Bioethics for Breakfast: Mental Health Care Access: Making the Dollars and “Common Sense” Case for Parity

Bioethics for Breakfast Seminars in Medicine, Law and Society

Malkia Newman, Anti-Stigma Team Supervisor at CNS Healthcare, and Dr. Debra A. Pinals of MDHHS and the University of Michigan presented at the Feb. 25 Bioethics for Breakfast session, offering perspectives and insight on the topic “Mental Health Care Access: Making the Dollars and “Common Sense” Case for Parity.” Bioethics for Breakfast is generously sponsored by Hall, Render, Killian, Heath & Lyman.

People with mental health disabilities face disproportionately high rates of poverty, housing and employment discrimination, and criminalization. The upheaval caused by the coronavirus outbreak has exacerbated these disparities for those disabled prior to the crisis, while exposing more people to trauma, loss, and uncertainty. Considering mental health care from a justice and equity perspective, this session examined the following: 1) What social and ethical challenges are embedded in the current mental health epidemic? 2) How might such challenges be effectively addressed? 3) What community-based models can improve access? 4) What are the cost benefits of equitable treatment vs. cost of untreated mental healthcare in the U.S.?

Malkia Newman addressed the first question above on the social and ethical challenges embedded in the current mental health epidemic. Through sharing her personal life story, Ms. Newman focused on trauma, stigma, and disparities in behavioral healthcare. Ms. Newman defined types of trauma, focusing on inter-generational trauma. She noted that racism and social inequities are now regarded by many as a health crisis, especially in light of the COVID-19 pandemic. Stigma that individuals face can include many layers, and that stigma can exacerbate mental health and substance use disorders. With regard to mental health disparities, she shared that access to mental health care is only one piece—quality treatment, addressing the shortage of qualified providers, and the need for equitable funding of treatment for all individuals is also crucial. Many in the U.S. are facing financial insecurity, which can also exacerbate mental illness and be a barrier to accessing treatment. Bringing forth the idea of resilience, Ms. Newman ended by sharing her hope for the future, that “resilience can spring forth, and resilience can be taught.”

Dr. Debra A. Pinals provided a physician and policymaker perspective, first addressing the question: why is mental health relegated to second tier status in healthcare financing? There is a long history of viewing mental illness, including substance use disorders, as not being “real” illness—blame, stigma, and stereotypes still play a part in this attitude. Stigma “allows the discrimination of someone based on a label.” However, it is very important to understand that these are illnesses that have causes and treatments. COVID-19 may be putting more focus on mental health, and that may be one positive thing to come from the pandemic. What community-based models can improve access? Dr. Pinals discussed the problems with the current crisis system and the involvement of law enforcement when responding to a crisis, and then put forth a new model that would involve a behavioral health response, specially-trained law enforcement as a backup, and many other pieces related to community services and supports. Referencing her paper on crisis services, Dr. Pinals shared that improving access has to be accessible, interconnected, effective, and just. Dr. Pinals also discussed building out Certified Community Behavioral Health Clinics (CCBHCs) in Michigan, and the siloed nature of current services. Dr. Pinals emphasized the need to understand the existing disparities in mental health services, also discussing the prison system, the opioid epidemic, and child welfare impacts.

During the discussion portion, both speakers discussed the need to make space for people’s stories, particularly within the context of policy work. Ms. Newman shared the importance of including both behavioral health professionals and individuals with mental illness during the planning process for policies and programs, such that their input is actively included. Further discussion touched on teletherapy access and programs for youth and families.

Related Resources

About the Speakers

Malkia Newman
Malkia Newman is Anti-Stigma Team Supervisor at CNS Healthcare. Behavioral health conditions are common in Malkia’s family. Suicidal, unemployed, and homeless, Malkia accessed care at CNS Healthcare in 2004. Once stabilized, she was able to pursue a job with the CNS Healthcare Anti-Stigma Program in 2005. The Peer-Led program challenges stigma and provides community education on a number of different behavioral health topics. Using poetry, singing and other creative expressions, Malkia shows that “hope and recovery is possible.” The program has reached over 100,000 people in Detroit, Lansing, Marquette, MI; Washington, D.C., New York City, Houston, San Antonio, Las Vegas, Chicago, Phoenix, Honolulu, Hawaii, and Nova Scotia, Canada.

