Policy considerations that support equitable access to responsible, accountable, safe, and ethical uses of psychedelic medicines

There is mounting evidence suggesting psychedelic and entactogen medicines (namely psilocybin and 3,4-methylenedioxymethamphetamine [MDMA]), in conjunction with proper psychosocial support, hold the potential to provide safe, rapid acting, and robust clinical improvements with durable effects. In the US, both psilocybin and MDMA have been granted Breakthrough Therapy designations by the US Food and Drug Administration and may potentially receive full FDA approval with similar regulatory considerations occurring in multiple countries. At the same time, regulatory changes are poised to increase access to legal or decriminalized psychedelic use in various non-medical settings. This review provides a brief discussion on the historical use of psychedelic medicines, the status of the empirical evidence, and numerous significant policy considerations that must be thoughtfully addressed regarding standards-of-practice, consumer protection, engagement of communities, safeguarding access for all, and developing data standards, which supports the responsible, accountable, safe, and ethical uses of these medicines in clinical, faith-based, and other contexts. We provide suggestions for how public health and harm reduction can be supported through a public-private partnership that engages a community of stakeholders from various disciplines in the co-creation and dissemination of best practices and public policies.

Ethics Dilemmas in Managing Hunger Strikes

There is no agreement on how to manage hunger strikers. The health professionals called to intervene in a hunger strike are faced with a dilemma: commit themselves to good order and discipline or comply with best practices for providing healthcare. Handling cases of hunger strikers confronts practitioners with the ethics dilemma of managing apparent intentional behavior that carries serious morbidity or mortality, but recognizing that hunger striking is a military and political tactic, and not a medical condition. The study by Reeves, et. al published in the Journal enhances our understanding of the motives and psychology of hunger strikers. Their analysis indicates that improving communication with custody administration and mitigating unnecessarily aversive housing environments can likely reduce the incidence of hunger strikes.

At Risk for Violence in the Military

Understanding the occurrence and nature of violence in the military entails appreciating military culture, the sociology and demographics of its personnel, military training, combat experiences, and injuries and illnesses that veterans suffer. The military is grounded in the principles and practice of conducting violent operations, and the psychology of violence fundamentally anchors its professionalism. The occurrence of unwanted violence and tragic incidence of suicides, homicides, and abuse expose the challenges to containing the behavior outside of the combat and training theaters.

Neglect of medical evidence of torture in Guantánamo Bay: a case series

BACKGROUND

In the wake of the September 11, 2001 attacks on the US, the government authorized the use of "enhanced interrogation" techniques that were previously recognized as torture. While the complicity of US health professionals in the design and implementation of US torture practices has been documented, little is known about the role of health providers, assigned to the US Department of Defense (DoD) at the US Naval Station Guantánamo Bay, Cuba (GTMO), who should have been in a position to observe and document physical and psychological evidence of torture and ill treatment.

METHODS AND FINDINGS

We reviewed GTMO medical records and relevant case files (client affidavits, attorney-client notes and summaries, and legal affidavits of medical experts) of nine individuals for evidence of torture and ill treatment and documentation by medical personnel. In each of the nine cases, GTMO detainees alleged abusive interrogation methods that are consistent with torture as defined by the UN Convention Against Torture as well as the more restrictive US definition of torture that was operational at the time. The medical affidavits in each of the nine cases indicate that the specific allegations of torture and ill treatment are highly consistent with physical and psychological evidence documented in the medical records and evaluations by non-governmental medical experts. However, the medical personnel who treated the detainees at GTMO failed to inquire and/or document causes of the physical injuries and psychological symptoms they observed. Psychological symptoms were commonly attributed to "personality disorders" and "routine stressors of confinement." Temporary psychotic symptoms and hallucinations did not prompt consideration of abusive treatment. Psychological assessments conducted by non-governmental medical experts revealed diagnostic criteria for current major depression and/or PTSD in all nine cases.

CONCLUSION

The findings in these nine cases from GTMO indicate that medical doctors and mental health personnel assigned to the DoD neglected and/or concealed medical evidence of intentional harm.

Data-gathering tools for "real world" clinical settings: a multisite feasibility study

OBJECTIVE

To determine the mental health needs and optimal treatments for children and families in "real world" settings, data-gathering strategies are needed that can be easily implemented across a variety of clinical settings. To address this need, the authors developed and piloted a "clinician-friendly" questionnaire that includes demographic, psychosocial, medical, and family history variables, such as those routinely gathered in standard clinical evaluations.

METHOD

Optical scanning technology was used to encode data from more than 1,900 children, including 1,458 consecutive referrals in four military child psychiatry clinics, 285 consecutive admissions to a civilian psychiatric state hospital, 71 pediatric patients, and a community sample of 113 children.

RESULTS

Despite geographic and logistic obstacles, clinical data were reliably obtained across multiple settings. Data analyses revealed meaningful differences across samples in subjects' presenting complaints, and a range of psychosocial, demographic, and background variables. Data were characterized by an apparently high degree of accuracy and completeness.

