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D'Imperio A, Ienca M. Deep brain stimulation and suicide attempts in treatment-resistant patients: a case report and neuroethical analysis. Front Psychiatry 2024; 15:1398777. [PMID: 38988738 PMCID: PMC11234500 DOI: 10.3389/fpsyt.2024.1398777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Accepted: 06/04/2024] [Indexed: 07/12/2024] Open
Abstract
This case presents the situation of a 66-year-old woman diagnosed with Multiple System Atrophy Parkinsonian Type who underwent deep brain stimulation (DBS) therapy and subsequently made two suicide attempts. Despite receiving treatment and extensive psychotherapy, her condition did not improve, leading to suicidal behavior over the course of a year. Notably, she held unrealistic beliefs about the effectiveness of DBS therapy, expressing dissatisfaction with its outcomes. Family dynamics were complex, with the patient concealing her psychological distress while coping with her worsening health condition. This severe distress culminated in two suicide attempts within a relatively short timeframe. Our psychiatric team promptly intervened, implementing a suicidality protocol and adjusting her medication regimen. Despite a documented prevalence of suicidal ideation and attempts post-DBS in the literature, the exact causes remain uncertain, with the suggested involvement of neuroimmune or neurological pathways. This case contributes to scientific understanding by shedding light on suicide attempts following ineffective DBS interventions, emphasizing the patient's right to be informed about potential suicide risks and the possibility of assisted suicide through a neuroethical analysis. Therefore, our case underlines the importance of psychiatric evaluation and intervention in DBS patients to prevent further suicidality, focusing on a multidisciplinary approach tailored to the patient's autonomy and neuroethical principles.
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Affiliation(s)
- Ambra D'Imperio
- Département de Psychiatrie, Hôpitaux Universitaires de Genève, Geneva, Switzerland
- Institut für Geschichte und Ethik der Medizin, Technische Universität München, Munich, Switzerland
| | - Marcello Ienca
- Institut für Geschichte und Ethik der Medizin, Technische Universität München, Munich, Switzerland
- College of Humanities, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
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Balzekas I, Richardson JP, Lorence I, Lundstrom BN, Worrell GA, Sharp RR. Qualitative Analysis of Decision to Pursue Electrical Brain Stimulation by Patients With Drug-Resistant Epilepsy and Their Caregivers. Neurol Clin Pract 2024; 14:e200245. [PMID: 38585236 PMCID: PMC10996908 DOI: 10.1212/cpj.0000000000200245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 12/01/2023] [Indexed: 04/09/2024]
Abstract
Background and Objectives To understand why patients with drug-resistant epilepsy (DRE) pursue invasive electrical brain stimulation (EBS). Methods We interviewed patients with DRE (n = 20) and their caregivers about their experiences in pursuing EBS approximately 1 year post device implant. Inductive analysis was applied to identify key motivating factors. Results The cohort included participants aged from teens to 50s with deep brain stimulation, vagus nerve stimulation, responsive neurostimulation, and chronic subthreshold cortical stimulation. Patients' motivations included (1) improved quality of life (2) intolerability of antiseizure medications, (3) desperation, and (4) patient-family dynamics. Both patients and caregivers described a desire to alleviate burdens of the other. Patient apprehensions about EBS focused on invasiveness and the presence of electrodes in the brain. Previous experiences with invasive monitoring and the ability to see hardware in person during clinical visits influenced patients' comfort in proceeding with EBS. Despite realistic expectations for modest and delayed benefits, patients held out hope for an exceptionally positive outcome. Discussion Our findings describe the motivations and decision-making process for patients with DRE who pursue invasive EBS. Patients balance feelings of desperation, personal goals, frustration with medication side effects, fears about surgery, and potential pressure from concerned caregivers. These factors together with the sense that patients have exhausted therapeutic alternatives may explain the limited decisional ambivalence observed in this cohort. These themes highlight opportunities for epilepsy care teams to support patient decision-making processes.
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Affiliation(s)
- Irena Balzekas
- Bioelectronics Neurophysiology and Engineering Laboratory (IB, BNL, GAW); Biomedical Engineering and Physiology Graduate Program (IB); Department of Neurology (IB, BNL, GAW); Mayo Clinic Medical Scientist Training Program (IB); Biomedical Ethics Research Program (JPR, IL, RRS); Department of Quantitative Health Sciences (JPR, IL, RRS); Mayo Clinic Alix School of Medicine (JPR), Mayo Clinic, Rochester, MN; and Columbia University Vagelos College of Physicians and Surgeons (IL), New York, NY
| | - Jordan P Richardson
- Bioelectronics Neurophysiology and Engineering Laboratory (IB, BNL, GAW); Biomedical Engineering and Physiology Graduate Program (IB); Department of Neurology (IB, BNL, GAW); Mayo Clinic Medical Scientist Training Program (IB); Biomedical Ethics Research Program (JPR, IL, RRS); Department of Quantitative Health Sciences (JPR, IL, RRS); Mayo Clinic Alix School of Medicine (JPR), Mayo Clinic, Rochester, MN; and Columbia University Vagelos College of Physicians and Surgeons (IL), New York, NY
| | - Isabella Lorence
- Bioelectronics Neurophysiology and Engineering Laboratory (IB, BNL, GAW); Biomedical Engineering and Physiology Graduate Program (IB); Department of Neurology (IB, BNL, GAW); Mayo Clinic Medical Scientist Training Program (IB); Biomedical Ethics Research Program (JPR, IL, RRS); Department of Quantitative Health Sciences (JPR, IL, RRS); Mayo Clinic Alix School of Medicine (JPR), Mayo Clinic, Rochester, MN; and Columbia University Vagelos College of Physicians and Surgeons (IL), New York, NY
| | - Brian Nils Lundstrom
- Bioelectronics Neurophysiology and Engineering Laboratory (IB, BNL, GAW); Biomedical Engineering and Physiology Graduate Program (IB); Department of Neurology (IB, BNL, GAW); Mayo Clinic Medical Scientist Training Program (IB); Biomedical Ethics Research Program (JPR, IL, RRS); Department of Quantitative Health Sciences (JPR, IL, RRS); Mayo Clinic Alix School of Medicine (JPR), Mayo Clinic, Rochester, MN; and Columbia University Vagelos College of Physicians and Surgeons (IL), New York, NY
| | - Gregory A Worrell
- Bioelectronics Neurophysiology and Engineering Laboratory (IB, BNL, GAW); Biomedical Engineering and Physiology Graduate Program (IB); Department of Neurology (IB, BNL, GAW); Mayo Clinic Medical Scientist Training Program (IB); Biomedical Ethics Research Program (JPR, IL, RRS); Department of Quantitative Health Sciences (JPR, IL, RRS); Mayo Clinic Alix School of Medicine (JPR), Mayo Clinic, Rochester, MN; and Columbia University Vagelos College of Physicians and Surgeons (IL), New York, NY
| | - Richard R Sharp
- Bioelectronics Neurophysiology and Engineering Laboratory (IB, BNL, GAW); Biomedical Engineering and Physiology Graduate Program (IB); Department of Neurology (IB, BNL, GAW); Mayo Clinic Medical Scientist Training Program (IB); Biomedical Ethics Research Program (JPR, IL, RRS); Department of Quantitative Health Sciences (JPR, IL, RRS); Mayo Clinic Alix School of Medicine (JPR), Mayo Clinic, Rochester, MN; and Columbia University Vagelos College of Physicians and Surgeons (IL), New York, NY
