You want to do what?!?! The importance of informed consent in treatment

By Gail  A. Edelsohn, MD, MSPH

We come across ads in print, on television
and on the Internet for medications and therapies that promise to make your child
do his homework without a screaming match, behave better and generally restore
harmony to home life. Not so easy, taking a medication raises a host of
questions:  How long does the therapy
take? Should I as the parent sign off on this? What about the possible serious
side effects, such as significant weight gain, thoughts about suicide, risk of
diabetes or a life-threatening condition?

Parents and legal guardians make
decisions about psychosocial therapy and medication treatment for children and
adolescents every day. But who should give permission and sign informed
consent?  What should parents, advocates,
guardians be looking for or consider before signing informed consent? Is
signing a form enough?  What about the child
or teen - do they have a voice regarding their own treatment?

What is Informed Consent?

Psychiatric informed consent
involves a parent or legal guardian giving
permission for his/her child to undergo evaluation and treatment.  It is a
process which partly involves receiving sufficient relevant information about
the condition, prognosis, risks and benefits of treatment to be given and other
types of treatment available. Informed consent is NOT simply a signed and dated
form. Parents and guardian should expect informed consent to include:

  The purpose of the treatment

• To address a specific condition or diagnosis?

• To lessen symptoms?

•  To change behaviors?

  The effects of treatment

• How will you know if it is working?

•  How long till you see an effect?

  Risks of treatment

• Side effects of medications

• Consequences of psychosocial treatment (e.g., therapy
  can be emotionally difficult)

  Risks of NO treatment

• Will symptoms improve over time without
  treatment?

• Will things get worse or lead to other
  consequences? (e.g., Untreated individuals are more likely to use substances,
  get into legal trouble)

  What alternative treatments are available?
  

For medication

• Is it FDA approved for this age and condition?
  (i.e., prescribed FDA on label)

• If it is prescribed off-label, why?

• Are there any FDA warnings about the medication
  and what do they mean?

• What is the plan for stopping or phasing out the
  medication?

     Parents and legal guardians are
asked to give legal permission or informed consent for treatment.  If a child is in foster care, it may be the
parent or it may be child welfare service or court that can give consent.   Where a child is living (home, out of home
placement) does not tell you who the legal guardian is.  In some states an adolescent may give
informed consent for psychiatric treatment depending on the state’s legislation
about mental health procedures. Ideally the parents/guardians and the child
should be involved in treatment decision making.

Children also have a voice in
this process.  Children and youth should
be involved in giving assent.  Assent involves providing the child or teen
with information about the therapy or medication in terms appropriate to their
age and stage of development. The assent process should include opportunities
for the child/adolescent to ask questions and have their concerns addressed.

Gail A.
Edelsohn, MD, MSPH, is senior medical officer with Community Care Behavioral
Health, clinical professor of psychiatry and human behavior,  Jefferson
Medical College, and clinical professor of psychiatry and behavioral science,
Temple University School of Medicine.

How Psychotherapy Changes the Brain

By Serina Deen, MDMPH



When I first see patients for evaluation, they often tell me
that they’ve debated starting a “biological” treatment such as medication,
versus a “psychological” treatment such as psychotherapy. I’m happy to report
that as brain imaging technology advances, we’re finding that this distinction
may be obsolete. 

Psychotherapy is also “biological” in that it can lead to
real functional and structural changes in the brain.   In fact, sometimes psychotherapy and
medication produce surprisingly similar changes in the brain.  We still have a lot to learn about the topic,
but below are some examples of what researchers have been finding so far.

Functional Changes in
the Brain:

In one study, researchers at UCLA found that people who
suffered from depression had abnormally high activity in an area of the brain
called the prefrontal cortex.  Those who
got better after they were treated with a type of therapy called interpersonal
therapy (IPT) showed a decrease in activity in the prefrontal cortex after
treatment.  In other words, IPT seemed to
“normalize” brain activity in this hyperactive region.



Another study looked at people who have obsessive compulsive disorder (OCD), who tend to have an overactive area of the brain called the
caudate nucleus.  Treatment with a type
of therapy called cognitive behavior therapy (CBT) was associated with a
decrease in the hyperactivity of the caudate nucleus, and the effect was most
evident in people who had a good response to CBT.  In other words, the better the therapy seemed
to work, the more the brain activity changed.

