Home Uncategorized WK 1 SOCW 6443 Discussion 2: Ethical Dilemas for Mental Health Professionals

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WK 1 SOCW 6443 Discussion 2: Ethical Dilemas for Mental Health Professionals

Mental health professionals are charged with the task of assisting their clients’ efforts in obtaining the best care available to them. Often, this might mean making recommendations and referrals, teaming with other medical and mental health professionals, and developing and expanding competencies to meet the needs of their clients. Although there are strict limits to some mental health professional roles in reference to medication management, mental health professionals can serve a vital role in the process.

For this Discussion, review the media titled “The Role of the Mental Health Professional in Psychopharmacological Intervention” and the Learning

Resources

. Explore the limits of practice in psychopharmacological intervention. Search your professional practice code of ethics and consider how ethical dilemmas that arise in the course of treatment might be mitigated. Check actual final video

This is a discussion so questions in bold and then answers 300 to 500 words not including the questions

Post an explanation of how mental health professionals might prepare themselves to best work with medical professionals in the example you provided in this week’s Discussion 1 which is attached (include the need for using a signed release of information).

Next, identify a potential ethical dilemma for mental health professionals related to your example and explain why this could be a dilemma.

Then, provide the most effective strategy mental health professionals can use to mitigate the dilemma and justify your selection.

Finally, as a future mental health professional, explain some of the concepts in the field of psychopharmacology in which you would like to explore the role further to gain more knowledge.

Be sure to support your postings and responses with specific references to the Learning Resources.

Be sure to support your postings and responses with specific references to the Learning Resources. 7th addition APA format intext citing and full references

Resources

Preston, J. D., O’Neal, J. H., & Talaga, M. C. (2017). Handbook of clinical psychopharmacology for therapists (8th ed.). Oakland, CA: New Harbinger.

Chapter 1, “Introduction” (pp. 3–14)

Chapter 2, “Integrated Models” (pp. 15–27)

Running Head: PSYCHOPHARMACOLOGICAL INTERVENTIONS 1

PSYCHOPHARMACOLOGICAL INTERVENTIONS 2

Psychopharmacological Interventions.

Students Name:

Professors Name:

Date.

Post and describe one example of where psychopharmacological interventions are warranted in mental health practices.

Psychopharmacological interventions are the study of how the medication should be administered to treat and handle medical disorders. This study is so complex and therefore requires the professionals involved to remain engaged in ongoing and progressive studies to update themselves with sufficient knowledge on the new advancements and other upcoming disorder-related issues (PMC, 2020)). Currently, the most effective well-known treatments for attention include the use of stimulants and atomoxetine.

Psychopharmacological interventions are fully justified to be used in youth with a disorder known as Attention Deficit Hyperactivity because they are the first line of treatment in such complications in most children as it is believed to have an effectiveness of 80% (John D. Preston et al, 2017). Perhaps this attention is well known for its effectiveness in improving concentration, hyperactivity, and stereotyped movements. Although in the previous example the use of this type of drugs is entirely justified, it is essential to highlight that the role of the mental health professional who attends this type of case is of great importance since they must consider factors such as right dosage, time or length of time for treatment and the essence of carrying out complementary tests so as to avoid problems associated with the consumption of this type of drug.

Likewise, the specialist must analyze the appropriate time to withdraw the treatment; once the decision has been made to withdraw it. It is crucial to keep a close follow-up and plan a very gradual withdrawal from treatment. At this stage, it will be necessary to make clear to the child and his family what the first warning signs of a possible recurrence may be. Another aspect that the specialist in the prescription of psychotropic drugs in children with Attention Deficit Hyperactivity Disorder should consider is the side effects (John D. Preston et al, 2017). An example where psychopharmacological interventions are warranted in mental health practice can be when the patient proves to be in apprehension. The client concentration becomes challenging, limiting progress in mental health treatment. The client fails to attain daily goals.

Explain the mental health professional’s role in the example that you provided.

The health professional’s role or would be to ensure the patient’s symptoms are understood. The causes of the mental challenge will be determined with the counselor through professional analysis. Psycho-pharmacological intervention is essential to a client to ensure drug-induced remedy the condition. Situations that would require Psychopharmacological intervention include when the client fails to achieve planned goals for the day due to mental illness (John D. Preston et al, 2017) When the client has a looming danger, they will be required to seek changes through Psychopharmacological intervention when the patient is powerless.

Health professionals are tasked with assisting the client in receiving adequate treatment. It is essential to consider the perspective of the client before making assertions. The role of mental health professionals will be to point out the cause of the psychological problem. Concerns that should be handled with the client will be identified with the mental health professional. The counselor will link the client with a psychiatrist to enhance effective treatment and recovery (PMC, 2020).

References

GoodTherapy. (2016, April 18). Psychopharmacology. GoodTherapy.org Therapy Blog.

https://www.goodtherapy.org/blog/psychpedia/psychopharmacology

John D. Preston et al, B. (2017, April 27). Handbook of clinical psychopharmacology for therapists, 8th edition : John D. Preston : 9781626259256. Book Depository: Free delivery worldwide on over 20 million books.

https://www.bookdepository.com/Handbook-Clinical-Psychopharmacology-for-Therapists-8th-Edition-John-D-Preston/9781626259256

PMC. (2020, January 26). A review of Psychopharmacological interventions post-disaster to prevent psychiatric sequelae. PubMed Central (PMC).

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5274533/

The Role of the Mental Health Professional in Psychopharmacological Intervention

The Role of the Mental Health Professional in
Psychopharmacological Intervention
Program Transcript

[MUSIC PLAYING]

JASON PATTON: One of my clients needs psychopharmacological medication.
We’re counselors. Why would we support medication if we’re counseling?

There are a few major reasons why clients benefit from a combination of both
counseling and medication to treat their mental health symptoms. Medication
might provide the boost the client needs to get over that initial hump to really
begin the process of counseling. Additionally, a client may be a danger to him or
herself, or others. Clients may also be in such a debilitating state that medication
is the only way to turn their condition around.

Several diagnoses are so severe that medication is truly necessary. Clients
undergoing combined treatment often have better outcomes and longer lasting
treatment results. In order to meet our clients’ needs, therefore, clients must
collaborate with other mental health professionals in order to meet some of our
clients’ needs.

What does the term collaborative care mean? How about integrative care?
Essentially, these terms refer to efforts across medical, mental, allied, and other
health paradigms to meet the needs of patients and clients. Research suggests
that collaborative care meets clients health needs quickly, positively, and
effectively, with less follow-up care necessary.

Counselors serve important roles on these teams when clients have mental
health care needs that warrant medication management, hospitalization, or some
advanced level of care. Given the appropriate permissions, counselors have the
opportunity to learn information in the process of client treatment that might have
otherwise not have been available to mental health care professionals. Other
counselors are privy to information that clients might intentionally or
unintentionally fail to communicate to their other health professionals, as well.

For example, a client discusses abusing her or his anti-anxiety medication
without telling her or his doctor. Here, she might be afraid that the physician
would stop offering this prescription if they were to disclose that information. How
might a counselor act on one of these teams? She or he may be an organizer, a
participant, or a consultant.

In the most engaged of these scenarios, counselors may be present for every
meeting and facilitate every discussion involving the client. However, in most
cases, counselors engage one-on-one with psychiatrists, prescribing physicians,

The Role of the Mental Health Professional in Psychopharmacological Intervention

psychologists, and social workers. One important part of this is the counselor’s
ability to speak the language of the constituents with whom she or he works. This
course represents an important step in the process of learning how to converse
with other professionals in this language.

As you move forward, pay particular attention to any areas in which you might
have had less experience and might be more likely to have blind spots. These
blind spots could potentially lead to some ethical issues. Remember, the most
important thing for you to learn about psychopharmacology relates to the limits of
your sphere of competence and scopes of practice. Good fortune as you move
forward.

The Role of the Mental Health Professional in
Psychopharmacological Intervention
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Ethics & Behavior

ISSN: 1050-8422 (Print) 1532-7019 (Online) Journal homepage: https://www.tandfonline.com/loi/hebh20

Ethical Care for Vulnerable Populations Receiving
Psychotropic Treatment

Darren R. Bernal, Rachel Becker Herbst, Brian L. Lewis & Jennifer Feibelman

To cite this article: Darren R. Bernal, Rachel Becker Herbst, Brian L. Lewis & Jennifer Feibelman
(2017) Ethical Care for Vulnerable Populations Receiving Psychotropic Treatment, Ethics &
Behavior, 27:7, 582-598,

DOI: 10.1080/10508422.2016.1224187

To link to this article: https://doi.org/10.1080/10508422.2016.1224187

Accepted author version posted online: 16
Aug 2016.
Published online: 20 Sep 2016.

