The enduring psychiatric myth is that particular personal, interpersonal and social problems in living are manifestations of ‘mental illness’ or ‘mental disease’, which can only be addressed by ‘treatment’ with psychiatric drugs. Psychiatric drugs are used only to control ‘patient’ behaviour and do not ‘treat’ any specific pathology in the sense understood by physical medicine. Evidence that people, diagnosed with ‘serious’ forms of ‘mental illness’ can ‘recover’, without psychiatric drugs, has been marginalized by (...) drug-focused research, much of this funded by the pharmaceutical industry. The pervasive myth of psychiatric drugs dominates much of contemporary ‘mental health’ policy and practice and raises discrete ethical issues for nurses who claim to be focused on promoting or enabling the ‘mental health’ of the people in their care. (shrink)

In this essay, I use the theological anthropology of the apostle Paul as a diagnostic lens in order to bring into focus some implicit assumptions about human personhood in the goals and methods of treatment with psychotropic medications. I argue that Paul views the body as a mode of participation in larger relational matrices in both vulnerable and vital ways. He thus sees the self as constituted relationally rather than as fundamentally isolated and self-determining. Such an understanding of personhood yields (...) an account of human agency as co-constituted and freedom as interpersonally mediated and sustained. From this perspective, the proper goal for psychiatric medication is the removal of barriers to life-giving human connections; methods of care for persons in psychological distress may include medication, but they also require embodied personal encounter. (shrink)

Developmental, epidemiological, and neurobiological studies indicate that the adaptive and maladaptive functions, as well as immediate and long-term consequences of drug use, may vary by age. Early initiation seems to be associated with a reduced ability to use drugs purposely in a temporally stable, non-addictive manner. Prevention strategies should consider social environmental factors and aim to delay age at initiation.

This paper brings the concept of affective scaffolding to bear on a much-debated controversy: the expanding use of psy- chiatric medications to treat an increasingly broad range of human discontents. ‘Affective scaffolding’ refers to the variety of ways that agents engage with, recruit or modify their environments to actively shape their emotions, moods, or other affective phenomena. Psychiatric drugs are designed, marketed, and prescribed as technologies that have the special power to transform affective life by intervening on the (...) pathological underpinnings of distress and suffering to change how we feel. The paper develops an account of psychiatric drug use as affective scaffolding and examines how psychiatrization – the complex social process through which psychiatry comes to influence more and more domains of human life – impacts this form of scaffolding. I propose that psychiatrization influences affective scaffolding by biasing individuals toward psychiatric drugs to manage an expanding array of affective experiences. In some cases, I argue, this results in bad pharmaceutical scaffolding. Bad pharmaceutical scaffolding emerges when an agent is influenced to select and rely upon psychiatric drugs in attempts to exert individual control over distress and suffering where (1) at least some of the key determinants of these affective experiences are properties of the agent’s environment, in contrast to, in a strict sense, properties internal to the person, and (2) pharmaceutical scaffolding obviates the need for or displaces other non-pharmaceutical options that would better serve the agent's affective needs and interests. (shrink)

Grunbaum claims that the remedial failure of atreatment's characteristic factors is thegeneric, objective property of a placebo. Hestipulates that a treatment is placebic if thisremedial failure exacerbates the targetdisorder. This stipulation can subsume asplacebic effects that might be solelypharmacological, e.g., paradoxical reactions tocertain psychiatric drugs. If that exacerbationcan be explained pharmacologically, then wemight question whether Grunbaum's definitionalscheme captures the core identity of what weusually intend by the placebo concept. Ipropose that this core identity is bestcaptured by a symbolic (...) meaning hypothesis inwhich psychological factors exert thedeterminative influence. (shrink)

