Ethical Issues in the Evaluation and Treatment of Depression

Clinical assessments for patients experiencing depression constitute one of the most common scenarios for psychiatrists practicing today. In fact, depressive disorders are estimated to affect more than 12% of Americans during their lifetimes, contributing to impairments in functional status and quality of life, in addition to costing the U.S. economy more than $43 billion annually (1, 2).

The term depression, first appearing in the late 1600s, stems from the classical Latin verb deprimere, which translates literally as “to press down,” denoting a sensation of heaviness that one may feel when plagued by a sustained sad or “down” mood (3). When persistent low mood, loss of interest in activities, or both combine with other unremitting depressive symptoms, such as change in appetite, low energy, sleep difficulty, psychomotor fluctuation, feelings of worthlessness, poor concentration, or suicidal thoughts, a patient may be so impaired as to meet criteria for major depressive disorder (4). Depressive symptoms also factor into diagnoses such as bipolar I and II disorders, anxiety disorders, substance-induced mood disorders, and somatic symptom and related disorders.

Mainstay treatments for depression include pharmacologic therapy with antidepressant and augmenting agents, psychotherapy for patients with mild to moderate depression, and electroconvulsive therapy (ECT) for patients who are acutely psychotic, extremely suicidal, or unable to take medications (1). Newer treatments include transcranial magnetic stimulation, vagus nerve stimulation, ketamine, and other NMDA (N-methyl-d-aspartate) antagonists aimed at targeting patients who might be initially categorized as treatment resistant (1, 5). Although the risk of relapse always lingers, properly treated depression helps patients to experience relief of symptoms and to resume active and fulfilling lives (5).

The prevalence of depressive symptoms and the variety of available management options make the ethical considerations surrounding the evaluation and treatment of depression particularly compelling. These ethical imperatives include respect for law, beneficence, compassion, nonmaleficence, justice, veracity or honesty, confidentiality or privacy, fidelity, altruism, autonomy, and integrity (6, 7). This article aims to engage readers in an examination of some of the contexts in which these ethical principles may be encountered in common practice settings.

Case Illustration 1

Jeremy Saunders, a 19-year-old college student on vacation for spring break, is visiting his aunt, Dr. Rebecca Saunders. Dr. Saunders recently graduated from residency training and now practices full time as a psychiatrist at the local hospital in Miami. One morning over coffee, Jeremy confides to his aunt that he has been “in a funk” for quite some time. He relates that he is often unable to get out of bed before noon and that he rarely leaves the dorm when at school. Jeremy misses many of his classes and recently failed two midterm examinations. In addition, socializing with friends is increasingly difficult because he is “afraid of bringing everybody down” with his sad mood. Jeremy’s appetite has decreased significantly during this time, and he describes the idea of food as having become “nauseating.” Even activities that used to interest him, such as composing lyrics, are no longer enjoyable. Jeremy states that he does not feel comfortable telling anyone else about his feelings. He hopes that now that his aunt has her medical license, she can prescribe a medication to help Jeremy “get back on track and complete the semester.” On further reflection, Dr. Saunders notes that her nephew seems to have lost weight since she last saw him a year ago and that he is having difficulty focusing on nightly chess games, which they used to enjoy together. She is concerned that her nephew might be experiencing a major depressive episode.

1.1 Which of the following ethical principles supports Dr. Saunders’ decision not to treat her nephew despite her concerns?

1. Respect for law

2. Autonomy

3. Integrity

4. Justice

The case continues.

Jeremy returns to school a week later, and, at his aunt’s urging, he makes an appointment to speak with Dr. Eric Percy, a psychiatrist whose office is close to campus. In addition to describing the symptoms that he told his aunt, Jeremy reveals that he has felt for some time that his “life is worthless” and that he frequently wonders “why I’m even here . . . why my parents brought such a failure into the world in the first place.” He quickly adds “Don’t worry—this isn’t a big deal.” Jeremy explains that he does not want his mother to know how he feels about his life because “it will only freak her out, and she has enough stress as it is, being a single mom and all.” Dr. Percy persuades Jeremy to let his mother join them for a family meeting at their next session, and while he encourages Jeremy to share his struggles at that time, he assures him that it will remain Jeremy’s decision how much to reveal.

1.2 Which of the following ethical considerations inform the psychiatrist’s determination not to disclose Jeremy’s expressions of worthlessness to his mother?

1. Autonomy and confidentiality

2. Justice and integrity

3. Honesty and altruism

4. Nonmaleficence and respect for law

The case continues.

At the family meeting, 2 weeks later, Jeremy divulges to his mother that he often wonders “why he has been put on this earth” and questions the value of continuing to be alive. Jeremy’s mother becomes extremely upset, says that her son is “obviously suicidal,” lacks anyone to look after him at the college dorm, and urges Dr. Percy to consider inpatient hospitalization. Jeremy confides that he sometimes fantasizes about driving into traffic and “ending it all” but that he has never actually tried to harm himself, and the last time he had one of these fantasies was before he started seeing Dr. Percy. Although Jeremy is agreeable to continuing to see Dr. Percy as an outpatient, he does not want to come into the hospital.

