|Year : 2020 | Volume
| Issue : 2 | Page : 100-106
Electroconvulsive Therapy: Knowledge and Attitudes Among Medical Interns and the General Public
Bilal Ahmad Bhat, Shabir Ahmad Dar, Arshad Hussain, Rouf Ahmad Mir
Department of Psychiatry, Government Medical College, Srinagar, Jammu and Kashmir, India
|Date of Submission||31-Jan-2020|
|Date of Decision||23-Mar-2020|
|Date of Acceptance||07-May-2020|
|Date of Web Publication||29-Aug-2020|
Bilal Ahmad Bhat
Government Psychiatric Disease Hospital, Srinagar, Kathi Darwaza 190003, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Background: Negative view of electroconvulsive therapy (ECT) is held not only by the general public, but also by the medical professionals. Aims: Aims were to assess the knowledge of ECT and attitude toward it in medical interns and general public. Materials and Method: This was a cross-sectional study in which knowledge of ECT and attitude toward this treatment were assessed in medical interns and general public using ECT knowledge and attitude questionnaire. A total of 36 participants from each group were included in the study. Results: Among the medical interns 75% reported the source of information as medical books whereas in general public 88.9% reported the primary source of information as media. Our participants from both groups were more knowledgeable about the consent, side effects, and procedure part of the questionnaire compared to other parts of it. The mean score for knowledge questionnaire was 16.58 ± 4.78 and 9.94 ± 4.82 for medical interns and general public respectively (t = 3.74; P = 0.001). The mean score on attitude questionnaire was 9.94 ± 4.82 and 0.83 ± 8.56 for medical interns and general public, respectively (t = 5.56; P = 0.0001). In both medical interns and general public, total score on knowledge questionnaire and total score on attitude questionnaire were correlated positively (rs = 0.542, P < 0.001 and rs = 0.446, P < 0.006 respectively). Conclusion: our study found a low knowledge of ECT in general public with less favorable attitude toward this treatment. With a good knowledge of ECT and more favorable attitude in medical students, still there are lacunae in them. However, in both these groups, there was a positive correlation between knowledge and favorable attitude.
Keywords: Attitude, electroconvulsive therapy, general public knowledge, medical interns
|How to cite this article:|
Bhat BA, Dar SA, Hussain A, Mir RA. Electroconvulsive Therapy: Knowledge and Attitudes Among Medical Interns and the General Public. MAMC J Med Sci 2020;6:100-6
|How to cite this URL:|
Bhat BA, Dar SA, Hussain A, Mir RA. Electroconvulsive Therapy: Knowledge and Attitudes Among Medical Interns and the General Public. MAMC J Med Sci [serial online] 2020 [cited 2020 Oct 23];6:100-6. Available from: https://www.mamcjms.in/text.asp?2020/6/2/100/293890
| Introduction|| |
Electroconvulsive therapy (ECT) has been a safe and effective treatment option for many years now for major psychiatric disorders, including major depression, bipolar affective disorder, and schizophrenia. It has been consistently shown that ECT is superior when compared with simulated ECT (anesthesia without electric stimulation), placebo (tablet), or antidepressant medications.,, Today, ECT has evolved into a modern procedure with a benign side effect profile, which is performed under anesthesia and the administration of muscle relaxants. Despite this, socially undesirable and negative attributes are still associated with it. In review of literature, the studies which have investigated general attitude toward ECT have found certain established misbeliefs, for example, that use of ECT leads to permanent loss of memory, that ECT results in permanent damage to brain, that ECT can damage other body-parts permanently, that most of patients receiving ECT develop epilepsy later, that patients fear conscious shocks and regard them as a barbaric, inhuman and compulsory treatment. Stigma associated with it is again a major hindrance to this treatment modality. This is further accentuated by media which portrays ECT inaccurately in movies as a form of cruel, inhuman, and harmful mode of treatment. Lack of knowledge and negative attitude towards ECT in general public also reinforces the negative connotations related to this treatment modality. There is lack of educational efforts from mental health professionals to inform the general public about advances in delivery of this treatment modality, which has allowed the negative view and its inaccurate portrayals to persist. With poor information about ECT, individuals are less likely to seek the help, if they need it. Worldwide, studies have shown the persistence of negative perception with regard to this treatment modality., Even people in developed countries have many misconceptions regarding this treatment modality. Good amount of research from both developed and developing countries has assessed the knowledge about ECT and attitude toward it among patients and their relatives, and evidence is suggestive of patients receiving ECT being poorly informed about it., Even medical students who were assessed for knowledge about and attitude toward ECT revealed inadequate knowledge and a negative bias toward ECT., Acceptance of ECT as a treatment is further influenced by social and cultural factors., Being a multicultural and metalinguistic country, the studies performed in other parts of India as well as in Western world may not apply to our society. Although a study was recently conducted to assess the knowledge about and attitude toward ECT in patients and their relatives from our hospital, the same have not been assessed in general public and medical students from here. Understanding what the general public knows about ECT and how they feel about it is very important. When general public is poorly informed about a mental health service, they are unlikely to accept that service. The present study was undertaken to assess the knowledge about and attitude toward ECT in general public and in medical interns. This will help us in recognizing the deficiencies in knowledge to be worked upon, so that the negative attitude toward this treatment gets corrected and it becomes a socially acceptable treatment.
