Mental illnesses affect men and women, children and the elderly, and communities and entire nations. Neuropsychiatric disorders, moreover, are the second-leading cause of disability throughout the world. Psychiatry centers on the care of people living with these severe and burdensome illnesses, and over the past 3 decades in particular, our profession has sought advances both in the neuroscience of these illnesses and in the development of novel, evidence-based treatments—including psychopharmacological interventions.1
Psychotropics are now among the most commonly prescribed of all medications, and the widened use of these agents has improved the lives of millions of individuals living with mental illness. Nevertheless, greater reliance on psychotropics has created ethical and societal concerns. Some concerns relate to the risks of pharmacological interventions, such as the paradoxical finding that depressed children who take antidepressants may have an increased risk of suicidal behavior relative to those receiving placebo. Moreover, there are potentially serious adverse metabolic effects (eg, hyperglycemia, diabetes) associated with atypical antipsychotics. There are also concerns about the widespread application (some would say overprescription) of psychotropics—a controversy that is further fueled by the fact that nonpsychiatric providers are the source of most psychotropic prescriptions in the United States.
There is no consensus that cosmetic psychopharmacology is absolutely unethical, and parallels have been drawn with plastic surgery for physical enhancement.
New ethical issues have arisen around the use of psychotropics (such as stimulants) to enhance the cognitive performance of healthy individuals. Readers are referred to a recent review of the “cosmetic” use of neuroenhancers by Geppert and Taylor.2
Psychopharmacological competency necessitates a sensitivity to ethical considerations (Figure 1).3 Our aim here is to provide a brief overview of how psychiatrists may approach psychopharmacological treatment in an ethical manner. We first describe the basis for prescribing these agents in sound clinical practice; we then briefly cover a handful of key topics on psychopharmacological ethics.
Basis for ethical prescribing
Before a patient is offered a psychotropic medication, a thorough diagnostic evaluation and careful review of the patient’s history (including past symptoms and response to treatment) are essential. Learning what the patient’s hopes, greatest concerns, and motivations are is essential to developing an appropriate therapeutic strategy that may include the use of psychopharmacological agents to address specific target symptoms. The goal is to prescribe psychotropic medications only when they are clearly indicated and when there is a strong evidence base. In many circumstances, combined biological and psychosocial interventions may offer the greatest therapeutic benefit.
What is already known about the ethical use of psychopharmacology?
? Psychotropic medications are among the most commonly prescribed of all pharmacological agents. Psychotropics have improved the lives of millions of individuals living with mental illness. Significant controversy exists surrounding ethical best practices in the prescription of psychotropics.
What new information does this article add?
? This article provides an overview of the salient ethical issues that practitioners encounter.
What are the implications for psychiatric practice?
? Psychiatrists who develop and refine their ethics “skill set” will be in a better position to anticipate and respond to ethical dilemmas as they arise in the course of their practice.
The ethical practitioner needs to keep up-to-date with empirical findings on all somatic and psychosocial treatments, including their indications, adverse effects, and contraindications. Moreover, clinicians who prescribe medications should be prepared to recommend relevant data-driven psychotherapies and psychosocial interventions that may be indicated as first-line treatment or as important adjunctive treatments—even if these must be provided by another practitioner. An ethical practitioner will also be able to engage in a trusting and grounded informed consent dialogue with the patient.
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