American Psychiatric Association 2013 Annual Meeting

May 18-22, 2013
San Francisco, California

"Brain Imaging and Psychiatric Diagnosis: Scientific and Societal Issues"
Martha Farah, Ph.D. and Helen Mayberg, M.D.

Abstract: Brain imaging permeates the media, with colorful scans showing the brain as it falls in love, craves drugs or makes economic decisions.  Laypersons are aware that brain imaging can reveal the normal activity of the human brain and abnormal patterns of activity associated with psychiatric illness.  The idea of diagnostic brain imaging in psychiatry is therefore plausible to non-experts and may increase patient confidence in the diagnostic process and subsequent clinical care.  Yet brain imaging currently plays no accepted role in psychiatric diagnosis, beyond ruling out medical factors such as tumors or traumatic brain injuries.  The goal of this session is to address the following questions concerning the role of brain imaging in psychiatry:  How has brain imaging been used in basic and translational research?  How do these uses differ from diagnosis?  Why is brain imaging not used in diagnosing primary psychiatric disorders (e.g., depression, bipolar disease, schizophrenia, and ADHD)?  What in the nature of brain imaging accounts for this?  What in the nature of our diagnostic categories accounts for this?  Why might patients and families nevertheless seek brain imaging for diagnosis?  Why might some physicians nevertheless use imaging for diagnosis?  The answers to these questions involve limitations of current science, technology and nosology, as well as the appeal of pictures, the promise of high technology, and the desire to ground psychiatry in neuroscience.

The APA 2013 Ethics Track was developed by The Scattergood Program for Applied Ethics in Behavioral Healthcare, the University of Pennsylvania Department of Medical Ethics & Health Policy, and The Thomas Scattergood Behavioral Health Foundation.

American Psychiatric Association 2013 Annual Meeting

May 18-22, 2013
San Francisco, California

"Deciding Who Decides: Surrogate Decision Making Policies Across the U.S."
Susan Rushing, M.D., J.D. and Andrew Siegel, M.D.

Abstract:

Part 1: Hospital-based consultation psychiatrists are often faced with complicated, high-risk clinical scenarios in which making accurate, evidence-based assessments and recommendations will protect the patient from harm.  These scenarios include complicated biological, legal and ethical questions the consultation psychiatrist must efficiently work through to knowledgeably advise the consulting medical team.  Within the last decade, many states have enacted legislation guiding the clinician on assigning Surrogate Decision Makers when patients lose the ability to make their own medical decisions.  This workshop will review the ethical framework of informed consent, of which decision-making capacity is one element.  We will review accepted frameworks for discussing and documenting a patient’s medical decision making capacity abilities.  We will then delve into the nuances of the state laws governing the assignment of surrogate decision makers.  We will look at the hierarchy of decision makers in various states and discuss the ethical and policy implications behind the selected hierarchy.  We will discuss specific limitations regarding when surrogates can consent on behalf of an incapacitated person.  In some states, this is limited to termination of life support if the patient is permanently unconsciousness; whereas in other states, surrogates may give consent for standard medical care, disposition, or participation in research protocols.  We will discuss whether states allow physicians or members of the ethics committee to serve as surrogates.  We will also review decision-making standards (substituted judgment vs. best interest).  Participants will be invited to discuss their experiences with their state law and how the implementation of the law has changed their practice.     

Part 2: Medical decision-making capacity is an essential capability of the fully autonomous patient.  Assessing patient capacity, however, engenders broad conceptual and practical questions, which have been the subject of much scholarship over the past few decades.  The workshop will first review some of the relevant philosophical, legal, and ethical determinants of medical decision making capacity.  In our study, we compile a set a model criteria against which to measure capacity, derived from such interdisciplinary insights.  Currently, there is no single professional standard for assessing capacity and prior studies have demonstrated poor interrater reliability when no standardized approach is used.  Consequently, hospitals have begun developing their own policies to guide capacity assessments in an effort to standardize the process, result in accurate and consistent judgments, and are in line with legal precedent and ethical considerations. In the second part of our study, we evaluate a sample of hospital policies across the U.S.  in terms of their variability of included elements in addition to the degree to which they include our model elements of medical decision making capacity.  Participants are invited to share their personal experience in conducting capacity assessments and their understanding of the relevant determinants of capacity.  I also hope to foster dialogue on how a systematic approach to capacity assessment may best be implemented.

The APA 2013 Ethics Track was developed by The Scattergood Program for Applied Ethics in Behavioral Healthcare, the University of Pennsylvania Department of Medical Ethics & Health Policy, and The Thomas Scattergood Behavioral Health Foundation.