Today in Japan psychoactive drugs are widely prescribed for various psychiatric disorders including so-called ‘functional’ disorders. They are undoubtedly effective in relieving various psychological and behavioral symptoms. However, Japan has yet to address some basic questions: (1) uncertainty concerning the cause of various psychiatric functional disorders; (2) unknown factors that affect the function of psychotropic drugs in patients; (3) the difficulty in obtaining objective data concerning the effects of these medications * both on the brain and (...) the psychological symptoms (behavior); and most importantly, (4) due to both the behavioral and organic (brain and CNS) effects of psychoactive drugs, the difficulty in evaluating the risk/benefit ratio between the behavioral (primary) effect and the organic (side) effect. In addition, there are bioethical problems, since these uncertainties tend to permit too broad a range of intention and too many modes of intervention in (a) prescribing and (b) taking psychoactive drugs on the part of therapists and patients, respectively. Though the increased risk of the inappropriate use of these drugs – the non-therapeutic uses, and their over-prescription – has been indicated in other industrialized countries, it has not yet been fully recognized and adequately discussed in Japan. Moreover, it is necessary to establish a sound basis for the ‘somato-psychic’ evaluation of these effects in the context of the physician-patient relationship, including the patient's family and even the broader society. Keywords: bioethics, pharmacological treatment, primary and secondary effects, psychiatric-functional disorders, risk/benefit ratio CiteULike Connotea Del.icio.us What's this? (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Psychiatric Hospitalization—Bridging the Gap Between Respect and ControlPaul P. ChristopherIntroductionThis issue of Narrative Inquiry in Bioethics offers varied and somewhat unique perspectives on the experience of psychiatric hospitalization. This commentary highlights a number of salient themes that emerge from reading these essays and attempts to explore how they relate to the broader academic literature on psychiatric hospitalization, particularly with regard to ethical considerations. In reading these (...) narratives, each several times, I was repeatedly struck by the courage required of the authors, both to share their stories publicly and to endure the challenges that the writing process no doubt demanded of them—revisiting and suspending themselves in deeply emotional and, at times, traumatic experiences in order to share the most compelling narrative. Their hard work clearly paid off—the stories are at once intimate and indelible. Still, in many instances, I found myself wanting to know more; to enter the story and sit with the individual through these events; to ask what they were thinking or feeling in a particular situation; to see and hear the world in which they found themselves. Such is the nature of good story telling—the reader, left with the lingering vision created in his mind, turns over the last page, eagerly hoping for more.Narrative ThemesI. Loss of Autonomy or ControlPerhaps the most notable theme had to do with the loss of control or freedom that followed from hospitalization. On first consideration, it may seem odd that this issue appears so often since patient autonomy constitutes one of the fundamental principles of medical ethics. Only under specific circumstances—e.g., when there is a risk of imminent harm—may autonomy be curtailed, and even then only to the extent that is minimally necessary. Yet, as these narratives highlight, there are a multitude of ways in which psychiatric hospitalization engenders actual or perceived restrictions in freedom (Newton-Howes & Mullen, 2011).Consistent with prior research (Goodwin et al., 1999), many of the authors describe a fear or the actual experience of not being able to leave the hospital freely, even when the admission seems to have been voluntary. For example, one writer worries, “I was so afraid that if I ever went ‘in,’ I would never get ‘out’... I thought I would never taste freedom again... alive.” Another describes:When it came time for my possible discharge they told me that I might not get discharged because I was ‘acting up the previous evenings.’ My anxiety level at this point went through the roof. The only reason I was discharged was because my father knew some politicians. If not [End Page 29] for him I would have been a patient there for perhaps years and my life would have been ruined.A third gives this example: “When I asked to sign the form to leave after three days, [the psychiatrist] told me if I did that she would have me committed.” Another writer fears not having any control of how the psychiatrist might approach the treatment: “... I was totally vulnerable... would the doctors blame me, drug me, shock me, kill me?”Somewhat surprising, however, was the fact that so few of the narratives take issue with the decision to hospitalize. This omission is especially striking in light of the fact that prior reports consistently note that a substantial minority (up to nearly half) of voluntarily admitted patients nevertheless experience their admission as coerced (Bonsack & Borgeat, 2005; Hiday et al., 1997; Katsakou et al., 2010; Rogers et al., 1993; Sheehan & Burns, 2011). Because many of these narrators had been hospitalized more than once, the relative absence of expressed resistance to being hospitalized seems strange, particularly when earlier hospital experiences or their aftermath are often described as negative. For example, one individual characterized the time after being released from the hospital as, “My sense of self was questioned. I felt as if I lost my soul.” Another put it this way:When I got out of the private hospital, I felt like my soul had been ripped out of me. I felt like I had a gaping hole in the center of my body... I felt psychically raped, dazed, and confused.Given these... (shrink)

Psychiatric research is in crisis because of repeated failures to discover new drugs for mental disorders. Lack of measurement validity could partly account for these failures. If researchers do not actually measure the effects of drugs on the disorders they aim to investigate, one should expect suboptimal treatment outcomes. I argue that this is the case, focusing on depression, and fear & anxiety disorders. In doing so, I show how psychiatric research illustrates a more general phenomenon (...) that I call “validity drift.” A validity drift occurs when, in the course of developing new measurement procedures, researchers end up studying something different from what they originally aimed to study. I analyze the different ways in which scientists attempt to validate procedures for measuring mental disorders for the purpose of testing drugs in animal models. I show how those validation efforts might fail, thereby leading to validity drifts. Overall, this analysis highlights the complex interplay between the development of new measurement procedures, their calibration, and scientific theories of the target phenomena. (shrink)

Cognitive‐enhancing drugs are prescribed to patients with psychiatric disorders, such as attention deficit hyperactivity disorder (ADHD) and Alzheimer's disease, to treat cognitive deficits. This chapter discusses the use of pharmacological agents to improve the cognition of both those with cognitive impairments and of the general population, as well as some of the benefits, risks, and ethical issues associated with the use of cognitive‐enhancing drugs. The chapter also talks about a survey run by the journal Nature, which was (...) prompted by a commentary by the authors of this chapter, that asked readers for their views on the issues surrounding cognitive enhancement. It can be seen that the ethical issues surrounding the use of cognitive‐enhancing drugs are complex and require discussion among different groups. With the development of new drugs and methods of enhancing cognition, such as brain stimulation, the need for further research and discussion is likely to become more pressing. (shrink)

The “hijacking” and “drug instrumentalization” models of psychoactive drug use predict opposite outcomes in terms of adaptive behavior and fitness benefits. Which is the range of applicability of each model? To answer this question, we need more data than those reported by studies focusing on medical, psychiatric, and legal problems in addicted users. An evolutionary analysis requires a much wider focus.

