Neuroimaging in mental health care: voices in translation

"It's all about delivery": researchers and health professionals' views on the moral challenges of accessing neurobiological information in the context of psychosis

Background

The convergence of neuroscience, genomics, and data science holds promise to unveil the neurobiology of psychosis and to produce new ways of preventing, diagnosing, and treating psychotic illness. Yet, moral challenges arise in neurobiological research and in the clinical translation of research findings. This article investigates the views of relevant actors in mental health on the moral challenges of accessing neurobiological information in the context of psychosis.

Methods

Semi-structured individual interviews with two groups: researchers employed in the National Health Service (NHS) or a university in England (n = 14), and mental health professionals employed in NHS mental health services (n = 14). This article compares results in the two groups (total n = 28).

Results

This article presents findings around three conceptual areas: (1) research ethics as mostly unproblematic, (2) psychosis, neurobiological information, and mental health care, and (3) identity, relationships, and the future. These areas are drawn from the themes and topics that emerged in the interviews across the two groups of participants. Researchers and health professionals provided similar accounts of the moral challenges of accessing—which includes acquisition, communication, and use of—neurobiological information in the context of psychosis. Acquiring neurobiological information was perceived as mostly unproblematic, provided ethical safeguards are put in place. Conversely, participants argued that substantive moral challenges arise from how neurobiological information is delivered—that is, communicated and used—in research and in clinical care. Neurobiological information was seen as a powerful tool in the process through which individuals define their identity and establish personal and clinical goals. The pervasiveness of this narrative tool may influence researchers and health professionals’ perception of ethical principles and moral obligations.

Conclusions

This study suggests that the moral challenges that arise from accessing neurobiological information in the context of psychosis go beyond traditional research and clinical ethics concerns. Reflecting on how accessing neurobiological information can influence individual self-narratives will be vital to ensure the ethical translation of neuroscience and genomics into mental health.

Trial registration

The study did not involve a health care intervention on human participants. It was retrospectively registered on 11 July 2018, registration number: researchregistry4255.

Defining Ourselves: Personal Bioinformation as a Tool of Narrative Self-Conception

Where ethical or regulatory questions arise about an individual's interests in accessing bioinformation about herself (such as findings from screening or health research), the value of this information has traditionally been construed in terms of its clinical utility. It is increasingly argued, however, that the "personal utility" of findings should also be taken into account. This article characterizes one particular aspect of personal utility: that derived from the role of personal bioinformation in identity construction. The suggestion that some kinds of information are relevant to identity is not in itself new. However, the account outlined here seeks to advance the debate by proposing a conception of the relationship between bioinformation and identity that does not depend on essentialist assumptions and applies beyond the narrow genetic contexts in which identity is customarily invoked. The proposal is that the identity-value of personal bioinformation may be understood in terms of its instrumental role in the construction of our narrative identities, specifically that its value lies in helping us to develop self-narratives that support us in navigating our embodied existences. I argue that this narrative conception provides useful insights that are pertinent to the ethical governance of personal bioinformation. It illuminates a wider range of ethical considerations in relation to information access; it accounts for variations in the utility of different kinds of information; and it highlights that the context in which information is conveyed can be as important as whether it is disclosed at all. These arguments are illustrated using an example drawn from psychiatric neuroimaging research.

Global mental health and neuroethics

BACKGROUND

Global mental health is a relatively new field that has focused on disparities in mental health services across different settings, and on innovative ways to provide feasible, acceptable, and effective services in poorly-resourced settings. Neuroethics, too, is a relatively new field, lying at the intersection of bioethics and neuroscience; it has studied the implications of neuroscientific findings for age-old questions in philosophy, as well as questions about the ethics of novel neuroscientific methods and interventions.

DISCUSSION

In this essay, we address a number of issues that lie at the intersection of these two fields: an emphasis on a naturalist and empirical position, a concern with both disease and wellness, the importance of human rights in neuropsychiatric care, and the value of social inclusion and patient empowerment.

SUMMARY

These different disciplines share a number of perspectives, and future dialogue between the two should be encouraged.

