|Jun. 30th, 2006 @ 07:33 pm Finishing up June....|
|This is a rather large entry – it outlines the articles I had read for journal club and just some interesting things to think about - |
The journal club this week was about articles I had previously read and found interesting about the decisional capacity of those severely depressed patients involving electroconvulsive therapy. The articles I had read for this journal club included:
Appelbaum, P.S., T. Grisso, E. Frank, S. O’Donnell and D.J. Kupfer. 1999. Competence of depressed patients for consent to research. Am J Psychiatry 156:1380-1384.
Depression does in fact impact the concentration, information process, and reasoning; however to what extent? The main question which arose throughout this article was do psychiatric patients truly have the capacity needed to consent to research? This is a new emerging topic that has been found in: popular media, professional literature, administrative agencies, & courts. Questions that arose from the article worth contemplating: are these patients more susceptible to succumbing to research (ie. Does depression make them more apt to research due to a possible decrease in motivation of protecting one’s self)? Also, to what point, concerning strict rules are helping these patients, and as to what extent are they beginning to hinder research and findings? The problem that needs first to be resolved is that there is no clear cut way to evaluate decision making capacities. Moreover, this study was very small, a group of 26 females who measured of a moderate intensity of severe depression. Psychopharmacy treatment was not used in this study and the women did not need hospitalization. Thus an important concern is what about the decision making of those who are hospitalized, on drugs, or severely depressed?
Lapid, M. I., T. A. Rummans, K. L. Poole, S. Pankratz, M. S. Maurer, K. G. Rasmussen, K. L. Philbrick and P. S. Appelbaum. 2003. Decisional capacity of severely depressed patients requiring electroconvulsive therapy. The Journal of ECT 19:67-72.
Electroconvulsive therapy is used with severely depressed patients as treatment. With the patient being severely depressed, are they still able to make the decision to proceed with electroconvulsive therapy? The person must be competent to decide, after weighing the risks and benefits if the treatment is appropriate for them. As there is “no widely accepted standardized approach to assess the decisional capacity of people to accept of refuse treatment” (67) it is even harder to make standards and evaluate if a patient is truly competent to make a decision. In general, psychiatric disorders, such as depression “typically affect emotion, cognition, and motivation and potentially impair the overall decision making capacity of people” (68). The patients were given a standard education including the reasons for electroconvulsive therapy and a videotape. The experimental portion received extra intervention with a psychiatrist with a specific session which had frequently asked questions and answers regarding the electroconvulsive therapy. It was found that the severely depressed were capable to make decisions. There was also improvement noted in testing by the education being given to the patients, but however, the experimental extra education did not necessarily equate to better decision making scores. How accurate though is the MacCAT-T test as some of the tests lasted 15 minutes but could range up to 1.5 hours in the interview? (71).
Wolpe, P.R. and A. Caplan. 2001. Ethical issues in research and treatment of patients with mood disorders. Treatment-resistant mood disorders. Pages 504-514.
This article outlined the main issues that patients with mood disorders present. Depressed patients often times are “indecisive or resistant to treatment, which raises the dilemma of when to consider such resistance a reasonable refusal of consent and when the resistance is a product of the illness itself” (504). It is necessary for the patients to understand the risks and benefits of the treatment and alternative treatments associated with their disorder prior to giving consent. As consent has become a legal issue, competence must be determined prior to making a decision and this decision must not be coerced. The capacity to give consent is difficult to measure, as there is neither clear nor acceptable test in existence. Current standards that are utilized by the courts include: “the ability to communicate a choice, the ability to understand information relevant to the decision about treatment, the ability to appreciate the significance for one’s own situation of the information disclosed about the illness and possible treatments, and the ability to manipulate the information rationally” (508). Those who suffer from depression also have judgment problems, as they focus on negative feedback and believe treatments will not work for them due to their feelings of hopelessness (509). There is also the question of morality of “washout studies”, as a person will be taken off the medication and thus susceptible to the suffering if they relapse, but on the other hand, a washout study insist that with care will not give the patient anymore risk of relapse and due to the side-effects of drugs a drug-free period is more beneficial if it works for the patient. Moreover, in terms of placebo testing, is it ethical to deny a patient treatment? Many conquer this issue by insisting placebo testing only be used when absolutely necessary and that the patient know before testing that if given placebo the risks with it and also having some form of therapeutic benefit.
Questions and Concerns which arose:
--Depression does in fact impact the concentration, information process, and reasoning; however to what extent?
--Do psychiatric patients truly have the capacity needed to consent to research?
--Are these patients more susceptible to succumbing to research – by this I mean does depression make them more apt to research due to a possible decrease in motivation of protecting one’s self?
--Another article questioned if because depressed patients often times are “indecisive or resistant to treatment, which raises the dilemma of when to consider such resistance a reasonable refusal of consent and when the resistance is a product of the illness itself” (Wolpe 504)?
--To what extent, concerning strict rules are helping these patients, and as to what extent are they beginning to hinder research and findings?
--In addition, depression has many symptoms that include pessimism regarding the self, world, future, sadness, diminished thinking/concentration etc… and these symptoms of depression may play a role in deciding if they want to refuse treatment or not – so what if a patient is deemed competent but still refuses treatment, but maybe it is due to the fact the patient does not care about the outcome due to their symptoms? Emotional/motivational factors – do they play a role also in competence?
--Another large problem that needs to be resolved is finding a clear cut standardized method of ascertaining if someone is at the capacity to make decisions (Am J 67).
--Currently – using MacArthur Competence Assessment Tool for Treatment instrument, and the problems that arose with it were that some people took 15 minutes others up to an hour and a half (Am J 71). Also, the scores after education were in the close to maximum range (J Ger 44), and the articles state it is possibly due to the ceiling effect, but what if the standard for making a decision is too low? How do you gauge then when a person is competent?
--Capacity to make a decision as outlined by the courts: “the ability to communicate a choice, the ability to understand information relevant to the decision about treatment, the ability to appreciate the significance for one’s own situation of the information disclosed about the illness and possible treatments, and the ability to manipulate the information rationally” (Wolpe 508). What does this mean for the testing and how do you measure this?
Problems within the Lapid articles:
--The “Decisional Capacity of Depressed Elderly to Consent to Electroconvulsive Therapy” article was found in both the Journal of Geriatric Psychology and Neurology and the Journal of ECT. In the Geriatric article, the authors are at first honest that they did not begin this study for geriatric vs. nongeriatric effects, but only after the study was completed realize this and then review the results (43 Intro then Data Analysis). How valid are their results if the study was not aimed at geriatric patients and the sample size was quite small?
The journal club discussion this week was interesting, as we discussed the various approaches specifically of the two Lapid articles and how the approach to even writing/presenting the studies may not have been honorable or appropriate, or even misgiving at times. The articles were interesting to read, and also it was interesting to read the editorial letters to the Journal of ECT and whether family should be present, and the one letter attributed the calming help of the husband of a patient when present, but that they had feared the wife would not consent without the husband – which is the husband calming her fears or acting more coercively? In addition, the test standard used was not properly managed it seems, as they were tested and then retested with the same test – what about knowing the answer to the questions because they had just been asked it days earlier? A control would seem to be necessary where someone was tested and then retested without education to see the level of improvement in testing, as they would know what answers were wanted.