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Find video protocols related to scientific articles indexed in Pubmed.
Hall v. Florida: defining intellectual disability in the shadow of the death penalty.
Psychiatr Serv
PUBLISHED: 10-02-2014
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When the U.S. Supreme Court held that persons with mental retardation (now called intellectual disability) could not be sentenced to death, it left the question of how to define the condition to the states. That issue was raised in Hall v. Florida, which challenged one state's "bright-line rule" barring consideration of defendants with IQs over 70. In an endorsement of the professional consensus, the justices ruled that a more flexible approach that takes into account both intellectual and adaptive functioning is required. The Court's posture may bode well for its acceptance of mental health expertise in future cases.
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The challenge of informed consent and return of results in translational genomics: empirical analysis and recommendations.
J Law Med Ethics
PUBLISHED: 09-30-2014
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As exome and genome sequencing move into clinical application, questions surround how to elicit consent and handle potential return of individual genomic results. This study analyzes nine consent forms used in NIH-funded sequencing studies. Content analysis reveals considerable heterogeneity, including in defining results that may be returned, identifying potential benefits and risks of return, protecting privacy, addressing placement of results in the medical record, and data-sharing. In response to lack of consensus, we offer recommendations.
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Using research evidence to reframe the policy debate around mental illness and guns: process and recommendations.
Am J Public Health
PUBLISHED: 09-11-2014
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Recent mass shootings have prompted a national dialogue around mental illness and gun policy. To advance an evidence-informed policy agenda on this controversial issue, we formed a consortium of national gun violence prevention and mental health experts. The consortium agreed on a guiding principle for future policy recommendations: restricting firearm access on the basis of certain dangerous behaviors is supported by the evidence; restricting access on the basis of mental illness diagnoses is not. We describe the group's process and recommendations.
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Views of preimplantation genetic diagnosis among psychiatrists and neurologists.
J Reprod Med
PUBLISHED: 08-08-2014
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To examine key aspects of neurologists' and psychiatrists' views and approaches regarding prenatal genetic testing (GT) and preimplantation genetic diagnosis (PGD).
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Psychiatrists' views of the genetic bases of mental disorders and behavioral traits and their use of genetic tests.
J. Nerv. Ment. Dis.
PUBLISHED: 06-17-2014
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We examined how 372 psychiatrists view genetic aspects of mental disorders and behaviors and use genetic tests (GTs). Most thought that the genetic contribution was moderate/high for bipolar disorder, schizophrenia, depression, Alzheimer's, intelligence, creativity, anxiety, and suicidality. In the past 6 months, 14.1% ordered GTs, 18.3% discussed prenatal testing with patients, 36.0% initiated discussions about other GTs, 41.6% had patients ask about GTs, and 5.3% excluded GT results from patient records. Many thought that GTs; were available for schizophrenia (24.3%) and major depression (19.6%). Women were more likely to report that patients asked about GTs; and were less certain about the degree of genetic contribution to several disorders. Psychiatrists perceive strong genetic bases for numerous disorders and traits, and many have discussed and ordered tests for GTs, but have relatively limited knowledge about available tests. These data suggest possible sex differences in psychiatrists' beliefs about genetic contributions to disorders and have implications for future research, education, policy, and care.
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Models of consent to return of incidental findings in genomic research.
Hastings Cent Rep
PUBLISHED: 06-11-2014
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Genomic research-including whole genome sequencing and whole exome sequencing-has a growing presence in contemporary biomedical investigation. The capacity of sequencing techniques to generate results that go beyond the primary aims of the research-historically referred to as "incidental findings"-has generated considerable discussion as to how this information should be handled-that is, whether incidental results should be returned, and if so, which ones.Federal regulations governing most human subjects research in the United States require the disclosure of "the procedures to be followed" in the research as part of the informed consent process. It seems reasonable to assume-and indeed, many commentators have concluded-that genomic investigators will be expected to inform participants about, among other procedures, the prospect that incidental findings will become available and the mechanisms for dealing with them. Investigators, most of whom will not have dealt with these issues before, will face considerable challenges in framing meaningful disclosures for research participants.To help in this task, we undertook to identify the elements that should be included in the informed consent process related to incidental findings. We did this by surveying a large number of genomic researchers (n = 241) and by conducting in-depth interviews with a smaller number of researchers (n = 28) and genomic research participants (n = 20). Based on these findings, it seems clear to us that routine approaches to informed consent are not likely to be effective in genomic research in which the prospect of incidental findings exists. Ensuring that participants' decisions are informed and meaningful will require innovative approaches to dealing with the consent issue. We have identified four prototypical models of a consent process for return of incidental findings.
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The double helix takes the witness stand: behavioral and neuropsychiatric genetics in court.
Neuron
PUBLISHED: 06-09-2014
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Data on neuropsychiatric and behavioral genetics have attracted legal interest, as attorneys explore their use in criminal and civil cases. These developments may assist judges and juries in making difficult judgments-but they bring substantial risk of misinterpretation and misuse.
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Attitudes towards cannabis use and genetic testing for schizophrenia.
Early Interv Psychiatry
PUBLISHED: 04-29-2014
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Within schizophrenia, genetic factors contribute greatly to risk, yet genetic testing for the disorder is not available. For some individuals with specific genotypes, cannabis use may increase risk of schizophrenia. It is possible that genetic tests could be offered in the future to inform individuals of the risk of schizophrenia if they use cannabis. Previous research, however, provides little guidance on how young adults might respond to such tests.
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The translational potential of research on the ethical, legal, and social implications of genomics.
Genet. Med.
PUBLISHED: 03-24-2014
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Federally funded research on the ethical, legal, and social implications (ELSI) of genomics includes a programmatic charge to consider policy-relevant questions and to communicate findings in venues that help inform the policy-making process. In addressing this goal, investigators must consider the range of policies that are relevant to human genetics; how foundational research in bioethics, law, and the social sciences might inform those policies; and the potential professional issues that this translational imperative raises for ELSI investigators. We review these questions in light of experiences from a consortium of federally funded Centers of Excellence in ELSI Research, and offer a set of policy recommendations for program design and evaluation of ELSI research. We conclude that it would be a mistake to require that ELSI research programs demonstrate a direct impact on science or health policy; however, ELSI researchers can take steps to increase the relevance of their work to policy makers. Similarly, funders of ELSI research who are concerned with facilitating policy development can help by building cross-disciplinary translational research capacities, and universities can take steps to make policy-relevant research more rewarding for scholars in the humanities, social sciences, and law.Genet Med advance online publication 19 June 2014Genetics in Medicine (2014); doi:10.1038/gim.2014.74.
