in the future? It is only due to God’s mercy – not necessarily supported by a rational argument – that human beings would not be punished again with the severity of the flood. Since the Bible was originally written in Hebrew, and translation is a hermeneutic task, it is not surprising to find that different translators hold different views pertaining to the translation of the Hebrew word kee (‫)כי‬, and consequently offer varying perspectives regarding the relationship between the inclination to evil and its impact on punishment. According to the King James Version, the translation of the key phrase is: …the LORD said in his heart, I will not again curse the ground any more for man’s sake; for the imagination of man’s heart is evil from his youth; neither will I again smite any more everything living, as I have done (36). Here, in accordance with the mitigating approach, the notion that “man’s heart is evil from his youth” leads to a reduction in punishment. On the other hand, according to the New International Version, the biblical phrase is translated as follows: The LORD… said in his heart: “Never again will I curse the ground because of man, even though every inclination of his heart is evil from childhood. And never again will I destroy all living creatures, as I have done (37). In this version, similar to Rabbi Sa’adia Gaon’s interpretation, in principle the human inclination to evil calls

for an aggravating approach. However, in spite of that legitimate demand, God chooses to embrace mercy and declares that he will never again inflict a punishment as grave as the flood, no matter how sinful humans may be. Conclusions We are confronting an era in which ethical and legal dilemmas inevitably will arise in parallel with the growth in our knowledge of the genetic bases of behavior. However, with regard to the impact of behavioral genetic data on criminal punishment, the core considerations are not entirely new. Whether one views genetically based propensities as mitigating or aggravating may reflect two contrasting moral intuitions regarding human misconduct. One approach is more lenient and inclines to clemency, while the other is stricter and more punitive. These two different human core dispositions likely reflect intuitive judgments, prior to reflection and apart from any intellectual justification. The presence of these opposing perspectives is evident in the very first chapters of the Bible, where they are presented without justification as representations of the state of mind, so to speak, of God on different occasions. Each perspective was further elaborated by biblical commentators and translators over the ages. Nevertheless, even the advocates of a mitigating approach do not argue that the inclination to evil is powerful enough to totally exculpate a person from punishment. What can be learned from the Bible’s framing of the dilemma as a universal problem, pertinent to all human beings and not necessarily limited to a particular highrisk group? In addition, what could be the meaning of God Himself maintaining two contradictory opinions concerning the subject on different occasions? Perhaps the text means to convey the following message: making an accurate and fair moral judgment of others’ bad behavior is a complicated task. Nevertheless, as human beings we are constantly and intuitively engaging in moral judgments of this sort. Questions regarding the influence of the inclination to misconduct on punishment are not limited to the courts but are ubiquitous and pertinent to our everyday judgments. For example, a parent or teacher may address the same misbehavior differently when it comes from a child whose temperament is explosive and whose behavior seems uncontrollable in comparison with a child whose actions appear more deliberate. Indeed, according to a well-known American proverb (ascribed to Oliver Wendell Holmes, 167


The Inclination the Punishment of Crime – from the Bible to Behavioral Genetics Isr J Psychiatry Relat Sci - Vol.to 51 Evil - No 3and (2014)

Sr.), “Even a dog knows the difference between being kicked and stumbled over.” However, there are situations in which the decision regarding the relationship between the inclination to evil and punishment is much more complex, demanding, and far-reaching. That happens when human beings are required to determine the future of another human being who has committed an offence, weighing the extent of the punishment that is called for, possibly even condemning the person to death. In such complicated cases, if as the Bible suggests, God Himself appears to vacillate between the two alternatives – it is not surprising that human beings have such a difficult time with these judgments. But perhaps bearing in mind God’s “inconsistency” concerning this subject matter reminds us that each case has its own special characteristics. Indeed, every individual is unique in terms of the interactions between his or her genes and the environment. Therefore, decisions should be made on an individualized basis and flexibility – as a cognitive capacity – must be a key component in our moral and legal decision making. References 1. Kim Y-K. Handbook of behavior genetics. New York, N.Y.: Springer, 2009. 2. Viding E. On the nature and nurture of antisocial behavior and violence. Ann N Y Acad Sci 2004;1036:267-277. 3. Baker LA, Bezdjian S, Raine A. Behavioral genetics: The science of antisocial behavior. Law Contemp Probl 2006;69:7-46. 4. Beecher-Monas E, Garcia-Rill E. Genetic predictions of future dangerousness: Is there a blueprint for violence? Law Contemp Probs 2006;69:301-341. 5. Galton F. Inquiries into human faculty and its development. London: Macmillan, 1883. 6. Baum ML. The monoamine oxidase A (MAOA) genetic predisposition to impulsive violence: Is it relevant to criminal trials? Neuroethics DOI: 10.1007/s12152-011-9108-6 (published on line 3 May 2011). 7. Lombroso C, Gibson M, Rafter NH. Criminal man. Durham, N.C.: Duke University, 2006. 8. McComas H. The heredity of mental abilities. Psychol Bull 1914 ;11: 379-383. 9. Steinfels MO, Levine C. The XYY controversy: Researching violence and genetics. Hastings Cent Rep 1980;10:1. 10. Brunner HG, Nelen M, Breakefield XO, Ropers HH, van Oost BA. Abnormal behavior associated with a point mutation in the structural gene for monoamine oxidase A. Science 1993;262:578-580. 11. Caspi A, McClay J, Moffitt TE, Mill J, Martin J, Craig IW, et al. Role of genotype in the cycle of violence in maltreated children. Science 2002;297:851-854. 12. Taylor A, Kim-Cohen J. Meta-analysis of gene-environment interactions in developmental psychopathology. Dev Psychopathol 2007;19:1029-1037. 13. Tremblay RE, Szyf M. Developmental origins of chronic physical aggression and epigenetics. Epigenomics 2010;2:495499.

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14. Weder N, Yang BZ, Douglas-Palumberi H, Massey J, Krystal JH, Gelernter J, et al. MAOA genotype, maltreatment, and aggressive behavior: The changing impact of genotype at varying levels of trauma. Biol Psychiatry 2009;65:417-424. 15. Alia-Klein N, Goldstein RZ, Kriplani A, Logan J, Tomasi D, Williams B, et al. Brain monoamine oxidase A activity predicts trait aggression. J Neurosci 2008 ;28:5099-5104. 16. Sjoberg RL, Ducci F, Barr CS, Newman TK, Dell’osso L, Virkkunen M, et al. A non-additive interaction of a functional MAO-A VNTR and testosterone predicts antisocial behavior. Neuropsychopharmacology 2008;33:425-430. 17. Buckholtz JW, Callicott JH, Kolachana B, Hariri AR, Goldberg TE, Genderson M, et al. Genetic variation in MAOA modulates ventromedial prefrontal circuitry mediating individual differences in human personality. Mol Psychiatry 2008;13:313-324. 18. Eisenberger NI, Way BM, Taylor SE, Welch WT, Lieberman MD. Understanding genetic risk for aggression: Clues from the brain’s response to social exclusion. Biol Psychiatry 2007;61:1100-1108. 19. Gunter TD, Vaughn MG, Philibert RA. Behavioral genetics in antisocial spectrum disorders and psychopathy: A review of the recent literature. Behav Sci Law 2010 ;28:148-173. 20. Bernet W, Vnencak-Jones CL, Farahany N, Montgomery SA. Bad nature, bad nurture, and testimony regarding MAOA and SLC6A4 genotyping at murder trials. J Forensic Sci 2007;52:1362-1371. 21. Appelbaum PS. Behavioral genetics and the punishment of crime. Psychiatr Serv 2005;56:25-27. 22. Hagerty B. Can your genes make you murder?: National Public Radio, July 1, 2010: [http://www.npr.org/templates/story/story. php?storyId=128043329]. 23. Forzano F, Borry P, Cambon-Thomsen A, Hodgson SV, Tibben A, de Vries P, et al. Italian appeal court: A genetic predisposition to commit murder? Eur J Hum Genet 2010;18:519-521. 24. Haidt J. The emotional dog and its rational tail: A social intuitionist approach to moral judgment. Psychol Rev 2001;108:814-834. 25. Alicke MD. Culpable control and the psychology of blame. Psychol Bull 2000 ;126:556-574. 26. Feigenson N, Park J. Emotions and attributions of legal responsibility and blame: A research review. Law Hum Behav 2006;30:143-161. 27. Endres J. Intuitive evaluation of guilt of violent offenders in relation to offender personality. Z Exp Psychol 1995;42:353-385. 28. Kane T, Joseph J, Tedeschi J. Perceived freedom, aggression, and responsibility, and the assignment of punishment. J Social Psychology 1977;103:257-263. 29. Rousseau J-J, Coleman P. Discourse on the origin of inequality. Oxford, New York: Oxford University, 2009. 30. Joyce R. The evolution of morality. Cambridge, Mass.: MIT, 2006. 31. Friedmann D. To kill and take possession: Law, morality, and society in biblical stories. Peabody, Mass.: Hendrickson, 2002. 32. Krašovec Jz. Reward, punishment, and forgiveness: The thinking and beliefs of ancient Israel in the light of Greek and modern views. Leiden, Boston: Brill, 1999. 33. Hobbes T, Gaskin JCA. Leviathan. Oxford, New York: Oxford University, 1998. 34. Freud S, Strachey J. Civilization and its discontents. New York: Norton, 2005. 35. Augustine, Outler AC. The confessions of St. Augustine. Mineola, N.Y.: Dover, 2002. 36. Carroll RP, Prickett S. The Bible: Authorized King James version. Oxford, New York: Oxford University, 2008. 37. Zondervan Publishing House (Grand Rapids Michigan). The Holy Bible. Grand Rapids, Mich.: Zondervan, 2007.


Isr J Psychiatry Relat Sci - Vol. 51 - No 3 (2014)

Adiel Doron et al.

Voting Rights for Psychiatric Patients: Compromise of the Integrity of Elections, or Empowerment and Integration into the Community? Adiel Doron, MD,1 Rena Kurs, BA,2 Tali Stolovy, PhD,1 Aya Secker-Einbinder, MD,1 and Alla Raba, MD1 1

Lev Hasharon Mental Health Center, Netanya, Israel, affiliated to Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel Sha’ar Menashe Mental Health Center, Sha’ar Menashe, Israel

2

Background

Abstract Background: Participation of the mentally-ill in elections promotes integration into the community. In many countries, individuals with compromised mental incompetence who have legal guardians are denied the right to vote. In Israel, mental health consumers are eligible to vote. We evaluated the capacity of psychiatric inpatients with and without legal guardians to understand the nature and effect of voting. Methods: Fifty-six inpatients with/without legal guardians were recruited to the study. Participants completed the Competency Assessment Tool for Voting (CAT-V), Brief Psychiatric Rating Scale and the Mini-Mental State Exam. Results: Cluster analysis determined voting capacity using CAT-V as a continuous variable. Subjects who scored >1.6 on the CAT-V (59%) had high capacity to vote. Subjects without guardians revealed significantly higher capacity to vote. Voting capacity positively correlated with cognitive state and negatively correlated with severity of illness. Among patients with legal guardians those who scored >1.6 on the CAT-V maintained the capacity to vote. Conclusions: The right to vote is an important basic right for individuals coping with mental disorders. However, it is important to evaluate the capacity to understand the voting process among individuals with mental disorders who have legal guardians. Thus, the integrity of the elections would be preserved by eliminating the risk of undue influence or manipulation of individuals who lack the capacity to understand the nature and meaning of voting, while preserving the right to vote for those with the capacity to do so, whether or not they have guardians.

Address for Correspondence:

Social movements that advocate the evolution of democracy focus primarily on participation in the electoral process.To fully comprehend the meaning of elections, the determination of who has and who does not have the right to vote must be considered. In the era of mental health reform, community based treatment and the emphasis on empowerment of psychiatric patients, limiting the right to vote of individuals with mental disorders undermines the goals of rehabilitation and integration into society. Conversely, the capacity of individuals with mental disorders to vote is scrutinized and in most democracies psychiatric inpatients, specifically those with legal guardians, are generally denied access to the polls (1). The lack of decision-making capacity is often used to deny access of psychiatric inpatients to the polls. Raad et al. (2) cite a 2001 United States Federal District Court decision in Maine that struck down the provision that denied the right to vote to all persons under guardianship because of mental disabilities, and adopted a narrow and specific test: persons are considered incompetent to vote only if they “lack the capacity to understand the nature and effect of voting such that they cannot make an individual choice,( known as the Doe Criteria [3]).” Criteria for mental illness vary across time, culture and politics, and while serious mental illness has often warranted disqualification, mental disorders do not necessarily preclude the ability to understand what it means to vote in governmental elections. Drawing a judicious line between serious and non-serious mental disabilities is Poster presented at the 14th National Conference of the Israel Psychiatric Association, David Intercontinental Hotel, Tel Aviv, Israel, May 15-17, 2012.

Adiel Doron, MD, Lev Hasharon Mental Health Center, POB 90000, Netanya 42100, Israel

adoron@lev-hasharon.co.il

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nearly impossible (4). In analyzing general restrictions on the right to vote in 63 democracies, Blais et al. (1) revealed that in almost all of these nations, the minimum voting age was 18 and the right to vote of “mentally deficient people” was restricted. The only countries that do not disenfranchise persons with a mental health or intellectual disability are Canada, Ireland, Israel, Italy and Sweden. Thus, in most countries, adults with mental disabilities do not have a constitutional or legal right to vote (5). Decision-making capacity and competency both describe patients’ ability to make decisions; however, they are not synonymous. Competency is a legal term and is determined by a court of law and decision-making capacity is a clinical assessment. When a person is declared incompetent it means that a court has ruled that the person is unable to make valid decisions and the court has therefore appointed a guardian to make decisions for that person (6). Hurme and Appelbaum (7) noted that in the United States, although guardianship laws define who is incompetent and in need of a guardian, only a few states have actual legal guidelines to determine whether or not a person has the capacity to vote. Four states have specific statutes that determine when a person is ineligible to vote, e.g., in Delaware, there must be evidence of “severe cognitive impairment which precludes exercise of basic voting judgment.” And in Iowa a person is incompetent to vote only if it can be determined that he/she “lacks sufficient mental capacity to comprehend and exercise the right to vote.” Although guardianship proceedings are aimed at determining if an individual is “incapacitated” owing to inability to manage money or attend to physical needs, these impairments are not necessarily related to the ability or capacity to vote. Nevertheless, in democracies where individuals who have guardians because of mental disabilities are denied the right to vote, a finding that the person is incompetent automatically triggers the voting ban (7). The relationship between schizophrenia and decisionmaking capacity remains equivocal. In patients with schizophrenia, decision-making abilities might be affected by cognitive factors and/or psychopathologic factors. Schizophrenia is usually, although not always, associated with mild to moderately severe neuropsychological impairments. Though psychotic symptoms fluctuate, cognitive deficits are generally stable over time. Impairments in attention, working memory, learning, and executive functions / abstract reasoning are clearly relevant when making decisions (8). However, there are also published studies that demonstrate a substantial heterogeneity in decision-making 170

capacity among people with schizophrenia, as well as among non-psychiatric controls, suggesting that the presence of schizophrenia does not necessarily mean the patient has impaired capacity to make decisions (9). Though mental illness is not synonymous with incompetence, there have been countries, such as those under fascist regimes, where people who voted “wrongly” were judged to be mentally ill and found themselves hospitalized (10). Under the guise of the attempt to preserve the integrity of elections, in most democracies patients with severe major cognitive impairment do not have the right to vote. In legal terms, how is mental incompetence defined? As previously mentioned, are patients under guardianship, or who are hospitalized in psychiatric hospitals considered incapable of exercising their right to vote (11, 12)? There is presently no clear consensus on what capacities a person actually requires to be able to vote (1), and many people with major cognitive impairments still have the right to vote in some countries (13). In the United States, state voting laws regarding mental illness vary. In 24 states a person judged “mentally incompetent” by a court is disqualified from voting unless the finding is reversed. In other states, a person under guardianship for mental disability is disqualified from voting. In New Jersey, a person judged incapable of understanding the act of voting by a court is disqualified from voting. Only six states have no statute or provision disqualifying a person with mental illness from voting, and in two of those states legislature may exclude a person from voting based on “mental incompetence” (14). The Council of Europe’s Commissioner for Human Rights issued a human rights comment stating that “persons with disabilities must not be denied the right to vote” based on a judgment issued by the European Court of Human Rights in May 2010 on the case of Hammarberg T on the case of Alajos Kiss v. Hungary (15). This decision concerned an adult man diagnosed with bipolar disorder and subsequently placed under partial guardianship in Hungary. This status resulted in his automatic exclusion from the right to vote, as provided for under Article 70(5) of the Hungarian Constitution. Mr. Kiss was not challenging his status as a person subject to partial guardianship, but was rather challenging the fact that any person placed under partial guardianship would be excluded from the right to vote in Hungary. The government argued that it should enjoy a wide margin of appreciation in determining those eligible to vote. The Court found in favor of Mr. Kiss, stating as follows:


Adiel Doron et al.

[...] if a restriction on fundamental rights applies to a particularly vulnerable group in society, who have suffered considerable discrimination in the past, such as the mentally disabled, then the State’s margin of appreciation is substantially narrower and it must have very weighty reasons for the restrictions in question [...] [t]he reason for this approach, which questions certain classifications per se, is that such groups were historically subject to prejudice with lasting consequences, resulting in their social exclusion. Such prejudice may entail legislative stereotyping which prohibits the individualized evaluation of their capacities and needs [...]. In the United States, despite legal protections, mentally ill individuals continue to suffer from discrimination that limits their rights to vote in elections. Some states adopted individualized functional determinations of competence to vote. In 2001 the Federal Court offered clear criteria for determining voting competence that are based on understanding the nature and effect of voting (the Doe standard [3]). The Doe standard was operationalized with the Competency Assessment Tool for Voting (CAT-V) along with measures of reasoning and appreciation. The interview questions were scored with good inter-rater reliability and took an average of less than five minutes to administer. Performance was high, with 92% scoring a 5 or 6 out of 6 possible points on the Doe-standard criteria. Performance did not correlate with cognition, verbal IQ, or symptom severity (2). According to the Israeli Elections Law, every citizen of Israel, age 18 or older, listed in the voting registry and physically present in Israel on Election Day, is eligible to vote. There are no statutes or provisions that disqualify a person with mental illness from voting. Prior to 1996, citizens could vote only in designated ballot boxes nearest their place of permanent residence. In 1996 the law was amended and the concept of mobile ballots in hospitals was introduced to enable physically and mentally ill patients to vote, while hospitalized (16). Thus, in a study conducted in Lev Hasharon Mental Health Center, Netanya, Israel, 204 of the total of 306 hospitalized patients (68.4%) participated in simulated elections, immediately following Knesset (Parliament) Elections. Voting ballots from the simulated election were compared with the actual electoral results, and did not significantly differ (17). As a sign of the times characterized by social movements, advocacy of democracy and empowerment of the mentally ill, accessibility to the ballot for the mentally ill was considered a step forward in the process of returning the patients to the community (18). In addition there are considerable therapeutic aspects of independent decision

making in the political landscape and in exercising the same civil rights as those enjoyed by the healthy population (19). But questions remains whether or not severely mentally ill psychiatric inpatients have decision-making capacity necessary to vote in municipal and general elections, and where the line should be drawn to determine which individuals with mental disorders can vote? Can a person who is unable to manage his own affairs and who requires a legal guardian to make health related as well as financial decisions participate in elections that will determine the future of a nation? While removing stigma is admirable, many people fear that disabled voters, who lack decisionmaking skills, could easily be manipulated by others when deciding for whom to vote. In an effort to enable individuals with mental illness in the world community to exercise their civil rights and to promote their participation in the process of government elections, we sought to evaluate the ability of hospitalized psychiatric patients with and without legal guardians to understand the meaning of voting in municipal elections, and to draw the line that would help identify those patients who retained the capacity to understand the voting process. Methods Sample

The study was approved by the Internal Review Board of Lev Hasharon Mental Health Center, in accord with the Helsinki Declaration. Patients from an open long-term hospitalization department, from a closed ward and from a psychogeriatric ward were approached to participate in the study. Participants had to be eligible to vote in Israel, i.e., 18 years or older, Israeli citizens, able to converse in Hebrew, and able and willing to provide informed consent or had a legal guardian willing to provide informed consent to participate in the study. Fifty-six inpatients who met all inclusion criteria and 12 healthy control subjects participated in the study. None of the potential participants refused to participate. All study subjects and/ or their guardians provided written informed consent after receiving a detailed explanation of study procedures, and prior to recruitment to the study. Seventy-eight percent of the inpatients met DSM-IV criteria for schizophrenia and the remaining 22% suffered from affective disorders. Instruments

Demographic questionnaire including gender, age, marital status, birthplace and years of education. 171


Voting Rights for Psychiatric Patients

Competency assessment tool for voting (CAT-V) (2). The instrument was designed to determine competence by assessing the capacity to vote by evaluating performance on four standard decision-making abilities: understanding, appreciation, reasoning, and choice. It is designed on the basis of the standard for voting capacity described in the Doe case (2) i.e. a person has the capacity to vote if he or she understands the nature and effect of voting and has the capacity to make a choice. The CAT-V operationalizes these criteria into three questions based on the Doe standard (“Doe standard questions”), which are distinct from the remaining CAT-V questions. The CAT-V was easy and efficient to administer and had high inter-rater reliability. In our study we used the CAT-V to examine the capacity to vote among a population of hospitalized individuals with serious mental illness. Following an introduction that asked the subject to imagine that it is election day for the governor of the state, an interviewer inquired about the person’s understanding of the nature of voting and then asked a question to assess understanding of the effect of voting. Scoring criteria used a 2, 1 or 0 scale where a score of 2 described adequate performance on the measure, 1 described marginal performance, and 0 described clearly inadequate performance. This questionnaire was translated to Hebrew and culturally adapted to Israeli society, then back-translated to English, specifically for use in this study.The present study found a satisfactory Cronbach’s alpha reliability of 0.84. Brief Psychiatric Rating Scale: The Brief Psychiatric Rating Scale (BPRS) is a widely used instrument for assessing the positive, negative and affective symptoms of individuals who have psychotic disorders, especially schizophrenia (20). The BPRS consists of 18 symptom constructs and takes 20-30 minutes for the interview and scoring. The rater enters a number ranging from 1 (not present) to7 (extremely severe); 0 is entered if the item is not assessed. The present study found a satisfactory Cronbach’s alpha reliability of 0.84. Mini-Mental State Exam: The Mini-Mental State Examination (MMSE) is a widely used, well-validated screening tool for evaluation of cognitive impairment (21). It briefly measures orientation to time and place, immediate recall, short-term verbal memory, calculation, language and construct ability. Each area tested has a designated point value, with the maximum possible score on the MMSE of 30/30. Test-retest reliability has been examined in many studies; in a review of his own studies, Folstein reported that for samples of psychiatric and neurologic patients, the test-retest reliability “has not fallen below 0.89; inter-rater 172

reliability has not fallen below 0.82” (22). Evaluation was performed during one session. Data Analyses

Cluster analysis was applied in order to produce two clusters: high and low capacity to vote, using the CAT-V measure as a continuous variable. The analysis included the entire sample, assuming that the healthy subjects would compose the high capacity cluster. T-test and chi-square tests were performed to compare the capacity to vote between the patients and the healthy comparison group. In addition, chi-square tests compared the capacity to vote between patients with and without a guardian and between patients who had voted or had not voted independently in previous elections. Pearson correlations assessed the relationship between the capacity to vote, severity of illness and cognitive state in the patient group. Regression analysis predicted the capacity to vote in the patient group. Results Participants’ characteristics

Fifty-six patients and 12 healthy comparison subjects participated in the study (Table 1). The cluster analysis produced two clusters of high and low capacity to vote, according to the CAT-V scores. Twenty-three patients (41% of the study group) composed cluster one, low capacity to vote. The 12 healthy subjects (100% of the comparison group) and 33 patients (59% of the study group) composed cluster two, high capacity to vote. This analysis validated the healthy group as a comparison group and the CAT-V as a discriminant continuous measure for assessing high and low capacity to vote. As stated before, the CAT-V is scored on a three point scale, where a score of 2 describes adequate performance on the measure, 1 marginal performance and 0 inadequate performance. The cluster analysis results (Table 2) show that subjects who scored below 1 in all six items of the CAT-V were clustered as low capacity to vote. Subjects who scored 1.6 or above were clustered together as a group with a high capacity to vote. Performance on the CAT-V

The healthy comparison subjects revealed significantly higher capacity to vote than the patient study group. Within the study group, subjects without a guardian revealed significantly higher capacity to vote than subjects with a guardian and subjects who had voted independently in previous elections showed significantly higher capacity to vote than subjects who had not voted independently previously (Table 3).


Adiel Doron et al.

Table 1. Characteristics of 68 participants who were tested for their capacity to vote

Variable Gender Men women

Study group (N=56)

Comparison group (N=12)

N (%)

N (%)

37 (66.1) 19 (33.9)

Table 2. Cluster analysis results to test a typology of high and low capacity to vote (CAT-V)1 Cluster low capacity

7 (58.3) 5 (41.7)

Age <40 40-60 60<

13 (23.2) 31 (55.4) 12 (21.4)

7 (58.3) 3 (25) 2 (16.7)

Marital status Single married divorced widowed

30 (53.6) 11 (19.6) 14 (25) 1 (1.8)

1 (8.3) 11 (91.7)

Birth place Israel Asia and Africa Europe and USA

31 (55.4) 11 (19.6) 14 (25)

11 (91.7) 1 (8.3)

Years of education primary school high school university

6 (10.7) 37 (66.1) 13 (23.2)

1 (8.3) 6 (50) 5 (41.7)

BPRS score1 (M±SD) MMSE score2 (M±SD) CAT-V score3 (M±SD)

42.9±14.8 23.6±4.2 1.3±0.6

1.9±0.1

Possible Brief Psychiatric Rating Scale scores range from 18 to 126, with higher scores indicating more severe psychiatric symptomatology. 2 Possible Mini-Mental State Examination scores range from 0 to 30, with higher scores indicating better cognitive ability. 3 Possible Capacity To Vote assessment tool scores (analyzed as continuous measure) range from 0 to 12, with higher scores indicating better capacity to vote. 1

The capacity to vote positively correlated with the patients’ cognitive state and negatively correlated with severity of illness. This indicates that the better the cognitive state the greater the capacity to vote and the more severe the illness, the lower the capacity to vote (Table 4). Accordingly, regression analysis revealed that illness severity and cognitive state predicted capacity to vote. The more severe the illness and the more deteriorated the cognitive state, the lower the predicted capacity to vote (Table 5). Discussion Though it has been suggested that individual assessments of competency should be performed before banning a person from participating in the election process, even being subject to assessment can be considered humiliating and could be viewed as a form of discrimination. It has been suggested that if a person can fill out a voting registration

high capacity

meaning

.91

1.61

influence

.74

1.89

choice

.78

1.95

deducing

.70

1.84

ability

.26

1.66

evaluation

.43

1.70

Possible Capacity To Vote assessment tool scores (analyzed as continuous measure) range from 0 to 12, with higher scores indicating better capacity to vote.

1

Table 3. Univariate comparison of the capacity to vote (CAT-V)1 between groups within the sample Groups

Mean

SD

T (df)

Study group (N=56)

1.26

.61

7.7 (64.2)**

Comparison group (N=12)

1.94

.11

Subjects with a guardian (N=14)

.79

.50

Subjects without a guardian (N=41)

1.4

.55

Subjects who voted independently before (N=35)

1.4

.61

Subjects who have not voted independently before (N=13)

.96

.54

-3.8 (53)** 2.3 (46)*

*p< .05; **p<.001. 1Possible Capacity To Vote assessment tool scores (analyzed as continuous measure) range from 0 to 12, with higher scores indicating better capacity to vote.

Table 4. Pearson’s correlations coefficients between the capacity to vote (CAT-V), clinical status (BPRS) and cognitive status (MMSE) (N=56) CAT-V

MMSE

BPRS

-.32*

-.04

MMSE

.54**

*p< .05; **p<.001

Table 5. Linear regression coefficients analysis predicting for the capacity to vote (CAT-V) B

β

t

SE

BPRS

-0.1

-.30**

-2.7

.005

MMSE

.08

.53**

4.8

.02

**p<.001; R2= .38, F (2,52) = 15.69, p< .001 Multicolinerarity was tested to control for extreme cases (tolerance> .10).

card, that person should then be considered competent to vote. “Someone in an active psychotic state is not likely to sit down and register to vote or to visit their local polling 173


Voting Rights for Psychiatric Patients

place” (23), thus patients in a severe psychotic state who do not have guardians are not likely to attempt to vote. Israel is one of the five countries that do not disenfranchise persons with mental health or intellectual disabilities (1). The amendment to the Israel Voting Law allows for mobile ballots in psychiatric hospitals. In this era of mental health reform and empowerment of psychiatric patients to promote rehabilitation, we sought to identify those patients who retained the capacity to understand the voting process. Though mental illness does not necessarily imply incompetence (10) and though some severely cognitively impaired persons still have the right to vote (13),we found a significant inverse correlation between severity of illness and capacity to vote. Contrary to Raad et al. (2), who did not find a significant correlation between CAT-V scores and cognition, we found a positive correlation between cognition and capacity to vote. In addition, patients with legal guardians performed worse than those without guardians The Council of Europe’s Commissioner for Human Rights (16) commented that “persons with disabilities must not be denied the right to vote,” and challenged the fact that persons under partial guardianship would be excluded from the right to vote in Hungary and consequently ruled that: Such prejudice may entail legislative stereotyping which prohibits the individualized evaluation of their capacities and needs. Based on our findings, we propose that it may be appropriate to perform individual assessments of competency only for those individuals who have legal guardians, in order to determine whether or not they understand the nature and effect of voting, and to identify patients who retained the capacity to vote. This suggestion is similar to that of Raad et al. (2) who recommended that the CAT-V be reserved as a screening instrument for individuals whose voting capacity is in question. This limited screening would not stigmatize the entire population of mentally ill individuals by disenfranchising the entire sector, and would promote representation of this minority in the elections. In addition, patients with legal guardians who in many countries are currently disenfranchised owing to their need for guardianship will have an opportunity to have their capacity to vote assessed. If found capable (score of 1.6 or higher on the CAT-V), though previously denied this basic civil right, they would be granted the right to vote. Thus, the integrity of the elections would be preserved by eliminating the risk of undue influence or manipulation of individuals who lack the capacity to understand the nature and meaning of voting, while preserving the right to vote for those with the capacity to do so, whether or not they have guardians. 174

Acknowledgement: The authors thank Adi Baum-Mizrachi and Dr. Karin Schlossberg for their assistance in data collection.

References 1. Blais A, Massicotte L, Yoshinaka A. Deciding who has the right to vote: Election laws in democracies. Elect Stud 2001;20:41-62. 2. Raad R, Karlawish J, Appelbaum PS. The capacity to vote of persons with serious mental illness. Psychiatr Serv 2009;60:624-628. 3. Doe v Rowe, 156 F Supp 2d 35 (D Me 2001). 4. Massicotte L. Who has the right to vote. In: Massicotte L, Blais A, Yoshinaka A, editors. Establishing the rule of the game: Election laws in democracies. Toronto: University of Toronto, 2004. 5. Prince MJ. The electoral participation of persons with special needs [Internet]. Chief Electoral Officer of Canada, 2007 [cited 2012 September 9]. Available at: http://elections.ca/res/rec/part/paper/special_needs/special_needs_e.pdf 6. National ethics committee of the veterans’ health administration. Ten myths about decision-making capacity. September 2002. A report by the national ethics committee of the veterans’ health administration. http://www.ethics. va.gov/docs/necrpts/nec_report_20020201_ten_myths_about_dmc.pdf 7. Hurme S, Appelbaum PS. Defining and assessing capacity to vote: The effect of mental impairment on the rights of voters. McGeorge Law Review 2007; 38: 931-979. 8. Dunn LB. Ethical issues in schizophrenia: Considerations for treatment and research. Psychopharmacol Bull 2007; 40: 145-155. 9. Jeste DV, Depp CA, Palmer BW. Magnitude of impairment in decisional capacity in people with schizophrenia compared to normal subjects: An overview. Schizophr Bull 2006;32:121-128. 10. Smoyak SA. Mental illness is not the same as incompetence: Voting rights, archaic laws & stigmatizing language. J Psychosoc Nurs Ment Health Serv 2007;45:8-9. 11. Appelbaum PS, Bonnie RJ, Karlawish JH. The capacity to vote of persons with Alzheimer’s disease. Am J Psychiatry 2005;162:2094-2100. 12. Karlawish JH, Bonnie R. Voting by elderly persons with cognitive impairment: Lessons from other democratic nations. McGeorge Law Rev 2007;38:880-916. 13. Bosquet A, Medjkane A, Voitel-Warneke D, Vinceneux P, Mahé I. The vote of acute medical inpatients: A prospective study. J Aging Health 2009;21: 699-712. 14. National Alliance on Mental Illness 2011. [Internet] [cited 2012 September 9]. Available at: http://www.nami.org/Template.cfm?Sec tion=Elections1&Template=/ContentManagement/ContentDisplay. cfm&ContentID=104206 15. Hammarberg T. Posted on March 22, 2011. Persons with disabilities must not be denied the right to vote. The Council of Europe commissioner’s Human Rights Comment.[Internet] [cited 2012, September 9] Available at: http://commissioner.cws.coe.int/tiki-view_blog_post.php?postId=127 16. Israel Ministry of Foreign Affairs. Elections in Israel March 2006. [Internet] [cited 2012 September 9]. Available at: http://www.mfa.gov.il/MFA/History/ Modern+History/Historic+Events/Elections+in+Israel+March+2006.htm 17. Melamed Y, Doron A, Finkel B, Kurs R, Behrbalk P, Noam S, Gelkopf M, Bleich A. Israeli psychiatric inpatients go to the polls. J Nerv Ment Dis 2007;195:705-708. 18. Nash M. Voting as a means of social inclusion for people with a mental illness. J Psychiatr Ment Health Nurs 2002;9:697-703. 19. Duckworth K, Kingsbury SJ, Kass N, Goisman R, Wellington C, Etheridge M. Voting behavior and attitudes of chronic mentally ill outpatients. Hosp Community Psychiatry 1994;45: 608-609. 20. Overall JE, Gorham DR. The brief psychiatric rating scale. Psychol Rep 1962;10:799-812. 21. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state.” A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-198. 22. Folstein MF, Robins LN, Helzer JE. The mini-mental state examination. Arch Gen Psychiatry 1983;40:812. 23. University of Arkansas release. December 3, 2003. Voting Laws Discriminate Against Mentally Disabled. [Internet] [cited 2012, September 9] Available at: http://mentalhealth.about.com/cs/legalissues/a/vote1000.htm


Isr J Psychiatry Relat Sci - Vol. 51 - No 3 (2014)

Shaul Lev-Ran et al.

Examining the Ethical Boundaries of Harm Reduction: From Addictions to General Psychiatry Shaul Lev-Ran, MD, 1,2 Uri Nitzan, MD,1 and Shmuel Fennig, MD1,2 1

Shalvata Mental Health Center, Hod Hasharon, Israel Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel

2

Abstract Harm reduction is a general term for pragmatic interventions aimed at reducing problematic behaviors. Emerging from addiction treatments, it is based on the understanding that people will continue to behave in ways that pose a risk to them and their communities, and that an important goal of any treatment program is to minimize the harm associated with these behaviors. Despite its evidencebased background, harm reduction is not readily applied in general psychiatry. This is mainly due to the complex ethical dilemmas arising within harm reduction practices, as well as a lack of scientific knowledge and theoretical frameworks essential for dealing with such ethical dilemmas. In this paper we introduce the fundamental theoretical and scientific base of harm reduction strategies, and present three clinical examples of the complex ethical dilemmas arising when working within a harm reduction practice. We finally present a theoretical framework for dealing with the ethical dilemmas and argue this may make harm reduction strategies more accessible in general psychiatry.