The profession of medicine is predicated upon an ethical mandate: first do no harm. However, critics charge that the medical profession’s culture and its public health mission are being undermined by the pharmaceutical industry’s wide-ranging influence. In this article, we analyze how drug firms influence psychiatric taxonomy and treatment guidelines such that these resources may serve commercial rather than public health interests. Moving beyond a conflict-ofinterest model, we use the conceptual and normative framework of institutional corruption to examine how (...) organized psychiatry’s dependence on drug firms has distorted science. We suggest that academic-industry relationships have led to the corruption of the evidence base upon which accurate diagnosis and sound treatment depend. We describe the current dependency corruption and argue that transparency alone is not a solution — and sometimes even produces iatrogenic effects. Furthermore, we argue that the corruption of the evidence base for diagnostic and practice guidelines renders obsolete the traditional informed consent process, and we offer suggestions for reforming this process. (shrink)

Recent years have witnessed an intensification of historical and philosophical research on the link between psychotropic drugs and psychiatric theories. For example, Kendler and Schaffner detailed how the dopamine hypothesis of schizophrenia was intimately linked to the dopamine theory of antipsychotic drug action. Here, a related case is explored: the use of antidepressants' neurochemical effects to speculate about the pathophysiology of depression.This rationale was central to American psychiatrist Schildkraut's landmark article on the catecholamine hypothesis of affective disorders. Accordingly, (...) the paper's hypothesis—that depressions may relate to decreased... (shrink)

This article contends that the enterprise of neuroleptic drug treatment of schizophrenia is conceptually and clinically - though not economically - bankrupt. Although new drugs spur hope and reinforce the dominant treatment paradigm, evidence from reports published during the last five years in leading psychiatric journals suggests that psychopharmacologists do not know what are the optimal doses of the most widely-used neuroleptics; that most patients do not "respond" to neuroleptic treatment; that toxic effects are routinely misdiagnosed; that prescribing (...) guidelines may have no impact on actual prescription patterns; that claims that the popular "atypical" neuroleptic clozapine is free of extrapyramidal symptoms are completely false; and finally, that penetration of the double-blind in studies of the effectiveness of psychotropics over placebos may be a common occurrence. In the light of these findings, it is argued that the field is in crisis and that major, paradigmatic change is absolutely necessary. (shrink)

Should Students Take Smart Drugs? If this were a straightforward question, you would not be reading about it in a philosophy magazine. But you are, so it makes sense that we try to clarify the terms of the discussion before wading in too far. Unfortunately (or fortunately depending on how you look at it), when philosophers set out to de-obfuscate what look to be relatively forthright questions, things usually get more complicated rather than less: each of the operative terms (...) at stake in the question, ‘should students take smart drugs?’ opens us up onto larger debates about the nature of medicine, health, education, learning, and creativity as well as economic, political and social structures and norms. So, in a sense, a seemingly rather narrow question about a relatively peripheral issue in the education sector morphs into a much larger question about how we think about and value learning; what constitutes psychiatric illness and in what ways should we deal with it; and what sort of productivity should educational institutions like universities, but also secondary and even primary schools value and be oriented towards? (shrink)

Each year, millions of individuals in the United States are treated for a variety of serious medical conditions with prescription drugs whose therapeutic benefits are well known. The vast majority of these medications are used to treat medical and psychiatric illnesses. Generally, they are used as prescribed, and contribute to a better quality of life for persons suffering from debilitating or life-threatening disorders.The fact that a small portion of these medications is diverted by those who seek their psychoactive (...) effects raises the important policy issue: how to make drugs easily available for medical use while limiting access for purposes of abuse.Such a responsibility poses challenges very different from those of the so-called “war” on illicit drugs, because this control must be achieved without impeding patients’ access to medical care. A rational public policy would attempt to achieve a balance between the need to minimize abuse and the need to provide relief. (shrink)

The potential to instrumentalize drug use based upon the detection of very many different drug states undoubtedly exists, and such states may play a role in psychiatric and many other drug uses. Nevertheless, nonaddictive drug use is potentially more parsimoniously explained in terms of sensation seeking/impulsivity and drug expectations. Cultural factors also play a major role in nonaddictive drug use.

In the first work of investigative journalism in decades to give a comprehensive view into contemporary psychiatric incarceration and forced interventions, Your Consent Is Not Required exposes how rising numbers of people from many walks of life are being subjected against their will to surveillance, indefinite detention, and powerful tranquilizing drugs, restraints, seclusion, and electroshock.

