Ethical Issues in the Diagnosis and Treatment of Bipolar Disorders

Bipolar disorder is a common and disabling psychiatric disorder, with often complex presentations, and it overlaps with other (more) common conditions, such as other mood and anxiety disorders (e.g., posttraumatic stress disorder, major depressive disorder, attention-deficit/hyperactivity disorder [ADHD]), substance use disorders, and personality disorders (1–6). Its diagnosis, therefore, is sometimes fraught, delayed, or mistakenly made. Bipolar disorder typically arises in late adolescence, and its symptoms and demand for treatment manifest during early adulthood (7). Many people with the disorder have great difficulty finding treatments that are persistently successful in preventing relapses of the condition, and—from longitudinal studies of subjects treated for the disorder—high proportions of patients remain symptomatic regardless of treatment with multiple medications and psychotherapies (8).

The complexity of treating bipolar disorder is well known. Unlike major depressive disorder, in which the presentation is by definition one of depressive episodes and symptoms, bipolar disorder involves episodes of mania and hypomania, each with its specific criteria for severity and duration. Because of the cyclical nature of the illness and the disability, morbidity, and death (from suicide, accidents, violence, or medical illness) associated with severe episodes of both depression and mania, the goals for treatment are several-fold, but they include the aggressive treatment of acute episodes (with hospitalization, if necessary) and the continuation of maintenance therapies to prevent recurrence (9–13).

The treatments for acute depression and the prevention of its recurrence are generally different (with some overlap) from those for acute mania and its prevention. Hypomanic episodes in general and bipolar II disorder as a whole have limited pharmacotherapies with adequate data to recommend them; in fact, only one drug, quetiapine, is approved by the U.S. Food and Drug Administration (FDA) for any phase of bipolar II disorder (and even then, only for the treatment of acute depressive episodes associated with it). There are also specific differences in the risks and benefits of several core medications used in bipolar disorder for women (especially those of childbearing age) compared with men that complicate decision making in the clinic (14).

A number of psychotherapies are reasonably well studied in bipolar disorder (and in bipolar II disorder), with high acceptability, but these manualized therapies are limited in their general use, in part because few clinicians are familiar with or trained in their implementation (15). Psychoeducation—also a formal, manualized treatment with both group and individual versions—may have some benefit, although no specific intensive therapy has stood out when compared with other therapies of equivalent intensity. This often leaves clinicians at the edge of the evidence base, having to implement therapies not studied for the complexity or specific diagnostic characteristics of the patient in the office or to manage patients with complex pharmacological regimens.

Because of the intricacies of a diagnosis of bipolar disorder, the chronicity of treatment usually required for it, and the paucity of successful treatment strategies for a great portion of patients that are evidence based over the whole of the illness, it may frequently be the case that patients are treated with multiple pharmacological treatments that are used “off-label” for their specific indication, including novel therapeutics (16). It follows that people under treatment rely on their prescribers to help them choose treatments that may have a variety of potentially grave side effects and to balance those risks with the potential for benefit or the consequences of forgoing such interventions (17, 18). The intentions of practitioners both to do no harm and to treat their patients who have been diagnosed with bipolar disorder are usually good. However, there are ethical issues that may arise in the diagnosis of bipolar disorder itself; in the selection of treatment; and in the communication with the patient of the goals, potential benefits, and risks of treatment selection of which the careful clinician must be aware.

The ethical dilemmas posed by the exigencies of the clinic must be managed in terms of capacity to consent, the use of mandated treatment or hospitalization, discussion of comorbidities, and communication with the patient of the benefits and risks of treatments when the benefits are not well studied. The case outlined below illustrates several of the ethical dilemmas that commonly arise in evaluating and treating patients with bipolar disorders.

