Exploring the Attitudes, Barriers, Concerns, Differences, and Ethics (ABCDEs) of Healthcare Decision Making of Vagus Nerve Stimulation

Vagus nerve stimulation (VNS) is an established neuromodulation therapy approved for treatment-resistant depression (TRD) and epilepsy, with growing interest in its application to other conditions. Despite demonstrated clinical efficacy, VNS remains underused in psychiatric care. This mixed-methods study examined stakeholder perceptions of VNS, focusing on access, stigma, ethical concerns, and acceptability across epilepsy, depression, heart failure (HF), and rheumatoid arthritis (RA). We conducted six focus groups and 20 semi-structured interviews with patients, clinicians, and one support person, and integrated qualitative themes with quantitative data on stigma and treatment barriers. Participants revealed stark disparities in VNS adoption: epilepsy patients reported fewer insurance barriers, while TRD participants faced delayed approvals, high out-of-pocket costs, and limited access to specialty care. Depression stakeholders reported higher stigma scores and expressed greater reluctance to consider surgical treatment, despite possessing comparable knowledge to epilepsy stakeholders. Ethical concerns, particularly regarding informed consent and impaired decision-making, surfaced frequently in the context of TRD. Most participants agreed that the appropriateness of VNS should align with disease severity and impact on quality of life. Many cautiously supported VNS for HF and RA, provided strong efficacy data supports its use. Hope emerged as a consistent theme, especially among TRD participants seeking alternatives after exhausting other treatments. These findings underscore the need to address insurance barriers, reduce stigma, and enhance provider education. As VNS expands into new indications, policymakers and clinicians must implement reforms that promote equitable access, decentralized care, and ethically sound consent practices to ensure inclusive neuromodulation therapy adoption.