American Psychiatric Association 2013 Annual Meeting

May 18-22, 2013
San Francisco, California

"Mental Health, Involuntary Treatment, and Due Process of Law"
Alex Guerrero, J.D., Ph.D.

Abstract: In the United States, indigent litigants have a federal constitutional right to counsel in criminal cases, but not in civil cases.  In a significant number of states, however, indigent individuals who are facing involuntary commitment to a mental health facility or involuntary treatment within a mental health facility have a state-level right to various elements of legal process, including, in some states, a right to state-provided counsel.  Unfortunately, what this means in practice is that the quality of legal process for indigent individuals with mental health issues varies widely from jurisdiction to jurisdiction and from state to state.  Additionally, even in states with substantial legal entitlements, there are real issues as to how and whether those entitlements are actually provided.  This workshop will address a number of issues that arise at the intersection of mental health, poverty, and law, including the following questions: (1) what are the current “best practices” with respect to procedural due process in the mental health context; (2) what are the most significant problems relating to procedural due process in the mental health context; and (3) what, if anything, does the recent Supreme Court decision in Turner v. Rogers (in which the Court found that procedural due process required “alternative procedural safeguards,” but not necessarily a right to counsel, in a civil contempt proceeding in which the individual faced loss of liberty as a potential consequence) mean for due process in the mental health context?  Finally, the workshop will consider whether mental health advocates should embrace recent significant efforts made to secure a Federal civil right to counsel in cases implicating basic human needs, efforts including the formation of a National Coalition for a Civil Right to Counsel and a 2006 American Bar Association resolution calling for a civil right to counsel.

The APA 2013 Ethics Track was developed by The Scattergood Program for Applied Ethics in Behavioral Healthcare, the University of Pennsylvania Department of Medical Ethics & Health Policy, and The Thomas Scattergood Behavioral Health Foundation.

American Psychiatric Association 2013 Annual Meeting

May 18-22, 2013
San Francisco, California

"Confidentiality and Release of Information: Overcoming the Moral and Legal Obstacles to Family Inclusion"
Jonathan Lukens, Ph.D. and Phyllis Solomon, Ph.D.

Abstract: There is a growing body of evidence that supports greater family inclusion in the planning and implementation of treatments for persons with severe mental illness.  Current practice standards as well as government care standards dictate family involvement.  Psychiatric advance directives--an important tool in recovery oriented services--require the involvement caregivers (often family members) to ensure they are implemented in time of crisis.  But while many practitioners and policy makers have come to regard family inclusion as a treatment imperative, there are significant obstacles to implementing services that include greater family involvement. Confidentiality laws as well as outmoded attitudes toward family involvement impede progress in family inclusion.  Firstly, some practitioners may hold negative attitudes toward family inclusion; these attitudes are often rooted in beliefs regarding the family as a contributor to psychiatric distress, or a lack of proper training in how to effectively collaborate with family members.  The persistence of such negative attitudes has clear and negative implications for treatment outcomes.  Secondly, inadequate knowledge of confidentiality policies results in black and white decision-making regarding release of information to family members, with many practitioners believing that confidentiality must be understood as almost absolute.  Fear or legal penalties for breaking confidentiality exacerbate this problem.  This presentation will explore the current clinical evidence supporting family inclusion.  The presenters will then illuminate the legal and moral issues related to release of information to family members, and provide attendees with an increased understanding of the importance of family involvement in treatment planning and implementation, how to navigate the legal and ethical standards of confidentiality, the kinds of information that may be shared with family members, and the circumstances under which such sharing may take place.

The APA 2013 Ethics Track was developed by The Scattergood Program for Applied Ethics in Behavioral Healthcare, the University of Pennsylvania Department of Medical Ethics & Health Policy, and The Thomas Scattergood Behavioral Health Foundation.

American Psychiatric Association 2013 Annual Meeting

May 18-22, 2013
San Francisco, California

"The Making and Unmaking of Alzheimer's Disease and its Ethical Implications"
Jason Karlawish, M.D.

Abstract: Alzheimer's disease is changing. What was once a disease defined by a clinical category-being demented-is becoming a disease defined along dimensions. These changes are unfolding in two notably different ways, one proposed by the field of Alzheimer's disease researchers and the other proposed by the American Psychiatric Association. The first group seeks to redefine Alzheimer's disease according to biological measures, commonly called "biomarkers." The second is proposing a novel category called "neurocognitive disorder" that is subcategorized into "major" and "minor" neurocognitive disorder and emphasizes the need to measure and scale cognition to then fit it within degrees of severity. This talk will review the ethical and social implications of these events. How we talk about what is Alzheimer's disease, and therefore what is and is not a healthy brain, has notable ethical implications because losses in brain function affect the capacity to act autonomously which, in turn, resonate with the heart of contemporary ethics. Even more compelling is labeling persons who are abnormal because they are at risk of the loss of brain function.

