Innovations In Clinical Neuroscience

MAY-JUN 2017

A peer-reviewed, evidence-based journal for clinicians in the field of neuroscience

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Innovations in CLINICAL NEUROSCIENCE [ V O L U M E 1 4 , N U M B E R 5 – 6 , M A Y – J U N E 2 0 1 7 ] 26 occasional suicidal ideation without any p lan or intent to die. She was started on a long-acting stimulant medication to treat ADHD, a selective serotonin reuptake inhibitors (SSRI) to treat depression, and daily group therapy to l earn social skills. Her mother was at home under hospice care for terminal colon cancer, and her father was minimally involved in M's care. The treatment team kept close contact with M's mother on the phone, as she was unable to attend family sessions because of her illness. M continued to have problems in school and at home despite treatment. The primary reasons for poor treatment outcome were likely psychosocial stressors and partial adherence with treatment. After three weeks in treatment, M came to the program seemingly intoxicated. She refused a urinary drug screen. M revealed, after requesting confidentiality, that she was occasionally stealing opioid medications from her mother to use recreationally. She denied any acute safety concerns. She denied taking more than one or two pills at a time, and no more than once every week. She denied a desire to harm herself or die by taking these medications. She denied diverting the medications. The treatment team encouraged M to tell her family about her medication abuse, but she refused. M did not want her dying mother to know about her substance use problem. M stated that her father did not care much about her, and she refused to tell him about taking the opioid pain medications. M was deemed by the treatment team to possess capacity to make an informed decision about not telling her family about her substance use. She understood the risks of using opioids, including death in the case of an accidental over-dose. M agreed to start a comprehensive specialized counseling program to address her substance use disorder. A phone call was made to M's mother to ask her about the behavior of the patient at home. In the ensuing discussion, the mother was advised to keep her medications secure at home. The mother appeared to have no k nowledge about M's theft. The next week, the parents pulled M out of the partial hospital treatment program because of a perceived lack of therapeutic benefit. Parents were never i nformed about M's occasional drug use habit. DISCUSSION Confidentiality is a widely accepted standard of care in mental health treatment. It is essential to enable a clinician to develop trust with the patient. If confidentiality is not protected, it can negatively affect the physician- patient relationship and negatively impact care. In accordance with the Health Information Portability and Accountability Act of 1997 (HIPAA), clinicians are required to protect the privacy of patients. 5 If there is imminent threat to the safety of the patient or others, then the right of confidentiality can be over-ridden. According to Piaget, 6 a minor enters the concrete operational stage of cognitive development at 11 or 12 years of age. Weithorn and Campbell 7 reported in their analysis that 14-year-olds did not differ significantly from adults in stated preferences regarding treatment options. This evidence supports the case for competency of minors to make informed treatment decisions. There is a significant body of literature concerning minors making informed decisions and giving assent for treatment, but there is a dearth of published literature regarding minors' refusal for treatment or their failure to assess the long-term risks of that refusal. A minor can initiate treatment or rehabilitation for drug and alcohol use, and this treatment cannot be disclosed to parents or legal guardians without the minor's consent. 8 In clinical practice, a situation like might become more complicated when a minor is using opioids. Recreational opioid use can be fatal in the case of an accidental or intentional overdose. Opioid use can quickly become habit forming and addictive. On the other hand, informing parents of recreational use of opioids medications without any indication by the minor of intention to harm, overdose, or commit suicide can be p erceived as a severe breach of confidentiality by the patient, potentially resulting in the end of a therapeutic alliance. The patient might terminate current treatment, might not seek further m ental health treatment, or might simply become dishonest with the clinician. In the presented case, the treatment team conducted a detailed safety assessment of the the patient. The patient denied any current or past suicidal ideation, plan, or intent. She also denied any history of self-harm or violence. She did not exhibit symptoms of opioid use disorder. Despite the presence of risk factors for suicidal behavior, which included potential bereavement following the imminent death of her mother and the patient's co- morbid depression and ADHD, the team concluded she was not in immediate danger of hurting herself or others. There is no one-size-fits-all answer regarding when to breach confidentiality. The clinician must make this decision on a case-to-case basis. Medical record keeping in these situations can become complicated. 9 In situations such as this described case, it is advisable to confer with peers and to contact the hospital ethical committee or legal department for advice. 10 While the patient's best interest and safety are the primary concern, it is often difficult to determine whether to forgo confidentiality in cases involving alcohol and substance use disorders. Clinicians are strongly advised to clearly document in the medical records of their patients the rationale for challenging decisions to respect or breach the right of privacy in order to mitigate potential medico-legal consequences. CONCLUSION Clinicians should be aware of state laws regarding consent for alcohol and substance use treatment for minors. While family participation is the ideal strategy for treatment, minors can invoke the right of confidentiality to bar clinicians from sharing information regarding substance use with their families. Clinicians should obtain appropriate consent for communications and maintain confidentiality when

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