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Ethical Care for Vulnerable Populations Receiving
Psychotropic Treatment

Darren R. Bernal, Rachel Becker Herbst, Brian L. Lewis, and Jennifer Feibelman

Department of Psychology
University of West Florida

The increasing use of pharmacotherapy raises specific ethical concerns for psychologists working
with vulnerable populations. Due to a shortage of trained specialists, professionals without training
in mental health, such as primary care providers, are increasingly prescribing and monitoring
psychotropic medications. Vulnerable populations (e.g., older adults, people currently low in social
status, immigrants, and racial/ethnic minorities) face additional barriers to mental health treatment
and are at heightened risk when these factors intersect. Hence, these patients experience unique
barriers to receiving optimal psychopharmacological care and are differentially vulnerable to dele-
terious outcomes associated with misdiagnosis and overmedication. Taken together, these factors fuel
inequities in the access, quality, and utilization of mental health care. Psychologists working with
these patients are ethically mandated to protect patients from harm and ensure equitable care across
patient populations. Specifically, psychologists must respond to the dilemma of how to effectively
treat patients within these vulnerable populations who have been misdiagnosed or poorly medicated
while remaining within the bounds of their competence. This article recommends pathways to
address these dilemmas through education, training, research, and advocacy.

Keywords: socioeconomic status, elderly, immigrants, ethics, psychotherapy

PSYCHOPHARMACOLOGICAL TREATMENT OF VULNERABLE POPULATIONS

Mental health treatment in the United States has evolved to include professionals from multiple
fields, both within and outside of psychology. Many patients receive psychopharmacological
interventions in conjunction with psychotherapy. As a result, psychologists may face ethical
dilemmas when patients in their care receive suboptimal treatment from other sources, such as
when psychotropic medications are prescribed by nonpsychiatrists. Populations such as the
working poor or racial/ethnic minorities have risk factors that leave them vulnerable to adverse

This article was accepted under the previous editor, Gerald P. Koocher.
Rachel Becker Herbst is now a Pediatric Psychologist at the Department of Physical Medicine and Rehabilitation,

Children’s Hospital Colorado. Brian L. Lewis is now in independent practice in Roanoke, Virginia. Jennifer Feibelman is
now with the Graduate Student Department of Psychology at University of West Florida.

Correspondence should be addressed to Darren R. Bernal, Department of Psychology, University of West Florida,
11000 University Parkway, Pensacola, FL 32514. E-mail: darrenbernal@gmail.com

ETHICS & BEHAVIOR, 27(7), 582–598

ISSN: 1050-8422 print / 1532-7019 online

DOI: 10.1080/10508422.2016.1224187

mailto:darrenbernal@gmail.com

side effects from psychotropic medications. This increased risk likely results from a confluence
of factors such as marginalization, interpersonal bias (Levine & Ambady, 2013), inadequate
treatment (Alegria et al., 2008), and provider–patient communication difficulties (Verlinde, De
Laender, De Maesschalck, Deveugele, & Willems, 2012; Zolnierek & DiMatteo, 2009). In
addition, the likelihood that psychologists will treat members of vulnerable populations is
increased by growth among these populations and increasing prevalence of psychotropic treat-
ment. Due to changes in health care professionals’ roles—especially concerning psychopharma-
cological prescriptions—it is important for mental health professionals to build competence to
respond to the needs of vulnerable populations. This article introduces ethical concerns for
treating vulnerable populations and offers guidelines for mental health professions working with
these populations.

Increasing Prescription Rate

Prescription of psychotropic medications such as antidepressants has undergone a dramatic change
in the past 25 years (Pincus et al., 1998) with usage increasing in American adults from 6.1% to
11.1% between the years 1988–1994 and 1999–2002 (Paulose-Ram, Safran, Jonas, Gu, & Orwig,
2007). Although research indicates that the use of antidepressants may have peaked in the early
2000s (Harman, Edlund, & Fortney, 2009), the prescription of antidepressant medications has shown
a continued increase in certain populations such as the elderly (Hanlon, Handler, & Castle, 2010),
older nursing home residents (Maguire, O’Reilly, Hughes, & Cardwell, 2011), and some racial/
ethnic minority groups including African Americans and Latinos (Paulose-Ram et al., 2007). The
role of psychopharmacology has become increasingly relevant in light of the declining use of
psychotherapy. Between 1998 and 2007 the reported rate of psychotherapy use decreased from
53.6% to 43.1% per 100 persons receiving outpatient treatment for depression (Marcus & Olfson,
2010; National Alliance of Professional Psychology Providers, 2010). This approximately 10% drop
in psychotherapy utilization was accompanied by an increase in prescription of psychotropic
medication (Marcus & Olfson, 2010). Despite this prescription increase, research on the use of
these medications with vulnerable populations is generally lacking in adequate drug trials. Thus,
there is an increased demand for and an expansion of medications, but there is insufficient informa-
tion about prescribing effectively in vulnerable populations. This is of particular concern, as the role
of the primary care provider has evolved from gatekeeper to direct and sole provider of mental health
care for many patients with depression.

Decreasing Referrals

Historically, primary care providers conducted assessments and referred patients to specialists when
needed, such as when psychological problems were suspected. However, the primary care setting has
emerged as the most common avenue to psychotropic treatment, thus disrupting the traditional
referral pathway to psychologists. The use of psychotropic medications as “the first line of defense”
(Gray, Brody, & Johnson, 2005; National Alliance of Professional Psychology Providers, 2010) is
not inherently problematic, as they are valuable for treating mental health concerns; however, several
factors complicate the treatment process. Due to greater demand for psychological skills in primary
care settings, existing gaps in treatment and training have become more pronounced. Deficiency in
psychological skills and increased medication prescription compound with risks particular to

VULNERABLE POPULATIONS, PSYCHOTROPICS, AND ETHICS 583

vulnerable populations and further increase risks. Because members of vulnerable populations are
underrepresented in clinical trials and because primary care providers may not be well versed in
multicultural mental health considerations, there is more risk for error in prescribing psychotropics to
members of vulnerable populations.

Psychiatrists maintain that there has been a long-standing problem of insufficient mental
health training for primary care providers and this is an area in need of improvement (Hodges,
Inch, & Silver, 2001). As a result of increased time pressures and inadequate training, primary
care providers often rely on brief screening methods, and residents have reported feeling
underprepared to deal with the psychosocial problems of their patients (Duke, Griffith, Haist,
& Wilson, 2001). In addition to feeling underprepared, primary care providers are not substitutes
for psychologists, as they are not trained to provide therapy. This undesirable situation may
present a larger disservice to the patient or provider.

Despite these concerns, primary care providers in the United States have been found to
prescribe up to 70% of antidepressants (National Alliance of Professional Psychology Providers,
2010), which belong to the second most prescribed class of drugs in America, preceded only by
antihypertensives (Lindsley, 2015). This increase of psychotropic medication prescription by
primary care providers is disconcerting, given these providers’ documented difficulty in
accurately identifying mental health problems (Furedi, Rozsa, Zambori, & Szadoczky, 2003;
Jones, Badger, Ficken, & Leeper, 1987; Von Ammon Cavanaugh & Elliott, 1988; Watts et al.,
2002) and their propensity to prescribe psychotropic medications without consistently making a
formal diagnosis (Beardsley, Gardocki, Larson, & Hidalgo, 1988). Studies using the NIMH
Diagnostic Interview Schedule found a low detection rate of mental health concerns by general
practitioners in their patients (Jones et al., 1987), as well as a low level of agreement between the
general practitioner’s diagnosis and standardized measures for diagnosis (Furedi et al., 2003),
with increased diagnostic accuracy when patients presented a lack of somatic complaints. The
purpose of highlighting these discrepancies is not to criticize primary care providers for making
diagnostic errors in the area of mental health, but rather to raise awareness among psychologists
of an ethical concern, as these errors have implications for our field and our patients. An
additional concern is the need for continued monitoring for some psychotropic medications
due to deleterious side effects. In a small number of cases, primary care providers may not able
to provide consistent monitoring of mental health and psychotropics due to lack of patient
follow-up.

Shifting Prescription Rights and Professional Roles

The number of health care professionals with prescription rights may compound the problem
of pharmacotherapy without adequate monitoring capacity. In addition to primary care provi-
ders, about one fourth of advanced practice psychiatric nurses have the ability to prescribe
independently in 15 states as of 2003 (Feldman, Bachman, Cuffel, Friesen, & McCabe, 2003).
In addition, nurses can collaborate with providers to prescribe in another 27 states (Feldman
et al., 2003). These nurses are often in the position to see vulnerable populations due to their
potentially lower billing rate and location in rural areas. This additional prescription authority
represents another health professional with whom psychologists may collaborate in order to
provide optimal services to their patients.

