The importance of genetic counseling for individuals with schizophrenia and their relatives: potential clients' opinions and experiences

Genetic counseling is a health service, which has been indicated for individuals with psychiatric conditions in their families. However, little is known about the awareness and/or experiences of genetic counseling of this group. This study was designed to assess the awareness and perceptions of genetic counseling among individuals affected by schizophrenia and their relatives. Data was collected via two online surveys. Study participants either had schizophrenia or had a relative with schizophrenia and were recruited via links from schizophrenia web sites. This study was granted IRB approval. Sixty-eight individuals with schizophrenia and 145 relatives completed the surveys. Ninety-four percent of all respondents had not been offered genetic counseling. Zero percent of affected individuals and only 5% of relatives had received genetic counseling. Forty-four percent of affected individuals and 41% of relatives indicated that their family planning decisions were influenced by the presence of schizophrenia in their family. Seventy four percent of relatives and 72% of people with schizophrenia thought genetic counseling would be useful to them. Respondents indicated that they felt genetic counseling would be useful for them and that they would like to see a genetic counselor. However, few individuals are being offered genetic counseling services. The awareness of genetic counseling needs to be raised among physicians and families affected by schizophrenia.

Exploring the discourse between genetic counselors and Orthodox Jewish community members related to reproductive genetic technology

OBJECTIVE

Genetic technology is complex, relatively new and involves sensitive issues pertaining to personhood and reproduction. While ethno cultural barriers to genetic care are well documented, little attention has been devoted to understanding religious beliefs pertaining to genetic services. This study evaluated the discourse between genetic counselors and Orthodox Jewish community members' perceptions of reproductive genetic technology.

METHODS

A cross section of the Orthodox Jewish community was sampled through purposeful and snowball recruitment for in-depth interviews with key informants.

RESULTS

Genetic counselors felt apprehensive about serving the Orthodox Jewish population and were unaware of social norms, religious and cultural practices unique to this population. Similarly, Orthodox Jewish consumers exhibited major misgivings about genetic testing. Importantly, stereotypic expectations by both counselors and consumers exacerbated existing communication difficulties.

CONCLUSION

Cultural differences and poor communication between genetic counselors and Orthodox Jewish community members impeded the ability of the Orthodox Jewish community to utilize genetic services.

PRACTICE IMPLICATIONS

This work illuminates complex issues pertaining to medical encounters between providers and patients with ideological, social and cultural differences. In particular, issues of access to care and transcultural competence in serving religious minority groups, such as Orthodox Jews are presented. On the whole, this group is largely unrecognized in the minority health literature in spite of barriers and challenges that they face. Findings of this study may have application to other cloistered and highly observant religious groups when dealing with reproductive technology and other populations with diverse values, beliefs and behaviors pertaining to reproductive health.

Enhancing the ethical conduct of genetic research: investigating views of parents on including their healthy children in a study on mild hearing loss

Clinical genetic research is often regarded as more ethically problematic than other forms of research, and in some countries is subject to specific regulation, requiring researchers to follow specialised guidelines. In this paper, an approach to enhancing the ethical conduct of genetic research is proposed, which is believed to be more effective than simply attempting to follow general guidelines. The potential concerns, likely areas of misunderstanding and negative reactions of the participant group are systematically investigated before starting a study on genetics. This would constitute, in effect, an ethical pilot study, similar to a feasibility pilot study to test equipment, procedures and logistics. The findings of the ethical pilot study would be used to help in designing ethically important aspects of research protocol, such as recruitment procedures, written and other information for potential participants, informed consent processes and reporting of results including ambiguous or uncertain results.

"Genetic exceptionalism" in medicine: clarifying the differences between genetic and nongenetic tests

Predictive genetic tests are now available for assessing susceptibility to a variety of conditions, including breast and colon cancer, hemochromatosis, and Alzheimer and Huntington disease. Much controversy surrounds the application of these tests, stemming from their similarities to and differences from other tests commonly used in asymptomatic persons. Some have argued that genetic tests are unique and therefore justify special consideration with regard to informed consent and privacy. This paper examines the arguments for such "genetic exceptionalism" and concludes that no clear, significant distinctions between genetic and nongenetic tests justify a different approach to testing by clinicians. Nevertheless, with many genetic tests, the results may cause stigmatization, family discord, and psychological distress. Regardless of whether a test is genetic, when this combination of characteristics is present and when health care providers are not specifically trained to interpret results, testing should be performed with particular caution and the highest standards of informed consent and privacy protection should be applied.