Introduction Harm reduction is an umbrella term for interventions aiming to reduce the problematic effects of behavior. It is both a philosophy as well as a practice, and has been called “compassionate pragmatism� (1) because it begins with the pragmatic acceptance that people are and will continue to behave in ways that pose threats to themselves and their communities. Its compassionate and understanding approach promotes collaboration between patients and therapists and enables effective Address for Correspondence:

interventions. Harm reduction has a human rights agenda in that it is committed to bringing effective treatment to marginalized groups that have traditionally been denied quality care. It is scientific in that it is committed to the discovery and implementation of evidence based interventions (2). Stemming from the field of illicit drug use in the 1980s (3), harm reduction currently accommodates a vast array of interventions. Perhaps the most well known of these are needle exchange programs, whose goal is to prevent HIV transmission and other blood borne infectious diseases, as well as overdose prevention, including naloxone distribution and opiate substitution treatment (methadone, buprenorphine). Other examples include prioritizing less risky drinking habits for underage drinkers to reduce the risk of alcohol poisoning, encouraging safe sex, and replacing binge eating with healthier alternatives. More extreme interventions would be for example providing clean razors for those engaged in self injurious behavior, or educating intravenous femoral vein injectors how to inject drugs to safer sites. Some harm reduction techniques have already become a norm (e.g., opiate substitution treatment), while others remain highly controversial (e.g., educating injecting users on how to properly inject drugs in order to minimize health consequences). In this paper we argue that harm reduction strategies are under-utilized in general psychiatry, mainly due to the complex ethical dilemmas these practices pose and a concern that such an approach may seem nihilistic. We describe the fundamentals of harm reduction and propose that pragmatic beneficence is at times more in-tune with medical ethical values than unattainable ideal beneficence. We shortly review the literature on the efficacy of harm reduction interventions introducing the reader to the scientific background. Finally, we present three clinical examples illustrating the challenging ethical dilemmas

Shaul Lev-Ran, MD, Shalvata Mental Health Center, POB 94, Hod Hasharon, 45100 Israel

  shauli.levran@gmail.com

175


Examining the Ethical Boundaries of Harm Reduction: From Addictions to General Psychiatry

when working within a harm reduction framework, and introduce a theoretical framework in which these can be effectively discussed. Ultimately, we wish to propose that though harm reduction has grown out of the field of addictions, a harm reduction standpoint should find its way to other branches of psychiatry in which current interventions are not effective enough. Principles of Harm Reduction Harm reduction attempts to “assess the actual harm associated with any [particular behavior] and then asks how these harmful effects may be minimized…within an amoral framework” (4). The key features of harm reduction include the understanding that the primary goal is reducing harm rather than problematic behavior per se; that problematic behaviors are a part of society and will never be eliminated; that priority is placed on immediate (and achievable) goals; and that harm reduction should provide a comprehensive public health framework (3, 5-7). Tatarsky and Marlatt (2) have further suggested these following principles of harm reduction that provide a clinical lens through which to see the patient, create the treatment relationship and guide the selection of interventions. Though these are originally aimed at addiction treatment, they have been adapted here to meet the needs of the general psychiatrist (using the term “problematic behaviors” to indicate behaviors such as non-adherence to medication, self-injury, binge eating, etc.). 1. Problematic behaviors are best understood and addressed in the context of the whole person in their social environment. 2. Meet the patient as an individual. 3. The patient has strengths that can be supported. 4. Challenge stigmatization. 5. Problematic behaviors are used for adaptive reasons. 6. Problematic behaviors use falls on a continuum of harmful consequences. 7. Do not hold any other preconceived notions as a precondition of the therapy before really getting to know the individual. 8. Engagement in treatment is the primary goal. 9. Start where the patient is. 10. Look for and mobilize the patient’s strength in service of change. 11. Develop a collaborative, empowering relationship with the patient. 12. Goals and strategies emerge from the therapeutic process. 176

At its core, harm reduction supports any steps in the right direction. It is realistic in that it realizes that ultimate goals may not be attainable, particularly in the short term. Critics may contend that harm reduction somehow enables or excuses poor choices. Although abstinence may be the ultimate goal in addictions treatment, and is of course the only way to avoid all negative consequences associated with substance use, the harm reduction practitioner seeks to meet with the patient where he or she is in regards to motivation and the ability to change. Similarly, though full adherence with medication may be the ultimate goal in treatment of severe psychiatric disorders, in the face of non-adherence harm reduction strategies may openly focus on alternative ways of minimizing risks (reducing substance use, managing psychosocial stressors, etc.). Within a harm reduction framework, the practitioner’s goals are secondary to what the patient wants. This does not imply that the practitioner has no opinion; rather, the practitioner respects the patient’s decisions both for and against change. As this is not merely a philosophical standpoint but rather one with practical clinical implications, we present below examples of treatment interventions in which these principles have been implemented effectively. Review of the Efficacy of Harm Reduction Strategies Harm reduction techniques range from prevention to intervention and maintenance (8). Here, we shortly present examples of the effectiveness of harm reduction in treating alcohol and substance abuse in a myriad of settings and with a multitude of patient populations. This will also demonstrate the spectrum of settings in which harm reduction is used, and the ethical dilemmas involved in some of these practices. Prevention: Clearly, the most effective way to reduce harm associated with drug use is to prevent initiation and misuse in the first place. As some abstinence-based programs have produced either no effects or potentially harmful effects (9), other programs focus on social skills training, resistance skills and normative education. Two school-based programs with explicit harm reduction goals have resulted in significant reduction in harmful alcohol use – the Integrated School and CommunityBased demonstration Intervention Addressing Drug Use among Adolescents (10) and School Health and Alcohol Harm Reduction Program (11). This last program included interactive interventions for 13-14 year


Shaul Lev-Ran et al.

old students, focusing on discussions based on scenarios suggested by students, with an emphasis on identifying alcohol-related harm and strategies to reduce harm, as opposed to formal alcohol-education sessions stressing the need for abstinence. Intervention: Substance abuse has been shown to be very prevalent among individuals with severe psychiatric disorders (12). Many practitioners and programs require that these individuals abstain from substances before receiving full treatment or before being accepted into residential programs. The example of the rehabilitation basket for psychiatric patients in Israel today is an unfortunate example of this, leaving thousands of patients suffering from concurrent psychiatric and substance use disorders without proper treatment programs. Harm reduction recognizes that although abstinence may reduce some of the harms executed by the individual, often these diagnoses are intertwined (13). Several harm reduction treatments have been shown effective for treating dual diagnosis patients. These include Seeking Safety (14, 15) which was effective in reducing substance use and symptoms of posttraumatic stress disorder and in improving family and social functioning, and Mindfulness-based relapse prevention (16) which has been successful in decreasing substance use and related problems in patients with dual diagnoses. Though most treatment programs for homeless alcoholics require maintenance of abstinence and require eviction from residential homes in case of relapse (17), harm reduction protocols seek to offer housing and services without contingencies. The Housing First study found that individuals in housing (without any preliminary contingencies) reported not only less drinking and less intoxication, but also saved money in terms of medical and social service expenses (18). Both nicotine substitution and opioid substitution are examples of harm reduction strategies that have been normalized. These therapies were identified to provide a less harmful substance (nicotine replacement or methadone/buprenorphine) and dozens of trials have shown their effectiveness across an array of outcomes, including reducing substance use and associated health risks (19, 20). These are, to date, perhaps the best examples of effective harm reduction treatments that have been incorporated into most health care systems in the world. Maintanence: Needle exchange programs were developed to reduce the spread of blood-borne disease (HIV and hepatitis) among injection drug users. These programs have been shown to be effective, safe and

cost-effective in many countries worldwide (21) with no evidence of deleterious effects (22). There are currently several governments that provide safe injection sites as well as needle exchange (8). In these sites drug users can inject their own drugs using clean equipment in the presence of medically trained personnel. Studies have shown a significant reduction of needle sharing, overdoses, and increase enrollment in detoxification and other treatment programs (23, 24). Clinical Example – Harm Reduction in Groin Injecting In order to demonstrate the ethical dilemmas arising when working within a harm reduction framework, we will illustrate the case of groin injection among drug users. Groin (or femoral) injecting is an often dangerous practice reported by up to 50% of injecting drug users (25). Complications of groin injection include deep vein thrombosis, accidental arterial injection, venous ulceration and local infections, all which can have serious health consequences. There is little margin for error while injecting into the femoral vein, especially since this practice may be attempted while intoxicated. In the U.K., it has been proposed that groin injection has moved from being a “risk boundary” to being an “acceptable risk” (26). This conclusion is supported by research findings that novice and early career injectors sometimes use the groin as their primary injecting site (27). One of the active provisions attempting to minimize harmful consequences of groin injection is assisting groin injectors to find other viable injecting sites within an appropriate environmental context. Practically, this means teaching drug-injectors how to inject into alternative veins within a medical setting. Though this practice can be seen as serving the principle values of autonomy (the patient’s autonomy is preserved because he is the one making the decision as to where he wishes to inject), beneficence and non-maleficence (the patient is being asked to engage in achievable behavior change within a safe context which minimizes immediate health risks), it clearly raises concerns regarding the physician’s active role in prescribing injection sites. Clinical Example – Harm Reduction in Hypersexual Behavior As previously proposed, harm reduction principles can and should be readily integrated into the work of the 177


Examining the Ethical Boundaries of Harm Reduction: From Addictions to General Psychiatry

general psychiatrist. Examples of situations in which harm reduction can be utilized include educating schizophrenia patients who announce they are planning to discontinue medications on how to taper off antipsychotic medications gradually or accepting drug-using psychiatric patients to residential programs without preliminary demands. We postulate that due to a lack of knowledge of the philosophy and practice of harm reduction, as well as concerns regarding professional and organizational norms, these practices are under-utilized. Regardless, ethical dilemmas will inevitably arise. We hereby present an example of supplying condoms to individuals with bipolar disorder and hypersexuality during a manic or hypomanic episode. One of the significant behavioral manifestations of manic and hypomanic states is an excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person engages in unrestrained sexual behaviors) (28). This lack of planning in sexual behavior can have catastrophic implications, jeopardizing the physical as well as mental health of the patient. In the case of impulsive sexual behavior, this may result in sexually transmitted diseases, unwanted pregnancies, and more (29). Moreover, there are issues of teratogenecity in women taking mood stabilizers if they were to become pregnant while taking lithium, carabamazepine or valproate (30). Though clearly the first line of clinical attention should be given to stabilizing the patient using conventional pharmacological measures and providing an adequate safe environment, many times patients in these situations have a lack of insight into their situation (31) and refuse pharmacological treatment or hospitalization. In these cases, particularly when patients in manic or hypomanic states do not fulfill criteria for being admitted against their consent, active provision of condoms may minimize some of the harmful consequences of the hypersexual state common in bipolar patients. Clinical Example – Harm Reduction in Self-cutting One of the most controversial practices proposed in harm reduction today is the supply of sterile razors to patients engaged in self-cutting – a practice coined “safe selfharm.” Though self-mutilating behavior has been found to be relatively rare in the general population (affecting 4% of the general population in the past six months), it has been found to affect 21% of clinical populations, with 178

self-cutting (of arms and legs) being the most common form (32). Dangers of self-cutting with non-sterile objects (e.g., metal, glass, etc.) include wound site infection and consequent health risks. More than 25% of psychiatrically hospitalized adolescents reported sharing cutting implements with other adolescents (33). This raises the risk for transmission of HIV and hepatitis. These risks can be reduced by providing clean razors to patients unable to resist the urge for self-cutting. Despite similarities to needle exchange program for drug injecting patients (in which sharp metal objects intended for harmful behavior are readily handed out), providing clean razors to patients is a much less acceptable practice. Though we could not find current literature as to the prevalence of programs handing out clean razors, we hypothesize that this is a rare practice. We do not pretend to propose a solution here to dealing with groin-injecting, hypersexual behavior or selfinjurious behavior, but rather argue for considering harm reduction strategies with a structured ethical framework. We therefore approach these challenging dilemmas with the decision-making framework below. Ethical Framework for Decision Making Sadly, there is little dialogue on key ethical issues in clinical practice (34), and many therapists are left struggling with the ethical boundaries of harm reduction (35). Typically in applied ethics, practitioners are guided to use their moral intuitions to determine which of the principles of autonomy, beneficence, non-maleficence and justice are most important given the particular facts of the situation. In complex cases, depending on moral intuitions is highly difficult and problematic. It is therefore helpful to be familiar with the philosophical theories from which the above-mentioned principles have been abstracted, as well as to work within a framework in which decision making may be facilitated. The ethical dilemmas surrounding harm reduction may be traced back to the conflicts between deontological (duty-driven) and utilitarian (consequence-driven) philosophies. Deontological ethics is derived from the philosophy of Immanuel Kant. According to Kant’s deontology, the moral quality of an action depends on the Categorical Imperative test – whether the principle can be universalized without contradiction. In deontological ethics, the concept of fulfilling a role and obligation are fundamental and an emphasis is put on personal choice and autonomy. Consequences are irrelevant when considering the moral


Shaul Lev-Ran et al.

quality of an action. As a physician, moral justification of an act must be based on adhering to the basic obligation of “do no harm.” Any kind of harm, according to a strictly deontological outlook, assisted by a physician, is not moral as it contradicts the physician’s basic obligations. Whether the harm caused is less than that which may have been caused without the physician’s intervention remains irrelevant according to this school of thought. The harm reduction approach cannot therefore be easily justified on a Kantian/deontological model, as its “raison d’être” is ultimately to avoid negative consequences. The principles of beneficence and maleficence derive from utilitarianism and the philosophy of John Stuart Mill. According to utilitarian ethics, an action is moral if it tends to promote the greatest benefit for the greatest number of people. This is essentially a consequence-based approach: only after considering the current policy environment and the scientific evidence for each approach can we decide whether it is morally appropriate. As it has been shown above that harm reduction policies have been shown to be effective in various fields and help avoiding many negative consequences, this approach is clearly in line with utilitarian ethics. As in many ethical dilemmas, situations in which harm reduction may be applicable include conflicts between different ethical principles, or moreover between ethical philosophies. This well-known tension between deontological and utilitarian ethical outlooks is at the base of many ethical dilemmas in medicine, including that of the justification of harm reduction. It has been proposed that an alternative to this narrow deontologicalutilitarian dichotomy is the school of virtue ethics, most commonly associated with Aristotle (36). Virtue ethics do not focus on isolated acts but rather on the character of the agent (i.e., compassion, honesty, kindness, etc.). The highly regarded character traits are those well-balanced between the extremes. Moreover Aristotle views morality as depending on contextual factors; it is necessary to do the right thing, in the right way, to the right person. Virtue ethics thus takes into account context and consequences, without reducing ethics into a simple matter of promoting pleasure, reducing pain or doing one’s duty. In the case of harm reduction, it is proposed that the necessary character trait for policy makers and practitioners is that of compassion, which should be balanced between aiding a particular act as opposed to encouraging it (36). This form of virtue-based morality can provide an ethical foundation for some harm reduction policies without resorting to utilitarianism.

Regardless, dealing with the ethical and moral aspects of harm reduction is challenging and requires a structural framework. Though several frameworks have been proposed, in the following examples we will use the model proposed by White and Popovits (34). This model of ethical decision making comprised of a series of related questions, ensuring ethical issues are addressed adequately. Their model of ethical decisionmaking consists of three related questions: 1. Whose interests are involved and who can be harmed? 2. What universal or cultural specific values apply to this situation and what course of action would be suggested by these values? Which of these values are in conflict in the situation? 3. What standards of law, professional propriety, organizational policy or historical practice apply to this situation? When addressing challenging ethical dilemmas like those described above, this framework facilitates a structured process which is critical if the complexity of the dilemmas are taken into account. The first principle highlights the fact that even in situations in which there is no apparent contradiction between values of autonomy, beneficence and non-maleficence for the patient, there are other individuals to be taken into account. In both cases described, although harm reduction practices (educating drug injectors about viable sites of injection and providing clean razors to self-cutters) support the patients’ autonomy to decide on their own behavior, have clear short-term benefits (reducing rates of infection) and adhere to principles of non-maleficence, other parties must be taken into account as well. The additional parties involved in these cases would include workers within the service providing the education (doctors, nurses, social workers), professional bodies (including associations, which have professional codes of conduct and standard), service commissioners (such as government health departments who focus on effectiveness and cost) and the local community. It is therefore important to note all of these, as ethical values can compete not only in the individual but among the different parties involved as well. As such, a beneficial act for one party may be experienced as maleficent for another. For example, supplying clean razors to self-cutters may benefit the patient (or, at least, this can be argued for), but at the same time compromise the professional integrity of the psychiatrist prescribing this practice, giving rise to competing ethical values between individuals – the patient and the doctor. 179


Examining the Ethical Boundaries of Harm Reduction: From Addictions to General Psychiatry

The second point emphasizes that alongside the wellknown universal values of autonomy, beneficence, nonmaleficence and justice, there are cultural values that must be considered as well. For example, this might suggest that though providing education regarding safe injection sites respects the patient’s autonomy and has short-term beneficence, it conveys the idea that drug injection in general is acceptable in the society, which can be at odds with fundamental cultural values. It is therefore important to recognize not only the core biomedical values but the cultural norms and values as well. The third point that White and Popovits emphasize is the very important and often overlooked influence that standards of law, professional propriety, etc., apply to the decision-making process and must be taken into account. In many cases, it may be these considerations, rather than competing values of autonomy, beneficence and non-maleficence, which determine the final course of action. It is therefore important to identify these considerations and openly recognize their importance. This means openly recognizing that one of the main factors taken into consideration when discussing the possible practice of educating drug injectors about safer sites of injection or handing out clean razors to self-cutters are those of professional propriety and potential malpractice. For example, can a psychiatrist be charged with malpractice if a self-cutting patient suffers severe injuries while using a razor prescribed by the psychiatrist? Adopting this question into ethical discussions allows raising the issue of what is achievable in the real world of clinical practice. Clinics operate on protocols that are “best fit” for the majority. This reinforces the need for simplicity and transparency in final guidelines, so that both staff and service users receive and acknowledge equitable treatment. Summary Balancing competing ethical principles is a challenging task for clinicians. Harm reduction is an effective humanistic and pragmatic approach attempting to address this challenge. Though some harm reduction practices have become the norm, others are controversial, and challenge us regarding the ethical boundaries of the approach. Naturally, harm reduction focuses on health and social issues around which there is often community misunderstanding, stigma and fear. Successful treatments in these areas depend on novel methods and interventions which may often push the limits of knowledge and 180

accepted moral standards. Recognizing the theoretical and scientific background of harm reduction and using a structured ethical decision-making framework can assist the clinician when dealing with these complex ethical dilemmas. This may allow for using harm reduction strategies in general psychiatry in complex clinical situations where more efficient interventions are currently lacking. References 1. Marlatt G. Harm reduction: Pragmatic strategies for managing high-risk behaviors. New York, NY: Guilford, 1998. 2. Tatarsky A, Marlatt GA. State of the art in harm reduction psychotherapy: An emerging treatment for substance misuse. J Clin Psychol 2010;66:117122. 3. Riley D, O’Hare P. Harm reduction: History, definition and practice. In: Inciardi JA, Harrison LD, editors. Harm reduction: National and international perspectives. Thousand Oaks, Cal.: Sage, 2000. 4. Rumbold G, Hamilton M. Addressing drug problems: The case for harm minimization. In: Hamilton M, Kellehear A, Rumbold G, editors. Drugs in Australia: A harm minimization approach. Singapore: Oxford University, 1998. 5. Single E. Defining harm reduction. Drug Alcohol Rev 1995;14:287-290. 6. Lenton S, Single E. The definition of harm reduction. Drug Alcohol Rev 1998;17: 213-219. 7. Heather N. Groundwork for a research programme on harm reduction in alcohol and drug treatment. Drug Alcohol Rev 1995;14:331-336. 8. Logan DE, Marlatt GA. Harm reduction therapy: A practice-friendly review of research. J Clin Psychol 2010;66:201-214. 9. Lynam DR, Milich R, Zimmerman R, Novak SP, Logan TK, Martin C, Leukefeld C, Clayton R. Project DARE: No effects at 10-year follow-up. J Consult Clin Psychol 1999;67:590-593. 10. Poulin C, Nicholson J. Should harm minimization as an approach to substance use be embraced by junior and senior high schools? Empirical evidence from an integrated school- and community-based demonstration intervention addressing drug use among adolescents. Int J Drug Policy 2005;16:403-414. 11. McBride N, Farringdon F, Midford R, Meuleners L, Phillips M. Harm minimization in school drug education: Final results of the School Health and Alcohol Harm Reduction Project (SHAHRP). Addiction 2004;99:278-291. 12. Drake RE, Wallach MA, McGovern MP. Future directions in preventing relapse to substance abuse among clients with severe mental illnesses. Psychiatr Serv 2005;56:1297-1302. 13. Dennig P. Practicing harm reduction psychotherapy: An alternative approach to the addictions. New York: Guilford, 2000. 14. Najavits LM. Clinicians’ views on treating posttraumatic stress disorder and substance use disorder. J Subst Abuse Treat 2002;22:79-85. 15. Najavits LM, Schmitz M, Gotthardt S, Weiss RD. Seeking Safety plus Exposure Therapy: An outcome study on dual diagnosis men. J Psychoactive Drugs 2005 ;37:425-435. 16. 16. Bowen S, Chawla N, Marlatt G. Mindfulness based relapse prevention. New York: Guilford, 2008. 17. Tsemberis S, Gulcur L, Nakae M. Housing First, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. Am J Public Health 2004;94:651-656. 18. Larimer ME, Malone DK, Garner MD, Atkins DC, Burlingham B, Lonczak HS, Tanzer K, Ginzler J, Clifasefi SL, Hobson WG, Marlatt GA. Health care and public service use and costs before and after provision of housing for chronically homeless persons with severe alcohol problems. JAMA 2009;301:1349-1357.


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19. Connock M, Juarez-Garcia A, Jowett S, Frew E, Liu Z, Taylor R, et al. Methadone and buprenorphine for the management of opioid dependence: A systematic review and economic evaluation. Health Technol Assess 2007;11:1-171. 20. Sweeney CT, Fant RV, Fagerstrom KO, McGovern JF, Henningfield JE. Combination nicotine replacement therapy for smoking cessation: Rationale, efficacy and tolerability. CNS Drugs 2001;15:453-467. 21. Wodak A, Cooney A. Do needle syringe programs reduce HIV infection among injecting drug users: A comprehensive review of the international evidence. Subst Use Misuse 2006;41:777-813. 22. Strathdee S, Vlahov D. The effectiveness of needle exchange programs. A review of the science and policy. AIDScience 2001;1:1-31. 23. Strathdee SA, Pollini RA. A 21st-century Lazarus: The role of safer injection sites in harm reduction and recovery. Addiction 2007;102:848-849. 24. Wood E, Tyndall MW, Zhang R, Montaner JS, Kerr T. Rate of detoxification service use and its impact among a cohort of supervised injecting facility users. Addiction 2007;102:916-919. 25. Miller PG, Lintzeris N, Forzisi L. Is groin injecting an ethical boundary for harm reduction? Int J Drug Policy 2008;19:486-491. 26. Rhodes T, Stoneman A, Hope V, Hunt N, Martin A, Judd A. Groin injecting in the context of crack cocaine and homelessness: From ‘risk boundary’ to ‘acceptable risk’? Int J Drug Policy 2006;17:164-170. 27. Maliphant J, Scott J. Use of the femoral vein (‘groin injecting’) by a sample of needle exchange clients in Bristol, UK. Harm Reduct J 2005;15:2-6. 28. American Psychiatric Association. Diagnostic and Statistical Manual

of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association, 2000. 29. Coverdale JH, Turbott SH, Roberts H. Family planning needs and STD risk behaviours of female psychiatric out-patients. Br J Psychiatry 1997;171:69-72. 30. Cohen LS. Treatment of bipolar disorder during pregnancy. J Clin Psychiatry 2007;68 Suppl 9:4-9. 31. Ghaemi SN, Stoll AL, Pope HG, Jr. Lack of insight in bipolar disorder. The acute manic episode. J Nerv Ment Dis 1995;183:464-467. 32. Briere J, Gil E. Self-mutilation in clinical and general population samples: Prevalence, correlates, and functions. Am J Orthopsychiatry 1998;68:609-620. 33. DiClemente RJ, Ponton LE, Hartley D. Prevalence and correlates of cutting behavior: Risk for HIV transmission. J Am Acad Child Adolesc Psychiatry 1991;30:735-739. 34. White W, Popovits R. Critical incidents: Ethical issues in the prevention and treatment of addiction (2nd ed.). Bloomington, Ill.: Chestnut Health Systems, 2001. 35. Solai S, Dubois-Arber F, Benninghoff F, Benaroyo L. Ethical reflections emerging during the activity of a low threshold facility with supervised drug consumption room in Geneva, Switzerland. Int J Drug Policy 2006;17:17-22. 36. Christie T, Groarke L, Sweet W. Virtue ethics as an alternative to deontological and consequential reasoning in the harm reduction debate. Int J Drug Policy 2008;19:52-58.

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Isr J Psychiatry Relat Sci - Vol. 51 - No 3 (2014)

Using Placebo Medications in the Clinical Setting – An Intellectual Game or a Possible Reality? Uri Nitzan, MD,1,2 Yuval Bloch, MD,1,2 and Shmuel Fennig, MD1,2 1

Shalvata Mental Health Care Center, Hod Hasharon, Israel Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel.

2

Abstract Prior to the development of the pharmaceutical industry and the advocacy of evidence based medicine in the late 20th century, placebo treatments were commonly used by physicians. In current clinical practice, neither a physician’s confidence in the efficacy of a specific treatment nor his personal ethical norms are any longer sufficient to initiate a given therapy. We will discuss whether placebo treatments can be ethically used in clinical practice as an alternative to standard therapy, and propose an innovative conceptualization of the factors involved in the exclusion of placebo treatments from the clinical setting. Patient-related ethical and interpersonal arguments and physician-related legal and ideological arguments concerning placebo usage are presented. We describe current use of placebo treatments in the healthcare system and suggest that placebo therapy thrives and that its therapeutic efficacy is widely acknowledged. There is currently “underground” use of placebo medication, open label placebo trials, and innovative approaches to informed consent to facilitate ethical prescription of placebo therapy. Finally, using the specific example of treatment for depression, we demonstrate how the arguments against placebo use might be undermined, to retrieve the legitimacy of placebo therapy.

Introduction Since ancient times, physicians have commonly used non-specific placebo treatments. An early example is the story of the Nehushtan in the Book of Numbers [21:8]; Address for Correspondence:

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“And the Lord said unto Moses, Make thee a fiery serpent, and set it upon a pole: and it shall come to pass, that every one that is bitten, when he looketh upon it, shall live.” Subsequently, and until the 20th century, placebo continued to be an essential component in the treatment of patients. In 1807 Thomas Jefferson wrote in a letter to Dr. Casper Wistar: “One of the most successful physicians I have ever known, has assured me, that he used more bread pills, drops of colored water, and powders of hickory ashes, than of all other medicines put together. It was certainly a pious fraud” (1). The first clinical trial using a placebo arm took place in 1931 (2). Since then, and following the development of effective and specific interventions, and the intensifying implementation of the principle of informed consent, placebo usage was gradually eliminated from the clinical setting. Nonetheless, in many randomized controlled trials a placebo arm is still considered the gold standard control method. An active control arm is another option, depending on the efficacy of standard treatment. Nussinovitch et al. (3) discuss in detail the ethical dilemma involved, and the essential question is: are we allowed to administer an inert pill to a sick patient when an efficient and approved drug already exists? Substantial literature addresses this dilemma. Emanuel and Miller (2) delineate strict guidelines for the use of placebos in clinical trials in their seminal paper in the New England Journal of Medicine. Additional guidelines were published by the European Agency for the Evaluation of Medicinal Products, as part of the International Ethical Guidelines for Biomedical Research involving Human Subjects, and a position paper regarding the matter was also published by the Israel Medical Association in 2004 (3). Discussing the interesting and complex role of placebo in clinical trial deserves a separate paper and is beyond the scope of the present manuscript. In a sense, medical science defines evidence-based efficacy of drugs by “excluding the placebo effect.” However,

Uri Nitzan, MD, 15 Hatet-Zain St., Ramat Hachayal, Tel Aviv 69276, Israel.

urini@clalit.org.il


Uri Nitzan et al.

the question remains whether or not a valuable tool is lost to clinical practice when this exclusion is endorsed. Placebo treatments are defined as “a treatment whose benefits (in the opinion of the clinician) derive from positive patient expectations and not from the physiological mechanism of the treatment itself ” (4). It should be emphasized that the placebo effect is routinely used by physicians in the clinical setting. This is accomplished with the physician’s verbal suggestions, the patient’s faith in the treatment, professional confidence, or the physician’s white robe (5). In this paper we focus on placebo treatments (sugar pills, sham procedures, etc.) their potential use and relevancy to clinical practice. The efficacy of placebo therapy has been asserted in various fields of medicine, including cardiology (6), surgery (7), neurology (8), and urology (9). In psychiatry the efficacy of placebo is known to be particularly significant, specifically in depression, schizophrenia, and anxiety disorders (10). Thus, clinical science employs placebo medications (inert pills) because its high efficacy was demonstrated in clinical trials to an extent that could not be ignored. Nonetheless, the same placebo pills that are routinely used in clinical trials are strictly prohibited in the clinical setting. We address the following questions: 1) Should placebo medications be used in clinical practice? 2) Under what circumstances can we ethically offer placebo medications as an alternative to a standard, proven therapy? We first present the arguments against use of placebos. Notwithstanding, we then describe current applications of placebo therapy in the clinical setting. Finally, we use the treatment of depression as a platform to discuss the legitimacy of placebo usage in the clinical setting. Exclusion of Placebo Treatments There are various arguments for opposing the use of placebo therapies in the clinical setting. We offer a novel conceptualization by dividing the arguments into four domains: 1. Patient-related ethical argument 2. Patient-related interpersonal argument 3. Physician-related ideological argument 4. Physician-related legal argument Patient–related ethical argument First and foremost, it is considered unethical and unwise to prescribe non-specific placebo treatments when a specific approved and efficient treatment is available. In addition, effective prescription of placebo calls for total ignorance

on the part of the patient regarding the true mechanism of action of the treatment. The physician in effect deceives the patient by violating the principle of full informed consent for treatment (11). This deception is necessary because an essential element in the efficacy of placebo is expectation. The patient’s expectation of an approved and efficient drug is in itself a component of the healing process. Part of the physician’s task is to provide information regarding the drug in a suggestive manner in order to convince the patient that he is being offered a specific, efficient, and approved treatment. This is not possible when administering placebo therapy. An additional ethical dilemma encountered in placebo treatment is potential decline in the patient’s sense of autonomy. The patient’s right to choose a treatment is somewhat nullified, because if he is not fully aware of the nature of his options (12) or of the existence of additional specific and helpful treatments, he cannot make an informed decision. Patient-related interpersonal argument Prescription of placebo therapy can potentially threaten trust and negatively affect the doctor-patient relationship. Placebo usage “contravenes the pact of confidentiality in the doctor-patient relationship, which is the nucleus of the therapeutic dialogue” (13). This dialogue is crucial to the ongoing compliance of many patients and harming it might have long lasting effects on the patients’ health. In a recent survey Fassler et al. (14) found that 70% of patients wanted to be explicitly informed when receiving a nonspecific intervention in the clinical setting, and 50% stated that they would be disappointed with their physician if they learned that they had been treated with pure placebo. Interestingly, a recent study demonstrated that in randomized controlled trials the specific components of placebos (sugar, vitamin, etc.) were seldom described to the subjects (15). This might have spared the investigators a negative effect on subjects’ attitudes and cooperation if the composition of the placebos had been brought to their knowledge. Possibly, the simple fact that a physician/ investigator prescribes an inert substance might threaten the trust of patients/subjects. Physician-related ideological argument

Thomas suggests that physicians prefer to perceive themselves as caregivers that implement progress and are part of the scientific project (16). They are educated along the lines of evidence-based medicine and are

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Using Placebo Medications in the Clinical Setting – An Intellectual Game or a Possible Reality?

expected to treat patients accordingly. The scientific stance is expressed in relation to patients, as well as colleagues, as it is an important element in the physician’s professional image and reputation. The modern physician believes in science, identifies with its values, and tends to renounce nonspecific treatments. In fact, prescribing placebo can be perceived as an irrational, nonprofessional therapy, identified more with alternative medicine then with medical science. Physician-related legal argument According to the Declaration of Helsinki (1964) every subject in a clinical trial should be treated with the most efficient treatment methods available (13). This is true in research, and more so in the clinical setting. The Israel Medical Association Code of Ethics addresses the use of placebo in clinical trials, but does not refer to placebo use in the clinical setting, probably because of the obvious exclusion of placebo treatments in clinical practice (3). In the Israeli “Patients Rights Law” (1996) it is clearly stated in clause 5, “A patient shall be entitled to proper medical care, having regard both to its professionalism and quality, and to the personal relations incorporated in it.” Accordingly, the physician is obliged to provide the patient with the most efficacious treatment available. The prescription of placebo might contradict this legal obligation when an effective and specific treatment is already available. Furthermore, clause 13 requires the physician to provide the patient with full information regarding his treatment, including the essence, procedure, aims, and expected benefits and limitations of the treatment. Thus, the “pious fraud” of prescribing placebo treatments might turn out to be a violation of the Israeli law (17). Latent Presence of Placebo Treatments Placebo therapy is not acceptable in the clinical setting due to the arguments described above. Nonetheless, accumulating data regarding placebo “abuse” by medical staff members in clinical practice and ongoing attempts to authorize placebo therapy is reflected by: 1. Underground usage of placebo 2. Open label trials 3. Tailored informed consent procedures Underground usage of placebo Thirty years ago the use of inactive substances to induce placebo effects was still commonplace in the clinical set184

ting. Senior medical staff members can openly testify to the extensive use of placebo in the treatment of psychiatric patients. Nitzan and Lichtenberg have found that underground usage of placebo therapy is still quite common (18). Among Israeli physicians and nurses 60% reported using placebo pills and procedures; the majority of them (62%) as often as at least once a month. The circumstances in which placebo treatments were routinely used included: unjustified demand for medication, as an analgesic, a diagnostic tool, to calm a patient, for non-specific complaints, or to gain time until the next regular dosage of medication was scheduled. Similar findings were later published in Europe (19), where 90% (n=270) of general practitioners admitted to actively propose treatments with non-specific effects. In a survey among 1,200 internists and rheumatologists in the U.S., about 50% reported prescribing placebo treatments on a regular basis, most of them believing it to be ethically permissible (4). Only 2-3% percent reported using pure placebo (sugar pills, saline), while 38-41% reported using active placebos (over the counter analgesics, vitamins). Physicians who reported using placebo treatments usually described them to the patient as “a medicine not typically used for your condition but might benefit you,” or as “a medicine with no known effects for your condition.” In another study 231 (45%) interns reported using placebo treatments; most commonly to calm patients or as a supplemental treatment (20). Interestingly, it was a Canadian survey revealed that most psychiatrists agree with the therapeutic effects of placebos and seem to administer significantly more placebo medications compared with non-psychiatrists. Open label trials Placebo treatments administered in open label trials have demonstrated therapeutic value in treating psychiatric patients (21, 22). Importantly, in this scenario full informed consent can be obtained and the physician continues to foster patient trust. Recently, Kaptchuk et al. (23) reported that in a two group (placebo pills vs no treatment), open label, randomized controlled trial, placebo pills administered without deception demonstrated efficacy in treating IBS (irritable bowel syndrome). In another open label prospective study placebo pills were found to be efficacious in the short-term treatment of some children with ADHD (24). ADHD behavior remained the same when stimulant medication dose was reduced, while remaining under treatment with placebo pills, but to deteriorate when


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reduced without placebo treatment. It seems that some patients are willing to use open-label placebo, and that there is growing evidence concerning the efficacy of this type of treatment in various pathological conditions. Tailored informed consent procedures The ethical problem with placebo is not that the patient is receiving an ineffective treatment, but rather that the doctor is deceiving the patient, concealing information and violating the principle of informed consent. Some caregivers have attempted to bypass this ethical conundrum with unique creative thinking concerning the concept of informed consent. Kihlbom (25) developed the construct of Negative Informed Consent, suggesting that “it is possible to exercise your autonomy without having the amount of and the kind of information that are assumed in the standard requirement of informed consent to medical treatment.” Kihlbom suggests that “if I, as a patient, choose to let you, as the physician, determine my treatment, and I have well founded beliefs that you will choose the treatment that best promote my values, and that the risks of the treatment you will choose is in accordance with my attitudes towards different kinds of risks, I will exercise my autonomy, not waive my right to exercise it… the norm of informed consent to medical treatments ought to be relaxed in contexts where substantive patient-doctor relationships of confidence or trust are established.” Shaw further suggested that using negative informed consent, “where a patient abdicates access to information to some extent,” facilitates perfect conditions for ethical use of placebos (26). According to Shaw the first step in offering effective placebo treatment would be to inform the patient that he is being offered a pill that “will hopefully make him better.” In case the patient asks for more information Lichtenberg and colleagues suggested alternative phrasing: “I would like to offer you a pill which I believe can help lessen your suffering. I do not know exactly how it works. I have other pills to offer whose mechanism is clearer, but I am not sure that they will work better for you, and they may also entail more serious side effects” (12). If asked about side-effects or the specific mechanism of action the physician can add that “this pill has few side-effects, but studies have shown that the more I tell you about how it works, the less effective it will be.” When specifically discussing placebo treatment for mild to moderate depression the physician can honestly inform the patient that the placebo treatment might be useful and that it possibly acts via its influence on specific neural circuits in the brain (27).

