1
|
Zingela Z, Sokudela F, Thungana Y, van Wyk S. Ethical principles, challenges and opportunities when conducting genetic counselling for schizophrenia. Front Psychiatry 2023; 14:1040026. [PMID: 37415685 PMCID: PMC10320156 DOI: 10.3389/fpsyt.2023.1040026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 06/05/2023] [Indexed: 07/08/2023] Open
Abstract
Ethical challenges of genetic counselling for schizophrenia include effective communication of critical scientific information in an easily understood manner by patients and relatives, and the ability to ensure communication is unencumbered by medical jargon. Levels of literacy in the target population may limit this process, making it difficult for patients to attain the desired levels of informed consent to make crucial decisions during genetic counselling. Multilingualism in target communities may further complicate such communication. This paper outlines the ethical principles, challenges and opportunities facing clinicians when conducting genetic counselling for schizophrenia and how these might be met, drawing on lessons from South African studies. The paper draws on reflections of clinician and researcher experiences gained from clinical practice or research on the genetics of schizophrenia and psychotic disorders in South Africa. The context of genetic studies in schizophrenia is used to illustrate the ethical challenges in genetic counselling for schizophrenia, both in clinical and research settings. Attention is also drawn to multicultural and multilingual populations, particularly where the preferred language lacks a well-developed scientific language of communication for some of the genetic concepts that have to be presented during the genetic counselling process. The authors describe the ethical challenges and how to address these to empower patients and relatives to make well-informed decisions despite these obstacles. Principles applied by clinicians and researchers during the genetic counselling are described. Potential solutions, including the establishment of community advisory boards to address potential ethical challenges inherent to the genetic counselling process, are also shared. Genetic counselling for schizophrenia still faces ethical challenges which require a balance of principles of beneficence, autonomy, informed consent, confidentiality and distributive justice, while striving to present accuracy in the science that guides the process. Evolution in language and cultural competency therefore needs to occur alongside scientific advances in genetic research. Key stakeholders need to partner and build capacity and expertise in genetic counselling through the provision of funding and resources. The goal of partnerships is to empower patients, relatives, clinicians and researchers to share scientific information in a manner guided by empathy while retaining scientific accuracy.
Collapse
Affiliation(s)
- Zukiswa Zingela
- Executive Dean’s Office, Nelson Mandela University, Port Elizabeth, South Africa
| | - Funeka Sokudela
- Department of Psychiatry, University of Pretoria, Pretoria, South Africa
| | - Yanga Thungana
- Executive Dean’s Office, Nelson Mandela University, Port Elizabeth, South Africa
- Department of Psychiatry and Behavioural Sciences, Walter Sisulu University, Mthatha, South Africa
| | - Stephan van Wyk
- Department of Psychiatry and Behavioural Sciences, Walter Sisulu University, Mthatha, South Africa
| |
Collapse
|
2
|
Real-World Implementation of Precision Psychiatry: A Systematic Review of Barriers and Facilitators. Brain Sci 2022; 12:brainsci12070934. [PMID: 35884740 PMCID: PMC9313345 DOI: 10.3390/brainsci12070934] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 07/08/2022] [Accepted: 07/12/2022] [Indexed: 01/27/2023] Open
Abstract
Background: Despite significant research progress surrounding precision medicine in psychiatry, there has been little tangible impact upon real-world clinical care. Objective: To identify barriers and facilitators affecting the real-world implementation of precision psychiatry. Method: A PRISMA-compliant systematic literature search of primary research studies, conducted in the Web of Science, Cochrane Central Register of Controlled Trials, PsycINFO and OpenGrey databases. We included a qualitative data synthesis structured according to the ‘Consolidated Framework for Implementation Research’ (CFIR) key constructs. Results: Of 93,886 records screened, 28 studies were suitable for inclusion. The included studies reported 38 barriers and facilitators attributed to the CFIR constructs. Commonly reported barriers included: potential psychological harm to the service user (n = 11), cost and time investments (n = 9), potential economic and occupational harm to the service user (n = 8), poor accuracy and utility of the model (n = 8), and poor perceived competence in precision medicine amongst staff (n = 7). The most highly reported facilitator was the availability of adequate competence and skills training for staff (n = 7). Conclusions: Psychiatry faces widespread challenges in the implementation of precision medicine methods. Innovative solutions are required at the level of the individual and the wider system to fulfil the translational gap and impact real-world care.
