The Ethical & Cultural Perspectives of Psychiatric Symptoms of Cushing’s Disease

The Cushing disease results from excess blood cortisol levels. This contributes to the formation of adrenocorticotropic hormone (ACTH)-benign tumor in one’s pituitary glands, referred to as pituitary adenoma according to Lamos & Munir (2014). The tumor leads to chronic excessive exposure to glucocorticoids and this brings about Cushing’s disease. This study focuses on identifying ethical and cultural perspectives of psychiatric symptoms of the Cushing’s syndrome. Concerning the ethical perspectives, the Americans with Disabilities Act (ADA) and Patient Protection and Affordable Care Act (PPACA), protect patients with psychiatric symptoms of CD from any possible denial of medical insurance. Ethical perspectives in studying CD-related psychiatric symptoms can take a deontological or utilitarian approach. These theories and other ethical principles discussed herein can help in studying psychiatric symptoms of patients with CD. Cultural norms and values influence the mental state of patients suffering from the psychiatric symptoms of CD. There is no study, which directly shows the cultural factors influencing patients with CD-related psychiatric symptoms. This study considers other general cultural norms and values and their influence on the mental health state of a person with CD-related psychiatric symptoms. The article Psychiatric disorders associated with Cushing's syndrome by Bratek, A., Koźmin-Burzyńska, A., Górniak, E., and Krysta, K (2015), highlights the need to be alert in early detection of CD to avoid its misdiagnosis. After understanding the psychiatric disorders related to CD the ethical and cultural perspectives of CD-related psychiatric symptoms, the society can be able to manage the disease in its early.

Introduction

The Cushing disease results from excess blood cortisol levels. This contributes to the formation of adrenocorticotropic hormone (ACTH)-benign tumor in one’s pituitary glands, referred to as pituitary adenoma according to Lamos & Munir (2014). The tumor leads to chronic excessive exposure to glucocorticoids and this brings about Cushing’s disease. The condition CD is very rare yet difficult to diagnose. The difficulty in diagnosing CD is due to its characteristic overlapping symptoms with other diseases, making it be overlooked.  Cushing’s disease frequently leads to neuropsychiatric disorders including, in particular, major depression. Because the disease severely afflicts people’s life, it is important to consider legal, ethical, and cultural aspects of its development and treatment. Regarding laws and regulations, PPACA, ADA, and FMLA protect people with Cushing’s disease in terms of medical insurance coverage and guarantee job security for employees with the CD (Fajuri, 2017). Ethical theories and various principles should be considered in studying the psychiatric symptoms resulting from CD. In particular, these studies should reflect the ethical principles of maximizing benefits and minimizing harm. It is also important to reconsider cultural norms and values in relation to Cushing’s disease since they influence mental state of patients with psychiatric symptoms of the CD.  This study focuses on highlighting the ethical and cultural perspectives of psychiatric symptoms of the Cushing’s disease. It includes a review of the different laws that protect CD patients with psychiatric symptoms, the ethical theories/principles that can be used in studying the condition, and the cultural norms that influence the mental state of CD patients with psychiatric symptoms. This study will also review of the article Psychiatric disorders associated with Cushing's syndrome by Bratek, A., Koźmin-Burzyńska, A., Górniak, E., and Krysta, K (2015), including the methodology and the results of the research.

Level 2 Research Questions

Ethical Perspective of Inquiry

ADA & PPACA on Protection of Patients with Cushing’s Disease-related Psychiatric Symptoms

The Cushing’s disease presents with psychiatric symptoms in most cases. There is thus need for these patients to be classified as needing special protection by the Americans with Disabilities Act (ADA) as well as by the Patient Protection and Affordable Care Act (PPACA) (Fajuri, 2017).  Both ADA and PPACA are regulations whose provisions are aimed at protecting people with disabilities including mental disabilities, as is the case for patients with the Cushing’s disease-related psychiatric disorders. In regard to the Americans with Disabilities Act (ADA), it is mandatory for every employer to provide medical insurance for all their employees, including people with Cushing’s disease (ADA National Network, 2017). In this regard, an employee who develops Cushing’s disease, which presents with psychiatric disorders, should still have their health employers remitting insurance premiums for them. This protects the patients from any fraudulent cancellation of their employer-provided health insurance covers in the wake of their psychiatric disorders.

Another provision of the Americans with Disabilities Act is that every employee that develops a disability is still guaranteed job security (ADA National Network, 2017). This means that employers are barred from firing an employee on the basis of having developed a disability such as the psychiatric symptoms that present in employees with Cushing’s disease. Therefore, psychiatric disorders resulting from the Cushing’s disease should not render an individual jobless. The ADA provisions thus protect these patients from any further depression that could herald from a lack of insurance cover, the burden of high medical bills and firing from work.