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Sankary LR, Zelinsky M, Machado A, Rush T, White A, Ford PJ. Exit from Brain Device Research: A Modified Grounded Theory Study of Researcher Obligations and Participant Experiences. AJOB Neurosci 2022; 13:215-226. [PMID: 34255614 PMCID: PMC10570922 DOI: 10.1080/21507740.2021.1938293] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
As clinical trials end, little is understood about how participants exiting from clinical trials approach decisions related to the removal or post-trial use of investigational brain implants, such as deep brain stimulation (DBS) devices. This empirical bioethics study examines how research participants experience the process of exit from research at the end of clinical trials of implanted neural devices. Using a modified grounded theory study design, we conducted semi-structured, in-depth interviews with 16 former research participants from clinical trials of DBS and responsive neurostimulation (RNS). Open-ended questions elicited motivations for joining the trial, understanding of study procedures at the time of initial informed consent, the process of exiting from research, and decisions about device removal or post-trial device use. Thematic analysis identified categories related to: limited preparedness for the end of research participation, straightforwardness of decisions to explant or keep the device, reconciling with the end of research participation, reconciling post-trial expectations, and achieving a sense of closure after exit from research. A preliminary theoretical model describes contextual factors influencing the process and experience of exit from research. Experiences of clinical trial participants should guide research practices to enhance the ethical design and conduct of clinical trials in DBS and other brain devices.
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Szabó JP, Fabó D, Pető N, Sákovics A, Bódizs R. Role of anterior thalamic circuitry during sleep. Epilepsy Res 2022; 186:106999. [DOI: 10.1016/j.eplepsyres.2022.106999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/22/2022] [Accepted: 08/10/2022] [Indexed: 12/01/2022]
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Loughran O, Finnegan M, Dud I, Galligan T, Kennedy M, McLoughlin DM. Decision-making Capacity for Treatment After Electroconvulsive Therapy for Depression. J ECT 2022; 38:24-29. [PMID: 34699391 DOI: 10.1097/yct.0000000000000804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Depression can impair decision-making capacity (DMC) for health care decisions. However, it is unclear whether DMC improves after treatments for depression such as electroconvulsive therapy (ECT). There is limited evidence available on DMC for treatment in patients with depression referred for ECT, and it is unknown whether ECT has any impact on DMC. We hypothesized that ECT will improve DMC in severely depressed patients and that this change will be associated with reduced depressive symptom severity. METHODS Using the MacArthur Competence Assessment Tool-Treatment, 4 abilities related to DMC were evaluated: Understanding, Appreciation, Reasoning, and Expressing a choice. This prospective study compared DMC abilities, depression severity, and cognition scores in 24 patients hospitalized with a major depressive episode before and 3 to 5 days after a course of ECT. RESULTS Although Understanding scores significantly improved after ECT (P = 0.004, r = 0.41), there was no change in other abilities related to DMC or cognition scores. As expected, there was a large improvement in mood ratings after ECT, but the change in DMC abilities was not associated with change in depressive symptoms. CONCLUSIONS To our knowledge, this is the first study to provide data on the effects of ECT on DMC in patients with depression. Abilities related to DMC that may be affected in this group before treatment include Understanding and Reasoning. Findings indicate that DMC to consent to treatment mostly does not change after a course of ECT and some aspects can improve in patients with depression.
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Affiliation(s)
- Orlaith Loughran
- From the Department of Psychiatry, Trinity College Dublin, St. Patrick's University Hospital
| | - Martha Finnegan
- From the Department of Psychiatry, Trinity College Dublin, St. Patrick's University Hospital
| | - Iulia Dud
- From the Department of Psychiatry, Trinity College Dublin, St. Patrick's University Hospital
| | - Toni Galligan
- From the Department of Psychiatry, Trinity College Dublin, St. Patrick's University Hospital
| | - Miriam Kennedy
- From the Department of Psychiatry, Trinity College Dublin, St. Patrick's University Hospital
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Thomson CJ, Segrave RA, Fitzgerald PB, Richardson KE, Racine E, Carter A. "Nothing to Lose, Absolutely Everything to Gain": Patient and Caregiver Expectations and Subjective Outcomes of Deep Brain Stimulation for Treatment-Resistant Depression. Front Hum Neurosci 2021; 15:755276. [PMID: 34658822 PMCID: PMC8511461 DOI: 10.3389/fnhum.2021.755276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 09/06/2021] [Indexed: 11/25/2022] Open
Abstract
Background: How "success" is defined in clinical trials of deep brain stimulation (DBS) for refractory psychiatric conditions has come into question. Standard quantitative psychopathology measures are unable to capture all changes experienced by patients and may not reflect subjective beliefs about the benefit derived. The decision to undergo DBS for treatment-resistant depression (TRD) is often made in the context of high desperation and hopelessness that can challenge the informed consent process. Partners and family can observe important changes in DBS patients and play a key role in the recovery process. Their perspectives, however, have not been investigated in research to-date. The aim of this study was to qualitatively examine patient and caregivers' understanding of DBS for TRD, their expectations of life with DBS, and how these compare with actual experiences and outcomes. Methods: A prospective qualitative design was adopted. Semi-structured interviews were conducted with participants (six patients, five caregivers) before DBS-implantation and 9-months after stimulation initiation. All patients were enrolled in a clinical trial of DBS of the bed nucleus of the stria terminalis. Interviews were thematically analyzed with data saturation achieved at both timepoints. Results: Two primary themes identified were: (1) anticipated vs. actual outcomes, and (2) trial decision-making and knowledge. The decision to undergo DBS was driven by the intolerability of life with severe depression coupled with the exhaustion of all available treatment options. Participants had greater awareness of surgical risks compared with stimulation-related risks. With DBS, patients described cognitive, emotional, behavioral and physical experiences associated with the stimulation, some of which were unexpected. Participants felt life with DBS was like "a roller coaster ride"-with positive, yet unsustained, mood states experienced. Many were surprised by the lengthy process of establishing optimum stimulation settings and felt the intervention was still a "work in progress." Conclusion: These findings support existing recommendations for iterative informed consent procedures in clinical trials involving long-term implantation of neurotechnology. These rich and descriptive findings hold value for researchers, clinicians, and individuals and families considering DBS. Narrative accounts capture patient and family needs and should routinely be collected to guide patient-centered approaches to DBS interventions.
