Risk communication in genetic counseling: Exploring uptake and perception of recurrence numbers, and their impact on patient outcomes

The ethics of polygenic scores in psychiatry: minefield or opportunity for patient-centered psychiatry?

Recent advancements in psychiatric genetics have sparked a lively debate on the opportunities and pitfalls of incorporating polygenic scores into clinical practice. Yet, several ethical concerns have been raised, casting doubt on whether further development and implementation of polygenic scores would be compatible with providing ethically responsible care. While these ethical issues warrant thoughtful consideration, it is equally important to recognize the unresolved need for guidance on heritability among patients and their families. Increasing the availability of genetic counseling services in psychiatry should be regarded as a first step toward meeting these needs. As a next step, future integration of novel genetic tools such as polygenic scores into genetic counseling may be a promising way to improve psychiatric counseling practice. By embedding the exploration of polygenic psychiatry into the supporting environment of genetic counseling, some of the previously identified ethical pitfalls may be prevented, and opportunities to bolster patient empowerment can be seized upon. To ensure an ethically responsible approach to psychiatric genetics, active collaboration with patients and their relatives is essential, accompanied by educational efforts to facilitate informed discussions between psychiatrists and patients.

The Return of Biomarker Results in Research: Balancing Complexity, Precision, and Ethical Responsibility

Recent research aimed at the discovery, integration, and communication of health outcome measures (or "biomarkers") in Alzheimer's disease has raised challenging questions related to whether, how and when results from these investigations should be disclosed to research participants. Reflecting the apparent heterogeneity of many neurodegenerative diseases, biomarker or other risk factor results are often probabilistic, interactive, multi-modal, and selective. Such characteristics make it very complex to summarize and communicate to clinicians, researchers, and research participants. Whereas the format and content of academic literature is well-managed by the peer-review process, reporting individualized results to participants involves complex, sensitive, and ethical considerations. This paper describes three key factors to consider in decisions about the return of results to research participants: complexity, precision, and responsibility. The paper also presents six practical recommendations for implementing meaningful and ethical communication with research participants.

Using Rasch measurement theory to explore the fitness for purpose of the genetic counseling outcome scale: a tale of two scales

BACKGROUND

The genetic counseling outcome scale (GCOS-24) is commonly used in clinical genetics to measure patient empowerment; however, there is inconclusive psychometric evidence about this scale.

METHODS

Using data from an urban Canadian clinic where the GCOS-24 is routinely administered before (T1) and 1 month after (T2) genetic counseling, we used Rasch measurement theory (RMT) to test the ordering of response option thresholds, fit, spread of item locations, residual correlations, person separation index (PSI), and stability across time.

RESULTS

Data from 379 participants showed that the original GCOS-24 items had poor fit to the Rasch model (χ² = 367.8, p < 0.001). Two models emerged that demonstrated excellent fit to the Rasch model. In Model 1, the response scale options were collapsed and 8 items were removed, leading to an excellent fit to the Rasch model (χ² = 112.4, df = 144, p = 0.975), good reliability (rp = 0.82), and responsiveness to change (mean = 0.75 logits, F = 125.68, p < 0.001). In Model 2, the response scale options were collapsed, 3 items were removed, and the scale divided into two sets (GCOS-Pos, GCOS-Neg). The GCOS-Pos set showed excellent overall fit to the Rasch model (χ² = 92.5, df = 90, p = 0.407), good reliability (rp = 0.73), and responsiveness to change (mean = 0.74 logits, F = 80.12, p < 0.001). The GCOS-Neg set showed excellent overall fit to the Rasch model (χ² = 84.55, df = 97, p = 0.81), but poor reliability (rp = 0.19) and small, but significant responsiveness to change (mean = 0.19 logits, F = 28.73, p < 0.001).

CONCLUSION

These models show that there are psychometric issues with the GCOS-24 scale, and our study provides options for how to measure empowerment more robustly.

