Ethics in psychiatric research: study design issues

Ethics Guideline Development for Neuroscience Research involving Patients with Mental Illness in Japan

This study aims to develop guidelines of key concepts and specific considerations to make the research more ethical when conducting neurological examinations and treatment interventions in mentally ill patients. We analyzed guideline development theory and literature, previous issues, and discussions with specialists of philosophy, medicine, sociology, and bioethics. The selection of research participants, drafting of intervention plans, and informed consent process were examined with reference to the dual burden; the minimal risk as a general rule of ethical allowance levels, assent and dissent to assess the individual's judgment capacity for consent, relational autonomy for personal consent with assistance by the proxy, and risk/benefit assessments. When conducting studies, this guideline requires that these three processes be set up appropriately on a case-by-case basis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41649-023-00240-x.

Complexity changes in functional state dynamics suggest focal connectivity reductions

The past two decades have seen an explosion in the methods and directions of neuroscience research. Along with many others, complexity research has rapidly gained traction as both an independent research field and a valuable subdiscipline in computational neuroscience. In the past decade alone, several studies have suggested that psychiatric disorders affect the spatiotemporal complexity of both global and region-specific brain activity (Liu et al., 2013; Adhikari et al., 2017; Li et al., 2018). However, many of these studies have not accounted for the distributed nature of cognition in either the global or regional complexity estimates, which may lead to erroneous interpretations of both global and region-specific entropy estimates. To alleviate this concern, we propose a novel method for estimating complexity. This method relies upon projecting dynamic functional connectivity into a low-dimensional space which captures the distributed nature of brain activity. Dimension-specific entropy may be estimated within this space, which in turn allows for a rapid estimate of global signal complexity. Testing this method on a recently acquired obsessive-compulsive disorder dataset reveals substantial increases in the complexity of both global and dimension-specific activity versus healthy controls, suggesting that obsessive-compulsive patients may experience increased disorder in cognition. To probe the potential causes of this alteration, we estimate subject-level effective connectivity via a Hopf oscillator-based model dynamic model, the results of which suggest that obsessive-compulsive patients may experience abnormally high connectivity across a broad network in the cortex. These findings are broadly in line with results from previous studies, suggesting that this method is both robust and sensitive to group-level complexity alterations.

Factors Influencing Perceived Helpfulness and Participation in Innovative Research: A Pilot Study of Individuals with and without Mood Symptoms

Little is known about how individuals with and without mood disorders perceive the inherent risks and helpfulness of participating in innovative psychiatric research, or about the factors that influence their willingness to participate. We conducted an online survey with 80 individuals (self-reported mood disorder [n = 25], self-reported good health [n = 55]) recruited via MTurk. We assessed respondents' perceptions of risk and helpfulness in study vignettes associated with two innovative research projects (intravenous ketamine therapy and wearable devices), as well as their willingness to participate in these projects. Respondents with and without mood disorders perceived risk similarly across projects. Respondents with no mood disorders viewed both projects as more helpful to society than to research volunteers, while respondents with mood disorders viewed the projects as equally helpful to volunteers and society. Individuals with mood disorders perceived ketamine research, and the two projects on average, as more helpful to research volunteers than did individuals without mood disorders. Our findings add to a limited empirical literature on the perspectives of volunteers in innovative psychiatric research.

Safety of research into severe and treatment-resistant mood disorders: analysis of outcome data from 12 years of clinical trials at the US National Institute of Mental Health

BACKGROUND

Placebo-controlled trials in drug-free patients have long been considered a key research component in the study of mood disorders and relevant treatment mechanisms. However, concerns have been raised about the ethics of such research, leading to an ongoing debate as to whether placebo controls are ethically acceptable. We aimed to assess the cumulative effects of research in individuals with mood disorders and to provide data to address ethical concerns regarding research in this population.

METHODS

We obtained empirical data for patients screened between between Dec 13, 2001, and Jan 31, 2014, with either major depressive disorder or bipolar disorder who were enrolled in one or more of 18 clinical trials at a US National Institute of Mental Health (NIMH) inpatient or outpatient behavioural health research clinic. We assessed the cumulative effects of research in our patient population, including the effects of drug taper, drug washout, and placebo administration on mood state. Two subgroups were examined: patients enrolled in trials explicitly requiring treatment resistance and patients with a current or past history of suicidal ideation or behaviour. We used the percentage change from screening as the primary outcome measure for statistical analysis of change in mood over study periods. This study is registered with ClinicalTrials.gov, number NCT00024635.

