Perceived Barriers to Using Neurostimulation: A National Survey of Psychiatrists, Patients, Caregivers, and the General Public.

Objectives: Neurostimulation interventions often face heightened barriers limiting patient access. The objective of this study is to examine different stakeholders' perceived barriers to using different neurostimulation interventions for depression.

Methods: We administered national surveys with an embedded experiment to 4 nationwide samples of psychiatrists (n = 505), people diagnosed with depression (n = 1050), caregivers of people with depression (n = 1026), and members of the general public (n = 1022). We randomly assigned respondents to 1 of 8 conditions using a full factorial experimental design: 4 neurostimulation modalities (electroconvulsive therapy [ECT], repetitive transcranial magnetic stimulation [rTMS], deep brain stimulation [DBS], or adaptive brain implants [ABIs]) by 2 depression severity levels (moderate or severe). We asked participants to rank from a list what they perceived as the top 3 barriers to using their assigned intervention. We analyzed the data with analysis of variance and logistic regression.

Results: Nonclinicians most frequently reported "limited evidence of the treatment's effectiveness" and "lack of understanding of intervention" as their top 2 most important practical barriers to using ECT and TMS, respectively. Compared with nonclinicians, psychiatrists were more likely to identify "stigma about treatment" for ECT and "lack of insurance coverage" for TMS as the most important barriers.

Conclusions: Overall, psychiatrists' perceptions of the most important barriers to using neurostimulation interventions were significantly different than those of nonclinicians. Perceived barriers were significantly different for implantable DBS and ABI) versus nonimplantable (rTMS and ECT) neurostimulation interventions. Better understanding of how these barriers vary by neurostimulation and stakeholder group could help us address structural and attitudinal barriers to effective use of these interventions.