Genetic counseling and testing in families with hereditary nonpolyposis colorectal cancer

BACKGROUND

Genetic testing to refine cancer risk is available. However, little is known about factors affecting the uptake of testing for the most common hereditary colon cancer, hereditary nonpolyposis colorectal cancer. This study investigated attitudes, intentions, and uptake of genetic testing within newly identified families with hereditary nonpolyposis colorectal cancer.

METHODS

Cohort study conducted at the National Institutes of Health between April 15, 1996, and November 20, 1999. Data were collected through questionnaires before semistructured education sessions, individual counseling sessions, and the offer of genetic testing.

RESULTS

Of the 111 eligible first-degree relatives, 51% chose to participate in education and individual counseling sessions. Participation was associated with greater numbers of first-degree relatives with cancer; no association was found between participation and personal history of cancer. Before education and individual counseling sessions, 64% of participants had heard little about genetic testing for cancers; however, most (97%) stated intentions to pursue testing. Fifty-one percent identified learning about their children's risks as the most important reason to consider testing. Thirty-nine percent identified the potential effect on their health insurance as the most important reason to not undergo testing. Of the 111 eligible first-degree relatives, 51% chose to undergo genetic testing. Participants' intentions to pursue genetic testing were significantly affected by concerns regarding the ability to handle the emotional aspects of testing and the psychosocial effect on family members.

CONCLUSIONS

Genetic counseling and testing offers the potential to focus cancer screening resources in individuals truly at increased risk, thereby reducing mortality and morbidity. Fears of discrimination and concerns about psychological and psychosocial issues may present barriers to the use of current cancer prevention strategies, including genetic counseling and testing.

What is 'public opinion' about genetics?

Every biotechnology success story increases the number of decisions that the lay public must make about genetics. But vibrant public discussion about these far-reaching changes has been rare, and research on the public's understanding of genetics has barely scratched the surface. This article reviews what we know about the public's attitudes towards genetics, proposes some concepts for thinking about public involvement and indicates some future lines of research.

Genetic technologies and achieving health for populations

The remarkable progress in genetics over the last 50 years has led to the development of genetic technologies to identify or alter genes in living organisms, and these technologies can be applied to people. This article presents background information on the role of genetics in human disease, outlines the technologies, and discusses the sources of the strong push for a genetic approach to ill-health and some implications and harmful consequences of using these genetic technologies. The determinants of most diseases are complex and are embedded in a social context. To focus on only one strand of this web--the genetic strand--because it is one that may be amenable to biological/pharmaceutical treatment, although profitable for industry, does not address other important determinants of health and may lead to a harmful overemphasis on genetic approaches. The author outlines some limitations to the potential contribution of genetic technologies to population health across the globe and the need for policy development if these technologies are to have an appropriate place in health care.

Gene technology: also a gender issue. Views of Dutch informed women on genetic screening and gene therapy

The reported research was conceived as a pilot study to explore the views of women on the implications of the analysis of the human genome. The data were gathered by interview and questionnaire from a group of Dutch women, most likely to have an informed opinion. However, even women who were assumed to be informed express a serious lack of knowledge. Nevertheless, they mention a whole range of problematic issues. Overall, women are likely to think that gene technology does affect them differently than it does men. They draw attention to the social reality of women's lives, mentioning the greater responsibility of mothers for the embryo and childbirth and pointing to the fact that women are subjected to more complicated and painful examinations. In the public debate attentional for gender implications of gene technology is lacking. A plea is made to improve the quality of the debate by integrating sex and gender specific issues.

Gene technology and social acceptance

About 10% of the human genome has now been mapped and for more than 1000 diseases closely linked DNA polymorphisms or the responsible genes have been identified. These developments have extended the scope of (prenatal) diagnosis and carrier detection which already was possible by biochemical analysis of protein defects in some 400 Mendelian disorders. Together with the study of chromosomal aberrations these activities form the basis for genetic counselling and carrier screening programmes. A brief overview of the activities in clinical genetics will be presented and their importance for the prevention of congenital disorders and for informed decisions of couples at risk will be emphasized. Reproductive decisions are, however very closely related to culture, religion, education and the socioeconomic status of individuals and populations. Up to now genetic services have mainly been developed in wealthy postindustrial countries with a low infant mortality. But even among these countries there are major differences in the implementation of gene technology as will be shown by comparisons of the United States, Europe and Japan. In the developing countries where about 95% of the world's future children will be born there are major hindrances in the development of clinical genetics such as poverty, illiteracy of women, low contraceptive use and a high infant mortality. There are, however, examples of developing countries that give high priority to the application of gene technology such as Cuba and China. While the developing countries are struggling to improve their basic health care, research on gene technology in the western countries proceeds fast. The early identification of a particular gene constitution will show whether a young adult is at higher risk of important diseases such as various forms of cancer, cardiovascular disease, diabetes or psychiatric disorders. The therapeutical, preventive, psychological and some ethical aspects of this new era of predictive medicine will be discussed.

