|Year : 2021 | Volume
| Issue : 2 | Page : 92-99
Knowledge about and attitude toward electroconvulsive therapy among those who agree and those who refuse electroconvulsive therapy treatment
Sandeep Grover, Natarajan Varadharajan, Subho Chakrabarti
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Submission||13-Dec-2020|
|Date of Decision||30-Dec-2020|
|Date of Acceptance||02-Jan-2021|
|Date of Web Publication||02-Feb-2022|
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
Background: Electroconvulsive therapy (ECT) is although one of the most effective treatments in psychiatry, and many a times patients refuse the same. Although, there is information about the knowledge about and attitude towards ECT among people who receive the same, little is known about these among those who refuse ECT. Aim: This study attempted to assess and compare the knowledge about and attitude toward ECT in patients with severe mental illness who accepted and refused ECT. Methodology: 68 patients divided into 3 groups (readily accepted; accepted, with initial reluctance; refused) based on the readiness for ECT were evaluated using ECT knowledge and attitude questionnaire. The higher proportion of those who refused had poor knowledge about the frequency of ECT sessions, investigations required before ECT and believed that ECT can be given against patient and family members' consent. Higher proportion of those who initially refused but later agreed believed that ECT can be given without the patient or family members'consent and it is given only to those patients who are unlikely to improve when compared to those who agreed ECT. Compared to those who agreed spontaneously, higher proportion of the participants in other two groups believed that ECT is not useful in the treatment of psychiatric disorders and they lacked knowledge about headache being a side effect of ECT. In terms of attitude toward ECT, higher proportion of those who refused ECT (n = 24; 89%) had a negative attitude in terms of not recommending the same for their relatives and were reluctant to receive ECT themselves. Conclusions: The results highlight that negative perception toward ECT in patients who refuse to receive ECT. Thus, it is essential to convey adequate information about ECT to enhance their understanding and acceptance.
Keywords: Attitude, electroconvulsive therapy, knowledge
|How to cite this article:|
Grover S, Varadharajan N, Chakrabarti S. Knowledge about and attitude toward electroconvulsive therapy among those who agree and those who refuse electroconvulsive therapy treatment. J Mental Health Hum Behav 2021;26:92-9
|How to cite this URL:|
Grover S, Varadharajan N, Chakrabarti S. Knowledge about and attitude toward electroconvulsive therapy among those who agree and those who refuse electroconvulsive therapy treatment. J Mental Health Hum Behav [serial online] 2021 [cited 2022 Sep 29];26:92-9. Available from: https://www.jmhhb.org/text.asp?2021/26/2/92/337168
| Introduction|| |
Electroconvulsive therapy (ECT) is one of the most effective treatments for many psychiatric disorders and is at times lifesaving.,,, However, despite evidence for its efficacy, the treatment is also associated with a lot of stigma and misunderstandings among the general public and due to this it is often not accepted readily by patients and their families.,, Many studies across the globe have evaluated the patients and their caregivers to understand their knowledge and attitude towards ECT.,, Most of these studies have focused on patients, who undergo the ECT procedure. These studies, in general, suggest that a significant proportion of the patients undergoing ECT are poorly informed about the ECT procedure and many a times, patients report that ECT was used with coercion., However, studies done by the users suggest that a significant proportion of patients are dissatisfied with various aspects of ECT procedure, the consent procedure, and information provided to them about the side effects of ECT.
In routine clinical practice, many patients and/or their caregivers refuse ECT. However, there is a lack of information about the knowledge and attitude of the patients and their caregivers who refuse ECT treatment. In this background, this study aimed to evaluate and compare the knowledge and attitude of patients who accepted the ECT treatment and those who refused the ECT treatment.
| Methodology|| |
This study was conducted in a tertiary care multispecialty hospital in North India. The study included both inpatients and outpatients. The study was approved by the Research and Ethics Committee of the Institute. The patients were recruited after they provided written informed consent.
