Dominic A. Sisti

Improving long-term psychiatric care: bring back the asylum.

This Viewpoint discusses new models for patient-centered, long-term psychiatric care in the United States.

How Do High School Students Justify Internet Plagiarism

Internet plagiarism continues unabated and may even be increasing. Questions pertaining to the ethical-moral construct employed by students to justify Internet plagiarism among high school students have remained relatively untouched. Understanding not simply the prevalence of Internet plagiarism but also the variety of explanations used by students to justify their plagiarism seems crucial to curtailing its practice. In this study, I surveyed 160 high school students and endeavored to understand and describe the practices of students who use the Internet for schoolwork and who engage in copy-paste plagiarism or paper-buying practices. The results indicate that students are more easily able to justify copy-paste plagiarism for a variety of reasons that mirror justifications of other forms of conventional plagiarism. Most students indicated they would never purchase a paper for reasons ranging from fear of getting caught to more principled and nuanced ethical claims. Based on these results I also offer educators suggestions for refining assignments and evaluation methods.

Immune to addiction: the ethical dimensions of vaccines against substance abuse

Promising advances have been made in recent years for a unique class of immunotherapies that use vaccination to combat substance-use disorders. Although such vaccines are potentially useful for addictions, they raise a variety of ethical and social questions.

Proceed with Caution: Off-label Ketamine Treatment for Major Depressive Disorder

Ketamine offers a promising new option for the treatment of depression, but its increasing off-label use is ethically and clinically inappropriate at the moment.

Defining mental illnesses: can values and objectivity get along?

BackgroundThe creation of each edition of the Diagnostic and Statistical Manual (DSM) of psychiatry has proven enormously controversial. The current effort to revise the ‘bible’ of disorder definitions for the field of mental health is no exception. The controversy around DSM-5 reached a crescendo with the announcement from National Institute of Mental Health (NIMH) that the institute would focus efforts on the development of their own psychiatric nosology, the Research Domain Criteria (RDoC) (NIMH, 2013).DiscussionThe RDoC seem to be structured around the concern that the only way to find objectivity in the classification of diseases or disorders in psychiatry is to begin with biology and work back to symptoms. Values infuse medical categories in various ways and drive practical considerations about where and how to divide up constellations of already agreed upon symptoms.SummaryWe briefly argue that all nosologies are infused with values and, while we should continue to sharpen the psychiatric nosology, normativity will permeate even the strictest biologically based taxonomy; this need not be a bad thing.

Views about responsibility for alcohol addiction and negative evaluations of naltrexone

BackgroundMoral philosophers have debated the extent to which persons are individually responsible for the onset of and recovery from addiction. Empirical investigators have begun to explore counselors’ attitudes on these questions. Meanwhile, a separate literature has investigated counselors’ negative attitudes towards naltrexone, an important element of medication-assisted treatment for alcohol addiction. The present study bridges the literature on counselor views about responsibility for addiction with the literature on attitudes towards naltrexone. It investigates the extent to which a counselor’s views of individual responsibility for alcohol addiction are related to that counselor’s views of naltrexone.MethodsUsing a vignette-based survey of 117 addiction treatment professionals, the study analyzes the relationship between an addiction counselor’s views about individual responsibility for alcohol addiction and using naltrexone to treat it.ResultsWe find a significant difference in counselors who assign greater responsibility to a person for the onset of alcohol addiction. They agreed more strongly with several objections to naltrexone, including worries about compliance, naltrexone’s side effects outweighing its benefits, naltrexone treating symptoms but not underlying causes, and the idea that medication may undermine a person’s motivation to recover. Combined views of greater responsibility for addiction’s onset and recovery also significantly predicted stronger agreement with objections.ConclusionsWe conclude that there is a strong relationship between a counselor assigning higher individual responsibility for addiction and holding more negative views about naltrexone. The study also sheds light on one reason why the model of addiction as a brain disease has had limited impact on clinical practice.

The ethical boundaries of patient and advocate influence on DSM-5.

&NA;This article discusses the relationship between disease-advocacy groups and the revision process for the Diagnostic and Statistical Manual of Mental Disorders. We discuss three examples in which patient-advocacy groups engaged with the DSM-5 revision process: Autism Speaks’ worries about the contraction of the autism diagnostic category, the National Alliance on Mental Illness’s support for the inclusion of psychosis risk syndrome, and B4U-ACT’s critique of the expansion of pedophilia. After a descriptive examination of the cases, we address two prescriptive questions. First, what is the ethical basis for patient and advocate influence on DSM diagnoses? Second, how should the American Psychiatric Association proceed when this influence comes into conflict with other goals of the revision process? We argue that the social effects of, and values embedded in, psychiatric classification, combined with patient and advocates’ experiential knowledge about those aspects of diagnosis, ethically justify advocate influence in relation to those particular matters. However, this advocate influence ought to have limits, which we briefly explore. Our discussion has implications for discussions of disease categories as loci for social movements, for analyses of the expanding range of processes and institutions that advocacy groups target, and for broader questions regarding the aims of the DSM revision process.

The Ethics of Behavioral Health Information Technology: Frequent Flyer Icons and Implicit Bias

A subpopulation of individuals with serious mental health conditions makes repeated and frequent visits to emergency departments and psychiatric crisis centers. These so-called super utilizers often have financial problems and present with chronic or untreated comorbid psychiatric and substance use disorders.1 These patients are often well known to clinical staff and are sometimes colloquially labeled “frequent flyers.” A pejorative branding, “frequent flyers” are often assumed to be problem patients. In psychiatric settings, these patients are sometimes said to be “borderlines,” “drug seekers,” “malingerers,” or “treatment resistant.” These patients can be identified in different ways. Some emergency departments maintain lists or files of patients with frequent visits. One electronic medical record system provides an airplane icon, which system administrators may elect to configure so that clinicians can identify a patient as a high utilizer. The icon appears near the patient’s name and various colors indicate strata of utilization. This iconography is ethically and clinically inappropriate for 2 interdependent reasons. First, the icon reinforces and encourages the use of disrespectful and stigmatizing terminology. Second, the icon may frame the

Assessing Decision-Making Capacity: A Primer for the Development of Hospital Practice Guidelines

Decision making capacity (DMC) is a fundamental concept grounding the principle of respect for autonomy and the practice of obtaining informed consent. DMC must be determined and documented every time a patient undergoes a hospital procedure and for routine care when there is reason to believe decision making ability is compromised. In this paper we explore a path toward ethically informed development and implementation of a hospital policy related to DMC assessment. We begin with a review of the context of DMC assessment before discussing some considerations relevant to policy creation by healthcare ethics committees. The discussion concludes in a presentation of a typology of capacity assessment policies, which draws upon a sampling of currently used hospital policies to illustrate relevant ethical considerations.

County Jail or Psychiatric Hospital? Ethical Challenges in Correctional Mental Health Care:

Approximately 20% of the roughly 2.5 million individuals incarcerated in the United States have a serious mental illness (SMI). As a result of their illnesses, these individuals are often more likely to commit a crime, end up incarcerated, and languish in correctional settings without appropriate treatment. The objective of the present study was to investigate how correctional facility personnel reconcile the ethical challenges that arise when housing and treating individuals with SMI. Four focus groups and one group interview were conducted with employees (n = 24) including nurses, clinicians, correctional officers, administrators, and sergeants at a county jail in Pennsylvania. Results show that jail employees felt there are too many inmates with SMI in jail who would benefit from more comprehensive treatment elsewhere; however, given limited resources, employees felt they were doing the best they can. These findings can inform mental health management and policy in a correctional setting.