Charlotte Blease

Too many ‘friends,’ too few ‘likes’? Evolutionary psychology and ‘Facebook depression’.

Psychologists (and subsequently the media) have defined ‘Facebook depression’ as the affective result of spending too much time on the social networking site (Selfhout et al., 2009; Kross et al., 2013). Some social psychologists have denied that Facebook is causally implicated in any such negative affect (Jelenchick et al., 2013). This article argues that if we want to understand modern mass media and new social media, we need a better understanding of the (old) psychology bequeathed us by natural selection (Barkow et al., 2012). Disentangling the relationship between social media and depression using evolutionary social competition theories of depression, I argue that the mismatch between current social milieu and the environment of evolutionary adaption affords some predictions about the use of social media as a trigger for mild depression or dysphoria. I hypothesize that users of Facebook may be more susceptible to causal triggers for mild depression under the following (specific) circumstances: (a) the greater the number of ‘friends’ that the user has online; (b) the greater the time that the user spends reading updates from this wide pool of friends; (c) the user does so regularly; and (d) the content of the updates tends to a bragging nature. I hypothesize that the frequency and the number of displays of higher status cues observed by the user may incur the perception of low relative social value among users (automatically triggering this response). The article concludes with directions for future research on the behavioral and cognitive effects of social media sites such as Facebook.

Are Open‐Label Placebos Ethical? Informed Consent and Ethical Equivocations

The doctor-patient relationship is built on an implicit covenant of trust, yet it was not until the post-World War Two era that respect for patient autonomy emerged as an article of mainstream medical ethics. Unlike their medical forebears, physicians today are expected to furnish patients with adequate information about diagnoses, prognoses and treatments. Against these dicta there has been ongoing debate over whether placebos pose a threat to patient autonomy. A key premise underlying medical ethics discussion is the notion that the placebo effect necessitates patient deception. Indeed, the American Medical Association guidelines imply that placebo treatment necessary entails a form of deception. As a consequence of this assumption, the fulcrum of debate on the use of placebo treatment has hinged on whether that deception is ever justified. Recently performed experiments with open-label transparently prescribed placebos have begun to challenge the notion that deception is necessary in eliciting the placebo effect and such effects necessarily involve a binary distinction between autonomy and beneficence. In this article we focus on the content of disclosures in distinctive open-label, transparently disclosed placebo studies and inquire whether they might be said to invoke deception in clinical contexts, and if so, whether the deception is unethical. We find that open placebos may be said to involve equivocation over how placebos work. However, drawing on surveys of patient attitudes we suggest that this equivocation appears to be acceptable to patients. We conclude that open placebos fulfil current American Medical Association guidelines for placebo use, and propose future research directions for harnessing the placebo effect ethically.

Electroconvulsive therapy, the placebo effect and informed consent

Major depressive disorder is not only the most widespread mental disorder in the world, it is a disorder on the rise. In cases of particularly severe forms of depression, when all other treatment options have failed, the use of electroconvulsive therapy (ECT) is a recommended treatment option for patients. ECT has been in use in psychiatric practice for over 70 years and is now undergoing something of a restricted renaissance following a sharp decline in its use in the 1970s. Despite its success in treating severe depression there is continued debate as to the effectiveness of ECT: in some studies, it is argued that ECT is marginally more effective than sham ECT. In addition, there is still no clear explanation of how ECT works; among the range of hypotheses proposed it is claimed that ECT may work by harnessing placebo effects. In light of the uncertainties over the mechanism of action of ECT and given the risk of serious side effects that ECT may produce, I contend that the process of informed consent must include comprehensive accounts of these uncertainties. I examine the possible consequences of providing adequate information to potential ECT patients, including the consideration that ECT may still prove to be effective even if physicians are open about the possibility of it working as a placebo. I conclude that if we value patient autonomy as well as the professional reputation of medical practitioners, a fuller description of ECT must be provided to patients and their carers.

