Sport-related concussion research agenda beyond medical science: culture, ethics, science, policy.

The Concussion in Sport Group guidelines have successfully brought the attention of brain injuries to the global medical and sport research communities, and has significantly impacted brain injury-related practices and rules of international sport. Despite being the global repository of state-of-the-art science, diagnostic tools and guides to clinical practice, the ensuing consensus statements remain the object of ethical and sociocultural criticism. The purpose of this paper is to bring to bear a broad range of multidisciplinary challenges to the processes and products of sport-related concussion movement. We identify lacunae in scientific research and clinical guidance in relation to age, disability, gender and race. We also identify, through multidisciplinary and interdisciplinary analysis, a range of ethical problems resulting from conflicts of interest, processes of attributing expertise in sport-related concussion, unjustifiably narrow methodological control and insufficient athlete engagement in research and policy development. We argue that the sport and exercise medicine community need to augment the existing research and practice foci to understand these problems more holistically and, in turn, provide guidance and recommendations that help sport clinicians better care for brain-injured athletes.

Do Neurobiological Understandings of Smoking Influence Quitting Self-Efficacy or Treatment Intentions?

Introduction: Addiction is increasingly defined as a "brain disease" caused by changes to neurochemistry. While nicotine addiction has historically been excluded in the brain disease model of addiction (BDMA), it is beginning to be labeled a chronic brain disease. We investigated whether Australian smokers endorse brain-based explanations of smoking, and whether these beliefs are associated with quitting self-efficacy or treatment intentions. Method: Cross-sectional study of Australian smokers (N = 1538) who completed a survey measuring their agreement with statements on the brain's role in smoking. Logistic regressions tested associations between these items and socio-demographic variables, quitting self-efficacy and intention to use cessation medications. Results: The majority (57.9%) agreed that smoking changed brain chemistry and 34.4% agreed that smoking was a brain disease. Younger participants and those with more education were more likely to endorse brain-based understandings of smoking. Participants who agreed smoking changed brain chemistry were more likely to report an intention to use cessation medicines (OR 1.5, 95% CI = 1.0-2.2) as were those who agreed that smoking was a brain disease (OR 1.5, 95% CI = 1.1-2.1). Self-efficacy did not differ between those who agreed and disagreed that smoking changed brain chemistry. However, those who agreed that smoking was a brain disease had higher self-efficacy than those who disagreed (OR 1.7, 95% CI = 1.3-2.3). Conclusion: A neurobiological view of smoking does not dominate public understandings of smoking in Australia. Endorsement of neurobiological explanations of smoking were associated with increased intention to use cessation aids, but were not associated with reduced self-efficacy. Implications: Explaining tobacco dependence in neurobiological terms is unlikely to induce feelings of fatalism in relation to smoking cessation. Those who endorse biomedical explanations of smoking may be more open to using cessation pharmacotherapies. Describing smoking in terms of alterations in brain chemistry may be more acceptable to smokers than labeling smoking a "brain disease" or "brain disorder."

Over-diagnosed and over-treated: a survey of Australian public attitudes towards the acceptability of drug treatment for depression and ADHD.

BACKGROUND: Over the last decade the use of psychotropic medications to treat common mental health problems has increased in Australia. This paper explores: 1) public attitudes towards the acceptability of using prescription drugs to treat depression and attention deficit hyperactivity disorder (ADHD), and 2) beliefs about over-diagnosis of depression and ADHD. METHOD: 1293 members of the general public were surveyed about their attitudes towards drug treatment for depression and ADHD through the Queensland Social Survey (QSS), an omnibus state-wide survey of households in the state of Queensland. The survey was administered through a CATI (computer-assisted telephone interviewing) system. Logistic regression analyses were used to predict belief that drug treatment is acceptable, and that depression and ADHD are over-diagnosed. RESULTS: Most participants (60.9%) said that it was acceptable to use prescription drugs to treat depression. In contrast, attitudes towards the use of prescription drugs to treat ADHD were much less positive with around the same proportion saying it was acceptable (42.1%) as unacceptable (38.2%). More than half of the sample agreed that too many people are diagnosed with depression when they don't really have it (57.7%), and 78.3% of participants agreed that too many children are diagnosed with ADHD when they don't really have it. Participants who said depression or ADHD were over-diagnosed were less likely to say that it is acceptable to treat these conditions with prescription drugs. CONCLUSIONS: Despite increases in prescribing rates there is still considerable scope for increasing the public's acceptance of treating common mental illnesses with psychotropic drugs. Furthermore, the public's views on over-diagnosis of depression and ADHD appear to reflect ongoing controversy about the proper identification of these conditions, and these views negatively impact attitudes towards drug treatment. This may be a barrier to effective treatment of these conditions given that drug treatment is often recommended as a first line response.

