Reply to lokhandwala and westefeld

Abstract

Lokhandwala and Westefeld's article highlighting the ethical dilemma in rational suicide raises the pragmatic question of how one would actually assess a client's situation. A particularly relevant diagnosis that should be ruled out is clinical depression. The DSM-IV lists nine symptoms of major depressive disorder, eight of which could easily be masked as symptoms of the physical illness or side effects of treatment. These symptoms can be grouped into three categories: central features of depression, physical signs of depression, and cognitive signs of depression. All three of these categories, particularly physical signs, could easily be mistaken for medical problems. Reviewing the nine criteria for a diagnosis of clinical depression might be a good way to explore the possibility of clinical depression in a terminally ill person who is supposedly making a “rational” decision to commit suicide.     

The effect of cognitive behavior therapy on decision making in adolescents who self-harm: a pilot study

Research shows poor decision making in adolescents who self-harm and a positive correlation between decision-making abilities and duration since last self-harm episode. This exploratory study investigated whether decision making in self-harming adolescents could be improved through treatment with a novel cognitive behavior therapy (CBT). It also investigated whether improvement in decision making following treatment was linked to self-harm cessation. Adolescent self-harmers receiving CBT (n = 24) or no treatment (n = 9) and healthy controls (n = 22) were longitudinally compared on the Iowa gambling task (IGT). Significant IGT improvements were only observed for adolescents who self-harm following CBT. CBT may benefit adolescent self-harmers and generate decision-making improvements.     

Impairment in risk-sensitive decision-making in older suicide attempters with depression

Suicidal behavior is a potentially lethal complication of late-life depression. In younger adults, suicide has been linked to abnormal decision-making ability. Given that there are substantial age-related decreases in decision-making ability, and that older adults experience environmental stressors that require effective decision-making, we reasoned that impaired decision-making may be particularly relevant to suicidal behavior in the elderly. We thus compared performance on a probabilistic decision-making task that does not involve working memory ("Cambridge Gamble Task") in four groups of older adults: (1) individuals with major depression and a history of suicide attempt (n = 25), (2) individuals with major depression with active suicidal ideation but no suicide attempt (n = 13), (3) individuals with major depression without suicidality (n = 35), and (4) nondepressed control subjects (n = 22). There was a significant effect of group on quality of decision-making, whereby the suicide attempters exhibited poorer ability to choose the likely outcome, compared with the nonsuicidal depressed and nondepressed comparison subjects. There were no group differences in betting behavior. The suicide attempters differed in several aspects of social problem-solving on a self-report scale. Quality of decision-making was negatively correlated with the score on the impulsive/careless problem-solving subscale. These data suggest that older suicide attempters have a deficit in risk-sensitive decision-making, extending observations in younger adults. More specifically, older suicide attempters seem to neglect outcome probability and make poor choices. These impairments may precipitate and perpetuate suicidal crisis in depressed elders. Identification of decision-making impairment in suicidal elders may help with designing effective interventions.     

Anchor effects in decision making can be reduced by the interaction between goal monitoring and the level of the decision maker’s executive functions

Models of decision making postulate that interactions between contextual conditions and characteristics of the decision maker determine decision-making performance. We tested this assumption by using a possible positive contextual influence (goals) and a possible negative contextual influence (anchor) in a risky decision-making task (Game of Dice Task, GDT). In this task, making advantageous choices is well known to be closely related to a specific decision maker variable: the individual level of executive functions. One hundred subjects played the GDT in one of four conditions: with self-set goal for final balance (n?=?25), with presentation of an anchor (a fictitious Top 10 list, showing high gains of other participants; n?=?25), with anchor and goal definition (n?=?25), and with neither anchor nor goal setting (n?=?25). Subjects in the conditions with anchor made more risky decisions irrespective of the negative feedback, but this anchor effect was influenced by goal monitoring and moderated by the level of the subjects' executive functions. The findings imply that impacts of situational influences on decision making as they frequently occur in real life depend upon the individual's cognitive abilities. Anchor effects can be overcome by subjects with good cognitive abilities.     