Examining the effect of patient personality types and coping styles on outcomes of genetic counseling

Both empirical data and genetic counselors' clinical experience suggest that patients differ in the extent to which they benefit from genetic counseling (GC). Understanding the origins of these differences could help adapt services to ensure that all patients benefit fully, and potentially inform triage. Although patient personality dimensions and coping styles have been shown to influence outcomes of other psychological interventions, they have remained largely unexplored in relation to GC outcomes. We conducted an exploratory, descriptive study to assess relationships between patient personality dimensions, coping styles, and outcomes of GC. We recruited patients from a psychiatric genetics clinic who had - in the prior 7 years - completed the GC Outcomes Scale (GCOS, a measure of empowerment) immediately prior to, and approximately one month after their appointment, and asked them to complete validated measures of personality and coping style. Interactions between each personality dimension or coping style and GCOS score were assessed using mixed-effects linear regression models. Among the 169 participants, GCOS score increased by an average of 16.48 points (SD = 12.59). Though extraversion, conscientiousness, neuroticism, and all three coping styles significantly predicted GCOS score (p < 0.02), there was no relationship between these variables and time. For example, though a high score on conscientiousness predicted higher GCOS scores, it did not predict greater change in GCOS - people with higher scores on this dimension of personality had higher GCOS scores both pre- and post- GC. These preliminary data suggest that genetic counseling may increase empowerment regardless of personality dimensions and coping styles.

Psychiatric genetic counseling for people with copy number variants associated with psychiatric conditions

22q11.2 deletion is one of the most well-known copy number variants (CNVs) associated with developing a psychiatric condition (e.g. schizophrenia), but there is a growing list of other CNVs which also confer substantial risk for developing psychiatric conditions. With increased use of chromosome microarray and exome sequencing, the frequency with which these CNVs are detected is increasing. While individuals with such CNVs often receive genetic counseling, research shows that associated psychiatric conditions are less often addressed - clinicians tend to focus on the non-psychiatric manifestations of the CNV. This represents an important service gap for people with these CNVs and their families, as research shows that genetic counseling about psychiatric illness can produce meaningful positive outcomes for people, including increases in empowerment, and self-efficacy. Therefore, there is a need to ensure that individuals with psychiatric condition-associated CNVs are being counseled about these manifestations of their condition in a way that can promote best outcomes. In this paper we describe the process of providing genetic counseling in two clinical scenarios in which a psychiatric susceptibility CNV is identified: 1) in an individual who has not been diagnosed with a psychiatric condition and 2) in an individual with an established psychiatric condition.

Outcomes of psychiatric genetic counseling in relation to time since diagnosis and symptom onset

To our knowledge, no studies have yet evaluated whether genetic counseling (GC) outcomes are influenced by the timing of the counseling session in relation to the onset or diagnosis of the condition of interest. We conducted an exploratory retrospective chart review using a database from a psychiatric GC (pGC) clinic, to examine the relationship between GC outcomes and time elapsed between: (a) onset of psychiatric symptoms (time since onset, TSO) and/or (b) psychiatric diagnosis (time since diagnosis, TSD), and the pGC session. Linear regression was used to assess the relationship between change in Genetic Counseling Outcome Scale (GCOS) scores from pre-GC to 1 month post-GC and TSO and/or TSD. Charts of 271 patients (80% women, mean age = 39.9 years old) seen between 2012 and 2018 were included in the analyses. Mean TSO = 19.6 years (range 0-62 years), and mean TSD = 11.1 years (range 0-43 years). Overall, empowerment increased after GC regardless of TSO/TSD (p < 0.0001, d = 1.11). While there was no relationship between GCOS change and TSD, a negative relationship was observed for TSO (p = .032) suggesting better outcomes with shorter TSO, although the effect size was very small (f²  = 0.019). Post hoc analysis revealed this effect was driven by two diagnoses, depression (n = 164, p = 0.013) and schizoaffective disorder (n = 6, p = 0.042). For the former, the effect size was very small (f²  = 0.038) and for the latter, the probability of type 2 error was high. In sum, our data suggest that TSO/TSD plays a negligible role in outcomes of pGC, with patients benefitting from pGC, regardless how long ago symptoms started/diagnosis was made.