Case Illustration and Questions

Wanda B. is a 33-year-old single woman with a diagnosis of bipolar I disorder. She initially came into mental health treatment during her teens when her teachers became concerned because her grades dropped and she stopped handing in schoolwork. She was started on fluoxetine and apparently did well enough to graduate from high school and begin college. When she was 20 years old, in her junior year of college, she had a manic episode that required hospitalization against her will. She was started on divalproex sodium (titrated to 1,500 mg a day) and olanzapine (20 mg a day), and the fluoxetine was discontinued.

• 1. Which ethical principle is most likely to be violated by involuntary hospitalization?

  1. Beneficence

  2. Justice

  3. Nonmaleficence

  4. Autonomy

  5. Veracity

Ms. B. continued on these three medications after hospitalization but gained 40 pounds over the next year and stopped the olanzapine during her senior year in college. She still managed to graduate, but with significant depressive symptoms. She continued on divalproex sodium and fluoxetine. She understood reasons for the use of olanzapine for mania and bipolar disorder but reported that the potential for weight gain was not discussed with her during her hospitalization.

• 2. Many medications have side effects, and there are often multiple treatment options. Which of the following aspects of the informed consent process might not have been followed during Ms. B.’s hospitalization?

  1. Determination of capacity

  2. Discussion of FDA approval

  3. Discussion of benefits

  4. Discussion of risks

  5. Discussion of patient autonomy

When Ms. B began treatment this year with her current psychiatrist, she had been prescribed multiple trials of medications, including quetiapine up to 150 mg (too sedating to increase) and paroxetine up to 60 mg (no clear benefit). She currently smokes one-half to one pack per day of cigarettes and uses cannabis most nights “for sleep.” She has an intermittent employment history in spite of her educational level and is often sick from work but currently has a steady job. Her prior psychiatrist, she reports, told her that stopping cigarettes would destabilize her bipolar disorder and that he would continue to treat her only if she stopped using cannabis. She feels that the cannabis helps her sleep “better than any medication,” does not believe that it is making her mood symptoms worse, says she was “never manic on it,” and insists on continuing to use it.

• 3. What pair of ethical principles should guide a psychiatrist to assist with smoking cessation while continuing to provide care for a patient who is not completely following the provider’s recommendations?

  1. Beneficence and veracity

  2. Nonmaleficence and justice

  3. Justice and autonomy

  4. Veracity and justice

  5. Fidelity and autonomy

• 4. When understanding Ms. B’s decision to continue to use cannabis, which of the following aspects of her decision making should the psychiatrist most attend to?

  1. Expression of choice

  2. Understanding

  3. Reasoning

  4. Appreciation

Ms. B. states that she cannot “function” at work. She feels constantly distracted and unable to get her work done. She has a few residual depressive symptoms, such as feeling down on herself and wanting to spend nights home alone (when she previously went out socially with her friends). She states that she read an article on ADHD in a magazine and heard that a medication that “lasts all day” can help with ADHD, saying, “I really think I’ve had ADHD since I was a kid, but it hasn’t been diagnosed.” Her psychiatrist says that she wants to examine Ms. B.’s bipolar disorder treatment more carefully, review her sleep and medication side effects, and make sure she is on the optimal treatment for depression before starting any medications for a diagnosis of ADHD.

• 5. After multiple attempts at stabilization of depression, the psychiatrist decides that individual psychotherapy would be beneficial to the patient as a treatment for depression. The psychiatrist, however, has not had formal training in specific therapies with strong evidence for the treatment of bipolar disorder, although she practices cognitive-behavioral therapy (CBT) for depression with some of her patients. What is the most appropriate approach for the psychiatrist to take?

  1. Opt not to offer psychotherapy to the patient because the psychiatrist does not practice the evidence-based options.

  2. Inform the patient about the range of evidence-based psychotherapies for bipolar disorder and ask her to research possible treatment centers that offer it and choose one.

  3. Tell the patient that there are many evidence-based psychotherapies for bipolar disorder but that the psychiatrist can offer CBT to her on the basis of her understanding of CBT for depression.

