Glossary
Major Depressive Disorder (MDD)
A common and serious mood disorder characterized by persistent feelings of sadness and hopelessness. Antidepressants are generally recommended as first-line treatment of mild to moderate MDD [1], although other guidelines recommend psychotherapy and exercise for mild or subclinical depression [2]. However, only 36.8% of MDD patients achieve remission with the first antidepressant medication [3], and only 70% of MDD patients achieve remission after 4 treatments [4]. This leaves about 30% of MDD patients in the US in need of an alternative regime for managing their depression.
Treatment-Resistant Depression (TRD)
A form of depression that has not responded well to first-line treatments like pharmaceuticals and psychotherapy. TRD is associated with reduced quality of life [5], as well as increased morbidity [6] and economic burden [7,8].
Stigma
Refers to enduring, negative social beliefs and attitudes about an object (i.e., group, organization, or thing) that are resistant to change. Stigma involves unwarranted and unfair judgements of some mental, social, or physical deficiency that disgrace or stain the object’s social reputation. We focus not only on stigma associated with using PEIs to treat depression but also on stigma associated with having depression.
Psychiatric Electroceutical Interventions (PEIs)
Psychiatric electroceutical interventions are therapies that use electrical stimulation to treat psychiatric conditions. These include FDA-approved therapies like electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS), vagal nerve stimulation (VNS), and experimental technologies like deep brain stimulation (DBS) and adaptive brain implants (ABIs). These procedures work by administering an electric current to the brain to elicit a therapeutic effect.
Electroconvulsive therapy (ECT)
An approved US Food and Drug Administration (FDA) treatment for major depressive disorder that has not responded well to other types of therapies (aka, “treatment-resistant” depression). It is also FDA-approved for treating bipolar disorder. During ECT, which is often administered in general hospital psychiatric units and in psychiatric hospitals, patients are given a muscle relaxer and are then put to sleep under general anesthesia. An ECT-trained psychiatrist places electrodes on the patient’s scalp, and electrical current is used to initiate a seizure, which lasts for about a minute. This electrical current delivers the therapeutic effect. Patients usually receive ECT 2-3 times a week for a total of 9-18 treatments. ECT is estimated to produce substantial improvement in depression symptoms for 80% of patients.
Transcranial magnetic stimulation (rTMS)
An approved US Food and Drug Administration (FDA) treatment for major depressive disorder that has not responded well to other types of therapies (aka, “treatment-resistant” depression). It is also FDA-approved for treating pain associated with certain migraine headaches. During a rTMS session, which is often administered in an outpatient setting, a rTMS-certified physician places an electromagnetic coil against the patient’s scalp. This coil delivers repetitive magnetic pulses into areas of the brain associated with mood control, activating regions of the brain that have decreased activity in people with depression. Treatment sessions, which vary in length depending on the rTMS coil used and the number of pulses delivered, typically last around 30-40 minutes. A typical course of rTMS is done 5 times a week for 4-6 weeks. However, this can vary depending on an individual’s response to treatment. rTMS requires neither surgery nor sedation, and it does not cause seizures.
Deep Brain Stimulation (DBS)
Not yet been approved by the US Food and Drug Administration (FDA) for the treatment of major depressive disorder. However, there currently are ongoing clinical trials to test whether it is effective for depression that has not responded well to other types of therapies (aka, “treatment-resistant” depression). DBS is FDA-approved for treating essential tremor, Parkinson’s disease, obsessive-compulsive disorder, and epilepsy. DBS involves the surgical implantation of electrodes into the brain by a neurosurgeon. These electrodes are connected to a small battery-powered device implanted under the skin of the upper chest. The device delivers electrical stimulation to the brain through the electrodes. DBS therapy may help restore normal activity in brain circuits that are not working properly, acting like a “pacemaker” for the brain. The amount and frequency of the stimulation are customized to the individual patient. Current evidence is inconclusive regarding the efficacy of DBS for depression.
Adaptive Brain Implants (ABIs)
A newer form of deep brain stimulation (DBS), have not yet been approved by the US Food and Drug Administration (FDA) for the treatment of major depressive disorder. However, there is ongoing discussion regarding its potential use as a treatment for depression that has not responded well to other types of therapies. ABIs have been used for treating epilepsy and are currently undergoing clinical trials for treating Parkinson’s disease. Similar to DBS, the procedure involves the surgical implantation of electrodes in the brain by a neurosurgeon. These electrodes are connected to a small battery-powered device implanted under the skin of the upper chest. The device delivers electrical stimulation to the brain through the electrodes. Like traditional DBS, ABIs may help restore normal activity in brain circuits that are not working properly, acting like a “pacemaker” for the brain. Yet, unlike traditional DBS, which delivers constant stimulation to a part of the brain, ABIs vary the amount of stimulation they deliver in response to the patient’s brain activity. By automatically adjusting the electrical stimulation delivered, future ABIs have the potential to reduce side effects currently seen in DBS.
