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Abstract
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The editorial 'Protection or paternalism?' in the recent The Lancet Psychiatry publication raises pertinent questions around ethical issues faced by researchers dealing with mental health problems, especially suicide. The issue gets compounded when research is with children.
A cluster randomised controlled trial, ARTEMIS (Adolescents' Resilience and Treatment Needs for Mental Health in Indian Slums) has thrown up ethical dilemmas. In ARTEMIS adolescents at high risk for stress, depression and suicide were identified using PHQ9 (Patient Health Questionnaire). As per protocol requirements, adolescents with a depression score ≥15 or ≥2 in the suicide related question, are advised to seek help. Adolescents who were >18 years, were directly advised by the research team to seek help. For minor adolescents we planned to inform their parents. However, some adolescents voiced strenuous objections to this, fearing that parents would suspect that they had discussed family matters with 'outsiders' (researchers), impose restrictions, and/or start monitoring their activities. They also indicated that they may run away or commit suicide if such information was shared with parents.
The risk of increased self-harm would be a breach of the biomedical ethical principle of nonmaleficence (do no harm). Thus, we needed to find a balance between ethics and adolescents' agency to take decisions. These ethical dilemmas have been recognised earlier too. In ARTEMIS, through repeated efforts, we were able to arrive at a process that worked. We first asked adolescents to identify a trusted adult who could speak to their parents instead of our field staff. Adolescents rejected this. We then suggested that they identify responsible adults other than parents who would help them seek care. This was also rejected. Finally, we suggested that we would not share their PHQ9 scores with their parents but would let them know that their children were suffering from stress possibly due to COVID related restrictions, including missing out on school and lack of social interactions. Adolescents found this strategy acceptable, and we were able to urge their parents to take them to counsellors. This helped maintain a balance between protecting the interest of children while respecting their right to exert competence
Language: en |