Conceptual competence in psychiatric training: building a culture of conceptual inquiry

Building a culture of conceptual inquiry in psychiatric training requires the development of conceptual competence: the ability to identify and examine assumptions that constitute the philosophical foundations of clinical care and scientific investigation in psychiatry. In this article, we argue for the importance of such competence and illustrate approaches to instilling it through examples drawn from our collective experiences as psychiatric educators.

Are Psychedelic Experiences Transformative? Can We Consent to Them?

Psychedelic substances have great promise for the treatment of many conditions, and they are the subject of intensive research. As with other medical treatments, both research and clinical use of psychedelics depend on our ability to ensure informed consent by patients and research participants. However, some have argued that informed consent for psychedelic use may be impossible, because psychedelic experiences can be transformative in the sense articulated by L. A. Paul (2014). For Paul, transformative experiences involve either the acquisition of knowledge that cannot be obtained in any other way or changes in the self. Either of these characteristics may appear to undermine informed consent. This article argues, however, that there is limited evidence that psychedelic experiences are transformative in Paul's sense, and that they may not differ in their transformative features from other common medical experiences for which informed consent is clearly possible. Further, even if psychedelic experiences can be transformative, informed consent is still possible. Because psychedelic experiences are importantly different in several respects from other medical experiences, this article closes with recommendations for how these differences should be reflected in informed consent processes.

What Do Psychiatrists Think About Caring for Patients Who Have Extremely Treatment-Refractory Illness?

Questions about when to limit unhelpful treatments are often raised in general medicine but are less commonly considered in psychiatry. Here we describe a survey of U.S. psychiatrists intended to characterize their attitudes about the management of suicidal ideation in patients with severely treatment-refractory illness. Respondents (n = 212) received one of two cases describing a patient with suicidal ideation due to either borderline personality disorder or major depressive disorder. Both patients were described as receiving all guideline-based and plausible emerging treatments. Respondents rated the expected helpfulness and likelihood of recommending each of four types of intervention: hospitalization, additional medication changes, additional neurostimulation, and additional psychotherapy. Across both cases, most respondents said they were likely to provide each intervention, except for additional neurostimulation in borderline personality disorder, while fewer thought each intervention would be helpful. Substantial minorities of respondents indicated that they would provide an intervention they did not think was likely to be helpful. Our results suggest that while most psychiatrists recognize the possibility that some patients are unlikely to be helped by available treatments, many would continue to offer such treatments.

AI as a Mental Health Therapist for Adolescents

This Viewpoint discusses benefits and risks of using conversational artificial intelligence platforms to deliver psychotherapy to adolescents.

Hard Choices: How Does Injustice Affect the Ethics of Medical Aid in Dying?

Critics of medical aid in dying (MAID) often argue that it is impermissible because background social conditions are insufficiently good for some persons who would utilize it. I provide a critical evaluation of this view. I suggest that receiving MAID is a sort of "hard choice," in that death is prima facie bad for the individual and only promotes that person's interests in special circumstances. Those raising this objection to MAID are, I argue, concerned primarily about the effects of injustice on hard choices. I show, however, that MAID and other hard choices are not always invalidated by injustice and that what matters is whether the injustice can be remediated given certain constraints. Injustice invalidates a hard choice when it can, reasonably, be remedied in a way that makes a person's life go better. I consider the implications of this view for law and policy regarding MAID.

Does It Matter Whether a Psychiatric Intervention Is "Palliative"?

Palliative interventions are intended to alleviate suffering and improve quality, not quantity, of life and are not intended to cure illness. In psychiatry, uncertainty about which interventions count as palliative stems from the fact that psychiatry generally prioritizes symptom management irrespective of diagnosis or specific pathophysiology of illness. This commentary on a case considers how distinctions between palliative and other psychiatric interventions might not be all that helpful in resolving clinical and ethical questions about which interventions are-and when they are-appropriate.

Medical Assistance in Dying in Neurology

An increasing number of jurisdictions have legalized medical assistance in dying (MAID) with significant variation in the procedures and eligibility criteria used. In the United States, MAID is available for persons with terminal illnesses but is frequently sought by persons with neurologic conditions. Persons with conditions that cause cognitive impairment, such as Alzheimer dementia, are often ineligible for MAID, as their illness is not considered terminal in its early stages, whereas in later stages, they may have impaired decision-making capacity.

