Across the health sector there is increased recognition of the ethical significance of interventions that constrain or coerce. Much of the recent interest stems from debates in public health over the use of quarantines and active monitoring in response to epidemics, as well as the manipulation of information in the service of health promotion (or ‘nudges’). But perhaps the area in which these issues remain most pressing is mental health, where the spectre of involuntary treatment has always loomed large. Indeed, (...) there are good reasons to think of psychiatry as ethically exceptional given its broader role as social and legal arbiter. This is compounded by the fact that mental health treatment has other special features that can serve as potential entry points for more subtle forms of pressure and influence. These include the relative cognitive and emotional vulnerability of patients, the highly confidential information involved, and the importance of the therapeutic relationship. Thus the field of mental health needs to grapple with a range of closely related issues concerning the ethics of influence. In this chapter I explore several, with a primary focus on clinical concerns, although implications for research ethics are also touched on. Discussion of treatment pressure has traditionally focused on ‘coercion,’ or, very roughly, the use of threats or force to get someone to do something they otherwise would not. Here I follow suit, beginning with discussion of its conceptual standing alongside other categories of influence, including manipulation and persuasion. As it stands, there is nothing close to a consensus on these matters. But a relatively broad understanding of coercion is available and can be useful for ethical deliberation. Or so I suggest here. Interestingly enough, there is also a growing body of empirical literature on coercion in psychiatry, including research on the use of coercive measures such as hospitalization, physical restraint, and forced medication, as well as the construct of ‘perceived coercion,’ which tracks patients’ experiences of treatment pressure. I briefly describe several key findings and their relation to recent recommendations to reduce coercion. Building on all of this, I then take up the normative questions directly, by way of evaluating a recently proposed framework for the ethical analysis of influence. (shrink)

The application of human right frameworks is an increasingly important part of efforts to accelerate progress in global mental health. Much of this has been driven by several influential legal and policy instruments, most notably the United Nations’ Convention on the Rights of Persons with Disabilities, as well as the World Health Organization’s QualityRights Tool Kit and Mental Health Action Plan. Despite these significant developments, however, much more needs to be done to prevent human rights violations. This chapter focuses on (...) a critical component of this broader challenge, which is the question of how best to regulate and reduce the use of coercive measures. The recent literature on coercion in psychiatry – which addresses involuntary commitment, seclusion, restraint, and forced medication – represents a useful resource that can help guide tractable solutions in global mental health. These issues are evaluated from the perspective of global health governance, and several general recommendations are made in order to improve monitoring and enforcement, provide guidance for domestic legislative reform, and strengthen health systems. (shrink)

The field of mental health continues to struggle with the question of how best to structure its diagnostic systems. This issue is of considerable ethical importance, but the implications for public health approaches to mental health have yet to be explored in any detail. In this article I offer a preliminary treatment, drawing out several core issues while sounding a note of caution. A central strand of the debates over diagnosis has been the contrast between categorical and dimensional models, with (...) renewed attention due to recent publication of the DSM-5, launch of the RDoC, and ongoing work on the ICD-11. This dispute involves an interesting assortment of ethical and empirical considerations, many with direct relevance for public health. It has been proposed, for example, that dimensional diagnosis may be morally preferable because it can help reduce the stigma associated with mental disorder. This is a pressing concern, as preventive strategies are expanded in mental health, often operating under dimensional assumptions that target various risk factors. But this type of proposal relies upon an empirical claim and the scientific status of dimensionality remains unresolved, including its relation to stigma. I suggest, then, that the current state of the evidence does not yet warrant clear adjudication between competing frameworks, and thus any implications for public mental health remain highly provisional. More research is needed to help resolve these issues, including ethical analysis. (shrink)

In recent years there has been increased recognition of the global burden of mental disorders, which in turn has led to the expansion of preventive initiatives at the community and population levels. The application of such public health approaches to mental health raises a number of important ethical questions. The aim of this collection is to address these newly emerging issues, with special attention to the principle of prevention and the distinctive ethical challenges in mental health. The collection brings together (...) an interdisciplinary group of experts in bioethics, mental health, public health, and global health. (shrink)

