Using the CABLES model to assess and minimize risk in research: control group hazards

Ethical complexities of screening for depression and intimate partner violence (IPV) in intervention studies

Background

Intervention studies for depression and intimate partner violence (IPV) commonly incorporate screening to identify eligible participants. The challenge is that current ethical evaluation is largely informed by the four principle approach applying principles of beneficence, non-maleficence, and respect for justice and autonomy. We examine three intervention studies for IPV, postnatal depression (PND) and depression that used screening from the perspective of principlism, followed by the perspective of a narrative and relational approach. We suggest that a narrative and relational approach to ethics brings to light concerns that principlism can overlook.

Discussion

The justification most commonly used to incorporate screening is that the potential benefits of identifying intervention efficacy balance the risk of individual harm. However, considerable risks do exist. The discovery of new information may result in further depression or worries, people might feel burdened, open to further risk, unsure of whether to disclose information to family members and disappointed if they are allocated to a control group. This raises questions about study design and whether the principle of equipoise remains an adequate justification in studies with vulnerable groups. In addition, autonomy is said to be respected because participants give informed consent to participate. However, the context of where recruitment is undertaken has been shown to influence how people make decisions.

Summary

The four principles have been subjected to criticisms in recent years but they remain prominent in public health and medical research. We provide a set of simple, interrogative questions that are narrative and relationally driven which may assist to further evaluate the potential impacts of using screening to identify eligible research participants in intervention studies. A narrative and relational based approach requires seeing people as situated within their social and cultural contexts, and as existing within relationships that are likely to be affected by the results of screening information.

[Provides a guide to self-treatment as ethically acceptable compensation for having participated in a psychiatry research project]

Due to ethical constraints imposed by Research Ethics Board, it may be difficult to offer participants adequate compensations for their involvement in the study, or compensations that do not have a coercive impact on the participant's ability to refuse to participate. The current study aims at providing empirical data supporting an innovative solution: the provision of a self-help treatment manual. The samples consists of 33 adults (24 females, 9 males) aged between 20 and 59 and all suffering from pathological fear of heights. After participating in an experimental study, participants received a self-help manual to treat their acrophobia on their own. The severity of their claustrophobia was measured before and six months after participants were instructed on how to use the self-help book as a compensatory measure for their participation. Data also suggests that the participants were satisfied with the help provided in the self-treatment manual and that this is perceived in a positive way. To sum up, this study is not an outcome study for a new form of therapy; it simply offers researchers data supporting the use of an alternative compensatory measure. Indeed, using a self-help book represents an interesting solution.

Research risk for persons with psychiatric disorders: a decisional framework to meet the ethical challenge

OBJECTIVE

There is a lack of consensus on how to evaluate the risk of research studies conducted with persons who have psychiatric disorders. The authors reviewed research on vulnerability, risk, and procedures to mitigate risk in studies with this population to help inform evaluation of such research.

METHODS

Searches of MEDLINE (1966-2006), PsycINFO (1967-2006), and Google Scholar used combinations of the terms mental illness, vulnerable, psychiatric, schizophrenia, and depression combined with terms such as research risk, vulnerability, research harm, capacity, risk, and mitigation of risk. Articles were identified from reference lists, and additional searches used terms from identified articles.

RESULTS

Evidence for two types of vulnerability--capacity based and power based--is presented, which supports the notion of vulnerability as a state, rather than a trait, among persons with psychiatric disorders. Three categories of risk are described--minimal risk, minor increment over minimal risk, and greater than minor increment. Evidence shows that many common types of studies pose risk in the first two categories when conducted with this population. The literature also describes procedures for reducing vulnerability and mitigating risk that should be considered in study evaluations. The authors offer a framework for evaluating the category of risk posed by a study.

CONCLUSIONS

Although more research is needed, there is sufficient evidence that many common types of research present minimal risk or only a minor increment over minimal risk for large segments of the population of persons with psychiatric disorders, as they do for persons in the general population.

Online psychoeducational support for infertile women: a randomized controlled trial

BACKGROUND

The study goal was to develop and test the effectiveness of a brief online education and support program for female infertility patients.

METHODS

A randomized-controlled trial was conducted. Using a Solomon-four group design, 190 female patients were recruited from three US fertility centers and were randomized into two experimental and two no-treatment control groups. The psychological outcomes assessed included infertility distress, infertility self-efficacy, decisional conflict, marital cohesion and coping style. Program dosage and satisfaction were also assessed at four weeks follow-up.

RESULTS

Women exposed to the online program significantly improved in the area of social concerns (P = 0.038) related to infertility distress, and felt more informed about a medical decision with which they were contending (P = 0.037). Trends were observed for decreased global stress(P = 0.10), sexual concerns (P = 0.059), distress related to child-free living (P = 0.063), increased infertility self-efficacy (P = 0.067) and decision making clarity (P = 0.079). A dosage response was observed in the experimental groups for women who spent >60 min online for decreased global stress (P = 0.028) and increased self efficacy (P = 0.024).

CONCLUSIONS

This evidence-based eHealth program for women experiencing infertility suggests that a web-based patient education intervention can have beneficial effects in several psychological domains and may be a cost effective resource for fertility practices.