Differences in decision-making development between expert and novice invasion game players

This cross-sectional study investigated the differences between young expert soccer players' (n = 55) and novice players' (n = 74) decision-making ability during performance of invasion games (ages: 7-8, 9-10, 11-12, and 13-14 years). Decision-making ability was assessed in invasion games that were appropriately modified for age and expertise. Games were modified to meet the developmental needs and previous learning of the participants, so interference between motor execution and decision making was minimized. Game performance was videotaped, and measures of cognitive components were developed from observational analysis. Decision making was measured at two levels: (a) decision making restricted to the selection of the technical-tactical skills (passing, moving with the ball, getting free, marking, tackling, double teaming, and interception) and (b) decision making in the adaptation to the tactical context of the game. Expert players remained superior in decision-making ability when variation in skill execution was controlled. Decision-making differences between levels of expertise decreased with age with regard to the first level (skill selection) and increased with age in relation to the second level (tactical-context adaptation). Findings are discussed in terms of implications for instructional focus and task design.     

Stress and depression of facing death: Investigation of psychological symptoms in patients with mesothelioma

Cancer often results in psychological impairment, and lung cancer has been associated with greater morbidity and higher levels of psychological distress than any other form. Chronic exposure to asbestos is a significant risk factor for development of lung cancer, called mesothelioma. Few have studied the psychological consequences of chronic asbestos exposure and mesothelioma. This study investigated stress and depression symptoms in 49 men (M = 51.1 years, SD = 6.0) diagnosed with mesothelioma. Participants completed traumatic stress, depression and general psychological health questionnaires. All participants reported significant levels of traumatic stress symptoms, which was associated with increased symptoms of depression, anxiety, somatic complaints and social dysfunction. The results provide important suggestions for clinicians treating such terminally ill patients.     

Assessing hopelessness in terminally ill cancer patients: development of the Hopelessness Assessment in Illness Questionnaire

Hopelessness has become an increasingly important construct in palliative care research, yet concerns exist regarding the utility of existing measures when applied to patients with a terminal illness. This article describes a series of studies focused on the exploration, development, and analysis of a measure of hopelessness specifically intended for use with terminally ill cancer patients. The 1st stage of measure development involved interviews with 13 palliative care experts and 30 terminally ill patients. Qualitative analysis of the patient interviews culminated in the development of a set of potential questionnaire items. In the 2nd study phase, we evaluated these preliminary items with a sample of 314 participants, using item response theory and classical test theory to identify optimal items and response format. These analyses generated an 8-item measure that we tested in a final study phase, using a 3rd sample (n = 228) to assess reliability and concurrent validity. These analyses demonstrated strong support for the Hopelessness Assessment in Illness Questionnaire providing greater explanatory power than existing measures of hopelessness and found little evidence that this assessment was confounded by illness-related variables (e.g., prognosis). In summary, these 3 studies suggest that this brief measure of hopelessness is particularly useful for palliative care settings. Further research is needed to assess the applicability of the measure to other populations and contexts.     

Anxiety and Depression in Medically Ill Older Adults

Anxiety and depression are extremely common in the elderly with medical problems. They can manifest not only as symptoms of a primary psychiatric illness, but also as physiologic sequelae of medical illnesses and medical treatments. Recognition and treatment of depression and anxiety in the medically ill is especially difficult. If these states go untreated, they result in higher morbidity and mortality, higher health care costs and utilization, and poorer functional status and outcomes. Three of the most common medical illnesses that afflict geriatric patients, cardiovascular disease, pulmonary disease, and rheumatoid arthritis, will be presented to illustrate the difficulty in recognizing depression and anxiety and the impact of treating these symptoms in the medically ill elderly. Multidisciplinary approaches combining optimal medication regimens and psychosocial interventions can be effective for treatment of anxiety and depression in the medically ill elderly.     