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Affiliation(s)
- Cassandra J. Thomson
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Clayton, VIC, Australia
| | - Rebecca A. Segrave
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Clayton, VIC, Australia
| | - Paul B. Fitzgerald
- Epworth Centre for Innovation in Mental Health, Epworth Healthcare, Camberwell, VIC, Australia
- Department of Psychiatry, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Karyn E. Richardson
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Clayton, VIC, Australia
| | - Eric Racine
- Pragmatic Health Ethics Research Unit, Institut de Recherches Cliniques de Montréal, Montreal, QC, Canada
- Department of Medicine and Social and Preventive Medicine, Université de Montréal, Montreal, QC, Canada
- Medicine and Biomedical Ethics Unit, Department of Neurology and Neurosurgery, McGill University, Montreal, QC, Canada
| | - Adrian Carter
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Clayton, VIC, Australia
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Smilan LE. The Revised Common Rule and Mental Illness: Enduring Gaps in Protections. AMERICAN JOURNAL OF LAW & MEDICINE 2020; 46:413-444. [PMID: 33413011 DOI: 10.1177/0098858820975532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Lisa E Smilan
- Lisa E. Smilan, Visiting Scholar, Institute of Law, Psychiatry, and Public Policy, University of Virginia, Charlottesville, VA; J.D., George Washington University Law School, Washington, D.C.; LL.M., specialization in health law, University of Maryland Francis King Carey School of Law, Baltimore, MD; Member, National Institutes of Health Intramural Institutional Review Board, Bethesda, MD. The opinions here expressed are those of the Author and completely independent of the National Institutes of Health. The Author thanks Ellen Wright Clayton for supporting this scholarship and for comments on earlier drafts. Thanks, also, to Leslie Meltzer Henry for her guidance and encouragement, and both Richard Bonnie and Xuemei Ding for their hospitality at the University of Virginia and for facilitating access to university libraries. Finally, thanks to the anonymous peer reviewers for their observations, probing questions, and helpful suggestions, and AJLM editors Jessa Boubker and Sharon Jaquez for their dedication and meticulous care in preparing this Article for publication
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8
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Wilkins JM, Forester BP. Informed consent, therapeutic misconception, and clinical trials for Alzheimer's disease. Int J Geriatr Psychiatry 2020; 35:430-435. [PMID: 31895474 PMCID: PMC7141972 DOI: 10.1002/gps.5262] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 12/21/2019] [Indexed: 11/07/2022]
Affiliation(s)
- James M. Wilkins
- Division of Geriatric Psychiatry, McLean Hospital, Belmont, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Brent P. Forester
- Division of Geriatric Psychiatry, McLean Hospital, Belmont, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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Thurin K, Aftab ZN, Cooper JJ. How Neuroscience Is Informing Treatments: Ethical Issues. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2019; 17:35-40. [PMID: 31975958 PMCID: PMC6493147 DOI: 10.1176/appi.focus.20180028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Kristina Thurin
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago (Thurin, Aftab); Department of Psychiatry, University of Illinois at Chicago, Chicago (Cooper)
| | - Zehra N Aftab
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago (Thurin, Aftab); Department of Psychiatry, University of Illinois at Chicago, Chicago (Cooper)
| | - Joseph J Cooper
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago (Thurin, Aftab); Department of Psychiatry, University of Illinois at Chicago, Chicago (Cooper)
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Bilge MT, Gosai AK, Widge AS. Deep Brain Stimulation in Psychiatry: Mechanisms, Models, and Next-Generation Therapies. Psychiatr Clin North Am 2018; 41:373-383. [PMID: 30098651 PMCID: PMC6092041 DOI: 10.1016/j.psc.2018.04.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Deep brain stimulation has preliminary evidence of clinical efficacy, but has been difficult to develop into a robust therapy, in part because its mechanisms are incompletely understood. We review evidence from movement and psychiatric disorder studies, with an emphasis on how deep brain stimulation changes brain networks. From this, we argue for a network-oriented approach to future deep brain stimulation studies. That network approach requires methods for identifying patients with specific circuit/network deficits. We describe how dimensional approaches to diagnoses may aid that identification. We discuss the use of network/circuit biomarkers to develop self-adjusting "closed loop" systems.
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Affiliation(s)
- Mustafa Taha Bilge
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, 149 13th Street, Charlestown, Boston, MA 02129, USA
| | - Aishwarya K Gosai
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, 149 13th Street, Charlestown, Boston, MA 02129, USA
| | - Alik S Widge
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, 149 13th Street, Charlestown, Boston, MA 02129, USA; Picower Institute for Learning and Memory, Massachusetts Institute of Technology, Cambridge, MA, USA.
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11
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Stahl D, Cabrera L, Gibb T. Should DBS for Psychiatric Disorders be Considered a Form of Psychosurgery? Ethical and Legal Considerations. SCIENCE AND ENGINEERING ETHICS 2018; 24:1119-1142. [PMID: 28653164 DOI: 10.1007/s11948-017-9934-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 06/17/2017] [Indexed: 05/13/2023]
Abstract
Deep brain stimulation (DBS), a surgical procedure involving the implantation of electrodes in the brain, has rekindled the medical community's interest in psychosurgery. Whereas many researchers argue DBS is substantially different from psychosurgery, we argue psychiatric DBS-though a much more precise and refined treatment than its predecessors-is nevertheless a form of psychosurgery, which raises both old and new ethical and legal concerns that have not been given proper attention. Learning from the ethical and regulatory failures of older forms of psychosurgery can help shed light on how to address the regulatory gaps that exist currently in DBS research. To show why it is important to address the current regulatory gaps within psychiatric DBS, we draw on the motivations underlying the regulation of earlier forms of psychosurgery in the US. We begin by providing a brief history of psychosurgery and electrical brain stimulation in the US. Against this backdrop, we introduce psychiatric DBS, exploring current research and ongoing clinical trials. We then draw out the ethical and regulatory similarities between earlier forms of psychosurgery and psychiatric DBS. As we will show, the factors that motivated strict regulation of earlier psychosurgical procedures mirror concerns with psychiatric DBS today. We offer three recommendations for psychiatric DBS regulation, which echo earlier motivations for regulating psychosurgery, along with new considerations that reflect the novel technologies used in DBS.