Collapse
|
3
|
Rowlatt AE, McAllister M, Cuthbert A. Attitudes toward offering genetic counseling for psychiatric conditions among genetics healthcare practitioners in the United Kingdom: A qualitative study. J Genet Couns 2021; 31:279-290. [PMID: 34363721 DOI: 10.1002/jgc4.1492] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 07/06/2021] [Accepted: 07/18/2021] [Indexed: 02/06/2023]
Abstract
Psychiatric conditions affect a large proportion of the population. High heritability estimates have been reported for commonly diagnosed conditions, suggesting both environmental factors and genetic variation significantly contribute to the chance of psychiatric outcomes. Despite growing interest in the provision and receipt of genetic counseling services for these conditions, such specialized interventions are not routinely available in most healthcare systems, including in the United Kingdom (UK). This study examined the attitudes of fourteen National Health Service employed genetic counselors and clinical geneticists, from seven regional genetic centers, toward offering psychiatric genetic counseling (PGC) in the UK. A qualitative methodology was adopted and individual semi-structured interviews were conducted either by telephone or face-to-face, audio recorded, transcribed in full and analyzed using thematic analysis. Participants' attitudes were organized under three themes: "Demand," "Readiness to Provide Support," and "Patient Experience." Participants cited key informational and resource needs which included increased workforce capacity, access to further psychological support for patients and more knowledge about the following: specific genes involved, available genetic testing, recurrence/occurrence risk figures, clinical manifestations, diagnostic criteria, patient concerns associated with the impact of psychiatric conditions and interpersonal skills. While some participants appreciated the value of PGC, some reported apprehension and raised concerns around a lack of available genetic testing, the perceived utility of current management options, and a potential negative psychological impact of PGC. This study identified important barriers to the delivery of PGC in the UK by genetics healthcare practitioners. Our findings highlight the importance of a collaborative, multidisciplinary approach to delivering this intervention and the need for additional training. Further research is required to better understand demand for, nature of, and barriers to provision of PGC in the UK, particularly in terms of genetic counselors' perceptions of their role.
Collapse
Affiliation(s)
- Amy E Rowlatt
- Centre for Medical Education, Cardiff University, Cardiff, UK.,MRC Institute for Genetics and Molecular Medicine, The University of Edinburgh, Edinburgh, UK
| | | | - Andrew Cuthbert
- MRC Centre for Neuropsychiatric Genetics and Genomics, School of Medicine, Cardiff University, Cardiff, UK
| |
Collapse
|
4
|
Sabatello M, Chen Y, Herrera CF, Brockhoff E, Austin J, Appelbaum PS. Teenagers and Precision Psychiatry: A Window of Opportunity. Public Health Genomics 2021; 24:14-25. [PMID: 33503628 PMCID: PMC7920903 DOI: 10.1159/000512475] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 10/16/2020] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE Precision medicine raises hope for translating genetic-based knowledge about psychiatric risks into mental health benefits by motivating health-related, risk-reducing behaviors. Teenagers (ages 14-17) are an important age-group to engage in preventive efforts but, their views about psychiatric genetics are understudied. METHOD An online survey with a nationally representative sample of teenagers (n = 417) was conducted. Participants were randomly assigned to receive 1 of 2 handouts, 1 emphasizing the genetic underpinnings of psychiatric conditions; the other agency-oriented and focusing on gene-environment interactions. Survey questions queried their views about behavioral changes in response to psychiatric genetic risk information and expressed willingness to undertake them. Participants' decision-making characteristics (i.e., self-efficacy, empowerment, intolerance of uncertainty, and sensation-seeking) were assessed at baseline. RESULTS Teenagers strongly valued the information provided and its potential usefulness for their mental health. Information about psychiatric genetics alone impacted views about the causes of mental illness. Contrary to our hypothesis, the type of handout did not impact participants' expressed willingness to make behavioral changes to reduce their risk of developing a psychiatric condition, but their sense of empowerment played a key role in their responses. CONCLUSION Educating teenagers about gene-environment interactions may help facilitate the translational efforts of precision psychiatry. Research with teenagers across racial/ethnic groups, especially those with family histories, is needed to better understand the factors that impact teenagers' empowerment in psychiatric genomic settings and to identify measures, including the best enablers of empowerment (e.g., educators, parents), which would allow them to reap the benefits of precision psychiatry.