584 BERNAL ET AL.

Further complicating the treatment process, psychiatry, a discipline that is typically
associated with psychology, has a personnel shortage (Lipzin, 1979; Thomas, Ellis,
Konrad, Holzer, & Morrissey, 2009). The current data indicate a shortage of psychiatrists
in 96% of American counties (Thomas et al., 2009), and this overall trend is expected to
continue until at least 2020, according to the U.S. Department of Health and Human
Services (2006). This shortage also increases the difficulty of finding psychiatrists who
have expertise in areas underrepresented in research, such as treatment of specific immigrant
cultures. Not having enough psychiatrists to meet the demand puts an additional burden on
the primary care providers to address mental health needs.

With a shifting psychopharmacological atmosphere, it is important to define the roles of
psychologists in treatment of medicated patients (McGrath & Rom-Rymer, 2010). A psycholo-
gist may have prescription rights or may work more indirectly by advocating for patients and
collaborating with other health care professionals. Psychologists must assess whether they have
the competence required for collaborating on medication prescription decisions and must decide
if their input regarding medication prescription is to the benefit of the patient. Factors that may
influence these decisions include the number of clientele taking psychotropic medications,
consideration of medications’ side effects, age of patients, race and ethnicity of patients, and
severity of patients’ illness or symptoms. Currently, there is a gap within the health care delivery
system, with a large proportion of psychotropic medication prescriptions being ordered by
primary care providers who have not had extensive mental health care training. Similarly,
most psychologists have not had extensive biological or medical training. Psychologists can
close this gap by collaborating with providers, by advocating for their patients, and by serving as
consultants for other health care professionals.

THE ROLE OF THE PSYCHOLOGIST

Vulnerable populations may receive substandard health care, which can result in increased,
rather than decreased, suffering. Patients receiving substandard pharmacotherapy while engaged
in psychotherapy may misattribute their side effects. For example, patients may attribute
increased mood fluctuation or depressed mood to their participation in psychotherapy if they
are not properly informed about their medications. The advent of integrated care, increased use
of psychotropic medications, and the burgeoning size of vulnerable populations such as Latinos
and the elderly in the United States (U.S. Census Bureau, 2012) have combined to create a new
frontier in the treatment of mental health concerns. Psychologists are thus faced with a new role
and new challenges, and this is particularly true when helping marginalized populations.

To address psychologists’ role of working with pharmacotherapy, the American Psychological
Association’s (APA’s) ethics task force concluded that issues related to prescriptive authority were
addressed under current sections of the Ethical Principles of Psychologists and Code of Conduct
(APA, 2010) and did not require a special section (Resnick & Norcross, 2006). Therefore, the
current Code of Conduct (APA, 2010) lacks specific guidance on potential ethical dilemmas
associated with psychotropic medication; however, it does provide a framework from which to
approach these ethical concerns. In this section, we discuss the broad application of this framework
to the psychologist’s role in working with patients from vulnerable populations who are receiving

VULNERABLE POPULATIONS, PSYCHOTROPICS, AND ETHICS 585

pharmacotherapy. We build upon this foundation in subsequent sections, where we present
considerations specific to different vulnerable populations.

The Code of Conduct (APA, 2010) has two principles and one standard that are particularly
salient to ethical dilemmas posed by working directly with vulnerable populations who are being
prescribed psychotropic medications. The first relevant principle is Principle E: Respect for
People’s Rights and Dignity. This principle states, “Psychologists try to eliminate the effect on
their work of biases based on those factors, and they do not knowingly participate in or condone
activities of others based upon such prejudices” (APA, 2010, p. 4). The vulnerable populations
discussed in this may have been subjected to biases such as those based on age, language, race,
and social status—biases that could affect the accuracy of their evaluations for psychotropic
prescription. If the psychologist suspects that his or her patient may have been misdiagnosed and
subsequently may have received suboptimal treatment, Principle E becomes pertinent. The
implication is that the psychologist must take action to avoid condoning the less than optimal
treatment that may stem from bias against these vulnerable populations.

When faced with a member of a vulnerable population who is receiving suboptimal psychotropic
treatment based on membership in that group, a psychologist may choose to help the patient work more
effectively with his or her primary care provider or obtain consent to cooperate directly with the primary
care provider. It may be advantageous for potential prescriber collaboration to be covered in the initial
informed consent for treatment. The second relevant APA guideline, Principle B: Fidelity and
Responsibility, reads, “Psychologists consult with, refer to, or cooperate with other professionals and
institutions to the extent needed to serve the best interests of those with whom they work” (APA, 2010,
p. 3). Although psychologists typically do not have the training necessary to be competent in the
prescription of psychotropic medication, it could be argued that some working knowledge of the usage
and effects of these medications is necessary for competently treating patients where these medications
are(or should be) used.Indeed,courseworkonpsychopharmacologyisarequired curricular component
of some doctoral programs in counseling and clinical psychology and are available through continuing
education. So when faced with a patient who is having adverse effects or potential misdiagnosis, is it
within the scope of competence to take action?

The APA’s (2010) Code of Conduct 2.01: Boundaries of Competence states, “Psychologists
provide services, teach, and conduct research with populations and in areas only within the
boundaries of their competence, based on their education, training, supervised experience, consulta-
tion, study, or professional experience” (p. 4). Reassessing or working with psychotropic medication
is beyond the scope of competence of most psychologists; however, diagnosing psychopathology in
vulnerable populations is within the scope of competence. If the psychologist finds himself or herself
frequently faced with the dilemma of patients who may not be receiving optimal treatment due to
inappropriate medication, additional efforts to develop competence in this area are warranted. The
section titled Boundaries of Competence further states that in the absence of standards, psychologists
must “take reasonable steps to ensure the competence of their work and to protect patients … and
others from harm” (APA, 2010, p. 5). Additional training in this case would not be to obtain
prescription rights but merely to make the psychologist a better advocate for the patient and
collaborator with prescription writers such as the primary care provider.

Social justice is also a component of a psychologist’s interaction with patients who receive poor
mental health care based on classism, ageism, or racism. Social justice is integral to the APA
principles (e.g., justice, beneficence, and nonmaleficence). By refraining from intervening, a psy-
chologist may be causing harm. Psychologists are in a difficult position when addressing this

586 BERNAL ET AL.

injustice because they do not possess the training. However, they are in a position to help their
patients receive and understand the psychopharmacological information patients deserve. When
necessary to protect the welfare of the patient, psychologists can act as intermediaries, provided that
informed consent is obtained beforehand. Acting as an intermediary may be useful if the patient is an
inconsistent reporter of symptoms or situation. In the spirit of social justice, however, it is preferential
to empower the patient to relay the information directly.

VULNERABLE GROUPS

Psychologists are ethically bound by their responsibility to act in their patient’s best interest and
to ensure that their patients’ rights to optimal care are maintained. Factors placing patients at a
heightened risk of receiving substandard care due to bias or underrepresentation compels
psychologists to possess the knowledge, skills, and awareness to identify these potential
dilemmas and intervene according to an ethical decision-making framework. Therefore,
psychologists need foundational knowledge about populations vulnerable to these risks: older
adults, people of low social status, immigrants, and racial/ethnic minorities. For increased
understanding and readability, we present the literature for distinct categories of vulnerable
populations. However, we acknowledge that intersectionality exists, such that members of one
group (e.g., low social status) may also belong to another group (e.g., racial/ethnic minorities).
In such cases, the intersection of factors, such as ethnicity and unemployment, may result in an
accumulative risk for mental health issues (Mallett, Leff, Bhugra, Pang, & Zhao, 2002). Thus,
reducing the complexity of an individual to one factor, such as social status, and then grouping
that individual in a vulnerable population based on that factor is inherently problematic. Such a
practice has great potential to miss the nuanced intersection of factors that compose an
individual’s biological, psychological, and social contexts, as well as the person’s strengths
and vulnerabilities. However, some research indicates that solitary factors can be associated with
negative outcomes such as the overdiagnosis of schizophrenia in some ethnic groups (Snowden
& Cheung, 1990; Strakowski et al., 2003). These factors represent a confluence of societal and
psychological elements; therefore, we identify group memberships such as race or being of a low
social status to highlight the “cause of the causes” and not to imply that belonging to the specific
group is the problem. In other words, living below the poverty line does not directly translate
into an increased risk for poor mental health; it is the social, biological, and psychological
stresses of having low social status that are relevant to mental health risks. Other potentially
vulnerable populations such as those distinguished by sexual orientation, gender, and disability
were not reviewed directly but are also subject to bias in health care treatment and may be party
to similar ethical considerations.