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Impact of behavioral genetic evidence on the adjudication of criminal behavior.
J. Am. Acad. Psychiatry Law
PUBLISHED: 03-13-2014
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Recent advances in behavioral genetics suggest a modest relationship among certain gene variants, early childhood experiences, and criminal behavior. Although scientific research examining this link is still at an early stage, genetic data are already being introduced in criminal trials. However, the extent to which such evidence is likely to affect jurors' decisions has not been explored. In the present study, a representative sample of the U.S. population (n = 250) received a vignette describing an apparently impulsive homicide, accompanied by one of four explanations of the defendant's impulsivity: childhood abuse, genetic predisposition, childhood abuse and genetic predisposition, or simple impulsive behavior. The participants were asked to identify the crime that the defendant had committed and to select an appropriate sentence range. Evidence of genetic predisposition did not affect the crime of which the defendant was convicted or the sentence. However, participants who received the abuse or genetic + abuse explanation imposed longer prison sentences. Paradoxically, the genetic and genetic + abuse conditions engendered the greatest fear of the defendant. These findings should allay concerns that genetic evidence in criminal adjudications will be overly persuasive to jurors, but should raise questions about the impact of genetic attributions on perceptions of dangerousness.
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Impact of Behavioral Genetic Evidence on the Perceptions and Dispositions of Child Abuse Victims.
Public Health Genomics
PUBLISHED: 01-30-2014
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Background: Behavioral genetic research is beginning to elucidate some of the genetic contributions to human behaviors - including criminal and other problematic behaviors - and their interactions with environmental influences. One of the most studied of these interactions involves low-activity alleles of the monoamine oxidase A (MAOA) gene, which appear to increase the risk of antisocial behavior among males in the wake of childhood maltreatment. Some scholars have suggested that decisions about disposition of child abuse victims should be shaped by these findings, but the extent of public support for such approaches has not been assessed. Methods: In this study, a representative sample of the US population (n = 250) was presented with a vignette about a child, physically abused by his mother, who was tested for the presence of an allele that increases the risk of future impulsive violent behavior. Participants were asked about their views regarding the child's disposition, including return to his mother, and medical or psychological treatment. Results: Although participants thought that genetic data should be taken into account, the presence of an allele that increases the risk of impulsive violent behavior did not affect views regarding the child's return to his mother. However, it did increase respondents' willingness to provide the child with medical treatment and their view of the child as dangerous to other children. Conclusions: The findings suggest that behavioral genetic evidence has effects on perceptions of dangerousness and tendencies to view problems as medical but that the public is cautious about the use of genetic findings in child abuse adjudications. © 2014 S. Karger AG, Basel.
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Law and psychiatry: regulating psychotherapy or restricting freedom of speech? California's ban on sexual orientation change efforts.
Psychiatr Serv
PUBLISHED: 01-03-2014
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California's new law banning sexual orientation change efforts by licensed therapists for patients under 18 immediately provoked court challenges. Therapists, parents, and patients argued that the statute infringed constitutional rights to freedom of speech and parental rights to select treatments for their children. The U.S. Court of Appeals for the Ninth Circuit rejected all of these claims in a unanimous decision upholding the law. However, the decision evokes concerns that other forms of psychotherapy could be subject to similar regulation. Tort remedies may provide less intrusive means for discouraging use of ineffective and potentially harmful therapies.
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Law & psychiatry: Does the constitution require an insanity defense?
Psychiatr Serv
PUBLISHED: 10-02-2013
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Idaho is one of four states that have abolished the insanity defense. Hence, John Delling, on trial for two murders in Idaho, was unable to plead insanity or to argue that he lacked intent to kill, the only available option under Idaho law. After being sentenced to life in prison without parole, Delling challenged the constitutionality of Idahos law. The states supreme court rejected his appeal, holding that--despite the long history of the insanity defense and its widespread acceptance--there was no constitutional right to an insanity defense. Dellings petition to the U.S. Supreme Court was turned away, leaving the constitutional status of the insanity defense uncertain.
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Participants with schizophrenia retain the information necessary for informed consent during clinical trials.
J Clin Psychiatry
PUBLISHED: 07-12-2013
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Cognitive impairment is a characteristic of schizophrenia. This impairment may affect the retention of information required for ongoing knowledgeable participation in clinical trials. This study monitored retention of study-related knowledge-including assessment of therapeutic misconception-in people with stable, DSM-IV schizophrenia during participation in placebo-controlled clinical trials of adjunctive agents. Stability was defined as being on an antipsychotic with no change in medication or dose over the previous 4 weeks.
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Use of Genetic Tests among Neurologists and Psychiatrists: Knowledge, Attitudes, Behaviors, and Needs for Training.
J Genet Couns
PUBLISHED: 06-12-2013
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This study explores neurologists and psychiatrists knowledge, attitudes, and practices concerning genetic tests. Psychiatrists (n?=?5,316) and neurologists (n?=?2,167) on the American Medical Association master list who had agreed to receive surveys were sent an email link to a survey about their attitudes and practices regarding genetic testing; 372 psychiatrists and 163 neurologists responded. A higher proportion of neurologists (74 %) than psychiatrists (14 %) who responded to the survey had ordered genetic testing in the past 6 months. Overall, most respondents thought that genetic tests should be performed more frequently, but almost half believed genetic tests could harm patients psychologically and considered legal protections inadequate. Almost half of neurologists (49 %) and over 75 % of psychiatrists did not have a genetics professional to whom to refer patients; those who had ordered genetic tests were more likely than those who did not do so to have access to a genetic counselor. Of respondents, 10 % had received patient requests not to document genetic information and 15 % had received inquiries about direct-to-consumer genetic testing. Neurologists reported themselves to be relatively more experienced and knowledgeable about genetics than psychiatrists. These data, the first to examine several important issues concerning knowledge, attitudes and behaviors of neurologists and psychiatrists regarding genetic tests, have important implications for future practice, research, and education.
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Computerized assessment of competence-related abilities in living liver donors: the Adult-to-Adult Living Donor Liver Transplantation Cohort Study.
Clin Transplant
PUBLISHED: 06-04-2013
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Despite its importance, determination of competence to consent to organ donation varies widely based on local standards. We piloted a new tool to aid transplant centers in donor assessment.
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Processes and factors involved in decisions regarding return of incidental genomic findings in research.
Genet. Med.