How is acceptance of the brain disease model of addiction related to Australians' attitudes towards addicted individuals and treatments for addiction?

BACKGROUND: We investigated whether beliefs about addiction being a 'disease' or 'brain disease', and holding certain beliefs about addiction aetiology, are associated with public views about addicted persons and support for different types of treatment, coerced treatment and punishment for addiction. METHODS: Data were collected as part of the 2012 Queensland Social Survey, a computer assisted telephone interview of 1263 residents of Queensland, Australia. Participants were presented with scenarios of two addicted males, one who was addicted to heroin and the other addicted to alcohol. Participants were then asked a series of questions for both characters. RESULTS: There was widespread support for all treatment modalities (alcohol: 80.8-98.0%, heroin: 89.9-97.2%). There was less support for coerced treatment for alcohol than heroin addiction (alcohol: 41%, heroin: 71%, χ(2) = 273.90, p < 0.001). Being 35 years of age or older (alcohol: OR = 0.58 (0.37-0.91), heroin: OR = 0.49 (0.28-0.85)) and having 15 or more years of education (alcohol: OR = 0.60 (0.44-0.81), heroin: 0.55 (0.40-0.75)) predicted less support for coerced treatment. 31.7% of respondents agreed heroin use should be punished by imprisonment and being 35 years of age or older (OR = 0.51 (0.33-0.80)) predicted lack of support. The sample agreed that an alcohol or heroin dependent person would suffer career damage (alcohol: 96.2%, heroin: 98.9%), marriage breakdown (alcohol: 92.2%, heroin: 97.3%) and get in trouble with the law (alcohol: 92.3%, heroin: 98.9%). Respondents expressed more comfort with encountering alcohol rather than heroin addicted persons in the workplace or at a dinner party. Beliefs that addiction was a 'brain disease' or a 'disease' did not predict any of these attitudes. Beliefs about addiction aetiology were inconsistent predictors of outcomes measured. CONCLUSIONS: Age and educational attainment were the most consistent predictors of stigmatising beliefs and beliefs about coercion and punishment. Beliefs that addiction is a 'disease' or a 'brain disease' were not associated with an overall reduction in beliefs about stigma, coercion or punishment. Beliefs in different causes of addiction were not consistent predictors of beliefs about stigma, coercion or punishment.

Better evidence for safety and efficacy is needed before neurologists prescribe drugs for neuroenhancement to healthy people.

In this paper we question the guidance offered to neurologists by the Ethics, Law and Humanities Committee of the American Academy of Neurology (Larriviere, Williams, Rizzo & Bonnie, 2009) on how to respond to requests for "neuroenhancement": the use of pharmaceuticals to enhance cognitive function in cognitively normal people. The guidance assumes that the benefits of using neuroenhancers will prove to outweigh the risks in the absence of any evidence that this is the case. However, the principle of nonmaleficence dictates that the use of these drugs by healthy people should not be condoned before reliable evidence for their short and long term safety and efficacy is at hand. The proposed ethical framework for neuroenhancement prescribing also neglects the broader social implications of condoning such practices. The adoption of these guidelines by neurologists could have adverse social and medical effects that need to be more carefully considered.

Public attitudes towards the acceptability of using drugs to treat depression and ADHD.