Increased awareness of the importance of mental health for global health has led to a number of new initiatives, including influential policy instruments issued by the World Health Organization (WHO) and the United Nations (UN). This policy brief describes two WHO instruments, the Mental Health Action Plan for 2013–2020 (World Health Organization, 2013) and the Mental Health Atlas (World Health Organization, 2015), and presents a comparative analysis with the Sustainable Development Goals (SDGs) of the UN’s 2030 Agenda for Sustainable Development (...) (United Nations, 2015). The WHO’s Action Plan calls for several specific objectives and targets, with a focus on improving global mental health governance and service coverage. In contrast, the UN’s SDGs include only one goal specific to mental health, with a single indicator tracking suicide mortality rates. The discrepancy between the WHO and UN frameworks suggests a need for increased policy coherence. Improved global health governance can provide the basis for ensuring and accelerating progress in global mental health. (shrink)

Despite widespread recognition that psychiatry would be better served by a classificatory system based on etiology rather than mere description, it goes without saying that much of the necessary work is yet to be done. In this chapter I take up the increasingly important question of how mechanistic explanation fits into the larger effort to build a scientifically sound etiological and nosological framework. I sketch a rough picture of what mechanistic explanation should look like in the context of psychiatric research, (...) with a focus on several potential challenges posed by the special features of many psychiatric conditions. These include the role of social and environmental factors, the relatively transient nature of symptoms, the presumably complex organization of underlying systems, and the likelihood that many disorders are the product of nonstandard development. I suggest that these explanatory challenges can be met with a sufficiently broad notion of mechanism, one that allows for something less than the flawless execution of internal operations, appeals to the influence of contextual factors, and attends to organizational relations both within the mechanism itself and across the wider cognitive system. (shrink)

In 1996, the Royal College of Psychiatrists recommended that all psychiatric facilities in the UK develop policies concerning sexuality and sexual expression for persons contained in those facilities. This paper analyses the prevalence and content of such policies in English forensic psychiatric facilities. While the College recommends an individualised approach to sexual and emotional relationships, most hospitals in fact either prohibit or actively discourage such expression as a matter of policy. The paper considers the advantages and disadvantages of that approach. (...) The paper also considers the legal issues surrounding these policies, and in particular the legal authority for governing the sexual and emotional expression of hospital residents and the relevant human rights implications. (shrink)

Given that the concept of coercion remains a central concern for bioethics, Quigley's (Monash Bioethics Rev 32:141–158, 2014) recent article provides a helpful analysis of its frequent misapplication in debates over the use of ‘nudges’. In this commentary I present a generally sympathetic response to Quigley’s argument while also raising several issues that are important for the larger debates about nudges and coercion. I focus on several closely related topics, including the definition of coercion, the role of empirical research, and (...) the normative concerns at the core of these disputes. I suggest that while a degree of precision is certainly required when deploying the relevant concepts, perhaps informed by empirical data, we need to continue to push these debates towards more pressing normative considerations. (shrink)

The most recent global refugee figures are staggering, with over 82.4 million people forcibly displaced and 26.4 million registered refugees. The ongoing conflict in Syria is a major contributor. After a decade of violence and destabilization, over 13.4million Syrians have been displaced, including 6.7 million internally displaced persons and 6.7 million refugees registered in other countries. Beyond the immediate political and economic challenges, an essential component of any response to this humanitarian crisis must be health-related, including policies and interventions specific (...) to mental health. This policy and practice review addresses refugee mental health in the context of the Syrian crisis, providing an update and overview of the current situation while exploring new initiatives in mental health research and global health policy that can help strengthen and expand services. Relevant global health policy frameworks are first briefly introduced, followed by a short summary of recent research on refugee mental health. We then provide an update on the current status of research, service provision, and health policy in the leading destinations for Syrians who have been forcibly displaced. This starts within Syria and then turns to Turkey, Lebanon, Jordan, and Germany. Finally, several general recommendations are discussed, including the pressing need for more data at each phase of migration, the expansion of integrated mental health services, and the explicit inclusion and prioritization of refugee mental health in national and global health policy. (shrink)