Debra A. Pinals, MD
Debra A. Pinals, MD, is the Medical Director of Behavioral Health and Forensic Programs for the Michigan Department of Health and Human Services, Director of the Program in Psychiatry, Law, & Ethics, Clinical Professor of Psychiatry at the University of Michigan Medical School, and Clinical Adjunct Professor at the University of Michigan Law School. Dr. Pinals’ roles have included serving as the Assistant Commissioner of Forensic Services as well as the Interim State Medical Director for the Massachusetts Department of Mental Health. She has worked in outpatient and inpatient settings, forensic and correctional facilities, emergency rooms and court clinics, has received public service awards, and has been an expert witness in many cases. She is Board Certified in Psychiatry, Forensic Psychiatry, and Addiction Medicine.

About Bioethics for Breakfast:
In 2010, Hall, Render, Killian, Heath & Lyman invited the Center for Ethics to partner on a bioethics seminar series. The Center for Ethics and Hall Render invite guests from the health professions, religious and community organizations, political circles, and the academy to engage in lively discussions of topics spanning the worlds of bioethics, health law, business, and policy. For each event, the Center selects from a wide range of controversial issues and provides two presenters either from our own faculty or invited guests, who offer distinctive, and sometimes clashing, perspectives. Those brief presentations are followed by a moderated open discussion.

Dr. Cabrera co-authors article in ‘Frontiers in Human Neuroscience’

Laura Cabrera photo

Center Assistant Professor Dr. Laura Cabrera is co-author of an article published last month in Frontiers in Human Neuroscience. Appearing in the Brain Imaging and Stimulation section of the journal, “International Legal Approaches to Neurosurgery for Psychiatric Disorders” was written by an international group of researchers.

Abstract: Neurosurgery for psychiatric disorders (NPD), also sometimes referred to as psychosurgery, is rapidly evolving, with new techniques and indications being investigated actively. Many within the field have suggested that some form of guidelines or regulations are needed to help ensure that a promising field develops safely. Multiple countries have enacted specific laws regulating NPD. This article reviews NPD-specific laws drawn from North and South America, Asia and Europe, in order to identify the typical form and contents of these laws and to set the groundwork for the design of an optimal regulation for the field. Key challenges for this design that are revealed by the review are how to define the scope of the law (what should be regulated), what types of regulations are required (eligibility criteria, approval procedures, data collection, and oversight mechanisms), and how to approach international harmonization given the potential migration of researchers and patients.

The full article is available online with free and open access from Frontiers.

Dr. Cabrera gives community talk on psychiatric neurosurgery

Laura Cabrera photoOn February 18, Center Assistant Professor Dr. Laura Cabrera presented a talk entitled “The ethics of psychiatric neurosurgery” at Schuler Books & Music in Okemos. The event was part of the Cafe Scientifique series presented by the Lansing Community College Science Department.

In her presentation Dr. Cabrera shared results from her Science and Society at State grant with the audience, and discussed how the insights from that project led to her current NIH-funded project, “Is the Treatment Perceived to be Worse than the Disease?: Ethical Concerns and Attitudes towards Psychiatric Electroceutical Interventions.” The presentation also highlighted the role of neuroethics in examining and addressing public perceptions and values around psychiatric neurosurgery.

Visit the Lansing Community College website for information on future Cafe Scientifique events, which are free to attend and open to the public.

Article from Dr. Laura Cabrera in November ‘Bioethics’ issue

Laura Cabrera photoAn article by Center Assistant Professor Dr. Laura Cabrera has been published in the November 2019 issue of Bioethics. The article, “A human rights approach to low data reporting in clinical trials of psychiatric deep brain stimulation,” advocates for “the importance of reporting clinical trial data of invasive procedures in highly vulnerable populations, such as psychiatric DBS trials.”