PUBLISHED: 05-21-2013
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Purpose:Studies have begun exploring whether researchers should return incidental findings in genomic studies, and if so, which findings should be returned; however, how researchers make these decisions-the processes and factors involved-has remained largely unexplored.Methods:We interviewed 28 genomics researchers in-depth about their experiences and views concerning the return of incidental findings.Results:Researchers often struggle with questions concerning which incidental findings to return and how to make those decisions. Multiple factors shape their views, including information about the gene variant (e.g., pathogenicity and disease characteristics), concerns about participants well-being and researcher responsibility, and input from external entities. Researchers weigh the evidence, yet they face conflicting pressures, with relevant data frequently being unavailable. Researchers vary in who they believe should decide: participants, principal investigators, institutional review boards, and/or professional organizations. Contextual factors can influence these decisions, including policies governing return of results by institutions and biobanks and the study design. Researchers vary in desires for: guidance from institutions and professional organizations, changes to current institutional processes, and community-wide genetics education.Conclusion:These data, the first to examine the processes by which researchers make decisions regarding the return of genetic incidental findings, highlight several complexities involved and have important implications for future genetics research, policy, and examinations of these issues.Genet Med advance online publication 26 September 2013Genetics in Medicine (2013); doi:10.1038/gim.2013.140.
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Informed consent for return of incidental findings in genomic research.
Genet. Med.
PUBLISHED: 04-28-2013
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Purpose:Researchers face the dilemma of how to obtain consent for return of incidental findings from genomic research. We surveyed and interviewed investigators and study participants, with the goal of providing suggestions for how to shape the consent process.Methods:We performed an online survey of 254 US genetic researchers identified through the NIH RePORTER database, abstracts from the 2011 American Society of Human Genetics meeting, and qualitative semi-structured interviews with 28 genomic researchers and 20 research participants.Results:Most researchers and participants endorsed disclosure of a wide range of information about return of incidental findings, including risks, benefits, impact on family members, data security, and procedures, for return of results in the event of death or incapacity and for recontact. However, most researchers were willing to devote 30?min or less to this process and expressed concerns that disclosed information would overwhelm participants, a concern shared by many participants themselves.Conclusion:There is a disjunction between the views of investigators and participants about the amount of information that should be disclosed and the practical realities of the research setting, including the time available for consent discussions. This strongly suggests the need for innovative approaches to the informed consent process.Genet Med advance online publication 24 October 2013Genetics in Medicine (2013); doi:10.1038/gim.2013.145.
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Researchers views on return of incidental genomic research results: qualitative and quantitative findings.
Genet. Med.
PUBLISHED: 04-01-2013
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Comprehensive genomic analysis including exome and genome sequencing is increasingly being utilized in research studies, leading to the generation of incidental genetic findings. It is unclear how researchers plan to deal with incidental genetic findings.
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Structured assessment of mental capacity to make financial decisions in Chinese older persons with mild cognitive impairment and mild Alzheimer disease.
J Geriatr Psychiatry Neurol
PUBLISHED: 03-15-2013
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Previous studies suggested that patients with mild cognitive impairment (MCI) or dementia can have impaired and declining financial skills and abilities. The purpose of this study is to test a clinically applicable method, based on the contemporary legal standard, to examine directly the mental capacity to make financial decisions and its component decision-making abilities among patients with MCI and early dementia. A total of 90 patients with mild Alzheimer disease (AD), 92 participants with MCI, and 93 cognitively normal control participants were recruited for this study. Their mental capacity to make everyday financial decisions was assessed by clinician ratings and the Chinese version of the Assessment of Capacity for Everyday Decision-Making (ACED). Based on the clinician ratings, only 53.5% were found to be mentally competent in the AD group, compared with 94.6% in the MCI group. However, participants with MCI had mild but significant impairment in understanding, appreciating, and reasoning abilities as measured by the ACED. The ACED provided a reliable and clinically applicable structured framework for assessment of mental capacity to make financial decisions.
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Use of intervention strategies by assertive community treatment teams to promote patients engagement.
Psychiatr Serv
PUBLISHED: 03-02-2013
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This study explored the range of interventions and the use of more intrusive techniques by staff of assertive community treatment (ACT) teams to promote engagement, manage problem behaviors, and reinforce positive behaviors among patients. Individual and organizational characteristics that may be associated with these practices were identified.
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Alternative decision-makers perspectives on assent and dissent for dementia research.
Am J Geriatr Psychiatry
PUBLISHED: 02-06-2013
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Investigators generally address the ethical dilemma of patients decisional impairment in Alzheimer disease (AD) research by obtaining consent from alternative or surrogate decision makers ("proxies") as well as assent from patients. How these proxies conceptualize patient assent, or lack of objection, to participate may influence decisions made of the patients behalf, but has been little studied. This report examines statements of proxies relevant to how they conceptualized assent and dissent to research.
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"Thinking about it for somebody else": Alzheimers disease research and proxy decision makers translation of ethical principles into practice.
Am J Geriatr Psychiatry
PUBLISHED: 02-06-2013
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Ethical guidelines suggest that, when enrolling patients with dementia in research, alterative decision makers (proxies) should base their decision on a "substituted judgment" of how the patient would have decided. If unable to make a substituted judgment, proxies are asked to decide on the basis of the patients best interests. This mixed-methods study is the first to examine explicitly whether and to what degree proxies differentiate between these two approaches and what considerations influence their mode of decision making.
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Forensic and nonforensic clients in assertive community treatment: a longitudinal study.
Psychiatr Serv
PUBLISHED: 02-02-2013
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OBJECTIVE This study compared rates of arrest and incarceration, psychiatric hospitalization, homelessness, and discharge from assertive community treatment (ACT) programs for forensic and nonforensic clients in New York State and explored associated risk factors. METHODS Data were extracted from the New York State Office of Mental Healths Web-based outcome reporting system. ACT clients admitted between July 1, 2003, and June 30, 2007 (N=4,756), were divided into three groups by their forensic status at enrollment: recent (involvement in the past six months), remote (forensic involvement was more than six months prior), and no history. Client characteristics as of ACT enrollment and outcomes at one, two, and three years were compared over time. RESULTS Clients with forensic histories had a significantly higher ongoing risk of arrest or incarceration, and those with recent criminal justice involvement had a higher risk of homelessness and early discharge from ACT. Psychiatric hospitalization rates did not differ significantly across groups. Rates of all adverse outcomes were highest in the first year for all ACT clients, especially for those with a recent forensic history, and rates of psychiatric hospitalization, homelessness, and discharge declined over time for all clients. For all ACT clients, homelessness and problematic substance abuse at enrollment were significant risk factors for arrest or incarceration and for homelessness on three-year follow-up. CONCLUSIONS Clients with recent forensic histories were vulnerable to an array of adverse outcomes, particularly during their first year of ACT. This finding highlights the need for additional strategies to improve forensic and other outcomes for this high-risk population.