  4. Help the patient download an app for bipolar disorder.

• 6. A prior psychiatrist continued to treat the patient with divalproex sodium and did not inform the patient that it might be responsible for her endocrine symptoms. The patient had never been treated with lithium for bipolar disorder, but the psychiatrist has never been comfortable with it so does not offer it as a treatment option. Which of the following ethical principles are being violated with this scenario?

  1. Justice and veracity

  2. Nonmaleficence and justice

  3. Autonomy and justice

  4. Veracity and nonmaleficence

Answers

1. The answer is D. The most likely ethical principle violated by involuntary hospitalization is autonomy, which is fundamentally breached in pursuit of the other mentioned ethical principles. The principle of justice concerns the equitable distribution of resources and power (which is not breached in this case). The principles of beneficence and nonmaleficence (which derive historically from a doctor-patient relationship long based on paternalism in the West) are upheld in this case, and the principle of veracity (from the information given in this case) is likely upheld, unless the patient was not given information about viable alternatives to treatment or otherwise might have chosen voluntary (rather than involuntary) hospitalization.

2. The answer is D. It is most likely, from this scenario, that the risks of treatment were not discussed with the patient. It is important that risks of treatments be openly discussed with patients as part of the informed consent process, even (or especially) if those risks might lead the patient to decide against such treatment. This is often difficult in an acute setting, where the provider may feel that stabilization of symptoms is more of a priority than giving full informed consent to a patient. In this case, the patient was clearly stabilized prior to discharge, and this discussion needed to occur. The discussion of FDA approval is most important to disclose if the treatment is not being used for an FDA-labeled indication but less so if it is (19). The benefits of treatment appear to have been disclosed. It is unclear whether a capacity determination was made, but the patient appears to have assented to the treatment. Although a discussion of autonomy might not have occurred, it is important in this case that the patient later denied being aware of a common side effect associated with olanzapine.

3. The answer is C. The ethical principles are justice and autonomy, which in this circumstance are linked. It is important in providing care to patients to ensure that care is provided equitably to those seeking it and that, as part of shared decision making, the patient can make independent choices regarding care and assert his or her independence. This is particularly difficult to follow in the setting of addictions and the behaviors attendant on them. The principle of justice is violated by the bias of the provider toward patients who use substances.

4. The answer is C. It is important, in the context of making a health care choice, to consider several aspects of decision making: understanding, reasoning, appreciation, and choice. In this case, the psychiatrist must assess the patient’s ability to understand what choices she is making, whether she can appreciate the choices available to her, and whether she can express a choice. In this case, the patient demonstrates her reasoning with regard to a decision with which the psychiatrist clearly does not agree. Given the disagreement, it is important that the psychiatrist undertake a thorough review of the patient’s reasoning with regard to her wish to stop smoking while continuing to use cannabis.

5. The answer is C. The correct answer to this difficult question is to explain what the evidence base is for psychotherapy for bipolar disorder and offer an available option, albeit one that is evidence based for major depression. The importance of balancing feasibility with availability means balancing the principles of veracity, beneficence, and autonomy. In this case, not offering any treatment, offering treatment with no evidence to support it, or only discussing treatments that would be unlikely to be available to the patient should be rejected in favor of offering the patient a choice of options, including one available by the psychiatrist (20).

6. The correct answer is D. In this case, the most correct answer is veracity and nonmaleficence. Veracity is violated in that the psychiatrist does not communicate with the patient that there are alternative treatments that might be beneficial (and that might be preferable to the offered treatment) because of the psychiatrist’s discomfort and lack of knowledge about one of them (lithium). Nonmaleficence is violated in that the psychiatrist does not share the potential risks of a given treatment, in this case the endocrine side effects of divalproex. Justice would be violated if the psychiatrist did not give all patients the same treatment options. Autonomy might be violated if the patient were not allowed to participate in decision making—but in this case the patient was not given the options at all (20).