Coping with conflict situations: middle-aged and elderly men

In this study we investigated the coping responses of fairly healthy, middle-aged (40-64 years, n = 76) and elderly (65-92 years, n = 106) men to five conflict situations (i.e., decision making, defeat in a competitive circumstance, frustration, authority conflict, and peer disagreement). Coping responses were measured by the Life Situations Inventory, developed to assess three forms of coping: problem-solving, avoidance, and resignation. Scales were based on a 28-item questionnaire and were derived rationally through item analysis. Alpha coefficients ranged from .75 to .82. Elderly subjects used avoidance significantly less often than did middle-aged subjects in handling decision-making and authority-conflict situations. No differences were noted between the age groups in use of problem solving or resignation. Both middle-aged and elderly persons favored use of problem solving in managing all conflicts. Results suggest that studies that do not address potential interactions between age and stress situation may be missing an important element in the age-coping relation.     

Predictors of adolescent female decision making regarding contraceptive usage.

The relationship of cognitive capacity, cognitive egocentrism, and experience factors to decision making in a contraceptive usage problem was examined. Fifty sexually active, unmarried females, ages 14-19, served as subjects. Using correlational, regression, and canonical correlational analyses, cognitive capacity and cognitive egocentrism variables, not experience with contraceptives, were found to be significantly related to, and predictive of, five of seven decision-making variables. Forty-one percent of the variance was accounted for in predicting the canonical decision-making variable. The implications of these results for future research are discussed.     

Social influence on group moral decisions: the interactive effects of moral reasoning and sex role orientation

In this study, we examined the effects of moral reasoning level and sex role orientation on social influence in group decision making. We predicted that these two individual difference constructs would have an interactive effect such that people who are compatible or nonconflicted on the two dimensions would have more influence on a group task with moral implications than would people who are conflicted. All subjects individually completed a distributive decision task that required ranking terminally ill patients for access to a life-saving kidney machine. They then met in small groups and reached a group decision on the same task. The subjects' moral reasoning level and sex role orientation--assessed via the Rest Defining Issues Test (Rest, 1979) and the Bem Sex Role Inventory (Bem, 1974), respectively--were used to predict influence on the group decision. Influence was measured in three ways: similarity between individual and group ranks, self-rated influence, and selection of the most influential group member. The results of all three influence measures provided support for the interactive hypothesis. In the discussion we consider the implications of the data for individual difference models of moral reasoning, the need for further understanding of goal competition and personality conflict, and the importance of considering the impact of moral factors on group decision-making proceses.     

Decision Pattern Analysis as a General Framework for Studying Individual Differences in Decision Making

This paper investigated decision pattern analysis (DPA) as a general and standard framework for studying individuals' consistent decision making behavior within and between contexts. DPA classifies decisions on the basis of judgement accuracy and the goal orientation of the decided‐upon action. Over repeated decisions, patterns of individuals' decision behavior are described by five variables: competence, optimality, recklessness, hesitancy and decisiveness. A fictitious medical decision making test and three standard cognitive ability tests (extended with confidence ratings and a ‘submit answer for marking’ decision) were used to investigate the psychometric properties of these DPA variables. Internal consistency of the decision patterns ranged from good to excellent. Convergent validity was assessed via cognitive abilities, metacognitive confidence and a control criterion imposed on confidence that determines the decision to be made: the point of sufficient certainty. Personality variables were included to assess discriminant validity. As hypothesised, cognitive abilities showed positive correlations with competence and optimality. High confidence, low points of sufficient certainty and a greater discrepancy between them were associated with higher decisiveness and recklessness, and lower hesitancy. Personality measures showed mixed and generally weak correlations with the DPA variables. These convergent and discriminant results also held after controlling for all variables in regression. The results provide preliminary psychometric support for DPA as a general framework of behavioral decision making. DPA has the potential to be exploited in many contexts for uses that, to date, have been unachievable in a psychometrically valid manner. Copyright © 2015 John Wiley & Sons, Ltd.     