In this chapter we outline ethical issues raised by the application of public health approaches to the field of mental health. We first set out some of the basics of public health ethics that are particularly relevant to mental health, with special attention to the ongoing debate over the traditional presumption of non-infringement, increased recognition of the social determinants of health, and the concept of prevention. Then we turn to the moral particularities of mental health, focusing on questions concerning coercion (...) and treatment pressure, personal identity and sociocultural factors (including stigma), and unresolved conceptual and methodological issues in psychiatry that complicate its extension into the domain of public health. (shrink)

This chapter examines the core explanatory strategies of cognitive science and their application to the study of psychopathology. In addition to providing a taxonomy of different strategies, we illustrate their application, with special attention to Autism Spectrum Disorder and Major Depressive Disorder. We conclude by considering two challenges to the prospects of a developed cognitive science of psychopathology.

The topic of coercion has a long and contentious history in both political philosophy and medical ethics. This substantial literature centers on two fundamental questions: What is coercion? And when is it justified? In the context of psychiatry there has been a recent upsurge of interest in coercion, with particular focus on the latter question. For example, a number of research groups have been investigating the relationship between coercion and clinical outcomes. But of course such research relies heavily on assumptions (...) about the former question, that of the concept of coercion. Coercion is often tracked in these studies by various measures of “perceived coercion,” in response to the recognition that involuntary legal status is a poor gauge of the presence of coercion. A result of this approach is that empirical research has started to provide an interesting picture of a variety of coercive pressures and experiences. And these newly emerging findings, in turn, underscore the need for further conceptual analysis. The aim of this paper, then, is to draw out provisional implications for philosophical debates about coercion from recent research in psychiatry. (shrink)

Background: The aim of this study was to investigate associations between demographic and clinical variables and duration of untreated psychosis (DUP) in a sample of cases of psychosis across an adult early intervention in psychosis service and a child and adolescent community team. Method: Cross-sectional baseline data for cases of psychosis across the two teams on the caseload at a given time point were collected, including age of onset, gender, ethnicity, referral route, and DUP. Results: The median DUP across the (...) entire sample was 91 days, while those patients with initial treatment for psychosis from the child and adolescent team had a median DUP of 69 days. Using multiple linear regression, there were two variables that showed a significant association with DUP: referral route (p < .001), and age of onset, with earlier age of onset associated with shorter DUP (p = .015). Conclusion: These findings are discussed in relation to possible explanatory factors, with particular focus on service-level variables and pathways to care. It is suggested that the involvement of child and adolescent teams is vital to the work of early intervention in psychosis services. (shrink)

Recent cognitive models of delusions have attempted to explain why delusions are commonly circumscribed, in that they tend to center on isolated beliefs, and incorrigible, as they often persist in the face of countervailing evidence. In this effort, the suggestion has been made that ‘modularity’ – a concept originating in seminal accounts of the architecture of perceptual and cognitive processes – may help explain delusions. The aim of this paper is to take up this suggestion, critically evaluating the applicability of (...) modularity and its attendant features to the explanation of delusions. The conclusion presented here is that although a modular explanation of delusions may be relatively consistent with models that implicate dysfunctional cognitive components such as motor control and ‘theory of mind’ (ToM) systems, ultimately the application of modularity to delusions conflicts with traditional understandings of cognitive architecture and does not help provide satisfactory or sufficient explanations of delusional symptomatology. (shrink)

