Defining Autonomy in Psychiatry

Critically appraising the cass report: methodological flaws and unsupported claims

BACKGROUND

The Cass Review aimed to provide recommendations for the delivery of services for gender diverse children and young people in England. The final product of this project, the Cass report, relied on commissioned research output, including quantitative and qualitative primary research as well as seven systematic reviews, to inform its recommendations and conclusions.

METHODS

We critically evaluated the Cass report and the research that was commissioned to inform it. To evaluate the Risk of Bias within the seven systematic reviews commissioned by the Cass Review, we applied the ROBIS tool - a domain-based assessment of risk of bias within systematic reviews. It focuses on four domains (i) study eligibility criteria, (ii) identification and selection of studies, (iii) data collection and study appraisal, and (iv) synthesis and findings. To maintain rigour, the ROBIS tool was applied to each systematic review by two independent assessors, within Covidence, with conflicts resolved by an additional two independent assessors. We also conducted a detailed critical evaluation of the methods used in the survey of gender services for young people in Europe, the two quantitative studies of health records, and the qualitative study on the experience of gender dysphoria among young people and the claims made in the Cass report based on these studies.

RESULTS

Using the ROBIS tool, we identified a high risk of bias in each of the systematic reviews driven by unexplained protocol deviations, ambiguous eligibility criteria, inadequate study identification, and the failure to integrate consideration of these limitations into the conclusions derived from the evidence syntheses. We also identified methodological flaws and unsubstantiated claims in the primary research that suggest a double standard in the quality of evidence produced for the Cass report compared to quality appraisal in the systematic reviews.

CONCLUSIONS

We discuss these issues in relation to how evidence regarding gender affirming care is framed, the wider political context, and the future for gender affirming care. The Cass report's recommendations, given its methodological flaws and misrepresentation of evidence, warrant critical scrutiny to ensure ethical and effective support for gender-diverse youth.

Ethical Considerations in Substance Use Treatment for Youth: Assessing Clinical Practices and Policy Frameworks for Potential Harm

The current conceptual review highlights considerations surrounding the potential for non-beneficence and undue coercion within the practices of psychologists and other clinicians providing substance use treatment for youth. The potential for nonbeneficence and undue coercion is assessed at three key stages of treatment for youth with substance use disorders (SUDs): the informed consent process, maintaining confidentiality, and treatment planning. We explore these concerns as they relate to the ethical principles of psychologists as outlined by the American Psychological Association (American Psychological Association [APA], 2017), as well as pertinent state and national legislative guidelines. The paper culminates in actionable recommendations to resolve these inconsistencies in practice and emphasizes opportunities for professionals at all career stages to engage in ethical policy initiatives. These endeavors aim to reduce potential for undue coercion and nonbeneficence from psychologists treating youth with substance use disorders and to elucidate beneficial treatment pathways for youth navigating substance use challenges.

The uneven triad: a qualitative study of perspectives of relatives, patients, and professionals on (not) involving relatives in mental health

INTRODUCTION

Recognition of the value of involving relatives in mental health care is growing. This study explores the ambivalence surrounding their role, including formalisation, instrumental use, burden, and potential benefits. Collaboration between relatives, patients, and professionals is essential to recovery-based approaches. Thus, despite challenges, the involvement of relatives remains crucial. This study aims to understand perspectives on involving relatives in mental health care, within the larger context of collaboration across the triad of relatives, patients, and professionals.

METHODS

We conducted a qualitative study using semi-structured interviews with relatives (n = 7), patients (n = 7), and professionals (n = 10) connected to various mental health care organizations. The study took place in The Netherlands. Data were analysed using thematic analysis.

RESULTS

For collaboration in the triad, we found five aspects to be of importance: the significance of involving relatives, changing roles from relative to caregiver, relatives' intermediary role in patient-professional relationship, negative experiences of relatives in the triad, and ambivalence about patient's autonomy. Notably, because collaboration between professionals and relatives is often challenging, it often leads to tensions.

CONCLUSION

Our study uncovers varying perspectives both on involving relatives and on collaboration within the triad. Recovery-oriented approaches do not always align with patients' and relatives' intentions and values. Although relatives want to be involved, they often feel unheard and unseen by professionals. Relatives' roles -especially the intermediary role- are surprisingly underrepresented in the recovery-oriented literature. This study reveals several tensions between the three perspectives, culminating in a so-called uneven triad. We conclude that although the concept of involving relatives is highly advocated in recovery-based approaches, actual practice is lagging behind.

Measurement Invariance of the Basic Psychological Need Satisfaction Subscale Between Individuals With Psychiatric and Non-psychiatric Disabilities

This study aimed to examine the measurement invariance of the Basic Psychological Need Satisfaction Subscale (BPNSS) and compare the latent factor means of basic psychological needs between individuals with psychiatric and non-psychiatric disabilities. This cross-sectional study included 97 individuals with psychiatric and 102 individuals with non-psychiatric disabilities. Prior to comparing scores on basic psychological needs across these groups, we evaluated the measure invariance of the BPNSS and confirmed scalar invariance. Individuals with psychiatric disabilities had significantly lower autonomy scores than those with non-psychiatric disabilities. There were no significant mean differences in competence and relatedness between the groups. These findings suggest wide applicability of the BPNSS across individuals with psychiatric and non-psychiatric disabilities. Practitioners should support individuals with psychiatric disabilities to improve their autonomy. Replication with large, diverse samples is crucial to validate the findings and investigate intragroup variances.