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Disclosures of conflicts of interest in psychiatric review articles.
J. Nerv. Ment. Dis.
PUBLISHED: 02-01-2013
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To characterize disclosures of conflicts of interest in review articles in psychiatry, we identified 285 reviews from 10 high-impact journals in psychiatry and 2 in general medicine. Disclosures were reliably coded as biotechnology/pharmaceutical/other material interests, nonprofit/government, communication companies, or other. The authors in both types of journals frequently reported industry ties. However, the reviews in the psychiatric journals were significantly less likely to include industry-related disclosures (32% of the reviews; 18% of the authors) compared with the general medical journals (64% of the articles; 40% of the authors). The most common types of industry-related disclosures were for consulting, research support, and speaking fees. Disclosures seemed to be of limited utility in helping readers assess possible biases because the nature and the extent of the relationships being disclosed were often unclear. Efforts to screen out authors with significant financial relationships pertaining to the topic under review may be more effective than are disclosures in protecting the integrity of the medical literature.
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How important is accuracy of surrogate decision-making for research participation?
PLoS ONE
PUBLISHED: 01-31-2013
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There is a longstanding concern about the accuracy of surrogate consent in representing the health care and research preferences of those who lose their ability to decide for themselves. We sought informed, deliberative views of the older general public (?50 years old) regarding their willingness to participate in dementia research and to grant leeway to future surrogates to choose an option contrary to their stated wishes.
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Publics approach to surrogate consent for dementia research: cautious pragmatism.
Am J Geriatr Psychiatry
PUBLISHED: 01-12-2013
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To describe how members of the older general public deliberate with one another in finding solutions to the dilemma of involving persons with decisional incapacity in dementia research.
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Neuropsychological correlates of capacity determinations in Alzheimer disease: implications for assessment.
Am J Geriatr Psychiatry
PUBLISHED: 01-11-2013
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To explore the neuropsychological correlates of the capacity to consent to research and to appoint a research proxy among persons with Alzheimer disease.
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Law & psychiatry: imposed insanity defenses and political crimes.
Psychiatr Serv
PUBLISHED: 01-03-2013
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Anders Breiviks murder of 77 people in Norway in 2011 led to an unusual clash of interests. With conflicting psychiatric reports regarding his sanity, prosecutors argued that Breivik should be found not guilty by reason of insanity, whereas the defense strongly maintained that he was sane and responsible for his actions. Imposing an insanity defense on an unwilling defendant pits societal interests in fair adjudications against the right of defendants to control their defense. For crimes with political motivations, an imposed insanity verdict discredits the perpetrator and may distract the public from the threats posed by extreme political views.
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Genetic testing in psychiatry: a review of attitudes and beliefs.
Psychiatry
PUBLISHED: 12-16-2011
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The advent of genetic testing for psychiatric conditions raises difficult questions about when and how the tests should be used. Development of policies regarding these issues may be informed in a variety of ways by the views of key stakeholders: patients, family members, healthcare professionals, and the general public. Here, we review empirical studies of attitudes towards genetic testing among these groups. Patients and family members show strong interest in diagnostic and predictive genetic testing, and to a considerable extent psychiatrists share their enthusiasm. Prenatal test utilization seems likely to depend both on parental views on abortion and the seriousness of the disorder. Parents show a surprising degree of interest in predictive testing of children, even when there are no preventive interventions available. Many persons report themselves ready to alter their lifestyles and plans for marriage and family in response to test results. Respondents also fear negative consequences, from discrimination to being unable to cope with knowledge of their "genetic fate." Empirical studies of beliefs about genetic testing suggest tests are likely to be embraced widely, but the studies have methodologic limitations, reducing the certainty of their conclusions, and indicating a need for further research with more representative samples.
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Psychiatric hospitalization by court observation order in Israel: a ten year follow up study.
Isr J Psychiatry Relat Sci
PUBLISHED: 12-06-2011
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To explore the proportion of defendants hospitalized by court observation order (COO) who were diagnosed as having a psychiatric disorder during: 1) the COO period, or 2) a 10-year follow-up period.
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Lost in the crowd: prison mental health care, overcrowding, and the courts.
Psychiatr Serv
PUBLISHED: 10-05-2011
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Skyrocketing inmate populations have put considerable pressure on prison mental health services. In California, prison populations have exceeded 200% of capacity, and litigation to rectify constitutionally inadequate care has been under way for more than two decades. After the failure of other remedies, a federal court ordered the state to reduce its inmate population to 137.5% of capacity in two years. The U.S. Supreme Court upheld the order, although it signaled that California could obtain more time to comply. Other states now are on notice that the justices will not permit grossly inadequate treatment conditions to continue indefinitely.
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Enrolling in deep brain stimulation research for depression: influences on potential subjects decision making.
Depress Anxiety
PUBLISHED: 09-28-2011
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Ethical concerns regarding early-phase clinical trials of DBS for treatment-resistant depression (TRD) include the possibility that participants decisions to enroll might be motivated by unrealistic expectations of personal benefit or minimization of risks.
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Relationships between medicine and industry: approaches to the problem of conflicts of interest.
Annu. Rev. Med.
PUBLISHED: 09-01-2011
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Relationships between physicians and industry are prevalent in medical education, clinical practice, and research, as well as at the level of medical institutions. These relationships can be valuable for the advancement of medicine but have also received increased scrutiny in recent years because they create conflicts of interest that pose a risk of biasing the judgments of physicians. Responses to these conflicts of interest by medical institutions, journals, and governments have utilized four main tools: education, disclosure, management, and prohibition. Each of the four has its advantages and drawbacks. Medicine faces the challenge of tailoring the use of these tools to minimize the risk of bias while allowing useful medical-industry collaborations to proceed. Viewing the dilemmas created by physicians relationships with industry as a version of the principal-agent problem, which is much discussed by economists, may help in developing creative approaches to these issues.
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Law & psychiatry: Murder, inheritance, and mental illness.
Psychiatr Serv
PUBLISHED: 07-05-2011
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Should a murderer be allowed to inherit the victims estate? The question dates from biblical times, but most jurisdictions today have statutes in place that bar inheritance by convicted murderers. However, a special problem arises when the killer has a severe mental illness and has been found not guilty by reason of insanity. Should such people, who have not been convicted of a crime, be permitted to collect their inheritance? Jurisdictions vary in their responses, with the rules reflecting a mix of practical and moral considerations influenced by different perspectives about what determines the behavior of persons with mental illness.