| Materials and Method|| |
The study was carried out between May 1 and June 30, 2019. The study participants were adults from general public and medical interns. All the participants were explained the nature of our study. Informed consent was obtained from them. Approval from institute’s ethics committee was obtained. The sample of general public was taken at various public locations. Those who were health care workers, who had received ECT or had been an attendant to a patient who has received ECT, who had been psychiatric inpatient, who had never heard of ECT or had no opinion about ECT, and who couldn’t read and understand the questionnaire were excluded. Medical interns who came to psychiatry department for their compulsory rotatory internship during the study period were also included. Participants were required to complete the questionnaire aimed to measure the knowledge about and attitude toward ECT treatment. This questionnaire has been used to assess the knowledge and attitude toward ECT treatment previously in Indian studies and takes about 15–20 minutes for the participant to complete the questionnaire., The knowledge part of the questionnaire covers different aspects of ECT treatment such as the procedure, informed consent, efficacy of this treatment, and side effects of this treatment. In a total of 31 questions in this part, first item inquires about the primary source of information regarding ECT. In the rest part of this questionnaire, there are three options in every question; one option indicates a correct knowledge whereas other option indicates wrong knowledge. Third option is a response of “don’t know” which again indicates lack of knowledge and hence was considered as wrong. To understand the level of knowledge in our subjects, the correct response to any question from number 2 to 31 was given a score of “+1” and wrong responses or “don’t know” responses were given a score of “0”. Accordingly, the total knowledge score could vary from 0 to 30. The second part of this questionnaire specifically looks at the attitude toward ECT and has 16 items. In this part also, there are three possible responses to each item − one response suggesting positive attitude, another response suggesting a negative response, and a third response of “don’t know” suggesting a neutral attitude. To calculate the total attitude score, positive response; negative response and the neutral response were rated as “+1”, “−1”, and “0” respectively. Accordingly, the total attitude score could vary from −16 to +16.
Statistical analysis was carried out using SPSS version 16 (the Statistical Package for the Social Sciences; IBM Software, NY). Descriptive statistics consisted of frequency, percentages, means, and standard deviations. Comparisons between two groups were analyzed using independent samples t-test. Total score on knowledge questionnaire and total score on attitude questionnaire in two groups were correlated using Spearman’s rank correlation coefficient (rs). The level of significance was set at P ≤ 0.05.
| Results|| |
A total of 36 medical interns and 36 persons from general public were included in the study. The primary source of information about ECT was assessed in first item of the knowledge questionnaire. Among the medical interns, most of the participants (n = 27; 75%) reported the source of information as medical books whereas rest of them (n = 9; 25%) reported the primary source of information as media (movies, television, magazines). In general public, most of the participants (n = 32; 88.9%) reported the primary source of information as media (movies, television, magazines) whereas general word of mouth was source of information in rest (n = 4; 11.1%).
Our participants, from both groups, were more knowledgeable about the consent, side effects, and procedure part of the questionnaire compared to other parts of it. Frequencies of correct responses to individual questions are shown in [Table 1]. In two of the questions, that is “is ECT useful in treating psychiatric disorders?” and “does ECT result in permanent damage to brain?”, all the participants from general public gave correct response. None of the participants from either group could answer all the questions, that is a score of 30. The mean score for knowledge questionnaire was 16.58 ± 4.78 and 9.94 ± 4.82 for medical interns and general public respectively, and the difference between the two groups was statistically significant (t = 3.74; P = 0.001).
