Non-Communicable
Diseases, Mental Health, Drug Abuse
Case
Study #1: Section 1 2 3
4 5
1.
Background about the economic, social and political context
in the country(ies) in which the study is being planned or
conducted.
Technovy,
the hypothetical country, has only recently divested itself,
through violent revolution, from the rule of a despot. Under
his rule, the Technovy’s economy was artificially inflated,
allowing its citizens to purchase goods and services at unrealistically
low prices. Since his overthrow, the country has attempted
to institute capitalism and democracy. The majority of the
populace remains relatively poor, and the much of the country’s
wealth is held by a small minority. The most intelligent of
the educated young adults are leaving the country to seek
more lucrative employment opportunities abroad, as the award
of any professional position is often dependent upon political
connections, rather than merit. Many individuals, including
highly educated professionals, must work two or three jobs
to earn sufficient money to support their families.
Although the country once had a nationalized health care system,
the health care system has recently been reorganized and has
become employment-based. The government is now finding that
there is an inadequate economic base via this mechanism to
support medical care for those who are unemployed, such as
children, the elderly, and the institutionalized, in addition
to those who are employed. As a result, many individuals are
receiving suboptimal care. Although hospital stays appear
to be cost-free because they are paid for from this national
fund, patients must pay for their medications and procedures.
Recently, several physicians were arrested and charged with
criminal offenses for demanding payment from their patients
in addition to that provided to them through the government
insurance scheme.
The church is extremely strong in Technovy and has condemned
abortion and alternative lifestyles, such as cohabitation
without the benefit of marriage and homosexuality. Women,
in particular, are disadvantaged socially, politically, and
economically. There is a high rate of alcoholism in Technovy,
particularly among the men, but it has not been recognized
as a public health problem. There is an increasing incidence
of substance abuse, particularly of heroin, as Technovy is
en route between a major heroin supplier-nation and a major
distributor-nation. The incidence and prevalence of partner
violence and child abuse are extremely high, but have only
recently been acknowledged by health authorities. In general,
women and children have little recourse if they suffer from
family violence and there are few shelters throughout the
country. Individuals of minority groups, those suffering from
HIV, and those suffering from mental illness are often stigmatized
due to their ethnicity and/or disease.
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2.
Information about the disease or specific problem being addressed
by the research.
Although
schizophrenia is believed to be ubiquitous, its current prevalence
varies widely, from 1 in every 1,000 persons in non-Western
societies to more than 1 in every 100 in Western societies.
To some extent, variations in prevalence rates may exist due
to variations in diagnostic criteria and sampling methods.
There is considerable disagreement among mental health professionals
with respect to the recency of the disorder’s appearance,
with some arguing that schizophrenia has existed since classical
times, and others contending that it is a phenomenon of relatively
recent origin. Schizophrenia has been found to be relatively
uncommon in locations that do not have a system of wage labor,
although the reasons for this remain unclear.
A diagnosis of schizophrenia in North America and Europe is
currently guided by the criteria contained in the fourth edition
of the Diagnostic and Statistical Manual (DSM-IV).These include
the experience of two of the following for a significant period
of time during a one month interval: (1) delusions, (2) hallucinations,
(3) disorganized speech, (4) grossly disorganized or catatonic
behavior, and/or (5) flat or grossly inappropriate emotional
tone. Only one such symptom is required for diagnosis if the
individual has experienced bizarre delusions or hallucinations
that consist of a voice that makes a running commentary on
the individual’s behavior or thoughts, or of two voices
conversing with each other. These symptoms must have resulted
in decreased functioning in social relations, work, or other
areas of life. In addition, various other possible diagnoses
and factors that might explain the behavior, such as an autistic
disorder or drug intoxication, must have been ruled out.