Narcissism continues to be an important topic of research, with a great deal of ongoing empirical work in social and personality psychology. But there are theoretical issues that have received less attention recently, including those that relate to the foundational theories of the psychoanalytic tradition. As the first step in a larger project of reevaluation, this article offers a critical review of Freud and Heinz Kohut’s theories of narcissism. Centered on a theoretical reconstruction, it clarifies several significant – and often (...) underspecified – features of each account. I also explore the continuities and discontinuities between these two closely related systems. Most notably, both Freud and Kohut lacked fully developed accounts of primary narcissism and the relevant instinctual drives. At the same time, Kohut’s theory expanded upon Freud’s in innovative ways, particularly with its emphasis on a secondary line of narcissistic development that has positive, transformative features. In the final section, however, I introduce a speculative reading that describes theoretical prefigurations of these features in elements of Freud’s structural theory. (shrink)

Bioethics has increasingly become a standard part of medical school education and the training of healthcare professionals more generally. This is a promising development, as it has the potential to help future practitioners become more attentive to moral concerns and, perhaps, better moral reasoners. At the same time, there is growing recognition within bioethics that nonideal theory can play an important role in formulating normative recommendations. In this chapter we discuss what this shift toward nonideal theory means for ethical curricula (...) within healthcare education. In particular, we contend that more attention to the particularities of historical and social context needs to be incorporated into bioethics training. To make this argument, we focus on two examples: teaching units on race and medicine and those that focus on stigma and coercion in mental health. For both, we show how a pedagogical approach in which educators focus on social injustice could influence how practitioners engage in ethics in the clinic. This chapter, then, demonstrates what a commitment to nonideal theory can mean practically when it comes to bioethics education. (shrink)

The last few years have seen a marked increase of interest in the ethics of psychotherapy. As the field of mental health has recently taken on a new level of prominence, renewed commitment to the ethical analysis of psychiatric and psychological treatment is clearly required. In this review essay, we survey recent work on psychotherapy ethics, taking a critical yet generally sympathetic view of the new literature. There are important considerations that remain neglected or overlooked entirely, in our view, and (...) several substantive and methodological trends are in need of diagnosis and critical response. We structure the discussion around several themes, including the inherently moral nature of psychotherapy, the heterogeneity of such practices, the significance of social, cultural, and historical context, and, finally, questions concerning prevailing methodological assumptions. (shrink)

Bipolar affective disorder (BPAD) can be a devastating disorder for both sufferers and their relatives. In addition to the variety of distressing and severe affective symptoms, the consequences of illness onset may be equally debilitating, particularly as the illness may commonly present in early adulthood. As such, the developmental trajectory between late adolescence and early adulthood is commonly interrupted. Relationships with family, friends and partners may deteriorate, employment or studies may be interrupted, and criminal histories may be acquired. In turn, (...) such events worsen stress, reduce self-esteem, and may make the recovery process more difficult.... (shrink)

In the most inclusive sense, psychological mechanisms offer a type of causal explanation of mental states and behavior, often with reference to underlying processes, systems, activities, or entities. By postulating and investigating such mechanisms, researchers have sought explanations of a wide range of psychological phenomena. However, the concept has been deployed in dramatically different ways, with very different meanings, depending upon the particular school or tradition of psychology (and specific research program therein). In fact, usage has been so diverse as (...) to defy easy categorization or definition. But a historical perspective, even if rather selective, can trace the broad outlines of the significance of psychological mechanisms for the study of the mind. Perhaps most notable is the role they have played in the psychoanalytic tradition; research efforts within behaviorism and cognitive science have also made liberal use of versions of the concept in their explanatory frameworks (for discussion of evolutionary psychology, see the entry “evolved psychological mechanisms”). Cutting across all of these traditions are several key themes relating to psychological mechanisms, including questions concerning the scope of the relevant causal claims, debates about causal determinism and regularity, and the unresolved relation between mind and body. (shrink)

This chapter reviews past and present debates about the therapeutic relationship in order to draw out the ethical implications of relational practices in psychotherapy. The therapeutic relationship has been understood differently across psychotherapeutic approaches, with each tradition responding to the attendant ethical challenges in distinctive ways. Aside from practitioners’ theoretical and practical commitments, the therapeutic relationship has also been, and continues to be, shaped by broader societal influences. The chapter discusses the shifting ethical implications of relational practices, then, as situated (...) in their theoretical and historical contexts. The variability of concerns raised by the therapeutic relationship requires continued ethical analysis in order to confront the diversity and complexity of contemporary clinical practice. (shrink)

In this introduction to the edited volume, we briefly describe some of the current challenges faced by public mental health initiatives, at both the national and global level. We also include several general remarks on interdisciplinary methodology in public mental health ethics, followed by short descriptions of the chapters included in the volume.

