Inclusion of patients with severe mental illness in clinical trials: issues and recommendations surrounding informed consent

(Cost)-effectiveness and implementation of integrated community-based care for patients with severe mental illness: a study protocol

BACKGROUND

As severe mental illness (SMI) is associated with a high disease burden and persistent nature, patients with SMI are often subjected to long-term mental healthcare and are in need of additional social support services. Community-based care and support services are organized via different providers and institutions, which are often lacking structural communication, resulting in a fragmented approach. To improve the efficiency of care provision and optimize patient wellbeing, an integrated multi-agency approach to community-based mental health and social services has been developed and implemented.

AIM

To present a research protocol describing the evaluation of flexible assertive community teams integrated with social services in terms of effectiveness, cost-effectiveness, and implementation.

METHODS/DESIGN

A quasi-experimental study will be conducted using prospective and retrospective observational data in patients with severe mental illness. Patients receiving care from three teams, consisting of flexible assertive community treatment and separately provided social support services (care as usual), will be compared to patients receiving care from two teams integrating these mental and social services into a single team. The study will consist of three parts: 1) an effectiveness evaluation, 2) a health-economic evaluation, and 3) a process implementation evaluation. To assess (cost-)effectiveness, both real-world aggregated and individual patient data will be collected using informed consent, and analysed using a longitudinal mixed model. The economic evaluation will consist of a cost-utility analysis and a cost-effectiveness analysis. For the process and implementation evaluation a mixed method design will be used to describe if the integrated teams have been implemented as planned, if its predefined goals are achieved, and what the experiences are of its team members.

DISCUSSION

The integration of health and social services is expected to allow for a more holistic and recovery oriented treatment approach, whilst improving the allocation of scarce resources. This study aims to identify and describe these effects using a mixed-method approach, and support decision-making in the structural implementation of integrating mental and social services.

Correlation Between Insight and Capacity to Consent to Research in Subjects With Bipolar Disorder Type I and Schizophrenia

INTRODUCTION

Schizophrenia and bipolar disorder type I (BD-I) can affect patient autonomy and capacity to consent to participate in research. Other variables associated with the autonomy of patients must be explored in order to improve the quality of the currently available tools.

OBJECTIVE

To evaluate the relationship between insight and the capacity to consent to participate in research in patients with BD-I and schizophrenia.

METHODS

A cross-sectional and longitudinal study was conducted with 120 subjects (40 subjects with schizophrenia, 40 with BD-I, and 40 healthy controls). The tools used were the Scale Assessment Insight-Expanded (SAI-E) and the MacArthur Competence Assessment Tool-Treatment (MacCAT-CR), which was first adapted culturally, and its validity and reliability assessed. The results obtained on each scale were compared and the association between them were evaluated.

RESULTS

There is a direct correlation between the capacity to consent to research, measured using the MacCAT-CR tool, and the degree of insight, measured using the SAI-E scale, with an effect size of 1.3 for BD-I and 2.03 for schizophrenia.

CONCLUSIONS

The results suggest that there is a correlation between the degree of insight and the capacity to consent to research in subjects with schizophrenia and BD-I. Insight should therefore be included as a relevant variable to assess the capacity to consent, and future studies should include it when researching on or designing new tools which aim at a greater respect of patient autonomy.

Parent ratings of ability to consent for clinical trials in fragile X syndrome

Advances in understanding neurobiology and intellectual disabilities have led to clinical trials testing new medications. This study assessed parents' perceptions of the ability of their son or daughter with fragile X syndrome (FXS), an inherited form of intellectual disability, to participate in the consent process for clinical trials. Four hundred twenty-two families participated in a survey that included six items assessing various aspects of the ability to provide consent. A rank ordering of decisional tasks was found. The easiest task was to understand that the medication was different from his or her medical treatment; the most difficult was the ability to understand and weigh the potential benefits and risks of study participation. Factor analysis suggested that despite the range in difficulty, the six items were best summarized by a single decisional ability score. Parents of 29% of males reported that their son was not at all capable of participating, but the remainder exhibited a range of decisional skills. Factors associated with this variability include age and parents' willingness to enroll their child in clinical trials. We conclude that many individuals with FXS appear to be able to participate at some level in the consent or assent process, but will likely need individualized support to maximize effective participation.

[Research on humans suffering from dementia]

The urgent necessity for dementia research is justified by the prevalence and increase in dementia associated with the demographic changes, for which no causal treatment is available; however, during the progressive course dementia destroys the capacity for self-determination of persons affected and thereby an essential prerequisite for participation in research, i.e. a valid consent to a research intervention. Accordingly, not only sufficient information about all issues which are relevant for decision making by potential participants but also a flawless assessment of the capacity to consent are important; however, currently this is not satisfactorily possible. This article attempts to answer questions associated with these problems, such as how consent can be established, including that of a surrogate for consent of potential research participants by whom consent is no longer possible. In a second section the benefit-risk evaluation, which is also underdeveloped, will be dealt with using two concrete research examples, a diagnostic and a therapeutic research intervention for patients with dementia.