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Evaluating psychiatric disability: differences by forensic expertise.
J. Am. Acad. Psychiatry Law
PUBLISHED: 06-10-2011
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The task of evaluating psychiatric disability poses several ethics-related and practical challenges for psychiatrists, especially when they are responding to a request from a third party for a disability evaluation on their own patient. This study sought to evaluate the differences in how forensic and nonforensic psychiatrists approach and view evaluations for Social Security disability benefits. Thirty-two forensic and 75 nonforensic psychiatrists were surveyed on their practice patterns and perceptions of role, objectivity, and dual agency in the disability evaluation process. Significant differences were found between forensic and nonforensic psychiatrists perceptions of the dual-agency conflict, beliefs about who should perform evaluations, and beliefs about the weight given to different opinions when decisions of whether to award disability benefits are made. A minority of respondents in both groups reported having identified a patient as disabled, despite believing otherwise. The implications of these findings are discussed.
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Screening for suicidality in the emergency department: when must researchers act to protect subjects interests?
Arch Suicide Res
PUBLISHED: 05-05-2011
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The emergency department (ED) is a key site in preventing suicide. Yet there has been very little research on ED screening and interventions targeting the suicidal patient. Conducting research on interventions for preventing suicidal behavior in the ED population may evoke the dilemma of how to fulfill ethical obligations to protect research subjects when doing so can impair the validity of the study. In this paper we present a case study of a research protocol on the utility of routine screening with a brief intervention for suicidal ideation that raised issues regarding researchers obligation to disclose information about subjects suicidality to ED staff. After exploring the imperfect relationship between suicidal ideation and completed suicide (i.e., many people with ideation never attempt or commit suicide), we present an analysis of the causal relationship between these phenomena. This leads us to suggest that it should not be mandatory for researchers to disclose to ED staff when a subject reveals suicide ideation in a screening questionnaire-although other preventive measures may be called for. In general, the extent of the duty placed on researchers to intervene on behalf of their subjects should be proportional to the likelihood and magnitude of risk presented to subjects by the underlying condition, and should be balanced against the importance of the research question.
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Law & psychiatry: SSRIs, suicide, and liability for failure to warn of medication risks.
Psychiatr Serv
PUBLISHED: 04-05-2011
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When can pharmaceutical companies be held liable for failure to disclose medication risks--such as the link between selective serotonin reuptake inhibitors and suicidality of young people? The companies have claimed that Food and Drug Administration approval of labeling information, required by federal law, should preempt liability in state courts. Thus injured patients would either be left without recourse or be compelled to sue the clinicians who prescribed the medication. A recent U.S. Supreme Court decision, however, rejected the preemption defense and opened the door to patients suits that seek compensation. This column explores the application of this new approach and its implications for the mental health professions.
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Variability of judgments of capacity: experience of capacity evaluators in a study of research consent capacity.
Psychosomatics
PUBLISHED: 03-31-2011
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Assessment of decision-making capacity is a common and important function of psychiatric consultants. However, the sources of variability in evaluators judgments have not been well characterized.
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Longitudinal consent-related abilities among research participants with schizophrenia: results from the CATIE study.
Schizophr. Res.
PUBLISHED: 03-09-2011
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Research participants must have adequate consent-related abilities to provide informed consent at the time of study enrollment. We sought to determine if research participants with schizophrenia maintain adequate consent-related abilities during a longitudinal study. If participants lose abilities during a trial they may not be able to judge and protect their interests. If reduced abilities are common or can be predicted, special protections can be targeted appropriately.
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Preservation of the capacity to appoint a proxy decision maker: implications for dementia research.
Arch. Gen. Psychiatry
PUBLISHED: 02-09-2011
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Research involving persons with impaired decision-making capacity (such as persons with Alzheimer disease [AD]) remains ethically challenging, especially when the research involves significant risk. If individuals incapable of consenting to research studies were able to appoint a research proxy, it would allow for an appointed surrogate (rather than a de facto surrogate) to represent the subject.
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Law & psychiatry: reforming malpractice: the prospects for change.
Psychiatr Serv
PUBLISHED: 01-07-2011
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Previous efforts to change the U.S. medical malpractice system have involved such initiatives as time limits on filing claims, caps on noneconomic damages, and limiting attorneys fees. This column briefly reviews such past efforts and describes several new approaches. They include programs that encourage prompt disclosure of errors and offers of compensation, efforts to mediate complaints outside the courts, and use of administrative processes to adjudicate claims. "No-fault" systems, such as those in New Zealand, Sweden, and Denmark, may be most likely to satisfy the interests of both patients and physicians but may not be politically acceptable in the United States.
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Coping with the ethical conundra of forensic psychiatry: a tribute to Howard Zonana, MD.
J. Am. Acad. Psychiatry Law
PUBLISHED: 12-16-2010
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As part of the Festschrift in honor of Howard Zonana, MD, this article reviews two important concerns that emerged in the ethics of forensic psychiatry in the resolution of which he played critical roles. In the late 1980s and early 1990s, the question arose of what role, if any, was proper for psychiatrists to play with regard to evaluations of competence to be executed and treatment of incompetent prisoners. Dr. Zonana was a major force in developing the American Psychiatric Associations position, in which the rights of prisoners were balanced with protection of the integrity of the medical profession. He was then deeply involved in helping to persuade the American Medical Association to reject a more extreme position and to adopt this approach. Similarly, in the mid-2000s, Dr. Zonana brought to the attention of the American Psychiatric Association (APA) the participation of psychiatrists in interrogation of detainees in national security settings. The policy that he subsequently helped to craft was adopted by APA and influenced the subsequent, very similar AMA policy. These two examples, of the many that could have been chosen, illustrate the profound impact that Howard Zonana has had on the ethics of psychiatry as a whole and on the ethics of forensic psychiatry in particular.
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Law & psychiatry: facilitating testimony of people with mental illness.
Psychiatr Serv
PUBLISHED: 10-05-2010
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Persons with mental illness may face particular challenges when asked to testify at criminal trials. Mental illness, along with the pressures of testifying, may prevent them from testifying or may affect their testimony. This column discusses laws that, in certain circumstances, permit litigants to use out-of-court statements made by people with mental disorders as a substitute for in-court testimony; two U.S. Supreme Court cases that placed substantial limits on the use of out-of-court statements under these laws; and in light of these limits, alternatives that would permit use of out-of-court statements.