The Patient Protection and Affordable Care Act (PPACA) also play a major role in ensuring that people ailing from any given disease in America are protected as well as receive affordable healthcare. One of the main provisions of PPACA is that insurance companies cannot refuse to provide medical insurance coverage to a person, because of their pre-existing medical condition (mentalhealth.gov, 2017). This means that patients with the Cushing’s disease also fall under the favor of this particular provision. They, therefore, have a right to be enrolled in their desired medical coverage from any given insurance company. Availability of access to health insurance coverage is very important as it helps the patients to have lesser and/or no depressive issues that could aggravate their psychiatric conditions. Further, according to mentalhealth.gov. (2017), PPACA gives a guarantee to any person who is not able to afford medical insurance to be enrolled in the Medicaid program.

Other related regulations that protect people with psychiatric conditions related to the Cushing’s disease include the Family and Medical Leave Act (FMLA) and the Consolidated Omnibus Budget Reconciliation Act (COBRA). FMLA requires that an employee with a serious medical condition can have up to twelve weeks unpaid, job-protected leaf from work. If they do return to work, one might be eligible for Social Security Disability Insurance (mentalhealth.gov, 2017). Patients with Cushing’s disease-related psychiatric symptoms can thus be given a leaf to recuperate and this is likely to minimize their stress levels while still on treatment. According to COBRA, in case of leaving the job due to the health condition, a former employee has 60 days to purchase new insurance or to obtain insurance. COBRA allows a person to have the same insurance plan as the one before leaving the job, but he/she should pay the total premium. These acts thus fully support individuals suffering from the psychiatric symptoms of the Cushing’s disease.

Ethical Theories & Principles In Studying the Psychiatric Symptoms Of Cushing’s Disease

Ethics regulates all spheres of human life, including healthcare. There are two main approaches to the medical ethics: deontological and utilitarian. Deontological ethics focuses on the patient’s benefits while utilitarian ethics addresses the benefits of the whole society. Ethical theories evolve in the medical research (Reddy & Mythri, 2016). The main obstacle to ethical standards in treating Cushing’s disease appears because it is a rare condition. Thus, it is not easy to conduct the medical study based on existing ethical principles. For example, it is time-consuming to create two groups for investigation (intervention and control) and to apply statistical methods for analyzing obtained data. Thus, institutional review board should approve a design of medical research on people with Cushing’s disease.

In case of Cushing’s disease treatment, deontological ethics is more appropriate. The services provided by healthcare workers should lead to patient’s health state improvement. In fact, there are four main ethical principles of medical care, which could relate to Cushing’s disease: the principle of non-maleficence or doing no harm, beneficence, respect for autonomy, and fair treatment for everyone (Reddy & Mythri, 2016). Thus, deontological ethics addresses both the studies dedicated to Cushing’s disease and the treatment of this condition.

Medical research should be performed in accordance with such ethical principles as informed consent, non-exploitation, privacy and confidentiality, risk minimization, professional competence, transparency, maximization of public interests, and total responsibility (Avasthi, Ghosh, Sarkar, & Grover, 2013). However, some of these principles are difficult to consider during the studies on psychiatric disorders. First, people with mental illnesses frequently have impaired cognition and emotional state. These impairments are typical for people with Cushing’s disease (Pivonello et al., 2015). Thus, it can be difficult to obtain credible information and to make a person completely understand the objectives of the research. Second, new therapeutic approaches, which could potentially be harmful to patients, are often applied for the treatment of mental illnesses. To address these issues, the specialists should correspond to the utilitarian ethical theory (Avasthi et al., 2013). It means that before starting the study, the researchers should develop an elaborate plan that can maximize the potential benefits and minimize the risks of their intended study on CD related psychiatric symptoms.

Level 2 Research Questions

Cultural Perspective of Inquiry

Culture comprises a set of beliefs, values and even norms that are shared by a group (Lewis, 2016). Cultural norms of a given community affect largely, the mental state of people suffering from Cushing’s disease. Currently, barely any study has directly focused on highlighting cultural norms that affect people with the Cushing’s disease. Even so, there are studies that have established common cultural norms that can affect people mentally and determine their mental state. People with the Cushing’s syndrome are thus also likely to have their mental state affected by different cultural norms. According to the Yorke, C., Voisin, D., Berringer, K., & Alexander, L (2015), cultural norms and values influence the different ways in which patients from a given culture express and/or manifest their symptoms, coping style, family support, and health-seeking behavior. The culture of a clinician, as well as that of the service system, determines disease diagnosis, treatment and health service delivery.

First, in regard to race and ethnicity, it is clear that mental health disorders are still highly prevalent in every race (Yorke et al., 2015). This includes the case of Cushing’s disease-related mental problems. Considering that, mental health problems are caused by complex factors involving social, biological, psychological and cultural factors, the strength of these factors in a patient depends on the specific mental disorder (Mackenbach, 2014). Concerning races, the Cushing's disease occurs in every race but affects more women as compared to men (ratio of 3:1).  It is, however, a rare disease globally. Race and ethnicity thus do not influence Cushing’s syndrome unless other economic and social factors come into play.