Genetic testing for cancer in children. Short-term psychological effect

OBJECTIVE

To study the psychological effect of genetic testing in children.

DESIGN

We evaluated the psychological effect of predictive genetic testing through surveys of children at risk for familial adenomatous polyposis. Their psychological state was assessed before testing and 3 months later.

SETTING

A research clinic.

PARTICIPANTS

A volunteer sample of 41 children, aged 6 to 16 years, and their parents.

MAIN OUTCOME MEASURES

Self-report inventories of depression, anxiety, behavior problems, and competence.

RESULTS

Nineteen children were found to have a gene mutation (mutation-positive) and 22 did not (mutation-negative). Their depression, anxiety, and behavior problem and competence scores remained in the normal range after testing. Also, parents' depression scores remained within normal limits at follow-up. There were subclinical changes, however. Mutation-positive children with affected mothers had significantly higher depression scores at follow-up. Also, regardless of test results, children with affected mothers had significantly increased anxiety scores after testing. In families with mutation-positive and mutation-negative children, familial adenomatous polyposis-unaffected parents experienced significantly increased depressive symptoms at follow-up.

CONCLUSIONS

Predictive testing of children at risk for familial adenomatous polyposis did not lead to clinically significant psychological symptoms in tested children or their parents. However, it is premature to conclude that long-term follow-up will be equally favorable. Additional study will be needed to determine the families' understanding of the genetic information and the effect of the information on familial relationships.

Public information and the ethical responsibility of the industry

Biotechnology and gene technology are recognized by experts as invaluable and unique tools to find solutions to or improve many problems in health, agriculture and management of the environment, and are regarded as a driving economic force in the next century. They are, however, by large not accepted by the public and the discussion on gene technology is often emotional or even controversial. This situation is not favorable to a constructive and open debate. Science, economic forces and society coexist symbiotically and a broad debate on all aspects including the social and ethical issues of biotechnology is essential. A mutual understanding and acceptance are prerequisites to the democratic process of the elaboration of sound regulation and appropriate administration. To this aim, a task force was initiated in Switzerland by the pharmaceutical industry. Its goal is to provide information on relevant aspects of biotechnology and to participate in the dialogue with the Swiss public and politicians on critical issues like risk assessment, ethics, safety, novel food and legislation. A documentation service, teaching material, national poster campaign, exhibitions and debates on specific issues are the contributions of the industry to a fair information in favor of the improved background to an educated and open debate.

Understanding the decision to take the predictive test for Huntington disease

The predictive test for Huntington disease (HD) has allowed those at risk to determine gene status prior to symptoms. The purpose of this research was to understand the motivation and the anticipated reactions of those requesting the test. Forty persons at 50% risk for HD and 31 companions participated in a structured personal interview as part of the predictive test protocol. Reasons for taking the test centered on the reduction of anxiety and uncertainty associated with being at risk and enhanced planning and decision making. Participants also believed that taking the test would produce more positive than negative outcomes. With a favorable result, most anticipated a reduction of anxiety, a more normal future, and relief knowing their children would be at a very low risk. Most also cited benefits as more likely than consequences with an unfavorable result. Making the most of life, easier planning, and reduced uncertainty were rated as more likely than any of the adverse impacts, including short-term depression and becoming frightened. Almost all participants (95%) said they would rather learn that they have the HD gene than remain at 50% risk. The uncertainty, anxiety, and chronic stress associated with being at risk appears to underlie the motivation of many seeking the predictive test for HD.

[Presymptomatic DNA diagnosis in Huntington's chorea: reactions to the certainty of not being a genetic carrier]

Presymptomatic DNA diagnostics in Huntington's chorea make it possible to establish with approx. 98% certainty whether an at-risk person is a gene carrier. Sympathy and care are usually shown to those demonstrated to have the gene and so will become affected in the future. Persons shown not to be carriers sometimes do not experience the expected relief. The authors successively discuss the effects of a favourable finding on the family system, such as survivor's guilt and emotional numbing as aspects of a coping process. It is concluded that even a favourable finding needs to be worked through, a process that takes years rather than months.