A Focus Group Study of the Views of Persons with a History of Psychiatric Illness about Psychiatric Medical Aid in Dying

BACKGROUND

Medical aid in dying (MAID) is legal in a number of countries, including some states in the U.S. While MAID is only permitted for terminal illnesses in the U.S., some other countries allow it for persons with psychiatric illness. Psychiatric MAID, however, raises unique ethical concerns, especially related to its effects on mental illness stigma and on how persons with psychiatric illnesses would come to feel about treatment and suicide. To explore those concerns, we conducted several focus groups with persons with lived experience of mental illness.

METHODS

We conducted three video-conference-based focus groups involving adults residing in the U.S. who reported a prior diagnosis of any psychiatric illness. Only participants who reported thinking that MAID for terminal illness was morally acceptable were included. Focus group participants were asked to respond to a series of four questions. Groups were facilitated by a coordinator who was independent of the research team.

RESULTS

A total of 22 persons participated in the focus groups. The majority of participants had depression and anxiety disorders; no participants had psychotic disorders such as schizophrenia. Many participants strongly favored permitting psychiatric MAID, generally on the basis of respect for autonomy, its effects on stigma, and the severe suffering caused by mental illness. Others expressed concerns, typically related to difficulties in ensuring decision-making capacity and to the risk that MAID would be used in lieu of suicide.

CONCLUSIONS

Persons with a history of psychiatric illness, as a group, have a diverse array of views about the permissibility of psychiatric MAID, reflecting nuanced consideration of how it relates to the public perception of mental illness, stigma, autonomy, and suicide risk.

Public mental health during and after the SARS-CoV-2 pandemic: Opportunities for intervention via emotional self-efficacy and resilience

Importance

During the pandemic, the number of United States adults reporting clinically significant symptoms of anxiety and depression sky-rocketed, up from 11% in 2020 to more than 40% in 2021. Our current mental healthcare system cannot adequately accommodate the current crisis; it is therefore important to identify opportunities for public mental health interventions.

Objective

Assess whether modifiable emotional factors may offer a point of intervention for the mental health crisis.

Design setting and participants

From January 13 to 15, 2022, adults living in the United States were recruited via Amazon Mechanical Turk to complete an anonymous survey.

Main outcomes and measures

Linear regressions tested whether the primary outcomes during the SARS-CoV-2 pandemic (depressive and anxiety symptoms, burnout) were associated with hypothesized modifiable risk factors (loneliness and need for closure) and hypothesized modifiable protective factors (the ability to perceive emotions and connect with others emotionally; emotion-regulation efficacy; and resilience, or the ability to "bounce back" after negative events).

Results

The sample included 1,323 adults (mean [SD] age 41.42 [12.52] years; 636 women [48%]), almost half of whom reported clinically significant depressive (29%) and/or anxiety (15%) symptoms. Approximately 90% of participants indicated feeling burned out at least once a year and nearly half of participants (45%) felt burned out once a week or more. In separate analyses, depressive symptoms (Model A), anxiety symptoms (Model B), and burnout (Model C) were statistically significantly associated with loneliness (βModel A, 0.38; 95% CI, 0.33-0.43; βModel B, 0.30; 95% CI, 0.26-0.36; βModel C, 0.34; 95% CI, 0.28-0.41), need for closure (βModel A, 0.09; 95% CI, 1.03-1.06; βModel B, 0.13; 95% CI, 0.97-0.17; βModel C, 0.11; 95% CI, 0.07-0.16), recent stressful life events (βModel A, 0.14; 95% CI, 0.10-0.17; βModel B, 0.14; 95% CI, 0.11-0.18; βModel C, 0.10; 95% CI, 0.06-0.15), and resilience (βModel A, -0.10; 95% CI, -0.15 to -0.05; βModel B, -0.18; 95% CI, -0.23 to -0.13; βModel C, -0.11; 95% CI, -0.17 to -0.05). In addition, depressive and anxiety symptoms were associated with emotional self-efficacy (βModel A, -0.17; 95% CI, -0.22 to -0.12; βModel B, -0.11; 95% CI, -0.17 to -0.06), and beliefs about the malleability of emotions (βModel A, -0.08; 95% CI, -0.12 to -0.03; βModel B, -0.09; 95% CI, -0.13 to -0.04). Associations between loneliness and symptoms were weaker among those with more emotional self-efficacy, more endorsement of emotion malleability beliefs, and greater resilience, in separate models. Analyses controlled for recent stressful life events, optimism, and social desirability.

