Ethical Issues in the Treatment of Depression

The psychiatrist should make which of the following initial clinical decisions in response to the patient’s request for discharge?

The psychiatrist orders several lab tests, including a urine toxicology screen; a complete blood count; an electrolytes panel; and liver, thyroid, and renal function tests. These tests reflect the psychiatrist’s adherence to which principle?

The patient’s wife arrives at his bedside as the psychiatrist is completing her interview with the patient. The patient’s wife asks, in front of her husband, if she can speak to the psychiatrist and share additional information about the patient before she leaves. What should the psychiatrist do next?

The answer is C. The patient does not wish to receive treatment; however, he clearly meets clinical criteria for a major depressive episode and continues to express self-harm intent. In this case, the physician’s duty of beneficence, which prioritizes treatment of depression, conflicts with the patient’s initial autonomous desire to end his life. The psychiatrist should explore this tension by providing appropriate education to the patient of his diagnosis and clinical options and exploring if the patient would accept voluntary hospitalization.

The answer is D. The psychiatrist has a duty to “first do no harm.” This encompasses the imperative to ensure that medical issues are not left untreated and that any treatment plan (e.g., pharmacotherapy) will take the patient’s medical issues into consideration and will not increase the risk of clinical harm.

The answer is A. The psychiatrist is respecting the duty of confidentiality toward the patient and seeks his permission prior to speaking with his wife. In some emergency situations, there may be legal protections for gathering clinical information without the patient’s direct consent. However, if the patient is conscious and cooperative, it would be prudent for the physician to ask the patient for permission to speak with his wife first.

The student’s PCP starts her on fluoxetine for treatment of a major depressive episode but does not inform her of the potential risk of increased suicidality with this pharmacologic treatment. What ethical principle does the PCP fail to uphold?

The patient takes fluoxetine at a therapeutic dose for eight weeks. She denies experiencing side effects, but she has not noticed any change in her mood or anxiety and reports no changes in her sleep, appetite, concentration, or energy level. She feels that she continues to struggle in school and social relationships. Her PCP notes that the patient was able to complete her semester with passing grades. What should the PCP do next?

The PCP recommends that the patient supplement her fluoxetine treatment with individual psychotherapy. The patient finds a psychotherapist in private practice and begins seeing her once a week. The patient begins to feel improvement in her mood after several weeks and tells the therapist she is going to stop her medication because she thinks that therapy has been more helpful. What should the therapist do next?

The answer is E. The PCP has an ethical obligation to disclose, as truthfully as possible, the risks of treatment to this patient. In 2007, the U.S. Food and Drug Administration updated the black box warning on antidepressant labels with a notice of elevated risk of suicidality among young adult users ages 18 to 24 years. Failure to inform the patient of this risk would be a threat to the physician’s duty of veracity.

The answer is C. The PCP should uphold fidelity to treatment goals and respect for the patient as clinical imperatives, which, in this case, means focusing on the patient’s chief complaint (depressed mood and anxiety) and her report of continued struggles in academic and social settings. It is possible that the patient may be so severely ill that she is unable to notice or appraise her symptomatic improvements; however, given her continued clinical distress, the PCP would be well advised to seek additional clinical or collateral information before making a recommendation to continue the current treatment plan. Exploring whether the patient is actually taking her medication would be a prudent first step, and assessing whether antidepressant dosing should be increased or augmented (with other pharmacological agents, psychosocial treatment methods, or both) would be a sensible approach.

The answer is D. By encouraging direct discussion with the PCP and deferring medication changes until then, the therapist is appropriately recognizing the professional limits of her practice and upholding professional boundaries of her therapeutic relationship with the patient.

Does the patient exhibit the decisional capacity to consent to this research trial?

Deep brain stimulation is an invasive procedure that carries the risk of severe physical damage to the brain. What ethical principles shape the physician’s decision to proceed with this novel interventional treatment for this patient? (Choose all that apply.)

The answer is A. The patient exhibits all four cardinal features of decisional capacity: the abilities to communicate a decision, understand the risks and benefits of treatment and nontreatment, appreciate the clinical situation, and rationalize the decision in a clear and coherent manner. Although the patient’s description of how deep brain stimulation works may not be completely accurate, it does not affect her capacity to make an informed decision to participate in the treatment. Furthermore, there is no evidence of a psychotic illness or severe cognitive distortion that would raise suspicion of impaired insight or judgment.

The answers are A, B, and E. The physician’s decision to proceed with this interventional procedure reflects respect for the duties of autonomy, beneficence, and nonmaleficence. Balancing the potential benefits and risks of a novel procedure in the context of the patient’s treatment history and her desire to proceed with the intervention are key components of the physician’s decision-making process.

The role of the psychiatrist as a consultant in this setting involves which of the following ethical tensions?

The psychiatrist meets the patient for an initial consultation. At the conclusion of the assessment, she discloses to the patient that his clinical needs do not require specialty mental health services, so he will be followed primarily by his primary care doctor, with peripheral engagement by mental health consultants. The patient expresses his desire to be followed by the psychiatrist for his mental health needs, because “the other doctor doesn’t have time for these problems.” What ethical conflict between patient autonomy and physician duty is being raised here?

The answer is C. For this patient, an ethical tension arises in confidentiality within the integrated care setting. The patient may not be aware that his clinical information has been disclosed to a psychiatrist who is acting in the capacity of a mental health consultant. Integrated care clinics may alleviate this tension by adopting several safeguards in practice, including obtaining informed consent from patients, obtaining separate release of information agreements for mental health information, and ensuring billing accuracy. In this case, there is no apparent tension yet in autonomy, justice, or fidelity, because these principles are expected to be upheld by the primary care doctor once she initiates the treatment discussion and plan with her patient.

The answer is C. The patient wishes to be seen by a mental health specialist even though his level of care is not severe enough to necessitate a formal referral. The patient’s desires therefore conflict with the psychiatrist’s obligation to distribute mental health resources in a fair and just manner across the clinic’s patient population.

In originally respecting the patient’s wish to pursue CBT instead of a medication, the primary care physician’s decision was primarily governed by which of the following ethical principles?

In agreeing with the patient that using a smartphone app, which did not have a clinical evidence base, was an acceptable substitute for treatment, the primary care physician may have compromised which of the following ethical principles?

What should the primary care physician have done instead when the patient offered to pursue CBT through an app instead of seeing an individual therapist?

The answer is A. Both CBT and antidepressants have good efficacy and fall within the standard of care for moderate depression. The principle of autonomy supports accommodating patient preference while fulfilling the standard of care.

The answer is E. Although mobile technologies offer many promising new clinical tools, many such smartphone apps still lack strong clinical data, such as information on risks and benefits. In this case, the primary care physician had not heard of CBT apps and thus was unsure about their efficacy and safety. Similar to how medications should be prescribed, recommending treatments such as mobile apps without appropriate clinical knowledge can risk harm to patients.

The answer is D. The primary care physician is respecting patient autonomy by openly discussing a treatment alternative in which the patient has expressed interest, in the same way a physician would discuss an unknown herbal or supplemental remedy in response to a patient’s inquiry. Because much is unknown about the clinical benefits, risks, safety, and privacy of most mobile apps, the primary care physician should raise these issues in an informed discussion with the patient prior to proceeding with any substitution. To fulfill the appropriate standard of care, the primary care physician should examine the app and judge whether use of the app aligns with treatment goals and expectations and, if so, how additional safeguards, such as increased communication with the patient between visits or increased frequency of visits, could protect against unforeseen consequences.