discussion

 

ope Kuenker

MondayMay 27 at 8:43amManage Discussion Entry

The cautionary statement details an apparent disconnect between the use of diagnostic material in clinical versus in a forensic setting (American Psychiatric Association, 2013). According to Maruschak et al. (2021), nearly half of state prisoners and 23% of federal prisoners met the criteria of a mental health problem, meaning the intersection of clinical diagnoses and a forensic setting is nearly inevitable. Because of that, I would question what can be done to close this gap. To begin, it could be beneficial to make education in this area a part of police academies. Law enforcement is given an abundance of training regarding the law, firearms, defensive tactics, law, etc.; however, rarely are they adequately equipped to understand many of the people they deal with on a regular basis. It is also mentioned that additional information, including that which provides insight into the individuals functional impairments, is necessary to determine how a diagnosis affects the legal determination of competency, reliability, or things of that nature (American Psychiatric Association, 2013). My question with this would be what tangible steps can be taken to streamline the process of getting not only more comprehensive diagnoses, but also presenting the diagnosis in a way that is more digestible for a wide array of professionals. 

For this discussion, I have chosen to focus on bipolar I disorder. According to the DSM-5 in order to be diagnosed with bipolar I disorder, one must experience manic episodes, which are frequently followed by episodes of hypomania or depression (American Psychiatric Association, 2013). The diagnostic criteria goes on to further differentiate between these three subsets. For a manic episode, the overarching theme of the criteria is being in an abnormal yet persistently elevated, expansive or irritable mood, that is often met with increased energy and activity (American Psychiatric Association, 2013). This is often described as having an “on top of the world feeling” and frequently presents itself in things like being more talkative, having flights of ideas, not requiring a lot of sleep, or engaging in goal-directed activity (American Psychiatric Association, 2013). Not requiring sleep to adequately function is one of the main precursors to a manic episode. 

The criteria for being hypomanic is largely similar, with the main distinction being it lasts for four consecutive days, compared to the minimum of a week for manic. Also differentiating the two is the fact that hypomanic episodes are not severe enough to impair social or occupational functioning, however, the changes in behavior are apparent to others. The major depressive component requires a number of symptoms, one of which must be a depressed mood or loss of pleasure, to be present over a two week period. The symptoms include weightloss, insomnia or hypersomnia, recurrent thoughts of death or suicidal ideation, and/or feelings of worthlessness and indecisiveness (American Psychiatric Association, 2013). Similar to the manic episode, major depressive episodes result in significant impairment to important areas of functioning. Finally, to be diagnosed with bipolar I, the symptoms cannot be better explained through another disorder, such as schizoaffective disorder. 

There are an abundance of legal and ethical issues that can be at play when working with patients who have bipolar I disorder. For example, say a patient's symptoms are being adequately managed through medication. However, this patient wishes to become pregnant and the medications would harm the baby, therefore, she wishes to go off of them. As Srivastava (2011) explains, a psychiatrist in this position would have to figure out a way to ethically balance keeping the patient’s mood stable throughout pregnancy and the ability to safely care for the child afterwards, all while ensuring the baby remains unharmed. In this case, the psychiatrist may draw upon the ethical concepts of autonomy and voluntarism. The patient would need to have the ability to make a decision regarding her continued treatment that is both deliberate and without coercion through being provided enough information to make an informed choice (Srivastava, 2011). However, it isn’t as simple as giving the patient the options and trusting her judgment, rather, the psychiatrist must also ensure she has the capacity to make an informed refusal, should she wish to go against his medical advice. 

From a different angle, Srivastava (2011) describes a psychiatrist who was met with an enticing offer from a pharmaceutical company. If he were to enroll 20 patients within their study, he became eligible for bonus pay. One of his patients, C.R., has already undergone a number of clinical trials for medication to treat her major depressive episodes, none of which have proved successful (Srivastava, 2011). Given that she’s not responded to treatments in the past, the psychiatrist must weigh his research-oriented goals and monetary benefits against the well-being of his patient. As Srivastava (2011) explains, this psychiatrist would need to adhere to the principles of veracity and fidelity. Veracity describes the need to be truthful and avoid misrepresentation, whereas fidelity explains remaining faithful to the goals of treatment. In C.R. 's case, the psychiatrist could adhere to veracity through informing her of the nature of the trial as well as the likelihood of its effectiveness. Similarly, he should ensure that her participation in the trail would result in progress towards the ultimate goal of alleviating her depression. Taken as a whole, abiding by these principles would enable C.R. to make an autonomous and informed decision. 

As noted above, legal and ethical challenges are intertwined with nearly every part of the psychological and/or diagnostic process, regardless of the disorder being treated. The importance of the ability to make autonomous and informed decisions cannot be understated. Given that many patients seeking treatments for psychological disorders are doing so because the symptoms are causing severe impairments to their everyday lives, it’s important they receive comprehensive reports of the medications or treatment plans prior to beginning them. In fact, informed consent is cited as one of the most important things to obtain when conducting assessments, as it ensures the patient is informed of the nature and goal of testing, fees, confidentiality limitation, and the involvement of third parties (American Psychological Association, 2017). If the client is not in a state where they’re able to provide informed consent, the psychologist considers the persons’ interest and preferences and obtains appropriate consent from people legally authorized to provide it. This could possibly play a role in the treatment of bipolar I individuals, if they’re in a state where they are unable to adequately make an informed decision. Further, working with clients in this capacity can open doors for other ethical problems. For example, the psychologist would have to ensure they’re not engaging in multiple relationships with that client, nor a close relationship with someone who is a relative or closely associated with the individual they have a professional relationship with (American Psychological Association, 2017). 

References:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disordersLinks to an external site. (5th ed.). https://doi.org/10.1176/appi.books.9780890425596 

American Psychological Association. (2017). Ethical principles of psychologists and code of conduct: Including 2010 and 2016 amendmentsLinks to an external site.. https://www.apa.org/ethics/code

Maruschak, L., Bronson, J., & Alper, M. (2021). Indicators of mental health problems reported by prisoners. U.S. Department of Justice.

Srivastava, S. (2011). Bipolar disorder: Ethical considerations in the treatment of bipolar disorder. FOCUS, 9(4), 461–464. https://doi.org/10.1176/foc.9.4.foc461