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No Easy Answers in Bioethics Podcast

Public Perception of Psychiatric Interventions: Cabrera, Bluhm, and McKenzie - Episode 5

January 11, 2018 Laura Cabrera photo Robyn Bluhm photoRachel McKenzie photo

This episode features Dr. Laura Cabrera, Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Translational Science & Molecular Medicine, Dr. Robyn Bluhm, Associate Professor in the Philosophy Department and Lyman Briggs College, and undergraduate research assistant Rachel McKenzie. Together at Michigan State University they have collaborated on research regarding psychiatric interventions, including pharmacological interventions as well as neurosurgery, like deep brain stimulation. In this episode they share some highlights from their internally-funded Science and Society at State project, which focused on the public perceptions of such psychiatric interventions.

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This episode was produced and edited by Liz McDaniel in the Center for Ethics. Music: "While We Walk (2004)" by Antony Raijekov via Free Music Archive, licensed under a Attribution-NonCommercial-ShareAlike License.

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Episode Transcript

Liz McDaniel: Hello and welcome to another episode of No Easy Answers in Bioethics, the podcast from the Center for Ethics and Humanities in the Life Sciences at the Michigan State University College of Human Medicine. Today’s guests are Center Assistant Professor Dr. Laura Cabrera, Dr. Robyn Bluhm of the Philosophy Department and Lyman Briggs College, and undergraduate research assistant Rachel McKenzie. Together they have collaborated on research regarding psychiatric interventions, including pharmacological interventions as well as neurosurgery, like deep brain stimulation. In this episode they share some highlights from their internally-funded project, which focused on the public perceptions of such psychiatric interventions.

Laura Cabrera: Hi! Hello I am Dr. Laura Cabrera and I am an Assistant Professor in neuroethics at the Center for Ethics and Humanities in the Life Sciences.

Robyn Bluhm: And I'm Robyn Bluhm. I'm an Associate Professor in the Department of Philosophy in Lyman Briggs College here at MSU.

Rachel McKenzie: I'm Rachel McKenzie. I'm a senior studying neuroscience.

LC: And we are here today to share with you exciting highlights from our ongoing research collaboration. So it all started at the end of 2015, when Dr. Bluhm and I got our Science and Society at State, also known as S3, internal grant here at MSU. And the grant or that project was looking at two psychiatric interventions. So we focused on psychopharmacology, and we focused on psychiatric neurosurgery. And we were looking in particular at issues of values and public attitudes around these interventions, both in the academic setting and in the general public. Now this was a perfect collaboration in a way, because Robyn has been interested in doing research in areas connected to RDoC and diagnosis of mental health. And I’ve been doing research in neuroethics, so this was a great way to combine our interests and expertise. And then the other big reason why we decided to focus on this, was because psychiatry in a way deals or rather raises a lot of ethical issues. So if you think about what is a psychiatric disorder? In general involves maladaptations related to mood, behavior, cognition and perceptions. And then who decides what is a psychiatric disorder, or when you see that a maladaptation is so concerning that it becomes a disorder and not just something that we can you know deal with and live with as a society. So just think of homosexuality a few years ago when it was considered a mental health disorder.

RB: Yeah and I mean one of the things about getting the S3 grant that was really nice is the grants are meant to support new collaborations. Particularly interdisciplinary collaborations, but it was also the first year for both of us at MSU so it was really nice to get a chance to meet each other and find that we had things in common. And then to get some support for getting a collaboration off the ground. So I'm actually going to talk a little bit about what we did in the year that we had S3 funding. First and most important we hired Rachel which has probably been the best decision that we've made about any collaborating. So once Rachel started working with us we did a literature review to identify articles in the medical and bioethics literature on the one hand and then in the media on the other hand and we developed a tool to code these articles to see what different issues were being raised. So we compared not just the academic professional academic literature but we, looking at the media stories wanting to get a sense of how the public felt about psychiatric interventions. So we coded, using the same tool, comments on media stories in newspapers and magazines online. That took a long time and we are still analyzing and writing up the data. So that was a large chunk of what we did during that year. And then the other thing that we did was we organized a one day workshop and this was in the fall of 2016, to bring together potential future collaborators and people with an interest in the topic, to present some of our pilot data and get feedback from them. So we included scholars and graduate students from the health sciences, the social sciences, humanities, medicine, and ended up having a really rich and productive discussion. We're going to talk a little bit next about three of the papers that came out of this pilot project.