To be included in the study, the participants were required to be suffering from a severe mental illness (Schizophrenia, Unipolar depression, Bipolar disorder) and were advised ECT by the treating team, aged ≥18 years and able to read Hindi. The patients were diagnosed with mental disorders as per the International Classification of Diseases, Tenth Revision criteria. Patients who were uncooperative, had difficulty in reading due to vision problems and those with significant cognitive deficits (as assessed on clinical interview) were excluded. Caregivers of all these patients were also assessed separately. Data of caregivers is not presented in this paper. Depending on the readiness for ECT, the patients were grouped into three groups, i.e., “readily accepted,” accepted, with initial reluctance (i.e., asked time to discuss with others) and refused. All the patients of the first two groups were evaluated before any kind of psychoeducation about ECT. Participants of the third group were evaluated after psychoeducation for the ECT.
Patients fulfilling the selection criteria were approached by a postgraduate trainee who was not part of the treatment team and he explained the aims and objectives of the study to the patients. Consenting patients were asked to complete the Hindi version of the Knowledge and attitudes questionnaires designed in India. The knowledge part of the questionnaire comprises 32 questions which cover various aspects of ECT such as the procedure, informed consent, efficacy/usefulness of ECT, and side effects of ECT. The first item of the knowledge part of the questionnaire also enquires about the primary source of information regarding ECT. Other items of the knowledge questionnaire have three options, one of which indicates correct knowledge; another option indicates lack of knowledge, and the third option “don't know,” which again suggested lack of knowledge. For understanding the level of knowledge all the correct responses to question number 2–32 were given a score “+1” and wrong responses or “don't know” responses were scored as “0.” Accordingly, the total knowledge score could vary from 0 to 31.
The attitude part of the questionnaire has 16 items which assesses the attitude towards ECT. Each item in attitude questionnaire has three responses-a response suggesting positive attitude, the second response indicating a negative response and a “don't know” response indicating neutral attitude. For calculating the total attitude score, the positive attitude response was rated as “+1,” negative attitude was rated as “-1” and the neutral response was rated as “0”. Accordingly, the total attitude score could vary from −16 to 16.
These questionnaires were provided to the patients in the Hindi language, to reduce the bias of administration of the questionnaire, where the patient may end up giving some socially desirable answers.
Data were analyzed using the Statistical Package for the Social Sciences, 20 version (SPSS) (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.). Frequency and percentages were computed for the categorical variables. Means and standard deviations were computed for the continuous variables. ANOVA, Chi-square tests, t-test, Mann–Whitney U test, and Kruskal–Wallis tests were used to compare the different groups. For the ease of analysis and interpretation, “don't know” and “negative” responses were combined as both signified that they were unaware about the procedure or had negative attitude.
| Results|| |
Profile of patients
The study included 68 patients who were approached for possible treatment with ECT. Of these, 33 accepted the treatment without any hesitation, 8 patients initially refused but later agreed after getting more details about the procedure and 27 patients refused ECT even after the psychoeducation. There was no significant difference in the sociodemographic profile between the 3 groups in patients [Table 1]. However, when those who accepted (at the first instance or after psychoeducation) were compared with those who refused, it was seen that those who accepted had higher income [Table 1].
Clinical profile of the study sample
[Table 2] shows the clinical profile of all three groups of patients. Those who refused ECT more often had comorbid psychiatric disorders, were more often not receiving any mood stabilisers and were more often receiving sedatives in the form of benzodiazepines [Table 2].
Source of information about electroconvulsive therapy
For most of the patients, the most common source of information was the explanation by a psychiatrist/doctor and there was no significant difference between the three groups.
Knowledge about electroconvulsive therapy
In general, the three groups did not differ significantly from each other on various aspects of knowledge about ECT, except that a higher proportion of those who refused ECT, had poor knowledge about the frequency of ECTs per week, need to undergo investigations before ECT, higher proportion of them believed that ECT can be given against the will of the patient and ECT can be given against the wishes of the family members [Table 3]. Those who agreed for ECT without any hesitation differed from those who initially refused but later agreed in terms of the fact that higher proportion of those who initially refused but later agreed believed that ECT can be given without the written permission of the patient or the family members. Those who initially refused but later agreed also differed from those agreed without any hesitation in terms of higher proportion of the earlier group believing that ECT is given only to those patients who have little chance to improve. Compared to those who agreed without any hesitation, higher proportion of the participants in the other two groups believed that ECT is not useful in the treatment of psychiatric disorders and higher proportion of them lacked knowledge about headache being a side effect of ECT [Supplement Table 1].