Subtypes of schizophrenia include (1) the paranoid type, characterized
by a preoccupation with one or more delusions or frequent
hallucinations; (2) the disorganized type, in which disorganized
speech, disorganized behavior, and flat or inappropriate affect
are prominent features; (3) the catatonic type, in which two
or more of the following features are predominant: motoric
immobility, excessive motor activity, extreme negativism,
peculiarities of voluntary movement, and echolalia or echopraxia;
(4) the undifferentiated type; and (5) the residual type,
characterized by the absence of prominent delusions, hallucinations,
disorganized speech, and disorganized or catatonic behavior,
as well as the presence of negative symptoms or two or more
of the five diagnostic criteria. Continuous signs of the disturbance
must be present for at least six months to support a diagnosis
of schizophrenia.
Positive symptoms constitute distortions of normal functions,
and include hallucinations (distorted perceptions), delusions
(distortions in cognitive and inferential thinking), positive
formal thought disorders (distortion in language), and bizarre
behavior (distortion of behavior organization and control).
Negative symptoms represent a decrease or loss of normal function
and may include affective blunting, avolition, anhedonia,
and attentional impairment. Individuals suffering from schizophrenia
have invariably described the disease and its symptoms as
frightening, incomprehensible, and cruel.
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Factors found to be associated with the onset and distribution
of schizophrenia include various demographic characteristics.25
Researchers have consistently found an inverse relationship
between social class and schizophrenia.26 Two competing hypotheses
have been proffered to explain this apparent link. The first,
known as the selection-drift hypothesis, posits that individuals
who are prone to schizophrenia are either prevented from attaining
a higher social class level (selection) or, as a result of
the disease symptoms, move progressively downward (drift).
This hypothesis is premised on the observation that the onset
of the disease is often insidious and frequently commences
during adolescence, when social skills are often acquired.
The second theory asserts that various exposures that may
precipitate the onset of schizophrenia, such as infectious
agents, increased occupational hazards, and increased psychosocial
stress, are more prevalent in lower class areas.
Although numerous studies have reported an increased rate
of schizophrenia among males as compared with females, it
is unclear if this finding actually reflects differences in
the rate of hospitalization, rather than the rate of disease.
Unmarried individuals have been found to be at increased risk
for schizophrenia.
Several conditions have been identified that may serve as
predisposing characteristics for schizophrenia. These include
birth during the winter months of the year, obstetrical complications,
and genetic factors. Several other factors may precipitate
the onset of schizophrenia, including significant social stress
and urban residence.
Current approaches to the treatment of schizophrenia include
the use of antipsychotic drugs, social skills training, and
cognitive behavioral therapy. Antipsychotic drugs, in particular,
have significantly reduced the severity and duration of psychotic
episodes, as well as having lengthened the interval between
relapses. However, their use has not been unproblematic. Many
individuals experience non-neurological side effects, such
as drowsiness, lethargy, and sexual dysfunction. More rarely,
antipsychotics may cause liver dysfunction, cardiovascular
abnormalities, or a variety of blood disorders. Neurological
side effects may include a Parkinsonian syndrome, akathisia,
dystonia, or tardive dyskinesia. The occurrence of many of
the more severe side effects appears to have been reduced
with a number of the newer antipsychotic medications. The
prognosis for those diagnosed with schizophrenia varies geographically,
with those diagnosed in poorer countries more likely to experience
less severe disease and more likely to have a better outcome,
apparently due to the enhanced support that the individuals
receive from both their families and their communities.
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3.
Information about the design of the study.
A
physician in an institution wishes to test the use of a drug
in institutionalized patients diagnosed with schizophrenia
to see if it will control the hallucinations. The drug has
not been approved in Technovy or elsewhere for use for this
purpose. In fact, the drug is known to initiate psychosis
in particularly susceptible individuals. The physician has
decided to conduct this experiment by prescribing this nonconventional
drug to his individual patients, instead of their regular
therapeutic medications, and to monitor the progress of each
individual patient. Themajority of his patients are women,
who have often been brought to the institution by their family
members who are unable to care for them. Many of the women
suffered partner abuse while they were living in their homes.
He has not designed any form of controlled experiment and
has not submitted this plan to any review committee.
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4.
Description of the main ethical problem and what is at stake
for the affected parties.
There
are numerous ethical problems here.