Collapse
Affiliation(s)
- Maya Sabatello
- Department of Medicine, Columbia University, New York, New York, USA,
- Department of Medical Humanities and Ethics, Columbia University, New York, New York, USA,
| | - Ying Chen
- New York State Psychiatric Institute, New York, New York, USA
| | | | | | - Jehannine Austin
- Department of Psychiatry and Medical genetics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Paul S Appelbaum
- Department of Psychiatry, Columbia University, New York, New York, USA
| |
Collapse
|
5
|
Moldovan R, McGhee KA, Coviello D, Hamang A, Inglis A, Ingvoldstad Malmgren C, Johansson-Soller M, Laurino M, Meiser B, Murphy L, Paneque M, Papsuev O, Pawlak J, Rovira Moreno E, Serra-Juhe C, Shkedi-Rafid S, Laing N, Voelckel MA, Watson M, Austin JC. Psychiatric genetic counseling: A mapping exercise. Am J Med Genet B Neuropsychiatr Genet 2019; 180:523-532. [PMID: 31222934 DOI: 10.1002/ajmg.b.32735] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 03/12/2019] [Accepted: 04/19/2019] [Indexed: 11/08/2022]
Abstract
Psychiatric genetic counseling (PGC) is gradually developing globally, with countries in various stages of development. In some, PGC is established as a service or as part of research projects while in others, it is just emerging as a concept. In this article, we describe the current global landscape of this genetic counseling specialty and this field's professional development. Drawing on information provided by expert representatives from 16 countries, we highlight the following: (a) current understanding of PGC; (b) availability of services for patients; (c) availability of training; (d) healthcare system disparities and cultural differences impacting practice; and (e) anticipated challenges going forward.
Collapse
Affiliation(s)
- Ramona Moldovan
- Department of Psychology, Babeş-Bolyai University, Cluj-Napoca, Romania.,Division of Evolution and Genomic Sciences, School of Biological Science, University of Manchester, Manchester, United Kingdom.,Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Kevin A McGhee
- Faculty of Science and Technology, Bournemouth University, Poole, United Kingdom
| | - Domenico Coviello
- IRCCS Istituto Giannina Gaslini, Research Institute and Children Hospital, Genova, Italy
| | - Anniken Hamang
- Department of Medical Genetics, St. Olavs Hospital, Trondheim University Hospital
| | - Angela Inglis
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada.,Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Charlotta Ingvoldstad Malmgren
- Department of Public Health and Caring Science, Uppsala University, Uppsala, Sweden.,Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.,Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | | | - Mercy Laurino
- College of Medicine, Department of Pediatrics, University of the Philippines Manila, Philippine General Hospital, Manila, Philippines
| | - Bettina Meiser
- Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Lauren Murphy
- University of Texas Genetic Counseling Program, UT MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, TX, USA
| | - Milena Paneque
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal.,CGPP - Centre for Predictive and Preventive Genetics, Institute for Molecular and Cell Biology (IBMC), Universidade do Porto, Porto, Portugal
| | - Oleg Papsuev
- Moscow Research Institute of Psychiatry, Moscow, Russia
| | - Joanna Pawlak
- Department of Psychiatric Genetics, Department of Psychiatry, Poznan University of Medical Sciences, Poznan, Poland
| | - Eulàlia Rovira Moreno
- Departament de Ciències Experimentals i de la Salut, Universitat Pompeu Fabra, Barcelona, Spain.,Department of Clinical and Molecular Genetics, Hospital Vall d'Hebron, Barcelona, Spain
| | - Clara Serra-Juhe
- Department of Clinical and Molecular Genetics, Hospital Vall d'Hebron, Barcelona, Spain.,Medicine Genetics, VHIR, Barcelona, Spain
| | - Shiri Shkedi-Rafid
- Department of Genetics and Metabolic Diseases, Hadassah Medical Center, The Faculty of Medicine, The Hebrew University, Jerusalem
| | - Nakita Laing
- Division of Human Genetics, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | | | - Melanie Watson
- Wessex Clinical Genetics Service, University Hospital Southampton NHS Foundation Trust, Princess Anne Hospital, Southampton, United Kingdom
| | - Jehannine C Austin
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada.,Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
6
|