There are any number of important but frequently neglected research programs in biomedical ethics. Notable amongst these are projects deeply grounded in the history of philosophy as well as critical treatments of the methodological contours of the field. Fortunately the present volume, Applied Ethics in Mental Health Care: An Interdisciplinary Reader (MIT Press, 2013), edited by Dominic Sisti, Arthur Caplan, and Hila-Rimon-Greenspan, addresses another commonly overlooked topic, that of mental health – or psychiatric – ethics. Indeed, it can be argued (...) that the multidisciplinary field of mental health is particularly deserving of ethical analysis given several of its special features. These include the relative emotional and cognitive vulnerability of mental health patients, the highly personal and confidential information involved in therapeutic encounters, and the use of the therapeutic relationship itself as an instrument of treatment (Radden, 2002; APA, 2009). And of course these attributes figure against a background of broader, quite topical issues, such as recent developments in psychiatric classification and ongoing policy debates on the funding structure of healthcare systems (including the issue of coverage parity for mental health treatment). (shrink)

Nunez's description of the brain as a medium capable of wave propagation has provided some fundamental insights into its dynamics. This approach soon reaches the descriptive limits of the brain as a physical system, however. We point out some biological constraints which differentiate the brain from physical systems and we elaborate on its consequences for future research.

Recent advances in DNA sequencing have revolutionized the field of genomics, making it possible for even single research groups to generate large amounts of sequence data very rapidly and at a substantially lower cost. These high‐throughput sequencing technologies make deep transcriptome sequencing and transcript quantification, whole genome sequencing and resequencing available to many more researchers and projects. However, while the cost and time have been greatly reduced, the error profiles and limitations of the new platforms differ significantly from those of (...) previous sequencing technologies. The selection of an appropriate sequencing platform for particular types of experiments is an important consideration, and requires a detailed understanding of the technologies available; including sources of error, error rate, as well as the speed and cost of sequencing. We review the relevant concepts and compare the issues raised by the current high‐throughput DNA sequencing technologies. We analyze how future developments may overcome these limitations and what challenges remain. (shrink)

We believe that the task goal in voluntary movements provides meaning to existing information sources in the environment and determines, in a dynamic way, the use and relative importance of these different sources. This task-centered meaning bridges the apparent controversy between what information is available in principle (i.e., specification), and what information is perceived.

Circadian rhythm abnormalities in bipolar disorder have led to a search for genetic abnormalities in circadian "clock genes" associated with BD. However, no significant clock gene findings have emerged from genome-wide association studies. At least three factors could account for this discrepancy: complex traits are polygenic, the organization of the clock is more complex than previously recognized, and/or genetic risk for BD may be shared across multiple illnesses. To investigate these issues, we considered the clock gene network at three levels: (...) essential "core" clock genes, upstream circadian clock modulators, and downstream clock controlled genes. Using relaxed thresholds for GWAS statistical significance, we determined the rates of clock vs. control genetic associations with BD, and four additional illnesses that share clinical features and/or genetic risk with BD. Then we compared the results to a set of lithium-responsive genes. Associations with BD-spectrum illnesses and lithium-responsiveness were both enriched among core clock genes but not among upstream clock modulators. Associations with BD-spectrum illnesses and lithium-responsiveness were also enriched among pervasively rhythmic clock-controlled genes but not among genes that were less pervasively rhythmic or non-rhythmic. Our analysis reveals previously unrecognized associations between clock genes and BD-spectrum illnesses, partly reconciling previously discordant results from past GWAS and candidate gene studies. (shrink)