Secondly, social and economic inequality influences the mental state of people with psychiatric conditions from different ethnic and racial minority groups. This is the case of the US, where minority groups are exposed to social and economic inequalities (Yorke et al., 2015). These include but not limited to racial discrimination, poverty, and violence. A patient from such background suffering from the Cushing’s disease is more likely to have no medical insurance cover, low wages to sustain self and family, and thus aggravating their psychiatric symptoms (Nellesen, Truong, Neary, & Ludlam, 2016). These groups undergo additional depression and anxiety, making patients with diseases to have escalated mental health problems.

A third cultural norm or factor that influences the mental state of people with psychiatric conditions include stigma (Yorke et al., 2015). Stigmatization of people with Cushing’s disease and related psychiatric conditions can heighten the condition among patients. Stigma is likely to make an individual patient ignore or refuse to seek help when in need (Lewis, 2016). It is also apparent that minority groups have a more unfavorable attitude towards people with mental illness as compared to whites in the American setting.

Further, some communities and families have mistrust particularly in the mental health services (Lewis, 2016). This completely deters people especially from minority groups in America from seeking treatment. This is especially based on their establishment that there is a high likelihood of direct and/or indirect bias and stereotyping by clinicians. Patients with the Cushing’s disease presenting with mental health challenges from such backgrounds are likely to avoid treatment and have their condition worsened.

Case Study

Ethical and cultural factors play an important role in both studying and the management of patients with psychiatric symptoms of Cushing’s disease. Patients with the Cushing’s disease suffer a condition referred to as the Cushing’s syndrome, which presents with symptoms described as hypercortisolism. Hypercortisolism is an endocrine disorder involving over-secretion of the adrenocorticotropic Hormone. The disorder leads to various psychiatric comorbidities. These include among others, mood, psychotic, anxiety disorders, and cognitive dysfunctions.  A recent study carried out by Bratek et al (2015) established the psychiatric disorders, which are associated with the Cushing's syndrome. More specifically, the researchers aimed at establishing the prevalence, particular symptoms, and the consequences of psychiatric disorders especially in the course of the Cushing's syndrome. The results of this study are a rich source of information particularly for any study aimed at relating ethical and cultural factor influence on the mental state of patients with Cushing’s disease-related psychiatric symptoms.

 

Methodology

            The researchers carried out a thorough literature review by use of keywords to extract information secondary sources. Among the keywords used to sear and extract relevant data included: Cushing's syndrome and psychosis, Cushing's syndrome and depression, Cushing's syndrome, and mental disorders, and further, Cushing's syndrome and anxiety (Bratek et al., 2015). After reviewing the secondary qualitative data using grounded and content analysis approaches, the researchers presented the results of the study.

Results        

After the study, Bratek et al (2015) established that depression is the most prevalent among the psychiatric comorbidities of Cushing's syndrome. The rest included; mood, psychotic, anxiety disorders, and cognitive dysfunctions. The study also found out that psychiatric manifestations most likely precede full-blown Cushing's syndrome onset and this can lead to misdiagnosis of the condition. Further, the study established that while treating the underlying endocrine disease can mostly alleviate psychiatric symptoms, there is a persistent loss of a patient’s brain volume. In concluding their study, Bratek et al (2015) found that it is very important for caregivers including families and healthcare teams to be alert to hypercortisolism symptoms in psychiatric patients. This can help in avoiding misdiagnosis and thus enable the patients to receive required adequate treatment.

Conclusion

Conclusively, the above study has outlined the ethical and cultural perspectives of psychiatric symptoms of the Cushing’s syndrome. From the study, healthcare regulations including ADA and PPACA protect individuals with the psychiatric symptoms of CD from any possible denial of medical insurance. They also guarantee these patients job security particularly for employed patients. The deontological and utilitarian theories among other ethical principles discussed here can help in studying psychiatric symptoms of patients with CD. Regarding the cultural norms that influence the mental state of patients suffering from the psychiatric symptoms of Cushing’s disease, it is clear that no study has been done to establish this information. However, there are studies that outline generally, the cultural norms that influence the mental state of people with all mental health problems. This means that psychiatric symptoms of CD are also included among the disorders influenced by cultural norms and values that determine; how patients from a given culture express and/or manifest their symptoms, coping style, family support, and health-seeking behavior. The culture and values of a given clinician, as well as that of the service system, determine disease diagnosis, treatment and health service delivery. The review of the article Psychiatric disorders associated with Cushing's syndrome by Bratek, A., Koźmin-Burzyńska, A., Górniak, E., and Krysta, K (2015), highlighted the need to be alert in early detection of CD and avoidance of its misdiagnosis. By understanding psychiatric disorders related to CD, the ethical, and cultural perspectives of CD-related psychiatric symptoms, the society can be able to manage the disease in its early stages and even later. There is, however, a need for researchers to delve into establishing the exact cultural norms and values that influence the mental state of patients presenting with psychiatric symptoms of the CD.