Attitude towards electroconvulsive therapy
In terms of attitude towards ECT, it was seen that higher proportion of those who refused ECT had negative attitude toward ECT in terms of not recommending the same for their relatives and were not prepared to receive ECT themselves. However, no other significant differences were observed [Table 4].
|Table 4: Frequency of positive attitude towards electroconvulsive therapy|
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| Discussion|| |
The present study involved assessment of patients for their knowledge and attitude toward ECT, after they were offered ECT treatment and provided information about the same but had not yet received ECT. The present study provides important insight into the fact that, although many patients agree to receive ECT, their knowledge and attitude towards ECT is not much different than those who refuse ECT, except for few minor differences. As is evident from the present study, a major proportion of the patients who agree for ECT are not aware about the use of anesthetic medications during the ECT procedure, number of ECTs required during an ECT course, site of application of current, need for investigations before ECT, duration for which the current is applied, how is current applied, that ECT cannot be given against the wishes of the patients, use of ECT is not limited to those who have little chance of improvement, ECT can be given to elderly, outpatients, young persons and pregnant ladies. Additionally, the majority of the patients in all the groups believed that ECT can worsen the psychiatric illness, were not aware of the mechanism by which ECT works, the effect of ECT is short lasting, ECT does not lead to permanent cure and were not aware about the evidence favoring the usefulness of ECT. In terms of side effects too the majority of the patients, who agree for ECT are also not aware about the side effects of ECT. When we compare our findings with an earlier study from India, which evaluated the knowledge and attitude of patients after receiving ECT, it is evident that the knowledge of our patients was much lower than that reported in the earlier study. The knowledge of patients of the present sample was also lower than that reported by another study from India. Poor knowledge in our study could be either a true reflection of poor knowledge of the patients or it could be due to the methodological differences. Compared to the present study, the earlier study, from North India, evaluated the patients after about 2 weeks of the last ECT. It is quite possible that going through the whole course of ECT could have enhanced their knowledge about the procedure. Lack of difference in the knowledge between those who readily agreed, those who initially refused, and later agreed and those who maintained refusal for majority of the aspect of ECT, suggests that knowledge about the procedure is not the only determinant of agreeing to or refusing treatment. It is quite possible that many patients who agree for ECT may do so, either due to the feeling of coercion or may agree due to lack of assertiveness. Hence, it is important that future studies evaluating the knowledge and attitude of patients toward ECT, should also assess these variable.
The knowledge variables, for which, those who refused ECT, were found to be much more deficient that those who agreed for ECT included lack of knowledge about the frequency of ECTs per week, need to undergo investigations before ECT and lack of knowledge about the need for consent from the patients and/or family members. Further, compared to those who agreed for ECT without any hesitation, higher proportion of the participants in the other two groups believed that ECT is not useful in the treatment of psychiatric disorders and higher proportion of them lacked knowledge about headache being a side effect of ECT. These findings suggest that there is a need to improve the consent procedure, impart knowledge about the efficacy and side effects of ECT to all the patients approached for ECT. These findings possibly support the findings of user-led studies which suggest higher level of dissatisfaction of the patients with consent procedure, feeling coerced for receiving ECT and are not provided adequate knowledge about the side effects of ECT.
As with knowledge about ECT, the majority of the patients in all the groups had negative or ambivalent attitude toward ECT. Among those who agreed for ECT, the maximum percentage for positive attitude on any one item was only 45.5%. Again, when we compare the findings with the previous study from India, which evaluated the attitude after the ECT procedure, the present study suggests significantly higher prevalence of negative or ambivalent attitude toward ECT among the patients with mental disorders. In terms of attitude toward ECT, it was seen that higher proportion of those who refused ECT had negative attitude toward ECT in terms of not recommending the same for their relatives and were not prepared to receive ECT themselves. This finding is obvious by the fact that they refused ECT.
