Clinical Perspectives on Psychiatric Neurosurgery.

INTRODUCTION: Surgical interventions such as stereotactic radiosurgery and magnetic resonance-guided focused ultrasound, and neuromodulatory interventions such as deep brain stimulation (DBS) and vagal nerve stimulation, are under investigation to remediate psychiatric conditions resistant to conventional therapies involving drugs and psychological supports. OBJECTIVE: Given the complicated history of psychiatric neurosurgery and its renaissance today, we sought to examine current perceptions and predictions about the field among practicing functional neurosurgeons. METHODS: We designed a 51-question online survey comprising Likert-type, multiple-choice, and rank-order questions and distributed it to members of the American Society for Stereotactic and Functional Neurosurgery (ASSFN). Descriptive and inferential statistical analyses were performed on the data. RESULTS: We received 38 completed surveys. Half (n = 19) of responders reported devoting at least a portion of their clinical practice to psychiatric neurosurgery, utilizing DBS and treating obsessive compulsive disorder (OCD) most frequently overall. Respondents indicated that psychiatric neurosurgery is more medically effective (OR 0, p = 0.03242, two-sided Fisher's exact test) and has clearer clinical indications for the treatment of OCD than for the treatment of depression (OR 0.09775, p = 0.005137, two-sided Fisher's exact test). Seventy-one percent of all respondents (n = 27) supported the clinical utility of ablative surgery in modern neuropsychiatric practice, 87% (n = 33) agreed that ablative procedures constitute a valid treatment alternative to DBS for some patients, and 61% (n = 23) agreed that ablative surgery may be an acceptable treatment option for patients who are unlikely to comply with postoperative care. CONCLUSIONS: This up-to-date account of practices, perceptions, and predictions about psychiatric neurosurgery contributes to the knowledge about evolving attitudes over time and informs priorities for education and further surgical innovation on the psychiatric neurosurgery landscape.

Neurologists' Attitudes Toward Use and Timing of Deep Brain Stimulation.

OBJECTIVE: We sought to explore current perspectives and attitudes of general neurologists and movement disorder specialists toward deep brain stimulation (DBS) for Parkinson disease (PD), focusing on perspectives on its earlier use in the clinical course of the disease. METHODS: We designed a 30-question online survey comprised of Likert-type, multiple choice, and rank-order questions, which was distributed to 932 neurologist members of the American Academy of Neurology. We analyzed clinicians' sociodemographic information, treatment patterns used for patients with PD, reasons for and against patient referral for DBS, and general attitudes toward DBS. Data were analyzed using descriptive and inferential statistics. RESULTS: We received 164/930 completed surveys (completion rate of 18%). Overall, most respondents agreed that DBS was more useful after the appearance of motor complications and that DBS utilization offered better management of PD than medication alone. However, respondents were divided on issues like minimum duration of disease needed to consider DBS as a treatment option and timing of DBS referral relative to disease progression. Specifically, differences between movement disorder specialists and general neurologists were seen in medication management of symptoms and dyskinesia. CONCLUSIONS: There remains a lack of consensus on several aspects of DBS, including medical management before offering DBS and the appropriate timing of its consideration for patients. Given the effect of such lack of consensus on patients' outcomes and recent evidence on positive DBS results, it is essential to update DBS professional guidelines with a focus on medical management and the timely use of DBS.

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

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