Deception as treatment: the case of depression

Is it ever right to prescribe placebos to patients in clinical practice? The General Medical Council is ambivalent about the issue; the American Medical Association asserts that placebos can be administered only if the patient is (somehow) ‘informed’. The potential problem with placebos is that they may involve deception: indeed, if this is the case, an ethical tension arises over the patients autonomy and the physicians requirement to be open and honest, and the notion that medical care should be the primary concern. This paper examines the case of depression as an entry point for understanding the complexities of the prescription of placebos. Recent important meta-analyses of antidepressants claim that they are not significantly more effective in a clinical setting than placebos. Given that antidepressants have numerous adverse side effects and are hugely expensive, this provocative research has serious potential ethical and practical implications for patients and medical providers. Should placebos be prescribed in place of antidepressants? The case of depression highlights another important issue which medical ethical codes have hitherto overlooked: well-being is not synonymous with being realistic about oneself, ones circumstances and the future. While severely depressed individuals are unduly pessimistic about themselves and the world around them, treatment of depressed individuals can be deemed successful when patients have successfully attained those positive illusions that are indicative of psychological health. This is exactly what successful psychological treatments of depression seem to achieve. It is therefore possible that there may be a limited unavoidable role for deception in medicine.

Talking more about talking cures: cognitive behavioural therapy and informed consent

Cognitive behavioural therapy (CBT) has risen to prominence as an orthodox treatment option which is commonly recommended to patients with anxiety and depressive disorders. Mainstream healthcare institutions (including the National Health Service in the UK (NHS) and National Institute for Mental Health (NIMH)) assume that CBT works by helping patients to challenge and overcome ‘faulty cognition’. Even if we accept the empirical evidence which shows that CBT (like other forms of psychotherapy) is a beneficial treatment there are still problems with this therapy: mainstream medicine and psychotherapy are continuing to ignore established research that CBT does not work according to its core theoretical tenets. This paper presents evidence that psychotherapy is entrenched in such conventional ‘wisdom’ and that practitioners are failing to meet their own codified requirement of informed consent. I examine ethical arguments for and against upholding current informed consent procedures and focus, in particular, on the relationship between respect for patient autonomy and the duty of beneficence. I argue that (so far) there are no strong grounds for the claim that patient autonomy undermines therapeutic outcome. The modest conclusion of this paper is that psychotherapy (including CBT) needs to begin to adapt informed consent procedures to comply with ongoing scientific research into its efficacy.

The duty to be Well-informed: The case of depression

It is now an ethical dictum that patients should be informed by physicians about their diagnosis, prognosis and treatment options. In this paper, I ask: ‘How informed are the ‘informers’ in clinical practice?’ Physicians have a duty to be ‘well-informed’: patient well-being depends not just in conveying adequate information to patients, it also depends on physicians keeping up-to-date about: (1) popular misunderstandings of illnesses and treatments; and (2) the importance of patient psychology in affecting prognosis. Taking the case of depression as an entry point, this paper argues that medical researchers and physicians need to pay serious attention to the explanations given to patients regarding their diagnosis. Studies on lay understanding of depression show that there is a common belief that depression is wholly caused by a ‘chemical imbalance’ (such as ‘low serotonin’) that can be restored by chemically restorative antidepresssants, a claim that has entered ‘folk wisdom’. However, these beliefs oversimplify and misrepresent the current scientific understanding of the causes of depression: first, there is consensus in the scientific community that the causes of depression include social as well as psychological triggers (and not just biochemical ones); second, there is significant dissensus in the scientific community over exactly what lower level, biological or biochemical processes are involved in causing depression; third, there is no established consensus about how antidepressants work at a biochemical level; fourth, there is evidence that patients are negatively affected if they believe their depression is wholly explained by (the vague descriptor) of ‘biochemical imbalance’. I argue that the medical community has a duty, to provide patients with adequate information and to be aware of the negative health impact of prevalent oversimplifications—whatever their origins.

Informed consent and clinical trials: where is the placebo effect?