Social Status

Social status is the intersection of a person’s socioeconomic status, social class, and current
social context and is a key social determinant of health and psychotropic prescription. The
association between lower social status and increased prevalence of psychological problems has
been consistently supported (Chazelle et al., 2011; Kristensen, Gravseth, & Bjerkedal, 2010;
Stansfeld, Head, & Marmot, 1998). Social status has also been shown to influence physiological

VULNERABLE POPULATIONS, PSYCHOTROPICS, AND ETHICS 587

health status. The complex relationship between being lower on the social hierarchy and
physical health outcomes (e.g., life expectancy and hypertension) has been well established
across a variety of populations (Marmot, 2015; Satcher, 2001). Social status factors such as
employment, financial wealth, and social rank may account for some of the increased pathology
manifested in lower social classes and represent additional considerations for mental health
diagnosis and treatment. Considering these social determinants of health pharmacotherapy on its
own may not be the optimal response for the multiple factors that contribute to poor mental
health in people of low social status.

Financial disadvantage and minority status can interact to intensify the effects of poor mental
health outcomes or services. Limited financial resources and belonging to a minority population
have been linked to increased likelihood of being uninsured, underinsured, or lacking access to
health care (Newport & Mendes, 2009). Being uninsured has been consistently related to inadequate
levels of mental health treatment in minority populations, beginning in childhood (Kataoka, Zhang,
& Wells, 2002) and continuing into adulthood (Wang, Berglund, & Kessler, 2000). Employment
status is also consistently associated with mental health. The longitudinal White Hall studies of social
class found that work characteristics were responsible for much of the variation in depression and
well-being (Stansfeld et al., 1998). Although unemployment is not a stable dimension of identity, it
disproportionately afflicts minorities of all education levels and individuals with lower levels of
education. Being unemployed or having a lower level of education has also been linked to increased
anxiety and depression as diagnosed by providers (Ansseau et al., 2008). Similarly, patients who
were unemployed or had lower levels of education were prescribed more anxiolytics/antianxiety
medications by primary care providers when compared to employed and higher educated popula-
tions (Kisely, Linden, Bellantuono, Simon, & Jones, 2000).

Low social status has been linked to increased prescription of antidepressant medications
(Olfson & Marcus, 2009; Roer, Fonager, Bingley, & Mortensen, 2010; Von Soest, Bramness,
Pederson, & Wichsrtom, 2012). Individuals of low social status are therefore more likely to be
prescribed antidepressant medication despite being at increased risk for lack of adherence, poor
doctor–patient communication, and potential misdiagnosis. Meta-analysis of doctor–patient com-
munication identified differences in patient-centered behavior, nonverbal behavior, and affective
behaviors, suggesting that lower social status may disadvantage individuals when interacting with
the prescribers (Verlinde et al., 2012).

The status difference between a higher social status prescriber and a lower social status patient
affects quality of care and prescription adherence. Low social status has been related to premature
discontinuation of antidepressants use (Bocquier et al., 2014; Sundell, Waern, Petzold, & Gissler,
2013). A review of 60 years of research related prescriber–patient communication styles to differ-
ences in prescription adherence levels (Zolnierek & DiMatteo, 2009). Social status is related to a
more directive and less collaborative care style received by lower social status patients in prescriber
communication style (Willems, De Maesschalck, Deveugele, Derese, & Maeseneer, 2005).

In addition, social status may serve as a psychological barrier to seeking help. Lower social
status patients reported low confidence and low trust in primary care provider’s ability to address
their mental health needs (Kravitz et al., 2011). The combination of help-seeking behaviors,
systemic stressors, communication differences, and limited economic means can diminish the
agency needed to play an effective role in fine-tuning pharmacotherapy.

588 BERNAL ET AL.

Racial and Ethnic Minorities

The APA (2002) describes race as more “socially constructed, rather than biologically determined”
(p. 9), emphasizing that there is more in-group variation than between-group variation. Ethnicity is
also a social construct. The distinguishing factor, though, is its roots in individuals’ cultures of origin.
Ethnicity describes the cultural background of individuals and their related traditions. It is possible
for individuals to identify with multiple ethnicities.

Disparities in mental health have been established between African American, Latino, and White
American populations (Satcher, 2001). Moreover, African Americans not only are diagnosed at
different rates than White Americans but also have worse prognoses when diagnosed with common
conditions like major depressive disorder (Williams et al., 2007). African Americans are also more
likely than Whites to be diagnosed with schizophrenia and are typically prescribed higher levels of
medication (Snowden & Cheung, 1990; Strakowski et al., 2003). Ethnopsychopharmacology has
demonstrated ethnic variation in drug metabolization; African Americans and Asian Americans often
metabolize antipsychotic and antidepressant medications more slowly than Caucasians (Lin, 2001;
Strickland, Stein, Lin, Risby, & Fong, 1997). With the growing evidence on genetic variation in drug
response to common psychotropics such as selective serotonin reuptake inhibitors, the differences in
medication response will continue to be an issue (Chaudhry, Neelam, Duddu, & Husain, 2008). Race
affects psychotropic medication usage and response along physiological, psychological, and cultural
dimensions, and this complex interaction must be accounted for in treatment.

Diagnosis may be influenced by differential expression of symptoms of mental health
concerns. Disparities in the prevalence of mental health between racial/ethnic minority
groups indicate that thorough diagnostic assessment must take ethnicity into account. For
example, African Americans and Latinos have been shown to somaticize psychological
complaints (Ayalon & Young, 2003) more frequently than Americans of the dominant
culture. Health care providers must also balance the knowledge of different prevalence of
some mental health conditions without generalizing, developing bias, or failing to consider
individual differences.

Furthermore, help-seeking patterns may differ across racial/ethnic groups. African
Americans often seek help through informal sources such as friends and neighbors before
seeking help from medical professionals such as primary care providers (Ayalon & Young,
2005; Woodward et al., 2008). The use of informal networks may extend as far as sharing
medications (Comas-Díaz, 2012). It is not known whether this help-seeking behavior in
African Americans is detrimental to their treatment outcomes when they do seek treatment.
This help-seeking behavior may be an indication of strong social support, but it also
indicates that African Americans may interact differently with providers. If providers expect
that racial/ethnic minorities seek help in a similar manner as the dominant culture, this may
lead to misunderstandings and inappropriate treatment.

The nature of interactions between racial/ethnic minority populations and providers affects
treatment-seeking behaviors, quality of medication adherence, communication, and treatment
(Johnson, Roter, Powe, & Cooper, 2004; Manfredi, Kaiser, Matthews, & Johnson, 2010).
Cultural factors may contribute to lower medication adherence rates in Latinos and African
Americans (Diaz, Woods, & Rosenheck, 2005). Nonadherence may result from drug expense,
unavailability, and miscomprehension of dose and schedule. The combination of both lack of
monitoring and the potential for misdiagnosis with differences in metabolization of medication

VULNERABLE POPULATIONS, PSYCHOTROPICS, AND ETHICS 589

may lead to extrapyramidal side effects (Binder & Levy, 1981). Racial/ethnic minority
populations therefore could be particularly vulnerable to health complications, which may
become evident while under the care of a psychologist.

Older Adults

The World Health Organization (2014) defined the elderly as anyone who is age 60 or older. It
is projected that the world’s elderly population will double between the years 2,000 and 2,050
to reach about 2 billion, or about 22%. This growing demographic is often overmedicated
(Hanlon et al., 2010), especially in the nursing home setting (Maguire et al., 2011). Not only
are primary care providers the main prescribers of psychotropic medication to the elderly, but
pharmacotherapy is also the most commonly provided provider service to this group (Larson,
Lyons, Hohmann, Beardsley, & Hidalgo, 1991). In a review of the small body of literature on
psychotropic usage in older racial/ethnic minority groups, older African Americans were
found to use psychotropic medications at lower rates than White Americans (Voyer, Cohen,
Lauzon, & Collin, 2004). Elderly populations have been theorized to be at an increased risk for
medication nonadherence, but this predictive relationship is not conclusively supported in the
literature (Hughes, 2004). Overall medication adherence is higher for White Americans when
compared to African Americans and Latinos. Thus, older African Americans and Latinos may
be at risk for poor psychopharmacological treatment due to lower prescription adherence
(Lanouette, Folsom, Sciolla, & Jeste, 2009).