Conclusion and relevance

Public mental health interventions that teach resilience in response to negative events, emotional self-efficacy, and emotion-regulation efficacy may protect against the development of depressive symptoms, anxiety, and burnout, particularly in the context of a collective trauma. Emotional self-efficacy and regulation efficacy may mitigate the association between loneliness and mental health, but loneliness prevention research is also needed to address the current mental health crisis.

Epistemic injustice and the psychiatrist

BACKGROUND

Psychiatrists depend on their patients for clinical information and are obligated to regard them as trustworthy, except in special circumstances. Nevertheless, some critics of psychiatry have argued that psychiatrists frequently perpetrate epistemic injustice against patients. Epistemic injustice is a moral wrong that involves unfairly discriminating against a person with respect to their ability to know things because of personal characteristics like gender or psychiatric diagnosis.

METHODS

We review the concept of epistemic injustice and several claims that psychiatric practice is epistemically unjust.

RESULTS

While acknowledging the risk of epistemic injustice in psychiatry and other medical fields, we argue that most concerns that psychiatric practice is epistemically unjust are unfounded.

CONCLUSIONS

The concept of epistemic injustice does not add significantly to existing standards of good clinical practice, and that it could produce changes in practice that would be deleterious. Psychiatrists should resist calls for changes to clinical practice based on this type of criticism.

Three kinds of suffering and their relative moral significance

Suffering is widely assumed to have particular moral significance, and is of special relevance in medicine. There are, however, many theories about the nature of suffering that seem mutually incompatible. I suggest that there are three overall kinds of view about what suffering is: value-based theories, including the theory famously expounded by Eric Cassell, which as a group suggest that suffering is something like a state of distress related to threats to things that a person cares about; feeling-based theories, which equate suffering with aversive feelings or sensations like pain; and objective theories, which suggest that suffering is the absence of objective flourishing. Rather than argue that one or another of these kinds of theory most accurately captures the nature of suffering, I allow that the term is ambiguous and thus that it may have at least three different kinds. I further argue, however, that when we think about suffering as potentially justifying end-of-life interventions, especially for cognitively typical adults, we are interested mainly in value-based suffering. This is because the moral significance of value-based suffering for persons with decision-making capacity generally outweighs that of the other types; those other types of suffering achieve overriding moral significance only if they also constitute, or contribute to, value-based suffering.

Moral Distress and Involuntary COVID-19 Vaccination of a Mature Minor Receiving Inpatient Psychiatric Treatment

Mandatory vaccination against COVID-19 is a highly controversial issue, and many members of the public oppose it on the grounds that they should be free to determine what happens to their own body. Opinion has generally favored parental authority with respect to vaccination of children, but less attention has been paid to the ethical complexities of how to respond when mature minors refuse vaccination that is requested by their parents. We present a case in which an mature minor, who was psychiatrically hospitalized, refused vaccination that had been requested by her parents, which lead to significant moral distress for her caregivers.

Risk of suicide after discharge from inpatient psychiatric care: a systematic review

OBJECTIVE

The period following discharge from inpatient psychiatric care is recognised as an especially high-risk time for patient suicide. Astonishingly, there is a dearth of comprehensive studies examining risk and protective factors in this specific population. The aim of this study was to establish the protective and risk factors for suicide in the first year post-discharge (PD) from psychiatric facilities and their utility in categorising patients as high or low risk in a meaningful way to benefit clinical care and improve patient outcomes.

METHODS

A methodical search of three databases (PubMed, EMBASE, and PsychINFO) was used to identify reports describing risk factors for suicide after psychiatric discharge.

RESULTS

Predominantly, male sex, a history of self-harm, a history of suicide attempts, admission with suicidal ideation or suicidal behaviour, and hopelessness were identified as being associated with death by suicide after discharge. Lithium appeared to be protective against suicide in the studies reviewed. Other variables examined showed mixed results.