The APA 2013 Ethics Track was developed by The Scattergood Program for Applied Ethics in Behavioral Healthcare, the University of Pennsylvania Department of Medical Ethics & Health Policy, and The Thomas Scattergood Behavioral Health Foundation.

American Psychiatric Association 2013 Annual Meeting

May 18-22, 2013
San Francisco, California

"Hybrid Research-Advocacy Organizations and Disease Paradigms: A Case Study of Autism"
Rebecca Johnson, M.A. and Benjamin DiCicco-Bloom, M.A.

Abstract:

This workshop uses autism as a case study to examine the role of patient and family advocacy in shaping psychiatric research priorities and nosology. The DSM has come under scrutiny by patient and family advocates seeking to incorporate non-clinical concerns (i.e. insurance reimbursement, special education issues, etc.) into the manual, while simultaneously funding significant amounts of research into areas such as disease etiology and treatment more aligned with the DSM’s clinical and research aims. For example, the advocacy organization Autism Speaks has raised concerns about the social impact of more sensitive diagnostic criteria, while simultaneously allocating $87 million to 737 research projects and fellowships since 1997, including research funding to members of the DSM-5 Neurodevelopmental Disorders Work Group. What are the implications of this research-advocacy model for DSM nosology and how can conflicts of interest be managed?

Concretizing this question by examining different conceptualizations of autism by researchers and advocates, the second part of the workshop will provide a historical and ethnographic analysis of three conceptual paradigms of the disorder: psychogenic, mainstream science, and biopolitical. Each of these models eschews research into autism’s long-term prognosis, instead focusing on more youth-oriented concerns such as etiology and treatment. As a result, there remain important questions about and a lack of research on the child-to-adult transition for persons with autism, questions surrounding social integration, planning for the future of an aging child, and caregiving outside the family. What is the relationship between the DSM as a form of currency for many of these social services and its uses as a research tool and clinical document? How can the DSM adapt to emerging issues in the study of the child-to-adult transition in autism and how do hybrid research-advocacy either facilitate or hinder the incorporation of these emerging issues?

The APA 2013 Ethics Track was developed by The Scattergood Program for Applied Ethics in Behavioral Healthcare, the University of Pennsylvania Department of Medical Ethics & Health Policy, and The Thomas Scattergood Behavioral Health Foundation.

American Psychiatric Association 2013 Annual Meeting

May 18-22, 2013
San Francisco, California

"Health Reform and Behavioral Healthcare: Clinical, Policy, and Ethical Transformations"
Dominic Sisti, Ph.D. and Stephanie Hales, J.D.

Behavioral health care -- which includes treatment for substance abuse and mental illness -- in the U.S. is currently deeply fragmented, leading to poor access and bad outcomes.  These structural and systemic flaws create common ethical dilemmas for clinicians who aim to do right by their patients.  Issues include, among others, ineffective and disintegrated single-specialty treatment without appropriate wrap-around services; difficulties related to providing patient-centered (i.e., "recovery-based") services; cultural incompetence in dealing with particular populations; a lack of clarity around evidence-based treatment options; disruptions, inadequacies, or absence of treatment and services due to uninsured or underinsured status; and uncertainties as to how best to implement and honor requirements for mental health parity. 

In this workshop, we will examine several specific provisions within the ACA that hold strong promise to enhance the way in which behavioral healthcare is delivered, and which we believe should help resolve several common ethical problems encountered by behavioral healthcare professionals.  Though realization of this promise depends upon ongoing and future implementation efforts at the federal, state, and local levels, these ACA provisions lay the groundwork for achieving truly meaningful progress in transforming mental health care in America.  These provisions can be clustered around three key areas — (1) insurance coverage reform; (2) integrated care incentives; and (3) innovation (including research and technology initiatives) and education programs — all of which dovetail with the five key goals explicated in the 2003 report of the President's New Freedom Commission on Mental Health.  We aim to complement the APA’s own primer on Health Reform (2012) by highlighting how these changes offer both challenges and opportunities to psychiatry.

The APA 2013 Ethics Track was developed by The Scattergood Program for Applied Ethics in Behavioral Healthcare, the University of Pennsylvania Department of Medical Ethics & Health Policy, and The Thomas Scattergood Behavioral Health Foundation.

Featuring Joshua B. Kayser, MD, MPH, Assistant Professor of Clinical Medicine, Division of Pulmonary, Allergy and Critical Care. For a complete series schedule, please see the flyer below.