Lichtenberg et al. also developed guidelines that delineate the conditions under which placebo usage might be appropriate in the clinical setting (12). Placebo Treatments and Depression – A Prism to the Possible Future Use of Placebos Using the example of SSRI vs placebo pills for depression, we challenge the arguments against placebo therapy. We focus on the ethical and interpersonal patient-related arguments, and attempt to undermine them on the basis of current evidence based medicine. We briefly address physician-related arguments, however a sociological and cultural discussion is beyond the scope of this paper Depression is one of the most common debilitating psychiatric disorders (28). Some recent meta-analyses have clearly indicated that antidepressant’s (AD) have a minor advantage over placebos (29-32), or no advantage at all in treating mild to moderate depression (33). Kirsch et al. (33) used the Freedom of Information Act to obtain data from the U.S. Food and Drug Administration (FDA) instead of the published scientific literature. They based their meta-analysis on reviews of all placebo-controlled clinical trials, positive or negative, submitted by pharmaceutical companies for the approval of the six most widely used ADs. Most of the trials had negative results, and placebos were found to be 82% as effective as the AD. The efficacy of AD becomes more significant as the severity of the depression rises, and this can be attributed to one of the following: 1) the advantage of AD over placebo in treating severe depression, 2) weakening of the placebo response in severely depressed patients, 3) the high doses required to treat severely depressed patients. High doses of AD result in multiple side-effects that can “break the blind,” and strengthen the placebo effect in subjects receiving an active substance. Turner et al. also demonstrated that published data of antidepressant clinical trials is highly selective, with a bias towards publications of positive results (34). Another metaanalysis, that reviewed the published and unpublished data on the antidepressant reboxetine, found that 74% of the data on patients who participated in the trials was not published because the findings were negative (35). In any event, most caregivers would agree that placebo treatments can be useful in treating mild to moderate depression. Thus, the availability of approved and efficient antidepressants does not unequivocally exclude the usage of placebo from the ethical point of view. Moreover, in addition to its efficacy, placebo treatment has less side 185


Using Placebo Medications in the Clinical Setting – An Intellectual Game or a Possible Reality?

effects (36), and is less expensive for the patient. Using placebo therapy in clinical care apparently respects the principles of beneficence and non-malfeasance (13). Thus, it seems that the deception involved and the lack of informed consent are the main ethical obstacles that the physician encounters when considering the option of treating depressed patients with placebos. Theoretically these hurdles can be bypassed using negative informed consent. However this concept is yet to be considered acceptable or valid by most physicians and medical institutions. Surprisingly, few attempts were made to elucidate the viewpoint of laypeople or depressed patients regarding the placebo therapy. Without being asked they are deprived of the right to “not know” or “know less” and consequently enjoy the benefits of a safe and possibly useful treatment for depression. In an open label trial, using placebos in the treatment of ADHD, children and parents were generally receptive of the treatment (37). Fassler and colleagues (14) conducted a survey in an attempt to investigate the attitudes of patients and physicians regarding placebo use in clinical practice. In their study most of the patients were open to the option of being treated with nonspecific treatments such as placebo, although 70% of the patients wanted to be explicitly informed when receiving placebo or other nonspecific treatments. In the 2011 annual meeting of the EPA, we presented two surveys on the acceptability of placebo usage in the treatment of depression. In the first survey, conducted among 344 healthy students from five academic institutions in Israel, 70% of the study population expressed consent to receive placebo therapy as a first line treatment were they to suffer from mild to moderate depression. Most of the subjects did not feel that taking placebo medication would negatively affect their sense of autonomy or doctor-patient relationship. Similar results were found in a complementary study conducted among depressed patients. It seems that under certain conditions many depressed patients might opt to waive their right for complete information in order to receive a possibly useful and safe treatment (38). The physician-related legal argument seems unequivocal at first glance. Nonetheless, Loftus and Fries have already speculated whether “the purpose of informed consent in its rigid and routinely demanded version is not protection of subjects, but rather protection of investigators and sponsoring institutions from lawsuits based on the charge of subjects deception should a misadventure result” (39). These authors acknowledge the essential right of people to “determine what is done to their minds and bodies,” 186

but they question the current legalistic ritual associated with informed consent as the best way to ensure that this human right is protected (40). A good example presented is the explicit suggestion of adverse events required by the law as part of informed consent; causing many subjects to experience these effects by what is known as the nocebo effect (41). The law is out there, but it can always be creatively and innovatively interpreted. Broader discussion of the physician-related ideological argument is needed. There is tremendous influence of the zeitgeist on medical education and on our clinical conduct. Our attitudes and openness to non-specific treatment such as placebo are dictated by the spirit of the times, economic interests, and a strong hegemony of physicians who perceive placebo treatments as a deception rather than a “pious fraud.” Marinker claims that “general practitioners remain life-long prisoners of their early medical education, and that perhaps postgraduate training should be a process of liberation and unlearning” (42). Part of the definition of a placebo treatment is that at the time of its use it is believed to be a non-specific treatment for the condition for which it is prescribed. In the future, as science progresses, non-specific treatments might reveal a specific mechanism of action. This is already supported by promising basic science research that has been executed in the last decades on the neural mechanisms of placebo treatments (43). These scientific achievements might possibly direct the “lost placebo ship” back to its home harbor in the clinical setting. Alternatively, the cultural and ethical discussion regarding placebo treatments will advance, develop, and perhaps expand the bounds of medical practice; eventually turning placebo therapy to a legitimate clinical method - though restricted to specific situations delineated with clear guidelines - but implemented when appropriate and in the service of patient well being. Conclusions “Doctors should always bear the moral responsibility to act in their patients’ best interests” (13). We described various arguments that oppose the use of placebo medications in the clinical setting. Yet, it seems that these arguments are not always as firm as they seem, and are usually contextual to a specific doctor-patient-disorder interaction. We shed light on some controversial aspects of placebo usage in treating mild to moderate depression, and hope to advance its discussion among physicians and other health care workers.


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Forty years ago, in a BMJ editorial, it was suggested that “there must be occasions when an appropriately prescribed placebo will be less harmful and perhaps more beneficial than a complex and incompletely understood drug” (44). Ultimately, the responsibility for choosing the appropriate remedy at the proper time rests on the shoulders of the caregiver; in accord with Balint’s view of the physician himself as the most widely used drug in medicine (16). Acknowledgements We wish to thank Rena Kurs for her help and advice.

References 1. Nitzan U, Hersco-Levy U, Lichtenberg P. The placebo effect - a biochemical basis for a psychosomatic phenomenon. Harefuah 2002; 141:272-277, 314, 313 (Hebrew). 2. Emanuel EJ, Miller FG. The ethics of placebo-controlled trials--a middle ground. N Engl J Med 2001; 345:915-919. 3. Nussinovitch U, Eidelman L, Shoenfeld Y. Placebo use in clinical studies. Harefuah 2010; 149:365-369, 403 (Hebrew). 4. Tilburt JC, Emanuel EJ, Kaptchuk TJ, Curlin FA, Miller FG. Prescribing “placebo treatments”: Results of national survey of US internists and rheumatologists. BMJ 2008; 337:1938. 5. Chaput de Saintonge DM, Herxheimer A. Harnessing placebo effects in health care. Lancet 1994; 344:995-958. 6. Bienenfeld L, Frishman W, Glasser SP. The placebo effect in cardiovascular disease. Am Heart J 1996; 132:1207-1221. 7. Moseley JB, O’Malley K, Petersen NJ, Menke TJ, Brody BA, Kuykendall DH, Hollingsworth JC, Ashton CM, Wray NP. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 2002; 347:81-88. 8. de la Fuente-Fernandez R, Stoessl AJ. The placebo effect in Parkinson’s disease. Trends Neurosci 2002; 25:302-306. 9. Bradford A, Meston CM. Placebo response in the treatment of women’s sexual dysfunctions: A review and commentary. J Sex Marital Ther 2009; 35:164-181. 10. Laporte JR, Figueras A. Placebo effects in psychiatry. Lancet 1994; 344:1206-1209. 11. Hill J. Placebos in clinical care: For whose pleasure? Lancet 2003;362:254. 12. Lichtenberg P, Heresco-Levy U, Nitzan U. The ethics of the placebo in clinical practice. J Med Ethics 2004; 30:551-554. 13. Cahana A, Romagnioli S. Not all placebos are the same: A debate on the ethics of placebo use in clinical trials versus clinical practice. J Anesth 2007; 21:102-105. 14. Fassler M, Gnadinger M, Rosemann T, Biller-Andorno N. Placebo interventions in practice: A questionnaire survey on the attitudes of patients and physicians. Br J Gen Pract 2011; 61:101-107. 15. Golomb BA, Erickson LC, Koperski S, Sack D, Enkin M, Howick J. What’s in placebos: Who knows? Analysis of randomized, controlled trials. Ann Intern Med 2010; 153:532-535. 16. Thomas KB. The placebo in general practice. Lancet 1994; 344:1066-1067. 17. Patients rights law, 1996. 18. Nitzan U, Lichtenberg P. Questionnaire survey on use of placebo. BMJ 2004; 329:944-946. 19. Fassler M, Meissner K, Schneider A, Linde K. Frequency and circumstances of placebo use in clinical practice--a systematic review of empirical studies. BMC Med 2010; 8:15.

20. Sherman R, Hickner J. Academic physicians use placebos in clinical practice and believe in the mind-body connection. J Gen Intern Med 2008; 23:7-10. 21. Park LC, Covi L. Nonblind placebo trial: An exploration of neurotic patients’ responses to placebo when its inert content is disclosed. Arch Gen Psychiatry 1965; 12:36-45. 22. Aulas JJ, Rosner I. Efficacy of a non blind placebo prescription. Encephale 2003; 29:68-71.(French) 23. Kaptchuk TJ, Friedlander E, Kelley JM, Sanchez MN, Kokkotou E, Singer JP, Kowalczykowski M, Miller FG, Kirsch I, Lembo AJ. Placebos without deception: A randomized controlled trial in irritable bowel syndrome. PLoS One 2010; 5:e15591. 24. Sandler AD, Bodfish JW. Open-label use of placebos in the treatment of ADHD: A pilot study. Child Care Health Dev 2008; 34:104-110. 25. Kihlbom U. Autonomy and negatively informed consent. J Med Ethics 2008; 34:146-149. 26. Shaw DM. Prescribing placebos ethically: The appeal of negatively informed consent. J Med Ethics 2009; 35:97-99. 27. Mayberg HS, Silva JA, Brannan SK, Tekell JL, Mahurin RK, McGinnis S, Jerabek PA. The functional neuroanatomy of the placebo effect. Am J Psychiatry 2002; 159:728-737. 28. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005; 62:593-602. 29. Walsh BT, Seidman SN, Sysko R, Gould M. Placebo response in studies of major depression: Variable, substantial, and growing. JAMA 2002; 287:1840-1847. 30. Rief W, Nestoriuc Y, Weiss S, Welzel E, Barsky AJ, Hofmann SG. Metaanalysis of the placebo response in antidepressant trials. J Affect Disord 2009; 118:1-8. 31. Kirsch I, Sapirstein G. Listening to Prozac and hearing placebo: A meta analysis of antidepressant medication. Prevent Treat 1998; 1:1-17. 32. Fournier JC, DeRubeis RJ, Hollon SD, Dimidjian S, Amsterdam JD, Shelton RC, Fawcett J. Antidepressant drug; effects and depression severity: A patient-level meta-analysis. JAMA 2010;303:47-53. 33. Kirsch I, Deacon BJ, Huedo-Medina TB, Scoboria A, Moore TJ, Johnson BT. Initial severity and antidepressant benefits: A meta-analysis of data submitted to the Food and Drug Administration. PLoS Med 2008; 5:e45. 34. Turner EH, Matthews AM, Linardatos E, Tell RA, Rosenthal R. Selective publication of antidepressant trials and its influence on apparent efficacy. N Engl J Med 2008; 358:252-260. 35. Wieseler B, McGauran N, Kaiser T. Finding studies on reboxetine: A tale of hide and seek. BMJ 2010; 341:c4942. 36. Stimmel GL. How to counsel patients about depression and its treatment. Pharmacotherapy 1995; 15:100S-104S. 37. Sandler A, Glesne C, Geller G. Children’s and parents’ perspectives on open-label use of placebos in the treatment of ADHD. Child Care Health Dev 2008; 34:111-120. 38. Spiro H. Doctors, patients and placebos. New Haven: Yale University, 1986. 39. Loftus E, Fries JF. Informed consent may be hazardous to your health. Science 1979; 204:211. 40. Loftus EF, Fries JF. The potential perils of informed consent. McGill J Med 2008; 11:217-218. 41. Barsky AJ, Saintfort R, Rogers MP, Borus JF. Nonspecific medication side effects and the nocebo phenomenon. JAMA 2002; 287:622-627. 42. Marinker M. Studies of contact behaviour in a general practice. I. An exposition of methods and a consideration of meanings. J R Coll Gen Pract 1967; 14:59-66. 43. Zubieta JK, Stohler CS. Neurobiological mechanisms of placebo responses. Ann N Y Acad Sci 2009; 1156:198-210. 44. Editorial: The placebo effect. BMJ 1970; 11:437.

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Isr J Psychiatry Relat Sci - Vol. 51 - No 3 (2014)

Enhancing the Use of Institutional Ethics Committees in Mental Health Care in Israel Tal Bergman-Levy, MD,1 Adiel Doron, MD,2,3 and Rael D. Strous, MD1,3 1

Beer Yaakov Mental Health Center, Beer Yaakov, Israel Lev Hasharon Mental Health Center, Netanya, Israel 3 Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel 2

Institutional ethics committees were established and functioned in Israel prior to the application of the Patients Rights Act of 1996. These committees were voluntary and comprised of multidisciplinary teams in order to obtain numerous viewpoints stemming from various different fields. This intent was based on an understanding that the issue of ethics and the process of making ethical decisions inherently address moral and social considerations which are beyond the realm of medical practice. In contrast to the voluntary institutional ethics committees, the Patients Rights Act of 1996 instituted statutory ethics committees. These committees were mandated to investigate defined areas and, in contrast to the former committees that were considered to be valuable as advisory and enlightening entities, their decisions are binding. However, it appears that the utilization of these ethics committees within the domain of mental health facilities is limited in scope and their use varies greatly between institutions. The employment of these committees in mental health institutions focuses mainly around issues that relate to information management and mentally ill patients’ refusal of medical treatment. Several explanations exist for this phenomenon. Suggestions as to how the situation may be remedied are addressed as well as the complementary role that these ethics committees may play in modern day clinical practice.

U.S.A. during the 1970s. This rapid development created a need for introspective discussion within the medical field regarding implementation of medical technology in terminally ill patients or, alternatively, in patients whose physical handicaps are so grave and whose quality of life is so poor that medical treatment cannot ensure significant improvement (1). Over the years, ethics consultation has become increasingly sophisticated and most self-respecting medical institutions around the world encourage the process with practical guidelines in a range of medical disciplines. In Israel, the Patients Rights Act of 1996 (2) regularized and defined the operation and function of such committees within the framework of the Israeli legal code. A 2002 study conducted by Wenger et al. (3) found that five years after the law was legislated, only one third of Israel’s general hospitals, the larger ones among them, had established ethics committees and of those one third were inactive. The researchers posited that these findings stemmed, inter alia, from lack of resources, difficulty in recruiting committee members, questions related to the issue of legal liability, unsuitability to hospitals’ clinical needs and concern regarding the binding nature of committee decisions as determined by law. The difficulty in recruiting optimal committee members, including the recommendation for the appointment of a jurist to serve as chairperson, is compounded by the problematic need to rely on good will and voluntarism for operating a permanent legal body. This phenomenon of less than adequate use of ethics consultation committees is not unique to Israel and has been described in a number of countries around the world, including as noted in a recent study in the United Kingdom (4).

Introduction: In light of the rapid development of medical technology, institutional ethics committees began operating in the

Moreover, it appears that the utilization of ethics committees within the domain of mental health facilities is even more limited and varied. Thus for example, with regard to

Abstract

Address for Correspondence:   bergmantal@gmail.com

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Dr. T. Bergman-Levy, Beer Yaakov Mental Health Center, P.O. Box 1, Beer Yaakov 70350, Israel


Tal Bergman-Levy et al.

four well-known mental health centers in central Israel, over the past ten years the ethics committee in one of the facilities is inactive and in two others the committees deal with only 3-4 cases per year. The employment of these committees in mental health institutions focuses mainly around issues that relate to information management and patients’ refusal of medical treatment. Only one of the four institutions reports a heavily productive and active committee that has dealt with approximately 300 referrals over the past decade. It is assumed that frequent outreach by the committee to medical staff encouraging consultation as well as regular meetings every six weeks and committed and motivated committee members may have contributed to this level of activity (private communication). This article will attempt to determine why this variety in activity, or the lack of it, may be the case. Unfortunately, a formal body that keeps track of records from this latter hospital as well as from other institutions regarding the precise nature and number of referred cases does not exist. This surprisingly is the case despite the importance and value of the role of these committees. Furthermore, it is important to attempt to try and understand why colleagues do not refer issues to the ethics committee as is warranted and recommended in many challenging ethically-charged clinical situations. This paper aims to address some of these questions and explores the potential role such committees may play in psychiatry hospitals in Israel. Institutional Ethics Committees vs. Statutory Ethics Committees As in the U.S.A., institutional ethics committees were established and functioned in Israel prior to the application of the Patients Rights Act of 1996. These committees were voluntary and comprised of multidisciplinary teams so as to obtain numerous viewpoints stemming from various different fields, based on an understanding that the issue of ethics and the process of making ethical decisions inherently touch on moral and social considerations beyond the realm of medical practice and considerations, and rising from a need for a “societal stamp of approval.” The committees dealt with a wide range of issues and were tailored to the character of the institutions within which they operated. Beyond their involvement in specific, concrete cases, when the committees’ activities focused on ethical analysis and morally based decision making when presenting fitting alternatives for action, they were active in the areas of education and training surrounding common ethical dilemmas and also contributed to the development of institution

policy (5). Doctors presenting before the committee were not obligated to accept its recommendations and the final decision was at the doctor’s discretion. While presentation before the committee or adoption of its recommendations did not gain the doctor material immunity, doing so could be credited in his/her favor during legal proceedings (6). In contrast to the voluntary institutional ethics committees, the Patients Rights Act of 1996 (7) instituted statutory ethics committees. This law required institute hospital directors to form internal institutional ethics committees comprised of five members, including one jurist qualified to be appointed to the District Court bench, who would serve as the Committee Chairperson, two doctors, specialists from different medical fields, one psychologist or social worker and one public representative or clergyman. The law authorized the committees to investigate in five areas: 1. (Paragraph 13) (2) In order to obtain informed consent, the clinician shall supply the patient medical information to a reasonable extent, such as to enable the patient to decide whether to agree to the treatment proposed. The clinician may withhold medical information from the patient concerning his medical condition if an Ethics Committee has confirmed that giving this information is likely to cause severe harm to the patient’s mental or physical health. 2. (Paragraph 15) (2) Should the patient be deemed to be in significant danger but reject medical treatment, the ethics committee is entitled to approve enforcing treatment if it is convinced that the patient has received information as required to make an informed choice, that the treatment is anticipated to significantly improve the patient’s medical condition and there are reasonable grounds to suppose that, after receiving treatment, the patient will give his retroactive consent. 3. (Paragraph 18) (2) The patient shall be entitled to obtain medical information from his medical records. If a clinician declines to pass on to the patient part or all of the medical information, he shall immediately so inform the Ethics Committee and shall submit to it the withheld information and his arguments for withholding it. The Ethics Committee may endorse, rescind, or modify the clinician’s decision and is entitled to summon the patient or any other person prior to submitting its decision. 4. (Paragraph 20) (2) The Ethics Committee may approve the disclosure of information that has not been passed on by the patient (as per paragraph 18) to a third person. An Ethics Committee may decide, after giving the patient an opportunity to voice his opinion against the disclosure of 189


Enhancing the Use of Institutional Ethics Committees in Mental Health Care in Israel

said information, that disclosure of the medical information is vital for the protection of the health of others or the public, and that the need for disclosure overrides the interest in the information’s non-disclosure. 5. (Paragraph 23) (2) Should a patient or his representative believe that factual findings have not been entered into the medical record by the Quality Committee, they may submit an objection to an Ethics Investigative Committee. Should this Ethics Committee find that factual findings have not been entered as required, it shall order that they be entered in the medical record and shall so inform the patient or his representative. Should a case arise requiring an urgent decision of the Ethics Committee and circumstances do not permit its urgent convening, the District Court shall be empowered to act as an Ethics Committee (paragraph 24). These ethics committees are statutory in nature and, as opposed to the institutional committees which were considered to be valuable as advisory, enlightening and containing bodies, their decisions are binding. Treatment Dilemmas vs. Ethical Dilemmas Only a few studies have attempted to investigate the reasons why clinicians (none from the field of psychiatry) do or do not seek ethics consultation. A 1999 study conducted by Davis and Hudson (8) featured interviews with 12 doctors, hospital department and services directors, most of whom tended not to utilize or encourage using ethics consultation (ethics committees and ethics advisors). The interviewed doctors posited that the doctor is the main decision maker, that ethics consultation could undermine the doctor’s role and adversely affect the doctor-patient relationship, and that doctors who seek ethics consultation are attempting to lighten the degree of their responsibility for the case. In a 2006 published study, Orlowski et al. (9) compared the views held by doctors working in a university community hospital in Florida who claimed that they did not utilize ethics committees and ethics advisors with those of doctors who did claim to utilize ethics consultation. Most of the doctors who participated in the study said they did support ethics consultation, believing in the shared decision making process and presentation of different points of view. Doctors who claimed not to make use of consultation considered themselves to be capable decision makers and thought it was their sole responsibility to solve any problems that may arise regarding a patient and his/her family. They felt that only the treating physician could fully grasp the nuances 190

of the ethical dilemma and see the “complete picture,” as opposed to an advisor or external consultant. It may also be suggested that there may be clinicians who feel that when an ethical dilemma regarding a patient arises, they should consult with a professional, a colleague they know and respect, who is experienced in the same field of expertise and encounters similar situations in the course of his or her practice. Why would they turn to a committee whose members are not necessarily well known and essentially outsiders? This type of thinking may stem from a lack of knowledge about what the ethics consultation process entails or from a distorted and narrow view of the terminology. It is also possible that questions with ethical overtones tend to be perceived as medical or ethical questions that only professionals can fully grasp, thus it may be preferable to leave the resolution of such questions in the hands of those professionals from the same medical subdiscipline as their own. Ethics cannot, nor does it deign to replace professional consultation among colleagues. It cannot take the place of the experience and expertise that come with years in the field. Rather, ethics sheds light and exposes the dilemma and attempts to create alternate new ways of thinking which go beyond the boundaries of strictly professional observation to the realm of a highly complex value laden nature of clinical decision making (10). Hence, ethics committees are comprised of a variety of members, only one of whom actually represents the defined subspecialty. This allows the distance necessary for creating dialogue. Orlowski et al.’s study (9) reflects the development and change that have taken place in doctors’ viewpoints over the years and a transition from a paternalistic treatment approach to a more cooperative approach which, beyond the doctor’s relationship with patients, also allows the inclusion of an ethics committee or advisor. Ethics committees may be unjustifiably perceived as taking a judgmental stance toward clinicians, who must demonstrate courage and a willingness to be exposed if they are to present a case before an ethics committee for consultation. This situation resembles and reflects that of a psychiatric resident who begins practicing psychotherapy under the guidance of a more experienced therapist and finds it difficult to present precise vignettes, feeling anxious in face of possible negative feedback regarding his/her work. However, just as the role of such supervision is to expose elements which may be “invisible” or inaccessible to the resident, so the ethics committee may expose additional layers of the case. In the same manner in which the process of supervision entails constructive criticism, validation of the therapist’s work and exami-


Tal Bergman-Levy et al.

nation of additional treatment alternatives, the ethics committee may uncover concealed elements which could validate and support the doctor. This would allow him/ her to perform more confidently when dilemmas arise, and also offer additional avenues for implementation. Ethics Committees in Psychiatric Practice While not all may agree, the role of ethics committees, as defined by law in Israel, may be particularly relevant to the realm of mental health. For example, paragraph 15 of the Patients Rights Act addresses situations where medical treatment may be given to the patient without or in opposition to his/her consent and states: “should the patient be deemed to be in grave danger but reject medical treatment, which in the circumstances must be given soon, the clinician may perform the treatment against the patient’s will if an Ethics Committee, after hearing the patient, has approved such treatment, provided that it confirmed that all the following conditions apply: the patient has received information as required to make an informed choice, the treatment is anticipated to significantly improve the patient’s medical condition, and there are reasonable grounds to suppose that, after receiving treatment, the patient will give his retroactive consent” (11). There are many cases that occur within psychiatric mental health centers which meet the criteria of this paragraph, i.e., in which the patient may face grave danger, such as in the case of a hospitalized patient suffering from severe major depression with no psychotic symptoms and with intact reality testing, although with a high level of suicidal ideation. Other conditions relevant may include a patient with anorexia nervosa or a mentally-ill patient who puts himself at risk by not taking medication for a physical illness. Such patients could in fact be capable of understanding the information provided regarding the suggested treatment which could bring about a significant improvement in his/her condition and he/she may well consent retroactively after receiving that treatment. However, if the patient refuses any treatment whatsoever for his/her disorder, including medication or electroconvulsive therapy, the ethics committee may be able to provide a solution that may not be provided under the Mental Patients Treatment Act of 1991. it should be stated that there are varying opinions on such issues and probably not all would agree to input of the Ethics Committee in such situations. These other opinions would include the fact that the Mental Patients Treatment Act of 1991 is more specific to patients with mental illness and thus “trumps”

or overrides any consideration of the later Patients Rights Act of 1996. In addition, the experience of many is that although the law provides for involuntary treatment of patients with psychosis, many district psychiatrists would hospitalize a patient with major depression if there is also suicidality and if deemed to exhibit impaired judgment. This law in its current use recognizes the grave potential danger entailed in the deterioration of a patient’s condition where the patient is in a state of psychosis and acute danger to himself or others. The law allows for the compulsory hospitalization and treatment of such a patient, under certain conditions, in order to prevent that danger (12). The later legislated Patients Rights Act of 1996 however does not exclude or address the individual case of a mental patient; which may be materially different from that of another “medical” patient. The patient with the psychiatric disorder may possibly lack both a fundamental understanding of the information presented as required for consent and the ability to consent retroactively after his/her condition has improved in light of the treatment received. Nonetheless, despite varying opinions on the subject, it may be argued that this complexity in itself is worthy of further discussion perhaps allowing for additional solutions within the framework of mental health facilities’ ethics committees. The “verdict may still be out” on this issue and the potential remains for legal analysis of this legislation by appropriate members of the legal and legislative profession. the mental health field is extremely sensitive to the subject of information, which constitutes another focal area for these committees. Thus, when looking solely at the questions derived from the law, it is unclear why these committees are utilized so infrequently. Does it stem from a lack of faith in the role of ethics in clinical practice or possibly from insufficient education surrounding ethical sensitivity? Perhaps it is a basic lack of awareness regarding the existence of ethics committees within these facilities and the use that may be made thereof? Does an intense workload, combined with professional burnout and lack of time or the limited availability and encumbrance of convening the committee affect frequency of consultation? Modern psychiatry espouses a bio-psycho-social (BPS) model. As a medical profession, psychiatry does deal with the treatment of the “biological” aspects of a patient’s illness, although psychiatry especially devotes significant energy to psychological and environmental components and even more so to the effects they have on the severity and progress of the patient’s condition. Examples of this may be seen in cases where patients ask to continue seeing a therapist on a private basis after having begun 191


Enhancing the Use of Institutional Ethics Committees in Mental Health Care in Israel

seeing him/her within the public health system or ethical questions in the legal realm that supersede the patienttherapist relationship. These include dilemmas such as what should be done when a hospitalized patient reports to his/her doctor that in the past he/she spent time in prison for drug trafficking and recently used drugs for a suicide attempt taken from mentally ill patients residing in the hostel where he/she is employed which subsequently resulted in the current voluntary hospitalization. How should the doctor act with regard to the other hostel residents? Should he/she notify the patient’s employer of this incident? Should this information be passed on to any authorities? This example raises the conflict of dual loyalty of the psychiatrist: the right of the patient to confidentiality vs. the psychiatrist’s obligation to the other patients, the community and society. This in itself reflects a philosophical dilemma of the conflict between deontological and consequentualism approaches to ethical decision making. Ethics committees operating within the framework of mental health facilities must be fully authorized to examine any ethical question that arises with regard to a patient, including one that is not specifically based on current legislation. Future Perspective Increased activity on the part of ethics committees within mental health centers is warranted in a broad format similar to the institutional committees that operated prior to the Patients Rights Act of 1996. They must include those members mandated by law, but also anyone who is willing and able to contribute to the ethical discussion. Such committees must be available to psychiatrists in the public health arena as well as to those in the private sector, and they should project both availability and seriousness but with an open and accommodating atmosphere. Their decisions should be binding only in the areas in which they have been authorized to rule under the Patients Rights Act but they should address other issues as well. Including the ethics committee in frequent consultation when relevant issues arise is important, contributes to optimal health care provision and has even been described by some as “moral engagement” (13). In addition, defining the ethics committee as an entity with legal standing was an extremely important move toward strengthening recognition of the fact that ethical discussion is necessary when faced with issues bearing moral and social overtones. However, it appears that the specific definition of the role of such committees has led to a narrowing of their operation 192

and in some instances even to hesitation in presenting cases before them. Unfortunately, it seems that relative to many general medical hospitals, these important ethics committees are relatively underutilized and often even ignored in some psychiatry institutions. A renewed effort to encourage ethics consultation in mental health care provision should be encouraged as well as the consideration of creative technological approaches including online ethics consultation avenues such as has been suggested by some (14). Psychiatry is a sensitive medical subspecialty that is affected, for the good or for the bad, by the social and cultural climate nuances in which it operates and flourishes. Even its therapeutic basis draws from definitions and observations from the environment, thus we may assume that many ethical dilemmas surrounding patient treatment exist. The time has come to “talk ethics” and to restore the ethics committee to its proper and rightful place as an entity that can contribute to education and direct policy for all in the field. References 1. Rosner F. Hospital Medical Ethics committees: A review of their development. JAMA 1985;253:2693-2697. 2. Israel’s patient’s rights act 1996 available in English at http://waml/ haifa.ac.il/index/reference/legislation/israel/israel1.htm (last visited 19/06/2011). 3. Wenger NS, Golan O, Shalev C, Glick S. Hospital ethics committees in Israel: Structure function and heterogeneity in the setting of statutory ethics committees. J Med Ethics 2002;28:177-182. 4. Whitehead JM, Sokol DK, Bowman D, Sedgwick P. Consultation activities of clinical ethics committees in the United Kingdom: An empirical study and wake-up call. Postgrad Med J 2009 ;85:451-454. 5. Siegal G, Peled M. Ethics committees. Medicine & Law 1997;17:6-11 (Hebrew). 6. Guidelines for ethical committees in health care institutions Judicial council. JAMA 1985; 2698-2699. 7. Israel’s patient’s rights act 1996 paragraph 22-24 available in English at http://waml/haifa.ac.il/index/reference/legislation/israel/israel1.htm (last visited 19/06/2011). 8. Davis L, Hudson LD. Why don’t physicians use ethics consultations? J Clin Ethics 1999;10:116-125. 9. Orlowski JP, Hein S, Christensen JA, Meinke R, Sincich T. Why doctors use or do not use ethics consultation. J Med Ethics 2006;32:499-502 10. Aulisio MP, Arnold RM. Role of ethics committee, helping to address value conflicts or uncertainties. Chest 2008;134:417-424. 11. Israel’s patient’s rights act 1996 paragraph 15 available in English at http://waml/haifa.ac.il/index/reference/legislation/israel/israel1.htm (last visited 19/06/2011). 12. The Israel law for the treatment of the mentally ill, 1991, paragraph 9 (in Hebrew). 13. Moreno JD. Ethics consultation as moral engagement. Bioethics 1991;5:44-56. 14. Hsiung RC. Suggested principles of professional ethics for the online provision of mental health services. Stud Health Technol Inform 2001;84:1296-1300.


Isr J Psychiatry Relat Sci - Vol. 51 - No 3 (2014) David Greenberg and Gaby Shefler

Patient Suicide David Greenberg, MD, MRCPsych, and Gaby Shefler, PhD North Jerusalem Mental Health Center, Herzog Hospital, Jerusalem, Israel and The Hebrew University of Jerusalem, Jerusalem, Israel

Frequency of Patient Suicide among Psychiatrists

Abstract A series of studies reveals that patient suicide is experienced by most psychiatrists, particularly adult psychiatrists in the public sector. Psychiatrists respond to patient suicide with symptoms of grief, with an intensity in 25-50% of cases similar to those who have lost a parent and sought help, although the duration is more brief. Patient suicide usually results in psychiatrists becoming more defensive in their practice: extra careful to ask about suicidal ideation, more likely to suggest hospitalization and compulsory care, and seek colleagues’ consultation. The frequency of patient suicide and its emotional and professional impact have lead to recommendations that the psychiatrist is supported during the early phase of shock and grief, and receives ongoing support for a period after the suicide. Most families of suicide patients would wish to have contact with the psychiatrist after the event. While distress and fear of litigation may influence the psychiatrist’s actions, meeting with the family should be seen as part of care, and the psychiatrist should receive guidance and support in this process.

Introduction In 1991 William Menninger wrote: “The loss of a patient by death is always troubling to the clinical practitioner because it represents an insufficiency of the treater’s best efforts” and concluded that it “is a significant occupational hazard of mental health professionals, especially psychiatrists” (1). This review will examine to what extent patient suicide is an “occupational hazard” of psychiatrists, how they respond emotionally, whether it affects their self-confidence and style of practice, and how psychiatrists, their supervisors and the institutions in which they work should respond, both to the psychiatrist and the patient’s family. Address for Correspondence: Israel   davidg@mail.huji.ac.il

Just how common it is for a psychiatrist to experience the suicide of a patient has varied in a series of studies, and would seem to depend on the type of clinical exposure and the suicide rate of the country in which they live. Table 1 presents a series of studies, mainly of psychiatrists (1-14). The initial studies were in U.S. (1-4), subsequent studies in Europe (5-7), Canada (8) and Thailand (9); studies among residents are presented separately (10-14). In the first attempt to obtain a representative sample, Chemtob et al. (4) sent out a questionnaire to 643 randomly selected psychiatrists throughout the U.S. When only 269 responded, the authors made vigorous but unsuccessful attempts to contact 50 of the non-responders. The three they finally reached by telephone refused to answer questions on the subject, and the authors suggested that the actual frequency of patient suicides is likely to be higher than the 51% reported, but that psychiatrists have difficulty discussing the subject. The early U.S. studies had frequencies of 20-51%. Most subsequent studies have tended to survey psychiatrists working in the public sector. This presumably means they have a larger work load and more seriously ill patients than many of those surveyed in the earlier studies and as a result a higher chance of experiencing patient suicide, reporting a frequency of 50-98%. The highest frequency (98%) in Grad et al.’s (6) study of psychiatric hospital staff was in Slovenia, a country with one of the highest suicide rates in the world, while the study of Thomyangkoon and Leenaars (56%) (9) was carried out in Thailand with a low national suicide rate. Alexander et al. (7) considered only the frequency since becoming a consultant, and their finding of 67% would presumably have been higher if residency years had been included. A difficulty in interpreting some of the findings was that responding positively to a question if they had “experienced a patient suicide” may be understood to include a patient seen on duty or a patient of a colleague, rather than the psychiatrist

David Greenberg, MD, North Jerusalem Mental Health Center, Herzog Hospital, POB 3900, Jerusalem 91035,

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Patient Suicide

Table 1. Studies of the frequency of mental health professionals experiencing a personal patient committing suicide Authors, year

Profession of sample, country

Initial sample size, N responders, (response rate)

Early U.S. studies Litman, 1965 (2) Kahne, 1968 (3) Chemtob et al., 1988 (4) Menninger, 1991 (1)

Psychotherapists, U.S. Psychiatrists at McLean Hospital, U.S. Psychiatrists, U.S. Psychotherapists, U.S.