CONCLUSIONS

The findings of this review suggest that significant suicide predictors both common and unique to those established for suicide in the general population exist and can be utilised in a clinically meaningful way, despite the difficulties inherent in studying this population.KEY POINTSThe risk of suicide after psychiatric hospitalisation is high.Factors that predict suicide after psychiatric hospitalisation overlap only partially with risk factors for suicide in general.Important risk factors for suicide in the post-discharge period include male sex, a history of self-harm, a history of suicide attempts, the presence of suicidal ideation during the admission, and hopelessness.The conclusions that can be drawn from the existing literature are limited by small study sizes, different study populations, and different follow-up periods; additional research in this domain is needed.

Ending One's Life in Advance

If you developed Alzheimer disease, would you want to go all the way to the end of what might be a decade-long course? Some would; some wouldn't. Options open to those who choose to die sooner are often inadequate. Do-not-resuscitate orders and advance directives depend on others' cooperation. Preemptive suicide may mean giving up years of life one would count as good. Do-it-yourself methods can fail. What we now ask of family and clinicians caring for persons with dementia, and of patients given no better option than to go on with lives they may not want, is unacceptable. To explore how one might better control one's own dying and avoid burdening others with overwhelming care and morally painful choices, we propose a thought experiment: an advance directive implant that would enable persons with early dementia, while competent, to arrange their own deaths without the subsequent intervention of anyone else.

Effects of temporary psychiatric holds on length of stay and readmission risk among persons admitted for psychotic disorders

The practice of involuntary psychiatric commitment is central to the acute treatment of persons with severe mental illness and others in psychiatric crisis. Deciding whether a patient should be admitted involuntarily requires weighing respect for autonomy against beneficence, considering the clinical needs of the patient, and navigating ambiguous legal standards. The relative dearth of information about the impact of involuntary commitment on objective patient outcomes complicates matters ethically, legally, and clinically. To address this gap in the literature, we sought to determine the association between temporary psychiatric holds and length of stay and readmission rates among a retrospective sample of adult patients admitted to a large psychiatric hospital with diagnoses of schizophrenia, schizoaffective disorder, mania, and other psychotic disorders. In total, we identified 460 patients and 559 unique encounters meeting our inclusion criteria; 90 of the encounters were voluntary (involving a temporary psychiatric hold) and 469 were involuntary. Univariable and multivariable analyses suggested that temporary psychiatric holds were not significantly associated with either length of stay or readmission rate. These findings are relevant to clinicians who must decide whether to admit a patient involuntarily, as they suggest that making a patient involuntary is not associated with differences in length of stay or readmission risk.

Evidence of new-onset depression among persons with migraine after discontinuing antidepressants

Antidepressants have been hypothesized to cause tardive dysphoria-the delayed development of negative emotional symptoms. We assessed the risk of tardive dysphoria in a cohort of persons with migraine taking anti-migraine antidepressants with no known diagnosis of any mood or anxiety disorder. We included all outpatient encounters in a university hospital system for migraine from January 2008 through October 2018, excluding subjects with prior psychiatric diagnoses. Kaplan-Meier survival curves and multivariable Cox proportional hazards analyses were conducted. 13,048 subjects were included; 1191 took an antidepressant; 402 discontinued an antidepressant. In multivariable analyses examining the first year after exposure, antidepressant use was not significantly associated with risk of a depression, any mood disorder (including depression, mania, and other mood disorders), or anxiety. Antidepressant discontinuation was significantly associated with increased risk of depression, but not any mood disorder or anxiety. Among persons with migraine with no known psychiatric diagnosis, antidepressants did not appear to be associated with indicators of tardive dysphoria. Antidepressant discontinuation, however, was associated with increased risk of a depression diagnosis.

