Perceived Barriers to Using Neurostimulation: A National Survey of Psychiatrists, Patients, Caregivers, and the General Public.

OBJECTIVES: Neurostimulation interventions often face heightened barriers limiting patient access. The objective of this study is to examine different stakeholders' perceived barriers to using different neurostimulation interventions for depression. METHODS: We administered national surveys with an embedded experiment to 4 nationwide samples of psychiatrists (n = 505), people diagnosed with depression (n = 1050), caregivers of people with depression (n = 1026), and members of the general public (n = 1022). We randomly assigned respondents to 1 of 8 conditions using a full factorial experimental design: 4 neurostimulation modalities (electroconvulsive therapy [ECT], repetitive transcranial magnetic stimulation [rTMS], deep brain stimulation [DBS], or adaptive brain implants [ABIs]) by 2 depression severity levels (moderate or severe). We asked participants to rank from a list what they perceived as the top 3 barriers to using their assigned intervention. We analyzed the data with analysis of variance and logistic regression. RESULTS: Nonclinicians most frequently reported "limited evidence of the treatment's effectiveness" and "lack of understanding of intervention" as their top 2 most important practical barriers to using ECT and TMS, respectively. Compared with nonclinicians, psychiatrists were more likely to identify "stigma about treatment" for ECT and "lack of insurance coverage" for TMS as the most important barriers. CONCLUSIONS: Overall, psychiatrists' perceptions of the most important barriers to using neurostimulation interventions were significantly different than those of nonclinicians. Perceived barriers were significantly different for implantable DBS and ABI) versus nonimplantable (rTMS and ECT) neurostimulation interventions. Better understanding of how these barriers vary by neurostimulation and stakeholder group could help us address structural and attitudinal barriers to effective use of these interventions.

The differential effects of psychiatrists' and patients' prior experiences on views about psychiatric electroceutical interventions.

The aim of this study is to examine ways in which prior experiences and familiarity with psychiatric electroceutical interventions (PEI) shape psychiatrists' and patients' views about these interventions. We administered a national survey, with an embedded experiment, to psychiatrists (n = 505) and adults diagnosed with depression (n = 1050). We randomly assigned respondents to one of 8 conditions using a full factorial experimental design: 4 PEI modalities [ECT, rTMS, DBS, or adaptive brain implants (ABIs)] by 2 depression severity levels [moderate or severe]. We analyzed the survey data with ANOVA and OLS linear regression models. Patients having experience with any PEI reported more positive affect toward, but also greater perceived risk from, their assigned PEI than did patients with no such experience. Psychiatrists who referred or administered any PEI reported more positive affect toward and greater perceived influence on self and perceived benefit from their assigned PEI than did psychiatrists with no such familiarity. Limitations of our study include that our participants were randomly assigned to a PEI, not necessarily to the one they had experience with. Moreover, our study did not directly ask about the kind of experiences participants had with a given PEI. Overall, our survey data shows that greater experience with PEIs elicits more positive affect in both stakeholder groups. Beyond this, prior PEI experience shapes attitudes towards these interventions in complex ways. Further research linking different types of experience with a given PEI would help better understand factors shaping attitudes about specific PEIs.

"They Are Invasive in Different Ways.": Stakeholders' Perceptions of the Invasiveness of Psychiatric Electroceutical Interventions.

Medical interventions are usually categorized as "invasive" when they involve piercing the skin or inserting an object into the body. Beyond this standard definition, however, there is little discussion of the concept of invasiveness in the medical literature, despite evidence that the term is used in ways that do not reflect the standard definition of medical invasiveness. We interviewed psychiatrists, patients with depression, and members of the public without depression to better understand their views on the invasiveness of several psychiatric electroceutical interventions (treatments that involve electrical or magnetic stimulation of the brain) for the treatment of depression. Our study shows that people recognize several kinds of invasiveness: physical, emotional, and lifestyle. In addition, several characteristics of therapies influence how invasive they are perceived to be; these include the perceived capacity of an intervention to result in harm; how localized the effects of the intervention are; the amount of control retained by the person receiving the intervention; how permanent its effects are perceived as being; and how familiar it seemed to participants. Our findings contribute to a small literature on the concept of invasiveness, which emphasizes that categorizing an intervention as invasive, or as noninvasive, evokes a variety of other normative considerations, including the potential harm it poses and how it compares to other potential therapies. It may also draw attention away from other salient features of the intervention.

Looking through the lens of stigma: Understanding and anticipating concerns about the responsible development and use of psychiatric electroceutical interventions (PEIs).

