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Psychiatrists should help improve awareness on ECT: Study

18 Apr 2022

  • Employing communication modalities and clearer explanations for patients, caregivers recommended to reduce stigma 
BY Ruwan Laknath Jayakody  Psychiatrists should take a lead role in improving the knowledge of patients and the general public regarding electroconvulsive therapy (ECT) through patient information sessions, newsletters, press releases and other communication modalities, as such will not only improve the awareness and attitudes of the patients, caregivers and the general public towards ECT, but also reduce the stigma attached to this effective mode of treatment, a 2019 study noted. The study, titled “Awareness and attitudes regarding ECT among patients and caregivers at a psychiatry unit in a tertiary care hospital in Sri Lanka”, and authored by T. Gunasekera, R. Fernando, M.U.P.K. Peris, K.A.L.A. Kuruppuarachchi, and A. Hapangama (all attached to the Kelaniya University’s Medical Faculty’s Psychiatry Department), was published in the Sri Lanka Journal of Psychiatry 11 (2) in December, 2020. Gunasekera et al. carried out a descriptive, cross-sectional study among all patients (excluding patients who were grossly psychotic or acutely manic, and participants who were acutely intoxicated) and their caregivers, above the age of 18 years, attending in-patient or out-patient psychiatric facilities of the Colombo North Teaching Hospital in Ragama. Data was gathered during February and March, 2019, via an interviewer-administered questionnaire. The questionnaire gathered information about the knowledge, misconceptions, concerns, and attitudes towards ECT among the study population.  Out of the total study population, 65% (i.e., 32% of caregivers and 33% of patients) were aware that ECT is a treatment modality used for psychiatric disorders. However, 24.4% were of the opinion that ECT is a treatment modality for malignancies, while 9% thought that it is a form of treatment used in rheumatology (conditions causing chronic, often intermittent pain, affecting the joints or connective tissue).  Of the study participants, 58% were of the opinion that ECT was utilised in managing violence in the absence of a mental illness, and 18.6% were of the view that it is being used to punish people. There was no statistical significance between the educational level and the awareness that ECT is a treatment modality for mental illnesses.  Out of those who were aware that ECT is a treatment for mental illnesses, 43.3% reported medical professionals as the main source of information, and for 43.4%, the source of information had been a relative, while in 10.4%, the information had been obtained from social media. When individual psychiatric disorders were considered, 43% were aware that ECT was used as an effective treatment modality for depressive illnesses (mood disorder that causes a persistent feeling of sadness and loss of interest), while the figures for schizophrenia (a chronic and severe mental disorder and illness involving psychosis, characterised by distortions in thinking, perception, emotions, language, sense of self, and behaviour, with hallucinations [hearing voices or seeing things that are not there] and delusions [fixed and false beliefs] being experienced) and puerperal (during or relating to the period of about six weeks after childbirth during which the mother's reproductive organs return to their original non-pregnant condition) psychiatric disorders were 26.7% and 19%, respectively. There was no significant difference regarding this knowledge between the caregivers and the patients.  In the study group, 24% were aware that ECT can be administered to women after childbirth, while 30% thought that it should not be administered to pregnant women at any stage of the pregnancy, and also that it should not be given to people above the age of 60 years. Of the participants, 5% thought that ECT does not have a scientific basis in treating psychiatric illnesses and 19.5% thought that it was an inhuman way of treating patients. And 12% were of the view that ECT was administered without general anaesthesia.  Furthermore, 15.8% feared that people who receive ECT at some point had a greater risk of developing a seizure disorder in the future, compared to a person who has not received ECT. With regard to these opinions, there was no statistical difference between the caregivers and the patients. Out of 120 patients in the study, 53% had received ECT in the past. However, 39.1% were not aware as to why they had been given ECT, and 34.4% were not aware about the procedure. In terms of awareness regarding any side effects of the treatment, 79% were not aware of any side effects of the treatment. Of the patients or the caregivers of the patients who had received ECT in the past, 68.8% were of the opinion that they were not adequately informed about the reason for ECT or the procedure. Among those who had received ECT in the past, headache (93.8%), body aches (75%), and short-term memory problems (68.6%) were reported as the commonest side effects. Of those who had received ECT, 84.2% believed that their mental illness would have worsened if ECT was not administered at that point in their illness, and 29.7% believed that they would have died if they had not received ECT. And 46.9% of those who had received ECT in the past were of the view that they would receive ECT again if recommended. Out of the 157 participants who did not have a past history of either being treated or having a relative being treated with ECT, 57% were aware that the patient was administered a general anaesthetic prior to receiving ECT, and 75.7% were aware that a small electric current was applied during the procedure. However, 90.1% were not aware that the patient may have a seizure during the procedure.  