In late May 1984, Irish citizens were perturbed to hear that a thirty-one year old man died while participating, as a paid volunteer, in a clinical drug trial at the Institute of Clinical Pharmacology in Dublin. At the inquest, held in September 1984, the State Pathologist, Dr John Harbison, affirmed that the cause of death was the reaction of the trial drug Eproxindine 4/0091 with a major tranquillizer which had been given less than fifteen hours earlier as part of regular (...) treatment for a psychiatric disorder. The mixture of the two drugs, he went on to say, increased their effect by between twenty and thirty times their normal strength, and the volunteer had died of cardiac depression. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:A Threat to Selfhood: Moral Distress and the Psychiatric Training CultureEsther NathansonWhile many medical specialties offer to heal, or even cure, psychiatry—uniquely—places the doctor–patient relationship at the center of the therapeutic effort. Psychiatrists must possess a complex and challenging combination of broad medical knowledge, finely honed interpersonal and analytic skills and confidence in their abilities, despite limited understanding of the workings of the brain. Inpatient psychiatry in particular (...) demands a degree of strength to withstand emotional, and sometimes physical, assault from patients who may be suicidal, desperate, paranoid, aggressive or delusional. Beyond these abilities, a good psychiatrist must have robust but ‘therapeutically porous’ emotional boundaries that allow genuine empathy for the patient but, at the same time, limit internalization of the patient’s anguish as the practitioner’s own: the exquisite balance of ‘self–versus–other’ in the therapeutic encounter.Unfortunately, during my psychiatry residency in the UK, development of these intangible but essential boundaries was entirely absent from the curriculum. Early in training I struggled with my tendency to become an emotional chameleon with feelings and energies buffeted around by the prevailing emotions of each patient that walked through the door. I felt that patients expected me to offer tidy explanations for their suffering and provide answers to profound questions of meaning; to make the world a safe and understandable place. Given the complexity of mental illness and its interplay with social circumstances this was naïve and, I now realize, often unnecessary, but the weight of responsibility was unbearable. I was also completely unprepared for the intensity of human suffering I saw, and wholly unready to provide the level of interpersonal engagement required for genuine healing. My own emotional integrity felt threatened by the depth of patients’ needs, and my response—both physical and emotional—was intense and frightening.Much of my distress resulted from the profound and inevitable tension between the empathy necessary to comprehend patients’ experiences, which were often extreme and bewildering, and the need for resilience and self–protection at a time when my grasp of psychological theories and treatment practices was still rudimentary. I felt guilty that patients bore the brunt of my inexperience, and duplicitous purporting to help while burdening them with intolerable drug side–effects and stigmatizing, albeit effective, treatments such as electroconvulsive therapy (ECT). Time constraints and guidance from senior faculty encouraged expediency over treatment efficacy or durability; psychopharmacology was prioritized over the psychotherapeutic techniques and psychosocial interventions I found more effective for many patients. During the phase of our training that took place in a rambling, now defunct, asylum in the U.K, visits to the locked ward, which was reserved for patients considered a danger to others, were usually prompted by nurses’ requests for chemical restraint, the ‘pharmaceutical strait–jacket’. I was deeply uncomfortable with the role of ‘restrainer’ but had insufficient experience or seniority to propose other methods. It was only when, years later, I investigated re–training in the U.S that the senior psychiatry resident at a well–known program told me gently, ‘Oh, we assume that students will have a breakdown in their first year, so we have systems in place to help’. I’ll never forget those words; they are, to this day, the only validation of the emotional toll of my early training years.Adding to my discomfort were various ethically dubious administrative practices, the most troubling being the clinic’s unwillingness to disclose to patients that we were trainees, with little clinical experience. Senior faculty were dismissive when I asked whether my first psychotherapy patient had been told I was a trainee, indeed that I had never conducted psychotherapy before. My question was greeted with amusement and an assurance that, although she had not been told, I (not the patient, interestingly) would do fine.Due to the large number of no–shows in psychiatric outpatient clinics it was also standard practice to triple–book appointment times on the [End Page 115] assumption that one or more patients would fail to attend. Not uncommonly, more than one patient would arrive for the same appointment, leaving others to suffer agonizing waits that were often intensified by the deep discomfort... (shrink)

In psychiatry, pharmacological drugs play an important experimental role in attempts to identify the neurobiological causes of mental disorders. Besides being developed in applied contexts as potential treatments for patients with mental disorders, pharmacological drugs play a crucial role in research contexts as experimental instruments that facilitate the formulation and revision of neurobiological theories of psychopathology. This paper examines the various epistemic functions that pharmacological drugs serve in the discovery, refinement, testing, and elaboration of neurobiological theories of (...) mental disorders. I articulate this thesis with reference to the history of antipsychotic drugs and the evolution of the dopamine hypothesis of schizophrenia in the second half of the twentieth century. I argue that interventions with psychiatric patients through the medium of antipsychotic drugs provide researchers with information and evidence about the neurobiological causes of schizophrenia. This analysis highlights the importance of pharmacological drugs as research tools in the generation of psychiatric knowledge and the dynamic relationship between practical and theoretical contexts in psychiatry. (shrink)

The new generation of psychopharmacological products have proved their efficacy. Some neuro-degenerative diseases, such as Parkinson's and Alzheimer's diseases, could be treated by means of the gene therapy. Although the aetiology of such diseases is still not completely known, it has been proven that the patients lack some substances that could be produced by means of the transfer of in vivo or ex vivo genes that codify them in the proper places of the brain. Furthermore, it is announced that the (...) implantation in laboratory grown stem cells of diverse origins is very hopeful. Cerebral (micro)electronic implants could be effective to fight some motor diseases as well as sensory functions. All of these kinds of new treatments need to be tested through clinical research. Most national legislation includes provisions on the clinical trials of drugs and a series of guarantees, procedures and conditions which are designed to ensure protection for individuals used in experiments and to assure that the trial is indeed of scientific relevance. However, few lay down similar regulations or provide for specific controls for the research of other treatments. Finally, enhancement of psychic capacities pose new problems for society as well as do the need for new legal decisions. (shrink)

Cannabis use in some individuals can meaningfully introduce de novo risk for the initiation of opioid use and development of opioid use disorder. These risks may be particularly high during adolescence when cannabis use may disrupt critical periods of neurodevelopment. Current research studying the combination of genetic and environmental factors involved in substance use disorders is poorly understood. More research is needed, particularly to identify which adolescents are most at risk and to develop effective interventions addressing contributing factors such as (...) trauma and psychiatric comorbidity. (shrink)