Physician-assisted suicide in psychiatry and loss of hope

In the Netherlands, euthanasia and physician-assisted suicide (PAS) are considered acceptable medical practices in specific circumstances. The majority of cases of euthanasia and PAS involve patients suffering from cancer. However, in 1994 the Dutch Supreme Court in the so-called Chabot-case ruled that "the seriousness of the suffering of the patient does not depend on the cause of the suffering", thereby rejecting a distinction between physical (or somatic) and mental suffering. This opened the way for further debate about the acceptability of PAS in cases of serious and refractory mental illness. An important objection against offering PAS to mentally ill patients is that this might reinforce loss of hope, and demoralization. Based on an analysis of a reported case, this argument is evaluated. It is argued that offering PAS to a patient with a mental illness who suffers unbearably, enduringly and without prospect of relief does not necessarily imply taking away hope and can be ethically acceptable.

Off-licence prescribing and regulation in psychiatry: current challenges require a new model of governance

The growing worldwide use of pharmaceuticals is managed in some countries by a regulatory system which sharply divides legal use into licensed and unlicensed categories. We examine how for the range of psychotropics this simultaneously restricts the possible benefits to patients, prescribers and producers in some domains, while failing to manage the risks in others. A more flexible system, which shares at an earlier stage experience and evidence on benefits and risks in patients, previously marginalized on the grounds of age, diagnosis or comorbidity, would aid the development of safer, more effective 'real-world prescribing'. Practical recommendations are made for a new model of research and prescribing governance, to enable more effective repurposing of these treatments.

[Ethical questions in clinical research with the mentally ill]

The review deals with present problems of protecting mentally ill patients who are incompetent to give informed consent to participating in clinical research, and of assessment of the capacity to consent. 1. Clinical trials of drugs on efficacy and safety in incompetent patients are ethically justified and legally admissible if the investigational drug can be expected to exert a direct potential individual benefit and if such trials will be performed under defined criteria to protect these vulnerable patients. In Germany it is questionable how far these prescriptions of the German Drug Law (AMG) are transferable to other than drug research. 2. Research with no direct potential individual benefit or only a group-specific benefit in incompetent patients is controversially discussed. However, it may be ethically justified as an exception, and is in Germany legally admissible only in minors, but not in adults. 3. However, internationally there exists a wide range of legal regulations, terms, interpretations, and practices of research with vulnerable persons. In the past years a shift seems to have developed from normatively oriented discussions to more empirically based investigations. Especially vague but clinically relevant terms in protection declarations or guidelines have been better specified, put in concrete form by anchor examples, and empirically studied. 4. In general the criteria of protecting the dignity and, even if impaired, the autonomy of incompetent patients as subjects for research appear to guarantee a high standard of protection. However, the application of these criteria must be improved by practicable procedures. This is valid particularly for the assessment of the basic criterion whether a patient is capable of consenting or not. 5. Open Questions are formulated as need of research.

A review of ethics in psychiatric research

PURPOSE OF REVIEW

To summarize important recent contributions to the literature on the subject of ethics in psychiatric research.

RECENT FINDINGS

Current literature reflects an expansion in the range of psychiatric research on ethics topics. Articles continue to appear on core ethics subjects such as informed consent, but many recent contributions focus on diverse issues such as third-party privacy, the ethics of Internet-based research, revisiting the wisdom of imposing medical ethics requirements on observational research, and psychiatric research ethics as applied to special populations such as children or older persons.

SUMMARY

Psychiatric research is critical for the elucidation, prevention, and treatment of mental diseases. Increased attention and novel approaches taken to obtain informed consent, correcting therapeutic misconception, and guarding privacy will advance the research enterprise and continue to ensure that the subjective experiences of participants in psychiatric research remain positive.

Ethical and conceptual aspects of capacity assessments in psychiatry

PURPOSE OF REVIEW

To search the literature on conceptual and assessment issues of patient capacity.

RECENT FINDINGS

Current literature shows that many instruments have been developed in the last decade to measure patient capacity. Although these measures provide a rank-ordered scale of capacity, they cannot categorize patients into competent and incompetent, which relies heavily on the concept of authentic autonomy. The latter, however, should be carefully examined after considering the patient's cultural and subcultural background, and the quality of the doctor's communication skills.

SUMMARY

Academic and clinical psychiatry are posed with such questions as to how to categorically classify capacity and incapacity as well as to evidence the admissibility of measuring instruments when used in a civil commitment.