Genetic Testing and Neuroimaging: Trading off Benefit and Risk for Youth with Mental Illness

According to the World Health Organization, mental illness is one of the leading causes of disability worldwide. The first onset of mental illness usually occurs during childhood or adolescence. Neuroimaging and genetic testing have been invaluable in research on behavioral and intentional disorders, particularly with their potential to lead to improved diagnostic and predictive capabilities and to decrease the associated burdens of disease. The present study focused specifically the perspectives of mental health providers on the role of neuroimaging and genetic testing in clinical practice with children and adolescents. We interviewed 38 psychiatrists, psychologists, and allied mental health professionals who work primarily with youth about their receptivity towards either the use of neuroimaging or genetic testing. Interviews probed the role they foresee for these modalities for prediction, diagnosis, and treatment planning, and the benefits and risks they anticipate. Practitioners anticipated three major benefits associated with clinical introduction of imaging and genetic testing in the mental health care for youth: (1) improved understanding of illness, (2) more accurate diagnosis than available through conventional clinical examination, and (3) validation of treatment plans. They also perceived three major risks: (1) potential adverse impacts on employment and insurance as adolescents reach adulthood, (2) misuse or misinterpretation of the imaging or genetic data, and (3) infringements on self-esteem or self-motivation. Movement of brain imaging and genetic testing into clinical care will require a delicate balance of biology and respect for autonomy in the still-evolving cognitive and affective world of young individuals.

Media reporting of neuroscience depends on timing, topic and newspaper type

The rapid developments in neuroscientific techniques raise high expectations among the general public and therefore warrant close monitoring of the translation to the media and daily-life applications. The need of empirical research into neuroscience communication is emphasized by its susceptibility to evoke misconceptions and polarized beliefs. As the mass media are the main sources of information about (neuro-)science for a majority of the general public, the objective of the current research is to quantify how critically and accurately newspapers report on neuroscience as a function of the timing of publication (within or outside of periods of heightened media attention to neuroscience, termed "news waves"), the topic of the research (e.g. development, health, law) and the newspaper type (quality, popular, free newspapers). The results show that articles published during neuroscience news waves were less neutral and more optimistic, but not different in accuracy. Furthermore, the overall tone and accuracy of articles depended on the topic; for example, articles on development often had an optimistic tone whereas articles on law were often skeptical or balanced, and articles on health care had highest accuracy. Average accuracy was rather low, but articles in quality newspapers were relatively more accurate than in popular and free newspapers. Our results provide specific recommendations for researchers and science communicators, to improve the translation of neuroscience findings through the media: 1) Caution is warranted during periods of heightened attention (news waves), as reporting tends to be more optimistic; 2) Caution is also warranted not to follow topic-related biases in optimism (e.g., development) or skepticism (e.g., law); 3) Researchers should keep in mind that overall accuracy of reporting is low, and especially articles in popular and free newspapers provide a minimal amount of details. This indicates that researchers themselves may need to be more active in preventing misconceptions to arise.

Genetic Testing and Neuroimaging for Youth at Risk for Mental Illness: Trading off Benefit and Risk

BACKGROUND

According to the World Health Organization, mental illness is one of the leading causes of disability worldwide. The first onset of mental illness usually occurs during childhood or adolescence, with nearly 12 million diagnosed cases in the United States alone. Neuroimaging and genetic testing have been invaluable in research on behavioral, affective, and attentional disorders, particularly with their potential predictive capabilities, and ability to improve diagnosis and to decrease the associated burdens of disease. The present study focused specifically the perspectives of mental health providers on the role of neuroimaging and genetic testing in clinical practice with children and adolescents.

METHODS

We interviewed 38 psychiatrists, psychologists, and allied mental health professionals who work primarily with youth about their receptivity toward either the use of neuroimaging or genetic testing. Interviews probed the role they foresee for these modalities for prediction, diagnosis, treatment planning, and the benefits and risks they anticipate.

RESULTS

Practitioners anticipated three major benefits associated with clinical introduction of imaging and genetic testing in the mental health care for youth: (1) improved understanding of the brain and mental illness, (2) more accurate diagnosis than available through conventional clinical examination, and (3) legitimization of treatment plans. They also perceived three major risks: (1) misuse or misinterpretation of the imaging or genetic data, (2) potential adverse impacts on employment and insurance as adolescents reach adulthood, and (3) infringements on self-esteem or self-motivation.

LIMITATIONS

The nature of the interview questions focused on the future of neuroimaging and genetic testing testing research in the context of clinical neuroscience. Therefore, the responses from interview participants are based on anticipated rather than actual experience.

CONCLUSIONS

Continued expansion of brain imaging and genetic testing into clinical care will require a delicate balance of brain biology and respect for autonomy in the still-evolving cognitive and affective world of young individuals.