This article discusses the way how change in depressed patients included in clinical trials was both conceptualized and measured in the 1970s to decide on the efficacy of the first candidate drugs for the treatment of depression. Understanding how this issue was resolved is of major interest as the protocol designed to distinguish the diagnosis of the depressive syndrome from the measurement of its evolution over time built the contours of the methodological device to which the whole of standardized (...) evaluation in psychiatry has since referred. This paper draws on the debates in nascent psychopharmacology in both the United States and Europe and examines the protocols and findings of the research programs on depression the National Institute of Mental Health (NIMH) has developed in the United States at the same time, as well as on the writings of the main authors of the standardized evaluation. This investigation suggests that measurement of patients’ improvement could not be characterized on the basis of psychiatric inventories that were not well-suited to quantification, nor on the basis of psychometric tests which were intended for the evaluation of psychological invariants. This is why the answer given to the characterization of change in depression under therapy rather reveals a syncretism both conceptual and technical, mixing classificatory and psychometric traditions, a syncretism that the distinction endorsed by the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition,between syndromes and personality disorders no longer allows us to perceive. (shrink)

Advances in neuromodulation and an improved understanding of the anatomy and circuitry of psychopathology have led to a resurgence of interest in surgery for psychiatric disease. Clinical trials exploring deep brain stimulation (DBS), a focally targeted, adjustable and reversible form of neurosurgery, are being developed to address the use of this technology in highly selected patient populations. Psychiatric patients deemed eligible for surgical intervention, such as DBS, typically meet stringent inclusion criteria, including demonstrated severity, chronicity and a failure (...) of conventional therapy. Although a humanitarian device exemption by the US Food and Drug Administration exists for its use in obsessive-compulsive disorder, DBS remains a largely experimental treatment in the psychiatric context, with its use currently limited to clinical trials and investigative studies. The combination of a patient population at the limits of conventional therapy and a novel technology in a new indication poses interesting challenges to the informed consent process as it relates to clinical trial enrollment. These challenges can be divided into those that relate to the patient, their disease and the technology, with each illustrating how traditional conceptualisations of research consent may be inadequate in the surgical psychiatry context. With specific reference to risk analysis, patient autonomy, voluntariness and the duty of the clinician-researcher, this paper will discuss the unique challenges that clinical trials of surgery for refractory psychiatric disease present to the consent process. Recommendations are also made for an ethical approach to clinical trial consent acquisition in this unique patient population. (shrink)

Physicians who care for critically ill people with opioid use disorder frequently face medical, legal, and ethical questions related to the provision of life-saving medical care. We examine a complex medical case that illustrates these challenges in a person with relapsing injection drug use. We focus on a specific question: Is futility an appropriate and useful standard by which to determine provision of life-saving care to such individuals? If so, how should such determinations be made? If not, what alternative decisionmaking (...) framework exists? We determine that although futility has been historically utilized as a justification for withholding care in certain settings, it is not a useful standard to apply in cases involving people who use injection drugs for non-medical purposes. Instead, we are welladvised to explore each patient's situation in a holistic approach that includes the patient, family members, and care providers in the decision-making process. The scope of the problem illustrated demonstrates the urgent need to definitively improve outcomes in people who use injection drugs. Increasing access to high quality medication-assisted treatment and psychiatric care for individuals with opioid use disorder will help our patients achieve a sustained remission and allow us to reach this goal. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 10.3 (2003) 227-231 [Access article in PDF] World Traveling as a Clinical Methodology for Psychiatric Care Suzanne M. Jaeger Keywords embodiment, dialogical consciousness, interpersonal communication, epistemic responsibility, self-knowledge, understanding IN HER ARTICLE "Moral Tourists and World Travelers," Nancy Potter suggests a way in which psychiatrists and psychologists could gain a better understanding of their mentally ill patients' experiences. Rather than assuming that hallucinations and (...) incoherent speech and behavior are merely senseless disconnections from reality, Potter argues that mental health care clinicians ought to spend time engaging patients on their own terms. Even when mental illness is a result of brain disease, much can be learned about the patient's experiences of their disease by temporarily setting aside the scientific frameworks of diagnosis and medical treatment. Potter uses Maria Lugones' concept of world traveling and recommends playfully accepting, and even entering into the patient's world (Lugones 1990). She calls world traveling a methodology and explains it in some detail. Moreover, at the close of her essay, Potter suggests that clinicians have a moral obligation to understand the mentally ill patient's world from the patient's perspective. This obligation is based on an appeal to our sense of what it is to be a responsible knower who attends to issues of trust and truth. Relying on arguments made by Lorraine Code (1987), Potter asserts that to try to understand the other's perspective is the responsible thing to do.My discussion focuses on the notion of play to which Potter appeals, as well as on what she sees as the moral obligation of clinicians to communicate with their mentally ill patients in extra-professional ways. This moral obligation arises because (a) the theoretical and professional frameworks of medical science are seen as inadequate, and (b) playfulness opens up mutually respectful, authentic interaction between persons. I generally agree with Potter's claims, and I want to situate them in the wider framework of an epistemological debate about the status of our knowledge of others. A broader context will help to elucidate the strengths of Potter's analysis as well as some points for critical discussion. I begin with the relationship of trust between clinicians and patients.Few people would disagree with the claim that patients need to be able to trust that their physicians are not harming them, but helping them to get better. If patients feel misunderstood, they will not trust their caretakers. This is probably even truer for psychiatric patients, whose conditions and loss of autonomy make establishing trust even more challenging. Psychiatric patients [End Page 227] often have their own ways of compensating for the symptoms of their mental illness. If either their will to survive or their compensatory strategies go unrecognized or misinterpreted, patients may respond by rejecting the well-intentioned efforts of caretakers to restore them to a degree of ease, measured as it must be by the standards of the professionals under whose care the patient remains. 1 Despite the fact that these standards are established through scientific testing procedures for the treatment of diseases, they may be experienced by patients as indifferent to the particular and unique features of their condition. Nestled within the issue of trust is thus a question of truth.Although current scientific knowledge of the human brain, and of human behavior, has made available a range of sophisticated therapies and psychotropic drugs, there are still many mental illnesses that leave families and clinicians wondering whether the treatment plans are providing any help. Alzheimer's disease and schizophrenia are two examples. There is a difference between, on the one hand, containing the patient's behavior by admitting the patient to a psychiatric ward and managing symptoms with psychotropic medications, and, on the other hand, understanding what is happening for the patient, from his or her perspective. Although psychiatric patients may not have a realistic sense of either their abilities or the extent and nature of their disease, there may be much about their experiences that ought to be known and understood by the professionals caring for them... (shrink)