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Unconscious conflict of interest: a Jewish perspective.
J Med Ethics
PUBLISHED: 09-18-2010
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In contemporary medicine, it is not always obvious whether the acceptance of a benefit constitutes a conflict of interest. A particular area of controversy has been the impact of small gifts or other benefits from pharmaceutical companies on physicians behaviour. Typically, in such cases, the gift is not an explicit reward for cooperation; the physician does not perceive the gift as an attempt to influence his or her judgement; and the reward is relatively minor. Under these circumstances, physicians are generally of the view that acceptance of gifts will not affect their behaviour, notwithstanding findings from social psychology and neuroscience that the impact of gifts is often unconscious, shaping action without a persons awareness. Here, we draw on traditional texts of Jewish law pertaining to the prohibition of taking a gift to illustrate recognition by the ancients of unconscious conflicts of interest, and their approach to dealing with the problem.
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Psychiatrists relationships with industry: the principal-agent problem.
Harv Rev Psychiatry
PUBLISHED: 09-10-2010
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Psychiatrists relationships with the pharmaceutical and device industries have been a growing focus of attention, with questions raised about the impact of those relationships on prescribing practices, diagnostic criteria, practice guidelines, continuing education, conduct and reporting of research, and patients and public trust. Indeed, these concerns exist for the medical profession as a whole, with various remedial measures proposed. We suggest that such relationships can be understood as giving rise to a "principal-agent problem," which occurs when an agent (here, a physician) is engaged to advance the interests of another party, the principal (typically a patient), but also faces incentives to promote other interests. Studies suggest that at least some relationships--which include attending industry-sponsored presentations, meeting with marketing representatives, and accepting samples--can alter psychiatrists and other physicians behavior in ways that can compromise patients interests, and that industry-funded research may create bias in the medical literature. These effects are difficult to detect in specific cases, however, because of asymmetries of information and may not be apparent even to physicians themselves. Principal-agent analysis suggests that the possible responses to such problems, including appeals to ethical principles, monitoring behavior, and managing risk-inducing situations, should include consideration of aligning agents incentives with principals interests. This type of analysis underscores the similarity of the issues raised by physicians relationships with industry to problems that arise more generally in society, thus reducing physicians potential affective responses to these issues and efforts to address them. Finally, such analysis directs attention to the benefits and costs of each alternative, thereby encouraging reliance on evidence as a basis for policy.
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Law & psychiatry: Gun laws and mental illness: how sensible are the current restrictions?
Psychiatr Serv
PUBLISHED: 07-02-2010
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This column describes federal and state laws to restrict access to firearms among people with mental illness. The contribution to public safety of these laws is likely to be small because only 3%-5% of violent acts are attributable to serious mental illness, and most do not involve guns. The categories of persons with mental illnesses targeted by the laws may not be at higher risk of violence than other subgroups in this population. The laws may deter people from seeking treatment for fear of losing the right to possess firearms and may reinforce stereotypes of persons with mental illnesses as dangerous.
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Diagnosing consciousness: neuroimaging, law, and the vegetative state.
J Law Med Ethics
PUBLISHED: 06-29-2010
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In this paper, we review recent neuroimaging investigations of disorders of consciousness and different disciplines understanding of consciousness itself. We consider potential tests of consciousness, their legal significance, and how they map onto broader themes in U.S. statutory law pertaining to advance directives and surrogate decision-making. In the process, we outline a taxonomy of themes to illustrate and clarify the variance in state-law definitions of consciousness. Finally, we discuss broader scientific, ethical, and legal issues associated with the advent of neuroimaging for disorders of consciousness and conclude with policy recommendations that could help to mitigate confusion in this realm.
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Consent in impaired populations.
Curr Neurol Neurosci Rep
PUBLISHED: 06-16-2010
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Impairments in patients with dementia and other disorders affecting cognition may have a negative impact on their capacity to provide consent to treatment or to participation in research. A growing literature confirms that even patients with mild cognitive impairment may experience decrements in decisional abilities, findings that are more pronounced still in the early stages of dementia. However, most patients with mild dementia probably remain competent to provide a valid consent to treatment or research, and even some patients with moderate dementia may retain capacity in particular circumstances. Clinical evaluation of decisional competence has been augmented by structured approaches, including reliable instruments that may be used in the clinical setting. To avoid needlessly depriving patients of their right to make health care decisions, evaluations should be designed to maximize patient performance. However, when substitute consent is necessary, state laws generally provide a range of options, including advance directives and familial consent.
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Law & psychiatry: Genetic discrimination in mental disorders: the impact of the genetic information nondiscrimination act.
Psychiatr Serv
PUBLISHED: 04-03-2010
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Genetics is one of the most active areas of research on mental disorders. As genetic tests related to psychiatric disorders and their treatments proliferate in research and clinical settings, the possibility becomes more troubling that such information will be used for purposes other than those for which it was collected. Because of this, the federal Genetic Information Nondiscrimination Act of 2008 is of substantial importance to persons with mental disorders, persons at risk for the conditions, and family members of both groups. This column discusses the process of passing the legislation, along with the implications of the act.
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Preimplantation genetic diagnosis on in vitro fertilization clinic websites: presentations of risks, benefits and other information.
Fertil. Steril.
PUBLISHED: 11-05-2009
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To examine information on preimplantation genetic diagnosis (PGD) presented on IVF clinic websites.
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Law & psychiatry: mental retardation and the death penalty: after Atkins.
Psychiatr Serv
PUBLISHED: 10-03-2009
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In Atkins v. Virginia the U.S. Supreme Court declared execution of persons with mental retardation to constitute cruel and unusual punishment, and thus to be unconstitutional under the Eighth Amendment. However, the Court left all considerations regarding how to implement the decision explicitly to the states. Since Atkins was decided in 2002, legislatures, courts, and mental health experts have struggled with its implementation, highlighting the complexities that can arise when the courts base legal rules on clinical findings. This column reviews the Atkins case and considers the challenges associated with a clinical determination that can have life-or-death consequences for capital defendants.
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Multimedia consent for research in people with schizophrenia and normal subjects: a randomized controlled trial.