FINDINGS

We obtained data for 540 patients; 360 (71%) patients were enrolled in trials requiring treatment resistance, 58 (12%) of 465 patients had suicidal ideation at screening, and 191 (60%) of 321 patients had a history of suicidal ideation. Mean mood severity at screening was in the moderate to severe range. Full participation in research, including drug tapers, drug-free periods, and placebo-controlled trials, had a low risk of symptom exacerbation. Patients undergoing drug taper had a mean increase in symptom severity of 4·2% (SD 19·56, tdegrees of freedom 96=1·85; p=0·036). We recorded modest increases in the subgroup who tapered to no medications (mean percentage change 5·1% [SD 18·10], t56=2·12; p=0·039), but increases were not significant in participants enrolled in trials requiring treatment resistance (4·3% [18·60], t72=1·96; p=0·054) and those with a current or past history of suicidal ideation or behaviour (1·8% [18·78], t51=0·68; p=0·50). Six serious adverse events were reported, including one suicide attempt that occurred during the standard treatment phase and not during the clinical trial.

INTERPRETATION

In general, research participation at the NIMH was not detrimental to health and safety, and conferred benefit in many cases. This finding was true not only in our entire research population, but also in treatment-resistant subgroups and subgroups with a history of suicidality. Our study provides evidence to guide ethical analysis of issues in psychiatric research, and to support continued scientific investigation.

FUNDING

Intramural Research Program, NIMH, National Institutes of Health.

Informed consent in psychiatry clinical research: A conceptual review of issues, challenges, and recommendations

Obtaining informed consent in psychiatry clinical research involving subjects with diminished mental abilities and impaired consent capacity has been a challenge for researchers, posing many ethical concerns and procedural hurdles due to participants' cognitive deficits and impaired ability to judge reality. Regulations seem inadequate and provide limited guidance, not sufficient to address all the ethical issues inherent in different situations related to obtaining consent from decisionally impaired persons. Researchers are struggling to find a balance between risk-benefit ratio, research advancement, and autonomy of study subjects. Inspired to improve the consent process in psychiatry clinical research, many studies have been conducted focusing on various informed consent-related ethical concerns, with the aim of developing appropriate strategies and optimizing the informed consent procedure in psychiatry clinical research, overcoming the ethical concerns. This article critically reviews the various ethical issues and consent challenges, their underlying reasons, and investigates the appropriate strategies and practices needed to be adopted while obtaining informed consent from subjects with impaired consent capacity, participating in psychiatry clinical research.

Challenges in conducting psychiatry studies in India

A large number of psychiatry studies are conducted in India. Psychiatry studies are complex and present unique challenges in the Indian setting. Ethical issues pertaining to the risk of worsening of illness, use of placebo and validity of informed consents are commonly faced. Site selection can be difficult due to the relative paucity of ICH-GCP (International Conference on Harmonisation - Good Clinical Practice) trained psychiatry investigators in India. Recruitment can be challenging due to issues such as strict eligibility criteria, (lack of) availability of caregiver, illness-related considerations, etc. Assessment of the consent capacity of patients is not simple, while structured assessments are not commonly employed. As the illness fluctuates, the consent capacity may change, thus requiring continued assessment of consent capacity. Study patients run the risk of worsening of illness and suicide due to exposure to inactive treatments; this risk is counterbalanced by use of appropriate study designs, as well as the indirect psychotherapeutic support received. Psychiatry studies are associated with a high placebo response. This necessitates conduct of placebo-controlled studies despite the attendant difficulties. Also, the high placebo response is often the cause of failed trials. Rating scales are essential for assessment of drug response. Some rating instruments as well as some rater training procedures may not be suitable for the Indian setting. Technological advancements may increase the procedural complexity but improve the quality of ratings. Psychiatry studies present monitors and auditors with unique scenarios too. Utilization of psychiatry specific training and expertise is recommended to ensure successful conduct of these studies in India.

Mental Health Professionals’ Perceived Barriers and Benefits, and Personal Concerns in Relation to Psychiatric Research

Aim: Mental health professionals can contribute to generating a strong evidence base for policy and practice in psychiatry. An insight into their perception of psychiatric research is important for planning support strategies. This study explored healthcare professionals’ perceptions of barriers, benefits and concerns about psychiatric research in a Singapore psychiatric hospital. Materials and Methods: Self-administered questionnaire was employed to collect socio-demographic data and opinions on research. Likert scale was used for the responses and descriptive statistics and ordinal regression were used for data analysing. Results: 93.8% respondents perceived “contribution to medical knowledge/ public health” to be a major benefit of conducting research. 86.7% respondents felt that “learning experience” was important. “Prestige/publication” (52.7%) and “financial gain” (76%) were perceived to be unimportant. “Clinical load of patients”, “lack of skilled personnel to assist in research” and “insufficient funding” were identified as important barriers by 72.4%, 70.6% and 68.9% respondents. “Time constraints”, “patient and family readiness to research participation”, “insufficient training” and “concerns about patient welfare” are major concerns while conducting research. Conclusion: To the study team’s best knowledge, this is the only study of mental health professionals’ perceptions on psychiatric research. It is useful for strategising research planning and enhancing the research culture in the hospital. Key words: Healthcare professionals, Mental health research, Research planning strategies