Kostick K, Pereira S, Brannan C, Torgerson L, Lázaro-Muñoz G. Psychiatric genomics researchers' perspectives on best practices for returning results to individual participants. Genet Med 2019; 22:345-352. [PMID: 31477844 PMCID: PMC7000323 DOI: 10.1038/s41436-019-0642-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 08/13/2019] [Indexed: 12/26/2022] Open
Abstract
Purpose Large-scale array-based and sequencing studies have advanced our understanding of the genetic architecture of psychiatric disorders, but also increased the potential to generate an exponentially larger amount of clinically relevant findings. As genomic testing becomes more widespread in psychiatry research, urgency grows to establish best practices for offering return of results (RoR) to individuals at risk or diagnosed with a psychiatric disorder. Methods We interviewed an international sample (n = 39) of psychiatric genetics researchers to examine conceptualizations of “best practices” for RoR to individual research participants. Results While the vast majority of researchers do not offer RoR, most believed medically actionable findings (85%) and clinically valid but non–medically actionable findings (54%) should be offered. Researchers identified three main areas for improvement: interfacing with individual participants; interdisciplinary training, guidance, and integration; and quality planning and resource allocation for returning results. Conclusion There are significant gaps between researchers’ visions for “best” versus “actual” RoR practices. While researchers call for participant-centered practices, including consent practices that consider any special needs of participants with psychiatric disorders, return of individually meaningful results, and effective follow-up and provisions for treatment, the current reality is that consent and RoR practices lack standardized and evidence-based norms.
Collapse
Affiliation(s)
- Kristin Kostick
- Center for Medical Ethics & Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Stacey Pereira
- Center for Medical Ethics & Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Cody Brannan
- Center for Medical Ethics & Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Laura Torgerson
- Center for Medical Ethics & Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Gabriel Lázaro-Muñoz
- Center for Medical Ethics & Health Policy, Baylor College of Medicine, Houston, TX, USA.
| |
Collapse
|
7
|
Martorell L, Sanfeliu A, Blázquez A, Lojo E, Cortés MJ, de Pablo J, Vilella E. Genetics and genetic counseling in psychiatry: Results from an opinion survey of professionals and users. Mol Genet Genomic Med 2019; 7:e830. [PMID: 31254460 PMCID: PMC6687663 DOI: 10.1002/mgg3.830] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 05/08/2019] [Accepted: 05/17/2019] [Indexed: 12/16/2022] Open
Abstract
Background The heritability of several psychiatric disorders is high, and specific at‐risk variants have been identified. Therefore, genetic counseling and genetic testing can be prescribed to some psychiatric patients, but these services are not standardized for most of the population. The aims of the study were to gather opinions from mental health professionals and users regarding (a) the genetics of psychiatric disorders and (b) the usefulness of a genetic counseling unit in psychiatry. Methods The survey was conducted in the province of Tarragona (Spain), and we analyzed 152 valid questionnaires from professionals and 959 from users. Results Sixty‐one percent of professionals strongly believed that psychiatric disorders have a genetic basis, and 59% rated a genetic counseling unit in psychiatry as very or extremely useful. However, only a few professionals reported that patients asked them about the genetics of their diseases (12%) or the possibility of transmitting the disease to offspring (19%). Forty‐seven percent of users strongly believed that psychiatric disorders have a genetic basis, 30% responded that they talked with their families about the genetics of their diseases, and 43% were worried about transmitting the disease to offspring; however, only 14% reported that their psychiatrist had talked to them about this topic. Remarkably, 80% of users would consider a genetic counseling unit very or extremely useful. Conclusions The present study showed that mental health professionals were more aware of the genetic basis of psychiatric disorders than users, and both considered the implementation of a genetic counseling service very useful.