"Believing facilitates success": psychiatric nurses' perspectives on recovery

BACKGROUND

Psychiatric nurses play a crucial role in patient recovery processes, and their attitudes during these processes can directly influence the recovery of individuals with mental illness. However, the concept of recovery in psychiatric disorders is perceived differently among nurses, which, in turn, can affect the patient's recovery trajectory. This study aims to explore and investigate the perspectives, thoughts and experiences of nurses working in psychiatric clinics about recovery in mental illnesses.

METHODS

The study was conducted between September and December 2021 at a Mental and Neurological Illness Hospital. This research is a qualitative study employing conventional content analysis, with data collected during the same period. Fifteen psychiatric nurses were selected as participants using the snowball sampling method. Data collection was carried out through individual, in-depth and semi-structured interviews. Data were analyzed according to the approach outlined by Graneheim and Lundman (Nurse Educ Today 24(2):105-12, 2004), which facilitated the identification of participants' perspectives. MAXQDA qualitative data analysis software was used to assist with the analysis of interview data.

RESULTS

The analysis revealed four main themes: defining recovery, and the factors that aid recovery, roles of psychiatric nursing.

CONCLUSION

The findings indicate that psychiatric nurses are hopeful about patient recovery, stating that treatment and care, along with supporting the patient and facilitating their reintegration into the community, are essential to achieve recovery.

[The donkey bridge of patient autonomy in psychiatry]

In bioethics, patient autonomy is often considered a fundamental principle, even more important than beneficence, non-maleficence and justice. Inspired by liberal philosophies (such as J.S. Mill) and the morality of duty (especially Kant), this principle recognizes human dignity and the right of each individual to make free decisions about their health. In practice, this means that health professionals are obliged to provide patients with clear information and obtain their informed consent, while respecting professional confidentiality. In psychiatry, however, this principle is particularly challenging. Mental disorders can affect patients' capacity to make decisions, thereby compromising their autonomy. Delicate situations arise when a psychotic or severely depressed patient refuses necessary care. Carers then face an ethical dilemma: should they impose treatment 'for the good' of the patient, at the risk of adopting a paternalistic approach that is now frowned upon? This dilemma reveals a tension between individual autonomy and the reality of human vulnerability. Some ethicists propose a more relational approach to autonomy, in which the patient's choices are supported by those around him and by carers, creating a framework in which autonomy is exercised in interdependence. From this perspective, helping patients does not negate their autonomy, but rather supports it. Finally, in psychiatry, respect for autonomy must be nuanced, allowing in some cases the use of restricted care to protect the fundamental interests of the patient and those around him or her.

Positive mental health interventions for people with schizophrenia: A scoping review

BACKGROUND

Promoting positive mental health is crucial for maintaining a healthy balance of mental well-being, both for individuals with and without mental health conditions, including schizophrenia.

OBJECTIVE

To map interventions that promote positive mental health in individuals with schizophrenia.

METHODS

We conducted a scoping review following Joanna Briggs Institute recommendations. Searches were performed on Scopus, MEDLINE and CINAHL Complete (via EBSCOhost), and RCAAP for grey literature. Papers that met the following criteria were included: published from September 1999 to May 2023; involving only individuals diagnosed with schizophrenia; focused on interventions that promote positive mental health; presenting interventions with defined objectives and duration; designed for individuals or groups.

RESULTS

We identified 1111 potentially relevant records, which were screened by 2 independent researchers. 26 studies, published between 2004 and 2023 were found eligible. Most of the identified interventions were implemented in community-based settings (n = 22), in group formats (n = 20), with a total duration between 4 and 12 weeks (n = 20), session duration about 45-60 min (n = 13) and without follow up (n = 17). A significant number of interventions focused on improving interpersonal relationship capacity (n = 15) and personal satisfaction (n = 13). 9 interventions focused on enhancing autonomy, 3 on promoting self-control, 2 on problem-solving/self-actualization and 1 on promoting pro-social attitude.

CONCLUSIONS

This scoping review can contribute to improving the quality of care provided and optimizing health outcomes, enhancing the promotion of community health through increased knowledge in the field of positive mental health.

PTSD and challenges among older Chinese in Shenzhen during COVID-19 pandemic: Trust in authority and medical professionals as moderators

AIM

This research aimed to comprehensively explore the impact of diverse challenges encountered by older adults on the development of post-traumatic stress disorder (PTSD). It delved into how these effects vary depending on individuals' levels of trust in authority and medical professionals, providing a nuanced understanding of the interplay between external challenges, personal trust, and mental health outcomes in the older population.

BACKGROUND

The COVID-19 pandemic has imposed significant hardships, particularly on the ageing population, with potential psychological repercussions such as PTSD. Notably, there is a dearth of research exploring this association within the context of Chinese older adults, a group that may experience unique impacts due to cultural differences in the face of global crises.