200 79, 73 (92) 586, 269 (46) 199, 105 (53)

20 22 51 39

Later international studies Cryan et al., 1995 (5) Grad et al., 1997 (6) Alexander et al., 2000 (7) Ruskin et al., 2004 (8) Thomyangkoon & Leenaars, 2008 (8)

Consultant psychiatrists, Ireland Psychiatrists, psychologists, Slovenia Consultant psychiatrists, Scotland Past and present residents at one training scheme, Canada Psychiatrists, Thailand

178, 109 (61) 87, 63 (72) 315, 247 (78) 495, 239 (48) 320, 167 (52)

82 98 67 50 56

Studies of residents Brown, 1987 (9) Dewar et al., 2000 (10) Yousaf et al., 2002 (11) Pieters et al., 2003 (13) Pilkinton & Etkin, 2003 (12)

Residents, U.S. Senior registrars and registrars, Scotland Residents at one training scheme, U.K. Trainees, Dutch-speaking Belgium Residents, Canada

55 128, 103 (81) 89, 53 (60) 163, 114 (70) 428, 197 (46)

33 47 43 44 12.4

having experienced the death of their own patient. While this distinction was unclear in the study by Yousaf et al. (12), Pilkinton and Etkin (14) and Dewar et al. (11) reported figures of both the more general and more personal suicides; Table 1 includes the latter, a suicide of their own patient. The studies surveying the frequency among psychiatric residents have reported 12.4-47%, the latter figure including trainees with 3-13 years experience (11). Ruskin et al. (8) noted that patient suicide was most common very early in training, and observed that residency training usually begins on in-patient units so that the youngest and least experienced professionals are treating the most seriously ill who are at the greatest risk of suicide. In 2007, the journal Academic Psychiatry published a review by residents on the experiences of psychiatric residents with patient suicide (15). The editor contributed an editorial stressing the importance of the subject (16) and invited three expert commentaries (17-19). The surveys reviewed here show that a psychiatrist can expect to experience the suicide of at least one patient under his/her care and that it is an “occupational hazard.” Does this mean that it is expected and therefore does not have a strong emotional effect or impact on their professional sense of self? The Emotional Response to Patient Suicide The findings of all studies are unanimous: a patient’s suicide produces significant distress in a psychiatrist. A 194

% of professionals with personal patient suicide

range of questionnaires were used, but frequent responses were grief and sadness (1, 6, 9, 12), guilt (1, 4, 6, 9, 11, 12), shock (1, 6, 8, 12), anger (1, 4, 12), and diminished self esteem (4, 7, 8, 11, 12). Chemtob et al.’s (4) respondents reported thoughts of suicide (2.9 on a scale 1-7) (4), not replicated by other studies (9, 12). The Impact of Event Scale (IES, 20) was completed retrospectively for the two weeks after the suicide in four studies (Table 2). As shown, over 50% of the psychiatrists who had experienced patient suicide in Chemtob et al. (4) and Yousaf et al. (12) had retrospective IES scores similar to people seeking treatment after the death of a parent (21). While their distress was not necessarily as prolonged as in those bereaved of a parent, Alexander et al. (7) reported that of the 48 respondents who reported a duration for their distress, in a third it lasted for one month, a third three months, Table 2. Therapists’ mean scores of Impact of Event Scale (IES) after patient suicide compared with people bereaved of parents IES Intrusion score (0-35)

IES Avoidance score (0-40)

Chemtob et al. (4)

14.3

10.3

Cryan et al. (5)

10.8

5.8

Study

Yousaf et al. (12)

11.9

9.7

Ruskin et al. (8)

8

6

Zilberg et al. (21) Bereaved in treatment

20.2

20.8

Zilberg et al. (21) Bereaved not in treatment

13.5

9.4


David Greenberg and Gaby Shefler

and a third suffered for more than three months, while Ruskin et al. (8) reported one third still had distress at one month, and 7% beyond three months. The most in-depth evaluation and intervention on the subject was carried out by Hendin et al. (22), who invited 34 therapists (28 of whom were psychiatrists) of recently-suicided patients to complete a semi-structured questionnaire about the patient, write out a case history narrative and rate nine emotional responses to the death. They then participated in pairs in a one-day workshop in which the two cases were discussed and their emotional responses understood. Thirteen of the therapists (38%) experienced severe distress, and four main reasons were pinpointed for this distress: the patient had not been hospitalized after saying he was suicidal (three cases), decisions in the course of therapy that troubled the therapist (four cases), feeling blamed by their superiors for the suicide (two trainees), and fear of litigation (four cases). Well over half of the sample experienced grief, shock, guilt and anger, and some symptoms continued for years after the patient’s death. The Effect of Patient Suicide on Professional Functioning Following patient suicide, psychiatrists reported increased focus on suicide cues (1, 4, 5, 6, 7, 11, 12), increased consultation with colleagues (4, 5, 6, 12), careful record keeping (4, 5, 7, 12), attention to legal aspects (1, 4, 5, 7, 12), and being more likely to hospitalize (1, 4, 5, 7). Retirement was contemplated by 15% of Alexander et al.’s sample (7), while 9% of Dewar et al.’s sample of residents considered changing specialty, and it led some to decide not to pursue adult psychiatry with its increased risk of patient suicide (11). In contrast, some of Menninger’s sample concluded that they were now more accepting of suicide as a possible outcome (“In spite of your best efforts, you cannot take responsibility for what your patient says or does when the person leaves your office.” “You cannot prevent a person from committing suicide if he or she is determined to do it.”) (1). What do therapists report helps them cope with patient suicide? The people that residents reported were particularly supportive and helpful in coping with patient suicide were family and friends (6, 7, 8, 11, 14), colleagues (6, 7, 8, 11, 14), and supervisors (6, 8, 11, 14). In Ruskin et al.’s

sample, 17% found support in individual psychotherapy (8), in Menninger’s 5% (1). Chemtob et al., however, argued that although psychiatrists reported being helped by talking to colleagues and family, the level of distress that they reported retrospectively means that it was not sufficient (4). They supported the recommendations of Brown (10) that the likelihood of suicide and its emotional impact on therapists should be incorporated into training, and that therapists whose patients have died by suicide should receive structured support. Other helpful actions were psychological autopsy, attending burial or memorial service, and reading and writing professionally about suicide. Contact with the Family The reports of contact with the patient’s family, and attending the burial were varied: Only 15% of the Irish psychiatrists attended the funeral, which the authors suspected reflected avoidance in a culture in which burials are a part of everyday life; 55% of these found it helpful and 62% thought the family found it helpful (5); 59% of Ruskin et al.’s sample contacted the family (8), 14% of Pilkinton and Etkin (14), 26% of Yousaf et al. (12); 24 of Alexander et al.’s sample attended the funeral, of whom 15 found it helpful, and three found it unhelpful (7); 72% of the Thai psychiatrists prayed or did “merit” (chanting, doing good deeds, attending ceremonies to help the patient after death) which most found helpful (9); 55% of their sample attended the burial. Brownstein (23) found that in 12 cases of patient suicide, in only one case did the psychiatrist contact the family afterwards, while 11 out of the 12 families desired such contact. Markowitz (24) described attending the funeral, having discussed it first with the patient’s mother, and settled that there was no breaking of confidentiality in this case. He wrote of his response to the burial: “I felt less angry at myself and more enraged at schizophrenia…. We survivors experienced the commonality of loss” (p. 123). All of the authors of the Fang et al. (15) review were residents. One reported her personal experience: “In my first year of psychiatry training, a patient committed suicide while I was on call.... I was asked to speak to the victim’s family members who were present. I had never even met the patient!” (p. 342). Despite this death presumably occurring at night, the absence of senior staff and the treating psychiatrist in this situation seems to suggest not only a placing of excessive responsibility on a passing resident, but an avoidance of a difficult 195


Patient Suicide

role by others. Most discussions of this issue weigh the desire for contact, explanation and support against the concern that whatever is said may be used in possible litigation. Of Ruskin et al.’s (8) 120 respondents who had a patient suicide, there was legal action in 10, and two went to trial. Alexander et al. found 20 were depressed at the prospect of litigation, and 12 seriously depressed, although litigation was rarely reported (7). Fear of litigation must be an increasing concern in the reaction to patient suicide. In the decade 1998-2008, suicide or attempted suicide was the second commonest allegation brought against psychiatrists in the U.S. (25). Simon and Shuman write: “Short of not seeing patients, there is nothing a psychiatrist can do that will reduce the risk of a lawsuit to zero” (25, p. 155). Media publicity and the prospect of litigation were generally distressing, as were disciplinary proceedings, experienced as “scapegoating and witch-hunting” (7). The early studies were of psychotherapists from different disciplines and found no differences in the reactions of the different professions. This may be surprising considering the different emphases in the training of psychiatrists and nurses, who, in comparison to the other mental health professions, are exposed to illness and death in their medical studies, and medical students are exposed to dead bodies in their anatomical training. All of the subsequent surveys were of psychiatrists, one recent study of twelve psychoanalysts yielding similar findings (26). Wherever suicidal risk is present, a psychiatrist will be involved, coping with the responsibility of recommending medication or hospitalization, whether voluntary or compulsory. However, from the details of the emotional responses of the therapists, it is clear that it is not an acquaintance with death that modifies the response, rather the sense of loss of the patient one was treating that produces stress. Gitlin (27) has written a beautiful and insightful account of his powerful emotional responses to the suicide of his first private patient after completing residency. Based on his career experiences, he suggests that reactions are stronger earlier in a career (see also 8, 14), when one is a lone therapist, and also depending on the intensity of the relationship, noting that being in the role of psychopharmacologist does not mean that an intense connection may not develop over a lengthy period. In Sudak’s commentary (17) he discusses some of his experiences of patient suicide, and then adds the death by suicide of his divorcing wife, “my life’s worst experiences” (p. 334). He is an active member of a support group for “survivors” of suicide (SOS), 196

meaning the relatives affected by a person’s suicide, and he suggests that psychiatrists are also survivors who would benefit from a support group for mental health workers who have been through the experience of patient suicide. Discussion and Recommendations “Virtually all mental disorders have an increased risk of suicide” (28, p. 205). While the lifetime risk of suicide in schizophrenia was recently suggested to be 1.9% rather than the previously quoted 10%, this is still twelve times the risk in the general population (29). A long-term follow-up of over 400 mood disorder patients found that 11% had died by suicide (30). If psychiatrists persist in treating people with psychiatric disorders, and treat a lot of them, the chances of having a patient suicide are clearly high, and this is reflected in most of the frequency studies presented in Table 1. If these are the facts, then why are psychiatrists so shocked when it occurs? What is surprising about the findings was expressed eloquently by Grad et al.: “Even though the relationship between the psychiatrist and patient is a professional one, a sense of personal loss is found in the almost universal reaction of grief, anguish and guilt following a patient’s suicide” (6, p. 382). Why do therapists respond in this powerful way? The loss is not personal. It was not the parent who raised us or the child we loved. And yet, since psychiatrists and psychotherapists are involved in a therapeutic alliance with their patients, there is always a personal-emotional quality to the relationship as well as to the consequences of its tragic ending. Do we take it personally as if the suicide was done to us, or do we consider that our role was to prevent it, and we grieve our failure? We chose to work in the field of psychiatry in order to help, and are we tortured by the thought that not only did we not help in this case, but perhaps we hindered, as perhaps someone else might have prevented this result? Management Before and After Suicide Given the inevitability and impact of the event, patient suicide should be a subject in the training of all therapists, and its effects should be discussed (31). It is crucial that therapists are comfortable raising and not avoiding the possibility of suicide in their ongoing clinical work and they need to keep a record of the replies and their concerns. Therapists who are concerned about their patients’ suicidal risk should not keep their fears to themselves, but should discuss them with their supervisors/superiors


David Greenberg and Gaby Shefler

and these discussions should be clearly recorded in the patient’s notes. Once a patient has committed suicide, the individual therapist and the therapeutic team should go over the records carefully to try and understand the course of events, and within the next days they should have the opportunity to vent their distress and seek help if necessary. Most will share their distress with their partner/ family, and colleagues and particularly supervisors should be attentive and supportive. In the first weeks after the suicide it is important for the therapist to have a particular professional with whom the events can be discussed, doubts aired, and sadness expressed. If a trainee, this should be his supervisor, otherwise a senior professional. In Israel, the Area Psychiatrist receives a written report of the event, and may request a meeting with a committee. The report should be prepared by the therapist but closely supervised and supported by the supervisor, and the conclusions should be presented initially to the therapeutic team as a “psychological autopsy.” Although the Area Psychiatrist is usually careful to emphasize that the intention of a meeting before a committee is not witch-hunting, but to learn lessons, “to be supportive, positive and constructive” (9, p. 736) this is more likely if the attending staff are known to him personally. Some of the studies presented emphasized that support should not be short-term, as post-traumatic symptoms in the therapist were often still present years after the suicide. On the one hand, patient suicide is an event that will inevitably be experienced by most therapists. However, it is a source of severe distress for up to 50% of them. Brown found the expressions of feelings by therapists being interviewed about patient suicide were very powerful, and that they recalled the names and details from decades ago, and yet, over time, the experience was not one that had affected them negatively (32). With support and understanding, patient suicide contains lessons of our limitations that must be internalized at some stage in our work as clinicians. Management and the Family of a Suicide While this presentation has focused on the reaction of the therapist, the main loss and sorrow after patient suicide are experienced by the family members who have lived with the patient and his illness, loved him despite the trials they have had to live through, and now must cope with this tragic end. Having lived with the stigma of mental

illness, they now have the added stigma of suicide. It has been our experience, particularly as therapists in the community, to appreciate the crucial and complex role of family members living with a patient with a mental disorder. Throughout our lives as clinicians, the role of the therapist should always be to respect and support and inform the family, with the understanding and consent of the patient. Ideally, the family should be involved and included, as hospitalization, compulsory treatment, sideeffects of medications, limited responses to treatment, and suicide attempts are events that should be accompanied by explanations and support for the patient and the family. While the responsibility of the therapist is primarily to the patient, in the case of chronic disorders and where there is a known suicidal risk, the therapist’s relationship with the concerned family should never be neglected. The ultimate testing of the quality of that relationship will be following patient suicide. In the case of the suicide of an in-patient and even in the course of community work, it may be the therapist who brings news of the death to the family. (One of the authors was called by the employer of a patient who had committed suicide at work. A worker who had found the body came to the clinic and we proceeded to the patient’s home to inform his wife. We then accompanied her to the ER to identify the body.) In principle it is appropriate for the therapist to attend the burial and/or the shiva (seven days of mourning observed by first degree relatives in the Jewish tradition) (24). However, both are very public occasions. In some communities attending the burial or shiva may be seen as publicizing a connection that the family does not wish to be known. However, it is important to sit with the immediate relatives to discuss the events that lead up to the death, an opportunity for the family to express their own sense of responsibility and ask questions. More junior therapists should be accompanied by the ward or clinic or hostel director. Such a meeting is more complex if the relatives have not been in contact with the therapist before the suicide, and especially if they have already declared an intention to seek legal redress. In several studies there was an allegation against the therapist (8), and many therapists fear such a development (7). It is a common standpoint that ignoring the family will reduce allegations against the professionals. We think that the legal aspects of the case are separate from the emotional aspects. An allegation will not be made because the therapist came to talk to the family. We might even think that the opposite is true, although such a hypothesis cannot be studied. An 197


Patient Suicide

open sincere discussion with the family, handing them all the realistic information (and based on the assumption that there was no neglect or malpractice involved in the tragedy) may help discharge the family’s anger and wish to sue. A word of caution: While the desire to reach out to the family and discuss the case candidly may be appropriate in the majority of cases, this may well be contrary to the advice of the psychiatrist’s medical protection insurance agency, and in the minority of families who feel bitter and angry, their candid responses may subsequently be used against them by a lawyer. We believe that it is necessary to consider the emotional needs of the family, and meet for purposes of explanation and support, even if used as an opportunity to vent anger and blame. Meeting with the family should be an opportunity to evaluate whether close family members are in need of ongoing help. Support groups for longterm help are particularly relevant for family members. Conflict of interests The two authors have together accumulated over sixty years as therapists in community mental health services. They have both experienced patient suicide.

References 1. Menninger WW. Patient suicide and its impact on the psychotherapist. Bull Menninger Clin 1991; 55:216-227. 2. Litman RE. When patients commit suicide. Am J Psychother 1965; 19:570-576. 3. Kahne MJ. Suicide among patients in mental hospitals: A study of the psychiatrists who conducted their psychotherapy. Psychiatry 1968; 31:32-43. 4. Chemtob CM, Hamada RS, Bauer G, Kinney B, Torigoe RY. Patients’ suicides: Frequency and impact on psychiatrists. Am J Psychiatry 1988; 145:224-228. 5. Cryan EMJ, Kelly P, McCaffrey B. The experience of patient suicide among Irish psychiatrists. Psychiatric Bull 1995; 19:4-7. 6. Grad OT, Zavasnik A, Groleger U. Suicide of a patient: Gender differences in bereavement reactions of therapists. Suicide Life Threat Behav 1997; 27:379-386. 7. Alexander DA, Klein S, Gray NM, Dewar IG, Eagles JM. Suicide by patients: Questionnaire study of its effect on consultant psychiatrists. BMJ 2000; 320:1571-1574. 8. Ruskin R, Sakinofsky I, Bagby RM, Dickens S, Sousa G. Impact of patient suicide on psychiatrists and psychiatric trainees. Acad Psychiatry 2004;28:104-110. 9. Thomyangkoon P, Leenaars A. Impact of death by suicide of patients on Thai psychiatrists. Suicide Life Threat Behav 2008;38:728-740. 10. Brown HN. Patient suicide during residency training, I: Incidence, implications, and program response. J Psychiatr Ed 1987; 11:201-216.

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11. Dewar IG, Eagles JM, Klein S, Gray N, Alexander DA. Psychiatric trainees’ experiences of, and reactions to, patient suicide. Psychiatr Bull 2000;24:20-23. 12. Yousaf F, Hawthorne M, Sedgwick P. Impact of patient suicide on psychiatric trainees. Psychiatr Bull 2002;26:53-55. 13. Pieters G, De Gucht V, Joos G, et al: Frequency and impact of patient suicide on psychiatric trainees. Eur Psychiatry 2003;18:345-349. 14. Pilkinton P, Etkin M. Encountering suicide: The experience of psychiatric residents. Acad Psychiatry 2003;27:93-99. 15. Fang F, Kemp J, Jawandha A, Juros J, Long L, Nanayakkara S, Stepansky C, Thompson B, Anzia J. Encountering patient suicide: A resident’s experience. Acad Psychiatry 2007;31:340-344. 16. Coverdale AH, Roberts LW, Louie AK. Encountering patient suicide: Emotional responses, ethics and implications for training programs. Acad Psychiatry 2007;31:329-332. 17. Sudak H. Encountering patient suicide: The role of survivors. Acad Psychiatry 2007;31:333-335. 18. Balon R. Encountering patient suicide: The need for guidelines. Acad Psychiatry 2007;31:336-337. 19. Schwartz AC, Kaslow NJ, McDonald WM. Encountering patient suicide: A requirement of the residency program curriculum. Acad Psychiatry 2007;31:338-339. 20. Horowitz MJ, Wilner M, Alvarez W. Impact of events scale: A measure of subjectve stress. Psychosom Med 1979;41:209-218. 21. Zilberg NJ, Weiss DS, Horowitz MJ. Impact of events scale: A cross-validation study and some empirical evidence supporting a conceptual model of stress response syndromes. J Consult Clin Psychol 1982;50:407-414. 22. Hendin H, Haas AP, Maltsberger JT, Szanto K, Rabinowicz H. Factors contributing to therapists’ distress after the suicide of a patient. Am J Psychiatry 2004; 161:1442-1446. 23. Brownstein M. Contacting the family after a suicide. Can J Psychiatry 1992;37:208-212. 24. Markowitz JC. Attending the funeral of a patient who commits suicide. Am J Psychiatry 1990; 147:122-123. 25. Simon RI, Shuman DW. Therapeutic risk management of clinical-legal dilemmas: Should it be a core competency. J Am Acad Psychiatry Law 2009;37:155-161. 26. Tillman JG. When a patient commits suicide: an empirical study of psychoanalytic clinicians. Int J Psychoanalysis 2006; 87: 159-177. 27. Gitlin MJ. A psychiatrist’s reaction to a patient’s suicide. Am J Psychiatry 1999;156:1630-1634. 28. Harris EC, Barraclough B. Suicide as an outcome for mental disorders: A meta-analysis. Br J Psychiatry 1997;170:205-228. 29. Dutta R, Murray RM, Hotopf M, Allardyce J, Jones PB, Boydell J. Reassessing the long-term risk of suicide after a first episode of psychosis. Arch Gen Psychiatry 2010;67:1230-1237. 30. Angst J, Angst F, Gerber-Werder R, Gamma A. Suicide in 406 mooddisorder patients with and without long-term medication: A 40-44 years’ follow-up. Arch Suicide Res 2005;9:279-300. 31. Prabkakar D, Anzia JM, Balon R, Gabbard G, Gray E, Hatzis N, Lanouette NM, Lomax JW, Puri P, Zisook S. “Collateral damages”: Preparing residents for coping with patient suicide. Acad Psychiatry Advance 2013;36:497-499. 32. Brown HN. The impact of suicide on therapists in training. Compr Psychiatry 1987;28:101-112.


Isr J Psychiatry Relat Sci - Vol. 51 - No 3 (2014)

Amira Or Et al.

Real-life decision making of Serious Mental Illness patients: Opt-in and opt-out research participation Amira Or, MD, Yehuda Baruch, MD, MHA, Shelly Tadger, MD, and Yoram Barak, MD, MHA Abarbanel Mental Health Center, Bat Yam, Israel, affiliated with the Sackler School of Medicine, Tel Aviv University, Israel

Abstract Background: Patients’ decisions in relation to participation in clinical research depend on individual values and relevant outcomes. Presenting possible decisions by way of defaults (opt-in or opt-out) has been used to achieve desired outcomes. Our objective was to characterize patients willing to participate in clinical research and to assess the impact of defaults on patients with Serious Mental Illness (schizophrenia, schizoaffective disorder, major depression and bipolar disorder; SMI) during the decision process. Methods: Patients with SMI were requested to accept or reject participation in a novel drug treatment study using either the (1) opt-in condition, wherein they were told that our center’s policy is not to include them in drug studies; (2) the opt-out condition, wherein they were told that our center’s policy is to include them in drug studies; and the (3) neutral condition that required patients to state their preference with no prior information. Results: 311 patients with SMI completed the brief questionnaire within 48 hours of admission to a psychiatric ward. There were 227 (73%) patients suffering from schizophrenia and schizoaffective disorder, 40 (13%) suffering from bipolar disorder and 44 (14%) suffering from major depressive disorder. There were 156 men (50%) and 155 women in the sample, mean age 47.8±16.2 years. In the opt-in condition, 58% abstained, while 42% opted-in (p=0.003). In the opt-out condition, 58% participated, while 42% opted-out. In the neutral condition 51% indicated willingness to participate, 33% refused and 16% were undecided. The “willing” patient was characterized by younger age, previous hospitalizations, affective illness and more comorbid physical disorders. This study was supported by an Unrestricted grant from Lundbeck A/S.

Conclusion: Taken together these findings reveal the “profile” of patients with SMI willing to participate in clinical research and demonstrate an increase in participation preferences through the use of defaults.

Introduction Serious mental illness (SMI) is a major cause of significant disability in young adults. Treatment decisions in the context of SMI are often undertaken with the perspective of long-term outcomes. The collective purpose of clinical research is to explore and understand illness and to improve the quality of life of those who suffer. In the mental health arena, there are ethical concerns that the psychiatric clinical research may expose those being studied to potential harm (1). Despite a paucity of data, a recent systematic review suggests that negative reactions to research participation occur in <10% of patients (2). Individuals with complex psychopathology are more disposed to experience distress in clinical research settings (3). Specifically, there are reservations about research among individuals diagnosed as suffering from schizophrenia (1, 4). Nevertheless, the pressing needs of patients with SMI, their families and health care providers require continuing research in order for clinicians to be able to offer hope of remission or recovery (5). The past decade has not provided novel solutions or ground-breaking discoveries in the treatment or prevention of SMI and may have resulted in despair by mental health professionals (6). In a parallel process emphasized over the past decade, the pharmaceutical industry has begun to withdraw its investment in central nervous system (CNS) researchand-development. The high cost and high risk of CNS

Address for Correspondence: Yoram Barak, MD, MHA, Director, Psychogeriatrics, Abarbanel Mental Health Center, 15 Keren Kayemet Leisrael Street, Bat Yam 59100, Israel   mdybarak@gmail.com

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Real-life decision making of Serious Mental Illness patients: Opt-in and opt-out research participation

drug development coupled with decreased opportunities for pharmaceutical companies to recoup their investments and make profits to reinvest in further research and development is now reaching its logical conclusion: companies curtail developing new medications for CNS diseases (7). Thus, investigating patients with SMI preferences and choices as to participation in clinical research may enable the identification of patient subgroups that are amenable to participation. In addition, characterizing the “consenting” patient with SMI may be translated into benefits for patients, drug developers, regulatory agencies and other interested parties. Social psychologists have long been interested in decision making and several insights are relevant to the patient-physician dialogue concerning participation in research. When faced with momentous and non-trivial decisions, subjects are reluctant to make a decision and tend to avoid deciding and to rely on factors that should not affect their choice (8). Moreover, the role that patients play in decision making has shifted from physician paternalism towards informed autonomous relationships (9). The shift in the patient-physician-relationship has placed decision making in the center of this dialogue. One of the main themes in the study of decision making suggests that there are techniques that may result in better outcomes for patients. For example, defaults may be best when strong evidence suggests an option to be best for most people, but preserving patient choice is appropriate. Defaults in decision research are defined as a preselected option adopted when no alternative is specified. Alternatively, the use of environments that explicitly facilitate the optimal construction of preferences is most appropriate when choice depends on a patient’s ability to understand probabilities and outcomes (10). Respondents’ preferences, even for substantively important decisions, are influenced by factors that should not affect the choice, such as the wording used to present data (11). Social psychology demonstrates that subjects’ choice is influenced by opt-in versus opt-out presentation of decision algorithms. Defaults not only make a difference in what is chosen, they can also make decisions easier. Moreover, default decisions are optimal when subjects have a strong propensity to procrastinate (12). This factor is particularly relevant to SMI patients presented with complex and affectively loaded decisions. The impact of defaults have been emphasized in the general public by several unintended “natural experiments” in which governmental and public organizations randomly assign people to one program and then give the chance 200

to choose among a set of alternative ones - examples include assignment to health care plans, the adoption of privacy policies and organ donation, where the stakes are high (8). These “natural” experiments show that defaults have a substantial role in determining what is chosen. In most cases, the majority of people choose the default option to which they were assigned (13). We are facing a time of progressively more complex options in SMI research and treatment, in which data require continuous updating, and preferences and values become highly relevant. Patients are overwhelmed by information through the internet, personal contact with other patients, family physicians and patients’ organizations, while very few information sources are evidencebased, or are based on rigorous guidelines. Moreover, health messages on television and other mass media have the potential to significantly influence patients’ healthrelated knowledge and behavior, though little is known about patients’ ability to comprehend such messages (14). Serious ethical concerns come along with using defaults with vulnerable populations. While examining the impacts of defaults in a high-risk population like patients with SMI is addressing a gap in the literature, it must be done cautiously and any such investigation must take care to address the many ethical issues that arise, including the possibility of undue coercion of a vulnerable population. Thus, the present study was designed to evaluate the role of defaults in patient’s with SMI decisions to participate in clinical research in real-life, with the hope that the results would aid both treating psychiatrists and researchers in characterizing those patients willing to take part in clinical research. Methods Subjects

Patients admitted to the Abarbanel Mental Health Center were recruited between January and June, 2012, according to the following eligibility criteria: (1) a DSM-IV diagnosis of a SMI (schizophrenia, schizoaffective disorder, bipolar disorder and major depressive disorder), (2) availability to participate within 48 hours of admission and (3) aged 18 years and older. We excluded patients with cognitive impairment (mental retardation or dementia) and patients who had already participated in other studies related to informed decision making. Enrollment took place consecutively until the planned sample size was achieved.


Amira Or Et al.

Protocol

Randomization was carried out by a concealed allocation using a computer-generated list of random numbers. The ratio for randomization was 1:1:1 (neutral, opt-in, optout). The study was approved by the Abarbanel Mental Health Center IRB committee. We asked respondents to endorse a short questionnaire that focuses on whether they would participate in clinical research during the current hospitalization and specifically a study focusing on novel drug treatment for their condition using one of the following three options: Opt-in condition: patients were told that the policy in our center is not to enroll patients in clinical research; they were given a choice to confirm or change that decision. Opt-out condition: patients were told that the policy in our center is to enroll patients in clinical research; they were given a choice to confirm or change that decision. Neutral condition: patients were required to choose whether to participate in clinical research, with no prior option or information as to the policy in our center. In the opt-in and opt-out conditions a “no decision” answer was unacceptable. Participants were told the information they received was standard information in our center. We estimated that the great majority of patients would adhere to the default condition presented to them. We assumed that if inclinations concerning participation in research were strong, defaults would have only a minor effect. Statistical Analysis

Data were analyzed using a paired-samples and independent-samples approach. The two-tailed t-test and a nonparametric test were undertaken to evaluate differences between the evaluations for qualitative parameters. Examination of differences between the categorical parameters was based on the Pearson chi-square and contingency coefficient tests. All tests applied were twotailed, and a p-value of 5% or less was considered statistically significant. The data was analyzed using Statistical Analysis System software, version 6, 1990. Results We enrolled 311 SMI patients in this study. Patients were suffering from schizophrenia (n=166, 53%), schizoaffective disorder (n=63, 20%), MDD (n=40, 13%) or bipolar disorder (n=44, 14%). All completed the attitudes questionnaire within 48 hours following admission to an acute psychiatric ward. Patients sent for observation by court order were not

included as these are not eligible to participate in research in Israel. There were 156 men (50%) and 155 women in the sample, with a mean age 47.8 ± 16.2 years. In the “neutral” questionnaire (no stated position of researchers), 51% of 104 patients declared they would like to participate in research (45% of whom were schizophrenia and schizoaffective patients) and 33% declared they refused participation (73% of whom were schizophrenia and schizoaffective patients), and 16% were undecided if they wished to participate in research (of whom 41% were schizophrenia and schizoaffective patients). In the opt-out questionnaire (where we declared that we are assigning them to participate as research candidates), 42% of 101 patients actively declared they wish to withdraw from participation in research (60% of whom were suffering from schizophrenia and schizoaffective disorder), while 58% did not change their assigned position (47% of whom were suffering from schizophrenia and schizoaffective diorder). The proportion of patients who opted to decline participation in research in the opt-out arm was not significantly difference from chance (c2=0.434; p=0.071). Thus, in comparison to the neutral condition, 7% more patients “adhered” to the center’s policy to participate in research. In the opt-in questionnaire (where we declared that we do not seek research candidates), 42% of 106 patients actively sought to participate in research (43% of whom were schizophrenia and schizoaffective patients), while 58% did not change their assigned position (61% of whom were schizophrenia and schizoaffective patients). Thus, in comparison to the neutral condition 25% more patients “adhered” to the center’s policy not to participate in research. In comparison to the neutral condition, a smaller proportion of patients requested to be included in clinical research. In order to achieve this 42% of the patients had to “actively” opt- in, that is, to change the default and to participate in research, and this was significant (c2=9.49; p=0.004). This may imply that the “declared” policy not to participate in research had only a minor influence on patients’ choice. Comparisons between the three conditions (not with “chance” but to each other) demonstrated only one significant finding. In the opt-out condition SMI patients were older than in the two other groups (p<0.05). See Table 1 for details of patients’ preferences. We defined a “willing” participant as a patient who chose to participate in research in the neutral arm, to actively seek participation in research in the opt-in arm and to remain in the “offered” research position in the opt-out arm. In total, there was 155/311 (50%) “willing” patients who chose to participate in research. Of these, 201


Real-life decision making of Serious Mental Illness patients: Opt-in and opt-out research participation

Table 1. Details of patients’ preferences Neutral n=104

Opt-out n=101

Opt-in n=106

Total

Yes

53 (51%)

58 (58%)

44 (42%)

155 (50%)

Schizophrenia

24 (45%)

27 (47%)

19 (43%)

71 (43%)

No

34 (33%)

43 (42%)

62 (58%)

137 (44%)

Schizophrenia

25 (73%)

26 (60%)

38 (61%)

87 (53%)

Undecided

17 (16%)

-

-

17 (5%)

Schizophrenia

7 (41%)

-

-

7 (4%)

Total schizophrenia

56 (54%)

53 (52%)

57 (53%)

166 (53%)

only 70 were suffering from schizophrenia and schizoaffective (45%) were significantly under-represented in the “willing” group (p<0.04). Compared to patients who did not chose to participate in clinical research, the “willing” participants were statistically significantly younger, with more recurrent hospitalizations, higher rates of physical co-morbidity and diagnosis of an “affective” disorder (including schizoaffective) (p<0.05). See Table 2 for demographic details of all participants and the “willing” group. Discussion Clinicians who treat patients with SMI may encounter a variety of ethical issues related to both treatment of patients and their participation in clinical research. Neuropsychological impairments, as well as psychotic and severe affective symptoms and lack of insight, can affect patients’ abilities to make fully informed decisions about their own research participation. Attention to the process of informed consent as an ongoing dialogue strengthens the clinician-patient relationship and helps patients clarify preferences. In addition, investigators are attuned to and aligned with research participants in many, but not all, respects on the importance of participating in clinical studies. Investigators may bring a protective bias in their predictions of the vulnerabilities of ill volunteers (15). Decision-making abilities of people with SMI in research contexts call for in depth studies (16). The present study

aimed to add to the limited literature in this field. Our findings demonstrate that half of the acutely admitted patients declare their wish to participate in clinical research; the great majority of those who do not wish to participate are suffering from schizophrenia and schizoaffective disorder. Using the opt-out questionnaire, the percentage of SMI patients who actively remove themselves from participation decreases by more than 12%. Although not a huge drop, it lays the ground for psychoeducation and possibly other interventions to increase patients’ participation in research. Patients’ decisions depend on individual values and relevant outcomes. One obvious explanation may be that patients were not paying attention, or did not understand what they were consenting to. Patients’ reports about their participation preferences in medical decisions can be predicted to a considerable extent. For patients with SMI, poor treatment satisfaction, negative attitudes toward medication, better perceived decision making skills and higher education were related to higher participation preferences. Patients with SMI who want to participate in decision making are often dissatisfied with care or are skeptical toward medication. Patients who judge their decisional capacity as poor or who are poorly educated prefer not to participate in decision making (17). Research has repeatedly shown that the process of deciding is often difficult and even enigmatic. When faced with a decision that may impact our future significantly many of us circumvent the need to decide. The impediment to decision-making may often be the cost of making a decision. Since people consider this question aversive, there is some utility to choose the default, which allows people not to make choices, because making a decision is cognitively costly (18). In this context it should be pointed out that the assumption that people have reached a decision is frequently mistaken. Instead of expressing well-articulated preferences, the preference in regards to a medically significant decision is not well formed, suggesting the possibility that decisions are often constructed in response to the pertinent question. As a result, the form of the question influences the response (19, 20). One advantage of the present study is that it uses a

Table 2. Demographics Age (Mean ± SD)

Female (%)

Schizophrenia (%)

Schizoaffective (%)

MDD (%)

Bipolar (%)

All (N=311)

48.5 ± 14.6

50

53

20

13

14

“Willing” (N=155)

44.8 ± 15.7

46

31

14

32

23

“Willing” participant - a patient who chose to participate in research in the neutral arm, to actively seek participation in research in the opt-in arm and to remain in the “offered” research position in the opt-out arm. MDD – major depressive disorder

202


Amira Or Et al.

sample of patients for whom the choice to be made has important consequences. In that sense, this is a valuable field study. Patients with SMI actively participated in the decision-making process and specifically chose active options. Only a few (16% of patients in the neutral condition) could not make a definite choice. It is conceivable that the guidelines presented to the patients in the default conditions had swayed the hesitant patients into a clear-cut decision. While the neutral condition revealed that half of our SMI patients are inclined towards research participation, the opt-out default increased patients’ research participation choice moderately. On the other hand, in the opt-in condition more than 40% of the patients had indeed acted “against” the recommendations of our center’s physicians gravitating towards participation in research. Social psychology demonstrates that subjects’ choice is influenced by opt-in versus opt-out presentation of decision algorithms. Defaults not only make a difference in what is chosen, they can also make decisions easier. Moreover, default decisions are optimal when subjects have a strong propensity to procrastinate (12). This factor is particularly relevant to SMI patients presented with complex and affectively loaded decisions. The impact of defaults have been emphasized in the general public by several unintended “natural experiments” in which governmental and public organizations randomly assign people to one program and then give the chance to choose among a set of alternative ones – examples include assignment to health care plans, the adoption of privacy policies and organ donation, where the stakes are high (8). These “natural” experiments show that defaults have a substantial role in determining what is chosen. In most cases, the majority of people choose the default option to which they were assigned (13). However, it has not been conclusively demonstrated that in real-life situations, where patients have to commit a major disease-related act (start treatment, undergo surgery or participate in research), defaults play a significant role. A growing literature has examined how these findings may be placed within the context of the therapeutic relationship. Researchers involved in these studies suggest that many patients do not seek the level of involvement which the bioethics literature suggests they should wish. The strong preference for a shared role – physician-patient cooperation – suggests that patients wish to understand their disease and the choices available to them, and to be involved in aspects of decision-making that will affect their quality of life. However, they are willing to leave much of the responsibility for tasks that require expertise to the treating physician (21).

