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Smith JN, Dorfman N, Hurley M, Cenolli I, Kostick-Quenet K, Storch EA, Lázaro-Muñoz G, Blumenthal-Barby J. Adolescent OCD Patient and Caregiver Perspectives on Identity, Authenticity, and Normalcy in Potential Deep Brain Stimulation Treatment. Camb Q Healthc Ethics 2024:1-14. [PMID: 38602092 DOI: 10.1017/s0963180124000203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
The ongoing debate within neuroethics concerning the degree to which neuromodulation such as deep brain stimulation (DBS) changes the personality, identity, and agency (PIA) of patients has paid relatively little attention to the perspectives of prospective patients. Even less attention has been given to pediatric populations. To understand patients' views about identity changes due to DBS in obsessive-compulsive disorder (OCD), the authors conducted and analyzed semistructured interviews with adolescent patients with OCD and their parents/caregivers. Patients were asked about projected impacts to PIA generally due to DBS. All patient respondents and half of caregivers reported that DBS would impact patient self-identity in significant ways. For example, many patients expressed how DBS could positively impact identity by allowing them to explore their identities free from OCD. Others voiced concerns that DBS-related resolution of OCD might negatively impact patient agency and authenticity. Half of patients expressed that DBS may positively facilitate social access through relieving symptoms, while half indicated that DBS could increase social stigma. These views give insights into how to approach decision-making and informed consent if DBS for OCD becomes available for adolescents. They also offer insights into adolescent experiences of disability identity and "normalcy" in the context of OCD.
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Affiliation(s)
- Jared N Smith
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Natalie Dorfman
- Department of Philosophy, University of Washington, Seattle, WA, USA
| | - Meghan Hurley
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Ilona Cenolli
- Center for Bioethics, Harvard Medical School, Boston, MA, USA
| | - Kristin Kostick-Quenet
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Eric A Storch
- Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
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Okun MS, Marjenin T, Ekanayake J, Gilbert F, Doherty SP, Pilkington J, French J, Kubu C, Lázaro-Muñoz G, Denison T, Giordano J. Definition of Implanted Neurological Device Abandonment: A Systematic Review and Consensus Statement. JAMA Netw Open 2024; 7:e248654. [PMID: 38687486 DOI: 10.1001/jamanetworkopen.2024.8654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
Abstract
Importance Establishing a formal definition for neurological device abandonment has the potential to reduce or to prevent the occurrence of this abandonment. Objective To perform a systematic review of the literature and develop an expert consensus definition for neurological device abandonment. Evidence Review After a Royal Society Summit on Neural Interfaces (September 13-14, 2023), a systematic English language review using PubMed was undertaken to investigate extant definitions of neurological device abandonment. Articles were reviewed for relevance to neurological device abandonment in the setting of deep brain, vagal nerve, and spinal cord stimulation. This review was followed by the convening of an expert consensus group of physicians, scientists, ethicists, and stakeholders. The group summarized findings, added subject matter experience, and applied relevant ethics concepts to propose a current operational definition of neurological device abandonment. Data collection, study, and consensus development were done between September 13, 2023, and February 1, 2024. Findings The PubMed search revealed 734 total articles, and after review, 7 articles were found to address neurological device abandonment. The expert consensus group addressed findings as germane to neurological device abandonment and added personal experience and additional relevant peer-reviewed articles, addressed stakeholders' respective responsibilities, and operationally defined abandonment in the context of implantable neurotechnological devices. The group further addressed whether clinical trial failure or shelving of devices would constitute or be associated with abandonment as defined. Referential to these domains and dimensions, the group proposed a standardized definition for abandonment of active implantable neurotechnological devices. Conclusions and Relevance This study's consensus statement suggests that the definition for neurological device abandonment should entail failure to provide fundamental aspects of patient consent; fulfill reasonable responsibility for medical, technical, or financial support prior to the end of the device's labeled lifetime; and address any or all immediate needs that may result in safety concerns or device ineffectiveness and that the definition of abandonment associated with the failure of a research trial should be contingent on specific circumstances.