Lack of knowledge about placebos affects participants’ understanding of trials and breaches the ethical obligations of researchers, argue C R Blease, F L Bishop, and T J Kaptchuk

Epistemic injustice in healthcare encounters: evidence from chronic fatigue syndrome

Chronic fatigue syndrome or myalgic encephalomyelitis (CFS/ME) remains a controversial illness category. This paper surveys the state of knowledge and attitudes about this illness and proposes that epistemic concerns about the testimonial credibility of patients can be articulated using Miranda Frickers concept of epistemic injustice. While there is consensus within mainstream medical guidelines that there is no known cause of CFS/ME, there is continued debate about how best to conceive of CFS/ME, including disagreement about how to interpret clinical studies of treatments. Against this background, robust qualitative and quantitative research from a range of countries has found that many doctors (and medical students) display uncertainty about whether CFS/ME is real, which may result in delays in diagnosis and treatment for patients. Strikingly, qualitative research evinces that patients with CFS/ME often experience suspicion by healthcare professionals, and many patients vocally oppose the effectiveness, and the conceptualisation, of their illness as psychologically treatable. We address the intersection of these issues and healthcare ethics, and claim that this state of affairs can be explained as a case of epistemic injustice (2007). We find evidence that healthcare consultations are fora where patients with CFS/ME may be particularly vulnerable to epistemic injustice. We argue that the (often unintentional) marginalisation of many patients is a professional failure that may lead to further ethical and practical consequences both for progressive research into CFS/ME, and for ethical care and delivery of current treatments among individuals suffering from this debilitating illness.

In defence of utility: the medical humanities and medical education

The idea that a study of the humanities helps to humanise doctors has become a leitmotif within the field. It is argued that the humanities (especially, literature) help to foster insights beyond those provided by biomedical training. Healthy young medics, it is claimed, can thereby gain significant insights into patienthood, and obtain important skills that may be valuable for their professional life. But the instrumentality of the humanities is not the only justification proffered for its inclusion in medical curricula. In this paper I critically examine the two overarching justifications recurrently cited in the mainstream literature—namely, (1) the instrumental worth and (2) the intrinsic value of the medical humanities in educating doctors. Examining these theses (and focusing on the views of a leading medical humanities scholar) I show that the bifurcation into instrumental versus non-instrumental justifications is not supported by the argumentation. Instead, I find that the particulars of the supposedly intrinsic justifications amount to an unambiguously instrumental defence of the humanities. Contextualizing the present investigation to probe further, I describe a long history of debate about the role of the humanities in British education and find that it rests on unsupported dichotomies (utility vs non-utility, theoretical vs applied, educated vs trained). I conclude that the medical humanities’ manifesto would be more intellectually honest and coherent, and provide a more robust defence of its value in medical education, if it chose to embrace a wholly instrumental rationale for its role.

Mental health illiteracy? Perceiving depression as a disorder.

World Health Organization statistics reveal that depression is not only one of the leading causes of disability in the world today but it is an illness on the rise. I review research into public attitudes to depression and the effectiveness of recent education campaigns. I contend that while there appears to be evidence that depression is met with serious and persistent stigma, there is a dearth of research in this area. In this article, I forward an explanation for how we might understand the apparent persistence of, and some of the stigmatizing responses to, depression; I term this hypothesis the “Cheater-Detection Model of Depression Stigmatisation” (CDMD). This article proposes that certain behavioral traits associated with depression (specifically: fatigue, cognitive and motor retardation, occupational impairment) may be detected (erroneously) via a specific suite of cognitive mechanisms which were selected for their capacity to gauge cooperation and social exchange among individuals. I argue that the symptoms of depressive behavior which interfere with social and occupational capacities may trigger responses which were selected for in order to avoid exploitation by “cheaters” (that is to say, individuals who are perceived to benefit from social exchange but who are not judged to reciprocate). Evolutionary psychology informs us that perception of cheating behavior tends to elicit affective responses such as anger and avoidance: I argue that some symptoms of depression tend to induce “false-positive” stigmatizing responses. I conclude that until we understand the cognition underlying stigmatization we cannot expect to target it effectively.