In conclusion, this study evaluated a sample of inpatients facing an important medical decision. The impact of defaults is an important subject of current research and adding to our knowledge of the magnitude of their effects “in the field” is valuable. Unlike lay persons required to decide on important medical matters, patients with SMI take a stand preferring research participation moderately swayed by defaults presentation. We hope that the results would aid both treating psychiatrists and researchers in characterizing those patients willing to take part in clinical research. References 1. Wilson ST, Stanley B. Ethical concerns in schizophrenia research: Looking back and moving forward. Schizophr Bull 2006;32:30-36. 2. Jorm AF, Kelly CM, Morgan AJ. Participant distress in psychiatric research: A systematic review. Psychol Med 2007;37:917-926. 3. Boothroyd RA. The impact of research participation on adults with severe mental illness. Ment Health Serv Res 2000;2:213-221. 4. Roberts LW, Warner TD, Brody JL. Perspectives of patients with schizophrenia and psychiatrists regarding ethically important aspects of research participation. Am J Psychiatry 2000;157:67-74. 5. Barak Y, Bleich A, Aizenberg D. Psychosocial remission in schizophrenia: Developing a clinician-rated scale. Compr Psychiatry 2010;51:94-98. 6. Spurgeon D. Medicine, the unhappy profession? CMAJ 2003;168:751-752. 7. Nierenberg AA. The perfect storm: CNS drug development in trouble. CNS Spectr 2010;15:282-283. 8. Johnson EJ, Goldstein DG. Defaults and donation decisions. Transplantation 2004; 78: 1713-1716. 9. Coulter A. Paternalism or partnership? BMJ 1999;319:719-720. 10. Johnson EJ, Steffel M, Goldstein DG. Making better decisions: From measuring to constructing preferences. Health Psychol 2005;24:S17-22. 11. McNeil BJ, Pauker SG, Sox HC, Tversky A. On the elicitation of preferences for alternative therapies. N Eng J Med 1982; 306: 1259. 12. Carroll GD, Choi JJ, Laibson D, Madrian BC, Metrick A. Optimal defaults and active decisions. Quart J Economics 2009;124:1639-1674. 13. Norton MI, Frost JH, Ariely D. Less is more: The lure of ambiguity, or why familiarity breeds contempt. J Personal Soc Psychol 2007;92:97-105. 14. Kassirer JP. Incorporating patients-preferences into medical decisions. N Eng J Med 1994;330:1895-1896. 15. Roberts LW, Kim JP. Do investigators understand ethically-important perspectives of clinical research participants?: A “piggy-back” study of attunement and alignment in serious illness research. J Psychiatr Res 2014; 52: 36-43. 16. Dunn LB. Ethical issues in schizophrenia: Considerations for treatment and research. Psychopharmacol Bull 2007;40:145-155. 17. Hamann J, Mendel R, Reiter S, Cohen R, Bühner M, Schebitz M, Diplich S, Kissling W, Berthele A. Why do some patients with schizophrenia want to be engaged in medical decision making and others do not? J Clin Psychiatry 2011;72:1636-1643. 18. Deber RB, Kraetschmer N, Urowitz S, Sharpe N. Do people want to be autonomous patients? Preferred roles in treatment decision-making in several patient populations. Health Expect 2007;10:248-258. 19. Payne JW, Bettman JR, Johnson EJ. Behavioral decision research: A constructive processing perspective. Ann Rev Psychol 1992;43:87. 20. Chin-Parker S, Bradner A. Background shifts affect explanatory style: How a pragmatic theory of explanation accounts for background effects in the generation of explanations. Cogn Process 2010;11:227-249. 21. McNutt RA. Shared medical decision making: problems, process, progress. JAMA 2004;292:2516-2518.

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Isr J Psychiatry Relat Sci - Vol. 51 - No 3 (2014)

Ethics and the Psychiatry Journal Editor: Responsibilities and Dilemmas David Greenberg, MD,1,2 and Rael D. Strous, MD3,4 1

Herzog Hospital, Jerusalem, Israel Hadassah School of Medicine, The Hebrew University, Jerusalem, Israel 3 Beer Yaakov Mental Health Center, Beer Yaakov, Israel 4 Sackler Faculty of Medicine, Tel Aviv University, Ramat Gan, Israel 2

Abstract An array of potential ethical stumbling blocks awaits the editors of scientific journals. There are issues of particular relevance to mental health journals, and others unique to local journals with a relatively small circulation and low impact factor. The blind review system, conflict of interests, redundant publication, fraud and plagiarism, guest and ghost authorship and ghost writing, advertising, language and stigma, patient consent, and “rigging” the Impact Factor are all issues of importance. It is critical that editors are aware and informed of these important issues, and have an accessible forum for evaluating problems as they arise.

Introduction Editing a journal is not a simple task. There are many challenges: finding finance, authors, reviewers, publishers, and a reading public. One challenge not commonly addressed is the ethical considerations that go hand in hand with the responsibility of editorship. In general Roberts (1) has defined ethics as “ways of understanding what is good and right in human experience. It is about discernment, knowledge, self-reflection, and it is sustained through seeking, clarifying, translating. It is the concrete expression of moral ideals in everyday life. Ethics is about meaning, and it is about action.” With respect to academic publishing, while “ethical considerations” may be defined in several ways (2, 3), many would refer to the definition of ethics in editorship as conforming to a well-founded set Address for Correspondence:

204

of moral principles or to the rules of appropriate conduct in such endeavor. It relates to rightness and wrongness of certain behaviors and motives relating to the evaluation and publishing of academic manuscripts ensuring that standards of moral principles and appropriate conduct are maintained in the process. Ethical conduct in publishing does not exist in a philosophical vacuum or without various dilemmas including conflict at times between several competing philosophical principles including that of deontological (absolute right and wrong in individual cases) versus utilitarian considerations (the greater good for the greater number) (2). While some of the ethical issues are addressed in the literature and are commonly known to members of the medical profession (fraud, plagiarism, salami publishing, ghost authorship, “honorary authorship,” etc.), there are several issues, such as language and stigma, and confidentiality which are somewhat unique or have a unique connotation and require particular sensitivity in a psychiatric journal. In addition, a small journal such as the Israel Journal of Psychiatry (IJP) has to deal with matters not always faced by larger and more international journals. For example, manuscripts have been submitted, often for a special edition, which have already been published in a very similar form in other formats, be they academic journals, popular media, etc. It may be that the author considers republishing the article in a peripheral journal to be likely to pass unnoticed without considering the ethical implications. We see our function as editors to be sensitive but uncompromising on ethical standards for the journal despite limited exposure and readership compared to other international journals. Walter and Bloch (4) wrote an early review on ethics in psychiatric journals, at which point they were able to conclude that “publishing misconduct” was rare. It would

David Greenberg, MD, Herzog Hospital, POB 3900, Jerusalem 91035

davidg@mail.huji.ac.il


David Greenberg and Rael D. Strous

seem that since then more has been revealed of what has been happening over decades. Peer Review Manuscripts must be evaluated and the method of peer review is generally accepted. More than one review is sought, and, with the rapid expansion in the number of journals, this has created a huge industry of editors seeking reviewers, with the responsibility to find a suitably informed and willing reviewer. For decades, the method of double-blind reviewing was accepted. However, since a 1994 report published in Cardiovascular Research, despite their finding that most authors and reviewers favored anonymity (5), leading journals have moved to open reviews in which the authors’ and reviewers’ identities are known to each other. Regehr and Bordage (6) surveyed 2,435 authors and reviewers of Medical Education, with a response rate of only 34.4%, 838 out of 2,435. When asked what system they favored, 68% preferred no author names and 72% no reviewer names. Less experienced reviewers and authors were more in favor of anonymity. Blind review was favored as being more fair, honest, with less rivalry and conflicts, while reasons for open review were accountability and transparency. A team from the British Medical Journal (BMJ), van Rooyen et al. (7), compared open and blind reviews and did not find that open reviewing improved quality; open reviewing had a higher refusal rate: 35% versus 23%. The authors emphasize the overriding importance of transparency, as a blind reviewer can delay publication, prefer publication of like-minded researchers, and can even rob authors of ideas expressed in the manuscripts they have received for review. Taking transparency a step further, van Rooyen et al. (8) compared open review with online publication of the signed review and found online publication did not change the quality of the reviews. However, 55% of their sample of reviewers refused to participate on this understanding. As editors, we can understand the benefits of online publication of reviews, for the process is often highly educative. It can, however, be humiliating. Further, while non-blind reviewing may seem more ethical for authors, could it be less ethical for reviewers, as a more powerful author could become vengeful, and could the author’s name alone bring about acceptance? Baggs et al. (9) found that 93.6% of reviewers to nursing journals preferred blind review. An editorial in Nature (10) reported that most academics prefer blind review, although they saw it as less preferable for reasons of accountability.

Several other factors require mention on the subject. The high reviewer refusal rate in open reviewing has an important implication. Most of the studies quoted above were of high-impact factor journals, most of which have salaried administrative staff. Many journals, however, like the IJP, have no administrative staff whose task is to hunt for reviewers. An additional truth particularly apparent in smaller journals is that reviewing is a thankless task that is done by busy professionals in addition to all their other functions. They are a species that should be protected. In conclusion, after decades, the subject has still not been resolved. The reasons are clear on either side: transparency and the possibility of delay and idea theft, versus the impact of reputation over content, and the possibility of adversely affecting a reviewer’s career. As editors of a small journal in a small country, finding able and willing reviewers is not simple, and such pragmatic considerations have dictated that we do not follow the BMJ. Other ethical issues that the editor may need to deal with include how best to manage delayed reviewer responses and how to locate reviewers with appropriate proficiency for the task (11). The outcome of the review process may even be a foregone conclusion, for every experienced editor knows which reviewers are stringent or lenient, detailed or cursory, aggressive or polite, rapid or tardy. The editor’s best friend, besides the reviewer who sends a detailed review quickly, is the one who declines but recommends a suitable alternative. The editor’s worst friend is the colleague who agrees to review and does not answer all subsequent mail. This may be considered unethical behavior on the part of the reviewer at worst and at best unprofessional. Ethics in Advertising in Journals The attitude of most journals to advertising is of the righteous sinner: “We really shouldn’t deal with these people, but what can we do? We allow them to decorate our journals but of course we remain independent to form our own knowledge base.” Neill (12) reviewed the psychotropic advertisements from 1955-1980 and suggested the changing images served a function to reflect the psychiatrist’s identity, from 50s psychoanalysts, for whom medication was facilitating psychotherapy, through to 70s psychopharmacologists, for whom the drug was the message. Spielmans et al. (13) found that over 50% of claims in advertisements for psychiatric medications in two psychiatric and two general medical journals were unsubstantiated. In those with supporting citations, only 65% of the citations sup205


Ethics and the Psychiatry Journal Editor: Responsibilities and Dilemmas

ported the claims, and when the citation source was the drug company, they invariably refused to provide data. The authors concluded that advertisements may be misleading and journal editors should be more active in vetting advertisements. In 1992, the Annals of Internal Medicine published a study critical of the content of advertising in ten major journals (14), along with an editorial and response by the Commissioner of the FDA. The response to the publication was an orchestrated set of industry-financed negative evaluations of the study, reflecting the basis of the marriage between the medical publishing and the drug industries. To clarify the extent that the journal was free to publish, the Annals lost an estimated $1-1.5m in advertising as the drug companies responded by withdrawing their support, and the journal’s editors resigned (15). A further conflict of interests exists in that there is a clear motivation for a journal to publish a study that shows an advantage to a particular medication, in the knowledge that drug companies may spend sums on reprints (the IJP is spared this temptation as reprints are freely available online) (16). Despites these ethical problems, Ryan et al. (16) presume that drug advertising in psychiatric journals will not end, as both sides benefit in a symbiotic relationship, but they recommend the editors vet the content of advertisements, declare no link with the content of advertisements, advise readers to be skeptical as to the claims made, ensure that advertisements are separated from papers, avoid themes suggested by the drug industry, and advertisements that appear as academic contributions. Richard Smith, then editor of the BMJ, stated that the BMJ does not vet the contents of advertisements (17), as advertisers claims are restricted by law, and competitors will complain if they make excessive claims, as can readers. Journal owners, and therefore editors, have an interest in accepting advertisements, and he believes they should spend their time improving editorials, and not vetting advertisements unless for offensive imagery. This position seems over simplified to us, as most advertisers presumably will not attack their competitors unbased claims for fear of retaliation. Foster (18) compared the imagery and text in a year of advertisements of psychiatric versus non-psychiatric medication in the BMJ and British Journal of Psychiatry and found the former had less text, the text was uninformative, and the images were more stigmatic representations: general medical advertisements showed the patient after treatment, happy and well employed, while the psychiatric patient was invariably shown before treatment, 206

“passive, deviant and inactive” (p. 29). In conclusion, drug company advertisements are often misleading and stigmatic. It is up to a journal’s policy whether to vet these matters. Advertisements are apparently very financially rewarding for the drug companies, and at present are a sine qua non of medical publishing. Ethics of Authorship The ethical problems with authorship are of two types: gift and ghost authorship. Gift or honorary authors are listed in a publication for reasons of authority or as reciprocation for gift authorship, or for providing data, while ghost authors are those low in the hierarchy whose superiors decide they should not appear despite their significant contribution. There is an increasingly reported form of ghost authorship referred to as ghost writers whereby positive and flattering studies or reviews are written by drug company staff or medical communication companies in their employ for known names in academia to publish – thus providing significant legitimacy to the product. Over the decades the average number of authors per paper has increased. While this was understood to be a result of the increasing sophistication of medical research, it was apparent that gift or honorary authorship also contributed. In an attempt to curb the phenomenon, the International Committee of Medical Journal Editors (ICMJE) defined the scientific contribution that justifies authorship of a paper as follows: “1) substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; 2) drafting the article or revising it critically for important intellectual content; and 3) final approval of the version to be published. Authors should meet conditions 1, 2, and 3” (19). As is the case with the IJP, it was recommended that these criteria should appear in the instructions to contributors of a journal. Not all journals include these criteria, and many journals, including the IJP, do not require that each author signs and submits a declaration of authorship. Baerlocher et al. (20) compared leading medical journals to note the impact of authors having to complete declarations of authorship. They found that the trend of increasing numbers of authors was unaffected by the introduction of authorship declarations, suggesting it does not deter gift authorship. However, Wislar et al. (21) found in a survey of 630 authors (70.3% response rate) of six leading medical journals that the prevalence of honorary and ghost authorship decreased from 29.2% in 1996 to 21% in 2008. In the accompanying editorial, Baskin and Gross (22), editors of Neurology,


David Greenberg and Rael D. Strous

suggested the ICMJE criteria (meeting all three criteria) were impractical. Neurology requires participation in only one of the three areas and requires disclosure of specific contributions. They recommend increased transparency, with inclusion of professional ghost writers as authors. Some of the most public cases of ghostwriting have been in the remunerative field of psychiatric medication (23): a randomized control trial of treatment of adolescent depression published in JAACAP was ghostwritten, stating use of Paxil was safe and effective, although the trial’s data supported neither claim; a medical communication company was preparing 85 papers for the manufacturers of Zoloft, 55 of which appeared in leading journals until 2003; the manufacturers of Paxil employed a company to prepare letters downplaying its withdrawal effects, published in a leading journal by a leading psychiatrist. A committee in the House of Commons found evidence of ghostwriting in 50% of controlled trials. Attempting to find a formula for revealing ghostwriting, McHenry (23) recommends not only defining authorship, but requesting authors acknowledge and describe the role of others who helped prepare the manuscript. In conclusion, it would appear that both gift authorship and ghostwriting are unaffected by the measures that have been recommended. Ghostwriting is particularly sinister, as both sides to the agreement are benefitting themselves and misleading the medical and general public. In the publicized case of Vioxx this cost many lives. Whatever steps are taken, the sums at stake will mean that the perpetrators will usually be one step ahead of journal editors. The only means of limiting the phenomenon would seem to be severe sanctions taken by employing institutions. Redundant Publication “Salami” publishing (dividing a single study into several papers) and publishing the same findings in more than one journal have well reported examples in psychiatry (see response of the editors of the psychiatric journals involved [24]) and even publishing the same study in three journals (see editorial, 25 and the whistle blowers’ letter, 26). In our experience, the IJP has on two occasions been sent a manuscript that was found to have already been published verbatim. Walter and Bloch (4) report four cases of plagiarism in psychiatric publications. As the stolen material is often “buried” within a paper, it is usually difficult to detect, although an erudite reviewer has reported one case in our experience. The editors wrote to the author, who does not work in Israel and is not a

native English speaker. The author was apologetic, and no further action was taken (Babalola et al. [11] bring a vignette in which the editor wrote to the departmental head of an author who denied a new submission was identical to a previous publication [“self plagiarism”]). See also the Committee of Publication Ethics on plagiarism (27), and recent moves by journals to use programs to identify plagiarized texts (28). Fraud In the 1980s a series of studies of the use of tranquillizers in mentally retarded children were investigated by the NIMH, who concluded the studies had not been performed. The main researcher pleaded guilty to making false statements on grant applications and was sentenced to 60 days in a halfway house, community service and five years probation (29). In 1988 the journal editor of one of the papers published a detailed account of the responses of the author, yet to stand trial, and his coauthors. The editor noted: “Journals cannot retract – that is the obligation of authors, who must personally vouch for the accuracy and opinion their report contains. We can repudiate our association with a study” (30). The author’s publications investigated by NIMH appear in Pubmed along with links to the retractions. Language and Stigma Of all disorders, psychiatry is arguably associated with the greatest stigma. Stigma is an attitude of society, experienced by the sufferer and often their family, affecting their selfesteem, work, living arrangements and relationships. Mental health professionals have been found to have stigmatic attitudes towards their clients (31), and this may appear in professional publications. We view the use and avoidance of stigmatizing language as an ethical issue. In 2006, Psychiatric Services published a letter by Corrigan, a researcher and advocate of recovery and the effects of the media on stigma. Corrigan complained at the use of language in the title of a paper on “difficult patients”: “It frames a person’s experience in the pejorative. It implies that people with mental illness are responsible for the symptoms and disabilities that they face. It is patriarchal and suggests that the service provider, not the person, knows what is best. It chastises the person with mental illness for having a poor relationship with the health care provider” (32, p. 1218). Although accused of being awkward and politically correct, people-first language is gradually predominat207


Ethics and the Psychiatry Journal Editor: Responsibilities and Dilemmas

ing in journals. According to the concept of people-first language, people are no longer to be referred to as being schizophrenic, autistic or depressed, but rather as a “person with schizophrenia,” etc. This may not change attitudes to those who live with schizophrenia, but, as the term personfirst implies, similar to the above position by Corrigan, the message is that first of all, the person is a person. The illness is not all, a concept enthusiastically supported by the Recovery movement in psychiatric rehabilitation. While professional journals are neither written for nor read by the general public, with the expansion of communications their findings are increasingly the subject of interest of the general media, so that there is a wider responsibility to journalists and their readership. Besides language, choice of themes may also influence readers. Corrigan et al. (33) evaluated themes in 3,353 stories dealing with mental health issues in 70 newspapers with large readership in the U.S. over six weeks in 2002. Thirtynine percent dealt with violence and tended to be in the front section of the newspapers, while 20% dealt with advocacy and improving conditions for the mentally ill. The question of whether the press negatively influences public stigmatic attitudes by emphasizing the link between mental illness and violence or merely reflects the findings that violent crime is more commonly associated with the mentally ill is not answered by such studies. While it is not solely a journal’s role or even duty to change stigma, a journal with its editor does have some influence in correcting the often injustice to those who are mentally ill. Thus, as policy we believe that editors need to be sensitive to issues of stigma and insist on respectful terminology in addressing those with mental illness. Conflict of Interest Conflict of interest (COI) is when a person has a personal or financial link to the subject they are researching that may influence their handling of the subject. In medical research, this will apply to all authors, reviewers and editors. Presence of conflict of interest does not ipso facto mean that bias has occurred; however, the presence of a potential conflict must be reported. The ICMJE continues to update its form on COI, available for downloading by all journals at http://www.icmje.org/coi_disclosure.pdf. Journals should therefore enquire about COI and publish the response with the paper. Perlis et al. (34) looked at the clinical trials in psychiatry published over three years in four major journals. Of the 397 studies surveyed, 60% had pharmaceutical company funding, and 47% had an author 208

with COI. Of the 162 randomized double-blind placebocontrolled trials, having an author with COI was 4.9 times more likely to report a positive result for the medication. Of interest, Roseman et al. (35) found that while studies may publish statements on COI, meta-analyses usually do not give this detail about the studies they are surveying. They found that only two out of 29 meta-analyses in high impact journals in general medicine included data on drug company funding and none reported authors’ COI or drug company employment, despite the studies on which they were based having drug company funding (69% of the 62.5% that reported funding sources) and an author with COI (69% of the 30% that reported authors’ financial ties), and an author employed by a drug company (26% of the 95% that reported authors’ affiliations). Aware of the significant role played by the authors of reviews in selecting and interpreting the studies reviewed, Kopelman et al. (36) evaluated the declarations of COI of the authors of reviews in ten high impact factor psychiatric journals and two general medical journals. Although 32% of the psychiatric journal reviews had links with industry, the details provided were not a useful guide for the average reader to understand the possible impact on the reviews, leading Kopelman et al. to suggest journals that invite reviews should select the many potential authors who do not have these conflicts of interest. COI is a complex subject in complex times. Studies with a large sample and sophisticated design usually require financial support, and the drug companies are willing contributors. It is important that reporting of positive and negative findings is not influenced by the sponsors. To combat such a possibility, an open-access registry of clinical trials was set up by NIH at ClinicalTrials.gov, although it is early to evaluate its impact (37). In the interest of ethical publishing, the journal editor needs to be sensitive to these issues and encourage and ensure transparency and full disclosure along these lines. Consent and Confidentiality in Case Studies A hallmark of medical literature is the improvement of clinical management of individuals or groups of patients. This is attained by the sharing of experiences, successful or unsuccessful, of medical phenomenology or management, which may assist others in the field by virtue of disseminating information worldwide in a manner that would allow other practitioners to benefit from one’s experience. However, it is now accepted as critical that


David Greenberg and Rael D. Strous

patient consent is obtained prior to any individual case study being published. This is not a new stipulation of journals, although it has been made especially strict following several celebrated examples where the patient described in the medical literature has been able to be identified or has been identified by others. One prominent example was an account in the British Journal of Psychiatry, including the patient’s profession and external physical disabilities, that led to her identification by friends when a local newspaper picked up the story. As the case report included clinical and personal details and even expressed doubt at the veracity of her account, the patient turned to the General Medical Council as she had not given explicit consent and was understandably offended (38). This case lead to a change in policy by ICMJE, requesting that the patient sees the written case report and signs consent prior to its publication (39). Many journals now demand patient consent prior to any case study being published, or insist on changes in features of the patient such that there would be no way that the patient would be identifiable by any details quoted in the case study. Some journals require both, some only one of these criteria. For example, the British Journal of Psychiatry guidelines make it clear that consent should be obtained, and that if it is not, adequate attempts should be made to ensure that the patient’s identity is disguised, to the degree that the patient cannot identify himself (39). Our journal requires that all reports on human subjects “must include a statement that the subject gave informed consent and patient anonymity should be preserved.” The reason for patient consent is clear – the dignity and autonomy of the individual patient need to be preserved despite the utilitarian greater good that may arise from disseminating such a case to the general medical community. Levine and Stagno (40) observe that while patient consent avoids the risk of legal redress, it does not prepare patient or therapist for the effect that publication may have on the patient, the effect on others of the publication, and the effect on the therapeutic relationship. Gabbard (41) contends that utilizing clinical experience with patients for educational purposes or for publication creates “a conflict of interest between the protection of the patient’s privacy and the educational and scientific needs of the field” (p. 1071). Moreover, confidential clinical information becomes used for professional advancement of the patient’s treating professional. In order to confront this issue, Gabbard (41) suggests several possible solutions to the dilemma including making use of thick disguise, patient consent, the use of composites and substituting a colleague as author.

The issues are indeed complex. Most forensic cases, where a therapeutic relationship is often not present, are unlikely to give consent. Alternatively, patients with marked narcissistic or sado-masochistic tendencies may cooperate and try to insist on including lurid material that implicates others (42). Further, there is a growing general literature in which patient and therapist collaborate on a publication. While apparently ethical, patients and therapists often do not foresee the impact of this publicity on their lives and working relationships. A further complication arises in forensic psychiatry when information regarding the patient is already in the public domain and a psychiatrist merely takes this public information and analyzes it, sometimes in a very intimate and probing fashion. Since consent is now critical to publication in psychiatry, we believe there is no room for compromise and it would be unethical to publish such a case study without patient consent. As physicians, medical editors need to be cognizant of this and safeguard patient autonomy and dignity even if this is not always protected by law in the public domain. As medical professionals, confidentiality should not be breached regardless of what the media may publish. This is especially true since the “analyzing physician” may add professional comments in such a manner that new material would be added to what is in the public domain and thus further potentially adversely affect the patient’s dignity. Ethics and the Impact Factor The purpose of a journal should be to publish good research, stimulate discussion and keep its readers informed and up-to-date. The Impact Factor (IF) is a measure of how many times a journal has been quoted by other journals in the last two years. The existence of the IF has created a league table whereby one journal is evaluated numerically against others, and, more critical, the authors who publish in it are evaluated, so that it has become the most vital component in a researcher’s chances of academic advancement, and research funders and faculty respect publication only in the premier league (43). This has lead to a new primary criterion for a journal, and Gallagher (44) has suggested this leads editorial boards to lose their way and proper purpose. Editors have noted that it is possible to “rig the IF” by selecting articles of dubious value that will provoke controversy (44, 45) or have a policy of publishing reviews. Indeed Falagas and Alexiou (46) note that 16 of the top 25 top-flight science journals publish reviews only and 209


Ethics and the Psychiatry Journal Editor: Responsibilities and Dilemmas

publish no original research. In board meetings of the IJP, the Impact Factor has often been discussed. We have been shown letters sent by editors of other journals informing the author that a manuscript has been accepted, but, prior to final acceptance, they would be grateful if the author would consider adding references from the last year’s publications in the journal, and would cite references to the journal in their other publications. Indeed, Foo (47) presented the remarkable case of a journal editorial that quoted 66 of its journal’s papers in order to double its IF (and was penalized by having no IF the next year). These are unethical attempts to “rig the IF.” Lundh et al. (48) noted that high IF journals publish more industry-backed RCTs and metanalyses, and low IF journals publish more clinical studies, while Kanaan et al. (49) noted that low IF journals serve an important function in accepting negative outcome studies that the other journals reject as unlikely to attract citation, although their publication may be of critical importance to the field (see section on conflict of interests). Falagas and Alexiou (46) have listed the top ten “tricks” for rigging the IF: 1) return the accepted manuscript asking to add citations from the journal’s recent publications, 2) summarize and cite papers recently published, 3) cite the journal’s papers in editorials and correspondence, 4) decrease the IF denominator (number of citable articles) by including articles with no abstracts, and editorials, with few references, 5) publish more reviews, less original research and even fewer case reports, 6) reject negative studies and confirmatory studies, 7) publish from large known groups with many authors, 8) publish renowned scientists even if dubious quality research, 9) publish on popular controversial subjects, 10) have a short turnaround time to publication so that citations do not pass their IF “sell-by” date of two years. Ethical Decision Making and the Journal Editor It is clear from the above that ethical issues are abundant in medical publishing in general, and psychiatry in particular. It is important, however, not only to know what the issues are, but also how to deal with them. After identifying ethical concerns, a process of optimal ethical decision making is demanded. How is this achieved? There are several approaches to ethical decision making, and, while ethical decisions may differ, it is critical that the process begins, is comprehensive, has some element of peer review and discussion and is open to revisitation 210

(50). There are various approaches to ethical decision making including Siegler’s (51) “Four Topics Method” and that of the World Medical Association (2). Often there are competing arguments on each side within each principle, but some model is required for engaging the ethical discussion process. From the perspective of a medical journal editor, it is also critical that some form of consultation team for ethical dilemmas encountered by editors of a journal should be set up. Several journals have on an informal basis various advisors/ethics experts with whom they consult. This may take the form of individuals or even ethics clinical consultation teams similar to what hospitals are required to have in the context of “ethics committees” in addition to an IRB. On several occasions, the IJP has made use of ethics advisers when questions have arisen regarding manuscripts submitted to the journal. This process is worthwhile and should be encouraged. Discussion What is apparent from the above, and from other discussions of the ethics of editorship (11) is that every act of the editor has the potential of being performed unethically: delaying sending a manuscript out to review, selecting aggressive or tardy reviewers, not editing offensive remarks by the reviewers, refusing, or, perhaps worse, delaying publication. The author also has a large onus: did the research reported actually take place, does the actual author’s name appear, did all the listed authors actually participate adequately, has the study already been published, is conflict of interests declared? So too, the editorial staff: is people-first language used, are stigmatic terms removed, are adverts stigmatic, do they make invalid claims? Are there active maneuvers of IF rigging? The editorial board of the IJP meets twice a year. At these meetings it has become common for at least one ethical issue to be discussed. Similarly, the journal’s four editors are in regular contact, and it is not uncommon for questions of ethics to be discussed, and sent on to acknowledged experts for their opinion. It may be that each journal should have a standing ethics committee similar to many medical institutions to discuss ethical issues. In these ways, we try to be awake to potential ethical stumbling-blocks. The process of encouraging ethical sensitivity and dialogue in medicine is not confined to the practice of clinical medicine and research. Rather it extends as well to the publication of medical information and, as presented, the journal editor plays an important role.


David Greenberg and Rael D. Strous

References 1. Roberts LW. Ethics as endeavor in psychiatry: principles, skills, and knowledge. Psychiatric Times 2002; 12:19. 2. Williams JR (editor). WMA Medical Ethics Manual. World Medical Association, 2005. 3. Frankena WK. Ethics, 2nd edition. Englewood Cliffs, N.J.: Prentice Hall, 1973. 4. Walter G, Bloch S. Publishing ethics in psychiatry. Aust NZ J Psychiatry 2001;35:28-35. 5. Fabiato A. Anonymity of reviewers. Cardiovasc Res 1994;28:1134-1139. 6. Regehr G, Bordage G. To blind or not to blind? What authors and reviewers prefer. Med Educ 2006;40:832-839. 7. van Rooyen S, Godlee F, Evans S, Black N, Smith R. Effect of open peer review on quality of reviews and on reviewers’ recommendations: A randomised trial. BMJ 1999;318:23-27. 8. van Rooyen S, Delamothe T, Evans SJ. Effect on peer review of telling reviewers that their signed reviews might be posted on the web: Randomised controlled trial. BMJ 2010:341:c5729 doi:10.1136/bmj.c5729. 9. Baggs JG, Broome ME, Dougherty MC, Freda MC, Kearney MH. Blinding in peer review: The preferences of reviewers for nursing journals. J Adv Nurs 2008;64:131-138. 10. Editorial. Working double blind: Should there be anonymity in peer review? Nature 2008;451:605-606. 11. Babalola O, Grant-Kels JM, Parish LC. Ethical dilemmas in journal publication. Clinics Dermatol 2012;30:231-236. 12. Neill JR. A social history of psychotropic drug advertisements. Soc Sci Med 1989;28:333-338. 13. Spielmans GI, Thielges SA, Dent AL, Greenberg RP. The accuracy of psychiatric medication advertisements in medical journals. J Nerv Ment Dis 2008;196:267-273. 14. Wilkes MS, Doblin BH, Shapiro MF Pharmaceutical advertisements in leading medical journals: Experts’ assessments. Ann Intern Med 1992;116:912-919. 15. Tsai AC. Conflicts between commercial and scientific interests in pharmaceutical advertising for medical journals. Int J Health Serv 2003;33:751-768. 16. Ryan C, Walter G, Robertson M. College activities and the ethics of advertising. Australas Psychiatry 2010;18:101-105. 17. Smith R. Medical journals and pharmaceutical companies: Uneasy bedfellows. BMJ 2003;326:1202-1205. 18. Foster JL. Perpetuating stigma? Differences between advertisements for psychiatric and non-psychiatric medication in two professional journals. J Ment Health 2010;19:26-33. 19. International Committee of Medical Journal Editors, 2009 http://www. icmje.org/ethical_1author.html. 20. Baerlocher MO, Gautam T, Newton M, Tomlinson G. Changing author counts in five major general medicine journals: Effect of author contribution forms. J Clin Epidemiol 2009;62:875-877. 21. Wislar JS, Flanagin A, Fontanarosa PB, Deangelis CD. Honorary and ghost authorship in high impact biomedical journals: A cross sectional survey. BMJ 2011 Oct 25;343:d6128. doi: 10.1136/bmj.d6128 22. Baskin PK, Gross RA. Honorary and ghost authorship. BMJ 2011 Oct 25;343:d6223. doi: 10.1136/bmj.d6223. 23. McHenry L. Of sophists and spin-doctors: industry-sponsored ghostwriting and the crisis of academic medicine. Mens Sana Monogr 2010;8:129-145. 24. Gelenberg AJ, Ottosson JO. Editorial statement. Acta Psychiatr Scand 1995;91:145. 25. Shader RI, Greenblatt DJ. Twice may be too many: Redundant publications. J Clin Psychopharmacol 1996;16:1-2. 26. Mittmann N, Knowles SR. Repetitive publication, meta-analysis, and

adverse events. J Clin Psychopharmacol 1996;16:77. 27. Committee on Publication Ethics. http://publicationethics.org/search/ site/plagiarism accessed 23.4.13. 28. Kleinert S. Checking for plagiarism, duplicate publication, and text recycling. Lancet 2011;377:281-282. 29. Garfield E, Welljams-Dorof A. The impact of fraudulent research on the scientific literature. The Stephen E. Breuning case. JAMA 1990;263:14241426. 30. Freedman DX. Request for retraction. Arch Gen Psychiatry 1988;45:685686. 31. Schulze B. Stigma and mental health professionals: A review of the evidence on an intricate relationship. Int Rev Psychiatry 2007;19:137-155. 32. Corrigan PW. Language and stigma. Psychiatr Serv 2006;57:1218. 33. Corrigan PW, Watson AC, Gracia G, Slopen N, Rasinski K, Hall LL. Newspaper stories as measures of structural stigma. Psychiatr Serv 2005;56:551-556. 34. Perlis RH, Perlis CS, Wu Y, Hwang C, Joseph M, Nierenberg AA. Industry sponsorship and financial conflict of interest in the reporting of clinical trials in psychiatry. Am J Psychiatry 2005;162:1957-1960. 35. Roseman M, Milette K, Bero LA, Coyne JC, Lexchin J, Turner EH, Thombs BD. Reporting of conflicts of interest in meta-analyses of trials of pharmacological treatments. JAMA 2011;305:1008-1017. 36. Kopelman AM, Gorelick DA, Appelbaum PS. Disclosures of conflicts of interest in psychiatric review articles. J Nerv Ment Dis 2013;201:84-87. 37. Ross JS, Tse T, Zarin DA, Xu H, Zhou L, Krumholz HM. Publication of NIH funded trials registered in ClinicalTrials.gov: cross sectional analysis. BMJ 2012 Jan 3;344:d7292. doi: 10.1136/bmj.d7292. 38. Court C. GMC finds doctors not guilty in consent case. BMJ 1995 Nov 11;311(7015):1245-6. 39. Wilkinson G, Fahy T, Russell G, Healy D, Marks I, Tantam D, Dimond B. Case reports and confidentiality. Opinion is sought, medical and legal. Br J Psychiatry 1995;166:555-558. 40. Levine SB, Stagno SJ. Informed consent for case reports: The ethical dilemma of right to privacy versus pedagogical freedom. J Psychother Pract Res 2001;10:193-201. 41. Gabbard GO. Disguise or consent. Problems and recommendations concerning the publication and presentation of clinical material. Int J Psychoanal 2000;81 Pt 6:1071-1086. 42. Stoller RJ. Patients’ responses to their own case reports. J Am Psychoanal Assoc 1988;36:371-391. 43. Schüklenk U. Publishing bioethics and bioethics--reflections on academic publishing by a journal editor. Bioethics 2011;25:57-61. 44. Gallagher A. The ethics of impact factors. Nurs Ethics 2011;18:3-5. 45. Jackson G. Never mind the content, measure the impact: Spin bowling for journal impact factors vs. the importance of patient impact. Int J Clin Pract 2010;64:1461-1462. 46. Falagas ME, Alexiou VG. The top-ten in journal impact factor manipulation. Arch Immunol Ther Exp (Warsz) 2008;56:223-226. 47. Foo JY. Impact of excessive journal self-citations: A case study on the Folia Phoniatrica et Logopaedica journal. Sci Eng Ethics 2011;17:65-73. 48. Lundh A, Barbateskovic M, Hróbjartsson A, Gøtzsche PC. Conflicts of interest at medical journals: The influence of industry-supported randomised trials on journal impact factors and revenue - cohort study. PLoS Med 2010 Oct 26;7(10):e1000354. 49. Kanaan Z, Galandiuk S, Abby M, Shannon KV, Dajani D, Hicks N, Rai SN. The value of lesser-impact-factor surgical journals as a source of negative and inconclusive outcomes reporting. Ann Surg 2011;253:619-623. 50. Strous RD. Ethical considerations in clinical training, care and research in psychopharmacology. Int J Neuropsychopharmacol 2011;14:413-424. 51. Siegler M. Decision-making strategy for clinical ethical problems in medicine. Arch Int Med 1982;142:2178-2179.

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Isr J Psychiatry Relat Sci - Vol. 51 - No 3 (2014)

Presenting Problems and Treatment Expectations Among Service Users Accessing Psychiatric Outpatient Care: Are There Gender Differences? Ora Nakash, PhD,1 Maayan Nagar, MA,1 and Itzhak Levav, MD2 1

School of Psychology, Interdisciplinary Center (IDC), Herzliya, Israel Department of Community Mental Health, Faculty of Social Welfare & Health Sciences, Haifa University, Haifa, Israel

2

Abstract Background: Community-based studies have documented gender differences in mental health problems and service utilization. This mixed methods study explored gender differences in severity of emotional distress, referral paths, presenting problems and care expectations among service users upon accessing outpatient psychiatric care. Methods: Consecutive service users (N=284, 64% women) who presented for a new or repeated episode of care in adult outpatient clinics completed questionnaires on a measure of emotional distress, treatment history and referral path. These variables were quantitatively analyzed. Also, users completed two open-ended questionnaires on reasons for seeking care and expectations from the services. These variables were qualitatively analyzed using thematic analyses. Results: No significant gender differences emerged on any of the variables examined among new and repeated users. The main reasons for seeking care were psychiatric symptoms as well as non-specific psychopathology. The most frequent expectations from the services were receiving psychotherapy and specific tools to better manage life problems. Limitations: The sample of new male service users was relatively small. Conclusions: Once care is initiated, men and women showed similar clinical presentation and care expectations.