Effect of Delays in Civil Commitment Hearings on Outcomes Among Psychiatric Inpatients

Patients admitted involuntarily to psychiatric hospitals may face waits of varying lengths before receiving civil commitment hearings. We aimed to assess the effects of the time spent awaiting a hearing on outcomes for such patients in a university health system, hypothesizing that patients with a longer prehearing length of stay (LOS) would also have increased LOS after their hearings. We included subjects who were admitted from January 1 through December 31, 2013, and had county court records of commitment hearings. Models for each outcome were constructed using generalized linear models to control for available confounding variables. 109 subjects were included in the analysis, 58 (53.2%) of whom had delayed commitment hearings (with prehearing LOS greater than seven days). The average posthearing LOS for the delayed group was 6.2 days greater. After controlling for covariates, prehearing LOS was statistically predictive of posthearing LOS, even after controlling for potential confounds. These results suggest that delays in involuntary civil commitment hearings for psychiatric inpatients are associated with extended posthearing LOS and extended total LOS, implying that LOS for involuntary patients could be improved by measures to increase the efficiency of commitment processes.

Physician Aid-in-Dying and Suicide Prevention in Psychiatry: A Moral Crisis?

Involuntary psychiatric commitment for suicide prevention and physician aid-in-dying (PAD) in terminal illness combine to create a moral dilemma. If PAD in terminal illness is permissible, it should also be permissible for some who suffer from nonterminal psychiatric illness: suffering provides much of the justification for PAD, and the suffering in mental illness can be as severe as in physical illness. But involuntary psychiatric commitment to prevent suicide suggests that the suffering of persons with mental illness does not justify ending their own lives, ruling out PAD. Since both practices have compelling underlying justifications, the most reasonable accommodation might seem to be to allow PAD for persons with mental illness whose suffering is severe enough to justify self-killing, but prohibit PAD for persons whose suffering is less severe. This compromise, however, would require the articulation of standards by which persons' mental as well as physical suffering could be evaluated. Doing so would present a serious philosophical challenge.

Altitude and risk of depression and anxiety: findings from the intern health study

Multiple studies suggest that the risks of depression and suicide increase with increasing altitude of residence, but no studies have assessed whether changing altitude changes these risks. To address this gap, this study used data from the Intern Health Study, which follows students from the end of medical school through the first year of residency, recording depression via the 9-item Patient Health Questionnaire (PHQ-9), anxiety via the 7-item Generalized Anxiety Disorder Questionnaire (GAD-7), and multiple risk factors for these symptoms. Data from 3764 medical students representing 46 schools and 282 residencies were available. Odds ratios (OR) representing the effects of altitude on psychiatric symptoms were estimated using generalized linear models. After excluding participants with missing altitude data, 3731 medical students were analyzed. High altitude residence (> 900 m) was significantly associated with PHQ-9 total score (OR = 1.32, 95% CI = 1.001-1.75, p < 0.05), and PHQ-9 suicidal ideation (OR = 1.79, 95% CI = 1.08-0.02, p = 0.02). Moving from low to high altitude was significantly associated with PHQ-9 total score (OR = 1.47, 95% CI = 1.087-1.98, p = 0.01), GAD-7 total score (OR = 1.40, 95% CI = 1.0040-1.95, p < 0.05), and PHQ-9 suicidal ideation (OR = 1.10, 95% CI = 1.01-1.19, p = 0.02). The data suggest that moving from low to high altitude is associated with increasing symptoms of depression, anxiety, and suicidal ideation.

Treatment-refractory Tourette Syndrome

Tourette Syndrome (TS) is a complex neurodevelopmental condition marked by tics and frequently associated with psychiatric comorbidities. While most cases are mild and improve with age, some are treatment-refractory. Here, we review strategies for the management of this population. We begin by examining the diagnosis of TS and routine management strategies. We then consider emerging treatments for refractory cases, including deep brain stimulation (DBS), electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS), and novel pharmacological approaches such as new vesicular monoamine transporter type 2 inhibitors, cannabinoids, and anti-glutamatergic drugs.

Advances in mechanistic understanding and treatment approaches to Tourette syndrome

Tourette syndrome (TS) is a childhood onset neurodevelopmental disorder characterized by semi-involuntary, repetitive movements and sounds (motor and phonic tics). Transient tics in childhood are common, and their persistence in TS may be due to failure of maturation of frontal-subcortical circuits mediated by genetic predisposition and environmental factors. Tic improvement by young adult years is common, but its mechanism and predictive factors are unclear. Though tics can often be managed with nonmedical therapies, pharmacotherapy is often used for refractory, severe, or injurious tics but is complicated by side effects and incomplete benefit. This review summarizes the current understanding of TS pathophysiology, current and future treatment options, and recommendations for future research.