Desire for euthanasia or physician-assisted suicide in palliative cancer care.

OBJECTIVE: To investigate the attitudes of terminally ill individuals toward the legalization of euthanasia or physician-assisted suicide (PAS) and to identify those who would personally desire such a death. DESIGN: In the Canadian National Palliative Care Survey, semistructured interviews were administered to 379 patients who were receiving palliative care for cancer. Patients who expressed a desire for physician-hastened death were followed prospectively. MAIN OUTCOME MEASURES: Attitudes toward the legalization of euthanasia or PAS were determined, as was the personal interest in receiving a hastened death. Demographic and clinical characteristics were also recorded, including a 22-item structured interview of symptoms and concerns. RESULTS: There were 238 participants (62.8%) who believed that euthanasia and/or PAS should be legalized, and 151 (39.8%) who would consider making a future request for a physician-hastened death. However, only 22 (5.8%) reported that, if legally permissible, they would initiate such a request right away, in their current situations. This desire for hastened death was associated with lower religiosity (p=.010), reduced functional status (p=.024), a diagnosis of major depression (p<.001), and greater distress on 12 of 22 individual symptoms and concerns (p<.025). In follow-up interviews with 17 participants, 2 (11.8%) showed instability in their expressed desire. CONCLUSION: Among patients receiving palliative care for cancer, the desire to receive euthanasia or PAS is associated with religious beliefs; functional status; and physical, social, and psychological symptoms and concerns. Although this desire is sometimes transitory, once firmly established, it can be enduring.     

Family Caregivers of Persons With Spinal Cord Injury: Predicting Caregivers at Risk for Probable Depression

OBJECTIVE: To determine the percentage of family caregivers of persons with spinal cord injury (SCI) with probable depression and to test the hypothesis that dysfunctional problem-solving abilities would be significantly predictive of risk status after taking into account important demographic characteristics and caregiver health. DESIGN: Correlational and logistic regression analyses of data collected in a cross-sectional design. PARTICIPANTS: Eighteen men and 103 women caregivers (mean age of caregivers = 45.66 years, SD = 12.88) of individuals with SCI. MAIN OUTCOME MEASURE: The Inventory to Diagnose Depression. RESULTS: Nineteen caregivers (15.7%) met criteria on the Inventory to Diagnose Depression for a major depressive disorder. A dysfunctional problem-solving style was significantly predictive of caregiver depression, regardless of the severity of physical impairment of the care recipient or the physical health of the caregiver and caregiver demographic variables. CONCLUSIONS: The percentage of caregivers with probable depressive disorder may parallel that observed among persons with SCI, using a more conservative self-report measure designed to assess symptoms associated with a depressive syndrome. Family caregivers with a dysfunctional problem-solving style and assisting individuals with more severe injuries may have probable depression.     

Psychological Factors that Link Socioeconomic Status to Depression/Anxiety in Patients with Systemic Lupus Erythematosus

Our analyses examined whether reserve capacity factors would explain the relationship between socioeconomic status (SES) and symptoms of depression/anxiety in patients with systemic lupus erythematosus (SLE). We assessed disease activity, depression/anxiety symptoms, and intrapersonal and interpersonal reserve capacity measures in 128 patients with SLE. Multiple meditational analyses revealed that intrapersonal and interpersonal psychosocial aspects of reserve capacity fully mediated the relationship between SES and depression/anxiety. Lower SES was indirectly associated with higher symptoms of depression and anxiety through the effects of psychosocial resilience. Interventions aimed at improving modifiable reserve capacity variables, such as self-esteem and optimism, may improve anxious/depressive symptomatology in patients with SLE.     