A systematic review of the literature found that inappropriate prescription of psychotropic
medication occurred approximately 9% to 24% of the time for the elderly (Mort & Aparasu,
2002). In some cases, the side effects of these medications have interfered with psychotherapy
and have even led to fatal outcomes, prompting the government to issue warnings (U.S. Food
and Drug Administration, 2005). Psychopharmacologic treatment of the elderly population is
particularly problematic because specific dosages of psychotropic medications are tested less
frequently on the elderly than on younger adult populations due to the difficulty of recruiting
elderly participants who meet study criteria. This underrepresentation increases the need for
monitoring side effects. As a result, the elderly may be considered especially vulnerable and
require a greater level of psychological care than they are currently receiving.

Immigrants

Immigrants encounter many of the same challenges faced by other vulnerable populations;
however, unique factors have the potential to impact immigrant health and treatment. For
example, immigrants tend to earn significantly less than native-born individuals, and many
are from nondominant racial/ethnic groups (Camarota, 2005; Kochhar, 2008). Immigrants
from the Latino and Caribbean Black populations have demonstrated deteriorating mental
health associated with increased length of stay in the United States (Alderete, Vega, Kolody,
& Aguilar-Gaxiola, 2000; Jackson et al., 2007). Although the mechanism of this phenom-
enon is unclear, the immigrant paradox requires health care providers to attend to the length
of time an immigrant has resided in the United States and to be aware that a longer stay may
intimate increased vulnerability. Acculturative factors related to a decrease in health, such as
language barriers, may also be associated with potential difficulties with pharmacotherapy.

590 BERNAL ET AL.

For example, studies have found a relationship between limited English proficiency and
difficulties obtaining health insurance coverage and accessing health care (DeNavas-Walt,
Proctor, & Smith, 2008; Yu, Huang, Schwalberg, & Nyman, 2006).

Beyond the more salient characteristics of language and time spent in the United States,
considerations related to help-seeking behaviors and symptom presentation must be examined.
These elements of culture, which are more covert and dynamically intertwined with individuals’
health schemas, may significantly influence the type of health care received. The role of doctor
differs by culture (Neighbors et al., 2007). Immigrants’ vestigial schemas of health care systems
in their native countries may interfere with their ability to receive adequate care in the United
States, especially when individuals need to be clear from whom to seek medication advice and
how to understand potential pharmacological side effects. Psychosomatic manifestation of
symptoms also differs by culture, and this may obfuscate accurate diagnoses (Patel, 2001),
which places additional barriers on immigrants’ receipt of adequate health care.

Factors associated with immigration status, socioeconomic status, racial minority status, and
acculturation place individuals in a vulnerable position within the health care system.
Furthermore, the intersectionality effect of these factors (Cole, 2009) places these individuals
at a higher risk than individuals from the dominant culture for deleterious experiences in the
management of their mental health concerns. Therefore, it is important for providers and
psychologists alike to be mindful of ethical dilemmas that may arise when employing pharma-
cotherapy treatment with immigrant patients.

RECOMMENDATIONS

Psychologists must take proactive steps to address ethical concerns for psychopharmacological
treatment of vulnerable populations. This requires the use of an ethical decision-making
framework that integrates the aforementioned standards from the APA’s Code of Conduct
with specific knowledge of risk factors within vulnerable groups. To facilitate this process, we
provide strategies to help address these concerns through education, training, direct clinical
care, consultation, advocacy, policy change, and research.

Education and Training

Psychologists have a role to play in decreasing the risk of negative outcomes for vulnerable
populations in regard to psychotropic medications. Psychologists should seek further specia-
lized training to meet the needs of the current landscape where psychotropic medications are
an integral part of treatment. Incorporation of the knowledge of additional psychotropic
medication risks associated with underrepresented populations is essential. Failing to do so
could indicate negligence, as it would leave psychologists unable to understand the full gamut
of their patients’ concerns. Providing input on psychotropic medication, without having had
specific training, is outside the scope of competence and could be considered unethical. There
is evidence that training psychologists to advise patients about psychotropics may be feasible,
as Gutierrez and Silk (1998) found evidence in the literature that psychologists are capable of
prescribing effectively. Alternatively, psychologists can also adopt and expand on the APA’s
recommendations (Smyer et al., 1993), in particular those encouraging increased collaboration.

VULNERABLE POPULATIONS, PSYCHOTROPICS, AND ETHICS 591

Furthermore, consultation steps recommended by Haley et al. (1998) should be considered an
integral part of the response in vulnerable cases.

Consultation and Advocacy

Consultation with prescribers is a concrete step that psychologists can take to improve
quality of patient care and to respond to the additional risks faced by vulnerable populations.
In the new mental health landscape, psychologists must be open and willing to collaborate in
a consulting role to provide a high level of treatment service for those who choose
medication only to address mental health concerns. The role of a good consultant includes
components of advocacy and social justice. In integrated care settings, consultation and
collaboration with prescribers is actively encouraged; however, in external or colocated
systems, psychologists may need to initiate relationships with primary care providers and
emphasize the benefit of the role of collaboration for patient well-being. This outreach is
particularly salient because primary care providers often report difficulty finding mental
health care for their patients (Cunningham, 2009). In an environment of increased liability,
collaboration to correctly diagnose and treat patients is an attractive proposition. However, a
psychologist’s mere presence in a collaborative relationship is not enough; optimal treatment
obliges the psychologist to establish themselves as resource for both the patient and
prescriber.

Diagnostic Clarification

Members of vulnerable populations may express and respond to mental health concerns
differently. The somatization of psychological concerns can be addressed through psychoe-
ducation with the patient and training provided to prescribers regarding differential cultural
expression of symptoms. This psychoeducation may also increase medication adherence by
addressing the potential disconnect between treating somatic symptoms with medicine
perceived to be psychological prescription.

Misdiagnosis or overmedication may result from communication challenges, improper or
damaged screening tools, or lack of feedback about side effects. Prescribers utilizing brief screening
tools that rely on the self-report of psychological symptoms may be less effective in identifying
mental health concerns in racial/ethnic minority groups than in the dominant White American
population (Ayalon & Young, 2003). This dilemma may be mitigated by the psychologist commu-
nicating directly with the prescriber or indirectly through the patient. Power differentials between the
prescriber and patient are also a viable target of intervention for psychologists who can change the
patient’s schema of the prescriber–patient relationship to a more collaborative one. For example,
psychologists who work with overmedicated elderly patients may intervene by discussing with their
patients the possibility that they are inappropriately medicated. A collaborative relationship between
the psychologist and the prescriber may result in significant benefits for the patient.

Promoting Adherence

Psychologists’ training positions them to directly respond to potential disparities and ethical
dilemmas in pharmacotherapy. For example, consistent adherence to medication is required

592 BERNAL ET AL.

for the desired effect; however, adherence issues and the underutilization of services in
vulnerable populations may necessitate an additional emphasis on monitoring. Some aspects
of medication nonadherence may directly relate to vulnerable groups’ risk factors, such as
lack of insurance, transportation difficulties, lack of education/understanding of the impor-
tance of adherence, and differential response to medication resulting in an ineffective dose
response. Periodic checks on the patient’s adherence and communication with the prescriber
may bridge the gap between prescriber visits. Psychologists can also facilitate the identifica-
tion of potential barriers to adherence, engaging the patient in motivational interviewing and
behavioral strategies to promote adherence.

Patient–Prescriber Communication

Communication between the patient and prescriber may be impeded by a mismatched communica-
tion style, mistrust, and power differentials that can be ameliorated by a psychologist. For example,
the less collaborative communication received by lower social status patients (Willems et al., 2005)
may be counteracted by raising patient awareness of these differences. Patients receiving treatment
from a prescriber who has a more directive style of communication may benefit from assertiveness
training focused on advocating for their treatment preferences. Psychologists can also offer training to
prescriber colleagues, presenting research regarding potential communication pitfalls and evidence-
informed communication strategies (e.g., motivational interviewing, open-ended questioning).
Mistrust of treatment providers may be addressed in therapy through the clarification of roles,
expectations, and reflection on negative experiences. If perceived as beneficial and empowering,
psychologists may also facilitate difficult dialogues between patients and prescribers regarding
mistrust, engaging in strategies to strengthen the patient–prescriber relationship. Psychologists’
training regarding effective communication, relationship building, and power differentials uniquely
positions them to identify these potential ethical concerns and guide them to empower, advocate for,
and educate their patient.