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Affiliation(s)
- Devan Stahl
- Michigan State Univeristy, College of Human Medicine, East Fee Hall, 965 Fee Rd, RmC213, East Lansing, MI, 48824, USA.
| | - Laura Cabrera
- Michigan State University, College of Human Medicine, East Fee Hall, 965 Fee Rd, RmC211, East Lansing, MI, 48824, USA
| | - Tyler Gibb
- Western Michigan University Homer Stryker M.D. School of Medicine, 1000 Oakland Drive, Kalamazoo, MI, 49008, USA
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Mandarelli G, Moretti G, Pasquini M, Nicolò G, Ferracuti S. Informed Consent Decision-Making in Deep Brain Stimulation. Brain Sci 2018; 8:E84. [PMID: 29751598 PMCID: PMC5977075 DOI: 10.3390/brainsci8050084] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 05/07/2018] [Accepted: 05/08/2018] [Indexed: 12/20/2022] Open
Abstract
Deep brain stimulation (DBS) has proved useful for several movement disorders (Parkinson’s disease, essential tremor, dystonia), in which first and/or second line pharmacological treatments were inefficacious. Initial evidence of DBS efficacy exists for refractory obsessive-compulsive disorder, treatment-resistant major depressive disorder, and impulse control disorders. Ethical concerns have been raised about the use of an invasive surgical approach involving the central nervous system in patients with possible impairment in cognitive functioning and decision-making capacity. Most of the disorders in which DBS has been used might present with alterations in memory, attention, and executive functioning, which may have an impact on the mental capacity to give informed consent to neurosurgery. Depression, anxiety, and compulsivity are also common in DBS candidate disorders, and could also be associated with an impaired capacity to consent to treatment or clinical research. Despite these issues, there is limited empirical knowledge on the decision-making levels of these patients. The possible informed consent issues of DBS will be discussed by focusing on the specific treatable diseases.
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Affiliation(s)
- Gabriele Mandarelli
- Department of Human Neurosciences (Former Department of Neurology and Psychiatry), "Sapienza" University of Rome, 00185 Rome, Italy.
| | - Germana Moretti
- Department of Mental Health, ASL Roma 5, 00034 Colleferro, Italy.
| | - Massimo Pasquini
- Department of Human Neurosciences (Former Department of Neurology and Psychiatry), "Sapienza" University of Rome, 00185 Rome, Italy.
| | - Giuseppe Nicolò
- Department of Mental Health, ASL Roma 5, 00034 Colleferro, Italy.
| | - Stefano Ferracuti
- Department of Human Neurosciences (Former Department of Neurology and Psychiatry), "Sapienza" University of Rome, 00185 Rome, Italy.
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Neuhaus CP. Ethical issues when modelling brain disorders innon-human primates. JOURNAL OF MEDICAL ETHICS 2018; 44:323-327. [PMID: 28801311 DOI: 10.1136/medethics-2016-104088] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 07/13/2017] [Accepted: 07/20/2017] [Indexed: 06/07/2023]
Abstract
Non-human animal models of human diseases advance our knowledge of the genetic underpinnings of disease and lead to the development of novel therapies for humans. While mice are the most common model organisms, their usefulness is limited. Larger animals may provide more accurate and valuable disease models, but it has, until recently, been challenging to create large animal disease models. Genome editors, such as Clustered Randomised Interspersed Palindromic Repeat (CRISPR), meet some of these challenges and bring routine genome engineering of larger animals and non-human primates (NHPs) well within reach. There is growing interest in creating NHP models of brain disorders such as autism, depression and Alzheimer's, which are very difficult to model or study in other organisms, including humans. New treatments are desperately needed for this set of disorders. This paper is novel in asking: Insofar as NHPs are being considered for use as model organisms for brain disorders, can this be done ethically? The paper concludes that it cannot. Notwithstanding ongoing debate about NHPs' moral status, (1) animal welfare concerns, (2) the availability of alternative methods of studying brain disorders and (3) unmet expectations of benefit justify a stop on the creation of NHP model organisms to study brain disorders. The lure of using new genetic technologies combined with the promise of novel therapeutics presents a formidable challenge to those who call for slow, careful, and only necessary research involving NHPs. But researchers should not create macaques with social deficits or capuchin monkeys with memory deficits just because they can.
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Affiliation(s)
- Carolyn P Neuhaus
- Division of Medical Ethics, New York University School of Medicine, New York, USA
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Wang YY, Wang SB, Ungvari GS, Yu X, Ng CH, Xiang YT. The assessment of decision-making competence in patients with depression using the MacArthur competence assessment tools: A systematic review. Perspect Psychiatr Care 2018; 54:206-211. [PMID: 28543187 DOI: 10.1111/ppc.12224] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 03/19/2017] [Accepted: 04/22/2017] [Indexed: 01/10/2023] Open
Abstract
PURPOSE This is a systematic review of the usefulness of the MacArthur Competence Assessment Tools (MacCAT) in assessing the decision-making competence in patients with depression. DESIGN AND METHODS A systematic literature search was performed. FINDINGS Eleven studies met the search criteria. The decision-making capacity was impaired in 9-31% of the patients with depression. There was inconsistency regarding the differences of MacCAT scores between patients with depression and controls, while relatively large effect sizes were found on the Appreciation and Reasoning MacCAT subscales. PRACTICE IMPLICATIONS The MacCAT appears to be a useful tool for measuring decision-making capacity in patients with depression, but the association between depression and competence is not consistent. The mechanisms mediating such association are likely to be complex and multifactorial.