Address for Correspondence:   onakash@idc.ac.il

212

Introduction While the term “sex” designates a biological trait, “gender” refers to socially constructed attributes and behaviors applied to men and women within a given culture (1). These may differentially affect their health care status and behaviors. For example, epidemiological surveys found higher rates of internalizing disorders among women than men, and conversely for externalizing disorders (2-6). Several explanations were raised to account for these differences that included both biological (e.g., genetic vulnerability, pubertal hormones, pubertal timing and development; 7-9); and psychosocial factors (e.g., emotional reactivity, rumination, cognitive style;10-12) (for integrative models see 13-16). The “gender role” hypothesis which received considerable support in the literature, proposes that gender differences in emotional distress result from the types of stressors and coping mechanisms to meet them, as well as from opportunity structures for expressing psychological predicaments (2, 17, 18). Gender differences were also documented in helpseeking behaviors for mental health problems, e.g., women were more likely than men to seek care for mental health problems (e.g., 19-21). Community studies suggest that such a behavior is partly due to their higher likelihood to recognize a mental health problem compared to men (22, 23). The differential expectations associated with gender roles were proposed as a possible explanation for these findings (21). For example, many of the tasks associated with help-seeking for a mental health problem, such as relying on others, admitting need for help, or recognizing and labeling an emotional problem, conflict with the messages men receive about the importance of self-reliance, physical toughness, and emotional control (21, 24, 25).

Ora Nakash, PhD, School of Psychology, Interdisciplinary Center (IDC) Herzliya, POB 167, Herzliya 46150, Israel.


Ora Nakash et al.

Relatively less research examined gender differences in the process of help-seeking. In a study on referral patterns among students and faculty in universities in the U.S., the gender of the source was significantly associated with referrals (i.e., women compared to men were more likely to refer to mental health services) while the gender of the referral recipient was not significant (26). Objectives In this study we investigated gender differences in variables related to the process of help-seeking once individuals traverse the clinic threshold. More specifically, we examined gender differences in 1) socio-demographic (e.g., education), degree of emotional distress and servicerelated factors (e.g., referral path), and (2) service users’ reports of reasons to seek care and expectations from the mental health service. Methods Sample and procedure

The sample included Jewish service users (N=284, 64% women), who presented consecutively for a new (N=78, 28%) or repeated (N= 206, 72%) episode of care in four adult public outpatient mental health clinics in two large Israeli cities. All repeated users were in treatment before (32.1% received treatment in the same clinic while 67.9% received treatment in other clinics in the past) and returned for a new episode of care. The study took place between June 2011 and April 2012 and data were collected consecutively in the four clinics (two month in each clinic). All participating clinics offer free mental health services (including psychotherapy and psychopharmacology) to a diverse adult service user population in the catchment area of the clinic. Access to specialized care does not necessitate medical referral (27). Participants filled out self-administered questionnaires in their native language (Hebrew or Russian), that were handed out by the administrative personnel upon their first contact with the clinic (n=13 declined participation). Completion of measures took approximately 15 minutes. The study was approved by the Institutional Ethics Committees at Shalvata Mental Health Center, Abarbanel Mental Health Center, and Eitanim – Kfar Shaul Mental Health Center in Israel. Data collection was in compliance with human subject protocols at all participating clinics.

Measures

Demographic and treatment-experience questionnaire. The questionnaire included information on: age, gender, years of education, income (below average, average, above average), employment status (employed, unemployed), country of birth, family status (married, single, divorced, widowed), degree of religiosity (secular, traditional, religious). In addition, it included questions about history of mental health treatment, and satisfaction with past treatment. Service-users were also asked about the referral source for the present episode of care. Lastly, participants completed two open- ended questions: (1) “describe in your own words what brought you to the clinic today?” (2) “what do you hope to receive from the clinic that would help you?” The General Health Questionnaire (GHQ-12) (28). This 12- item scale is a well-documented screening measure for common psychiatric disorders and assesses emotional distress in the last month. It has been used in many countries (29), including Israel (30). Items are rated on a 4- point Likert scale. Final score was computed as the summary for all items, where higher scores indicate increased emotional distress. The overall internal consistency reliability for the scale was high (Cronbach’s alpha =.88). Analysis

Quantitative analysis. Independent samples t-tests and chi-square analyses were performed to identify gender differences in socio-demographic and service-related factors, for continuous and categorical variables, respectively. Analysis was performed using the SPSS version 20.0 (SPSS Inc., Chicago, IL). Qualitative analysis. The two open questions were qualitatively analyzed based on thematic analysis, using ATLAS.ti version 7 (Scientific Software Development, Berlin). Analyses procedures were conducted by the first two authors following Braun and Clarke’s recommendations (31), and comprised of three steps: 1) independent open coding (32); 2) grouping and labeling key categories to organize them into themes; and 3) integration of the information of each theme to draw a coherent representation. Throughout the process, the team met to discuss coding challenges as well as disagreements. When disagreement arose, the team attempted to identify the source of the discrepancy and coded sections which were reviewed again until consensus was reached (32, 33). Lastly, Chi-square tests of independence were performed to identify gender differences in frequencies of the identified thematic cat213


presenting Problems and Treatment Expectations in Users Accessing Psychiatric Outpatient Care

egories. The mean number of words participants included in their answers to the open question about the presenting problem was 18.3 words (SD=14.0) and about expectations from care 10.1 words (SD=9.0).

by a family/friend/neighbor or other mental health providers. Among returning service users, women compared to men reported lower utilization of psychotropic medications in the past (68.1%, 84% respectively; χ2= 6.4, p=.01) and lower satisfaction with past treatment (M=2.6 SD=1.2, M=3.0 SD=1.4, respectively; t=2.06, p=.04. There were no significant gender differences in referral paths and other clinical variables among new and repeated service users (Table 2).

Results Socio-demographic and clinical characteristics of the sample

The majority of the new and repeated service users were secular Israel-born females. Table 1 presents their characteristics. There were significant gender differences among repeated service users in years of formal education (men: M=12.2 SD=3.10 women: M=13.5 SD=3.4; t=-2.51, p=.01) and family status (significantly more men were single, 53% compared with women 34.7%; χ2=6.87, p=.03) Men and women who were either new or repeat users reported similar mean level of emotional distress upon accessing services. The majority of all users reported being referred

Reasons for seeking care and expectations from the mental health service

Table 3 presents the main reasons for seeking care and expectations for mental health services. The most common reported reason to seek care included specific psychiatric symptoms or disorders (e.g., suicidal thoughts or previous attempts) and recent stressors (e.g., car accident) (repeated users: men: 34.7% women: 31.4%; χ2= 0.23 n.s.; new users: men: 30% women: 26.4%; χ2= 0.09 n.s); and non-specific psychopathology such as general emotional distress (repeated users:

Table 1. Socio-demographic characteristics of new and repeated service users by gender (N=284) Repeated service users (n=206)

Age (years);

Men (n=82)

Women (n=124)

N

N

mean 82 (SD)

38.2 (14.7)

124

Statistic

P

New service users (n=78) Men (n=20)

Women (n=58)

N

N

Statistic

P

41.2 (15.8)

t=-1.42

n.s.

20

39.2 58 (13.0)

42.9 (16.2)

t=0.92

n.s.

66.9%

χ2=2.78

n.s.

17

85% 39

70.9%

χ2=1.54

n.s.

3

15% 16

29.1% n.s.

Country of birth Israel

63

77.8% 81

Other

18

22.2% 40

33.1%

Yes

33

40.7% 50

41%

No

48

59.3% 72

59%

Married

18

21.9% 38

30.6%

Single

44

53.7% 43

Separated/ Divorced

20

24.4% 43

Secular

34

43.6% 51

44%

Traditional

22

28.2% 38

Religious

22

28.2% 27

Formal education: mean 76 (SD) (years)

12.2 117 (3.1)

13.5 (3.4)

t=-2.51

p=.01

19

χ2=2.23

n.s.

Employment χ2=0.00

n.s.

13

68.4% 29

50% χ2=1.96

6

31.6% 29

50%

9

45% 23

39.7% χ2=2.05

34.7%

8

40% 17

29.3%

34.7%

3

15% 18

31%

Family status χ2=6.87

p=.03

n.s.

Religiosity 5

25%

15

27.3%

32.8%

8

40% 23

41.8%

23.2%

7

35%

30.9%

χ2=0.74

n.s.

χ2=0.12

n.s.

12.6 53 (2.5)

12.9 t=-0.55 (2.5)

n.s.

5

27.8% 22

44.9% χ2=2.12

n.s.

17

Income Much below average

41

51.9% 53

48.6%

Below average

12

15.2% 25

22.9%

2

11.1% 6

12.2%

Average

14

17.7% 14

12.8%

7

38.9% 15

30.6%

Above average

12

15.2% 17

15.6%

4

22.2%

6

12.2%

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Table 2. Emotional distress, referral path and history of mental health treatment among new and repeated service users by gender (N=284) Repeated service users

Emotional distress;

Men

Women

N

N

Statistic

New service users P

Men

Women

N

N

P

t=1.35

n.s.

81

30.5 121 (9.0)

31.0 t=-0.48 (7.5)

n.s.

20

30.7 56 (6.9)

Family/friend/ neighbor

20

25% 39

32% χ2=4.78

n.s.

7

35% 22 39.3% χ2=3.28

Rabbi

1

1.2% 0

0%

1

5% 2

3.6%

Police/judge

0

0% 2

1.6%

0

0% 1

1.8%

Medical doctors

15 18.8% 23 18.9%

4

20% 12

21.4%

Mental health providers

31 38.8% 37 30.3%

4

20% 10

17.9%

Self

8

11.5%

2

10% 8

14.3%

Other

5

5.7%

2

10% 1

1.8%

mean (SD)

28.2 (7.2)

Statistic

Referral path

Past treatment satisfaction;

mean (SD)

80

10% 14 6.2% 7 3.0 118 (1.4)

2.6 t=2.06 (1.2)

n.s.

p=.04

Past psychotropic medication use Yes

68

84% 81 68.1% χ2=6.40

No

13

16% 38 31.9%

men: 34.7% women: 31.4%; χ2= 0.23 n.s; new users: men: 50% women: 26.4%; χ2= 3.66 n.s). Other reasons for coming for care included interpersonal and work- related problems, distress related to physical illness, help with eligibility for social security benefits and following referral from primary care doctor or other professionals. There were no significant gender differences in any of the categories of reasons for seeking care among both new and repeated users (Table 3). The most frequently reported expectations from the mental health services among men and women were receiving psychotherapy (repeated users: men: 35.3% women: 37.5%; χ2= 0.09 n.s.; new users: men: 29.4% women: 23.9%; χ2= 0.2 n.s) and specific tools to manage life problems (repeated users: men: 32.4% women: 31.2%; χ2= 0.02 n.s.; new users: men: 52.9% women: 50%; χ2= 0.04 n.s). Other expectations included receiving psychotropic medications, general support, and help regarding eligibility for social security benefits. There were no significant gender differences in any of the categories of expectations from the services among both new and repeated users (Table 3). Discussion In this study we explored gender differences with regard to selected clinical and service-related variables as well as expectations from the service among a consecutive sample of new and repeated service users upon accessing specialized care. In contrast to gender differences in

p=.01

service utilization patterns found in most community studies (3, 34), our findings based on the quantitative study component, suggest that once care was initiated significant gender differences are no longer present with regard to 1) socio-demographic variables associated with access to care (e.g., employment, religiosity), 2) referral pathways, and 3) degree of emotional distress. The single difference we found referred to satisfaction with previous treatment; men more often than women reported higher satisfaction from past treatment. Patient satisfaction is an important measure of service-users’ experiences with the health care system. It is also recognized as a measure of effectiveness of provider-patient communication and quality of care (35). In addition, patient satisfaction is associated with better compliance with medical advice (36). Other research, mostly from general health fields, has shown that more women compared to men change doctors due to dissatisfaction (37). Women and men may have different expectations about the course and process of care, which may affect their satisfaction with services (38). For example, studies have shown that women place a higher value on time and explanations from their doctors compared to men (39). Other research suggests that factors such as general quality of life that is not directly under the control of professionals may influence an individual’s satisfaction with the mental health care (40). Congruent with previous research, our findings show that most often men and women that start care are referred 215


presenting Problems and Treatment Expectations in Users Accessing Psychiatric Outpatient Care

Table 3. Thematic analysis of self-reported reasons to seek care and expectations from mental health services by gender among new and repeated service users upon accessing specialized care (N=284) Repeated service users Description of thematic categories

Men N (%)

Women N (%)

Specific psychiatric symptoms/disorders* and recent stressors

25 (34.7)

Non-specific psychopathology

New service users

Statistic

Men N (%)

Women N (%)

Statistic

Verbatim examples

46 (39)

χ2(1)=0.35 n.s.

6 (30)

14 (26.4)

χ2(1)=0.09 n.s.

“I had panic attacks last week, low energy to do things, fatigue, difficulty sleeping” (1001)

25 (34.7)

37 (31.4)

χ2(1)=0.23 n.s.

10 (50)

14 (26.4)

χ2(1)=3.66 n.s.

“I need help, my soul aches, I feel bad in life” (1006)

Interpersonal difficulties

8 (11.1)

21 (17.8)

χ2(1)=1.55 n.s.

6 (30)

21 (39.6)

χ2(1)=0.58 n.s.

“Two weeks after the birth of my oldest son I discovered that my husband is addicted to sex. It has been six months since then, and I am afraid to take the move of divorcing him, and on the other hand I have a lot of anger toward him, I cry a lot, and sometimes feel I hate him and other time pity on him” (1020)

Work- related problems

6 (8.3)

14 (11.9)

χ2(1)=0.59 n.s.

5 (25)

5 (9.4)

χ2(1)=2.98 n.s.

“I’m in a crisis as a result of being laid off from work” (1024)

Distress related to physical illness

3 (4.2)

4 (3.4)

χ2(1)=0.08 n.s.

2 (10)

4 (7.5)

χ2(1)=0.12 n.s.

“I have many fears and worries about my medical problems, my blood pressure, diabetes and other physical problems” (1074)

Social security eligibility

2 (2.8)

2 (1.7)

χ2(1)=0.25 n.s.

Referral (from primary care doctor or other professionals)

13 (18.1)

16 (13.6)

χ2(1)=0.70 n.s.

Reasons to seek care

“Social security office referred me here for the evaluation process to determine my disability” (1002) 2 (10)

2 (3.8)

χ2(1)=1.09 n.s.

“My primary care doctor referred me” (2025)

Expectations from services provided at the psychiatric clinic Psychotherapy and group therapy

24 (35.3)

42 (37.5)

χ2(1)=0.09 n.s.

5 (29.4)

11 (23.9)

χ2(1)=0.20 n.s.

“Psychotherapy twice a week to help me get back to myself” (2078)

Specific tools to manage life problems

22 (32.4)

35 (31.2)

χ2(1)=0.02 n.s.

9 (52.9)

23 (50)

χ2(1)=0.04 n.s.

“Get guidance and tools to manage better with the kids and improve my self-esteem”(1068)

Medications

19 (27.9)

20 (17.9)

χ2(1)=2.54 n.s.

1 (5.9)

1 (2.2)

χ2(1)=0.56 n.s.

“To be balanced again with my medications” (2051)

Support/ talk to someone

6 (8.8)

19 (17)

χ2(1)=2.35 n.s.

2 (11.8)

9 (19.6)

χ2(1)=0.52 n.s.

“Get help, support, talking with someone who will listen to my problems” (1090)

Help receiving social benefits

3 (4.4)

5 (4.5)

χ2(1)=0.00 n.s.

----

3 (6.5)

χ2(1)=1.16 n.s.

“Help with approving my disability and receive social benefits” (1069)

Don’t know/ general help

1 (1.5)

4 (3.6)

χ2(1)=0.69 n.s.

---

2 (4.3)

χ2(1)=0.76 n.s.

“I don’t know what they offer so I don’t know what to expect”(2113)

Diagnostic assessment

3 (4.4)

1 (0.9)

χ2(1)=2.41 n.s.

---

1 (2.2)

χ2(1)=0.38 n.s.

“Someone who can help tell me if I have ADHD” (3005)

*Specific self-reported psychiatric symptoms/disorders included: suicidality (including thoughts plans or previous attempts; men=3.3%, women=5.8%); OCD (men=3.3%, women=2.3%); depression (men=15.2%, women=12.9%); anxiety (men=1.1%, women=3.5%); ADHD (men=0%, women=0.6%); trauma (men=2.2%, women=5.8%); substance use (men=0%, women=0.6%) and eating disorders (men=0%, women=1.2%).

by a friend, relative or other confidant (41). Our findings support other research that found little evidence for gender bias with regard to the referral recipient (i.e., the gender of alleged service user did not affect the likelihood of referral to services) as a possible explanation to women’s higher utilization of services (20). The results from the qualitative analyses in the study showed that approximately only a third of service users 216

among both men and women reported accessing care for specific psychiatric symptoms or disorders and/or following a recent stressful event. The remaining users reported coming to care for a more general sense of emotional distress and/or interpersonal and work related problems. These findings are congruent with other research documenting that approximately two-thirds of patients presenting for psychotherapy report significant


Ora Nakash et al.

personality problems or interpersonal difficulty which are not always diagnosable under current psychiatric classification systems (42). Our findings expand on this research to show that both men and women approach mental health services with either presenting generalnonspecific problem, or with a wider range of problems related to their social and interpersonal functioning. Our findings suggest that no significant gender differences emerged on any of the presenting problems and expectations from care among new and repeated service users. These findings diverge from studies conducted in the community, and from predictions made by the gender role theory. These predictions suggest that gender differences in emotional distress are due to the types of stressors and opportunity structures for expressing psychological distress that differ for men and women (2, 17). Although it is plausible that the relatively low sample size of new male service users precluded the power to detect differences that may exist, our findings may support the notion that gender role orientations are socially constructed (15, 18, 21) and as such may present within person and across situation variability (i.e., some men/ women under some conditions, will seek help for some problems but not for others). Therefore, among those persons who seek care, within gender variability may overshadow possible differences between men and women that are more visible among community respondents. The study has several limitations. First, although we included a consecutive client sample in the current naturalistic study, the relatively high percentage of repeated users may have resulted in a conservative estimation of the gender differences in the outcome variables. It is plausible that among new users this association would be different. In addition, it is plausible that examining referral paths and expectations from care among repeated users reflects in part actual previous experiences with the care system. Future studies that include only novel clients may shed light on these questions. Second, although the study was conducted in four public mental health clinics the findings may not generalize to all clinics. Future replication studies are needed. Third, although we collected information on emotional distress, it is possible that the diagnoses of the users who were not included in the current study may affect the relationship between gender and service utilization patters. Finally, although we attempted to present the richness of themes that emerged from the qualitative data, the number of participants in some of the themes is small and may have precluded statistical strength to detect gender differences when they may

have existed. Future studies should include additional qualitative sources of data such as in depth interviews. Our findings suggest that gender is a critical determinant of mental health (3), including for help-seeking behaviors that can partly affect the probability of accessing care. As in other community studies, in our consecutive sample more women compared to men turned to care (22, 43). However, among those who do seek care the presenting problems and care expectations are generally similar between men and women. Clinicians, thus, should be wary of gender bias, insofar as treating gender roles as stable, internal, trait-like constructs (25), rather than being sensitive to within gender and situational variability among those seeking help. References 1. Brody LR, Muderrisoglu S, Nakash-Eisikovits O. Emotions, defenses, and gender. In: Bornstein RF, Masling JM, editors. The psychodynamics of gender and gender role: Empirical studies in psychoanalytic theories. 10. Washington, D.C: APA Books, 2002: pp. 203-249. 2. Seedat S, Scott KM, Angermeyer MC, Berglund P, Bromet EJ, Brugha TS, et al. Cross-national associations between gender and mental disorders in the WHO World Mental Health Surveys. Arch Gen Psychiatry 2009;66:785-795. 3. Kuehner C. Gender differences in unipolar depression: An update of epidemiological findings and possible explanations. Acta Psychiatr Scand 2003;108:163-174. 4. Pigott TA. Gender differences in the epidemiology and treatment of anxiety disorders. J Clin Psychiatry 1999;60:4-15. 5. Brady KT, Randall CL. Gender differences in substance use disorders. Psychiatr Clin North Am 1999;22:241-252. 6. Dohrenwend BP, Levav I, Shrout PE, Schwartz S, Naveh G, Link BG, et al. Socioeconomic status and psychiatric disorders: The causationselection issue. Science 1992;255:946-952. 7. Nishizawa S, Benkelfat C, Young S, Leyton M, Mzengeza S, De Montigny C, et al. Differences between males and females in rates of serotonin synthesis in human brain. Proc Natl Acad Sci USA 1997;94:5308-5313. 8. Sjoberg R, Nilsson KW, Nordquist N, Ohrvik J, Leppert J, Lindstrom L, et al. Development of depression: Sex and the interaction between environment and a promoter polymorphism of the serotonin transporter gene. Int J Neuropsychopharmacol 2006;9:443-449. 9. van Broekhoven F, Verkes RJ. Neurosteroids in depression: A review. Psychopharmacology 2003;165:97-110. 10. Nolen-Hoeksema S. Gender differences in depression. Curr Dir Psychol Sci 2001;10:173-176. 11. Mezulis AH, Abramson LY, Hyde JS. Domain specificity of gender differences in rumination. J Cogn Psychother 2002;16:421-434. 12. Else-Quest NM, Hyde JS, Goldsmith HH, Van Hulle CA. Gender differences in temperament: A meta-analysis. Psychol Bull 2006;132:33-72. 13. Grigoriadis S, Robinson GE. Gender issues in depression. Ann Clin Psychiatry 2007;19:247-255. 14. Lynch WJ, Roth ME, Carroll ME. Biological basis of sex differences in drug abuse: Preclinical and clinical studies. Psychopharmacology 2002;164:121-137. 15. Nakash O, Brody L. The effects of social roles and personality motives on autobiographical memory. Sex Roles 2006;54:39-56. 16. Nolen-Hoeksema S, Hilt L. Possible contributors to the gender differences in alcohol use and problems. J Gen Psychol 2006;133:357-374.

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17. Wauterickx N, Bracke P. Unipolar depression in the Belgian population. Soc Psychiatry Psychiatr Epidemiol 2005;40:691-699. 18. Nakash O, Brody L. The effects of power imbalances and gender on autobiographical memory. Self Identity 2007;6:304-321. 19. Bland RC, Newman SC, Orn H. Health care utilization for emotional problems: Results from a community survey. Can J Psychiatry 1990;35:397-400. 20. Doherty DT, Kartalova‐O’Doherty Y. Gender and self‐reported mental health problems: Predictors of help seeking from a general practitioner. Br J Health Psychol 2010;15:213-228. 21. Addis ME, Mahalik JR. Men, masculinity, and the contexts of help seeking. Am Psychol 2003;58:5-14. 22. Kessler RC, Brown RL, Broman CL. Sex differences in psychiatric helpseeking: Evidence from four large-scale surveys. J Health Soc Behav 1981:49-64. 23. Leaf PJ, Bruce ML. Gender differences in the use of mental healthrelated services: A re-examination. J Health Soc Behav 1987;28:171-183. 24. Pollack W. Real boys: Rescuing our sons from the myths of boyhood. New York, N.Y.: Macmillan, 1999. 25. Mahalik JR, Good GE, Englar-Carlson M. Masculinity scripts, presenting concerns, and help seeking: Implications for practice and training. Prof Psychol Res Pr 2003;34:123-131. 26. Lott JK, Ness ME, Alcorn JS, Greer RM. The impact of gender and age on referrals to psychological counseling. J Couns Psychol 1999;46:132-136. 27. Levav I, Grinshpoon A. Mental health services in Israel. Int Psychiatry 2004;4:10-14. 28. Goldberg DP. The detection of psychiatric illness by questionnaire. Oxford: Oxford University Press, 1972. 29. Kessler RC, Ustun TB. The WHO World Mental Health Surveys. Cambridge: Cambridge University Press, 2008. 30. Levav I, Al-Krenawi A, Ifrah A, Geraisy N, Grinshpoon A, Khwaled R, et al. Common mental disorders among Arab-Israelis: Findings from the Israel National Health Survey. Isr J Psychiatry Relat Sci 2007;44:104-113.

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31. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006;3:77-101. 32. Corbin JM, Strauss AL. Basics of qualitative research: Techniques and procedures for developing grounded theory. Thousand Oaks, Cal.: Sage, 2008. 33. Nakash O, Alegría M. Examination of the role of implicit clinical judgments during the mental health intake. Qual Health Res 2013;23:645-654. 34. Gonzalez JM, Alegría M, Prihoda TJ, Copeland LA, Zeber JE. How the relationship of attitudes toward mental health treatment and service use differs by age, gender, ethnicity/race and education. Soc Psychiatry Psychiatr Epidemiol 2011;46:45-57. 35. Kaplan SH, Greenfield S, Ware Jr JE. Assessing the effects of physicianpatient interactions on the outcomes of chronic disease. Med Care 1989;27:S110-S127. 36. Cvengros JA, Christensen AJ, Hillis SL, Rosenthal GE. Patient and physician attitudes in the health care context: Attitudinal symmetry predicts patient satisfaction and adherence. Ann Behav Med 2007;33:262-268. 37. Bean‐Mayberry BA, Chang CCH, Neil MA, Whittle J, Hayes PM, Hudson Scholle S. Patient satisfaction in women’s clinics versus traditional primary care clinics in the Veterans Administration. J Gen Intern Med 2003;18:175-181. 38. Schmittdiel J, Grumbach K, Selby JV, Quesenberry CP. Effect of physician and patient gender concordance on patient satisfaction and preventive care practices. J Gen Intern Med 2000;15:761-769. 39. Hall JA, Roter DL, Katz NR. Meta-analysis of correlates of provider behavior in medical encounters. Med Care 1988:657-675. 40. Blenkiron P, Hammill C. What determines patients’ satisfaction with their mental health care and quality of life? Postgrad Med J 2003;79:337-340. 41. Saunders SM. Applicants’ experience of the process of seeking therapy. Psychotherapy 1993;30:554-564. 42. Westen D, Arkowitz-Westen L. Limitations of Axis II in diagnosing personality pathology in clinical practice. Am J Psychiatry 1998;155:1767-1771. 43. World Health Organization. Gender in mental health research. Geneva: World Health Organization, 2004.


Isr J Psychiatry Relat Sci - Vol. 51 - No 3 (2014)

Sarah Roer et al.

Negative Emotional Eating among Obese Individuals with and without Binge Eating Behavior and Night Eating Syndrome Sarah Roer, PhD,1 Yael Latzer, DSc,2,3 and Allan Geliebter, PhD1,4 1

St. Luke’s – Roosevelt Hospital and New York Obesity Research Center Columbia University, New York, N.Y., U.S.A University of Haifa, Faculty of Social Welfare & Health Sciences, Haifa, Israel 3 Eating Disorders Clinic, Division of Psychiatry, Rambam Medical Center, Haifa, Israel 4 Touro College, New York, N.Y., U.S.A. 2

Abstract Objective: To assess and compare negative emotional eating among individuals with and without Night Eating Syndrome (NES) and Binge Eating behavior (BE). Method: The sample consisted of 76 obese participants, who were divided into four groups: the NES Only group; the BE Only group; the BE & NES group; and the overweight control group with neither BE or NES. Results: Results showed significantly higher negative emotional eating among the BE Only group, whereas those with NES Only did not report eating in direct response to negative emotions and situations. Discussion: Results suggest that individuals with BE may be using food as a maladaptive coping mechanism, while individuals with NES eat in the evening hours as a way to avoid the experience of negative emotions.

Introduction Binge eating disorder (BED) and night eating syndrome (NES) are two eating disorders commonly associated with obesity (1). The American Psychiatric Association’s (APA)(1994) Diagnostic Statistical Manual of Mental Disorders, 4th Edition (DSM-IV, Appendix) suggests that the key features which define and characterize BED are: 1) the consumption of an objectively large amount of food

in a discrete time period; 2) the experience of a lack of control during the eating episode; and 3) a lack of compensatory behaviors following the binge. The updated and recently published Diagnostic Statistical Manual of Mental Disorders, 5th Edition (DSM-5) (2) recognizes BED as a diagnosable Axis I eating disorder. Compared to the previous appendix definition, the new criteria define binge eating episodes as occurring once a week for a period of at least three months, versus twice a week for six months. Although most prevalent among overweight individuals, BED has also been diagnosed in non-overweight individuals. Studies of weight loss programs have found that among obese individuals, one in three report engaging in some type of binge eating behavior, and one in five meet criteria for BED (3). Other research studies indicate that among obese individuals, 30% have BED, with a male to female ratio of 2:3 (3-5). In comparison to their obese non-BED counterparts, overweight BED individuals present with an earlier onset of weight gain, an overall significant increase in daily caloric intake, more frequent dieting attempts, and increased levels of depression (6, 7). Night Eating Syndrome was first described in 1955 as a disorder evolving as a response to stress, with its symptoms including morning anorexia, evening hyperphagia, and insomnia (5, 6, 8). Research in NES was originally conducted mainly with obese individuals who were refractory to standard weight loss treatments. A core feature identified among NES individuals was the presence of a delayed circadian shift in both eating and mood patterns. Specifically, an inverse relationship was identified, featuring a progressive increase in eating and a decrease in mood during the evening hours (8).

Address for Correspondence: Prof. Yael Latzer, Faculty of Social Welfare & Health Sciences, University of Haifa, Mount Carmel, Haifa 31905, Israel   yLatzer@univ.haifa.ac.il

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Negative Emotional Eating with and without Binge Eating Behavior and Night Eating Syndrome

The diagnostic criteria of NES have evolved over the years, and various criteria have been used since the original description in 1955 (9-11). Among the significant modifications to the criteria were the inclusion of nocturnal ingestions (i.e., waking during the sleep period to eat) (12) and the degree of awareness of one’s eating behaviors and ingestions. The First International Night Eating Symposium convened in 2008 to propose new diagnostic criteria for individuals presenting with an eating pattern marked by increased intake in the evening and/or nighttime. As a result a set of new criteria were proposed for NES (13), and used for the DSM-5 (2) in the Other Specified Feeding or Eating Disorders (OS-FED) subcategory under eating disorders. The proposed criteria include: A) evening hyperphagia, defined as the consumption of 25% or more of total daily caloric intake after the evening meal, and/or two nocturnal ingestions on average per week; B) awareness of one’s eating behaviors and ingestions; C) three of the following: 1) morning anorexia, 2) the desire to eat between dinner and sleep, 3) sleep onset insomnia, 4) the belief that one needs to eat in order to fall asleep, 5) depressed or lowering of mood in the evening and nighttime; D) distress or impaired functioning; E) a period of three months or more under these conditions; and F) these conditions not secondary to any medical condition (13). While NES may occur among normal weight individuals, it is more prevalent among obese individuals (14). Within the obese and overweight population, individuals with NES are reported to have an earlier age of obesity onset, higher rates of depression, lower self-esteem, and a poorer prognosis for long-term weight loss and maintenance (11, 14-21). Research has shown that even individuals with NES who have lost weight through a dieting program or surgical intervention, still report eating patterns that meet criteria for NES (22). Despite their similarities, NES and BED have distinct features that differentiate them from each other. Two of the most important differences between them are the amount and time of food consumption (23). Individuals with NES typically consume food, while still maintaining a sense of control; choosing snack-like portions during their eating episodes. However, individuals with BED consume abnormally large meals, accompanied by a loss of control (6). Moreover, individuals with NES consume a minimum of 25% of their daily caloric intake in the evening hours and most experience morning anorexia, likely as a result of the evening intake. In comparison, individuals with BED do not necessarily have a preferred eating time and often binge eat throughout the day. 220

Despite their differences, there are shared characteristics between individuals with NES and BED, most notably the propensity towards obesity, increased rates of depression, and binge-like eating behaviors. These similarities have led researchers to analyze the psychopathological communalities of these two disorders in an attempt to better understand their placement along the obesity and eating disorder continuum. Adding to the complexity of the shared relationship, research has also identified a history of neglect and emotional abuse among both NES and BED individuals, which may be an important correlate for better understanding of the psychopathological communalities (24). A final shared communality of BED and NES is the role played by emotional eating. Emotional eating is a form of reactionary eating behavior, either overeating or under eating in response to emotionally charged feelings or situations (25). While individuals may eat in response to either positive or negative emotions, research studies have shown that overweight individuals, compared to underweight and normal weight individuals, eat primarily in response to negative affective emotions, including, but not limited to, anger, depression and anxiety (25, 26). Among overweight individuals, eating in response to emotions has been characterized as a maladaptive learned coping behavior, aimed at reducing stress and other negative feelings (25). Binge eating episodes, reported by individuals with BED, have been directly associated with emotional overeating (25). As such, binge-eating episodes can be viewed as a maladaptive coping mechanism employed in situations of emotional distress in order to suppress the experience and awareness of the uncomfortable emotions (26, 27). Studies have suggested that emotional eating, even among non-clinical populations, is indicative of unhealthy eating behaviors and attitudes (18, 23, 26). To the best of our knowledge, no studies have been conducted on the relationship between NES and BED in relation to emotional eating. Thus, the aim of this study was to assess and compare emotional eating, both negative and positive, of overweight individuals with and without NES to those with and without BED. It was hypothesized that significant differences would be found between BED and NES on both negative and positive emotional eating patterns. Methods Participants

Participants were recruited through local advertisements as part of a clinical outpatient weight loss program at St.


Sarah Roer et al.