Policy Change

The increased prevalence of mental health disorders has been identified as a result of social
determinants of health (Marmot, 2015). Considering the contextual factors that contribute to the
increased prevalence of psychological disorders, a complete solution must also include
contextual factors. Treating a social problem with prescription may be a short-term solution.
Psychologists must advocate for policies that address inequities in treatment such as lack of
insurance, underrepresentation in research, and communication difficulties.

Psychologists can affect public and organizational policy, both individually and through organiza-
tions such as the APA. The social justice mandate of the APA principles calls for psychologists to be
aware of and active in policies that have ramifications for their patients, at an organizational and
government level. Knowledge of policy changes, such as the establishment of Medicaid criteria for
appropriate psychotropic medication use, is needed to effectively serve vulnerable populations.
Opening a discussion about psychotropic public policies, such as prescription rights for psychologists,
may raise awareness that could facilitate a subset of psychologists to provide consultation services.
Creating organizational policies that mandate the availability of therapy or provide information about

VULNERABLE POPULATIONS, PSYCHOTROPICS, AND ETHICS 593

psychotherapy to individuals using psychotropic medications may ensure a consistent quality of care.
These actions of advocacy have the potential to close the treatment-monitoring gap for patients.

Research Priorities

Further research on the manifestation of psychopathology in diverse populations may also
help to reduce misdiagnosis and to improve both psychotropic and psychotherapeutic treat-
ments. Specifically needed is research that facilitates documentation of the prevalence of
psychological illness across populations, validation of screening measures in underrepre-
sented groups, and increased understanding of societal and contextual factors that may
contribute to differences in treatment outcomes. Many of the previously established associa-
tions, such as the relationship between low social status and poor mental health, should
continue to be examined with the aid of new multivariate statistical techniques in order to
clarify the modifiable psychological factors. Further study is also necessary to understand
collaboration trends between primary care providers and psychologists when dealing with
vulnerable populations. It is equally important to expand the examination of this collabora-
tion in residential facilities for disabled or older adults and in settings where a psychologist
is unlikely to be consulted, such as private primary care practices. Research already indicates
positive results in integrated care by specialists who collaborate with treatments
(Pampallona, Bollini, Tibaldi, Kupelnick, & Munizza, 2004).

CONCLUSION

The intersection of the risks factors experienced by patients in vulnerable populations creates the
potential for unequal and potentially substandard quality of psychotropic care. Inequity remediation in
psychotropic care for vulnerable populations is a systemic problem and requires more interdisciplinary
collaboration. Optimal treatment requires raising the level of specific training to increase expertise for
working with these populations. For instance, psychological specialization (e.g., geropsychology)
positions psychologists to collaborate more effectively with experts in psychopharmacology.
Demographic characteristics such as low social status, race, age, or immigrant status and their inter-
section appear to be associated with vulnerabilities in psychotropic treatment. Consideration of this
vulnerability is the ethical responsibility of a psychologist. Trends in the prescription and use of
psychotropic medication impel psychologists to proactively establish collaborative relationships with
prescribers, contribute to organizational and public policy change, support research into pharmacother-
apy and treatment considerations with vulnerable populations, seek specialized training in pharma-
cotherapy, and engage in patient-level advocacy. Through engaging in an active role in the
pharmacotherapy management of vulnerable populations, psychologists can prevent ethical dilemmas,
improve the quality of patient care, and ameliorate health disparities.

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Abstract

PSYCHOPHARMACOLOGICAL TREATMENT OF VULNERABLE POPULATIONS
Increasing Prescription Rate
Decreasing Referrals
Shifting Prescription Rights and Professional Roles
THE ROLE OF THE PSYCHOLOGIST
VULNERABLE GROUPS
Social Status
Racial and Ethnic Minorities
Older Adults
Immigrants
RECOMMENDATIONS
Education and Training
Consultation and Advocacy
Diagnostic Clarification
Promoting Adherence
Patient–Prescriber Communication
Policy Change
Research Priorities
CONCLUSION
REFERENCES

https://doi.org/
https://doi.org/

Ther Adv Psychopharmacol

2018, Vol. 8(8) 231 –239

DOI: 10.1177/
2045125318765725

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journals.sagepub.com/home/tpp 231

Antipsychotics:
Advances, Limitations, and Alternatives

Special Collection

Introduction
Psychosis is an umbrella term for a clinical pres-
entation conceptualized, both by the American
Psychiatric Association1 and the World Health
Organization,2 as a combination of hallucina-
tions, delusions, disorganized thinking or behav-
iour, negative or catatonic symptoms, and
functional impairment.3 In the current diagnostic
classification systems, impaired reality testing
remains its hallmark. Psychotic symptoms are the
essential feature of schizophrenia spectrum disor-
ders, but may also be present in mood disor-
ders,4–6 autism spectrum disorders,7 personality
disorders,8,9 substance misuse6,10 and in the nor-
mal population.11,12 Psychosis may add to impair-
ment and disability,13 affect cooperation with
treatment14 and increase stigma associated with
mental health difficulties.15 The evaluation of
psychotic symptoms and identification and treat-
ment of psychosis are, therefore, important tar-
gets of the assessment and intervention of patients
seen by the mental health services.

The current prevailing explanatory model for psy-
chosis, mainly developed through studies of
schizophrenia, points towards the condition being
neurodevelopmental in origin, with the interac-
tion between genetic and environmental factors
marking the beginning of brain pathophysiologi-
cal processes long before the overt manifestation
of clinical symptoms. Several lines of evidence
suggest that psychosis is more severe, is associ-
ated with more neurodevelopmental deviance
and possibly has poorer prognosis, the earlier it
presents.16–19 Within this framework, early-onset
psychosis (EOP) has received particular attention
as it provides on the one hand a unique opportu-
nity to explore the aberrant neurodevelopmental
origins of the condition and on the other hand,
potential opportunities to affect its long-term
course. Despite research into the phenomenol-
ogy, epidemiology, pathophysiology and treat-
ment options in EOP, there are several challenges
that clinicians face in the assessment and manage-
ment of children and young people presenting

Dilemmas in the treatment of early-onset
first-episode psychosis
Daniel Hayes and Marinos Kyriakopoulos

Abstract: Early-onset first-episode psychosis (EOP) is a severe mental disorder that can pose
a number of challenges to clinicians, young people and their families. Its assessment and
differentiation from other neurodevelopmental and mental health conditions may at times
be difficult, its treatment may not always lead to optimal outcomes and can be associated
with significant side effects, and its long-term course and prognosis seem to be less
favourable compared with the adult-onset disorder. In this paper, we discuss some dilemmas
associated with the evaluation and management of EOP and propose approaches that can be
used in the clinical decision-making process. A detailed and well-informed assessment of
psychotic symptoms and comorbidities, a systematic approach to treatment with minimum
possible medication doses and close monitoring of its effectiveness and adverse effects, and
multidimensional interventions taking into consideration risks and expectations associated
with EOP, are paramount in the achievement of the most favourable outcomes for affected
children and young people.

Keywords: adolescents, antipsychotics, children, first episode, psychosis, schizophrenia,
treatment

Received: 6 December 2017; revised manuscript accepted: 26 February 2018

Correspondence to:
Daniel Hayes
National and Specialist
Bethlem Adolescent Unit,
Bethlem Royal Hospital,
Child and Adolescent
Mental Health Clinical
Academic Group, South
London and the Maudsley
NHS Foundation Trust,
Monks Orchard Road,
Beckenham, Kent BR3
3BX, UK
daniel.hayes@slam.
nhs.uk

Marinos Kyriakopoulos
National and Specialist
Acorn Lodge Inpatient
Children’s Unit, South
London and the Maudsley
NHS Foundation Trust,
London, UK

Institute of Psychiatry,
Psychology and
Neuroscience, King’s
College London, London, UK

Icahn School of Medicine
at Mount Sinai, New York,
USA

Review

https://uk.sagepub.com/en-gb/journals-permissions

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mailto:daniel.hayes@slam.nhs.uk

https://doi.org/10.1177/2045125318765725

http://crossmark.crossref.org/dialog/?doi=10.1177%2F2045125318765725&domain=pdf&date_stamp=2018-03-26

Therapeutic Advances in Psychopharmacology 8(8)

232 journals.sagepub.com/home/tpp

with psychotic symptoms for the first time. In this
paper, we will discuss some of the dilemmas
related to the treatment of psychosis presenting
for the first time in children and adolescents and
ways to navigate through these (Table 1).