Depression symptoms: Their association with socio-demographic factors and health among adults in South Africa

The aim of this study was to assess depression symptoms and socio-demographic and health correlates in a recent (2014-2015) national population-based survey of South Africa adults (n = 22 752; females =57.5%; mean age 37.1 years, SD = 17.6). The participants reported on their socio-demographic variables, health statuses, and experience of depression symptoms the previous four weeks. About 13% of the sample scored positive for depression symptoms. In adjusted logistic regression analysis, being female, older age, being long term sick or disabled, having two or more pain disorders, having been diagnosed with diabetes, and having smoked regularly were associated with high risk for depression symptoms. Being a student, having below or average household income, and having exercised three or more times a week was associated with lower risk for depression symptoms.     

Comparison of Informed Consent Preferences for Multiplex Genetic Carrier Screening among a Diverse Population

Multiplex genetic carrier screening is increasingly being integrated into reproductive care. Obtaining informed consent becomes more challenging as the number of screened conditions increases. Implementing a model of generic informed consent may facilitate informed decision-making. Current Wayne State University students and staff were invited to complete a web-based survey by blast email solicitation. Participants were asked to determine which of two generic informed consent scenarios they preferred: a brief versus a detailed consent. They were asked to rank the importance of different informational components in making an informed decision and to provide demographic information. Comparisons between informational preferences, demographic variables and scenario preferences were made. Six hundred ninety three participants completed the survey. When evaluating these generic consents, the majority preferred the more detailed consent (74.5 %), and agreed that it provided enough information to make an informed decision (89.5 %). Those who thought it would be more important to know the severity of the conditions being screened (p?=?.002) and range of symptoms (p?=?.000) were more likely to prefer the more detailed consent. There were no significant associations between scenario preferences and demographic variables. A generic consent was perceived to provide sufficient information for informed decision making regarding multiplex carrier screening with most preferring a more detailed version of the consent. Individual attitudes rather than demographic variables influenced preferences regarding the amount of information that should be included in the generic consent. The findings have implications for how clinicians approach providing tailored informed consent.     

Faulty Judgment,Expert Opinion,and Decision-Making Capacity

An assessment of decision-making capacity is the accepted procedure for determining when a person is not competent. An inferential gap exists between the criteria for capacity specific abilities and the legal requirements to understand relevant information and appreciate the consequences of a decision. This gap extends to causal influences on a person'scapacity to decide. Using a published case of depression, we illustrate that assessors' uses of diagnostic information is frequently not up to the task of bridging this inferential gap in a justifiable way. We then describe cases of faulty judgement which challenge the understanding of diagnostic causal influences. These cases help to clarify the nature of the expertise required for capacity assessments. In practice, the requirements of decision-making capacity are often abandoned to other considerations due to a lack of requisite expertise. The legal policy supporting decision-making capacity as a means to protective intervention is justified only if the requisite expertise is developed. We propose the requisite expertise to be developed in the long term as a distinct multidisciplinary endeavour.     

Cross-cultural Differences in Self-reported Decision-making Style and Confidence

The Melbourne Decision Making Questionnaire (Mann, Burnett, Radford, & Ford, 1997) measures self-reported decision-making coping patterns. The questionnaire was administered to samples of University students in the US (N = 475), Australia (N = 262), New Zealand (N = 260), Japan (N = 359), Hong Kong (N = 281), and Taiwan (N = 414). As predicted, students from the three Western, individualistic cultures (US, Australia, and New Zealand) were more confident of their decision-making ability than students from the three East Asian, group-oriented cultures (Japan, Hong Kong, Taiwan). No cross-cultural differences were found in scores on decision vigilance (a careful decision-making style). However, compared with Western students, the Asian students tended to score higher on buck-passing and procrastination (avoidant styles of decision making) as well as hypervigilance (a panicky style of decision making). Japanese students scored lowest on decision self-esteem and highest on procrastination and hypervigilance. It was argued that the conflict model and its attendant coping patterns is relevant for describing and comparing decision making in both Western and Asian cultures.