A literature search was conducted on studies of new drugs used with patients with schizophrenia reported by U.S. and non-U.S. researchers from 1966–1993, yielding 41 U.S., and a total of 24 other non-U.S. studies, among them 11 British studies. Results of the U.S. and non-U.S. studies were pooled separately and compared. Among several comparable conditions discussed, the lack of any data on suicides in the U.S. studies was observed. For a second statistical analysis of suicide rates ‘person-years’ were calculated (...) to adjust for differing washout durations. The results obtained include findings that the percentage of patients relapsing in U.S. studies was slightly lower than in non-U.S. studies ; the percentage of patients dropping out in U.S. studies was higher than in non-U.S. studies ; known location of dropout patients in U.S. studies was 1.7%, compared to 2.6% in non-U.S. studies. The most interesting finding was that no suicides were reported in U.S. studies, compared to 0.6% of patients reported in British studies. Some U.S. studies used ‘challenge doses’, such as amphetamines or L-dopa; no non-U.S. studies reported their use. Compared to U.S. studies, those by non-U.S., and particularly British, researchers appeared to report adverse events in their studies. ‘Challenge’ drugs were not used; suicides were reported. It is estimated that the probability that no patients suicided who participated in the U.S. is small—one in 500. (shrink)

This paper conducts a critical examination of the "usual psychopharmacology standards" for clinical research. Four main areas are inspected: What is "it" that is being treated in a clinical drug study? How much is really known concerning the psychological alterations brought about by psychiatric drug treatment? To what extent are sources of bias actually controlled for in "controlled" drug treatment studies? How does the usual "dropout pattern" influence the alleged "clinical findings" of controlled drug treatment studies? The overall conclusion (...) reached is that the "usual standards" cannot produce a realistic picture of either safety or efficacy. Conceptual and methodological reforms are suggested. (shrink)

Science fiction is fast becoming reality as scientists and engineers seek to develop new ways of directly accessing and controlling our brains through brain-computer and even brain-to-brain interfaces. If such research is to receive continuing public approval and support—and not invite opposition—it must anticipate the special ethical challenges it creates. By pointing to some of the acute concerns raised by neural engineering technologies—around issues of identity, normality, authority, responsibility, privacy, and justice—Eran Klein and colleagues model and stimulate the kind of (...) reflection that will be needed as new brain technologies are developed. And yet, as I read their informative discussion, I find myself asking even more questions. One concerns the ethical novelty of these technologies. For example, in terms of questions of identity, normality, responsibility, and authority, how different is deep brain stimulation from the potent psychiatric drugs that have been administered for decades? How different in terms of issues of liability associated with malfunction or misuse are brain-computer interfaces from other complex devices now routinely in use? Neither ethics nor law will have to rethink things from scratch as new neural devices and capabilities are introduced: the groundwork for answering some of these questions has already been laid in a variety of fields from bioethics, to health and product liability law. Nevertheless, I conclude that there are new questions here. It is not simply the fact that neural technologies pose questions of identity, privacy, and the like but that they do so with a degree of intensity that creates qualitatively new challenges. (shrink)

Neuroscience and psychiatry -- Psychotherapy and psychiatry -- Diagnosis in psychiatry -- The boundaries of mental disorders -- Mood and mental illness -- Psychiatry's problem children -- Evidence-based psychiatry -- Psychiatric drugs: miracles and limitations -- Talk therapies: the need for a unified method -- Psychiatry in practice -- Training psychiatrists -- Psychiatry and society -- The future of psychiatry.

There has been considerable debate about the ethical acceptability of using placebo-controls in clinical research. Although this debate has been rich in rhetoric, considering that much of this research is predicated upon the assumption that data from this research is vital to clinical decision-making, it is ironic that researchers have introduced little data into these discussions. Using some published research concerning the use of placebo-controls in clinical research in hypertension and psychiatric drug trials, I suggest some ways that such (...) data might be incorporated into the ethical analysis concerning placebo use in clinical trials. This approach promises to be important for enhancing conceptual and scientific understanding as well as public policy decision-making. (shrink)