Psychiatric electroceutical interventions (PEIs) show promise for treating depression, but few studies have examined stakeholders' views on them. Using interview data and survey data that analyzed the views of psychiatrists, patients, caregivers, and the general public, a conceptual map was created to represent stakeholders' views on four PEIs: electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (TMS), deep brain stimulation (DBS), and adaptive brain implants (ABIs). Stigma emerged as a key theme connecting diverse views, revealing that it is a significant factor in the acceptance and usage of PEIs. Stigma not only discourages seeking mental health services for depression but also inhibits the acceptance of PEIs. Addressing the pervasive and complex effects of stigma highlights the need to change societal attitudes toward mental illnesses and their treatments and to provide support to patients who may benefit from these interventions. The map also demonstrates the value of conceptual mapping for anticipating and mitigating ethical considerations in the development and use of PEIs.

Jumping through the hoops: Barriers and other ethical concerns regarding the use of psychiatric electroceutical interventions.

Stakeholders' perceptions of barriers to and other ethical concerns about using psychiatric electroceutical interventions (PEIs), interventions that use electrical or magnetic stimuli to treat psychiatric conditions like treatment-resistant depression (TRD), may influence the uptake of these interventions. This study examined such perceptions among psychiatrists, patients with depression, and members of the public. We conducted semi-structured qualitative interviews with 16 members of each group to examine their views on practical barriers and ethical concerns. We used qualitative content analysis to identify relevant themes, and compared findings across stakeholder groups. Access limitations to the interventions, including cost and availability of the interventions, cut across all PEIs-including those that are still experimental, and were raised by all groups. Most participants across all groups raised concerns about informed consent, in terms of receiving adequate, appropriate, and understandable information. Our results suggest that these three stakeholder groups perceive similar structural and attitudinal barriers to, and have similar ethical concerns about, using PEIs for TRD. These results identify key issues that must be addressed for the full potential of PEIs to be realized. Future research with larger samples will help to better understand how to address these barriers to treatment for individuals with TRD.

They Affect the Person, but for Better or Worse? Perceptions of Electroceutical Interventions for Depression Among Psychiatrists, Patients, and the Public.

Responding to reports of cases of personality change following deep brain stimulation, neuroethicists have debated the nature and ethical implications of these changes. Recently, this literature has been challenged as being overblown and therefore potentially an impediment to patients accessing needed treatment. We interviewed 16 psychiatrists, 16 patients with depression, and 16 members of the public without depression, all from the Midwestern United States, about their views on how three electroceutical interventions (deep brain stimulation, electroconvulsive therapy, and transcranial magnetic stimulation) used to treat depression might affect the self. Participants were also asked to compare the electroceuticals' effects on the self with the effects of commonly used depression treatments (psychotherapy and pharmaceuticals). Using qualitative content analysis, we found that participants' views on electroceuticals' potential effects on the self mainly focused on treatment effectiveness and side effects. Our results have implications for both theoretical discussions in neuroethics and clinical practice in psychiatry.

Beyond the Cuckoo's Nest: Patient and Public Attitudes about Psychiatric Electroceutical Interventions.

Recent research emphasizes the role of psychiatric electroceutical interventions (PEIs), bioelectronic treatments that employ electrical stimulation to affect and modify brain function, to effectively treat psychiatric disorders. We sought to examine attitudes about three PEIs-electroconvulsive therapy, transcranial magnetic stimulation, and deep brain stimulation-among patients with depression and members of the general public. As part of a larger study to assess different stakeholders' attitudes about PEIs, we conducted semi-structured key informant interviews with 16 individuals living with depression and 16 non-depressive members of the general public. We used a purposive sampling approach to recruit potential participants based on eligibility criteria. We performed qualitative content analysis of interview transcripts. Participants from both groups expressed an overall cautionary attitude towards PEIs, yet there were mixed attitudes in both groups. Patients commonly described electroconvulsive therapy as scary, traumatic, or intense, while members of the general public often referenced the treatment's negative portrayal in One Flew over the Cuckoo's Nest. Patients and the general public saw transcranial magnetic stimulation as a potentially viable option, but in most cases only if medication was not effective. Deep brain stimulation attitudes were predominantly negative among patients and cautionary among public. The overall cautionary attitudes towards PEIs, together with the technological features and social aspects underlying those attitudes, highlight the need for unbiased education to fill the gaps in knowledge and inform perceptions of those who may benefit from these treatments.

A qualitative study of key stakeholders' perceived risks and benefits of psychiatric electroceutical interventions.