An internship in psychiatric genetic counseling: Impact on genetic counseling graduates' practice and career choices

Though psychiatric genetic counseling has been shown to have meaningful positive impacts on patient outcomes, there is currently only one specialist psychiatric genetic counseling clinic (located in Vancouver, BC). The service is inconsistently offered elsewhere, leaving this patient population largely underserved. In an effort to expand psychiatric genetic counseling, the clinic in Vancouver has been providing specialist internship training to genetic counseling students since 2012. This study explored the impact of the internship training on genetic counseling graduates' careers. Using an interpretive description approach, we recorded and transcribed interviews with past interns. Coding and data analysis were conducted concurrently. The interview guide was iteratively revised through the interview process and memoing was used to record ideas about the data and interviews throughout. From interviews with 15 past interns, we generated a theoretical model-'a fragile dream, easily broken'-describing the impact of the training on participants' careers. Completing an internship in psychiatric genetic counseling positively influenced participants' desire to provide psychiatric genetic counseling; however, most were unable to find work in the subspecialty. Some participants made efforts to create specialist positions for themselves, but setbacks and hurdles left many feeling defeated, resulting in them accepting established roles in other disciplines. We contextualize our findings in a discussion of what may be needed in order to successfully expand psychiatric genetic counseling.

The impact of a "Psychiatric Genetics for Genetic Counselors" workshop on genetic counselor attendees: An exploratory study

Genetic counseling is the process of supporting patients' and families' adaptation to genetic information. Psychiatric genetic counseling has been proven to be effective in improving empowerment, self-efficacy, and knowledge even in the absence of genetic testing. Despite this, only one specialist psychiatric genetic counseling clinic currently exists. In order to engage genetic counselors in providing psychiatric genetic counseling, a 2-day workshop: "Psychiatric Genetic Counseling for Genetic Counselors", was developed and implemented aimed at empowering genetic counselors to feel confident and competent in this practice domain. The aim of the study was to qualitatively explore the impact of the workshop. Semistructured interviews were carried out with 12 genetic counselors who attended the workshop between 2015 and 2018. Thematic analysis revealed that the workshop empowered all participants to feel comfortable and confident offering psychiatric genetic counseling to patients. Participants also reflected how the workshop highlighted the stigma associated with mental illnesses and offered support in normalizing these conditions. Overall, this study presents that the "Psychiatric Genetic Counseling for Genetic Counselors" workshop fulfilled its proposed aims and outcomes.

An ethical analysis of divergent clinical approaches to the application of genetic testing for autism and schizophrenia

Genetic testing to identify genetic syndromes and copy number variants (CNVs) via whole genome platforms such as chromosome microarray (CMA) or exome sequencing (ES) is routinely performed clinically, and is considered by a variety of organizations and societies to be a "first-tier" test for individuals with developmental delay (DD), intellectual disability (ID), or autism spectrum disorder (ASD). However, in the context of schizophrenia, though CNVs can have a large effect on risk, genetic testing is not typically a part of routine clinical care, and no clinical practice guidelines recommend testing. This raises the question of whether CNV testing should be similarly performed for individuals with schizophrenia. Here we consider this proposition in light of the history of genetic testing for ID/DD and ASD, and through the application of an ethical analysis designed to enable robust, accountable and justifiable decision-making. Using a systematic framework and application of relevant bioethical principles (beneficence, non-maleficence, autonomy, and justice), our examination highlights that while CNV testing for the indication of ID has considerable benefits, there is currently insufficient evidence to suggest that overall, the potential harms are outweighed by the potential benefits of CNV testing for the sole indications of schizophrenia or ASD. However, although the application of CNV tests for children with ASD or schizophrenia without ID/DD is, strictly speaking, off-label use, there may be clinical utility and benefits substantive enough to outweigh the harms. Research is needed to clarify the harms and benefits of testing in pediatric and adult contexts. Given that genetic counseling has demonstrated benefits for schizophrenia, and has the potential to mitigate many of the potential harms from genetic testing, any decisions to implement genetic testing for schizophrenia should involve high-quality evidence-based genetic counseling.

