Lauder S, Chester A, Castle D, Dodd S, Gliddon E, Berk L, et al. A randomized, head-to-head study by MoodSwings.net.au: An Internet-based support program for bipolar disorder. J affect Disord. 2015;171:13–21. The MoodSwings 2.0 alarm signal monitoring system (see Fig. 2, 3) is designed to identify and guide participants who may be approaching a clinical crisis. While MoodSwings 2.0 was designed to complement local clinical care, a Red Flag system provides an ethical approach to fulfilling participants` clinical responsibility. When a participant signed consent and enrolled in the study, they had to provide information to someone who could be reliably contacted in an emergency. During regular online and telephone reviews, there were two basic ways to get a “red flag” from the system.
First, scores above a validated threshold on various self-reports or interview-based feeling-related actions generated a red flag that sends an automated internal email with instructions to the participant to contact their healthcare provider. Most of these were the result of high overall scores on assessments of depression or mania, and in such cases, study staff reassessed mood within 7 days. The challenges in choosing treatment are not limited to pharmacological interventions. Annette Mendola and Richard L. Gibson evaluate the effectiveness of widely used substance and addiction treatment programs and how a clinician might proceed ethically given the limited evidence available. Challenges may also arise from patients` attitudes toward treatment. In a case commentary, Constance E. George discusses the ethical challenges psychiatrists face when all treatments fail; She questions if and when depression should ever be considered an incurable disease and considers the nature, scope and relevance of a physician`s role in promoting hope for patients with refractory depression. One of the most commented blogs I`ve written in my 15-year blogging career is the one about bipolar disorder and job performance.
Comments range from praise to criticism for my inability to properly explain bipolar disorder. I think it`s a good time to review my latest blog on the subject and share some of my readers` comments. I have not named them in order to preserve the confidentiality with which I ask readers to comment. The appropriate use of online resources depends, in part, on an appropriate correspondence between the resource and the participant`s problem. A challenge for online resources is self-diagnosis and self-selection for treatment. Bipolar disorder is notoriously complex to diagnose and has many differential diagnoses. A significant degree of diagnostic instability characterizes all psychiatric diagnoses. And “externalized” diagnoses, such as bipolar disorder, may be more appealing to people than some “internalizing” diagnoses, such as personality disorders. All of this is reinforced by Internet resources that rely much more on self-diagnosis and self-selection than on face-to-face therapy and research. This carries some risk and a corresponding ethical question, which will pose a challenge for the field. MoodSwings 2.0 used phone interviews as a partial solution to this problem, but many online testing websites don`t have the resources to do so, which is not feasible if one wants to realize the promise of scale-independent adoption of these resources. Keywords: bioethics; Bipolar disorder; Stigmatization.
Among the strengths and benefits of the Red Flag surveillance system, MoodSwings 2.0, was its benevolent goal of catching participants during clinical crises and helping them by encouraging them to contact local health care providers. Most of the time, the research team agreed that the red flag system was useful to participants and researchers. However, there were notable exceptions where implied limitations had to be highlighted. For example, if study staff cannot or cannot communicate with a participant or emergency contact by telephone for several days, what measures should be taken to ensure patient safety? This is an ethical grey area associated with online interventions. How long should study staff continue to communicate with them? What if a participant is excited about MoodSwings 2.0`s automated email communication, which can happen up to once a week when they`re in the middle of the episode? Psychiatry is a critical but often overlooked area of medicine. Although mental illness and substance use disorders are the leading cause of disability worldwide [1], 2014 World Health Organization (WHO) statistics show that the median number of practicing psychiatrists worldwide is 0.1 per 10,000 people [2]. In the United States, we have more than ten times that number – 1.2 psychiatrists per 10,000 inhabitants [2] – and yet federal statistics suggest that more than half of the counties in this country do not have a single behavioral medicine practitioner [3]. A recent study found that the average wait time for a first outpatient psychiatric clinic in large urban areas is 25 days [4].
Here are some of the responses I`ve received on this blog and others about bipolar disorder. The potential benefits for participants in programs such as MoodSwings 2.0 are substantial. Access to specialized care and evidence-based clinical information for bipolar disorder is often difficult for patients, especially those living in rural areas or with minimal financial resources (Zeber et al. 2009). Consumers are often forced to seek personal medication management from available doctors who may be excellent GPs but have no specialist training in treating serious mental illnesses such as bipolar disorder. From home, MoodSwings participants were able to access psychoeducational materials reviewed by global experts in bipolar disorder. In addition, individuals interacted in discussion forums, supported each other, and shared tips and techniques with others around the world struggling with similar mood symptoms. A recent open-label pilot study of a mindfulness-focused intervention for advanced bipolar disorder modeled obtaining ethics approval in one national jurisdiction (Swinburne University, Australia) and focused on efforts to recruit one study into another (Canada) (Murray et al. 2015). This seems to be an ideal, honest and transparent model for multinational Internet-based intervention research initiatives. Participants can then be clearly informed in consent documents that the project they intend to participate in has undergone ethical review by a single institution in a given geographic and legal jurisdiction.
The challenge in a consent document then seems to be to practically inform potential participants that it does not matter if they themselves are still bound by legal and ethical precedent in their own geographical jurisdiction. Perlis RH, Ostacher MJ, Patel JK, Marangell LB, Zhang H, Wisniewski SR, et al. Predictors of recurrence in bipolar disorder: primary outcomes of the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). Am J Psychiatry. 2006;163(2):217-24. Quetiapine and lithium have overlapping but distinct roles at different stages of bipolar disorder, and further studies of these drugs (especially in combination with each other) are warranted. Sensitivity to others in the workplace who are different from the “average” employee is an issue that is becoming increasingly important. Whether it`s bipolar disorder, autism or other learning disabilities, it`s important for managers to understand how best to treat workers as individuals with individual needs and not treat everyone equally. An ethical workplace fosters a welcoming environment for people of different religions, nationalities, races, genders, sexual orientations, etc., but also for people with differently diagnosed mental disorders. The Diagnostic and Statistical Manual of Mental Disorders defines bipolar disorder into two categories: bipolar I and bipolar II.
Bipolar I people experience one or more manic/mixed episodes followed by a major depressive episode, while bipolar II people experience one or more depressive episodes followed by a hypomanic episode. Bipolar I is more severe than bipolar II. One commentary suggests that “the speed at which the Internet can create new ethical dilemmas has so far naturally outpaced the speed at which organized psychology can develop ethical principles in a prudent and deliberate manner” (Humphreys et al. 2000). The development of the MoodSwings 2.0 program and accompanying study represented a collision of many different “worlds,” including proprietary software development companies, academics from the United States and Australia, clinical researchers accustomed to studies personally involving human subjects, ethics boards with standards designed for personal studies, and participants with serious mental illness from around the world.