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Affiliation(s)
- Michael S Okun
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, Gainesville, Florida
- Department of Neurosurgery, Norman Fixel Institute for Neurological Diseases, Gainesville, Florida
| | - Timothy Marjenin
- Musculoskeletal Clinical Regulatory Advisers, Washington, District of Columbia
| | - Jinendra Ekanayake
- Department of Neurosurgery, National Guard Hospital, Riyadh, Saudia Arabia
- Department of Electronic Engineering, Imperial College London, United Kingdom
- Quetz Ltd, Chelmsford, England
| | | | - Sean P Doherty
- Department of Medical Physics and Biomedical Engineering, University College London, London, England
- Amber Therapeutics Limited, London, England
| | | | | | - Cynthia Kubu
- Center for Neuro-Restoration, Cleveland Clinic, Cleveland, Ohio
| | - Gabriel Lázaro-Muñoz
- Center for Bioethics, Massachusetts General Hospital, Harvard Medical School, Boston
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Timothy Denison
- Amber Therapeutics Limited, London, England
- Medical Research Council Brain Network Dynamics Unit, Departments of Engineering Sciences and Clinical Neurosciences, University of Oxford, Oxford, England
| | - James Giordano
- Department of Neurology, Georgetown University Medical Center, Washington, District of Columbia
- Department of Biochemistry, Georgetown University Medical Center, Washington, District of Columbia
- Neuroethics Studies Program, Georgetown University Medical Center, Washington, District of Columbia
- Defense Medical Ethics Center, Uniformed Services University of the Health Sciences, Bethesda, Maryland
- Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Scaife JC, Eraifej J, Green AL, Petric B, Aziz TZ, Park RJ. Deep Brain Stimulation of the Nucleus Accumbens in Severe Enduring Anorexia Nervosa: A Pilot Study. Front Behav Neurosci 2022; 16:842184. [PMID: 35571282 PMCID: PMC9094709 DOI: 10.3389/fnbeh.2022.842184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 02/15/2022] [Indexed: 12/17/2022] Open
Abstract
Introduction Anorexia nervosa (AN) is one of the most debilitating psychiatric disorders, becoming severe and enduring in a third of cases; with few effective treatments. Deep brain stimulation is a reversible, adjustable neurosurgical procedure that has been gaining ground in psychiatry as a treatment for depression and obsessive-compulsive disorder, yet few studies have investigated AN. Abnormal eating behavior and the compulsive pursuit of thinness in AN is, in part, a consequence of dysfunction in reward circuitry and the nucleus accumbens (NAcc) is central to reward processing. Methods Phase 1 prospective open-label pilot study of seven individuals with severe enduring AN. Electrodes were implanted bilaterally into the NAcc with stimulation at the anterior limb of the internal capsule using rechargeable implantable pulse generators. The protocol of 15 months included 12 months of deep brain stimulation incorporating two consecutive, randomized blind on-off fortnights 9 months after stimulation onset. The primary objectives were to investigate safety and feasibility, together with changes in eating disorder psychopathology. Results Feasibility and safety was demonstrated with no serious adverse events due to deep brain stimulation. Three patients responded to treatment [defined as > 35% reduction in Eating Disorders Examination (EDE) score at 12 months] and four patients were non-responders. Responders had a statistically significant mean reduction in EDE scores (50.3% reduction; 95% CI 2.6-98.2%), Clinical Impairment Assessment (45.6% reduction; 95% CI 7.4-83.7%). Responders also had a statistically significant mean reduction in Hamilton Depression Scale, Hamilton Anxiety Scale and Snaith-Hamilton pleasure scale. There were no statistically significant changes in Body Mass Index, Yale-Brown-Cornell Eating Disorder Scale, Yale-Brown Obsessive-Compulsive Scale and World Health Organization Quality of Life Psychological subscale. Conclusion This study provides some preliminary indication that deep brain stimulation to the NAcc. Might potentially improve some key features of enduring AN. In this small study, the three responders had comorbid obsessive-compulsive disorder which predated AN diagnosis. Future studies should aim to further elucidate predictors of outcome. Clinical Trial Registration [www.ClinicalTrials.gov], identifier [Project ID 128658].
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Affiliation(s)
- Jessica C. Scaife
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, United Kingdom
- Oxford Health NHS Foundation Trust, Oxford, United Kingdom
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital Oxford, University of Oxford, Oxford, United Kingdom
| | - John Eraifej
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital Oxford, University of Oxford, Oxford, United Kingdom
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Alexander L. Green
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital Oxford, University of Oxford, Oxford, United Kingdom
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Nuffield Department of Clinical Neuroscience, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Beth Petric
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Tipu Z. Aziz
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital Oxford, University of Oxford, Oxford, United Kingdom
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Nuffield Department of Clinical Neuroscience, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Rebecca J. Park
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, United Kingdom
- Oxford Health NHS Foundation Trust, Oxford, United Kingdom
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