Doing participant observation in a psychiatric hospital— Research ethics resumed

Social scientists who employ participant observation methods in medical settings are often held accountable for their research methods, specifically in regard to medical research ethics. However, the medical research ethics tradition rubs uneasily against participant observation and the anthropological understanding of the research process. The underlying premise for considering research ethics in the current case is the notion of the vulnerability of psychiatric patients as a participant group. Based on this notion of vulnerability among psychiatric patients, this article discusses the epistemological grounds for vulnerability in anthropological and medical research ethics. The authors draw on their experience with the Regional Committee for Medical Research Ethics in Norway, and the consequences of the guidelines used for participant observation as a research method in a psychiatric hospital. Social science researchers are required to follow medical ethical guidelines, such as informed consent, the principle of voluntariness, and estimation of risks and benefits. Ethnographers have found these guidelines to be obstructive when doing social science research in a psychiatric hospital. The article suggests the need for reformulation of research guidelines for participant observation in medical settings.

Subjective evaluations of research participation by persons with mental illness

The present study focuses on the subjective experience of psychiatric patients who participate in psychobiological research, based on patients' self-reported evaluations of the experience. We studied 313 persons with mental illness admitted to an inpatient research unit. Each participant was administered the Patient Satisfaction Questionnaire, a structured self-report questionnaire designed to assess satisfaction with research participation and clinical care. Individuals who completed the research protocol were significantly more satisfied globally and more likely to express that treatment had been effective. Factors contributing to willingness to participate in future research included favorable perceptions of: (a) psychoeducation, (b) safety, and (c) comfort level with research procedures. Research participants were willing to participate in future research regardless of their perception of medication efficacy. This study emphasizes the importance of understanding the opinions of persons with mental illness who participate in research. Overall, the data suggest that persons with mental illness find psychiatric research to be beneficial. Although therapeutic misconception cannot be ruled out given the methodology used, at the very least the data indicate no sign that subjects found research participation to be harmful. Further studies should explore the source of this perception and attempt to separate the effect of "therapeutic misconception" from possible real benefit of protocol-driven assessment and treatment in a reputable clinical environment.

Research governance: regulating risk and reducing harm?

Risk assessment can be thought of as the lens through which we anticipate the consequences of research and the impact of the actions of researchers. The way in which risk of harm is managed in research is strongly influenced by the surrounding social and political environment, leading to differences in national and local styles of regulation and review. Different research studies carry different risks, so systems for review and approval must adapt to the question being asked and the nature of the study. Researchers can never wholly guarantee safety in any research but participants and researchers must be offered reasonable protection within any study, with appropriate arrangements in place should something go wrong.

Research governance: regulating risk and reducing harm?

Risk assessment can be thought of as the lens through which we anticipate the consequences of research and the impact of the actions of researchers. The way in which risk of harm is managed in research is strongly influenced by the surrounding social and political environment, leading to differences in national and local styles of regulation and review. Different research studies carry different risks, so systems for review and approval must adapt to the question being asked and the nature of the study. Researchers can never wholly guarantee safety in any research but participants and researchers must be offered reasonable protection within any study, with appropriate arrangements in place should something go wrong.

Healing psychiatry: a pragmatic approach to bridging the science/humanism divide

Competing urges to think of human mental suffering as comprehensible and susceptible to scientific formulation, or as deeply complex and beyond the reach of scientific analysis, have torn at the fabric of psychiatry for many years and have left the field conceptually divided between science and humanism. Conceptual reparation of psychiatry is now a core mission of a field that is trying to heal itself so that it is equipped to heal the patients it serves. To formulate their cases comprehensively and provide patients with cutting-edge care, psychiatrists must heal the conceptual wounds that have resulted from dividing the human individual into an object of scientific scrutiny and a subject of personal experience. They must synthesize science and humanism in order to generate new understanding of mental disorders and to train future clinicians and researchers. Principles of classical American pragmatism, I argue in this article, can help to transcend the science/humanism divide in psychiatry. Clinical pragmatism focuses on favorable treatment outcomes by respecting the practical, pluralistic, participatory, and provisional aspects of psychiatric care. It demands that psychiatrists have the skill and flexibility to use multiple explanatory concepts in a collaborative, open-ended process with their patients. These themes are explored from the perspectives of contemporary psychiatric treatment, training, and research.