LC: So the first paper was looking at the professional literature. And that was because that was the first data set that we finished coding. And there were some results that we expected but there were some that we just, we didn’t, which that’s what is nice about empirical research. So to start the technology that, the technologies that were discussed or the interventions. So if we look at the psychopharmacology literature. Things like Prozac, so antidepressants, or stimulants like Ritalin would be the two type of interventions that will be discussed the most. In the case of psychiatric neurosurgery, deep brain stimulation was by far the most discussed intervention.

RB: That was really interesting too because before we started working together I had no idea what deep brain stimulation was.

LC: Yeah. And that even though I've been looking at deep brain stimulation, this was the first time that I look at it from like a mental health, as used in mental health. Now for it those of you in the audience that might not know too much about what deep brain stimulation is. So deep brain stimulation is relatively new psychiatric neurosurgery intervention that has a long history, but the new form is recent, and is widely used in movement disorder such as Parkinson or Dystonia. And now it is mostly investigational for psychiatric disorders, even though it has a humanitarian device exemption for obsessive compulsive disorder. And what it, it’s basically two electrodes or one electrode implanted in deep nuclei in the brain, and it has a brain pacemaker or like a battery and that's why some people talk about deep brain stimulation as being a brain pacemaker. So kind of an analogy to a brain um, to a heart pacemaker. Okay so that was a technology that was discussed the most. Now, another thing that was interesting to see from that data set was a type of advantages and disadvantages that were discussed. Percentally the neurosurgical literature had more discussion of both advantages and disadvantages and this would go from, in terms of advantages, it would be related to the reversibility and adjustability of the device of deep brain stimulation. And in terms of the disadvantages it would be related to the invasiveness of the procedures – you know it requires brain surgery. And then also connected to the issues of direct modification of the brain. Now there were two issues there were widely discussed in articles on the pharmaceutical interventions but that there were somehow neglected in the neurosurgical articles and that had to do with issues of medical professionalism and industry involvement. So in a way, what we thought and what we discussed mostly in the paper is: are there things that we can learn from the big and rich literature on conflicts of interest within the pharmaceutical industry that can be adapted to medical devices conflicts of interest, and where are new areas that need to be addressed differently that are in a sense unique to the medical device industry.

RM: So another paper of ours that's currently a work in progress will be focusing specifically on public comments. After identifying the ethical issues present in these comments our further analysis showed that there were a few concerns that were interrelated or often discuss together. The most prominent concerns had to do with aspects of medicalization, and the use of alternative treatments to the drugs and surgeries that we were focusing on in our analysis. Of particular interest were the issues of overprescribing and what actually counts as a mental health disorder. The issues with over-medicalization were understandably coupled with suggestions for treatments that didn't involve substantial risk. Sometimes different pharmaceuticals, but primarily therapy. Over-medicalization and desires for alternative treatments were often discussed alongside medical profession issues. Primarily mistrust of doctors and scientists and questioning whether the doctors really knew enough about the treatments and procedures they were prescribing. So far these [comments] have shown an interesting perspective on these questions. They have the potential to tell us more about how the understanding and opinions on longstanding research methods and prescribing practices are impacting how the public feels about new treatment options, as well as how they're talking with their doctors.

