Transcript Psychopharmacology and Ethics: Big Pharma and Little Karma

Psychopharmacology and Ethics:
Big Pharma and Little Karma
Law and Ethics in Counseling Conference 2016
New Orleans April 7, 2016
J. Scott Hinkle, Ph.D., NCC
Introduction
This presentation will cover some ethical
considerations with the administration
and maintenance of
psychopharmacological agents
 Informed consent, side effects and clinical
cases will be discussed

Background Information
Psychopharmacological agents are
commonly prescribed medications
 Pharmacotherapy has enhanced the lives
of millions of people

◦ Yet, ethical concerns abound with their use
◦ Everyday counseling rarely resembles
textbook instruction
Background Information
Needing to take medications, especially
over a long time periods, engenders
feelings of loss of control
 There often multiple choices of
medications for a given mental disorder
and the deciding factor can include the
level of side-effects

◦ The patient may choose to live with the sideeffects (e.g., clozapine, 1/10,000 die, 10%
reduction suicide rate)
Background Information

The FDA approves medications for a specific
condition (e.g., depression)
◦ However, doctors can prescribe a medication for
anything they think is clinically warranted
 This is how it came to be know that anti-depressants
work rather well for anti-anxiety disorders such as panic
and OCD
 Evidence is strong for medications for psychosis and
bipolar disorder
 Less convincing for depression (counseling may be as effective
as medication)
 So, a decision needs to be made about medication treatment,
non-medicine treatment, or a combination of treatments
Psychopharmacology Training
The influence of managed care has
increased the numbers of counselors
collaborating with physicians
 Yet, less than 6% of CACREP-accredited
programs recommend a course in
psychopharmacology

Background Information

Two broad goals of medication treatment
◦ Acute treatment and symptom relief (shortterm)
◦ Maintenance treatment (long-term)
 Clients need to be informed about which goals or
objectives may be best for their circumstances
 Failing to take medications as prescribed is
common and a major cause of relapse
 On-going dialogue between the counselor,
prescriber and consumer (this may include family
members)
Psychopharmacology Training

81% of counselors have reported not being
required to take basic education in
psychopharmacology,
◦ But 89% reported they work with clients on
psychotropic medications
Can counselors provide comprehensive
treatment planning, ensure client well-being, and
minimize professional liability without at least
minimal training in psychotropic medications?
 Are counselors obtaining the training they need
to provide collaborative services that include
integrated care within clinical care?

Psychopharmacology Training

Should psychopharmacological education
be required in counselor education
training programs?
◦ How much training is enough?

Would training assist counselors with the
ethical and legal dilemmas they face
regarding clients and medication?
Medication Referrals

Given that 80% of the response to
antidepressant medication is duplicated in
placebo control groups, and 57% of
pharmacological studies do not show a
significant difference between placebo and
medication treatment –
◦ What are the ethical implications of a
counselor referring a client for a medical
evaluation?
Medication Outcomes
Counselors have minimal access to
research data that disconfirms the effects
of medications
 Recovery rates from mental disorders
have remained rather flat for more than
50 years despite “advances” in
neuroscience and psychopharmacology
 How does this impact ethical decisionmaking?

Big Pharma – Little Karma?

How much does the pharmaceutical industry
influence the sculpting of counseling practice
with consequences for clients, counselors,
doctors and society at large?
◦ Doctors are provided incentives for prescribing a
“big pharma” company’s medication

Is this ethically problematic for the
counselor who refers to a physician who is
accepting gifts for writing prescriptions?
Big Pharma – Little Karma?



Is professional judgment compromised by a
conflict of interest between the welfare of
the client/patient and financial gain of the
prescriber (who may be considered to be
working for Big Pharma)?
Are mental health conditions becoming a
commodity?
How much risk are counselors willing to
take in making referrals?
◦ Can this result is less Karma for counselors?
Big Pharma = Big Bucks
https://freedocumentaries.org/documentary/big-bucks-big-pharma-marketing-disease-and-pushingdrugs#watch-trailer
Ethical Issues in
Psychopharmacology
Psychotropic Use Informed Consent
The ethical practitioner should keep upto-date with the effects of somatic
therapies, and their adverse effects and
contraindications
 Psychotropics should only be used when
clearly indicated and there is a strong
evidence base
 Ethical practitioners will have informed
consent dialogues with their client

Ethical Questions
Is the risk of maleficence greater when
counselors neglect to address
psychopharmacological issues, including side
effects and noncompliance, during the counseling
relationship?
 Should clients be informed of all available
treatment methods, including
psychopharmacology? How informed is the
counselor?
 When the diagnosis is not clear, the goals of
treatment are not clear, or the practitioner is not
confident about what steps to take, consultation
with someone with relevant expertise is prudent

Ethical Stakes



Higher stakes decisions, those that include
potential risk to the client or community, are
held to a more rigorous standard
Counselors who have an “ethical skill set”
are in a better position (good Karma is more
viable)
The potential liability of not making a
referral when one may be needed is higher
than making a referral when one may
actually not be needed
Ethical Stakes



Counselors need to be mindful of cosmetic
pharmacotherapy (subclinical)
e.g., if a client is not clinically depressed, but
is unhappy about his job, medication likely
should not be suggested to alleviate
difficulties with a boss or monotonous job
responsibilities
e.g., if a client is not clinically depressed, but
is unhappy about a relationship that has gone
badly, medication is likely contraindicated
Ethical Questions
What about referrals for medications
within agencies that have limited sessions,
but the client needs life-long care?
 Is it ethical for a counselor to utilize only
counseling methods - when combining
psychopharmacological strategies and
counseling may be more beneficial and
efficient?