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Affiliation(s)
- Yuan-Yuan Wang
- Unit of Psychiatry, Faculty of Health Sciences, University of Macau, Macau, SAR, China
| | - Shi-Bin Wang
- Unit of Psychiatry, Faculty of Health Sciences, University of Macau, Macau, SAR, China
| | - Gabor S Ungvari
- University of Notre Dame Australia/Marian Centre, Perth, Australia.,School of Psychiatry & Clinical Neurosciences, University of Western Australia, Perth, Australia
| | - Xin Yu
- Peking University Sixth Hospital, Peking University Institute of Mental Health, Key Laboratory of Mental Health, Ministry of Health (Peking University), Beijing, China
| | - Chee H Ng
- Department of Psychiatry, University of Melbourne, Melbourne, Victoria, Australia
| | - Yu-Tao Xiang
- Unit of Psychiatry, Faculty of Health Sciences, University of Macau, Macau, SAR, China
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Nugent AC, Miller FG, Henter ID, Zarate CA. The Ethics of Clinical Trials Research in Severe Mood Disorders. BIOETHICS 2017; 31:443-453. [PMID: 28503892 PMCID: PMC5469708 DOI: 10.1111/bioe.12349] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Mood disorders, including major depressive disorder (MDD) and bipolar disorder (BD), are highly prevalent, frequently disabling, and sometimes deadly. Additional research and more effective medications are desperately needed, but clinical trials research in mood disorders is fraught with ethical issues. Although many authors have discussed these issues, most do so from a theoretical viewpoint. This manuscript uses available empirical data to inform a discussion of the primary ethical issues raised in mood disorders research. These include issues of consent and decision-making capacity, including patients' motivations for participating in research. We also address drug withdrawals, placebo controls, and the overall safety of research. Finally, we examine the extant literature for studies discussing potential indirect benefits of clinical trials research to participants. Taken together, the evidence suggests that clinical trials research incorporating drug withdrawals and placebo controls can be conducted safely and ethically, even in patients with severe or treatment-resistant mood disorders. In fact, given the dearth of effective treatment options for this population, it is our opinion that a moral imperative exists to extend the offer of research participation to severely ill or treatment-resistant groups.
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Beeker T, Schlaepfer TE, Coenen VA. Autonomy in Depressive Patients Undergoing DBS-Treatment: Informed Consent, Freedom of Will and DBS' Potential to Restore It. Front Integr Neurosci 2017; 11:11. [PMID: 28642690 PMCID: PMC5462943 DOI: 10.3389/fnint.2017.00011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 05/22/2017] [Indexed: 12/17/2022] Open
Abstract
According to the World Health Organization, depression is one of the most common and most disabling psychiatric disorders, affecting at any given time approximately 325 million people worldwide. As there is strong evidence that depressive disorders are associated with a dynamic dysregulation of neural circuits involved in emotional processing, recently several attempts have been made to intervene directly in these circuits via deep brain stimulation (DBS) in patients with treatment-resistant major depressive disorder (MDD). Given the promising results of most of these studies, the rising medical interest in this new treatment correlates with a growing sensitivity to ethical questions. One of the most crucial concerns is that DBS might interfere with patients' ability to make autonomous decisions. Thus, the goal of this article is to evaluate the impact DBS presumably has on the capacity to decide and act autonomously in patients with MDD in the light of the autonomy-undermining effects depression has itself. Following the chronological order of the procedure, special attention will first be paid to depression's effects on patients' capacity to make use of their free will in giving valid Informed Consent. We suggest that while the majority of patients with MDD appear capable of autonomous choices, as it is required for Informed Consent, they might still be unable to effectively act according to their own will whenever acting includes significant personal effort. In reducing disabling depressive symptoms like anhedonia and decrease of energy, DBS for treatment resistant MDD thus rather seems to be an opportunity to substantially increase autonomy than a threat to it.
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Affiliation(s)
- Timo Beeker
- Department of Psychiatry and Psychotherapy, Medical School Brandenburg Theodor FontaneRüdersdorf, Germany
| | - Thomas E. Schlaepfer
- Department of Interventional Biological Psychiatry, Freiburg University Medical CenterFreiburg, Germany
- Medical Faculty, Freiburg UniversityFreiburg, Germany
| | - Volker A. Coenen
- Medical Faculty, Freiburg UniversityFreiburg, Germany
- Department of Stereotactic and Functional Neurosurgery, Freiburg University Medical CenterFreiburg, Germany
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Park RJ, Singh I, Pike AC, Tan JOA. Deep Brain Stimulation in Anorexia Nervosa: Hope for the Hopeless or Exploitation of the Vulnerable? The Oxford Neuroethics Gold Standard Framework. Front Psychiatry 2017; 8:44. [PMID: 28373849 PMCID: PMC5357647 DOI: 10.3389/fpsyt.2017.00044] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 03/03/2017] [Indexed: 01/13/2023] Open
Abstract
Neurosurgical interventions for psychiatric disorders have a long and troubled history (1, 2) but have become much more refined in the last few decades due to the rapid development of neuroimaging and robotic technologies (2). These advances have enabled the design of less invasive techniques, which are more focused, such as deep brain stimulation (DBS) (3). DBS involves electrode insertion into specific neural targets implicated in pathological behavior, which are then repeatedly stimulated at adjustable frequencies. DBS has been used for Parkinson's disease and movement disorders since the 1960s (4-6) and over the last decade has been applied to treatment-refractory psychiatric disorders, with some evidence of benefit in obsessive-compulsive disorder (OCD), major depressive disorder, and addictions (7). Recent consensus guidelines on best practice in psychiatric neurosurgery (8) stress, however, that DBS for psychiatric disorders remains at an experimental and exploratory stage. The ethics of DBS-in particular for psychiatric conditions-is debated (1, 8-10). Much of this discourse surrounds the philosophical implications of competence, authenticity, personality, or identity change following neurosurgical interventions, but there is a paucity of applied guidance on neuroethical best practice in psychiatric DBS, and health-care professionals have expressed that they require more (11). This paper aims to redress this balance by providing a practical, applied neuroethical gold standard framework to guide research ethics committees, researchers, and institutional sponsors. We will describe this as applied to our protocol for a particular research trial of DBS in severe and enduring anorexia nervosa (SE-AN) (https://clinicaltrials.gov/ct2/show/NCT01924598, unique identifier NCT01924598), but believe it may have wider application to DBS in other psychiatric disorders.