OBJECTIVE: This paper examines public attitudes towards the acceptability of using prescription drugs to treat depression and attention deficit hyperactivity disorder (ADHD), and whether attitudes are influenced by familiarity with the use of pharmacological treatments for these disorders. METHOD: Participants were 1265 members of the general public aged 18-101 years (50% female) participating in the Queensland Social Survey (QSS), an omnibus state-wide survey of households in the state of Queensland. The survey was administered through a CATI (computer-assisted telephone interviewing) system. RESULTS: Most members of the public thought that the drug treatment of depression was acceptable (55%) but attitudes were much less positive towards the use of drugs to treat ADHD (35.6% acceptable). Regression analyses showed that respondents who knew someone who had received pharmacological treatment for depression were more likely to find it acceptable. However, participants were divided about the acceptability of drug treatment for ADHD regardless of whether they knew someone who had received drug treatment for ADHD or not. Participants with a higher level of education were more likely to find drug treatment for depression and ADHD acceptable. Participants who did not know anyone who had received drug treatment were less likely to have a definite opinion on whether it was acceptable or unacceptable. CONCLUSIONS: Attitudes towards the acceptability of the use of prescription drugs are more positive for depression than for ADHD. This may broadly reflect ongoing controversies in the public sphere about the potential over-diagnosis of ADHD or overmedication of children with ADHD. Members of the public who do not know anyone with depression or ADHD may need particular information from prescribers in the event that they (or their child) are diagnosed.

Community perceptions on the significant extension of life: an exploratory study among urban adults in Brisbane, Australia.

Some researchers in the field of ageing claim that significant extension of the human lifespan will be possible in the near future. While many of these researchers have assumed that the community will welcome this technology, there has been very little research on community attitudes to life extension. This paper presents the results of an in-depth qualitative study of community attitudes to life extension across age groups and religious boundaries. There were 57 individual interviews, and 8 focus groups (totalling 72 focus group participants) conducted with community members in Brisbane, Australia. Community attitudes to life extension were more varied and complex than have been assumed by some biogerontologists and bioethicists. While some participants would welcome the opportunity to extend their lives others would not even entertain the possibility. This paper details these differences of opinion and reveals contrasting positions that reflect individualism or social concern among community members. The findings also highlight the relationship between Christianity, in particular belief in an afterlife, and attitudes to life extension technology. Overall, the study raises questions about the relationship between interest in life extension, the medicalisation of ageing and the increasing acceptability of enhancement technologies that need to be addressed in more representative samples of the community.

Ethical concerns in the community about technologies to extend human life span.

Debates about the ethical and social implications of research that aims to extend human longevity by intervening in the ageing process have paid little attention to the attitudes of members of the general public. In the absence of empirical evidence, conflicting assumptions have been made about likely public attitudes towards life-extension. In light of recent calls for greater public involvement in such discussions, this target article presents findings from focus groups and individual interviews which investigated whether members of the general public identify ethical issues surrounding life-extension, and if so, what these ethical issues are? In this study, while some participants were concerned primarily with the likely personal consequences of life-extension, for others the question of whether or not to pursue interventions to extend longevity, and how they should be implemented, clearly raised important ethical issues, many of which have been prominent in debates among bioethicists.

Australian University Students' Coping Strategies and Use of Pharmaceutical Stimulants as Cognitive Enhancers.

BACKGROUND: There are reports that some university students are using prescription stimulants for non-medical 'pharmaceutical cognitive enhancement (PCE)' to improve alertness, focus, memory, and mood in an attempt to manage the demands of study at university. Purported demand for PCEs in academic contexts have been based on incomplete understandings of student motivations, and often based on untested assumptions about the context within which stimulants are used. They may represent attempts to cope with biopsychosocial stressors in university life by offsetting students' inadequate coping responses, which in turn may affect their cognitive performance. This study aimed to identify (a) what strategies students adopted to cope with the stress of university life and, (b) to assess whether students who have used stimulants for PCE exhibit particular stress or coping patterns. METHODS: We interviewed 38 university students (with and without PCE experience) about their experience of managing student life, specifically their: educational values; study habits; achievement; stress management; getting assistance; competing activities and demands; health habits; and cognitive enhancement practices. All interview transcripts were coded into themes and analyzed. RESULTS: Our thematic analysis revealed that, generally, self-rated coping ability decreased as students' self-rated stress level increased. Students used emotion- and problem-focused coping for the most part and adjustment-focused coping to a lesser extent. Avoidance, an emotion-focused coping strategy, was the most common, followed by problem-focused coping strategies, the use of cognition on enhancing substances, and planning and monitoring of workload. PCE users predominantly used avoidant emotion-focused coping strategies until they no longer mitigated the distress of approaching deadlines resulting in the use of prescription stimulants as a substance-based problem-focused coping strategy. CONCLUSION: Our study suggests that students who choose coping responses that do not moderate stress where possible, may cause themselves additional distress and avoid learning more effective coping responses. Helping students to understand stress and coping, and develop realistic stress appraisal techniques, may assist students in general to maintain manageable distress levels and functioning. Furthermore, assisting students who may be inclined to use prescription stimulants for cognitive enhancement may reduce possible drug-related harms.