In this group where neither the patient nor the caregiver had received ECT in the past, only 10% were aware of the side effects of ECT and of those who knew about the side effects, 83% reported headache as a possible side effect, while 70% reported possible short-term memory problems and body aches as common side effects. Negative attitudes, such as ECT being used to punish or take revenge, and that ECT is an inhuman way of treatment, were significantly more common among those participants whose main source of information regarding ECT was the mass media (with no significant difference between the patients and the caregivers regarding these attitudes). Of all the participants, 45.6% were of the opinion that they would recommend ECT for any of their relatives or friends. In the study sample, more than half of the participants were aware of ECT as a treatment modality for psychiatric illnesses. Doctors were the commonest source of knowledge for the patients and their caregivers in this group. Gunasekera et al. pointed out that the fact that the study was conducted among a group of service users, rather than in the community, may have influenced this finding. No significant association was found between the participants’ awareness that ECT is being used as a treatment modality in psychiatric disorders and the participants’ educational attainment. However, the aforementioned Pakistani study reported that patients with a lower educational level were significantly more likely to have poor knowledge regarding ECT as a treatment modality. Gunasekera et al. explained that once again, the fact that the participants in the study were service users may have influenced the finding. About 43% of the study population were aware that ECT is a treatment modality for depressive illnesses. However, despite proven efficacy and being recommended by worldwide guidelines such as the National Institute for Health and Care Excellence (NICE) guidelines for the treatment of ante-natal as well as post-natal psychiatric disorders, almost two-thirds of the study population were of the view that ECT should not be used in any stage of the pregnancy, and half of the study population were of the view that ECT should not be used in the post-partum period. This, Gunasekera et al. observed, appears to be a common public misconception. A quarter of the study participants were of the opinion that ECT was indicated for malignancies, and a minority thought that it was used for rheumatological disorders. These findings, per Gunasekera et al., suggest that patients and caregivers either misidentify or misperceive ECT as radiotherapy or infrared therapy, which in turn may be due to the use of colloquial language among the general public to describe ECT in mental illnesses, as well as radiotherapy in malignancies and infrared therapy in rheumatological diseases, as the “administration of a current”, and therefore, indicates the need for clearer explanations for patients and caregivers. The cognitive side effects were the most feared among the participants of the study. Medical practitioners were the commonest source of information regarding ECT for the study population. The fact that the participants were either patients or caregivers in touch with the medical services, Gunasekera et al. add, may have influenced this finding. However, a significant proportion of the patients in the study group, who had been treated with ECT in the past, were of the opinion that they were not given adequate information by the treating team regarding the indication for ECT, its procedure, or the side effects. Negative attitudes (inhuman ways of treating patients, and being used as a punishment method) towards ECT were significantly more prominent among participants whose source of knowledge regarding ECT was through the mass media.  Some of the participants in this study were of the opinion that their mental illness would have worsened or that they would have died of it had they not received ECT. Just less than half of the patients in the study who had received ECT in the past said that they would be happy to receive it again if indicated. A limitation in Gunasekera et al.’s study is that the study participants were limited to those who were service users of a psychiatry unit, whereas the awareness level and attitudes of users of services of other disciplines in the hospital and the general public may differ from patients who use psychiatry services. In conclusion, Gunasekera et al. stated that the cohort of participants in this study appear to have a reasonably positive awareness and attitudes regarding ECT.


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