Luke’s Roosevelt Hospital Center in New York. Exclusion criteria for the weight loss program were diabetes, cancer (in active treatment or remission of less than five years), heart disease, and pregnancy or lactation. Additionally, those individuals reporting active psychotic and suicidal thoughts and/or episodes were excluded. A physical examination was conducted to ensure good health prior to beginning the weight loss program. The physical examination included a full medical history report as well as an electrocardiogram and blood tests. A total of 81 individuals who enrolled in the weight loss program participated in the current research study. Among the 81 participants, 76 had complete data, and 5 were excluded for missing data. The statistical analyses were conducted on the 76 participants with complete data. The final sample included 15 males and 61 females, ranging in age from 19 to 63 years (mean age: 45.6 ± 11.0 years). Participants in the study had BMIs ranging from 25.4 to 63.8 (mean BMI: 38.0 ± 8.5). Instruments

Following the initial intake and physical examination and prior to the beginning of the research study and clinical weight loss program, the participants were asked to complete three questionnaires: 1) the Emotional Appetite Questionnaire (EMAQ) (25, 28). 2) the Questionnaire on Eating and Weight Patterns (QEWP-R) (29); and 3) the Night Eating Diagnostic Questionnaire (NEDQ) (15, 29, 30) Completion of these questionnaires took about 30 minutes. 1. The Emotional Appetite Questionnaire (EMAQ) (25, 28) was used to assess the negative and positive dimensions of emotional eating. The EMAQ is a two-page questionnaire, with the first page including items on negative and positive emotions and the second page including negative and positive situations. The items are rated on a nine-point Likert scale, indicating whether the subjects eat much less, the same, or much more relative to their usual eating behavior in response to various negative and positive emotional states and situations. Two additional responses are NA (not applicable) or DK (don’t know). The negative and positive emotions include 14 items: sad, bored, confident, angry, anxious, happy, frustrated, tired, depressed, frightened, relaxed, playful, lonely, and enthusiastic. The negative and positive situations include eight items: when under pressure, after a heated argument, after a tragedy of someone close to you, when falling in love, after ending a relationship, when engaged in an

enjoyable hobby, after losing money or property, and after receiving good news. Scoring for the EMAQ averaged the responses for each category of positive emotions, negative emotions, positive situations, and negative situations. Positive emotions and situations, were then averaged as were negative emotions and situations to obtain a total positive emotional eating score and a total negative emotional eating score. The EMAQ has been shown to have construct validity, with a convergent validity of r=.54, p<.001 and a discriminate validity of r=.63, p<.001 (28). The four dimensions (negative emotions, negative situations, positive emotions, and positive situations) on the EMAQ were also found to have good reliability (r =.89, .95, .90, and .71, respectively) and acceptable internal consistency (Cronbach alpha = .78, .75, .65, and .57, respectively) (25, 28). 2. The Questionnaire on Eating and Weight Patterns Revised (QEWP-R) (30) was used to assess BED. The QEWP is a 28-item self-report questionnaire that was used in the DSM-IV field trials for the assessment of BED and in two multi-site field trials assessing BED prevalence (29-31). The QEWP-R includes items on demographics, frequency and duration of binge eating, engagement in compensatory behavior for weight control, degree of associated distress with binge episodes and eating, loss of control and any associated behavioral indicators of loss of control (30). The QEWP-R diagnostic criteria were subdivided along a hierarchy of four categories: non-binge eating disorder (non-BED); objective overeating (B); binge eating (BE); and binge eating disorder (BED). Those individuals who reported eating large amounts of food within a two-hour period of time, but did not experience loss of control, were classified as B. Those individuals who reported eating large amounts of food with a loss of control, but did not report symptoms for more than six months, were classified as sub-threshold BED or BE. Those who met the full diagnostic criteria according to the DSM-IV were given a diagnosis of BED (31). The QEWP has been shown to be reliable and valid in the assessment of BED, with an internal consistency of .75 in a weight control sample and .79 in a community sample (27). 3. The Night Eating Diagnostic Questionnaire (NEDQ) (15, 29) was used to assess night eating syndrome. The questionnaire was based on the criteria of morning anorexia, evening hyperphagia, and insomnia (15). The NEDQ is a 23-item self-report questionnaire assessing the occurrence and frequency of nighttime awakening, 221


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night eating during awakenings, nighttime eating patterns, and percentage of food intake after 7:00pm and after the dinner meal. It also assesses distress associated with nighttime eating, overall daytime and evening mood, and general sleep disturbances. Those individuals who work during the nighttime, evening, or on nighttime rotating work shifts were excluded from a diagnosis of night eating syndrome (and included in the normal group). The diagnoses were subdivided into a hierarchy of severe, moderate, mild, and non-NES. Scoring for the NEDQ was based on the responses to various questions directly related to the criteria for NES. Those questions included: “Do you generally experience loss of appetite in the morning?” (Question 3); “How often do you eat breakfast after your final morning awakening?” (Question 4); “Do you generally consume 50% or more of your daily food intake after 7:00pm?” (Question 6); “Do you generally consume 50% or more of your daily food intake after the dinner meal?” (Question 8); “Do you generally have trouble falling asleep at night?” (Question 9); and “Do you generally have trouble staying asleep at night?” (Question 10). Specific cut-off scoring was as follows: 1. Normal: no night eating (q6 and q8 = no). 2. N: mild night eater (q6 or q8 = yes). 3. NE: moderate night eater ([q6 or q8 = yes] and [q3=yes or q4 ≤ 3 days/week]). 4. NES: severe night eater ([q6 or q8 = yes] and [q3=yes or q4 ≥ 3 days/week]) and [q9 or q10 ≥ 3 days/week], and meets each of the above criteria for ≥ 3 months duration). If all of the above criteria are met, but for less than three months, then the subject was coded as NE. Study groups

The final sample of 76 participants was divided into four subgroups: 1) binge eating only (BE Only); 2) night eating only (NES Only); 3) night eating and binge eating (NES & BE); and 4) the overweight control group. The NES only group contains both moderate and severe night eating categories. Participants were divided into the subgroups according to the following criteria: The BE Only study group included 20 overweight subjects who were diagnosed with BE only and did not have a diagnosis of NES. Individuals defined in this study as BE were those who met the criteria for a full BED diagnosis and/or BE, but did not report symptoms occurring two times a week for at least six months. The NES Only study group included nine overweight subjects who were diagnosed with NES only and did not 222

report having BED or BE. Individuals defined in this study as NES were those who met the criteria for severe and moderate NES, while those who met the criteria for mild NES were excluded from the study group for NES and included in the overweight control group. The BE & NES study group included 12 overweight subjects who were diagnosed with both NES and BE. The Overweight Control group included 35 overweight subjects who did not meet the criteria for either BE or for severe or moderate NES. Our research was conducted prior to the publication of the DSM-5 (2) and used the DSM-IV criteria for BED and NES. Data analysis

Means and SDs were calculated. A one-way ANOVA was used to compare the groups on the EMAQ average scores of negative emotions and situations, and the EMAQ average scores of positive emotions and situations. Separate one-way ANOVAs were used to assess between group comparisons on the EMAQ scores of negative emotions and the EMAQ scores of negative situations. Post hoc tests were conducted when the overall F value was significant to determine specific pair-wise differences. . Data were analyzed using the Statistical Package for the Social Sciences (Version 13.0, SPSS, Chicago, IL). Results Descriptive Results

Statistical analyses did not control for participant characteristics, as the initial results indicated that age, gender, BMI, and race were not significant covariates and did not differ by group. Means, SDs and significance levels are in Table 1. Combined Mean Negative Emotions and Situations by Group

As described above, a one-way analysis of variance was conducted comparing the four groups with respect to their levels of eating in response to combined negative emotions and situations. The overall F test from this analysis was found to be statistically significant (F3,76=4.95, p<0.01). These results indicated that at least one pair of these groups, differed significantly from one another. In order to determine which pair or pairs of these groups were implicated in the overall differences, a series of multiple comparison tests was conducted. These tests showed that the BE


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Only group reported significantly greater mean levels of overall combined negative emotional eating as compared to the Overweight Controls (6.36±0.88 vs. 5.47±1.22, p = .009). Similarly, the BE Only group reported significantly greater mean levels of overall combined negative emotional eating as compared to the NES Only group (6.36±0.88 vs. 4.63±0.98, p = .001). Finally, the BE & NES group reported significantly greater mean levels of overall combined negative emotional eating as compared to the NES Only group (5.83±1.61 vs. 4.63±0.98, p = .001).

The overall F test from this analysis was found to be statistically significant as presented in Table 1. A series of multiple comparison tests indicated that the BE Only group reported significantly greater mean levels of eating in response to negative emotions as compared to the Overweight Controls (6.62 vs. 5.56, p = .002). Similarly, the BE Only group reported significantly greater mean levels of eating in response to negative emotional situations as compared to the NES Only group (6.62 vs. 5.68, p = .045).

Table 1. Means and SD of the EMAQ scores among groups

Combined Mean Positive Emotions and Situations by Group

N

Calculated negative situations and emotions

Negative situation

Negative emotions

Overweight Controls

35

5.47 (1.22)

5.37 (1.54)

5.56 (1.02)

Binge Eaters Only

20

6.36 (0.88)

6.1 (1.06)

6.62 (0.86)

Night Eaters Only

9

4.63 (0.98)

3.62 (1.47)

5.69 (1.33)

Binge & Night Eaters

12

5.83 (1.61)

5.36 (20.7)

6.27 (1.39)

F(3,76)=4.95, p<0.01

F(3,76)=5.56, p<0.01

F(3,76)=3.92, p<0.01

F values Sig.

Mean Negative Emotional Eating Situations by Group

A one-way analysis of variance was conducted in which the four groups – BE Only, NES Only, BE & NES, and Overweight Controls – were compared with respect to their levels of eating in response to negative emotional situations. The overall F test was found to be statistically significant as presented in Table 1. A series of multiple comparison tests indicated that the Overweight Controls reported significantly greater mean levels of eating in response to negative emotional situations as compared to the NES Only group (5.37 vs. 3.62, p = .003). Similarly, the BE Only group reported significantly greater mean levels of eating in response to negative emotional situations relative to the NES Only group (6.11 vs. 3.62, p < .001). Finally, the combined BE & NES group reported significantly greater mean levels of eating in response to negative emotional situations when compared with the NES Only group (5.35 vs. 3.62, p = .012). Mean Negative Emotional Eating by Group

A one-way analysis of variance was conducted in which the four groups – BE Only, NES Only, BE & NES, and Overweight Controls –were compared with respect to their levels of eating in response to negative emotions.

A one-way analysis of variance was conducted in which the four groups – BE Only, NES Only, BE & NES, and Overweight Controls – were compared with respect to their levels of combined positive emotional eating. The overall F test was not found to be statistically significant. Two additional one-way analyses of variance were conducted using the components of the combined mean positive emotional eating, that is, emotions and situations, with similar results (Emotions: (F=1.37, df=(3.75),p=.26), Situations: (F=.344, df=(3,72), p=.79). Discussion The aim of this study was to assess and compare negative and positive emotional eating among individuals with and without NES, as compared to those with and without BED. The main results, as hypothesized, showed significant differences between individuals with NES and individuals with BED on measures of negative emotional eating, with the Binge Eating behavior (BE) group having significantly higher scores. The BE Only group had significantly higher scores on all measures of negative emotional eating (combined, situations, and emotions), as compared to either the NES Only group or the Overweight Controls. Results showed that individuals in the NES Only group reported the lowest scores on the combined negative emotional eating measure relative to the other three groups. Interestingly, individuals with a combined diagnosis of BE and NES had significantly higher scores on eating in response to negative emotions in comparison to the NES only group and to the Overweight controls. These results suggest that emotional eating is related primarily to BE behavior, rather than night eating behavior or overweight as independent factors. One possible explanation for these results is that the increased negative 223


Negative Emotional Eating with and without Binge Eating Behavior and Night Eating Syndrome

emotional eating levels found among individuals with BE behavior may be related to the higher psychiatric co-morbidity associated with BE behavior (6, 17, 18, 32). It is suggested that the increased prevalence of psychopathology among individuals with BE behavior may negatively influence eating behavior, further exacerbating their eating in response to psychopathological stressors relative to individuals with a diagnosis of NES only (33). In order to understand the divergent results between individuals with NES and individuals with BE, it is important to take into account their distinct patterns of eating behavior. Individuals with BE behavior may employ food as a continuous and reactive maladaptive coping mechanism to negotiate stressful experiences and subsequent emotions. In contrast, the particular night eating pattern among individuals with NES may suggest a distinct and unusual pattern of behavior designed to avoid the experience of distressing emotions and situations. As such, this nighttime eating behavior may be a habituated preventive-avoidance response to emotions and situations prior to their occurrence. Thus, it is suggested that individuals with NES may eat in the evening hours in an attempt to help them cope with any future negative emotions and situations that may occur, whereas individuals with BE eat in direct response to emotions and situations that are occurring in real time. Alternatively, individuals with NES may possess a stronger set of coping skills relative to individuals with BE. According to their patterns of eating, individuals with BE behavior use food to negotiate stressful life events occurring any time of the day or night, whereas individuals with NES behavior may be able to cope throughout the day, but are unable to cope during the evening hours in their own home environment. The pattern of eating among individuals with BE, which is to engage in binge type episodes throughout the day, may be indicative of an overall significant lack of coping skills. In contrast, individuals with NES seem to demonstrate healthier coping skills while they are busy during the daytime, as their disordered eating episodes occur only in the evening hours or at nighttime. These evening or nighttime eating episodes may be a maladaptive coping mechanism in reaction to any lingering upsetting emotions that the coping mechanisms employed during the daytime were not able to mange. This explanation is supported by Latzer and Tzischinsky’s research, in which individuals with NES reported intense feelings of loneliness during the nighttime when they were alone and not as busy (34). Further analysis of the specific negative situations and 224

emotions, which were subsumed within the averaged negative emotional score, showed that negative situations had a significantly stronger effect on negative emotional eating than did negative emotions. The act of binge eating may be a specific maladaptive coping mechanism that an individual engages in so as to avoid dealing with difficult experiences or events. Often, individuals who use food as a coping mechanism can recall the situation that “triggered” the binge eating episode, but have difficulty identifying the specific emotions they were feeling, as the food is used to “stuff down” the feelings. One surprising finding in need of further explanations that individuals in the overweight control group reported significantly higher levels of negative emotional eating in response to negative situations than did individuals with NES. A possible explanation for these findings may be the increased low self-esteem and depression reported among overweight individuals, who struggle, some for a lifetime, with the stigma of obesity, as well as the teasing and bullying they experience as a result of their weight (35). Individuals with NES may not necessarily have been overweight their whole lives, but rather only since the onset of their disordered eating behavior, and therefore may have developed a resiliency and positive self-esteem on which they can rely to manage various unpleasant situations. This interpretation is supported by the present research findings that individuals with NES have lower psychopathology relative to individuals with BED or individuals with a combined diagnosis of BED and NES, and that individuals with BED have the highest amount of psychopathology (17, 18, 23, 27, 36). The results also found a lack of emotional eating in response to positive situations and emotions, suggesting that positive events may be subjectively interpreted as negative life experiences, rather than the expected positive ones. For example, an individual who interprets the process of dating and falling in love as a stressful life experience may not be able to internalize and assess it as a positive experience. There were a number of limitations in this study. First, once subdivided into four groups, what was initially a moderate sample size left a less than ideal size within each subgroup for analysis. This limitation may inhibit the ability to generalize these results to the larger NES and BED populations. Second, the number of individuals who had a complete BED and NES diagnosis was limited, which compelled us to combine individuals with a full BED diagnosis with those who had a partial diagnosis of BE. Finally, this study utilized an NES questionnaire that was based on


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a previous criteria set, rather than on the new proposed criteria by Allison et al. (13). In addition, it should be noted here that the 50% criterion of evening hyperphagia (percent of intake after dinner) was used in the current study rather than nocturnal ingestions. Examining NES and BED using the new criteria (2, 13) would be worthwhile. These results, which show that individuals with BED eat in response to negative emotions and that individuals with NES do not, may contribute to a better understanding of BED and NES in relation to emotional eating. The results may also help in understanding the continuum of obesity, suggesting that BED is more pathological than NES. Independent of the continuum of obesity is the continuum of psychopathology that this research highlights. Specifically, individuals with NES and BED have increased levels of psychopathology relative to individuals with NES only. Both continuums are key components that are interrelated and important for future research as well as treatment and preventative interventions. Acknowledgement We would like to thank Miriam Baldinger and Rachel Rubin for their valuable contribution to this paper.

References 1. Tanofsky-Kraff M, Yanovski SZ. Eating disorder or disordered eating? Non-normative eating patterns in obese individuals. Obes Res 2004;12:1361-1366. 2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed.: Arlington: American Psychiatric Association, 2013. 3. Ochner CN, Geliebter A. Binge eating disorder. Obes Management 2007;44:161-167. 4. Geliebter A, Yahav EK, Gluck ME, Hashim SA. Gastric capacity, test meal intake, and appetitive hormones in binge eating disorder. Physiol Behav 2004;81:735-740. 5. Allison KC, Grilo CM, Masheb RM, Stunkard AJ. Binge eating disorder and night eating syndrome: a comparative study of disordered eating. J Consult Clin Psychol 2005;73:1107-1115. 6. Stunkard AJ, Allison KC. Two forms of disordered eating in obesity: Binge eating and night eating. Int J Obes Relat Metab Disord 2003;27:1-12. 7. Pull CB. Binge eating disorder. Curr Opin Psychiatry 2004;17:43-48. 8. O’Reardon JP, Ringel BL, Dinges DF, Allison KC, Rogers NL, Martino NS, et al. Circadian eating and sleeping patterns in the night eating syndrome. Obes Res 2004;12:1789-1796. 9. Allison KC, Engel SG, Crosby RD, de Zwaan M, O’Reardon JP, Wonderlich SA, et al. Evaluation of diagnostic criteria for night eating syndrome using item response theory analysis. Eat Behav 2008;9:398-407. 10. de Zwaan M, Burgard MA, Schenck CH, Mitchell JE. Night time eating: A review of the literature. Eur Eat Disord Rev 2003;11:7-24. 11. Striegel-Moore RH, Franko DL, Garcia J. The validity and clinical utility of night eating syndrome. Int J Eat Disord 2009;42:720-738. 12. Birketvedt GS, Florholmen J, Sundsfjord J, Osterud B, Dinges D, Bilker W, et al. Behavioral and neuroendocrine characteristics of the nighteating syndrome. JAMA 1999;282:657-663. 13. Allison KC, Lundgren JD, O’Reardon JP, Geliebter A, Gluck ME, Vinai P, et al. Proposed diagnostic criteria for night eating syndrome. Int J

Eat Disord 2010;43:241-247. 14. Aronoff NJ, Geliebter A, Zammit G. Gender and body mass index as related to the night-eating syndrome in obese outpatients. J Am Diet Assoc 2001;101:102-104. 15. Gluck ME, Geliebter A, Satov T. Night eating syndrome is associated with depression, low self-esteem, reduced daytime hunger, and less weight loss in obese outpatients. Obes Res 2001;9:264-267. 16. Marshall HM, Allison KC, O’Reardon JP, Birketvedt G, Stunkard AJ. Night eating syndrome among nonobese persons. Int J Eat Disord 2004;35:217-222. 17. Faith MS, Butryn M, Wadden TA, Fabricatore A, Nguyen AM, Heymsfield SB. Evidence for prospective associations among depression and obesity in population-based studies. Obes Rev 2011;12:e438-53. 18. Vander Wal JS. Night eating syndrome: a critical review of the literature. Clin Psychol Rev 2012;32:49-59. 19. Dalle Grave R, Calugi S, Ruocco A, Marchesini G. Night eating syndrome and weight loss outcome in obese patients. Int J Eat Disord 2011;44:150-156. 20. Gluck ME, Venti CA, Salbe AD, Krakoff J. Nighttime eating: commonly observed and related to weight gain in an inpatient food intake study. Am J Clin Nutr 2008;88:900-905. 21. Andersen GS, Stunkard AJ, Sorensen TI, Petersen L, Heitmann BL. Night eating and weight change in middle-aged men and women. Int J Obes Relat Metab Disord 2004;28:1338-1343. 22. Rand CS, Macgregor AM, Stunkard AJ. The night eating syndrome in the general population and among postoperative obesity surgery patients. Int J Eat Disord 1997;22:65-69. 23. Latzer Y, Tzischinsky O. Night eating syndrome and other eating disorders. In: Lundgren JD, Allison KC, Stunkard AJ, editors. Night eating syndrome: Research, assessment, and treatment. New York: Guilford, 2012: pp. 108-126. 24. Allison KC, Grilo CM, Masheb RM, Stunkard AJ. High self-reported rates of neglect and emotional abuse, by persons with binge eating disorder and night eating syndrome. Behav Res Ther 2007;45:2874-2883. 25. Geliebter A, Aversa A. Emotional eating in overweight, normal weight, and underweight individuals. Eat Behav 2003;3:341-347. 26. Waller G, Osman S. Emotional eating and eating psychopathology among non-eating-disordered women. Int J Eat Disord 1998;23:419-424. 27. Napolitano MA, Head S, Babyak MA, Blumenthal JA. Binge eating disorder and night eating syndrome: psychological and behavioral characteristics. Int J Eat Disord 2001;30:193-203. 28. Nolan LJ, Halperin LB, Geliebter A. Emotional Appetite Questionnaire. Construct validity and relationship with BMI. Appetite 2010;54:314-319. 29. Yanovski SZ. Binge eating disorder: current knowledge and future directions. Obes Res 1993;1:306-324. 30. Nolan LJ, Geliebter A. Night eating is associated with emotional and external eating in college students. Eat Behav 2012;13:202-206. 31. American Psychiatric Association Committee on Nomenclature, and Statistics. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), Fourth Edition. Washington, DC: American Psychiatric Association, 1994. 32. de Zwaan M, Mitchell JE, Seim HC, Specker SM, Pyle RL, Raymond NC, et al. Eating related and general psychopathology in obese females with binge eating disorder. Int J Eat Disord 1994;15:43-52. 33. Dingemans AE, Bruna MJ, van Furth EF. Binge eating disorder: a review. Int J Obes Relat Metab Disord 2002;26:299-307. 34. Latzer Y, Tzischinsky O. Binge Eating Disorder (BED) - A subgroup of obesity or a subgroup of Bulimia Nervosa? Harefuah 2003;142:544549 (in Hebrew). 35. Faith MS, Matz PE, Jorge MA. Obesity-depression associations in the population. J Psychosom Res 2002;53:935-942. 36. Stunkard A, Berkowitz R, Wadden T, Tanrikut C, Reiss E, Young L. Binge eating disorder and the night-eating syndrome. Int J Obes Relat Metab Disord 1996;20:1-6.

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Isr J Psychiatry Relat Sci - Vol. 51 - No 3 (2014)

Antenatal Group Therapy Improves Worry and Depression Symptoms Angela Bowen, RN, PhD,1 Marilyn Baetz, MD, FRCP,2 Laura Schwartz, BA, MSc,1 Lloyd Balbuena, PhD,2 and Nazeem Muhajarine, PhD3 1

College of Nursing, University of Saskatchewan, Saskatoon, Canada Department of Psychiatry, College of Medicine, University of Saskatchewan, Saskatoon, Canada 3 Department of Community Health and Epidemiology, College of Medicine, University of Saskatchewan, Saskatoon, Canada 2

Abstract Introduction: Antenatal anxiety and depression occur in approximately 20% of pregnant women with potentially deleterious effects to mother and child. While effective in reducing symptoms, some pregnant women are often reluctant to take psychotropic medications. We tested the effectiveness of group therapy to provide worry and depression symptom relief. Methods: Women (N=38) in 15-28 weeks of gestation were recruited to antenatal Psychotherapy Groups using either interpersonal or mindfulness based therapy. We collected data at three times, upon intake to and at completion of the group and at four weeks postpartum. Descriptive, Chi-square, and GEE analyses were used to compare depression and worry symptoms with a matched control group of pregnant women (N=68). Limitations: Small sample size in both groups required a matched control group with no randomization. Results: Attending group therapy significantly reduced worry and depression symptoms over pregnancy into the postpartum compared to women receiving no therapy. There was no difference in symptom reduction between different types of groups attended. Discussion: Engaging pregnant women in group therapy can significantly improve worry and depression symptoms, with lasting effects.

Introduction Depression is the number one cause of disability in women worldwide (1). Approximately 20% of pregnant women experience depression, and this is a particularly vulnerable time for women given the effects of depression not only on themselves, but also on their unborn children (2). The effects of depression, anxiety and worry on the pregnant woman and her unborn baby are an increasing concern for women and their care providers. While medications have been shown to decrease depressive symptoms (3, 4), many physicians are often reticent to prescribe, or under prescribe antidepressant medications. When psychotropic medications are prescribed, women may be reluctant to take them during pregnancy (5). The levels of depression and anxiety symptoms are often highest at the onset of pregnancy, tending to decrease over the course of the pregnancy and into postpartum (3). This trend in decreasing depression symptoms over the perinatal period is seen regardless of whether or not the symptom scores indicate that the woman meets the criteria for depression or if she is being treated. Some studies also show a rise again in symptoms just before or after delivery (6, 7). In postpartum, the prevalence of depressive symptoms is highest in the first three months and then gradually falls over the first year (6). Different types of groups have been used to reduce depression and anxiety in perinatal women. Support groups for new mothers have been found to be effective in reducing, or preventing, postpartum depressive symptoms (8, 9). Women who participate in support groups for postpartum depression report ongoing benefit from the relaxation exercises, skills and the knowledge acquired in the group

Address for Correspondence: Angela Bowen, RN, PhD, College of Nursing, University of Saskatchewan, 107 Hospital Dr., Saskatoon, SK S7N5E5, Canada   angela.bowen@usask.ca

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and that they enjoyed the social support from peers long after they stopped attending the group (10). Despite the demonstrated success of group therapy and support groups in the postpartum period (9-11), research on psychological group interventions for pregnant women has been limited. Spinelli and Endicott showed a 60% improvement of prenatal depressive symptoms using individual interpersonal therapy compared to only 15% symptom improvement in a group receiving education only (N=50) (12). However, in a larger (N=206) Australian study of group antenatal education (no psychotherapy) to reduce depression, there was no difference between the treatment (education) and the control group (13); but, providing interpersonal therapy to 25 pregnant adolescents did result in a 50% reduction in depression symptoms (14). A randomized control trial of a seven-week course of group applied relaxation therapy (i.e., breathing and muscle relaxation) in 110 pregnant women in Iran found significant decreases in maternal anxiety, perceived stress and operative deliveries in the treatment group as compared to the controls (15). Alder et al. compared the effect of active or passive relaxation on anxiety levels, hypothalamicpituitary-adrenal (HPA) axis, and sympathetic-adrenalmedullary (SAM) system activity in 39 pregnant women with high versus low anxiety. They discovered that pregnant women with high anxiety showed no effect from the intervention compared to the women with low anxiety, who did show some benefit (16). A pilot project of an eight-week Mindfulness-Based Therapy (MBT) (N=10) was effective in decreasing depression, anxiety and stress symptoms in pregnant women, in 12 to 28 weeks of gestation (17). Studies of depression have shown that anxiety symptoms are often a significant component of the depression scores that women display in pregnancy compared to in the postpartum (18). Women who are improperly or untreated for depression or anxiety in pregnancy are at increased risk for postpartum depression (19, 20). Pregnant women must weigh the benefits of taking medication for depression against its possible side effects on the baby. This can cause some women to stop taking their medications that manage their symptoms, leaving them more vulnerable to recurrent and severe depression (21). Thus, we sought to investigate the efficacy of non-pharmacologic interventions such as therapy groups for pregnant anxious and depressed women. We hypothesized that women who participated in a facilitated therapy group would have decreased depression and worry symptoms and that this would be significantly

reduced from the decrease in depression and worry that women normally experience over the perinatal period. Our two main research questions included: 1) Does participating in a relaxation group decrease depression and worry over the course of pregnancy into the postpartum? And: 2) Is there a significant change in depression, stress and worry symptoms for the treatment groups compared to a control group? We were also interested in the women’s experiences with the group and suggestions for change in future groups. Methods We invited pregnant women in our health region who were between 15 and 25 weeks of gestation to participate in a six-week relaxation group. We chose this gestational time as we wanted to ensure that the women in the group were of similar gestation in their pregnancy, past the usual time for risk of miscarriage, and able to complete all six weeks of the group therapy. One of two experienced, registered psychologists facilitated the different Psychotherapy Groups (PG). One psychologist is trained and has a clinical practice focused entirely on Mindfulness-Based Therapy (MFB), specialized with women with body image and eating problems (22). The other therapist is a clinical health psychologist who is trained in Interpersonal Therapy (IPT) (23). We had funding for five group sessions, three groups were MFB and two groups were IPT. Thirty-eight women participated in the Psychotherapy Groups, 20 in the MFB groups and 18 in the IPT groups. The MFB groups included instruction in mindfulness, with an adaptation to increase body awareness and a greater sense of peace and acceptance of the changing body, greater awareness of emotional patterns and mental states specifically related to their pregnancy, and strategies to find more understanding and compassion for themselves. The group was process-oriented with time to connect with other women and discuss the particular challenges they were facing at that time related to their pregnancy or other issues. The primary theoretical approach in the IPT group was Interpersonal Psychotherapy, with strong components of psychoeducation and support, as needed by women in the group. It included interpersonal conflicts or disputes, role transitions unique to parenthood (23). An obstetrical nurse was invited to answer questions about labor and birth that were causing the women anxiety, for example about delivery processes or flu shots. We collected depression, anxiety, worry, stress, medication use, other therapies used, sociodemographic 227


Antenatal Group Therapy Improves Worry and Depression Symptoms

and obstetrical questionnaire data upon intake to the Psychotherapy Group. Women completed their second questionnaire when the group ended, approximately six weeks after they completed their initial assessment. Lastly, women completed a telephone interview at approximately four weeks postpartum. A graduate student was present throughout each group meeting. She administered the intake and final assessments during the group. The Edinburgh Postpartum Depression Scale (EPDS) was used to assess depression symptoms (24). The EPDS has also been validated in pregnant women (25).We used the Cambridge Worry Scale (CWS) to measure worry, as the tool evaluates worries determined to be specific among pregnant and postpartum women (e.g., fear of miscarriage, fear of birth) (26). Anxiety was determined by using the State scale of the State Trait Anxiety Inventory (STAI), the gold standard measure of anxiety (27), which has been validated to measure anxiety in pregnant women (28). The Maternity Social Support Scale (MSSS) was used to measure perceived support (29). At the postpartum assessment, we asked the women two open-ended questions about their satisfaction with the Psychotherapy Group: 1) What did they found most positive about the group? And: 2) What would they change in the group? We advertised through doctors’ offices and posters. There was no cost or remuneration to the women, although we did offer to reimburse transportation and childcare expenses to participate and no barriers to them receiving any other treatments, including pharmacological. If women were distressed they could receive immediate support within the group or if it was not resolved they could be referred to a Maternal Mental Health Program for assessment (30). The groups were held on a weekday evening at a women’s recreation facility. Approval was received from the University Ethics Board. All women signed an informed consent. The original intention of the project was to compare women participating in the Psychotherapy Group with women on a wait list for the group. However, despite extensive recruitment efforts in the community, there was never a wait list for this comparison. As the psychologists offered two different approaches to their therapy, we compared data on women in each group (MFB and IPT). We had assessed the effects of treatment (counseling or medication) on depression symptoms in perinatal women and concluded there was a significant impact on symptoms (3), and were optimistic that either approach intervention would yield effective results. 228

We were concurrently conducting a longitudinal study of perinatal depression (BLINDED—FIP) in the same community as psychotherapy participants. The FIP is a study of depression in 649 women at three time points, once in early pregnancy, later in pregnancy (N=603), and at around four weeks postpartum (N=593) differing sample sizes due mostly to obstetrical losses. FIP participants had completed many similar sociodemographic and obstetrical questionnaires, including support, the EPDS and the CWS; therefore, we felt confident to use FIP data as a control for the Psychotherapy Group data. Analyses: Descriptive statistics were done. Comparison was made between the MFB and IPT groups, using independent samples t-tests in SPSS software. Comparisons between age, marital status, number of children at home (Table 1), EPDS scores, STAI scores, CWS scores, and MMSS were made and the results can be found in Table 2. Matching: The 20 MFB and 18 IPT participants were pooled to constitute the psychotherapy group. Since our objective was to examine the effect of treatment, we selected matched controls from the FIP group. Using the Matchit computer algorithm (31), 68 control participants out of 531 women who were not being treated for depression by medication or counseling were matched with the treatment group participants in age, weeks of gestation, education and marital status. The nearestneighbor method, which finds the best match for each individual in the treatment group, was used at a 2:1 ratio of control and treatment group members. Four of the Psychotherapy Group participants had missing values on some variables, so we had 34 psychotherapy participants and 68 FIP subjects available for analysis. Once the two matched groups were formed, we compared outcomes, in this case, the EPDS and the Cambridge Worry Scale, to examine the treatment effect. Generalized Table 1. Comparison of sociodemographic factors of women in the Psychotherapy Groups using t-test

MFB group (N=20)

Average age (years±SD)

30.67 ± 3.94 28.94 ± 3.55 1.304, 0.201

Marital status • Married/Common Law • Single/Divorced/Widow

100% 0

85.7% 14.2%

10.0%

16.7%

Education • Grade 12/< than Post-Secondary • Post-Secondary/

IPT group (N=18)

t- value, p-value -0.690, 0.495

0.594, 0.556

90.0%

83.3%

Number of children at home

0.32 ± 0.478

0.17 ± 0.383

1.044, 0.304

Gestation at intake (weeks)

21.35 ± 5.59

23.42 ± 4.22

-1.275, 0.211


Angela Bowen et al.

estimating equation (GEE) models, as implemented in Stata, were developed comparing the results of the EPDS and Worry Scales between the FIP and the Psychotherapy Group women. GEE models the change in scores over time, taking into account their correlation pattern. We used an unstructured correlation matrix. Results Women in the two Psychotherapy Groups (MFB or IPT) were similar in age, gestation, marital status, education, and number of children at home (see Table 1). One woman in the MFB group did not complete the postpartum questionnaire of the study. Mean gestation at time of recruitment for the MFB group was 21.35 ± 5.59 weeks and mean gestation at time of recruitment for the IPT group was 23.42 ± 4.22 weeks. Women attended an average of 4.405 sessions (SD=1.235), there was no difference between the groups. There was no difference in the depression symptoms (EPDS scores), the anxiety symptom (STAI scores), or the amount of worry (CWS scores) from intake into the group, to the end of the group, to postpartum between the two Psychotherapy Groups (Table 2). However, with

the two Psychotherapy groups (IPT and MFB) combined there was a significant decrease in anxiety symptoms from intake to postpartum (t=3.416, p=0.002). Table 3 shows these results. In the combined group, the women who participated in either Psychotherapy Group (i.e., IPT or MFB) experienced a significant decrease in depression symptoms (EPDS score) (p<0.001) over pregnancy to postpartum. The amount of worry (CWS scores) also decreased (p<0.001) from intake to the end session of the groups and into the postpartum period compared to women in the FIP control group (see Figures 1 and 2). Table 3. Change in anxiety, as measured by the STAI from onset of group, at completion of group and postpartum STAI

Mean±SD

Time 1 (Intake)

47.51±4.8

Time 2 (Group Complete)

45.68±4.7

Time 3 (Four weeks postpartum)

44.32±3.9

Figure 1. Comparison of depression scores of Psychotherapy participants and FIP study participants

Table 2. Comparison of depression, anxiety, worry and support in two therapy groups using t-test MFB(N=19) (M±SD)

IPT (N=18) (M±SD)

Differences between groups (t,p)

Edinburgh Depression Scale (EPDS) at intake

9.05 ± 3.73

9.78 ± 3.89

-0.566, 0.881

EPDS after group complete

9.20 ± 4.30

8.28 ± 3.86

0.693, 0.882

EPDS 4 weeks postpartum

5.84 ± 4.79

6.72 ± 3.43

-0.640, 0.096

State Trait Anxiety Inventory (STAI)at intake

47.32 ± 4.81

47.72 ± 4.97

-0.253, 0.704

STAI anxiety score after group complete

46.55 ± 3.98

44.72 ± 5.32

1.207, 0.374

STAI anxiety score 4 weeks postpartum

44.42 ± 4.35

44.22 ± 3.49

0.153, 0.401

Cambridge Worry Scale (CWS)at intake

33.65 ± 7.67

34.22 ± 8.05

-0.224, 0.917

CWS after group complete

30.21 ± 9.00

28.33 ± 7.10

0.702, 0.559

CWS4 weeks postpartum

16.89 ± 5.60

17.22 ± 5.30

-0.183, 0.797

Maternal Mental Support Scale (MMSS)at intake

15.05 ± 2.16

13.67 ± 2.47

1.839, 0.959

MMSS after group complete

15.15 ± 2.37

15.17 ± 3.03

-0.19, 0.872

13.89 ± 2.83

1.997, 0.341

MMSS4 weeks postpartum 15.42 ± 1.74

Figure 2. Comparison of worry scores of Psychotherapy Group participants and FIP study participants

229


Antenatal Group Therapy Improves Worry and Depression Symptoms

Regarding their satisfaction with the Psychotherapy Groups, the women had many positive comments and very few things that they would change. Women in the MFB group told us that they enjoyed the body scans and breathing exercises and continued to use them to manage ongoing anxiety and stress. They reported that the groups were a good adjunct to prenatal classes and many wished that the group had continued after the baby was born. Some women enjoyed the meditation component, but two would have changed that aspect. Women who attended the IPT groups also enjoyed the breathing and relaxation that they did along with imagery, they enjoyed being with other women in similar situation. While a strength of the IPT group was its ability to respond to the questions of the group (e.g., bringing in a nurse to discuss flu or birthing facility), other women wanted more structure and to stay on-topic to ensure that there was time for relaxation exercises each week. Limitations

The participants were more likely to be married, better educated, and have higher incomes compared with women in the general population. Random assignment was not feasible, as only one group was run at a time, relative to availability of the individual therapists and the women’s stage of pregnancy; they were added to a group that was offered at that particular time. Women with depression may have been more likely to volunteer to participate in a study about relaxation or feelings in pregnancy. A diagnostic assessment for clinical depression was not done. Recruitment and retention were a challenge: This limited our ability to have a wait list for comparison, also women found it difficult to commit to all sessions due to work or school schedules, concurrent prenatal classes, and the health of themselves or other children in their family. At the time of the onset of the study, there was a major concern about flu outbreaks and pregnant women were reluctant to go out. Consequently, complete data were available on 37 women rather than the 38 who started the groups. This low sample size forced us to deviate from the original design and analysis plan to match with a concurrent study. Another limitation is combining the results from two therapy groups with different therapeutic orientations, we did assess for differences between the groups and did not find any, but it is feasible that there may be unique short and long-term effects with different therapeutic approaches. 230

Discussion Anxiety and depression symptoms tend to decrease over the course of pregnancy into the postpartum in all women, but the decrease is clinically and statistically significant in those women who were engaged in treatment, either pharmacological or counseling (3). Similar to other studies (12, 15), we found a positive significant effect on depression and worry symptoms as a result of taking part in a group designed to teach and provide relaxation in the antenatal period; this effect was not dependent on the type of therapy offered. This may help to alleviate concerns that some care providers have expressed about determining the exact therapy approach to use with perinatal populations. Social support provides relief and protection from depression in perinatal women (32). There may have been a positive impact from the women belonging to a group with other pregnant women and talking about their concerns rather than just the intervention. This social support may have provided relief from anxiety or depression no matter which therapeutic approach was used. One very interesting finding was that many women reported that they continued to use the lessons learned during these pregnancy relaxation classes while in labor and parenting. They volunteered that it helped keep them calm and focused. Importantly, some of those same women said they continued to use the relaxation, imagery and focusing to manage their emotions during the first postpartum weeks (that many women find to be a very challenging time). In a study of 10 women who participated in an eight-week Mindfulness Based group sessions during pregnancy, the authors also report an ongoing benefit of the therapy into the postpartum period (17). The goal of the study was to find alternative therapy to reduce depression and anxiety. Women did experience significant reductions in their symptoms, which will benefit their overall health and that of their baby. A recent review article confirms that antenatal relaxation interventions can have a positive effect on fetal behavior and on obstetric and neonatal outcomes (33). In conclusion, participating in either Mindfulness Based or Interpersonal Therapy groups offered an alternative to medications to lessen depression and worry symptoms in pregnant women into the postpartum. Women experienced ongoing positive effect from attending relaxation groups during pregnancy, which extended into their labor and birth experience and into the early


Angela Bowen et al.

postpartum period. Longitudinal studies of different intervention modes and social support are needed to determine best therapeutic approaches. We also need more research on the ongoing benefits of interventions on depression and anxiety symptoms into the postpartum period and their impact on maternal coping with parenting challenges over the first year. Care providers can be confident that suggesting different types of group therapy to their pregnant patients either as an adjunct to pharmacological treatment or as primary care for women can effectively reduce depression or worry symptoms. Acknowledgements We are grateful for the financial support of the Royal University Hospital Foundation, Saskatoon, SK, Canada and the Canadian Institutes for Health Research (Grant #145179).