Ethics

When considering medication therapy –
◦ Counselors need to respect the client’s
freedom of choice
 Client’s right to refuse services – and to be advised
of the consequences of the refusal of the treatment
◦ Share with the client information about
treatment limitations, and potential risks and
benefits
Ethics

When discussing potential medication
therapy, counselors should consider
◦ Awareness of personal values, attitudes, and
beliefs and avoid imposing them on clients
◦ Inform clients about the use of an
interdisciplinary treatment team
Ethics

If medication is being considered –
◦ A proper or accurate diagnosis needs to be
made
◦ Specific referral questions need to be
provided to the prescribing medical
professional
Children and Medication
Much of pediatric psychopharmacology is
inherently innovative due to the lack of
research in this area
 It is not clear what the
neurodevelopment impact of various
medications are on children

◦ Yet, not using them can result in devastating
consequences for the child and family
Children and Medication

Collaborations with primary care providers
and parents, in child and adolescent cases,
need to be diligent and include close
monitoring for adverse effects and drug
interactions
◦ If a child is presenting symptoms consistent with
AD/HD and being treated by a counselor and he
delays a well-established treatment strategy (i.e.,
medication), because the counselor believes the
problem is related to bad parenting, is the child
being treated in an ethical manner?
Children and Medication – More
Questions

Does the medication of children deny them
the right to “development freedom?”
◦ Are developmental opportunities minimized
when thoughts, behaviors and feelings are being
“controlled” by medication?
◦ Or, do medications help level the playing field for
children and increase their chances of success in
school and life?
◦ What happens when treatment providers are in
conflict with parents about the course of
treatment? (best interest of the child v. best
interest of the parents?
Case 1
A 15 year-old female high school student
has had comorbid disorders ruled/out and
it was concluded that she met the criteria
for ADHD, primarily inattentive type
 Since the student’s counselor had not
interviewed a female student with this
disorder, the counselor did not inform the
parents of the possibility of psychotropic
medication as an adjunct to counseling
and a referral was not made

Case 1 - Questions




Was the counselor up-to-date on the latest
scientific literature on improvements related
to pharmacotherapy?
Did the counselor understand ADHD-PI
type and its manifestation in females?
Does the treatment plan reflect a bias
against medication therapy?
If this were a male student, would the
counselor have been more aggressive in her
treatment plan?
Case 1 – More Questions




Did the counselor know that the standard
for treatment, for both genders, is a
medication evaluation?
Is the counselor ethically liable since she did
not feel obligated to inform the client and
parents about medication therapy, and thus
did not make a referral?
Should counselors avoid making a
medication referral if they believe
psychotropics will not be helpful?
When does the role of the counselor
include “consultant/collaborator?”
Case 1

This case reflects the need for counselors
to have –
◦ A working knowledge of psychopharmacology
and the standards of care for ADHD
◦ The ability to communicate medication
information to clients
◦ The need to make referrals for a medication
evaluation when appropriate
Case 2
A 13 year-old girl from an impoverished family is
in counseling for symptoms her parents indicate
are consistent with depression and anxiety
associated with trauma
 The client already has been prescribed
psychotropic medication for her issues which
appear somewhat vague upon further interview
by the counselor
 During the counseling, the counselor deducts that
his client’s parents may have encouraged a
diagnosis and prescription in order to collect
disability payments from the government

Case 2

What are the ethical considerations for
the counselor in this situation?
Case 3



A 17 year-old adolescent with non-suicidal
self-injury is in counseling for her behavioral
disorder and depressive mood
She has been prescribed medication which
has significantly improved her depression
However, the counselor’s treatment has
potentially resulted in side-effects including
the client becoming more disconnected from
her parents and rebellious at school
resulting in a two-week dismissal
Case 3

What ethical issues might need to be
considered in this case?
Case 4
Counseling is not progressing well for a
34 year-old male client with anxiety
symptoms
 Rather than refer to another counselor
who may have more expertise in treating
panic disorder, the counselor makes a
medication referral to a local primary
care physician who generally writes
prescriptions upon any referral
 Ethical implications?

Case 5



A 45 year-old business man is diagnosed
with dysthymia
The counselor discusses recommendations
about the use or nonuse of medications and
their side-effects, although the counselor
basically espouses an anti-medication stance,
and has established a cooperative
relationship with a medical professional who
supports the counselor’s position due to
their religious beliefs
Ethical implications?
Case 6
A 35 year-old male has clearly diagnosed
issues with anxiety including OCD and
generalized panic
 He is a recovered poly-drug abuser and has
been admitted to detox on two occasions
 During his initial counseling session he asks
the counselor about a referral for antianxiety medication
 What would be a prudent action by the
counselor?

Case 7



A 28 year-old female with a history of
bipolar disorder is managed on anti-manic
medication, and an adjunctive low-dose antipsychotic and anti-depressant medications
She informs her counselor that she and her
partner are considering becoming pregnant
What are the ethical implications of sharing
the risks to the fetus related to the potential
mother’s intake of psychotropics?
◦ Is a discussion about family planning an ethical
consideration?
Thank You!
J. Scott Hinkle
 [email protected]