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Affiliation(s)
- Rebecca J. Park
- OxBREaD Research Group, Department of Psychiatry, University of Oxford, Oxford, UK
| | - Ilina Singh
- Neuroscience Ethics and Society Research Group, Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - Alexandra C. Pike
- OxBREaD Research Group, Department of Psychiatry, University of Oxford, Oxford, UK
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Siegel AM, Barrett MS, Bhati MT. Deep Brain Stimulation for Alzheimer’s Disease: Ethical Challenges for Clinical Research. J Alzheimers Dis 2017; 56:429-439. [DOI: 10.3233/jad-160356] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Andrew M. Siegel
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Marna S. Barrett
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Mahendra T. Bhati
- Departments of Psychiatry and Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
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Klein E. Informed Consent in Implantable BCI Research: Identifying Risks and Exploring Meaning. SCIENCE AND ENGINEERING ETHICS 2016; 22:1299-1317. [PMID: 26497727 DOI: 10.1007/s11948-015-9712-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2015] [Accepted: 10/19/2015] [Indexed: 06/05/2023]
Abstract
Implantable brain-computer interface (BCI) technology is an expanding area of engineering research now moving into clinical application. Ensuring meaningful informed consent in implantable BCI research is an ethical imperative. The emerging and rapidly evolving nature of implantable BCI research makes identification of risks, a critical component of informed consent, a challenge. In this paper, 6 core risk domains relevant to implantable BCI research are identified-short and long term safety, cognitive and communicative impairment, inappropriate expectations, involuntariness, affective impairment, and privacy and security. Work in deep brain stimulation provides a useful starting point for understanding this core set of risks in implantable BCI. Three further risk domains-risks pertaining to identity, agency, and stigma-are identified. These risks are not typically part of formalized consent processes. It is important as informed consent practices are further developed for implantable BCI research that attention be paid not just to disclosing core research risks but exploring the meaning of BCI research with potential participants.
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Affiliation(s)
- Eran Klein
- Department of Philosophy and Center for Sensorimotor Neural Engineering, University of Washington, Seattle, WA, USA.
- Department of Neurology, Oregon Health and Sciences University, Portland, OR, USA.
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Klein E, Goering S, Gagne J, Shea CV, Franklin R, Zorowitz S, Dougherty DD, Widge AS. Brain-computer interface-based control of closed-loop brain stimulation: attitudes and ethical considerations. BRAIN-COMPUTER INTERFACES 2016. [DOI: 10.1080/2326263x.2016.1207497] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Eran Klein
- Center for Sensorimotor Neural Engineering and Department of Philosophy, University of Washington, Seattle, WA, USA
- Department of Neurology, Oregon Health and Science University, Portland, OR, USA
| | - Sara Goering
- Center for Sensorimotor Neural Engineering and Department of Philosophy, University of Washington, Seattle, WA, USA
| | - Josh Gagne
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Conor V. Shea
- Division of Neurotherapeutics, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Rachel Franklin
- Division of Neurotherapeutics, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Samuel Zorowitz
- Division of Neurotherapeutics, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Darin D. Dougherty
- Division of Neurotherapeutics, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Alik S. Widge
- Division of Neurotherapeutics, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Picower Institute for Learning & Memory, Massachusetts Institute of Technology, Boston, MA, USA
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Klein E, Ojemann J. Informed consent in implantable BCI research: identification of research risks and recommendations for development of best practices. J Neural Eng 2016; 13:043001. [PMID: 27247140 DOI: 10.1088/1741-2560/13/4/043001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Implantable brain-computer interface (BCI) research promises improvements in human health and enhancements in quality of life. Informed consent of subjects is a central tenet of this research. Rapid advances in neuroscience, and the intimate connection between functioning of the brain and conceptions of the self, make informed consent particularly challenging in BCI research. Identification of safety and research-related risks associated with BCI devices is an important step in ensuring meaningful informed consent. APPROACH This paper highlights a number of BCI research risks, including safety concerns, cognitive and communicative impairments, inappropriate subject expectations, group vulnerabilities, privacy and security, and disruptions of identity. MAIN RESULTS Based on identified BCI research risks, best practices are needed for understanding and incorporating BCI-related risks into informed consent protocols. SIGNIFICANCE Development of best practices should be guided by processes that are: multidisciplinary, systematic and transparent, iterative, relational and exploratory.
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Affiliation(s)
- Eran Klein
- Department of Neurology, Oregon Health and Science University, Portland, OR, USA. Department of Philosophy, University of Washington, Seattle, WA, USA. Center for Sensorimotor Neural Engineering, Seattle, WA, USA
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Youssef NA, McCall WV. Is Conduct of Research in Electroconvulsive Therapy Ethical? JOURNAL OF PSYCHOLOGY, NEUROPSYCHIATRIC DISORDERS AND BRAIN STIMULATION 2016; 1:105. [PMID: 28936488 PMCID: PMC5604863 DOI: 10.19104/jpbd.2016.105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Controversy surrounding ECT creates skepticism about the ethics of conducting ECT research. This paper discusses the ethical conduct of clinical research and then focus on the ethics as applied to ECT. METHODS PubMed was searched for articles related to the ethical conduct of research and that of ECT research published in English. RESULTS ECT research is ethically justified and should always continue to be conducted with the highest ethical standards. ECT research entails few ethical peculiarities such as involving multiple sessions were capacity to consent can change. It would be unethical not to conduct ECT research. CONCLUSION ECT research must be based on sound hypotheses in the presence of a clinical equipoise in well-designed studies. ECT studies must select a fair and non-biased sample of participants. It is important that participants represent the broad population of the people that would be receiving ECT for that specific indication. ECT research is ethical; and more research in this field could help decrease stigma and barriers to treatment, and/or reduce side effects and improve efficacy of a potentially life-saving intervention.
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Affiliation(s)
- NA Youssef
- Department of Psychiatry & Health Behavior, The Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | - WV McCall
- Department of Psychiatry & Health Behavior, The Medical College of Georgia, Augusta University, Augusta, Georgia, USA
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Nelson LR, Stupiansky NW, Ott MA. The Influence of Age, Health Literacy, and Affluence on Adolescents' Capacity to Consent to Research. J Empir Res Hum Res Ethics 2016; 11:115-21. [PMID: 27009303 DOI: 10.1177/1556264616636232] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
While adults are assumed to have the capacity to consent to medical research, and young children to have no capacity, adolescents' capacity to consent is not well described. Adapting the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR), we describe adolescents' capacity to consent to medical research and factors influencing that capacity. Our pilot study included a community-based sample of 30 adolescents, 14 to 21 years of age, who completed the MacCAT-CR after undergoing a simulated informed consent process. We found that adolescents' capacity to consent to research was associated with age, health literacy, and family affluence. These findings suggest that investigators and institutional review boards should be aware that factors other than age may influence capacity to consent, and, for modifiable factors, such as health literacy, consent processes for medical research with adolescents can be modified.