Amid a renewed interest in alternatives to psychotherapy and medication to treat depression, there is limited data as to how different stakeholders perceive of the risks and benefits of psychiatric electroceutical interventions (PEIs), including electroconvulsive therapy (ECT) and deep brain stimulation (DBS). To address this gap, we conducted 48 semi-structured interviews, including 16 psychiatrists, 16 persons diagnosed with depression, and 16 members of the general public. To provide a basis of comparison, we asked participants to also compare each modality to front-line therapies for depression and to neurosurgical procedures used for non-psychiatric conditions. Across all stakeholder groups, perceived memory loss was the most frequently mentioned potential risk with ECT. The most discussed benefits across all stakeholder groups were efficacy and quick response. Psychiatrists most often referenced effectiveness when discussing ECT, while patients and the public did so when discussing DBS. Taken as a whole, these data highlight stakeholders' contrasting perspectives on the risks and benefits of electroceuticals.

Teaching Medical Epistemology within an Evidence-Based Medicine Curriculum.

Issue: Epistemology, the branch of philosophy that deals with the nature, value, and use of knowledge, receives little or no formal attention in medical education. Yet the understanding of medical epistemology - focused on what kinds of medical knowledge are relevant to clinical decisions, the strengths and limitations of those different kinds of knowledge, and how they relate to one another and to clinical expertise - represents a critical aspect of medical practice. Evidence: Understanding the meaning of the term "evidence" is one of the fundamental tasks of medical epistemology. Other foundations of the evidence-based medicine movement, such as the "hierarchy of evidence" and the concept of "best" evidence, rest upon epistemological assertions, claims regarding the appropriate kinds and relative value of knowledge in medicine. Here we rely upon the work of philosophers of medicine who have been engaged in debates regarding the epistemic tenets of the evidence-based medicine movement. We argue that medical students and physicians-in-training should learn basic terminology and methods of epistemology as they are being introduced to the concepts and techniques of evidence-based medicine. Implications: The skepticism and critical analysis encouraged by EBM can and should be applied to the underlying assumptions and primary tenets of EBM itself. It is not enough for philosophers to partake in this endeavor; students, trainees, and clinicians need to carefully and constantly examine the reasons and reasoning that coalesce into clinical acumen. Our role as medical educators is to give them the tools, including a basic understanding of epistemology, to do that over a lifetime.

Online comments about psychiatric neurosurgery and psychopharmacological interventions: Public perceptions and concerns.

The field of biological psychiatry is controversial, with both academics and members of the public questioning the validity and the responsible use of psychiatric technological interventions. The field of neuroethics provides insight into these controversies by examining key themes that characterize specific topics, attitudes, and reasoning tools that people use to evaluate interventions in the brain and mind. This study offers new empirical neuroethical insights into how the public responds to the use and development of psychiatric technological interventions by comparing how the public evaluates pharmacological and neurosurgical psychiatric interventions, in the context of online comments on news media articles about these topics. We analyzed 1142 comments from 108 articles dealing with psychopharmacological and psychiatric neurosurgery interventions on websites of major circulation USA newspapers and magazines published between 2005 and 2015. Personal anecdote, medical professional issues, medicalization, social issues, disadvantages, scientific issues and cautionary realism were among the main themes raised by commenters. The insights derived from the comments can contribute to improving communication between professionals and the public as well as to incorporating the public's views in policy decisions about psychiatric interventions.

Comparison of philosophical concerns between professionals and the public regarding two psychiatric treatments.

BACKGROUND: Psychiatric interventions are a contested area in medicine, not only because of their history of abuses, but also because their therapeutic goal is to affect emotions, thoughts, beliefs, and behaviors that are regarded as pathological. Because psychiatric interventions affect characteristics that seem central to who we are, they raise issues regarding identity, autonomy, and personal responsibility for one's own well-being. Our study addresses two questions: (1) Do the public and academic researchers understand the philosophical stakes of these technologies in the same way? Following from this, (2) to what extent does the specific type of psychiatric technology affect the issues these two groups raise? This study compares how ethical issues regarding neurosurgical and pharmaceutical psychiatric interventions are discussed among the public and in the professional community of academic medicine and bioethics. METHODS: We analyzed (1) online public comments and (2) the medical and bioethics literature, comparing the discussions of pharmacological and neurosurgical interventions in psychiatry in each source. RESULTS: Overall, the public discussed philosophical issues less frequently than academics. For the two types of psychiatric interventions, we found differences between the academic literature and public comments among all themes, except for personal responsibility. CONCLUSIONS: These findings reveal some of the similarities and discrepancies in how philosophical issues associated with psychiatric treatments are discussed in professional circles and among the public. Further research into what causes these discrepancies is crucial.

Conflicts of interest and industry professional relationships in psychiatric neurosurgery: a comparative literature review.