Psychiatrists
Psychiatrists recruited for this study are board-certified clinicians, most of whom have had at least some experience with and/or interest in neuromodulation techniques.
Patients
Patients recruited for this study are adults in the general public who reported a prior diagnosis of clinical depression (MDD). They were not required to have experience with PEIs to participate.
Caregivers
Caregivers recruited for this study are adults in the general public with at least moderate experience caregiving for a family member or a close friend with clinical depression.
Public
Members of the general public recruited for this study are adults in the general population with no diagnosed psychiatric disorder or caregiving experience.
Experience with Caregiving
Refers to adults’ prior engagement helping and supporting a family member or close friend diagnosed with depression. We defined “care” as helping them with daily activities, driving them to appointments, offering emotional or financial support, preparing meals, etc.
Experience with PEI
Refers to participants’ prior engagement with PEIs. We measured non-clinicians’ level of awareness of PEIs. In addition, we asked patients if they had previously used PEIs. We asked psychiatrists about the extent to which they have referred patients for PEIs or directly administered the PEIs to patients.
Affect
Refers to participants’ immediate emotional response to their presented PEI, which we measured along a continuum of negative to positive attributes.
Perceived Barriers
Refers to participants’ assessment of the potential obstacles that may partially impede or completely prevent the use of their presented PEI. We consider two types of barriers.
Structural barriers are bureaucratic, economic, or infrastructural factors associated with health services, including availability of services, administrative challenges, limited resources, cost of equipment, and referral patterns by psychiatrists and other clinicians.
Attitudinal barriers are beliefs, attitudes, or emotions that inhibit seeking help and treatment—such as stigma, fear of treatment, negative health beliefs (e.g., concerns about memory loss), misinterpretations or uncertainty about treatment consequences, and perceived ethical issues.
Perceived Benefits
Refers to participants’ assessment of the likely positive impacts of using their presented PEI or the likely comparative advantage of using their presented PEI relative to another option (e.g., quicker results, safer, more easily adjustable).
Perceived Effects on Self
Refers to participants’ assessment of how much their presented PEI negatively or positively influences key aspects of their sense of self (e.g., their personality, independence, self-control, and free will).
Perceived Ethical Concerns
Refers to participants’ assessment of how fundamental principles of rights, fairness, and justice are upheld with the use of their presented PEI. Such concerns include the safety and effectiveness of treatments, the sufficiency of informed consent, and the invasiveness of the treatment.
Perceived Invasiveness
Refers to participants’ assessment of how much their presented PEI intrudes upon them physically, cognitively, psychologically, and socially and otherwise interferes with their daily life.
Perceived Risks
Refers to participants’ assessment of the likely negative consequences of using their assigned PEI (e.g., injury, dependence, psychological harm, and social stigma).
WHAT ARE SOME OTHER TREATMENTS FOR DEPRESSION?
Antidepressants
A class of medication that have been approved by the US Food and Drug Administration (FDA) for the treatment of depression. It usually takes 4-6 weeks for this medication to take effect, but some patients start to feel relief from symptoms in as little as one week. Antidepressants work by altering the levels of brain chemicals, or by making the chemicals more easily available for the brain to use.
Psychotherapy
Also known as talk therapy, is a series of directed conversations between patients and therapists to help control symptoms of depression and other psychiatric conditions. A psychotherapy session can be between 30-50 minutes long, and the number of sessions needed per week vary depending on the therapist and the condition being treated. There are several different types of psychotherapy. To get the most out of therapy, the patient must be cooperative, open, and honest with their therapist. Patients may need to try out psychotherapy with several different therapists before finding one they trust, and one they feel suits their needs. Psychotherapy can be, and often is, combined with other treatments for depression. While psychotherapy does not physically affect a patient, it can have emotional side effects.
Vagal Nerve Stimulation (VNS)
An approved US Food and Drug Administration (FDA) treatment for major depressive disorder that has not responded well to other types of therapies (aka, “treatment-resistant” depression). VNS involves the surgical implantation of a device by a neurosurgeon. The procedure takes about 45-90 minutes and is usually performed under anesthesia. This surgery does not involve the brain. Rather, the neurosurgeon makes two small incisions: one on the upper left side of the chest (where a battery-powered stimulator is implanted) and one on the left side of the lower neck (where thin, flexible wires are inserted to connect the stimulator to the vagus nerve). The neurospecialist programs the simulator to deliver an electrical pulse at a certain strength and duration. Patients are then given a handheld magnet that allows them to control the stimulator at home.