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Affiliation(s)
| | | | - Mary A Ott
- Indiana University School of Medicine, Indianapolis, USA
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Thong IS, Foo MY, Sum MY, Capps B, Lee TS, Ho C, Sim K. Therapeutic Misconception in Psychiatry Research: A Systematic Review. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2016; 14:17-25. [PMID: 26792036 PMCID: PMC4730932 DOI: 10.9758/cpn.2016.14.1.17] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 08/28/2015] [Accepted: 08/29/2015] [Indexed: 11/18/2022]
Abstract
Therapeutic misconception (TM) denotes the phenomenon in which research subjects conflate research purpose, protocols and procedures with clinical treatment. We examined the prevalence, contributory factors, clinical associations, impact, and collated solutions on TM within psychiatric research, and made suggestions going ahead. Literature search for relevant empirical research papers was conducted until February 2015. Eighty-eight reports were extracted, of which 31 were selected, summarised into different headings for discussion of implications and collated solutions of TM. We found variable and high rates of TM (ranging from 12.5% to 86%) in some psychiatry research populations. Contributory factors to TM included perceived medical roles of researchers, media, research setting and subject factors. Greater TM in affective, neurodevelopmental and psychotic spectrum conditions were associated with demographic variables (such as lower education, increased age), clinical factors (such as poor insight, cognitive deficits, increased symptoms, poorer self-rated quality of health), and social functioning (such as decreased independence). Inattention to TM may lead to frustration, negative impression and abandonment of participation in psychiatry research. Strategies such as the employment of a neutral educator during the informed consent process and education modules may be effective in addressing TM. Further research is warranted to examine the different TM facets, specific clinical correlates and more effective management strategies.
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Affiliation(s)
- Ivan Sk Thong
- The College of Arts and Sciences, University at Buffalo, Buffalo, New York, USA
| | - Meng Yee Foo
- The College of Arts and Sciences, University at Buffalo, Buffalo, New York, USA
| | - Min Yi Sum
- Research Division, Institute of Mental Health, Singapore, Singapore
| | - Benjamin Capps
- Department of Bioethics, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Tih-Shih Lee
- Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Calvin Ho
- Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kang Sim
- Research Division, Institute of Mental Health, Singapore, Singapore.,Department of General Psychiatry, Institute of Mental Health, Singapore, Singapore
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Klein E. Eloquent Brain, Ethical Challenges: Functional Brain Mapping in Neurosurgery. Semin Ultrasound CT MR 2015; 36:291-5. [PMID: 26233862 DOI: 10.1053/j.sult.2015.05.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Functional brain mapping is an increasingly relied upon tool in presurgical planning and intraoperative decision making. Mapping allows personalization of structure-function relationships when surgical or other treatment of pathology puts eloquent functioning like language or vision at risk. As an innovative technology, functional brain mapping holds great promise but also raises important ethical questions. In this article, recent work in neuroethics on functional imaging and functional neurosurgery is explored and applied to functional brain mapping. Specific topics discussed in this article are incidental findings, responsible innovation, and informed consent.
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Affiliation(s)
- Eran Klein
- Neurology Service, Portland VA Medical Center, Portland, OR; Department of Neurology, Oregon Health and Science University, Portland, OR; Department of Philosophy, University of Washington, Seattle, WA.
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Abstract
Major depressive disorder is a worldwide disease with debilitating effects on a patient's life. Common treatments include pharmacotherapy, psychotherapy, and electroconvulsive therapy. Many patients do not respond to these treatments; this has led to the investigation of alternative therapeutic modalities. Deep brain stimulation (DBS) is one of these modalities. It was first used with success for treating movement disorders and has since been extended to the treatment of psychiatric disorders. Although DBS is still an emerging treatment, promising efficacy and safety have been demonstrated in preliminary trials in patients with treatment-resistant depression (TRD). Further, neuroimaging has played a pivotal role in identifying some DBS targets and remains an important tool for evaluating the mechanism of action of this novel intervention. Preclinical animal studies have broadened knowledge about the possible mechanisms of action of DBS for TRD, Given that DBS involves neurosurgery in patients with severe psychiatric impairment, ethical questions concerning capacity to consent arise; these issues must continue to be carefully considered.
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Affiliation(s)
- Sibylle Delaloye
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Paul E Holtzheimer
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
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Schicktanz S, Schweda M, Ballenger JF, Fox PJ, Halpern J, Kramer JH, Micco G, Post SG, Thompson C, Knight RT, Jagust WJ. Before it is too late: professional responsibilities in late-onset Alzheimer's research and pre-symptomatic prediction. Front Hum Neurosci 2014; 8:921. [PMID: 25477802 PMCID: PMC4238325 DOI: 10.3389/fnhum.2014.00921] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 10/28/2014] [Indexed: 12/03/2022] Open
Abstract
The development of a wide array of molecular and neuroscientific biomarkers can provide the possibility to visualize the course of Alzheimer's disease (AD) at early stages. Many of these biomarkers are aimed at detecting not only a preclinical, but also a pre-symptomatic state. They are supposed to facilitate clinical trials aiming at treatments that attack the disease at its earliest stage or even prevent it. The increasing number of such biomarkers currently tested and now partly proposed for clinical implementation calls for critical reflection on their aims, social benefits, and risks. This position paper summarizes major challenges and responsibilities. Its focus is on the ethical and social problems involved in the organization and application of dementia research, as well as in healthcare provision from a cross-national point of view. The paper is based on a discussion of leading dementia experts from neuroscience, neurology, social sciences, and bioethics in the United States and Europe. It thus reflects a notable consensus across various disciplines and national backgrounds. We intend to initiate a debate on the need for actions within the researchers' national and international communities.
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Affiliation(s)
- Silke Schicktanz
- Department of Medical Ethics and History of Medicine, University Medical Center GöttingenGöttingen, Germany
| | - Mark Schweda
- Department of Medical Ethics and History of Medicine, University Medical Center GöttingenGöttingen, Germany
- Lichtenberg Kolleg, University of GöttingenGöttingen, Germany
| | - Jesse F. Ballenger
- Health Administration Department, Drexel UniversityPhiladelphia, PA, USA
| | - Patrick J. Fox
- Institute for Health & Aging, University of CaliforniaSan Francisco, San Francisco, CA, USA
| | - Jodi Halpern
- UC Berkeley-UCSF Joint Medical Program, School of Public Health, University of CaliforniaBerkeley, Berkeley, CA, USA
| | - Joel H. Kramer
- Memory and Aging Center, Sandler Neurosciences Center, University of CaliforniaSan Francisco, San Francisco, CA, USA
| | - Guy Micco
- UC Berkeley-UCSF Joint Medical Program, School of Public Health, University of CaliforniaBerkeley, Berkeley, CA, USA
| | - Stephen G. Post
- Compassionate Care & Bioethics, Stony Brook MedicineStony Brook, NY, USA
| | - Charis Thompson
- Department of Gender and Women’s Studies, University of CaliforniaBerkeley, Berkeley, CA, USA
- Department of Sociology, London School of EconomicsLondon, UK
| | - Robert T. Knight
- Department of Psychology, University of California, BerkeleyBerkeley, CA, USA
- Helen Wills Neuroscience Institute, University of CaliforniaBerkeley, Berkeley, CA, USA
| | - William J. Jagust
- UC Berkeley-UCSF Joint Medical Program, School of Public Health, University of CaliforniaBerkeley, Berkeley, CA, USA
- Helen Wills Neuroscience Institute, University of CaliforniaBerkeley, Berkeley, CA, USA
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Abstract
Neuroethics Now welcomes papers addressing the ethical application of neuroscience in research and patient care, as well as its impact on society.