References 1. WHO. The global burden of disease. WHO; 2002 [cited 2005 February 6]; Available from: http://www.ispn-psych.org/docs/4-00Global-Burden. pdf;http://www.who.int/healthinfo/paper54.pdf 2. Marcus SM, Flynn HA, Blow FC, Barry KL. Depressive symptoms among pregnant women screened in obstetrics settings. J Women's Health 2003;12:373-380. 3. Bowen A, Bowen R, Butt P, Rahman K, Muhajarine N. Patterns of depression and treatment in pregnant and postpartum women. Can J Psychiatry 2012;57:161-167. 4. Lam R, Kennedy S, Grigordias S, McIntyre R, Milav R, Ramasubbu R, et al. Canadian Network for Anxiety and Depression Treatment (CANMAT) Clinical guidelines for management of major depressive disorder in adults, III Pharmacotherapy. J Affect Disord 2009;117:s29-s43. 5. Bonari L, Koren G, Einarson TR, J.D. J, Taddio A, Einarson A. Use of antidepressants by pregnant women: Evaluation of perception of risk, efficacy of evidence based counseling and determinants of decision making. Arch Womens Ment Health 2005;8:214-220. 6. Banti S, Mauri M, Oppo A, Borri C, Rambelli C, Ramacciotti D, et al. From the third month of pregnancy to 1 year postpartum. Prevalence, incidence, recurrence, and new onset of depression. Results from the perinatal depression-research & screening unit study. Compr Psychiatry 2010;52:343-351. 7. Bergink V, Kooistra L, Lambregtse-van den Berg MP, Wijnen H, Bunevicius R, van Baar A, et al. Validation of the Edinburgh Depression Scale during pregnancy. J Psychosom Res 2011;70:385-389. 8. Registered Nurses' Association of Ontario. Interventions for postpartum depression. Toronto: Registered Nurses' Association of Ontario, 2005 April. http://rnao.ca/sites/rnao-ca/files/Interventions_for_Postpartum_ Depression.pdf 9. Dennis C-L. The effect of peer support on postpartum depression: A pilot randomized controlled trial. Can J Psychiatry 2003;48:115-124. 10. Avis K, Bowen AN. Postpartum depression support program evaluation. Saskatoon: CUISR; 2003 [updated 2004]; Available from: http://www.usask.ca/cuisr/docs/pub_doc/health/AvisBowen. pdf#search=%22Avis%20CUISR%20%22. 11. Dennis C-L. Psychosocial and psychological interventions for prevention of postnatal depression: Systematic review. BMJ 2005;331:15. 12. Spinelli MG, Endicott J. Controlled clinical trial of interpersonal

psychotherapy versus parenting education program for depressed pregnant women. Am J Psychiatry 2003;160:555-562. 13. Hayes BA, Muller R, Bradley BS. Perinatal depression: A randomized controlled trial of an antenatal education intervention for primiparas. Birth 2001;28:28-35. 14. Miller L, Gur M, Shanok A, Weissman M. Interpersonal psychotherapy with pregnant adolescents: Two pilot studies. J Child Psychol Psychiatry 2008;49:733-742. 15. Bastani F, Hidarnia A, Montgomery S, Aguilar-Vafaei ME, Kazmnejad A. Does relaxation education in anxious primigravid Iranian women influence adverse pregnancy outcomes? A randomized controlled trial. J Perinat Neonatal Nurs 2006;20:138-146. 16. Alder J, Urech C, Fink N, Bitzer J, Hoesli I. Response to induced relaxation during pregnancy: Comparison of women with high versus low levels of anxiety. J Clin Psychol Med Settings 2011;18:13-21. 17. Dunn C, Hanieh, Roberts R, Powrie R. Mindful pregnancy and childbirth: Effects of a mindfulness based intervention on women’s psychological distress and well-being in the perinatal period. Arch Womens Ment Health 2012;15:139-143. 18. Bowen A, Bowen RC, Maslany G, Muhajarine N. Anxiety in a socially high-risk sample of pregnant women in Canada. Can J Psychiatry 2008;53:435-440. 19. Austin M-P, Tully L, Parker G. Examining the relationship between antenatal anxiety and postnatal depression. J Affect Disord 2006;101:169-174. 20. Evans J, Heron J, Francomb H, Oke S, Golding J. Cohort study of depressed mood during pregnancy and after childbirth. BMJ 2001;323:257-260. 21. Cohen L, Altshuler LL, Harlow BL, Nonacs R, Newport DJ, Viguera AC, et al. Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA 2006;295:499-507. 22. Zindel Segal J, Williams M, Teasdale J. Mindfulness-based cognitive therapy for depression. New York: Guilford, 2003. 23. 23.Anchin J, Kiesler DJ, editors. Handbook of interpersonal psychotherapy. New York: Pergamon, 1982. 24. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987;150:782-786. 25. Murray D, Cox J. Screening for depression during pregnancy with the Edinburgh Depression Scale (EPDS). J Reprod Infant Psychol 1990;8:99-107. 26. Green JM, Kafetsios K, Statham HE, Snowdon CM. Factor structure, validity and reliability of the Cambridge Worry Scale in a pregnant population. J Health Psychol 2003;8:753-764. 27. Speilberger CD, Gorsuch RL, Lushene R. State-Trait Anxiety Inventory manual. Palo Alto, Cal.: Consulting Psychologists, 1970. 28. Gunning M, Denison F, Stockley C, Ho S, Sandhu H, Reynolds R. Assessing maternal anxiety in pregnancy with the State-Trait Anxiety Inventory (STAI): Issues of validity, location and participation. J Reprod Infant Psychology 2010;28:266-273. 29. Webster J, Linnane JWJ, Dibley LM, Hinson JK, Starrenburg SE. Measuring social support in pregnancy: Can it be simple and meaningful? Birth 2000;27:97-101. 30. Bowen A, Baetz M, McKee N, Klebaum N. Optimizing maternal mental health within a primary health care centre: A model program. Can J Commun Ment Health 2008;27:105-116. 31. Ho DE, Imai K, King G, Stuart EA. MatchIt: Nonparametric preprocessing for parametric causal inference. J Stat Softw 2011;42:1-28. 32. Cairney J, Boyle M, Offord DR, Racine Y. Stress, social support and depression in single and married mothers. Soc Psychiatry Psychiatr Epidemiol 2003;38:442-449. 33. Fink N, Urech C, Cavelti M, Alder J. Relaxation during pregnancy. What are the benefits for mother, fetus, and the newborn? A systematic review of the literature. J Perinat Neonat Nurs 2012;26:296-306.

231


‫מהמסגרות הקליניות‪ .‬נציג טיעונים אתיים הקשורים ביחס למטופל‪,‬‬ ‫טיעונים הקשורים לחוק וליחסי רופא‪-‬מטופל‪ ,‬וטיעונים הקשורים‬ ‫לאידיאולוגיה של המטפל‪.‬‬ ‫במאמר גם נתאר את השימושים הנפוצים כיום במערכת‬ ‫הבריאות בפלצבו‪ ,‬ונטען שהשימוש בכלי זה משגשג מתחת לפני‬ ‫השטח של העבודה הקלינית‪ ,‬ושההכרה בו ככלי טיפול יעיל הולכת‬ ‫וגדלה‪ .‬נציג נתונים הנוגעים לשימוש המחתרתי הנרחב שנעשה‬ ‫כיום בתרופות פלצבו בעבודה הקלינית של רופאים ובמחקרים‬ ‫קליניים פתוחים‪ ,‬ונתייחס גם לניסיונות תיאורטיים להכשיר את‬ ‫הליך ההסכמה מדעת‪ ,‬כך שניתן יהיה לעשות שימוש אתי בתרופות‬ ‫פלצבו‪ .‬לבסוף‪ ,‬נשתמש בדוגמה של הטיפול התרופתי בדיכאון‬ ‫כדי לבדוק את תקפות הטיעונים העיקריים נגד השימוש בפלצבו‬ ‫בקליניקה‪ ,‬תוך תקווה שיתפתח דיון מחודש בסוגיה חשובה זו‪.‬‬ ‫סיבות הפנייה לטיפול בקרב מקבלי שירות הפונים‬ ‫למרפאות נפש‪ :‬האם יש הבדלים בין המגדרים?‬ ‫א' נקש‪ ,‬מ' נגר וי' לבב‪ ,‬הרצליה‬

‫רקע‪ :‬במחקרים מבוססי קהילה נמצא כי יש הבדלים בין‬ ‫המגדרים בתחלואה במחלות נפש ובפנייה לשירותי בריאות‬ ‫הנפש‪ .‬במחקר זה נעשה שימוש בשיטות חקר משולבות על מנת‬ ‫לבחון את ההבדלים בין המגדרים בחומרת המצוקה הנפשית‪,‬‬ ‫באופני הפנייה‪ ,‬באופן הצגת בעיות הנפש ובציפיות מהטיפול‪,‬‬ ‫בקרב מטופלים הפונים לקבל טיפול פסיכיאטרי במרפאות חוץ‪.‬‬ ‫שיטה‪ :‬מטופלים עוקבים חדשים וחוזרים שפנו לקבלת טיפול‬ ‫פסיכיאטרי במרפאות חוץ למבוגרים השתתפו במחקר (‪284‬‬ ‫משתתפים‪ 64% ,‬נשים)‪ .‬המטופלים השיבו על שאלונים שבחנו‬ ‫מצוקה רגשית‪ ,‬היסטוריה של טיפול נפשי ונתיבי הפניה לטיפול‪.‬‬ ‫משתנים אלו נותחו בשיטות כמותיות‪ .‬נוסף על כך‪ ,‬המטופלים השיבו‬ ‫על שתי שאלות פתוחות שעסקו בסיבות הפנייה לטיפול ובציפיות‬ ‫מהטיפול‪ .‬משתנים אלו נותחו תוך שימוש בניתוח איכותני תמטי‪.‬‬ ‫תוצאות‪ :‬לא נמצאו הבדלים מובהקים בין המגדרים בקרב‬ ‫מטופלים חדשים וחוזרים בכל המשתנים שנבדקו‪ .‬הסיבות המרכזיות‬ ‫לפנייה לשירותי בריאות הנפש היו תסמינים פסיכיאטריים כמו גם‬ ‫פסיכופתולוגיה לא ספציפית‪ .‬הציפיות השכיחות ביותר משירותי‬ ‫בריאות הנפש היו קבלת טיפול פסיכותרפי וכלים ספציפיים שיעזרו‬ ‫למטופל להתמודד טוב יותר עם בעיות החיים ולנהל אותן‪.‬‬ ‫מגבלות‪ :‬מדגם הגברים בקבוצת המטופלים החדשים היה קטן‬ ‫יחסית‪.‬‬ ‫מסקנות‪ :‬לאחר הפנייה לשירותי בריאות הנפש‪ ,‬נמצאו בקרב‬ ‫גברים ונשים בעיות קליניות דומות וגם ציפיותיהם מהטיפול היו‬ ‫דומות‪.‬‬ ‫אכילה רגשית שלילית בקרב מטופלים‬ ‫הסובלים מהשמנה‪ ,‬עם או בלי דפוס של‬ ‫אכילה בולמוסית ותסמונת אכילה לילית‬

‫ש' רואר‪ ,‬י' לצר וא' גליפטר‪ ,‬חיפה‬

‫מטרה‪ :‬להעריך את האכילה הרגשית השלילית בקרב אנשים‬

‫שנמצאו אצלם דפוס של אכילה בולמוסית ותסמונת אכילת‬ ‫לילית ובקרב מי שלא נמצאו אצלו דפוסים אלה‪ ,‬ולהשוות‬ ‫ביניהם‪ .‬שיטה‪ :‬המדגם כלל ‪ 76‬משתתפים הסובלים מהשמנה‪,‬‬ ‫והם חולקו לארבע קבוצות‪ :‬קבוצת אכילה בולמוסית בלבד‪,‬‬ ‫קבוצת תסמונת אכילה לילית בלבד‪ ,‬קבוצה שנמצאה אצלה‬ ‫אכילה בולמוסית ותסמונת אכילה לילית וקבוצת ביקורת של‬ ‫אנשים הסובלים מהשמנה בלבד‪.‬‬ ‫תוצאות‪ :‬מהמחקר עלה כי תופעת האכילה הרגשית השלילית‬ ‫מתרחשת יותר באופן מובהק בקרב קבוצת האכילה הבולמוסית‬ ‫בלבד‪ ,‬בהשוואה לקבוצת תסמונת האכילה הלילית בלבד‬ ‫ולקבוצת הביקורת‪ .‬כמו כן נמצא כי אכילה רגשית שלילית נפוצה‬ ‫יותר בקרב חברי קבוצת האכילה הבולמוסית וחברי קבוצת‬ ‫תסמונת האכילה הלילית בהשוואה לקבוצת הביקורת‪ .‬בקבוצת‬ ‫תסמונת האכילה הלילית בלבד לא דווח על אכילה כתגובה‬ ‫לרגשות שליליים או לסיטואציות שליליות‪.‬‬ ‫דיון‪ :‬הממצאים יכולים להצביע על כך שאנשים שנמצאים‬ ‫אצלם דפוסי אכילה בולמוסית משתמשים באוכל כמנגנון‬ ‫להתמודדות עם בעיות הסתגלות‪ ,‬בעוד אנשים הסובלים‬ ‫מהפרעה של אכילה לילית נוטים לרכז את אכילתם בשעות‬ ‫הערב‪ ,‬כדי להימנע מהחוויה של רגשות שליליים‪.‬‬ ‫טיפול תרופתי לפני הלידה מוביל לשיפור‬ ‫בתסמיני הדאגה והדיכאון‬

‫א' בואן‪ ,‬מ' באץ‪ ,‬ל' שוורץ‪ ,‬ל' בלבואינה ונ' מהג'רין‪ ,‬ססקאצ'ואן‪ ,‬קנדה‬

‫מבוא‪ :‬כ־‪ 20%‬מהנשים בהיריון סובלות מחרדה ומדיכאון לפני‬ ‫הלידה‪ ,‬וההשפעות של תופעות אלה עלולות להזיק לאם ולעובר‪.‬‬ ‫למרות יעילותן של תרופות פסיכותרופיות בהפחתת התסמינים‪,‬‬ ‫חלק מהנשים ההרות מסתייגות מנטילת תרופות אלה‪ .‬במחקר זה‬ ‫נבדקה היעילות של טיפול קבוצתי בהקלת תסמיני דאגה ודיכאון‬ ‫בקרב נשים בהיריון‪.‬‬ ‫שיטות‪ :‬נשים (‪ 38‬משתתפות) בשבועות ‪ 28-15‬להיריון‪,‬‬ ‫גויסו לפני הלידה לקבוצות פסיכותרפיה‪ ,‬המבוססות על תרפיה‬ ‫בין אישית (‪ )interpersonal‬או על מודעות (‪ .)mindfulness‬נתונים‬ ‫נאספו בשלוש נקודות זמן ‪ -‬בתחילת המחקר‪ ,‬בסיום הטיפול‬ ‫הקבוצתי וארבעה שבועות אחרי הלידה‪ .‬ניתוחים תיאוריים‪chi ,‬‬ ‫‪ square‬ו־‪ GEE‬בוצעו כדי להשוות בין קבוצה זו לקבוצת ביקורת‬ ‫מתאימה של נשים הרות (‪ 68‬משתתפות) בכל הקשור לדיכאון‬ ‫ולתסמיני דאגה‪.‬‬ ‫מגבלות‪ :‬מדגם קטן בשתי הקבוצות דרש קבוצת ביקורת‬ ‫מתאימה לא אקראית‪.‬‬ ‫תוצאות‪ :‬בקרב נשים שהשתתפו בטיפול קבוצתי חלה ירידה‬ ‫משמעותית בתסמיני הדאגה והדיכאון בהיריון ובתקופה לאחר‬ ‫הלידה בהשוואה לנשים שלא השתתפו בקבוצות טיפול‪ .‬לא‬ ‫נמצא הבדל בהפחתת התסמינים בין הקבוצות השונות‪.‬‬ ‫דיון‪ :‬שילוב נשים הרות בטיפול קבוצתי עשוי לשפר במידה‬ ‫ניכרת תסמינים של דאגה ודיכאון‪ ,‬והשפעתו של טיפול כזה היא‬ ‫ארוכת טווח‪.‬‬ ‫‪232‬‬


‫החוק לזכויות החולה שנחקק בשנת ‪ 1996‬מיסד והגדיר‬ ‫את פעילותן של ועדות האתיקה הסטטוטוריות‪ .‬ועדות אלו‬ ‫קיבלו מנדט לפעול מתוקפו של החוק בתחומים מוגדרים‪,‬‬ ‫ובשונה מוועדות האתיקה הוולונטריות‪ ,‬שנחשבו לוועדות‬ ‫מייעצות ומרחיבות חשיבה על מקרים‪ ,‬החלטותיהן של הוועדות‬ ‫הסטטוטוריות מחייבות על פי חוק‪ .‬עם זאת נראה כי פעילותן‬ ‫של ועדות האתיקה בתחום בריאות הנפש שונה בין המרכזים‬ ‫ומוגבלת‪ ,‬ופועלן מתרכז בעיקר בסוגיות הקשורות להעברת‬ ‫מידע ולסירובו של חולה נפש לקבל טיפול רפואי‪ .‬המאמר מנסה‬ ‫להתחקות אחר הסברים אפשריים לתופעה זו‪ ,‬וכן להאיר מצבים‬ ‫שונים שבהם יכולות ועדות האתיקה לסייע לפרקטיקה היומיומית‪.‬‬ ‫כשמטופל מתאבד‬

‫ד‪ .‬גרינברג וג‪ .‬שפלר‪ ,‬ירושלים‬

‫כמה עבודות מצביעות על כך שכמעט כל הפסיכיאטרים‪ ,‬ובמיוחד‬ ‫פסיכיאטרים שמטפלים במבוגרים במסגרת השירות הציבורי‪,‬‬ ‫התמודדו עם התאבדות של מטופל או מטופלים‪ .‬ב–‪50%-25%‬‬ ‫מהמקרים‪ ,‬עצמתם של תסמיני הצער בקרב פסיכיאטרים בתגובה‬ ‫להתאבדות של מטופליהם דומה לזו של אבדן הורה‪ ,‬והם זקוקים‬ ‫לעזרה נפשית בעקבות כך‪ ,‬אף שמשך תגובת הצער קצר יותר‪.‬‬ ‫התאבדות מטופלים גורמת לפסיכיאטרים לנקוט גישה מתגוננת‬ ‫יותר בעבודתם‪ :‬הם נוקטים זהירות מופלגת כשהם מתשאלים‬ ‫מטופלים על רעיונות אובדניים‪ ,‬נוטים יותר להציע אשפוז או‬ ‫טיפול כפוי במצבים כאלה‪ ,‬ומחפשים ייעוץ מעמיתים‪.‬‬ ‫התדירות של התאבדויות מטופלים וההשפעות הרגשיות‬ ‫והמקצועיות שלהן על הפסיכיאטרים‪ ,‬הובילו לכמה המלצות‬ ‫שעיקרן מתן תמיכה לפסיכיאטר בעיקר בשלב הראשון של ההלם‬ ‫והצער בעקבות התאבדות המטופל‪ ,‬וגם לאורך תקופה ממושכת‬ ‫לאחר ההתאבדות‪ .‬מרבית המשפחות של מטופלים שהתאבדו‬ ‫מעוניינות להיות בקשר עם הפסיכיאטר לאחר האירוע‪ .‬אמנם דחק‬ ‫וחשש מתביעה עלולים להשפיע על הפסיכיאטר ועל פעולותיו‪ ,‬אך‬ ‫פגישה עם בני משפחת המטופל שהתאבד היא חלק מהטיפול‪ ,‬ועל‬ ‫הפסיכיאטר לקבל הדרכה והנחיה לשם קיום תהליך זה‪.‬‬ ‫החלטות בזמן אמת של הסובלים מתחלואת נפש‬ ‫חמורה‪ :‬השתתפות והימנעות ממחקר‬

‫א‪ .‬אור‪ ,‬י‪ .‬ברוך‪ ,‬ש‪ .‬טג'ר‪ ,‬י‪ .‬ברק‪ ,‬בת ים‬

‫רקע‪ :‬החלטות מטופלים להשתתף במחקר קליני תלויות בערכים‬ ‫אישיים ותוצאים מותאמים‪ .‬הצגת החלטות אפשריות באופן‬ ‫של ברירת–מחדל (להשתתף או להימנע) מביאה לעיתים להשגת‬ ‫בחירות רצויות‪ .‬מטרת המחקר הנוכחי הייתה לאפיין מטופלים‬ ‫המסכימים להשתתף במחקר קליני וכן להעריך את השפעת‬ ‫ברירת המחדל על מטופלים הסובלים מתחלואת נפש חמורה‬ ‫(שסעת‪ ,‬מחלה דו–קוטבית ודכאון רבא) בתהליך קבלת ההחלטות‪.‬‬ ‫שיטה‪ :‬מטופלים הסובלים מתחלואה חמורה התבקשו לקבל‬ ‫או לדחות השתתפותם במחקר תרופתי חדשני בעת שהוצגו‬ ‫לפניהם ברירות המחדל הבאות‪ )1( :‬הימנעות ‪ -‬נמסר למטופל‬ ‫‪233‬‬

‫שמדיניות המרכז הרפואי היא לא להכליל מטופלים במחקר‬ ‫קליני תרופתי; (‪ )2‬השתתפות ‪ -‬נמסר למטופל שמדיניות‬ ‫המרכז הרפואי היא תמיד להכליל מטופלים במחקר קליני‬ ‫תרופתי ו–(‪ )3‬ניטרלי ‪ -‬המטופל נתבקש להצהיר על עמדתו‬ ‫ביחס להשתתפות במחקר ללא ידיעת עמדת המרכז‪.‬‬ ‫תוצאות‪ :‬שלוש–מאות ואחד עשר מטופלים השלימו שאלון קצר‬ ‫במהלך ‪ 48‬שעות הראשונות מאישפוזם במחלקה פסיכיאטרית‪.‬‬ ‫משסעת או תחלואה סכיזואפקטיבית סבלו ‪ ,)73%( 227‬מחלה‬ ‫דו–קוטבית ‪ )13%( 40‬ומדיכאון רבא ‪ .)14%( 44‬במדגם השתתפו‬ ‫‪ 156‬גברים ו–‪ 155‬נשים בגיל ממוצע של ‪ 47.8 + 16.2‬שנים‪ .‬במצב‬ ‫ההימנעות ‪ 58%‬מהמטופלים לא שינו את ברירת המחדל ואילו ‪42%‬‬ ‫בחרו באופן פעיל להשתתף במחקר (‪ .)p=0.003‬במצב ההשתתפות‬ ‫‪ 58%‬לא שינו את ברירת המחדל ו–‪ 42%‬בחרו באופן פעיל להימנע‬ ‫מהשתתפות במחקר‪ .‬במצב הניטרלי ‪ 51%‬מהמטופלים הביעו כי‬ ‫עמדתם בעד הסכמה להשתתף במחקר תרופתי קליני‪ 33% ,‬התנגדו‬ ‫למחקר ו–‪ 16%‬לא הביעו דעתם‪ .‬המטופלים אשר בחרו באופן‬ ‫פעיל להשתתף במחקר אופיינו בגיל צעיר‪ ,‬אשפוזים פסיכיאטרים‬ ‫קודמים‪ ,‬תחלואה אפקטיבית ויותר תחלואה גופנית נלוות‪.‬‬ ‫מסקנות‪ :‬המחקר הנוכחי מאפשר אפיון מטופלים המעוניינים‬ ‫להשתתף במחקר וכן מדגים השפעה חיובית של ברירת מחדל על‬ ‫שיעורי המביעים הסכמתם‪.‬‬ ‫אתיקה והעורך של כתב עת לפסיכיאטריה‪:‬‬ ‫תחומי אחריות ודילמות‬ ‫ד‪ .‬גרינברג וי‪ .‬שטראוס‪ ,‬ירושלים‬

‫עורך של כל כתב עת מדעי צפוי לעמוד בפני אתגרים בתחום‬ ‫האתיקה‪ .‬נושאים שונים וחשובים עולים בייחוד בכתבי עת בתחום‬ ‫בריאות הנפש‪ ,‬וכן בכתבי עת מקומיים שמספר המנויים שלהם‬ ‫לא גדול וגורם ההשפעה (‪ )Impact factor‬שלהם אינו גבוה‪ .‬מערכת‬ ‫בקרה עיוורת‪ ,‬ניגוד עניינים‪ ,‬פרסום מיותר‪ ,‬זיוף והעתקה‪ ,‬מחברים‬ ‫"אורחים" ו"רפאים" וגם "סופר רפאים"‪ ,‬פרסומות של חברות‬ ‫תרופות‪ ,‬שימוש בשפה שיש בה סטיגמות‪ ,‬הסכמה של מטופלים‬ ‫לפרסום‪ ,‬והטיה של גורם ההשפעה ‪ -‬כל אלו נושאים חשובים שעל‬ ‫העורך לעסוק בהם‪ .‬על העורך להכיר ולהיות ער לנושאים אלו‪ ,‬וחשוב‬ ‫שיהיה לו פורום מומחים נגיש‪ ,‬שעמו יוכל לדון בשאלות אתיות‪.‬‬ ‫שימוש בתרופות פלצבו בעבודה הקלינית ‪-‬‬ ‫משחק אינטלקטואלי או מציאות אפשרית‬ ‫א‪ .‬ניצן‪ ,‬י‪ .‬בלוך וש‪ .‬פניג‪ ,‬הוד השרון‬

‫לפני התפתחות תעשיית התרופות והרפואה מבוססת הראיות‬ ‫במחצית השנייה של המאה העשרים‪ ,‬טיפולי פלצבו היו חלק בלתי‬ ‫נפרד מארגז הכלים של הרופא‪ .‬בעבודה הקלינית המוכרת לנו היום‪,‬‬ ‫הביטחון של הרופא ביעילות של טיפול מסוים או הנורמות האתיות‬ ‫הפרטיות שלו אינן מספיקות כדי להצדיק מתן תרופה למטופל‪.‬‬ ‫במאמר זה נדון בשאלות האתיות העולות משימוש בתרופות‬ ‫פלצבו בעבודה הקלינית כחלופה לטיפול הסטנדרטי‪ ,‬ונציע‬ ‫המשגה חדשה של הגורמים המעורבים בהדרה של טיפולי פלצבו‬


‫כתב עת ישראלי‬ ‫לפסיכיאטריה‬ ‫תקצירים‬ ‫נטייה מולדת לרוע והשפעתה על הענישה ‪-‬‬ ‫מהתנ"ך ועד עידן הגנטיקה ההתנהגותית‬

‫ע‪ .‬גולד ופ‪ .‬ס‪ .‬אפלבאום‪ ,‬ניו יורק‪ ,‬ארה"ב‬

‫התחום המתפתח של גנטיקה התנהגותית חושף בהדרגה את‬ ‫הקשר המורכב שבין גנטיקה לסביבה‪ .‬בתוך כך‪ ,‬מחקר מדעי‬ ‫הקשור להיבטים גנטיים של התנהגות אלימה מעורר מחדש דילמה‬ ‫עתיקת־יומין בנוגע לאחריות פלילית וענישה‪ :‬כיצד העובדה‬ ‫שהנטייה להתנהגות אלימה עשויה להיות תכונה המוטבעת‬ ‫מלידה‪ ,‬תשפיע על עונשו של העבריין? האם מדובר בגורם שאמור‬ ‫להוביל להקלה בעונשו או דווקא להחמרה בו? במציאות שבה‬ ‫פסיכיאטרים נדרשים להעיד במסגרת המשפט הפלילי על סוגיות‬ ‫הקשורות לגנטיקה התנהגותית‪ ,‬המאמר מספק חומר רקע בסיסי‬ ‫הנדרש להבנת ההיבטים המדעיים של דילמה זו‪ .‬כמו כן מוצגת בו‬ ‫ההתייחסות בתנ"ך וההתייחסות של מפרשיו לשאלה עקרונית זו‪,‬‬ ‫ואלה עשויות להעשיר ולהרחיב את הדיון בן־זמננו בסוגיה‪.‬‬ ‫זכות בחירה לסובלים ממחלות נפש‪ :‬סכנה לטוהר‬ ‫מערכת הבחירות או העצמה ושילוב בקהילה?‬

‫ע‪ .‬דורון‪ ,‬ר‪ .‬קורס‪ ,‬ט‪ .‬סטולובי ‪ ,‬א‪ .‬סקר־אינבינדר וא‪ .‬רבה‪ ,‬נתניה‬

‫רקע‪ :‬הסובלים ממחלת נפש הם בעלי זכות בחירה‪ ,‬ויש לכך חשיבות‬ ‫בשילובם בקהילה‪ .‬במדינות רבות נשללת זכות זו מסובלים ממחלות‬ ‫פסיכיאטריות שיש להם אפוטרופוס במקרים שבהם הם אינם יכולים‬ ‫להבין את משמעות הליך הבחירות‪ .‬במחקר זה ניסינו להעריך את‬ ‫יכולתם של סובלים ממחלות פסיכיאטריות שיש להם אפוטרופוס‬ ‫וכאלה שלא מונה להם אפוטרופוס‪ ,‬להבין את משמעות תהליך‬ ‫הבחירות ואת השפעתו‪ ,‬ולזהות מי הם המטופלים שיש להם יכולת כזו‪.‬‬ ‫שיטה‪ 56 :‬מטופלים מאושפזים הסובלים ממחלות נפש עם ובלי‬ ‫אפוטרופוס גויסו למחקר‪ .‬המשתתפים מילאו את שאלון ה–‪CAT-V‬‬ ‫(כלי להערכת היכולת להצביע)‪ ,‬את ה–‪( BPRS‬סולם לדירוג פסיכיאטרי‬ ‫קצר)‪ ,‬ואת ה–‪( MMS‬סולם קצר לקביעת המצב הנפשי הקוגניטיבי)‪.‬‬ ‫תוצאות‪ :‬בניתוח אשכולות (‪ )Cluster Analysis‬נמצא שהיכולת‬ ‫להצביע היא משתנה רציף לפי שאלון ה–‪ .CAT-V‬נמצא כי נבדקים‬ ‫שקיבלו מעל ‪ 1.6‬בשאלון זה (‪ )59%‬היו בעלי יכולת גבוהה להצביע‪.‬‬ ‫אצל נבדקים ללא אפוטרופוס נראתה יכולת גבוהה יותר באופן‬ ‫משמעותי להצביע‪.‬‬ ‫נמצא יחס ישר בין הבנת משמעות הבחירות לבין המצב‬

‫‪israel journal of‬‬

‫‪psychiatry‬‬ ‫כרך ‪ ,51‬מס' ‪2014 ,3‬‬

‫הקוגניטיבי ויחס הפוך בין היכולת להצביע לבין חומרת המחלה‪.‬‬ ‫בקרב הנבדקים שיש להם אפוטרופוס‪ ,‬אצל אלו שקיבלו מעל ‪1.6‬‬ ‫בשאלון ה–‪ CAT-V‬נראתה יכולת שמורה להבנת הבחירות‪.‬‬ ‫מסקנה‪ :‬זכות הבחירה היא זכות חשובה לסובלים ממחלות‬ ‫נפש‪ .‬חשוב להעריך את יכולת הבנת הליך הבחירות בקרב חולים‬ ‫במחלות פסיכיאטריות שיש להם אפוטרופוס‪ .‬בדרך זו יישמר‬ ‫טוהר מערכת הבחירות ויופחת הסיכון של השפעה חיצונית על‬ ‫אזרחים שאינם מבינים את ההליך הזה‪ .‬אלו מבין החולים שיש‬ ‫להם אפוטרופוס ומבינים את משמעות ההליך‪ ,‬יוכלו להמשיך‬ ‫לקחת חלק בבחירות‪.‬‬ ‫בחינת הגבולות האתיים של גישת צמצום הנזקים‪:‬‬ ‫מטיפול בהתמכרויות לפסיכיאטריה כללית‬

‫ש‪ .‬לב־רן‪ ,‬א‪ .‬ניצן וש‪ .‬פניג‪ ,‬הוד השרון‬

‫צמצום נזקים הוא ביטוי המתאר התערבויות מעשיות שמטרתן‬ ‫הפחתת התנהגויות בעייתיות‪ .‬הגישה‪ ,‬אשר צמחה מתחום‬ ‫הטיפול בהתמכרויות‪ ,‬מבוססת על ההבנה שבני אדם ימשיכו‬ ‫להתנהג באופן שבו הם מסכנים את עצמם ואת סביבתם‪ ,‬ושאחת‬ ‫המטרות החשובות בכל תכנית טיפול היא הפחתת הנזקים‬ ‫הכרוכים בהתנהגויות אלו‪ .‬למרות הרקע המחקרי המבוסס‪ ,‬לא‬ ‫נעשה כיום די שימוש בגישות של צמצום נזקים בפסיכיאטריה‬ ‫כללית‪ .‬הדבר נובע מקושי להתמודד עם הדילמות האתיות‬ ‫המורכבות העולות כאשר עובדים בגישה כזו ומחוסר ידע לגבי‬ ‫הבסיס המחקרי והמסגרות המסייעות להתייחס לסוגיות אתיות‬ ‫מורכבות‪ .‬במאמר זה אנו מציגים את היסודות ואת הרקע המדעי‬ ‫של גישת צמצום הנזקים‪ ,‬ומדגימים בעזרת שתי דוגמאות את‬ ‫הדילמות האתיות המורכבות העולות מעבודה בגישה זו‪ .‬לסיום‬ ‫אנו מציגים מסגרת תיאורטית המסייעת לדון בסוגיות אתיות‬ ‫מורכבות אלו וטוענים כי ניתן לאמץ אסטרטגיות של צמצום‬ ‫נזקים בעבודה בפסיכיאטריה כללית‪.‬‬ ‫הגברת השימוש בוועדות אתיקה מוסדיות‬ ‫בתחום בריאות הנפש בישראל‬

‫ט‪ .‬ברגמן לוי‪ ,‬ע‪ .‬דורון‪ ,‬י‪ .‬שטראוס‪ ,‬באר יעקב‬

‫ועדות אתיקה אשר פעלו במוסדות רפואיים הוקמו ופעלו בישראל‬ ‫גם לפני חקיקתו של "חוק זכויות החולה" בשנת ‪ .1996‬ועדות‬ ‫וולונטריות אלו הורכבו מצוותים רב מקצועיים כדי שיוכלו לבחון את‬ ‫הדילמה המוצגת לוועדה מנקודת מבט רחבה כלל האפשר‪ ,‬וזאת על‬ ‫בסיס ההבנה שבעת קבלת החלטות אתיות יש להתייחס להיבטים‬ ‫חברתיים ותרבותיים שהם מעבר למציאות הרפואית ה"טהורה"‪.‬‬ ‫‪234‬‬


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‫‪ | medic.co.il‬הרשמו עכשיו באתר וקבלו מנוי שנתי בהנחה מיוחדת‬ ‫יחזאל‪-‬זמיר ‪ | 054-7568656‬דוא"ל ‪sales@medic.co.il‬‬ ‫ֿ‬ ‫מדיק הוצאה לאור בע"מ | טלפון‪ | 09-9581960 :‬לרכישת מנוי‪ :‬רוני‬


‫גברים רבים הסובלים מ‪ ED -‬סובלים גם מתסמינים‬

‫שתי בעיות‪ .‬פתרון אחד‪.‬‬

‫סיאליס יומי ‪ 5‬מ"ג‪.‬‬ ‫סיאליס יומי לטיפול בהפרעה בזקפה וגם‬ ‫בתסמינים של הגדלה שפירה של הערמונית‪.‬‬

‫למידע מלא נא עיין בעלון לרופא כפי שאושר ע"י משרד הבריאות‪.‬‬ ‫‪Cialis 5mg: For the treatment of erectile dysfunction in adult men.‬‬ ‫‪Treatment of the signs and symptoms of benign prostatic hyperplasma (BPH).‬‬ ‫‪Treatment of ED and the signs and symptoms of BPH (ED/BPH).‬‬

‫יצרן‪ :‬אלי לילי בע"מ‪ ,‬בעל רישום‪ :‬אלי לילי ישראל בע"מ‪ ,‬ת‪.‬ד‪ 2160 .‬הרצליה פיתוח ‪ 46120‬טל‪09-9606234 :‬‬ ‫‪CI051225‬‬

‫‪*Reference: 1. Rosen R, et al. Eur Urol 2003;44:637‬‬

‫של ‪*BPH‬‬


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