Changes in empowerment and anxiety of patients and parents during genetic counselling for epilepsy

Genetic testing and counselling are increasingly important in epilepsy care, aiming at finding a diagnosis, understanding aetiology and improving treatment and outcome. The psychological impact of genetic counselling from patients' or parents' perspectives is, however, unknown. We studied the counselee-reported outcome of genetic counselling before and after genetic testing for epilepsy by evaluating empowerment - a key outcome goal of counselling reflecting cognitive, decisional and behavioural control, emotional regulation and hope - and anxiety. We asked patients or their parents (for those <16 years or intellectually disabled) referred for genetic testing for epilepsy in two university hospitals between June 2014 and 2017 to complete the same two questionnaires at three timepoints: before and after pre-test counselling and after post-test counselling. Empowerment was measured with the Genetic Counselling Outcome Scale (GCOS-18); anxiety with the short State Trait Anxiety Inventory (STAI-6). A total of 63 participants (55 parents with the age of 29-66 years; 8 patients with the age of 21-42 years) were included in our study. Empowerment significantly increased during the genetic counselling trajectory with a medium effect size (p < 0.001, d = 0.57). A small but significant increase in empowerment was already seen after pre-test counselling (p = 0.038, d = 0.29). Anxiety did not change significantly during the counselling trajectory (p = 0.223, d = -0.24). Our study highlights that patients with epilepsy or their parents show a clinically relevant increase in empowerment after genetic counselling. Empowerment was already increased after pre-test counselling, suggesting the importance of counselling before initiating genetic testing for epilepsy. However, individual differences in changes in empowerment and anxiety were seen, suggesting that counselling could be further improved, based on individual needs.

Genetic Risk Assessment in Psychiatry

Most psychiatric disorders of pediatric and adult onset are caused by a complex interplay of genetic and environmental risk factors. Risk assessment in genetic counseling is correspondingly complicated. Outside of neurodevelopmental conditions, genetic and genomic testing has not achieved clinical utility. Genetic counselors most often base risk assessment on the client's medical and family history and empiric recurrence risk data. In rare cases significant familial risk may arise from variants of large effect. New approaches such as polygenic risk scores have the potential to inform diagnosis and management of affected individuals and risk status for at-risk individuals. Research on the genetic and environmental factors that increase risk for schizophrenia and etiologically related disorders are reviewed, guidance in determining and communicating risks to families is delivered, and new opportunities and challenges that will come with translating new research findings to psychiatric risk assessment and genetic counseling are anticipated.

Evidence-Based Genetic Counseling for Psychiatric Disorders: A Road Map

Psychiatric disorders, such as schizophrenia, depression, anxiety, and bipolar disorder, are common conditions that arise as a result of complex and heterogeneous combinations of genetic and environmental factors. In contrast to childhood neurodevelopmental conditions such as autism and intellectual disability, there are no clinical practice guidelines for applying genetic testing in the context of these conditions. But genetic counseling and genetic testing are not synonymous, and people who live with psychiatric disorders and their family members are often interested in what psychiatric genetic counseling can offer. Further, research shows that it can improve outcomes like empowerment for this population. Despite this, psychiatric genetic counseling is not yet routinely or widely offered. This review describes the state of the evidence about the process and outcomes of psychiatric genetic counseling, focusing on its clinical implications and remaining research gaps.