Diseases, patients and the epistemology of practice: mapping the borders of health, medicine and care

Last year saw the 20th anniversary edition of JECP, and in the introduction to the philosophy section of that landmark edition, we posed the question: apart from ethics, what is the role of philosophy 'at the bedside'? The purpose of this question was not to downplay the significance of ethics to clinical practice. Rather, we raised it as part of a broader argument to the effect that ethical questions - about what we should do in any given situation - are embedded within whole understandings of the situation, inseparable from our beliefs about what is the case (metaphysics), what it is that we feel we can claim to know (epistemology), as well as the meaning we ascribe to different aspects of the situation or to our perception of it. Philosophy concerns fundamental questions: it is a discipline requiring us to examine the underlying assumptions we bring with us to our thinking about practical problems. Traditional academic philosophers divide their discipline into distinct areas that typically include logic: questions about meaning, truth and validity; ontology: questions about the nature of reality, what exists; epistemology: concerning knowledge; and ethics: how we should live and practice, the nature of value. Any credible attempt to analyse clinical reasoning will require us to think carefully about these types of question and the relationships between them, as they influence our thinking about specific situations and problems. So, the answers to the question we posed, about the role of philosophy at the bedside, are numerous and diverse, and that diversity is illustrated in the contributions to this thematic edition.

Genetic nondiscrimination and health care as an entitlement

The Genetic Information Nondiscrimination Act of 2008 prohibits most forms of discrimination on the basis of genetic information in health insurance and employment. The findings cited as justification for the act, the almost universal political support for it, and much of the scholarly literature about genetic discrimination, all betray a confusion about what is really at issue. They imply that genetic discrimination is wrong mainly because of genetic exceptionalism: because some special feature of genetic information makes discrimination on the basis thereof wrong. I suggest, to the contrary, that the best arguments against genetic discrimination assume that health care is an entitlement. I do this by examining two different exceptionalist arguments for genetic nondiscrimination, showing that they do not furnish good reasons for prohibiting genetic discrimination unless one supposes that health care is an entitlement.

Philosophy on steroids: why the anti-doping position could use a little enhancement

There is currently much concern over the use of pharmaceuticals and other biomedical techniques to enhance athletic performance--a practice we might refer to as doping. Many justifications of anti-doping efforts claim that doping involves a serious moral transgression. In this article, I review a number of arguments in support of that claim, but show that they are not conclusive, suggesting that we do not have good reasons for thinking that doping is wrong.

The Nuremberg Code: its history and implications

The Nuremberg Code is a foundational document in the ethics of medical research and human experimentation; the principle its authors espoused in 1946 have provided the framework for modern codes that address the same issues, and have received little challenge and only slight modification in decades since. By analyzing the Code's tragic genesis and its normative implications, it is possible to understand some of the essence of modern experimental ethics, as well as certain outstanding controversies that still plague medical science.

Identification and characterization of a calcium channel gamma subunit expressed in differentiating neurons and myoblasts

Transient elevations of intracellular calcium (calcium transients) play critical roles in many developmental processes, including differentiation. Although the factors that regulate calcium transients are not clearly defined, calcium influx may be controlled by molecules interacting with calcium channels, including channel regulatory subunits. Here, we describe the chick gamma4 regulatory subunit (CACNG4), the first such subunit to be characterized in early development. CACNG4 is expressed early in the cranial neural plate, and later in the cranial and dorsal root ganglia; importantly, the timing of this later expression correlates precisely with the onset of neuronal differentiation. CACNG4 expression is also observed in nonneuronal tissues undergoing differentiation, specifically the myotome and a subpopulation of differentiating myoblasts in the limb bud. Finally, within the distal cranial ganglia, we show that CACNG4 is expressed in placode-derived cells (prospective neurons), but also, surprisingly, in neural crest-derived cells, previously shown to form only glia in this location; contrary to these previous results, we find that neural crest cells can form neurons in the distal ganglia. Given the proposed role of CACNG4 in modulating calcium channels and its expression in differentiating cells, we suggest that CACNG4 may promote differentiation via regulation of intracellular calcium levels.