Schizophr Bull
PUBLISHED: 08-07-2009
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Limitations of printed, text-based, consent forms have long been documented and may be particularly problematic for persons at risk for impaired decision-making capacity, such as those with schizophrenia. We conducted a randomized controlled comparison of the effectiveness of a multimedia vs routine consent procedure (augmented with a 10-minute control video presentation) as a means of enhancing comprehension among 128 middle-aged and older persons with schizophrenia and 60 healthy comparison subjects. The primary outcome measure was manifest decisional capacity (understanding, appreciation, reasoning, and expression of choice) for participation in a (hypothetical) clinical drug trial, as measured with the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR) and the University of California San Diego (UCSD) Brief Assessment for Capacity to Consent (UBACC). The MacCAT-CR and UBACC were administered by research assistants kept blind to consent condition. Additional assessments included standardized measures of psychopathology and cognitive functioning. Relative to patients in the routine consent condition, schizophrenia patients receiving multimedia consent had significantly better scores on the UBACC and on the MacCAT-CR understanding and expression of choice subscales and were significantly more likely to be categorized as being capable to consent than those in the routine consent condition (as categorized with several previously established criteria). Among the healthy subjects, there were few significant effects of consent condition. These findings suggest that multimedia consent procedures may be a valuable consent aid that should be considered for use when enrolling participants at risk for impaired decisional capacity, particularly for complex and/or high-risk research protocols.
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Substance use, symptom, and employment outcomes of persons with a workplace mandate for chemical dependency treatment.
Psychiatr Serv
PUBLISHED: 05-05-2009
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This study examined the role of workplace mandates to chemical dependency treatment in treatment adherence, alcohol and drug abstinence, severity of employment problems, and severity of psychiatric problems.
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The capacity to vote of persons with serious mental illness.
Psychiatr Serv
PUBLISHED: 05-05-2009
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Despite legal protections, persons with mental illness continue to experience discrimination that limits their access to voting in elections. In response, a number of states have adopted individualized functional determinations of mental capacity to vote. A 2001 federal court decision offered clear criteria for determining voting capacity that are based on understanding the nature and effect of voting ("the Doe standard"). This study explored the performance on these criteria by a sample of individuals with serious mental illness.
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Capacity to make treatment decisions in Chinese older persons with very mild dementia and mild Alzheimer disease.
Am J Geriatr Psychiatry
PUBLISHED: 04-25-2009
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This study aims at assessing mental competence in Chinese patients with mild and very mild dementia with a semistructured assessment method and the impact of repeated presentations of information on patients mental competence.
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Law & psychiatry: deception, coercion, and the limits of interrogation.
Psychiatr Serv
PUBLISHED: 04-03-2009
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This column discusses the recent case of U.S. v. Boskic to highlight issues related to voluntariness--in particular, the voluntariness of a confession. At a meeting with U.S. government agents, Boskic, a Croat from Bosnia living in the United States, confessed to involvement in the 1995 Srebrenica massacre. The agents had deceived him about the meetings purpose and did not disclose that they had a warrant for his arrest. The courts were asked to decide whether the confession was involuntary, and thus not admissible as evidence, on the basis of whether the deception was coercive.
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Through a glass darkly: functional neuroimaging evidence enters the courtroom.
Psychiatr Serv
PUBLISHED: 03-31-2009
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This column discusses problems with use of evidence based on functional brain scans. It describes a 2007 case in which evidence from positron emission tomography of the defendants brain was used in an attempt to show that he was unable to have planned the sexual assault, which he did not contest committing, and so could not form an intent to commit the crime. Among the issues evident in such cases are the assumption that complex functions are localized to single areas of the brain and the large discrepancy between inferences that can be drawn from such evidence and legal standards that must be met in court.
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Non-invasive brain stimulation in the detection of deception: scientific challenges and ethical consequences.
Behav Sci Law
PUBLISHED: 03-07-2009
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Tools for noninvasive stimulation of the brain, such as transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS), have provided new insights in the study of brain-behavior relationships due to their ability to directly alter cortical activity. In particular, TMS and tDCS have proven to be useful tools for establishing causal relationships between behavioral and brain imaging measures. As such, there has been interest in whether these tools may represent novel technologies for deception detection by altering a persons ability to engage brain networks involved in conscious deceit. Investigation of deceptive behavior using noninvasive brain stimulation is at an early stage. Here we review the existing literature on the application of noninvasive brain stimulation in the study of deception. Whether such approaches could be usefully applied to the detection of deception by altering a persons ability to engage brain networks involved in conscious deceit remains to be validated. Ethical and legal consequences of the development of such a technology are discussed.
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Voluntariness of consent to research: a conceptual model.
Hastings Cent Rep
PUBLISHED: 02-14-2009
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A good deal of policy and practice in human subjects research aims to ensure that when subjects consent to research, they do so voluntarily. To date, however, voluntariness and its impairment have been poorly conceptualized and studied. The legal doctrine of informed consent could provide a useful model.
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Views of internists towards uses of PGD.
Reprod. Biomed. Online
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Preimplantation genetic diagnosis (PGD) is increasingly available, but how physicians view it is unclear. Internists are gatekeepers and sources of information, often treating disorders for which PGD is possible. This quantitative study surveyed 220 US internists, who were found to be divided. Many would recommend PGD for cystic fibrosis (CF; 33.7%), breast cancer (BRCA; 23.4%), familial adenomatous polyposis (FAP; 20.6%) and familial hypertrophic cardiomyopathy (19.9%), but few for social sex selection (5.2%); however, in each case, >50% were unsure. Of those surveyed, 4.9% have suggested PGD to patients. Only 7.1% felt qualified to answer patient questions about it. Internists who would refer for PGD had completed medical training less recently and, for CF, were more likely to have privately insured patients (P<0.033) and patients who reported genetic discrimination (P<0.013). Physicians more likely to refer for BRCA and FAP were less likely to have patients ask about genetic testing. This study suggests that internists often feel they have insufficient knowledge about it and may refer for PGD based on limited understanding. They view possible uses of PGD differently, partly reflecting varying ages of onset and disease treatability. These data have critical implications for training, research and practice. Preimplantation genetic diagnosis (PGD) allows embryos to be screened prior to transfer to a womans womb for various genetic markers. This procedure raises complex medical, social, psychological and ethical issues, but how physicians view it is unclear. Internists are gatekeepers and sources of information, often treating disorders for which PGD use is possible. We surveyed 220 US internists, who were found to be divided: many would recommend PGD for cystic fibrosis (CF; 33.7%), breast cancer (BRCA; 23.4%), familial adenomatous polyposis (FAP; 20.6%), and familial hypertrophic cardiomyopathy (FHC; 19.9%) and a few for sex selection (5.2%); but in each case, >50% were unsure. Of those surveyed, 4.9% have suggested PGD to patients. Only 7.1% felt qualified to answer patient questions. Internists who would refer for PGD completed medical training less recently and, for CF, were more likely to have privately insured patients and patients who reported genetic discrimination. Physicians more likely to refer for BRCA and FAP were less likely to have patients ask about genetic testing. This quantitative study suggests that internists often feel they have insufficient knowledge and may refer for PGD based on limited understanding. They view possible uses of PGD differently, partly reflecting varying ages of onset and disease treatability. Internists should be made aware of the potential benefit of PGD, but also be taught to refer patients, when appropriate, to clinical geneticists who could then refer the patient to an IVF/PGD team. These data thus have critical implications for training, research and practice.