Collapse
Affiliation(s)
- Lourdes Martorell
- Hospital Universitari Institut Pere Mata, IISPV, Universitat Rovira i Virgili, Reus, Spain.,Centro de Investigación Biomédica en Red en Salud Mental (CIBERSAM), Madrid, Spain
| | - Annabel Sanfeliu
- Hospital Universitari Institut Pere Mata, IISPV, Universitat Rovira i Virgili, Reus, Spain
| | - Ana Blázquez
- Department of Child and Adolescent Psychiatry and Psychology, Clinic Institute of Neurosciences, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Elia Lojo
- Hospital Universitari Institut Pere Mata, IISPV, Universitat Rovira i Virgili, Reus, Spain
| | - Maria José Cortés
- Hospital Universitari Institut Pere Mata, IISPV, Universitat Rovira i Virgili, Reus, Spain.,Centro de Investigación Biomédica en Red en Salud Mental (CIBERSAM), Madrid, Spain
| | - Joan de Pablo
- Germans Trias i Pujol Hospital. UAB, Badalona, Spain
| | - Elisabet Vilella
- Hospital Universitari Institut Pere Mata, IISPV, Universitat Rovira i Virgili, Reus, Spain.,Centro de Investigación Biomédica en Red en Salud Mental (CIBERSAM), Madrid, Spain
| |
Collapse
|
8
|
Palk AC, Dalvie S, de Vries J, Martin AR, Stein DJ. Potential use of clinical polygenic risk scores in psychiatry - ethical implications and communicating high polygenic risk. Philos Ethics Humanit Med 2019; 14:4. [PMID: 30813945 PMCID: PMC6391805 DOI: 10.1186/s13010-019-0073-8] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 02/14/2019] [Indexed: 06/09/2023] Open
Abstract
Psychiatric disorders present distinct clinical challenges which are partly attributable to their multifactorial aetiology and the absence of laboratory tests that can be used to confirm diagnosis or predict risk. Psychiatric disorders are highly heritable, but also polygenic, with genetic risk conferred by interactions between thousands of variants of small effect that can be summarized in a polygenic risk score. We discuss four areas in which the use of polygenic risk scores in psychiatric research and clinical contexts could have ethical implications. First, there is concern that clinical use of polygenic risk scores may exacerbate existing health inequities. Second, research findings regarding polygenic risk could be misinterpreted in stigmatising or discriminatory ways. Third, there are concerns associated with testing minors as well as eugenics concerns elicited by prenatal polygenic risk testing. Fourth, potential challenges that could arise with the feedback and interpretation of high polygenic risk for a psychiatric disorder would require consideration. While there would be extensive overlap with the challenges of feeding back genetic findings in general, the potential clinical use of polygenic risk scoring warrants discussion in its own right, given the recency of this possibility. To this end, we discuss how lay interpretations of risk and genetic information could intersect. Consideration of these factors would be necessary for ensuring effective and constructive communication and interpretation of polygenic risk information which, in turn, could have implications for the uptake of any therapeutic recommendations. Recent advances in polygenic risk scoring have major implications for its clinical potential, however, care should be taken to ensure that communication of polygenic risk does not feed into problematic assumptions regarding mental disorders or support reductive interpretations.
Collapse
Affiliation(s)
- A. C. Palk
- Department of Psychiatry, University of Cape Town, Groote Schuur Hospital, Observatory, Cape Town, 7925 South Africa
| | - S. Dalvie
- Department of Psychiatry and SA MRC Unit on Risk and Resilience in Mental Disorders, University of Cape Town, Groote Schuur Hospital, Observatory, Cape Town, 7925 South Africa
| | - J. de Vries
- Department of Medicine, University of Cape Town, Groote Schuur Hospital, Observatory, Cape Town, 7925 South Africa
| | - A. R. Martin
- Analytic & Translational Genetics Unit, Massachusetts General Hospital, Boston, MA USA
- Stanley Center for Psychiatric Research & Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA USA
| | - D. J. Stein
- Department of Psychiatry and SA MRC Unit on Risk and Resilience in Mental Disorders, University of Cape Town, Groote Schuur Hospital, Observatory, Cape Town, 7925 South Africa
| |
Collapse
|
9
|
Abstract
PURPOSE OF REVIEW Genetic testing for mental illness is likely to become increasingly prevalent as the science behind it is refined. This article identifies anticipated ethical challenges for patients, psychiatrists, and genetic counselors and makes recommendations for addressing them. RECENT FINDINGS Many of the ethical challenges of psychiatric genetic testing are likely to stem from failures to comprehend the nature and implications of test results. Recent studies have identified gaps in the knowledge base of psychiatrists and genetic counselors, which limit their abilities to provide patients with appropriate education. A small number of studies have demonstrated the value of counseling in empowering patients to deal with relevant genetic information. Psychiatrists and other health professionals must be able to assist patients and families in making informed decisions about genetic testing and interpreting test results. Filling their knowledge gaps on these issues will be a critical step towards meeting these responsibilities.
Collapse
|