Philosophers have long been involved in the pursuit of a goal shared by researchers in psychiatry and the cognitive sciences: understanding the relationship between the functioning of the human mind and human well-being or suffering. For this reason there is a very large area of overlap between philosophical and psychiatric research. The overlap is particularly significant in the domain of practical ethics, which is concerned with understanding the moral dimension of policies and actions in the real world. This chapter (...) reviews two distinct domains in which psychiatry and practical ethics overlap. First, issues in practical ethics arise out of new advances in psychopharmacology, including clinical and non-clinical use of new antidepressants drugs, the clinical use of placebo medications, and psychiatric drugs which enhance human cognition; these issues are frequently grouped under the banner of "neuroethics." Second, the understanding of fundamental questions in moral philosophy is being driven forward by evidence from psychology and psychiatry. Evidence from autism and the personality disorders is shedding light on the nature of moral motivation, while evidence from addiction and compulsion is generating progress in understanding moral responsibility. Finally, some areas are highlighted in which the science of psychiatry may benefit from the application of existing work in moral philosophy and practical ethics. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Lack of Autonomy: A View From the InsideSteve Weiner (bio)Keywordsagency, autonomy, deficit, determinismThe most vivid and truly overwhelming response I have to all arguments stressing agency/autonomy, that is, what lay people call free will, is this: that I’ve never had the sensation of acting autonomously since the onset of my mental illness on August 28, 1965. I have never been comfortable with saying that “I made a choice,” or (...) with other people either lecturing me or attempting to reassure me, often at the same time, by saying that I acted with autonomy/primary agency, as it were. That is my overwhelming subjective experience. I usually refrain from attempting to make a general case for determinism about myself or the universe in general, although, again, I feel far more determined than free. (I would note that Mary Midgley [2006] points out that the word determined and the concept, by extension, of determinism have two different meanings in say, social theory and geometry.)One strong criticism of this article I would put forward is that the Davidson and Shahan seemed to mention only depression among many diagnoses to make their case, although their French mentors/ co-thinkers apparently focused on schizophrenia, however unusually defined by them. In obsessive-compulsive disorder, we all have the very strong impression of the obsessive thoughts having been forced into our mind by something or someone else. My impression is that we all engage in our warding-off rituals, especially in the later, most frequent, most ritualistic repetitions, “against our will.”My most frequent diagnoses over the decades have been paranoid schizophrenia and schizoaffective disorder, and I more or less agree most of the time with those labels. I find Louis Sass’ “discovery” that our delusions are better thought of as semi-delusions with our simultaneously believing and not believing them, and our usual failure to take action on them, pretty well describes my own long-term experience. I know he is insistent on ascribing some degree of agency/whole personality involvement to us as compared with the standard National Alliance on Mental Illness/biological model, but I feel that he is getting closer to most of the “truth” when he talks about a subtle interweaving of affliction/deficit and agency.The authors’ reliance on French thinkers almost inevitably sends me back to a once-prominent French intellectual, one of my favorite writers Albert Memmi, the Tunisian-Jewish born socialist and Zionist. In a book that mentions The Story of O, (Memmi 1984) a story of extreme sexual submission or masochism, he makes the striking remark that the mentally ill are “oppressed from within.” I have spoken of this often because it seems to touch perfectly on my experience and that of fellow mentally ill people I have met. From the perspective of the outsider, it seems that the whole [End Page 237] and integrated person is involved in every behavior. What looks like agency to others, especially when it comes to undesirable behaviors, when experienced from within, is actually a situation of affliction from a seemingly autonomous place. We experience this as coming, yes, from within us, but not ultimately of us.I cannot be sure, but a belief in some degree of metaphysical choice from the beginning of one’s life seems to me the only way the authors of this article can firmly, enthusiastically come down on the side of agency as opposed to deficit/malfunction in trying to explain human problems. In contrast, I suppose I could be called a physicalist. I have noticed that physical substances (alcohol, caffeine, psychiatric drugs) have such a vivid and consistent effect on my mind that it makes sense to me to conclude that yes, mind is probably ultimately reducible to brain/body/experience of the senses. That is my private opinion based on experience as mediated through knowledge/intellect.One final point: Despite the (almost certainly) radical left politics of the authors, as an officially disabled person almost completely dependent on the welfare state, I fear that in competitive individualist America, the authors’ hoped-for far greater emphasis on autonomy will feed into popular “blame the victim” ideology. I believe... (shrink)

Psychiatric inpatients with capacity may be treated paternalistically under the Mental Health Act 1983. This violates bodily autonomy and causes potentially significant harm to health and moral status, both of which may be long-lasting. I suggest that such harms may extend to killing moral persons through the impact of psychotropic drugs on psychological connectedness. Unsurprisingly, existing legislation is overwhelmingly disliked by psychiatric inpatients, the majority of whom have capacity. I present four arguments for involuntary treatment: individual safety, (...) public safety, authentic wishes and protection of autonomy. I explore these through a case study: a patient with schizophrenia admitted to a psychiatric hospital under the Mental Health Act 1983 after an episode of self-poisoning. Through its discussion of preventative detention, the public safety argument articulates the (un)ethical underpinnings of the current position in English law. Ultimately, none of the four arguments are cogent—all fail to justify the current legal discrimination faced by psychiatric inpatients. I conclude against any use of involuntary treatment in psychiatric inpatients with capacity, endorsing the fusion approach where only psychiatric patients lacking capacity may be treated involuntarily. (shrink)

The way people come to report private stimulation arising within their own bodies is not well understood. Although the Darwinian assumption of biological continuity has been the basis of extensive animal modeling for many human biological and behavioral phenomena, few have attempted to model human communication based on private stimulation. This target article discusses such an animal model using concepts and methods derived from the study of discriminative stimulus effects of drugs and recent research on interanimal communication. We discuss (...) how humans acquire the capacity to identify and report private stimulation and we analyze intra- and interspecies differences in neurochemical mechanisms for transducing interoceptive stimuli, enzymatic and other metabolic factors, learning ability, and discrimination learning histories and their relation to psychiatric and developmental disabilities. (shrink)