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Coman A, Skårderud F, Reas DL, Hofmann BM. The ethics of neuromodulation for anorexia nervosa: a focus on rTMS. J Eat Disord 2014; 2:10. [PMID: 24690315 PMCID: PMC3977899 DOI: 10.1186/2050-2974-2-10] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Accepted: 03/16/2014] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Recently there has been emerging clinical and research interest in the application of deep brain stimulation (DBS) and repetitive transcranial magnetic stimulation (rTMS) to the treatment of anorexia nervosa (AN). To our knowledge, few studies have discussed ethical aspects associated with the increased use of neuromodulation in AN, some of which are quite specific to AN, despite the rapid development and dissemination of these new technologies. METHOD We provide a brief overview of three published rTMS studies for AN and discuss ethical issues involved in the use of neuromodulation for AN. RESULTS In contrast to neurosurgery or DBS, rTMS is a less invasive technique, with less associated risk, and thus has greater potential to become a more widespread augmentation or add-on therapy for AN. New therapeutic procedures are promising, yet they raise ethical questions regarding informed consent and patient selection. Illness-specific issues surrounding authenticity and autonomy are important to consider, ensuring an ethical approach to treatment for patients with AN. DISCUSSION We argue that ethical investigations for neuromodulation techniques are timely and important, and discussions should go beyond the immediate goals of patient safety, consent, and risk and benefit, to consider broader ethical concepts such as authenticity and autonomy.
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Affiliation(s)
- Alina Coman
- Regional Eating Disorders Service (RASP), Division of Mental Health and Addiction, Oslo University Hospital-Ullevål, P.O. Box 4956 Nydalen, Oslo N-0424, Norway
- Centre for Medical Ethics, University of Oslo, P.O. Box 1130, Blindern, Oslo N-0318, Norway
| | - Finn Skårderud
- Regional Eating Disorders Service (RASP), Division of Mental Health and Addiction, Oslo University Hospital-Ullevål, P.O. Box 4956 Nydalen, Oslo N-0424, Norway
- Institute of Special Needs Education, University of Oslo, Sognsveien 250, Oslo N-0863, Norway
| | - Deborah L Reas
- Regional Eating Disorders Service (RASP), Division of Mental Health and Addiction, Oslo University Hospital-Ullevål, P.O. Box 4956 Nydalen, Oslo N-0424, Norway
| | - Bjørn M Hofmann
- Centre for Medical Ethics, University of Oslo, P.O. Box 1130, Blindern, Oslo N-0318, Norway
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Williams NR, Okun MS. Deep brain stimulation (DBS) at the interface of neurology and psychiatry. J Clin Invest 2013; 123:4546-56. [PMID: 24177464 DOI: 10.1172/jci68341] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Deep brain stimulation (DBS) is an emerging interventional therapy for well-screened patients with specific treatment-resistant neuropsychiatric diseases. Some neuropsychiatric conditions, such as Parkinson disease, have available and reasonable guideline and efficacy data, while other conditions, such as major depressive disorder and Tourette syndrome, have more limited, but promising results. This review summarizes both the efficacy and the neuroanatomical targets for DBS in four common neuropsychiatric conditions: Parkinson disease, Tourette syndrome, major depressive disorder, and obsessive-compulsive disorder. Based on emerging new research, we summarize novel approaches to optimization of stimulation for each neuropsychiatric disease and we review the potential positive and negative effects that may be observed following DBS. Finally, we summarize the likely future innovations in the field of electrical neural-network modulation.
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Anderson D, Kartha N. Deep Brain Stimulation in Nonparkinsonian Movement Disorders and Emerging Technologies, Targets, and Therapeutic Promises in Deep Brain Stimulation. Neurol Clin 2013; 31:809-26. [DOI: 10.1016/j.ncl.2013.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Lozano A, Lipsman N. Probing and Regulating Dysfunctional Circuits Using Deep Brain Stimulation. Neuron 2013; 77:406-24. [DOI: 10.1016/j.neuron.2013.01.020] [Citation(s) in RCA: 423] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2013] [Indexed: 01/04/2023]
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Riva-Posse P, Holtzheimer PE, Garlow SJ, Mayberg HS. Practical considerations in the development and refinement of subcallosal cingulate white matter deep brain stimulation for treatment-resistant depression. World Neurosurg 2012; 80:S27.e25-34. [PMID: 23246630 DOI: 10.1016/j.wneu.2012.11.074] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Revised: 11/12/2012] [Accepted: 11/27/2012] [Indexed: 12/28/2022]
Abstract
BACKGROUND Deep brain stimulation has been investigated in the past decade as a viable intervention for treatment-resistant depression. METHODS Several anatomic targets have been tested, with the most extensive published experience found for the subcallosal cingulate (SCC) white matter. RESULTS This article reviews the current state of clinical research of SCC deep brain stimulation for treatment-resistant depression, including an overview of the rationale for targeting SCC, practical considerations for subject recruitment and evaluation, surgical planning, and stimulation parameters. CONCLUSION Clinical management of patients in the initial and long-term naturalistic phases of treatment, including the potential role for psychotherapeutic rehabilitation, is discussed.
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Affiliation(s)
- Patricio Riva-Posse
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA.
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Leuchter B, Pedley TA, Lisanby SH, Mayberg HS, Schiff ND. Brain stimulation in neurology and psychiatry: perspectives on an evolving field. Ann N Y Acad Sci 2012; 1265:vii-x. [PMID: 22882334 DOI: 10.1111/j.1749-6632.2012.06740.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Bruce Leuchter
- Department of Psychiatry, Weill Cornell Medical College of Cornell University, USA
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