Abstract: The reporting of clinical trial data is necessary not only for doctors to determine treatment efficacy, but also to explore new questions without unnecessarily repeating trials, and to protect patients and the public from dangers when data are withheld. This issue is particularly salient in those trials involving invasive neurosurgical interventions, such as deep brain stimulation (DBS), for ‘treatment refractory’ psychiatric disorders. Using the federal database ClinicalTrials.gov, it was discovered that out of the completed or unknown‐status trials related to psychiatric DBS up to November 2018, only two had submitted results to ClinicalTrials.gov. These results suggest that, despite federal requirements to report clinical trial data, reporting on psychiatric DBS trials is problematically minimal. It is argued that a human rights approach to this problem establishes a legal and ethical foundation for the need to report clinical trial results in this area.

The full text is available online via Wiley Online Library (MSU Library or other institutional access may be required to view this article).

Dr. Cabrera co-authors ‘AJOB Neuroscience’ commentary on deep brain stimulation for depression

Laura Cabrera photo“Interpreting Patients’ Beliefs About Deep Brain Stimulation for Treatment-Resistant Depression: The Need for Caution and for Context” is an open peer commentary available in the latest AJOB Neuroscience issue. Michigan State University co-authors Dr. Laura Cabrera, Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Translational Science & Molecular Medicine, and Dr. Robyn Bluhm, Associate Professor in the Department of Philosophy and Lyman Briggs College, are currently working on an NIH BRAIN Initiative funded project on a related topic.

Dr. Cabrera and Dr. Bluhm focus on two points raised by the Lawrence et al. paper. First, they discussed a couple methodological decisions made by the authors which may have had an important influence on the results presented in the article. The second point relates to the work of Dr. Cabrera and Dr. Bluhm, examining differences in the bioethics literature’s discussion of deep brain stimulation and public comments on newspaper and magazine studies covering the intervention; this part of the open peer commentary shows how their findings can help to deepen the analysis by Lawrence et al.

The full text is available online via Taylor & Francis Online (MSU Library or other institutional access may be required to view this article).

New article from Dr. Cabrera’s research team in ‘Social Science & Medicine’

Laura Cabrera photoCenter Assistant Professor Dr. Laura Cabrera is co-author of an article in the January issue of Social Science & Medicine. The article, “Online comments about psychiatric neurosurgery and psychopharmacological interventions: Public perceptions and concerns,” was written by Dr. Cabrera, Marisa Brandt, Rachel McKenzie, and Robyn Bluhm.

The study was supported by a Science and Society at State (S3) internal Michigan State University grant, “Psychiatric Interventions: Values and Public Attitudes.”

Abstract: The field of biological psychiatry is controversial, with both academics and members of the public questioning the validity and the responsible use of psychiatric technological interventions. The field of neuroethics provides insight into these controversies by examining key themes that characterize specific topics, attitudes, and reasoning tools that people use to evaluate interventions in the brain and mind. This study offers new empirical neuroethical insights into how the public responds to the use and development of psychiatric technological interventions by comparing how the public evaluates pharmacological and neurosurgical psychiatric interventions, in the context of online comments on news media articles about these topics. We analyzed 1142 comments from 108 articles dealing with psychopharmacological and psychiatric neurosurgery interventions on websites of major circulation USA newspapers and magazines published between 2005 and 2015. Personal anecdote, medical professional issues, medicalization, social issues, disadvantages, scientific issues and cautionary realism were among the main themes raised by commenters. The insights derived from the comments can contribute to improving communication between professionals and the public as well as to incorporating the public’s views in policy decisions about psychiatric interventions.

The full text is available online via Science Direct (MSU Library or other institutional access may be required to view this article).

Dr. Cabrera will help guide ethical development and use of electrical-based psychiatric treatments

Laura Cabrera photoA team led by Center Assistant Professor Dr. Laura Y. Cabrera will examine the ethical concerns, beliefs, and attitudes of psychiatrists, patients, and healthy members of the public, including caregivers, regarding the development and use of psychiatric electroceutical interventions (PEIs).