Relationships between patient- and session-related variables and outcomes of psychiatric genetic counseling

Little data currently exist regarding whether and how different characteristics of a patient and session influence outcomes of genetic counseling (GC). We conducted an exploratory retrospective chart review of data from a specialist psychiatric GC clinic (where patients complete the Genetic Counseling Outcome Scale (GCOS) as part of routine care before and after GC). We used ANOVA and linear regression to analyze GCOS change scores in relation to twelve patient/session-related variables. Three hundred and seven charts were included in analyses. Overall, GCOS scores increased significantly after GC, with large effect size (p < 0.0005, d = 1.10), and significant increases in all GCOS subdomains except adaptation. Significant associations with GCOS change score were identified for three variables: mode of delivery of GC (in-person/telephone/telehealth, p = 0.048, η² = 0.020), primary indication for the appointment (understanding recurrence risk versus other primary indications, p = 0.001, η² = 0.037), and baseline GCOS score (p < 0.000, R = 0.353). Our data showing that those with low baseline GCOS scores benefit most from GC could be used to explore the possibility of triaging those referred for GC based on this variable, and/or to identify individuals to refer to GC.

Genetics and genetic counseling in psychiatry: Results from an opinion survey of professionals and users

Background

The heritability of several psychiatric disorders is high, and specific at‐risk variants have been identified. Therefore, genetic counseling and genetic testing can be prescribed to some psychiatric patients, but these services are not standardized for most of the population. The aims of the study were to gather opinions from mental health professionals and users regarding (a) the genetics of psychiatric disorders and (b) the usefulness of a genetic counseling unit in psychiatry.

Methods

The survey was conducted in the province of Tarragona (Spain), and we analyzed 152 valid questionnaires from professionals and 959 from users.

Results

Sixty‐one percent of professionals strongly believed that psychiatric disorders have a genetic basis, and 59% rated a genetic counseling unit in psychiatry as very or extremely useful. However, only a few professionals reported that patients asked them about the genetics of their diseases (12%) or the possibility of transmitting the disease to offspring (19%). Forty‐seven percent of users strongly believed that psychiatric disorders have a genetic basis, 30% responded that they talked with their families about the genetics of their diseases, and 43% were worried about transmitting the disease to offspring; however, only 14% reported that their psychiatrist had talked to them about this topic. Remarkably, 80% of users would consider a genetic counseling unit very or extremely useful.

Conclusions

The present study showed that mental health professionals were more aware of the genetic basis of psychiatric disorders than users, and both considered the implementation of a genetic counseling service very useful.

Impact of the physical environment on patient outcomes of genetic counseling: An exploratory study

The psychology literature shows that the physical space in which counseling sessions are conducted influences outcomes of the interaction. However, this phenomenon has not been quantitatively explored in genetic counseling (GC). Through retrospective review of naturalistic data from a psychiatric GC clinic (where data on patient outcomes are routinely tracked from pre- to 1 month post-appointment using the Genetic Counseling Outcome Scale (GCOS, empowerment) and the Illness Management Self Efficacy Scale (IMSES), we tested the hypotheses that patients seen in comfortably furnished counseling (C-type) rooms would have greater increases in (a) empowerment and (b) self-efficacy after GC than patients seen in medically oriented (M-type) rooms. We matched each patient with complete GCOS and/or IMSES who was seen in a C-type room between February 2012 and December 2017 to four M-type room controls where possible. We used t tests to compare change in outcome scale scores between groups. There were no significant differences in change in scores between patients seen in M-type (GCOS n = 84, IMSES n = 56) and C-type rooms (GCOS n = 22, IMSES n = 18) (p = 0.241, d = 0.26, and p = 0.602, d = 0.14, respectively). The effect sizes we demonstrate allow estimation of sample size calculations for the design of future prospective studies.

Genetics of Eating Disorders: What the Clinician Needs to Know

Anorexia nervosa (AN), bulimia nervosa (BN), and binge-eating disorder (BED) are heritable conditions that are influenced by both genetic and environmental factors. Recent genome-wide association studies (GWAS) of AN have identified specific genetic loci implicated in AN, and genetic correlations have implicated both psychiatric and metabolic factors in its origin. No GWAS have been performed for BN or BED. Genetic counseling is an important tool and can aid families and patients in understanding risk for these illnesses.