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Law & psychiatry: punishing juveniles who kill.
Psychiatr Serv
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Punishment of juvenile murderers forces policy makers to weigh the developmental immaturity of adolescents against the heinousness of their crimes. The U.S. Supreme Court has progressively limited the severity of punishments that can be imposed on juveniles, holding that their impulsivity, susceptibility to peer pressure, and more fluid character render them less culpable for their actions. Having eliminated the death penalty as a punishment, the Court recently struck down mandatory life sentences without prospect of parole. The decision is interesting for its emphasis on rehabilitation, opening the door to further restrictions on punitive sentences for juveniles-and perhaps for adults too.
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Competing commitments in psychiatric research: an examination of psychiatric researchers perspectives.
Int J Law Psychiatry
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Clinician-researchers have responsibilities both to seek the best interests of the people they treat and to advance scientific knowledge. The purpose of this study was to examine researchers beliefs and behaviors regarding areas of tension between their clinical and scientific roles. We conducted and analyzed 19 in-depth interviews with psychiatric clinical researchers to explore these issues. Responses usually indicated that researchers recognize limits on their abilities to be helpful to patients, since they cannot know in advance whether a specific research intervention will help and whether participation is in the patients best interest. Hence, most researchers did not make special efforts to recruit patients doing poorly in standard care, although they occasionally tolerated minor deviations from recruitment and treatment protocols when they might be in participants interests. Often respondents asked the IRB to approve these deviations or change the protocol for all subjects, though it was unclear how often they may have acted without this approval. Despite researchers high regard for following the research protocol, clinical judgment remained the ultimate guide if patients were not doing well and needed alternative care. Hence, respondents expressed a strong commitment both to protecting patients interests and to advancing science. In cases of direct conflict between the two, many of the researchers tended to promote patients best interests even at some cost to scientific research.
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Therapeutic misconception in research subjects: development and validation of a measure.
Clin Trials
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Therapeutic misconception (TM), which occurs when research subjects fail to appreciate the distinction between the imperatives of clinical research and ordinary treatment, may undercut the process of obtaining meaningful consent to clinical research participation. Previous studies have found that TM is widespread, but progress in addressing TM has been stymied by the absence of a validated method for assessing its presence.
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The ethics of research on deep brain stimulation for depression: decisional capacity and therapeutic misconception.
Ann. N. Y. Acad. Sci.
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Research on deep brain stimulation (DBS) for treatment-resistant depression appears promising, but concerns have been raised about the decisional capacity of severely depressed patients and their potential misconceptions about the research. We assessed 31 DBS research participants with the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR), a well-validated capacity measure, and with a scale to measure therapeutic misconception, which occurs when subjects do not recognize key differences between treatment and clinical research. Correlations with baseline depressive symptoms were explored. Subjects performance on the MacCAT-CR was excellent, but therapeutic misconception was still apparent. A trend toward significance was found in the correlation between baseline depression ratings and total therapeutic misconception score. Responses to open-ended prompts revealed both reassuring and concerning statements related to expectations of risk, benefit, and individualization. Even severely depressed patients did not manifest impairments in their capacity to consent to DBS research. Therapeutic misconception, however, remained prevalent.
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Personalized disclosure by information-on-demand: attending to patients needs in the informed consent process.
J Law Med Ethics
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Obtaining informed consent has typically become a stylized ritual of presenting and signing a form, in which physicians are acting defensively and patients lack control over the content and flow of information. This leaves patients at risk both for being under-informed relative to their decisional needs and of receiving more information than they need or desire. By personalizing the process of seeking and receiving information and allowing patients to specify their desire for information in a prospective manner, we aim to shift genuine control over the informational process to patients. A new paradigm of Information on Demand, such as we suggest, would also enhance legal certainty, achieve greater congruence between the information patients want and the information they receive, and promote more meaningful patient-physician interactions, a desirable outcome that has been difficult to achieve by other means.
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Law & psychiatry: Treatment of incompetent, dangerous criminal defendants: parsing the law.
Psychiatr Serv
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The case of Jared Lee Loughner, who killed or wounded 19 people in a shooting rampage in Tucson, demonstrates the confusion inherent in current rules for the treatment of defendants with mental illness. Found incompetent to stand trial and committed for treatment, Jared Loughner refused medication. However, when he became dangerous and suicidal, the facility treated him. Loughners attorneys objected, arguing that the U.S. Supreme Court decision in Sell v. United States entitled him to a judicial hearing. The lack of clarity over the rules that should govern such cases stems from the courts failure to make explicit the rationale for its landmark decision.
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How closely do institutional review boards follow the common rule?
Acad Med
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To determine how closely institutional review board (IRB) discussions reflect the ethical criteria specified in the Common Rule federal regulations.
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Attitudes and practices among internists concerning genetic testing.
J Genet Couns
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Many questions remain concerning whether, when, and how physicians order genetic tests, and what factors are involved in their decisions. We surveyed 220 internists from two academic medical centers about their utilization of genetic testing. Rates of genetic utilizations varied widely by disease. Respondents were most likely to have ordered tests for Factor V Leiden (16.8 %), followed by Breast/Ovarian Cancer (15.0 %). In the past 6 months, 65 % had counseled patients on genetic issues, 44 % had ordered genetic tests, 38.5 % had referred patients to a genetic counselor or geneticist, and 27.5 % had received ads from commercial labs for genetic testing. Only 4.5 % had tried to hide or disguise genetic information, and <2 % have had patients report genetic discrimination. Only 53.4 % knew of a geneticist/genetic counselor to whom to refer patients. Most rated their knowledge as very/somewhat poor concerning genetics (73.7 %) and guidelines for genetic testing (87.1 %). Most felt needs for more training on when to order tests (79 %), and how to counsel patients (82 %), interpret results (77.3 %), and maintain privacy (80.6 %). Physicians were more likely to have ordered a genetic test if patients inquired about genetic testing (p
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