The U.S. National Institutes of Health BRAIN Initiative has awarded a four-year, $1,414,478 grant to the Michigan State University team, which also includes Professor Aaron M. McCright (Sociology), Associate Professor Robyn Bluhm (Philosophy and Lyman Briggs College) and Associate Professor Eric Achtyes (Director of the College of Human Medicine Division of Psychiatry and Behavioral Medicine).

Using electrical stimuli to treat psychiatric conditions, PEIs offer great promise in addressing the profound suffering related to such disorders. While PEIs have been available in various forms for years, divergent perceptions among medical professionals, patients, and the broader public have impeded their wider adoption in practice. Key stakeholders’ concerns, beliefs, and attitudes also might affect the future adoption of novel, more invasive PEIs. As new PEIs emerge in the neurotechnology landscape, it is urgent to understand such concerns and related social policy choices.

“This grant could not come at a better time, and we are grateful to the National Institutes of Health for recognizing the importance of this issue and supporting our proposal,” said Dr. Achtyes, who has seen firsthand the benefits of such treatments.

Cabrera-McCright-Achtyes-Bluhm
Pictured left to right: Laura Cabrera, Aaron McCright, Eric Achtyes, Robyn Bluhm.

Dr. Cabrera, whose research focuses on neuroethics and is leading the effort as the Principal Investigator, said, “I am delighted for this exciting opportunity to lead our team of experts and work together towards the sustained ethical development and translation of this type of psychiatric treatment.”

The significance of this work lies in anticipating potential future policy challenges in ways that will both effectively safeguard sustained ethical PEI development and translation, and benefit individuals affected by mental health disorders.

“One strength of our project is that we have experts from philosophy, neuroethics, psychiatry, and sociology working closely together. So, the insights we generate will likely transcend typical disciplinary boundaries and hopefully will be more meaningful to key stakeholders,” said Dr. McCright.

Please visit the Center’s website for updates on this project.

Why do psychiatrists choose not to disclose borderline personality disorder diagnoses with patients?

bbag-blog-image-logoTherapeutic Privilege in Psychiatry? The Case of Borderline Personality Disorder

Event Flyer

Borderline personality disorder (BPD) is a serious mental illness that effects 2-3% of the population, is highly stigmatized, and is often comorbid with other mental disorders. Although no pharmaceutical interventions exist, long-term psychotherapy has been shown to alleviate the symptoms of BPD. Nonetheless, behavioral health care professionals often hesitate to discuss BPD with their patients even when it is clear they have this disorder. Why do psychiatrists, in particular, fall silent? In this talk, Dr. Sisti will sketch the history of BPD and describe ethical arguments for and against of therapeutic nondisclosure. Dr. Sisti will summarize empirical data regarding psychiatrist nondisclosure of BPD, including recent research conducted by his team at Penn. Dr. Sisti will argue that diagnostic nondisclosure, while well-intentioned, can have long-term negative consequences for patients, caregivers, and the health system more generally. As a form of therapeutic privilege, nondisclosure of BPD is ethically inappropriate.

sept19-bbagJoin us for Dr. Sisti’s lecture on Wednesday, September 19, 2018 from noon until 1 pm in person or online.

Dominic Sisti, PhD is director of the Scattergood Program for the Applied Ethics of Behavioral Health Care and assistant professor in the Department of Medical Ethics & Health Policy at the University of Pennsylvania. He holds secondary appointments in the Department of Psychiatry, where he directs the ethics curriculum in the residency program, and in the Department of Philosophy. Dominic’s research examines the ethics of mental health care services and policies, including long-term psychiatric care for individuals with serious mental illness and ethical challenges in correctional mental health care. He also studies how mental disorders are defined, categorized, and diagnosed with a focus on personality disorders. Dr. Sisti’s writings have appeared in peer-reviewed journals such as JAMA, JAMA Psychiatry, Psychiatric Services, and the Journal of Medical Ethics. His work has been featured in popular media outlets such as the New York Times, NPR, Slate, and The Atlantic. Dr. Sisti received his PhD in Philosophy at Michigan State University, working under the supervision of Professor Tom Tomlinson. A native of Philadelphia, Dominic received his Master’s degree in bioethics from the University of Pennsylvania and his bachelor’s degree from Villanova University.