METHODS

Data were collected from a representative sample of 1,211 participants aged 60 years and above in Shenzhen. Logistic and hierarchical linear regression methods were utilized to investigate the relationship between the challenges posed by COVID-19, public trust, and the manifestation of PTSD symptoms.

FINDINGS

Higher levels of challenges related to 'supplies, services access and safety', 'abuse and conflicts', and 'anger and fear' were associated with PTSD. Furthermore, a lower level of challenges related to 'disease management and information' was associated with PTSD. Trust in authority or medical professionals was the moderator between the challenges brought about by COVID-19 and PTSD, which helped to lower the impact of challenges. Despite the challenges brought by COVID-19 to people, nurturing a stronger sense of trust in authority and medical professionals would ease older adults' psychological stress and concerns.

Patient Knowledge and Trust in Health Care. A Theoretical Discussion on the Relationship Between Patients' Knowledge and Their Trust in Health Care Personnel in High Modernity

In this paper we aim to discuss a theoretical explanation for the positive relationship between patients' knowledge and their trust in healthcare personnel. Our approach is based on John Dewey's notion of continuity. This notion entails that the individual's experiences are interpreted as interrelated to each other, and that knowledge is related to future experience, not merely a record of the past. Furthermore, we apply Niklas Luhmann's theory on trust as a way of reducing complexity and enabling action. Anthony Giddens' description and analysis of the high modern society provides a frame for discussing the preconditions for patient-healthcare personnel interaction. High modernity is dominated by expert systems and demands trust in these. We conclude that patient knowledge and trust in healthcare personnel is related because both knowledge and trust are future- and action-oriented concepts. The traits of high modernity provides opportunities and challenges as the personnel can and must perform discretion. This discretion must be made in a context where knowledge is considered uncertain and preliminary.

Undermining autonomy and consent: the transformative experience of disease

Disease radically changes the life of many people and satisfies formal criteria for being a transformative experience. According to the influential philosophy of Paul, transformative experiences undermine traditional criteria for rational decision-making. Thus, the transformative experience of disease can challenge basic principles and rules in medical ethics, such as patient autonomy and informed consent. This article applies Paul's theory of transformative experience and its expansion by Carel and Kidd to investigate the implications for medical ethics. It leads to the very uncomfortable conclusion that disease involves transformative experiences in ways that can reduce people's rational decision-making ability and undermine the basic principle of respect for autonomy and the moral rule of informed consent. While such cases are limited, they are crucial for medical ethics and health policy and deserve more attention and further scrutiny.

Striatal correlates of Bayesian beliefs in self-efficacy in adolescents and their relation to mood and autonomy: a pilot study

Major depressive disorder often originates in adolescence and is associated with long-term functional impairment. Mechanistically characterizing this heterogeneous illness could provide important leads for optimizing treatment. Importantly, reward learning is known to be disrupted in depression. In this pilot fMRI study of 21 adolescents (16-20 years), we assessed how reward network disruption impacts specifically on Bayesian belief representations of self-efficacy (SE-B) and their associated uncertainty (SE-U), using a modified instrumental learning task probing activation induced by the opportunity to choose, and an optimal Hierarchical Gaussian Filter computational model. SE-U engaged caudate, nucleus accumbens (NAcc), precuneus, posterior parietal and dorsolateral prefrontal cortex (PFWE < 0.005). Sparse partial least squares analysis identified SE-U striatal activation as associating with one's sense of perceived choice and depressive symptoms, particularly anhedonia and negative feelings about oneself. As Bayesian uncertainty modulates belief flexibility and their capacity to steer future actions, this suggests that these striatal signals may be informative developmentally, longitudinally and in assessing response to treatment.

Architectural Design Qualities of an Adolescent Psychiatric Hospital to Benefit Patients and Staff

OBJECTIVES

This study is focused on how architectural design of adolescent psychiatric hospitals could positively affect not only patients but also staff members working at the hospitals.

BACKGROUND

Adolescents between the ages of 12 and 18 are among the young population with the highest percentage of mental illness. However, there are limited number of intentionally designed psychiatric hospitals for adolescents. Staff who work in adolescent psychiatric hospitals may face workplace violence. Studies on environmental impacts suggest that the built environment affects patients' well-being and safety as well as staff's satisfaction, working condition, safety, and health. However, there are very few studies that focus on adolescent psychiatric hospitals and the impact of the built environment on both staff and patients.

METHODS

Data were collected through literature analysis and semi-structured interviews with staff of three psychiatric state hospitals with adolescent patient units. The triangulation of multiple data sources informed a set of environmental design conditions that captures the complexity and connectedness of architectural design and the occupants of an adolescent psychiatric hospital.

RESULTS

The results present architectural composition, atmosphere, lighting, natural environment, safety, and security as indispensable design conditions to create an enclosed and city-like campus that provides a serene, secure, and structured environment that benefit staff and adolescent patients.

CONCLUSION

The specific design strategies that need to be incorporated in the architectural design of a safe and secure adolescent psychiatric hospital include an open floor plan that respects patients' autonomy and offers privacy while always providing staff with full visibility of patients.