Ethical Implications of Diagnosing High-risk for Schizophrenia

In the last decade, there has been a push to develop and characterize a diagnosis for adolescents at high-risk for schizophrenia, called prodromal risk syndrome.¹ The Personal Assessment and Crisis Evaluation (PACE) clinic in Melbourne, Australia, was first to develop a classification of prodromal syndromes.² The disease of schizophrenia is most typically diagnosed in early adulthood, when most schizophrenics experience their first psychotic break, therefore, early intervention tactics are aimed at adolescents. This is one of the reasons that the PACE clinic is located in a shopping mall.³

On the other side of the globe, the North American Prodrome Longitudinal Study (NAPLS) has been developing and improving methods to reliably diagnose individuals in the prodrome stage. Once identified, they offer these individuals psychotherapy, family therapy, drugs, or cognitive training to hopefully lessen the progression of symptoms. Their method of assessment scores symptoms including family history of psychosis, unusual or fragmented thoughts, school or social troubles, as well as peculiar emotions, behaviors, and thinking, such as; paranoia. After following the individuals for two years, they developed an algorithm that successfully predicts progression to schizophrenia with an accuracy rate of 80%.¹ While this is an impressive rate of accuracy, many ethical implications are raised by both the existence of false positives and true positives. 

Regarding the false positives, individuals deemed high-risk who are actually not at risk of developing schizophrenia, one of the first issues deals with the effects of diagnosis and treatment. Anti-psychotic drugs can have side effects that may include excessive weight gain, galactorrhea, sedation, sexual side effects, and mild dystonia.^4,5 Some side effects of diagnosis, however, might be more hidden. The stigma involved may affect the patient's and family's expectations for the future, altering their choices in terms of employment, schooling, and life goals.⁶ This is a high price for an individual to pay if they otherwise would not have seen many consequences in their life. 

For those individuals who are true positives, there are also sacrifices made in the interest of early intervention. For many individuals who develop schizophrenia, their pre-symptomatic years are a period of time during which they have the best likelihood of living a life of normalcy. The potential of effective treatment needs to be weighed with the effect of tainting this pre-symptomatic period with knowledge of an impending lifelong struggle with mental illness. This cost increases with any shift towards earlier diagnosis or diagnosis in a less symptomatic population. If encouraging results from prodromal research are found, then many parties, including researchers and drug companies, will inevitably push for earlier and earlier diagnosis.⁶

Finally, for anyone receiving a prodomal diagnosis, there are many risks involving third parties such as insurance agencies, schools, employers, and peers.¹ Families need to be informed of the possible effects of disclosing medical information such as this, but patients and families may not always foresee the consequences involved.

One area in which the cost and benefit balance may be addressed is in who is targeted for screening. Most of the research done to this point has been on help-seeking families who have noticed something wrong and are looking for answers and treatment. This population's current quality of life may already be affected, they may be more symptomatic, and they may be more likely to view the early diagnosis as a cause for hope as opposed to a reason for despair.⁶ There will always be pressure, however, from competing interests that would rather expand the patient base through earlier and more widely applied screening. It is therefore imperative that we address these issues involving the interests of the patients before those with other financial incentives are permitted to steer the direction of the field.

--Kevin Watkins

Neuroscience Graduate Program

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Watkins, K. (2011). Ethical Implications of Diagnosing High-risk for Schizophrenia. The Neuroethics Blog. Retrieved on
, from http://www.theneuroethicsblog.com/2011/12/ethical-implications-of-diagnosing-high.html

References

1. Dobbs, D. Nature 468, 154-156 (2010).

2. McGorry, PD, Yung, A., & Phillips, L. Schizophr Res. 51, 17-29 (2001).

3. Yung, A.R. et al. Schizphr Bull. 22, 283–303 (1996).

4. Correll, C.U. et al. Biol Psychiatry 55, 147S (2004).

5. Tsuang, M.T. et al. Biol Psychiatry 45, 1412-1418 (1999).

6. Corcoran, C., Malaspina, D., & Hercher, L. Schizophr Res. 73, 173–184 (2005).