In person: This lecture will take place in C102 East Fee Hall on MSU’s East Lansing campus. Feel free to bring your lunch! Beverages and light snacks will be provided.

Online: Here are some instructions for your first time joining the webinar, or if you have attended or viewed them before, go to the meeting!

Can’t make it? All webinars are recorded! Visit our archive of recorded lecturesTo receive reminders before each webinar, please subscribe to our mailing list.

Announcing the Fall 2018 Bioethics Brownbag & Webinar Series

bbag-icon-decThe Center for Ethics and Humanities in the Life Sciences at Michigan State University is proud to announce the 2018-2019 Bioethics Brownbag & Webinar Series, which features a variety of bioethics topics. The series will begin on September 19, 2018. You are invited to join us in person or watch live online from anywhere in the world! Information about the fall series is listed below. Please visit our website for more details, including the full description and speaker bio for each event.

Fall 2018 Series Flyer

sept19-bbagTherapeutic Privilege in Psychiatry? The Case of Borderline Personality Disorder
Why do behavioral health care professionals often hesitate to discuss BPD with their patients even when it is clear they have this disorder?
Wednesday, September 19, 2018; C102 Patenge Room, East Fee Hall
Dominic A. Sisti, PhD, is Director, The Scattergood Program for Applied Ethics of Behavioral Health Care; Assistant Professor, Department of Medical Ethics & Health Policy; Assistant Professor, Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania.

oct-10-bbagEnding Medical Self-Regulation: Does Less Physician Control Improve Patient Safety and Protect Patient Rights?
Wednesday, October 10, 2018; E4 Fee Hall
Thaddeus Mason Pope, JD, PhD, is Director of the Health Law Institute at Mitchell Hamline School of Law.

In person: These lectures will take place from 12:00-1:00 PM (Eastern Time) in East Fee Hall on MSU’s East Lansing campus. Feel free to bring your lunch! Beverages and light snacks will be provided.

Online: Here are some instructions for your first time joining the webinar, or if you have attended or viewed them before, go to the meeting!

Can’t make it? Every lecture is recorded and posted for viewing in our archive. If you’d like to receive a reminder before each lecture, please subscribe to our mailing list.

Dr. Cabrera and team published in ‘Neurosurgical Focus’

Laura Cabrera photoCenter Assistant Professor Dr. Laura Cabrera and co-authors Hayden M. K. Boyce, MD, Rachel McKenzie, and Robyn Bluhm, PhD, have an article in the August 2018 issue of Neurosurgical Focus. “Conflicts of interest and industry professional relationships in psychiatric neurosurgery: a comparative literature review” stems from the authors’ Science and Society at State (S3) project, “Psychiatric Interventions: Values and Public Attitudes.”

Abstract: Objective: The research required to establish that psychiatric treatments are effective often depends on collaboration between academic clinical researchers and industry. Some of the goals of clinical practice and those of commercial developers of psychiatric therapies overlap, such as developing safe and effective treatments. However, there might also be incompatible goals; physicians aim to provide the best care they can to their patients, whereas the medical industry ultimately aims to develop therapies that are commercially successful. In some cases, however, clinical research may be aiming both at improved patient care and commercial success. It is in these cases that a conflict of interest (COI) arises. The goal of this study was to identify differences and commonalities regarding COIs between 2 kinds of somatic psychiatric interventions: pharmacological and neurosurgical.

The full text is available online via Journal of Neurosurgery (MSU Library or other institutional access may be required to view this article).

To learn more about this study, listen to Laura Cabrera, Robyn Bluhm, and Rachel McKenzie on the Center’s podcast, No Easy Answers in Bioethics: Public Perception of Psychiatric Interventions: Cabrera, Bluhm, and McKenzie – Episode 5.