CONCLUSIONS

Findings illustrate the importance and feasibility of standardized data-gathering approaches in routine clinical settings and clarify the hazards as well as the opportunities afforded by these research approaches. Such data-gathering tools appear to have significant merit and deserve further implementation and testing across a range of clinical and research settings.

Anxiety and depressive disorders in attention deficit disorder with hyperactivity: new findings

OBJECTIVE

The authors examined the discriminant validity of the diagnosis of attention deficit disorder with hyperactivity.

METHOD

They used standardized rating scales of life stresses and child and family functioning to assess psychosocial and family risk factors in 47 children who had the diagnosis of attention deficit disorder with hyperactivity, a matched group of 47 children in the community, and a matched group of 47 children seen in a psychiatric clinic.

RESULTS

Children who had the diagnosis of attention deficit disorder and children in the psychiatric clinic reported significantly more depression and anxiety than did the children in the community; furthermore, children diagnosed as having attention deficit disorder with hyperactivity had more externalizing symptoms than did children in the psychiatric clinic. Children diagnosed as having attention deficit disorder with hyperactivity plus a comorbid anxiety or depressive disorder had higher levels of coexisting life stresses and parental symptoms than did children who had the single diagnosis of attention deficit disorder with hyperactivity.

CONCLUSIONS

These results underscore the need for future studies to carefully assess children diagnosed as having attention deficit disorder with hyperactivity for concurrent psychiatric disorders as well as family and psychosocial stressors that may contribute to childhood symptoms. Such information is essential because different subtypes of attention deficit disorder with comorbid disorders may arise from different etiologic pathways, may require varying treatment options, and may foreshadow different eventual outcomes.

Consultation in the aftermath of an air tragedy

In the early morning hours of December 12, 1985, a chartered jet airliner carrying 248 soldiers crashed shortly after takeoff, killing all aboard. The day after, the authors were designated as a consultation team to the mental health staff at Fort Campbell who were providing services in the aftermath of the crash. This report describes and analyzes the experiences of this consultation on disaster management. Our consulting experience has been one of the most profound and demanding events of our professional lives. Salient lessons of the consultation include: (a) the need to clarify leadership roles among the local mental health care team; (b) the need to help the local team establish clear roles among team members; (c) the value of enabling the local team to mourn the loss of their fellow soldiers and community members; and (d) the value of establishing a clear plan of mental health services for both short-term and long-term management.

Group psychotherapy in the treatment of adolescent and preadolescent military dependents with recurrent diabetic ketoacidosis

The adolescent military dependent with recurrent diabetic ketoacidosis (DKA) is a difficult management problem. Career relocations and an absentee sponsor frequently preclude family-oriented interventions. We recently treated four patients with recurrent DKA who had failed to improve following intensive medical and educational programs. They were enrolled into weekly outpatient group psychotherapy in addition to routine medical management. Three out of the four patients improved in compliance and had a decrease in the frequency or severity of DKA. This approach may be effective when individual psychotherapy or lengthy hospitalization are either too far removed or too costly.

Diagnosis and treatment of attention deficit disorder in two general hospital clinics

In two clinics in military general hospitals, the charts of all children with a presumptive diagnosis of attention deficit disorder who were prescribed psychostimulants (N = 68) were audited to assess the quality of the primary physicians' evaluation and treatment. The audit instrument, constructed by a multidisciplinary team, indicated high interrater reliabilities, high face and concurrent validity, and moderate internal consistency. The audit found that only 51.5 percent of the children being treated with psychostimulants met the audit criteria for attention deficit disorder. A school intervention plan was documented in only 16.2 percent of the cases, and a psychotherapy intervention in only 19.1 percent; low rates were also found for other treatment and follow-up criteria. Overall, the assessment, the follow-up care, and the overall quality of care were found to be inadequate or less than adequate in about two-thirds of the cases.

Father absence: effects on child and maternal psychopathology

The effects of fathers' absences during the previous year on 213 military children were examined, using multiple measures of children's functioning and psychiatric symptoms. Children whose fathers had been absent 1 or more months during the previous 12 months experienced significantly higher self-reported depression and anxiety, but these symptoms were not apparent to adult observers (parents and teachers). These effects were not demonstrated when maternal psychiatric symptoms and intercurrent family stressors were controlled. Thus, the effects of father absence under routine conditions in relatively healthy samples may exert no significant effects independent of intervening family stressors or maternal psychopathology. Clinic referrals of children during times of father absence may partly be due to an effect of additional stressors impacting on the mother during the absence of the father.

Therapists' actions that influence their perceptions of "good" psychotherapy sessions

Psychotherapists' and an independent observer's ratings of the "good" to "poor" quality of therapy sessions were correlated with their ratings of various therapist actions. As predicted, significant positive correlations were obtained between the goodness ratings and the emphasis given by therapists to actions encouraging patients' expression of thoughts and feelings and the exploration of their reactions. For a number of other actions, however, therapists and the independent observer disagreed about whether emphasis of the actions correlated with "good" or "poor" sessions. Some possible causes and implications of these differences are discussed.