OBJECTIVE The research required to establish that psychiatric treatments are effective often depends on collaboration between academic clinical researchers and industry. Some of the goals of clinical practice and those of commercial developers of psychiatric therapies overlap, such as developing safe and effective treatments. However, there might also be incompatible goals; physicians aim to provide the best care they can to their patients, whereas the medical industry ultimately aims to develop therapies that are commercially successful. In some cases, however, clinical research may be aiming both at improved patient care and commercial success. It is in these cases that a conflict of interest (COI) arises. The goal of this study was to identify differences and commonalities regarding COIs between 2 kinds of somatic psychiatric interventions: pharmacological and neurosurgical. METHODS The authors conducted a study focused on professional concerns regarding pharmacological and neurosurgical psychiatric interventions. They used medical and bioethics journal articles as an indicator of professionals' concerns and carried out a thematic content analysis of peer-reviewed articles published between 1960 and 2015, using PubMed and Google Scholar. RESULTS One hundred thirty-seven relevant articles were identified, of which 86 papers focused primarily on psychopharmacology and 51 on neurosurgery. The intervention most discussed in the psychiatric neurosurgery data set was deep brain stimulation (n = 42). While there were no significant differences at the level of categories, pharmacological and neurosurgical interventions differ in the underlying themes discussed. Two issues widely discussed in the articles on pharmaceutical interventions, but largely neglected in the neurosurgery articles, were medical professional issues and industry involvement. CONCLUSIONS COIs are a neglected issue in the discussion of ethics concerns regarding medical devices in psychiatry. Yet as these interventions become more common, it is important to address them in part through learning from the discussion regarding COIs in the pharmaceutical industry and by developing approaches to address those aspects of COIs that are unique to the medical device industry.

An Epistemic Argument for Research-Practice Integration in Medicine.

Arguments in favor of greater research-practice integration in medicine have tended to be ethical, political, or pragmatic. There are good epistemic reasons to pursue greater integration, and it is important to think through these reasons in order to avoid inadvertently designing new systems in ways that replicate the epistemic elitism common within current systems. Meaningful transformation within health care is possible with close attention to all reasons in favor of greater research-practice integration, including epistemic reasons.

Reasoning, evidence, and clinical decision-making: The great debate moves forward.

When the editorial to the first philosophy thematic edition of this journal was published in 2010, critical questioning of underlying assumptions, regarding such crucial issues as clinical decision making, practical reasoning, and the nature of evidence in health care, was still derided by some prominent contributors to the literature on medical practice. Things have changed dramatically. Far from being derided or dismissed as a distraction from practical concerns, the discussion of such fundamental questions, and their implications for matters of practical import, is currently the preoccupation of some of the most influential and insightful contributors to the on-going evidence-based medicine debate. Discussions focus on practical wisdom, evidence, and value and the relationship between rationality and context. In the debate about clinical practice, we are going to have to be more explicit and rigorous in future in developing and defending our views about what is valuable in human life.

Theory, experience and practice.

Despite its potential hazards, the activity of questioning theoretical frameworks and proposing solutions is necessary if progress is even to be possible. Intellectual history has by no means ended, so we cannot expect to have all the answers, and from time to time the activity of critical questioning will be frustrating. But intellectual progress requires us to continue the process of asking fundamental questions. The alternative to thinking in this way is indeed unthinkable.

Diseases, patients and the epistemology of practice: mapping the borders of health, medicine and care.

Last year saw the 20th anniversary edition of JECP, and in the introduction to the philosophy section of that landmark edition, we posed the question: apart from ethics, what is the role of philosophy 'at the bedside'? The purpose of this question was not to downplay the significance of ethics to clinical practice. Rather, we raised it as part of a broader argument to the effect that ethical questions - about what we should do in any given situation - are embedded within whole understandings of the situation, inseparable from our beliefs about what is the case (metaphysics), what it is that we feel we can claim to know (epistemology), as well as the meaning we ascribe to different aspects of the situation or to our perception of it. Philosophy concerns fundamental questions: it is a discipline requiring us to examine the underlying assumptions we bring with us to our thinking about practical problems. Traditional academic philosophers divide their discipline into distinct areas that typically include logic: questions about meaning, truth and validity; ontology: questions about the nature of reality, what exists; epistemology: concerning knowledge; and ethics: how we should live and practice, the nature of value. Any credible attempt to analyse clinical reasoning will require us to think carefully about these types of question and the relationships between them, as they influence our thinking about specific situations and problems. So, the answers to the question we posed, about the role of philosophy at the bedside, are numerous and diverse, and that diversity is illustrated in the contributions to this thematic edition.