Taken together, the present study suggests that, if the patients are evaluated before ECT procedure, in general, they have poor knowledge and negative attitude towards ECT. Further, apparent agreement to receive does not mean that the patients have full knowledge about ECT. Neither agreement for ECT reflects that they do not have negative attitude toward ECT. Hence, all efforts must be made to develop an intervention package for patients considered for ECT, to address their deficits in knowledge about ECT and address their negative attitude toward ECT.
The present study has certain limitations. The sample size of the study was relatively small. The assessment was cross-sectional in nature and the investigators had no control over the information provided to the patients before they agreed or refused for ECT treatment. Future studies with larger sample should attempt to overcome these limitations.
| Conclusions|| |
To conclude, the present study suggests that if the patients are assessed for knowledge about and attitude towards ECT, just before ECT, in general, they have poor knowledge about and high proportion of them have negative attitude toward ECT. The knowledge and attitude do not differ on the majority of accounts among those who agree and who refuse ECT.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Fink M. ECT has much to offer our patients: It should not be ignored. World J Biol Psychiatry 2001;2:1-8.
Baghai TC, Möller HJ. Electroconvulsive therapy and its different indications. Dialogues Clin Neurosci 2008;10:105-17.
UK ECT Review Group. Efficacy and safety of electroconvulsive therapy in depressive disorders: A systematic review and meta-analysis. Lancet 2003;361:799-808.
Versiani M, Cheniaux E, Landeira-Fernandez J. Efficacy and safety of electroconvulsive therapy in the treatment of bipolar disorder: A systematic review. J ECT 2011;27:153-64.
Leiknes KA, Jarosh-von Schweder L, Høie B. Contemporary use and practice of electroconvulsive therapy worldwide. Brain Behav 2012;2:283-344.
Payne NA, Prudic J. Electroconvulsive therapy: Part II: A biopsychosocial perspective. J Psychiatr Pract 2009;15:369-90.
Dowman J, Patel A, Rajput K. Electroconvulsive therapy: Attitudes and misconceptions. J ECT 2005;21:84-7.
Griffiths C, O'Neill-Kerr A. Patients', carers', and the public's perspectives on electroconvulsive therapy. Front Psychiatry 2019;10:304.
Bustin J, Rapoport MJ, Krishna M, Matusevich D, Finkelsztein C, Strejilevich S, et al.
Are patients' attitudes towards and knowledge of electroconvulsive therapy transcultural? A multi-national pilot study. Int J Geriatr Psychiatry 2008;23:497-503.
Chakrabarti S, Grover S, Rajagopal R. Electroconvulsive therapy: A review of knowledge, experience and attitudes of patients concerning the treatment. World J Biol Psychiatry 2010;11:525-37.
Chakrabarti S, Grover S, Rajagopal R. Perceptions and awareness of electroconvulsive therapy among patients and their families: A review of the research from developing countries. J ECT 2010;26:317-22.
Rose D, Fleischmann P, Wykes T, Leese M, Bindman J. Patients' perspectives on electroconvulsive therapy: Systematic review. BMJ 2003;326:1363.
Rajagopal R, Chakrabarti S, Grover S, Khehra N. Knowledge, experience and attitudes concerning electroconvulsive therapy among patients and their relatives. Indian J Med Res 2012;135:201-10.
] [Full text]
Dan A, Grover S, Chakrabarti S. Knowledge and attitude of patients with psychiatric disorders and their relatives toward electroconvulsive therapy. Indian J Psychol Med 2014;36:264-9.
] [Full text]
Rose DS, Wykes TH, Bindman JP, Fleischmann PS. Information, consent and perceived coercion: Patients' perspectives on electroconvulsive therapy. Br J Psychiatry 2005;186:54-9.
[Table 1], [Table 2], [Table 3], [Table 4]