In this paper, we examine the case of psychedelic medicine for Alzheimer’s disease and related dementias (AD/ADRD). These “mind-altering” drugs are not currently offered as treatments to persons with AD/ADRD, though there is growing interest in their use to treat underlying causes and associated psychiatric symptoms. We present a research agenda for examining the ethics of psychedelic medicine and research involving persons living with AD/ADRD, and offer preliminary analyses of six ethical issues: the impact of psychedelics on autonomy (...) and consent; the impact of “ego dissolution” on persons experiencing a pathology of self; how psychedelics might impact caregiving; the potential exploitation of patient desperation; institutional review boards’ orientation to psychedelic research; and methods to mitigate inequity. These ethical issues are magnified for AD/ADRD but bear broader relevance to psychedelic medicine and research in other clinical populations. (shrink)

Antipsychotic medications are sometimes imposed on psychiatric patients deemed dangerous to themselves and others. This is based on the assumption that treatment is safe and effective, and that recovery depends on biological adjustment. Under new laws, patients can be required to remain on these medications after leaving hospitals. However, survivors attest that forced treatment used as a restraint can feel like torture, while the consequences of withdrawal can also be severe.

ABSTRACTThis article engages Bhaskar's category of absence and Foucault's notion of problematization in the context of explaining an example of the historical emergence of political activism. Specifically, it considers the emergence of the ‘psychiatric survivors’ social movement in the UK, with a focus on the ‘politics of self-harm’. The politics of self-harm refers to acts of self-injurious behaviour, such as drug over-dosage or self-laceration, which do not result in death and which bring individuals to the attention of psychiatric (...) services. For many years survivors have protested about the harmful treatment they receive from such services and have campaigned for their reform and for new, non-psychiatric understandings of the meaning of self-harm. The article explains how such activism emerged in the late 1980s. Its contribution is at the interface of critical realism and social movement studies. (shrink)

What is the relationship between negative experience, artistic production, and prudential value? If it were true that (for some people) artistic creativity must be purchased at the price of negative experience (to be clear: currently no one knows whether this is true), what should we conclude about the value of such experiences? Are they worth it for the sake of art? The first part of this essay considers general questions about how to establish the positive extrinsic value of something intrinsically (...) negative. The second part emphasizes the importance of various distinctions within the realm of the negative. We must distinguish between adversity (which is non-mental) and negative mental states, and between negative thoughts (or attitudes) and negative affect. Within the realm of negative affect, we must distinguish between negative emotions and moods, on the one hand, and negative affective perspectives on the other, and then between mildly negative affective perspectives and severely negative ones (for which I reserve the term ‘suffering’). These distinctions matter greatly, since different types of negative experience have very different degrees of prudential disvalue. Although many types of negative experience may be “worth it”—because their positive extrinsic value outweighs their negative value—this is rarely true of severe suffering. (shrink)

Long-standing psychiatric practice confirms the pervasive use of pharmacological therapies for treating severe mental disorders. In many circumstances, drugs constitute the best allies of psychotherapeutic interventions. A robust scientific literature is oriented on finding the best strategies to improve therapeutic efficacy through different modes and timing of combined interventions. Nevertheless, we are far from triumphal therapeutic success. Despite the advances made by neuropsychiatry, this medical discipline remains lacking in terms of diagnostic and prognostic capabilities when compared to other (...) branches of medicine. An ethical principle remains as the guidance of therapeutic interventions: improving the quality of life for patients. Unfortunately, psychotropic drugs and psychotherapies do not always result in an efficient remission of symptoms. In this paper I corroborate the idea that therapists should provide drug-resistant patients with every effective and available treatment, even if some of such interventions could be invasive, like Electroconvulsive Therapy (ECT). ECT carries upon its shoulders a long and dramatic history that should be better investigated to provide new insights. In fact, ECT has attracted renewed interest in recent years. This is due to the fact that antidepressant drugs in younger patients show often scarce effectiveness and unpleasant side-effects. Moreover, I show that, thanks to modern advances, ECT may work as a successful form of treatment for specific and rare cases, such as severe depression (with suicide attempts) and catatonia. (shrink)

The enlarging domain of psychiatric intervention is frequently associated with the undue medicalization of unusual experiences. In such a climate, it becomes of utmost importance to carefully choose appropriate candidates for the psychiatric gaze. This suggests a need to draw a distinction between religious experiences (with psychotic form) and pathological psychotic experiences. As Jackson and Fulford (1997) maintain, “spiritual experiences, whether welcome or unwelcome, and whether or not they are psychotic in form, have nothing (directly) to do with (...) medicine. It would be quite wrong, then, to “treat” spiritual psychotic experiences with neuroleptic drugs, just as it is quite wrong to “treat” political .. (shrink)

Examines the use of drug therapy and other medical techniques to treat psychiatric illness, describing the major mental illnesses and discussing the effects of specific medications.

Ketamine is a dissociative drug that has been used medically since the 1970s primarily as an anesthetic agent but also for various psychiatric applications. Anecdotal reports and clinical research suggest substantial potential for ketamine as a treatment in conjunction with psychological interventions. Here, we review historical and modern approaches to the use of ketamine with psychotherapy, discuss the clinical relevance of ketamine’s acute psychoactive effects, propose a unique model for using esketamine with Acceptance and Commitment Therapy, and suggest considerations (...) for moving medication-assisted psychotherapy forward as a field. (shrink)