1.3 Which of the following statements is accurate regarding Jeremy’s mother’s request for his admission to the psychiatric hospital at this time?

1. Jeremy should be admitted involuntarily to the hospital because he is likely suffering from a major depressive episode and thus is unable to make his own medical decisions because of his impaired judgment.

2. Jeremy should be admitted involuntarily to the hospital because of his mother’s altruistic concerns about his safety if left unsupervised on campus.

3. Jeremy was truthful in his statement that he does not want to come into the hospital; therefore, admitting him as a voluntary patient would be in contradiction to the ethical principle of respect for Jeremy’s honesty.

4. Jeremy can be admitted to the hospital voluntarily if he changes his mind, but he could also continue to see Dr. Percy as an outpatient after a thorough suicide safety plan is developed.

The case continues.

After a brief stay in the hospital, Jeremy is discharged home with a prescription for fluoxetine. At a follow-up appointment with Dr. Percy, Jeremy endorses improvement in his depressive symptoms. However, he complains that he is now experiencing daily headaches and difficulty having sexual intercourse with his girlfriend, whom he describes as “the only positive thing” in his life. Jeremy wants to stop taking fluoxetine immediately and is averse to starting another medication. Dr. Percy is aware that acknowledging fluoxetine’s possible side effects might lead his patient to discontinue medication management for his depression. Nevertheless, Dr. Percy engages in a thorough review of the risks of taking fluoxetine and other medications in the selective serotonin reuptake inhibitor class.

1.4 Dr. Percy’s discussion with Jeremy about fluoxetine’s side effect profile is required by which of the following ethical principles?

1. Justice

2. Veracity

3. Fidelity

4. Nonmaleficence

Case Illustration 2

Evelyn Kohler, a 32-year-old woman working as an administrative assistant, arrives for an initial appointment with Dr. Weber, a psychiatrist who specializes in ECT. Evelyn has no prior history of depression diagnosis or treatment but reports that she recently came across the Facebook post of a close friend, Betsy, who underwent ECT during an inpatient hospital stay for severe major depressive disorder. Betsy’s post expressed extreme gratitude for the availability of this treatment and reported that it “worked wonders” for Betsy’s “sex life and overall mood.” Evelyn tells Dr. Weber that she is “intent” on trying ECT herself because her own mood has been “a little down lately” after moving to a new city and struggling to maintain a long-distance relationship with her boyfriend of 4 years. Dr. Weber conducts a depression screen and inquires about Evelyn’s daily routine. Evelyn feels guilty that she has less time to spend with her boyfriend after the move but otherwise does not report any concerning changes in appetite, sleep patterns, or energy level. Evelyn likewise denies any feelings of worthlessness or hopelessness and when asked about suicidal thoughts states, “What me? Thinking about ending my life? Never!” Throughout the session, Evelyn becomes increasingly demanding that she be considered a candidate for ECT because, “I am hurting just as much as Betsy!” Although Dr. Weber sympathizes with Evelyn’s recent challenges, he explains that ECT would not be an appropriate treatment for her at this time and instead refers her to his colleague for consideration of initiating psychotherapy.

2.1 Dr. Weber’s decision not to treat Evelyn with ECT despite her pleas is grounded in which of the following ethical precepts?

1. Justice and respect for law

2. Integrity and nonmaleficence

3. Fidelity and autonomy

4. Compassion and confidentiality

The case continues.

Several months later, Evelyn’s younger sister Jane, who is 25 years old and 5 months pregnant with her first child, comes to see Dr. Weber on Evelyn’s recommendation. Jane reports that she is feeling scared and isolated, crying “every day for the past 3 months” since learning of her pregnancy. Jane can barely sleep and does not want to be around friends and family. She ultimately confides that she is thinking about ending her life by overdosing on acetaminophen, which she recently purchased at a local pharmacy and keeps at her bedside “just in case.” Jane expresses a worry that taking antidepressant medications during pregnancy will “irreversibly harm the baby,” and Dr. Weber recommends ECT as an alternative first-line treatment that is safe in pregnancy (8).

2.2 Which of the following ethical principles underlie Dr. Weber’s recommendation that Jane undergo treatment with ECT?

1. Beneficence and autonomy

2. Altruism and justice

3. Compassion and honesty

4. Fidelity and privacy

The case continues.

Toward the end of the session, Dr. Weber notices some significant bruising on Jane’s upper right arm, and he asks Jane about what happened. Jane tearfully confides that the pregnancy and her depression have been very stressful on her marriage. She states that sometimes her husband loses his temper and can be “a little rough.” Jane continues, “He’s a great man, and I’m sure he’ll be a great father. He does get angry but always apologizes and says he doesn’t mean it.” Dr. Weber practices in a jurisdiction that requires mandated reporting of suspected intimate partner violence.