Dilemma number 1: what are we treating?
The assessment of psychotic disorders can be
complicated, and its challenges can be exacer-
bated by the precocious onset of these conditions.
Psychosis presenting in childhood and adoles-
cence, whilst to a large extent characterized by the
same combination of symptoms as with the adult-
onset disorder, can manifest in ways that are more
easily subject to alternative diagnostic formula-
tions. Only a small percentage of psychosis cases
are manifest before adulthood,20,21 and presenta-
tions can be complicated by comorbidities22
which may both serve as vulnerability for the evo-
lution of the disorder, but also alter its clinical
picture. Furthermore, EOP is often characterized
by a more protean presentation, which can be
harder to differentiate from combinations of neu-
rodevelopmental (e.g. autism spectrum disor-
ders) with mental health conditions (e.g. anxiety
or mood disorders).7,23 In addition, given the rel-
ative infrequency of psychosis in adolescents and
the extreme rarity in children, more comprehen-
sive physical investigations need to be under-
taken, depending on the age at onset and clinical
presentation, in order to exclude neuropsychiatric
complications of physical conditions.7 The nature
of psychotic experiences in childhood and adoles-
cence is also subject to differences of interpreta-
tion, with evidence of childhood hallucinatory
experiences frequently indexing emotional and
conduct problems rather than a psychotic disor-
der.24 The prevalence of unusual experiences in
clinical populations of this age group has been
identified as very high. In a recent study, direct
evaluation through self report of psychotic-like
symptoms experienced by children and adoles-
cents attending community mental health clinics
was found to reach 68%, with 60% of these being
associated with distress or impairment.25 Finally,
the multiple routes into psychosis, affected both
by genetic liability26 and psychosocial adversity
and abuse27 may not always provide a good
pointer towards EOP as they are not unique to
psychosis, also being associated with a wide range
of brain changes and mental and behavioural dis-
orders with commonly adolescent onset.28–30 The
interaction between brain maturational processes,
environmental insults and proneness to mental

illness are more likely to give mixed or hard-to-
deconstruct clinical presentations in this age
when EOP incidence gradually reaches its peak.

Unravelling this diagnostic dilemma is crucial
because the provision of early, robust and effec-
tive treatment relies on accurate diagnosis. When
diagnostic clarity does occur, there is evidence of
good diagnostic stability over time for early-onset
schizophrenia,31,32 and bipolar disorder32 but not
as good for psychosis associated with other condi-
tions, for example, depressive disorder.32 It is
therefore very important to avoid premature diag-
nostic foreclosure in the face of uncertainty. The
evolution of psychosis does go through stages;
functional impairment in the prodrome can be
interpreted as affective disorder, or even a mani-
festation of normal adolescence, and a detailed
developing assessment and staged approach to
treatment interventions are warranted. Careful
consideration of developmental history and envi-
ronmental circumstances, characterization of psy-
chotic symptoms, comprehensive evaluation for
mood and anxiety disorders, exclusion of organic
conditions and substance misuse, and conclusion
about the degree of impairment associated with
psychotic symptoms are likely to facilitate the
diagnostic formulation. A balance between indis-
criminate classification of psychotic symptoms as
a psychotic disorder and reluctance to give the
diagnosis needs to be maintained. In early-onset
cases, the accurate characterization of the young
person’s difficulties, and a narrower approach to
psychosis as a disorder to include a more severe
and impairing combination of psychotic symp-
toms is likely to be the most appropriate, clini-
cally, to identify evidence-based interventions.

Dilemma number 2: how do we treat?
In children and young people, once the diagnosis
of psychosis is made, second-generation antipsy-
chotics (SGAs) are generally recommended.33
Although the choice of treatment is hampered by
some limitations in evidence base, both first- and
second-generation antipsychotics are of estab-
lished and comparable efficacy in psychosis but
differ in their side-effect profile.34,35 Use of SGAs
is almost ubiquitous, but perhaps needs to be
rebalanced in context of patient discussion about
acceptability of side effects, both in the short and
longer term, given the likelihood of necessity for
continuing treatment. First-generation antipsy-
chotics are generally to be avoided due to their
side-effect profile, in particular, high incidence of

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D Hayes and M Kyriakopoulos

journals.sagepub.com/home/tpp 233

movement disorders, including tardive dyskine-
sia.36 The safety of antipsychotics in childhood
and adolescence remains a key area of clinical
uncertainty, and risk/benefit analysis, mostly
favouring their use in severe mental illness, needs
to be undertaken in all cases.35 The choice of
antipsychotic is to a large extent determined by its
side-effect profile. Of all the SGAs, olanzapine is
associated with more weight gain and metabolic
side effects, so when this choice is made, it needs
to be discussed with young people and their fami-
lies.33 Most clinicians would not prescribe olan-
zapine routinely as first line in EOP. Additional
treatments may also be prescribed to target
comorbid conditions, for example, mood stabilis-
ers in presentations with a bipolar affective com-
ponent or selective serotonin reuptake inhibitors
for comorbid anxiety and depression. There are a
growing number of trials in this population
reflecting the importance of generating a child-
specific evidence base for prescribing antipsy-
chotics. To that end, international initiatives to
set standards and optimise the methodological
and practical aspects of research in children, such
as the Standards for Research in Children (STaR
Child Health) and the Child and Adolescent
Psychiatry Trials Network (CAPTN) group have
been developed.37,38

The only antipsychotic which seems to be more
efficacious compared with the rest of the SGAs is
clozapine.39–41 Although its superiority in meta-
analyses of adult samples has recently been a sub-
ject of debate,42,43 it was also argued that trials
including children and young people need to be
considered separately.44 The evidence base on
clozapine in this age group is very limited and clo-
zapine trials are generally difficult to conduct due
to the small number of cases that can potentially
be included in them. Clozapine remains an
underused drug across the lifespan40,45 that results
in treatment-resistant cases going through
repeated cycling through pharmacopoeia rather
than having clozapine tried. This is likely due to
barriers to acceptability, and whilst risk issues can
be a concern for patients and families, profes-
sional difficulties also compromise its use with
many child and adolescent psychiatrists being
wary of the drug due to unfamiliarity outside of
inpatient units. This situation may also be per-
petuated by lack of resources to initiate clozapine
in the community in this population and services
not being set up to manage the monitoring pro-
cesses required. However, in cases not respond-
ing to alternative SGAs, clinicians should become

more comfortable considering this option as the
majority of EOP patients who are eventually pre-
scribed clozapine appear to have a favourable
clinical outcome.40

In this younger age group, the principle of cau-
tious initiation and gradual increase of the dose of
antipsychotic is clinically applied, but needs to be
balanced against the risk of delayed or inadequate
treatment.46 Whilst the principle of ‘start low, go
slow’ is widely employed, young people are not
uniquely responsive to the beneficial effects of
medication, but rather sensitive to side effects
that can impair tolerability and compliance.47
The decision about when an antipsychotic is con-
sidered to not be effective has also been subject to
investigation, with some evidence suggesting that
this may be concluded as early as 2–3 weeks into
treatment with an adequate dose of the drug.48,49
However, taking the current guidelines into
account, it is important to consider that early dis-
continuation may affect eventual classification of
cases as treatment resistant,50 which is likely to
have implications for clozapine use. In addition to
the absence of clear treatment response, there can
also be uncertainty in relation to suboptimal
response, problems with tolerability or a combi-
nation of the two. Although these challenges
apply similarly to some extent to adults, ongoing
lack of capacity or competence in children and
young people make such discussions with the
wider family more complicated. Alongside clini-
cal judgement and close physical health monitor-
ing, the use of rating scales to quantify the young
person’s improvement and side effects are likely
to assist with these decisions.7,51

Alternative forms of administration, for example,
long-acting injectable (LAI) medication, have a
role in the management of young people when
there are concerns about nonadherence, but some-
times clarity about the necessity for using such
interventions only becomes apparent in retrospect.
Nonadherence certainly is an issue with adoles-
cents, not just with regard to psychotropic medica-
tion,52 but also for other diseases requiring
long-term pharmacological intervention e.g. diabe-
tes53 or epilepsy.54 This may be embedded in
developmental processes around autonomy and
control,55 and difficulties accepting long-term con-
sequences of current difficulties.56 Nevertheless,
when LAIs are considered for EOP, due to serious
adherence issues and significant risks associated
with the young people’s clinical presentation, care-
ful monitoring is warranted due to almost

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complete lack of trial evidence in this age group. It
is encouraging that, in adult studies, LAIs were
similar to oral antipsychotics regarding the fre-
quency of treatment discontinuation due to adverse
events and serious adverse events. However, their
use was associated with significantly more akinesia,
low-density lipoprotein cholesterol changes and
anxiety but also, interestingly, with significantly
lower prolactin change.57

Treatment with antipsychotics in schizophrenia
spectrum disorders is usually long term. No clear
evidence exists about when it may be safe to reduce
the dose or discontinue medication following the
first episode of EOP and, from a practical perspec-
tive, such approaches may only be discussed in the
case of full remission for a very considerable
amount of time. Under these circumstances,
potential reduction of medication needs to be very
gradual and be accompanied with very close moni-
toring of its outcome. With the first signs of clinical
deterioration, medication needs to be reinstated as

previously, to avoid another episode of psychosis.
The development of side effects may also trigger
discussions about medication discontinuation or
switching to an alternative antipsychotic. Only one
study to date58 has investigated antipsychotic with-
drawal in adolescents with schizophrenia using a
double-blind placebo-control randomized design.
In this study, patients were cross titrated and stabi-
lized from their antipsychotic treatment to ari-
piprazole, and then randomized to aripiprazole or
placebo in a 52-week double-blind maintenance
phase. Compared with placebo, active treatment
was associated with a significantly longer time to
exacerbation of psychotic symptoms or impending
relapse, lower rates of serious or severe adverse
events, lower rate of discontinuation due to serious
or severe adverse events, and similar or lower inci-
dences of extrapyramidal symptoms, weight gain,
and somnolence.