RB: Rachel you're the one who’s been doing the most work on that part of our project for so far, so I'm really looking forward to seeing what comes up. I remember when we were coding seeing a lot of these issues, but kind of getting a sense of what the big picture is is going to be a lot of fun. I actually asked Rachel and Laura whether I could talk about this third paper because as a philosopher it's a topic that's nearest and dearest to my heart. There's a lot of discussion in the philosophical and bioethics literature about whether deep brain stimulation actually threatens people's personal identity. So as Laura described deep brain stimulation involves implanting an electrode in somebody’s brain that then essentially governs their brain activity. And there are some cases that have been reported where individuals who've undergone deep brain stimulation have started to act in ways that are not, that are new, that didn't occur before the surgery so there's been a couple of case reports of people who have done things like develop a gambling habit, or experienced bouts of mania when they had never had that issue before. So from a philosophical perspective the question is: is the electrode actually making them a completely different person. And one of the things that I think is really interesting about this is, in our data set in the academic literature, we saw all kinds of discussion about this in the neurosurgical literature especially focusing on D.B.S., but almost nothing in the pharmacological literature even though obviously drugs also influence the brain. And I'm wondering whether this is in part because the electrode is perceived as being more permanent than the drugs, even though it is not necessarily always switched on. Or whether because patients have to keep taking medications, whereas once the implant is in there it's sort of perceived as being outside of the patient's control. Whether these are some of the reasons this seems like so much more of an issue in the case of D.B.S. than it does in the case of pharmacological therapy.

LC: Although, I mean it’s interesting now that you mention it that in the pharma literature there's a lot of discussion especially with Prozac about changes to self.

RB: Right.

LC: Whereas in the neurosurgery it's more about identity and personality.

RB: Yeah, and in the pharma literature as well a lot of it is in the discussion of enhancement, so people deliberately trying to change themselves. Whereas with deep brain stimulation it's viewed as being sort of a side effect of the procedure and therefore not something that's welcome or wanted.
Another interesting thing about this is that we didn't see any discussion of these philosophical issues, like personal identity or agency, in the public discussion. Instead what we saw was a lot of discussions about personal responsibility, which we saw especially in the pharmaceutical literature and which we saw in the pharmaceutical literature written by academics as well, and I’ll talk a bit more about that in a second. The public did actually, in the context of talking about neural implants, people talked about mind control, but it seemed to be more of a political concern. So people would say things like, I wouldn't want an electrode in my brain because then Big Brother will know what I'm thinking, or Big Brother can make me do what the government wants. So it wasn't really seen as a medical function. And I think a lot of those comments were actually sort of at least partly joking, but I also think that they reflect sort of a deeper underlying concern about loss of control. So I think it'll be interesting to get into that.
And then also with that paper I had mentioned that personal responsibility comes up a lot in both the academic literature and the public comments. But almost entirely in the discussion of pharmaceutical interventions so people are very concerned that instead of taking medications people should be taking responsibility for their condition, by doing things like changing their diet, or exercising, or going to some form of talk therapy. Or at the very least even if they're going to take medication that they should be doing these other things as well. So we're still sort of wading our way through that part of the data but there are some really interesting issues that are coming up.

LC: Well now, we've been collaborating for almost two years and so now I would like to ask Rachel what has been her experience and if you have liked it so far?

RM: Yeah. So when I, before I applied to be a research assistant, I assumed that neuroscience research was just sitting in a lab and looking through a microscope. I wasn't expecting to be a part of a project that focused on the implications of research in new treatments. And the ethical perspectives and the focus on public opinion that I’ve learned from being a part of this project helped me see new dimensions in my neuroscience courses, and it also helped me a refine my research interests, my goals for after my undergraduate education. So I could focus on science communication and science in society.

RB: And actually I just feel like I need to interject here that you know as a Briggs student you are seeing this in some of your classes but it's really awesome that you're getting a chance to really engage in the hands-on not lab related no microscope research. And just also to say again how wonderful it's been to work with you.

LC: Yeah Rachel has been a really bright student collaborator so. And so the other thing that we want to share with you is that our collaboration has not only yield you know papers and posters and presentations. But it has also allows us to have the pilot data to submit our first NIH, National Institute of Health grant. This was, we were lucky in a way, because last year they released the first call for grants specifically looking at neuroethics. So once that was released I said to Robyn, we have to give it a shot. We cannot lose this opportunity and fortunately she agreed that yes we should do this. And so now we submitted our grant last week and as we continue finalizing the publication of the papers that are still a work in progress we will be doing that with the hope that we'll have good news in a couple more months.

RB: Right and that in a couple more years we'll be doing another podcast on that research.

LC: Exactly. Well thank you for listening.

LM: Thank you for joining us today. Please visit us online at bioethics.msu.edu, and follow us on Twitter @MSUbioethics. This episode of No Easy Answers in Bioethics was produced and edited by Liz McDaniel.