2.3 Which of the following ethical considerations is essential to Dr. Weber’s decision to report Jane’s husband to the appropriate authorities for suspected abuse?

1. Confidentiality

2. Justice

3. Respect for law

4. Veracity

2.4–2.7 Match the following actions by the psychiatrist with the most relevant ethical principle (each term may only be used once):

1. Compassion

2. Honesty

3. Beneficence

4. Justice

___ 2.4 Dr. Weber applies a sliding scale to determine Jane’s ECT treatment costs after she explains that paying the rate determined by her insurance company would pose a financial hardship.

___ 2.5 Dr. Weber refers Jane to a colleague to discuss whether the addition of psychotherapy might be helpful to her overall treatment course.

___ 2.6 After Jane’s visit, Dr. Weber spends 30 minutes on the phone with Evelyn listening to her concerns about Jane and providing support despite being unable to reveal what was discussed without Jane’s permission.

___ 2.7 Dr. Weber tells Jane that he must report her husband for suspected physical abuse despite her continued protestations that this step is not necessary and that her husband can change on his own.

Answers

• 1.1 The answer is C. In declining to treat her nephew, Dr. Saunders adheres to the ideals of professionalism inherent in the principle of integrity. As laid out by the American Medical Association’s Code of Medical Ethics, physicians who provide treatment to a close relative risk compromising the precepts of professional objectivity, patient autonomy, and informed consent (9).

• 1.2 The answer is A. In respecting Jeremy’s wishes not to tell his mother about his feelings of worthlessness, Dr. Percy honors Jeremy’s capacity to make his own decisions and act accordingly (autonomy). Furthermore, Dr. Percy respects Jeremy’s right to confidentiality by not disclosing the details of their session without Jeremy’s permission.

• 1.3 The answer is D. In this scenario, Jeremy does not appear to be eligible for involuntary admission, as he currently denies having active suicidal thoughts (while willing to continue in outpatient treatment), and there is no evidence of him being in danger of harming others or not being able to take care of himself outside of the hospital. However, in the event that Jeremy changes his mind, he may benefit from voluntary admission to address his worsening depressive symptoms. Answer choice A is incorrect because Jeremy’s diagnosis of mental illness is not, by itself, determinative as to whether he has the capacity to make his own medical decisions. Answer choice B is incorrect because Jeremy’s mother’s concerns are not sufficient to require his hospitalization absent his meeting independent criteria for an involuntary legalhold. Although Jeremy’s truthfulness may be valuable in establishing a therapeutic alliance with Dr. Percy, it bears no relevance to whether he may be eligible for a voluntary admission (answer choice: C).

• 1.4 The answer is B. Dr. Percy’s explanation of fluoxetine’s side effect profile is consistent with the ethical imperative to be truthful to one’s patients even when that truthfulness has the potential to place a provider in a challenging situation. For example, in this case, Dr. Percy may feel that Jeremy should continue what appears to be a beneficial treatment for his depression and fear that knowledge of side effects would dissuade Jeremy from doing so.

• 2.1 The answer is B. Administering a treatment that is not medically indicated and risks harmful effects contravenes the ethical principle of nonmaleficence. Dr. Weber’s integrity would additionally be compromised in adhering to Evelyn’s requests simply because of her insistence.

• 2.2 The answer is A. Not only is ECT Jane’s preferred course of treatment, but its implementation would also be beneficial in treating her depression given Jane’s unwillingness to consider medication alternatives.

• 2.3 The answer is C. When practicing in a state that mandates reporting of suspected intimate partner violence, the psychiatrist has an obligation to comply with the requirements of the law regardless of his personal judgment or the patient’s explicit preference.

• 2.4 The answer is D. The ethical principle of justice dictates that there should be fairness in the distribution of benefits and burdens among patients. In allowing Jane and other patients experiencing financial hardship to pay with a sliding scale, Dr. Weber is ensuring equal access to crucial psychiatric treatment such as ECT.

• 2.5 The answer is C. In thinking about additional options to enhance Jane’s care and referring her to a colleague to further assist in that care, Dr. Weber is acting to provide the greatest benefit to his patient in a manner consistent with clinical excellence.

• 2.6 The answer is A. Dr. Weber spends time on the phone comforting Evelyn despite the fact that she is not his patient and he does not have Jane’s permission to reveal the details of her care. His behavior is thus in accordance with the ethical principle of compassion, which recognizes the experience of another person and compels a physician to act with kindness and regard for that person’s welfare.

• 2.7 The answer is B. The ethical imperative of honesty values the virtue in truthfulness, which Dr. Weber uses in telling Jane that he will report her husband for suspected abuse even though the discussion will be difficult to have, given Jane’s feelings.