Although antipsychotic medication is the first-line
treatment for EOP, psychological interventions

Table 1. Dilemmas in the treatment of early-onset first episode psychosis.

(1) What are we treating?

(a) Early-onset psychotic disorder is rare but psychotic symptoms are frequent.

(b) Frequent comorbidity and atypical presentation can complicate diagnosis.

(d) ‘Narrower’ approach to psychosis as a disorder is recommended.

(2) How do we treat?

(a) Second-generation antipsychotics are the treatment of choice.

(b) Side-effect profile guides treatment choice, given the similar effectiveness of different SGAs.

(d) Clozapine should be considered in treatment-resistant cases.

(e) Long-term treatment is likely to be needed.

(f) Psychological interventions should be offered.

(3) What should we expect from treatment?

(a) Resolution of symptoms should be the aim of treatment but prognosis is poorer compared with
adult-onset cases.

(b) Treatment of comorbidities is an important aspect of long-term management.

(d) Adverse effects of medication should be minimized.

SGAs, second-generation antipsychotics.

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D Hayes and M Kyriakopoulos

journals.sagepub.com/home/tpp 235

also have a role to play in its management.
Psychological therapies need to be adapted for
children and adolescents with psychosis.33 These
adaptations take into consideration cognitive,
social, psychological and practical aspects specific
to their age. From a practical perspective, com-
pared with mood and anxiety disorders, young
people with EOP seek psychological support less
often and their engagement may not be as good.
They need a flexible and creative approach; one
that adapts to their understanding and the lan-
guage they use about their experiences. The evi-
dence base for psychological therapies specific to
adolescent psychosis is very limited and there is
practically no evidence for their use in children.
Cognitive remediation therapy (CRT) seems to be
beneficial for improving cognitive ability in EOP59–
61 and also psychosocial functioning59 with the lat-
ter also being shown to improve by a combination
of cognitive behavioural therapy (CBT) and fam-
ily intervention in a small pilot study.62 Studies
focusing on EOP that examined therapy effects on
psychotic symptoms have reported negative
results.59,61,62 More research on psychological
interventions in this age group is needed.

Dilemma number 3: what should we expect
from treatment?
The majority of EOP patients will have further
episodes of illness and long-term difficulties.
Having at least one further episode requiring hos-
pitalization was reported to reach 83% of adoles-
cents with schizophrenia over a period of more
than 10 years63 with the majority of the sample
also having at least moderate educational and
occupational impairment and serious social disa-
bility. Two studies that followed up childhood-
onset patients over a period of 42 years18,64 also
reported poor outcomes, with half of them being
found to have continuous symptoms, 25% to be
in partial remission and less than a sixth showing
a favourable outcome. More than 70% did not
graduate from school and were unemployed at
the time of follow up.18 Two age cut-off points
delineating worse prognosis, as assessed by num-
ber of days in first admission, percentage of
patients with more than one admission, average
number of days in hospital and number of admis-
sions per illness year, seem to be around 17 and
12 years, with patients having earlier onset being
more affected.17

As in all other clinical conditions, the aim of treat-
ment in EOP should always be for symptom

resolution, with a return to premorbid levels of
functioning. However, this can be difficult to
achieve in the context of increased severity and
poorer prognosis associated with earlier onset,65
so there is an imperative to ensure all remediable
issues are dealt with, in terms of prompt effective
treatment in multiple modalities.33 Within EOP,
poorer premorbid functioning in childhood, the
severity of negative symptoms at baseline and the
duration of untreated psychosis are all associated
with a worse outcome.66 Inferior treatment
response to antipsychotic medication has also
been associated with comorbid autism spectrum
disorders.67 Even in the event of a good response
to treatment, EOP has a significant impact on
young people. The recovery model68 has had a
significant influence on mental health policy and
provision, and whilst its tenets are applicable to
young people with EOP, it is important to
acknowledge that despite symptomatic recovery,
young people are on a chronologically determined
trajectory through educational attainments and
social transitions that they cannot step out of, in
the context of an episode of illness, and return to
at the same point, rather than behind similarly
aged peers.

A particular concern in relation to long-term
management in EOP is suicide. Suicide rates for
people with schizophrenia are elevated compared
with the general population, with an estimated
lifetime risk of approximately 5%.69 The strongest
associations with later suicide include being
young and male, and experiencing a greater bur-
den of illness. In early-onset cases, suicide rates
may be much higher; a study following up 61
patients over a period of at least 11 years70 identi-
fied 9 patients dying of suicide (14.7%) with this
being particularly elevated in males (6/28;
21.4%). Considering the possibility of this devas-
tating outcome is directly relevant to risk manage-
ment in EOP, further emphasizing the necessity
for effective treatment for psychosis, including
the use of clozapine71 as a specific suicide-reduc-
tion strategy.

Taking into account the increased susceptibility
of young people to adverse side effects of medica-
tion, a not uncommon clinical dilemma emerges
when a good clinical response is associated with a
side-effect profile that has significant biological or
psychosocial implications, such as excessive
weight gain, sexual dysfunction or sedation. From
the clinician’s point of view, altering established
and effective medication regimes can generate

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understandable anxiety with regard to risk of
relapse. However, given the likelihood for the
necessity for long-term treatment, efforts should
be made to establish the minimum effective dose,
or to switch young people to medication with less
propensity to cause side effects of particular sali-
ence to them. This not only affects the young per-
son’s quality of life, physical health and long-term
morbidity and mortality, but increases the chances
of treatment compliance, which is a significant
concern in adolescent-onset psychotic disorders,
as mentioned above.

Significant dilemmas associated with long-term
expectations from treatment also emerge in rela-
tion to the management of comorbid conditions.
Comorbidities may include neurodevelopmental
disorders, like autism spectrum disorders, which
affect the clinical presentation of young people
with psychosis in remission and will require active
management of associated impairment on its own
right.7 Psychosis in young people is also highly
comorbid with depressive and anxiety disorders69
which can be harder to identify as they may be
considered to be part of the psychosis phenome-
nology or represent medication side effects and
are therefore left untreated. Low expectations of
full recovery may affect clinicians’ motivation to
diagnose additional conditions and therefore miss
the opportunity to implement evidence-based
interventions which are likely to significantly
improve the clinical progress of the young person.
Finally, substance misuse, frequently preceding
or coexisting with psychosis,72,73 can influence
not only the aetiological conceptualization of
young people’s symptomatology, but also lower
the expectations of recovery and lead to subopti-
mal treatments of both conditions.

Conclusion
First-episode EOP is a severe mental health
condition which requires timely specialist inter-
vention. Although our understanding of the sig-
nificance of psychotic symptoms in clinical and
nonclinical populations and our conceptualiza-
tion of EOP and its overlap with other conditions
have significantly evolved in the last few decades,
its treatment remains to a large extent subopti-
mal. Its clinical presentation and management
can be associated with significant difficulties, giv-
ing rise to dilemmas both for the treating clinician
and the young person and their family. Better
characterization of its phenomenology, identifica-
tion and application of the most favourable

treatment strategies, and realistic but also well
informed expectations are likely to result in the
achievement of the best possible clinical out-
comes, and assist in the young person reaching
their full potential. Further research targeting
improved medication effectiveness, optimal use
of current treatment options, evaluation of treat-
ment failure, side-effect reduction and the devel-
opment of psychosocial interventions in children
and young people with EOP is urgently needed.

Funding
This research received no specific grant from any
funding agency in the public, commercial, or not-
for-profit sectors.

Conflict of interest statement
The authors declare that there is no conflict of
interest.

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