Changes in Brain
Volume:

People with chronic fatigue syndrome (CFS) suffer from debilitating
fatigue.  People with CFS tend to have a
decrease in a type of brain tissue called grey matter in the prefrontal cortex
of the brain.  Researchers in the
Netherlands gave people with CFS 16 sessions of CBT, and found significant
increases in gray matter volume in the prefrontal cortex.  This seems to suggest that the CFS patients
were able to “recover” some gray matter volume after CBT.

Similarities and
Differences to Medications

Psychotherapy sometimes seems to work in similar ways as
medications, and other times appears to have different mechanisms of action.

In the study mentioned previously about people with
depression, both IPT and the antidepressant paroxetine (Paxil) showed a
decrease in prefrontal cortex activity.  And
with OCD patients, both CBT and the antidepressant fluoxetine (Prozac) produced
similar decreases in activity in the caudate nucleus. 

However in a different study, the antidepressant Venlafaxine
(Effexor) produced changes in different parts of the brain than IPT in
depressed patients.  This shows that there
is variability in how different treatments work in the brain.

How Psychotherapy
Produces Brain Change

We now know that the brain keeps changing, even after we
become adults.  Learning leads to the
production of new proteins, which in turn can change connectivity in our brains
in a process called neuroplasticity.   Indeed, researchers in Germany showed that
certain neurochemicals involved in neuroplasticity increased in depressed
patients who got better after a course of interpersonal therapy. 

Picking a Treatment
that Works Best for You

Even though we know that both medication and psychotherapy
can change our brain, we still have a long way to go in learning exactly how
that happens and when to use what treatment. Given a specific mental illness,
sometimes medications work best, sometimes psychotherapies are the best option,
and sometimes it’s a combination of the two. 
In addition, there are different types of psychotherapies that work for
different illnesses, just as there are many different types of
medications.  If you’re considering
seeking help for mental illness, it would be helpful to talk with a trained
professional about what would work best for you. 





Read tips on what to expect during your first visit with a psychiatrist  

"Let's Talk Facts" brochure on Psychotherapy

Brain Awareness blog post from NIMH Director Tom Insel, MD

APA Releases List
of Five Uses of Psychiatric Medication to Question

Six tips for talking to your doctor about medication

For more information about psychotherapy

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Effective Addiction Treatments are Available

By John Renner, MD and Frances Levin, MD

We are all saddened by the death of Philip Seymour Hoffman and the many other
individuals who have died because of overdoses of heroin or pain
medications.  For all of those individuals who struggle with opioid use
problems, it is important to realize that help is available and that effective
treatment can restore them to productive lives.  Some 4.7 million people
in the U.S. have used heroin at least once in their lives.  It is estimated that nearly a quarter of
people that use heroin become dependent on it.



Whether it be through mutual support programs such as NA, long-term residential
treatment, or addiction pharmacotherapy with buprenorphine, methadone or ER
naltrexone, no individual need fear that their condition cannot be
treated.  Friends and family members also need to be educated in the use
of intra-nasal naloxone for the reversal of opioid overdoses.  



APA has long fostered the development of addiction focused training programs
for psychiatrists.  Many psychiatrists have been specifically trained
to provide office-based addiction pharmacotherapy and to manage the
co-occurring psychiatric disorders that often complicate recovery from
substance use disorders.  

More information:

·        
Information on addiction

·         Opioid Overdose Prevention Toolkit (SAMHSA)

·        
Substance
use treatment locator (SAMHSA)

·        
Buprenorphine Physician
and Treatment locator (SAMHSA)

·        
For psychiatrists:  Providers
Clinical Support System for Medication Assisted Treatment

Blog
contributors:

John
Renner, MD

Member, APA Council on Addicition Psychiatry (Past Chair)
Director of Addiction Fellowship Program,

Professor of Psychiatry,  Boston University School of Medicine



Associate Chief of Psychiatry, VA Boston Healthcare System

Frances Levin, MD

Chair, APA Council on Addiction Psychiatry
Kennedy-Leavy Professor of Psychiatry, Columbia University Medical Center

Director, Addiction Psychiatry Fellowship,

New York Presbyterian Hospital

New York State Psychiatric Institute

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