Why Don't Smokers Want Help to Quit? A Qualitative Study of Smokers' Attitudes towards Assisted vs. Unassisted Quitting.

The development of prescription medication for smoking cessation and the introduction of evidence-based guidelines for health professionals has increasingly medicalised smoking cessation. There are debates about whether medicalisation is a positive development, or whether it has devalued unassisted quitting. In this debate the views of smokers have been neglected. This study explored the attitudes of smokers towards a range of quitting methods, and their considerations when judging their value. We conducted semi-structured interviews with 29 smokers and analysed data using thematic analysis. The results show that the perceived nature of an individual smoker's addiction was central to judgments about the value of pharmacological cessation aids, as was personal experience with a method, and how well it was judged to align with an individual's situation and personality. Unassisted quitting was often described as the best method. Negative views of pharmacological cessation aids were frequently expressed, particularly concerns about side effects from prescription medications. Smokers' views about the value of different methods were not independent: attitudes about cessation aids were shaped by positive attitudes towards unassisted quitting. Examining smokers' attitudes towards either assisted or unassisted quitting in isolation provides incomplete information on quitting preferences.

Researchers' perspectives on scientific and ethical issues with transcranial direct current stimulation: An international survey.

In the last decade, an increasing number of studies have suggested that transcranial direct current stimulation (tDCS) may enhance brain function in healthy individuals, and ameliorate cognitive and other symptoms in patients suffering from various medical conditions. This, along with its presumed safety, simplicity, and affordability, has generated great enthusiasm amongst researchers, clinicians, patient populations, and the public (including a growing "do-it-yourself" community). However, discussion about the effectiveness and ethics of tDCS thus far has been confined to small groups of tDCS researchers and bioethicists. We conducted an international online survey targeting the opinions of researchers using tDCS who were asked to rate the technique's efficacy in different contexts. We also surveyed opinions about ethical concerns, self-enhancement and public availability. 265 complete responses were received and analyzed statistically and thematically. Our results emphasize the potential uses of tDCS in clinical and research contexts, but also highlight a number of emerging methodological and safety concerns, ethical challenges and the need for improved communication between researchers and bioethicists with regard to regulation of the device. Neither the media reputation of tDCS as a "miracle device" nor concerns expressed in recent neuroethical publications were entirely borne out in expert opinion.

Dazed and confused: sports medicine, conflicts of interest, and concussion management.

Professional sports with high rates of concussion have become increasingly concerned about the long-term effects of multiple head injuries. In this context, return-to-play decisions about concussion generate considerable ethical tensions for sports physicians. Team doctors clearly have an obligation to the welfare of their patient (the injured athlete) but they also have an obligation to their employer (the team), whose primary interest is typically success through winning. At times, a team's interest in winning may not accord with the welfare of an injured player, particularly when it comes to decisions about returning to play after injury. Australia's two most popular professional football codes-rugby league and Australian Rules football-have adopted guidelines that prohibit concussed players from continuing to play on the same day. I suggest that conflicts of interest between doctors, patients, and teams may present a substantial obstacle to the proper adherence of concussion guidelines. Concussion management guidelines implemented by a sport's governing body do not necessarily remove or resolve conflicts of interest in the doctor-patient-team triad. The instigation of a concussion exclusion rule appears to add a fourth party to this triad (the National Rugby League or the Australian Football League). In some instances, when conflicts of interest among stakeholders are ignored or insufficiently managed, they may facilitate attempts at circumventing concussion management guidelines to the detriment of player welfare.