In [Table 2], it can be seen that the frequency of positive attitude in medical interns is more than that in general public. The mean score on attitude questionnaire was 9.94 ± 4.82 and 0.83 ± 8.56 for medical interns and general public, respectively and the difference between these two groups was statistically significant (t = 5.56; P = 0.0001)
|Table 2 Attitudes toward electroconvulsive therapy (n = 36 in each group)|
Click here to view
In medical interns, the total score on knowledge questionnaire and total score on attitude questionnaire were correlated positively (rs = 0.542, P < 0.001). In general public as well, total score on knowledge questionnaire and total score on attitude questionnaire were correlated positively (rs = 0.446, P < 0.006). This indicates that in both groups, better knowledge was associated with less negative attitude and vice versa.
| Discussion|| |
In the present study, medical interns differed from the general public in both knowledge of and attitude toward ECT with medical interns having more knowledge and more positive attitude. Poor knowledge and negative attitude toward ECT in general public are not a novel finding as different studies in past have found similar results., A recent web-based survey on knowledge and attitudes of ECT in Germany found that besides being negatively connoted, this treatment modality is distinctly rejected and is associated with low levels of knowledge and awareness among the German population. Most of our participants from general public cited media as a source of information. Previously as well, studies have reported media as the primary source of information among the lay public., All of us know how cruel and inhuman treatment is ECT procedure portrayed in media particularly movies and television serials. Analyses of movies and television serials on representation of ECT was carried out and it was concluded that except for few occasions, the representations of ECT in these programs are far away from reality and the overall message that is taken by an individual after watching these films and television serials is that ECT is a heavy handed, misguided, and ineffective intervention.,, This plays a crucial role in shaping attitude toward ECT in general public. Grözinger et al. gave multitude of reasons for disapproving attitude and low level of acceptance of ECT in general public, which range from opposition of using invasive treatment in psychiatry, fear of using electric current on human body, linking this treatment to a form of punishment to an association with development of epileptic fits. Medical interns are supposed to have a good knowledge of ECT as they have psychiatry, both theory and clinical, in their curriculum. Although in our study they had a good knowledge and more positive attitude, yet it was below our expectations. Most of them cited the source of information as medical books, yet the mean score on knowledge questionnaire was about 16.5 when the total score was 30. Only one among them cited the source as medical books plus clinical posting during which she had attended the ECT session. Out of 30 questions on knowledge, for 8 questions only, medical interns had a significant higher knowledge whereas for 4 questions, knowledge of medical interns was significantly low. For the remaining 18 questions, there was no significant difference between medical interns and general public. Different instruments have been used previously to assess the knowledge of ECT among medical students and most of the studies have found a poor knowledge in them.,, There could be many reasons for the poor knowledge of ECT in medical interns. Poor theoretical knowledge may be due to general overview of psychiatry given to medical students in theory classes with no specific lectures on ECT during their medical school. In their clinical placement, there is opportunity for medical students to attend and observe the ECT sessions but there are no clear guidelines in which it is mentioned that they have to attend ECT sessions. In United Kingdom, the medical students are expected to observe at least one ECT session during their psychiatry placement. Low interest in psychiatry among medical students could lead to decreased number of students attending theoretical and clinical classes related to psychiatry and could also explain their poor knowledge. Among our participants, only one had attended an ECT session, although there was opportunity for every student to attend and observe ECT sessions. In our study, the deficits in knowledge of ECT among medical students were more pronounced in procedure, effectiveness, and indications part of the questionnaire. Different studies have shown deficits in knowledge of ECT in different areas like procedure, risks and side effects, indications, efficacy etc.,,,
With a range of −16 to +16, the mean attitude score for medical interns was around 10 which was far better than that of general public. Still there were lacunae in their attitude. For example although about 80% of medical interns showed a positive attitude when asked they will advise their relative for ECT when needed but when the question asked they will themselves go for it when needed, none of them had a positive attitude and most of them were ambivalent. Similarly, none of the medical interns thought that if ECT fails as a treatment, other treatments could benefit the patient. For the question “is ECT dangerous and should not be used?” 50% were not sure and about 10% thought it to be dangerous. A study in Turkey on medical students, psychology students, and general public found similar results with medical students having a more positive attitude toward ECT. But there are studies, which have found an overall negative attitude toward ECT in medical students., In both groups from our study, there was a ppositive correlation between knowledge and attitude toward ECT. It has been found that ECT knowledge score significantly predicts the ECT attitude score. A transcultural study on ECT knowledge and attitude in medical students found an overall positive attitude in medical students with more knowledge and witnessing of an ECT session associated with more positive attitude. Further, studies which have found a little baseline knowledge of ECT in participants have also found an associated negative attitude toward this treatment modality., However certain studies have found a positive attitude in patients and relatives despite little knowledge of this treatment modality., Rejection of ECT as a treatment and low level of its acceptance in general public can be deduced from our results with low baseline knowledge of ECT and less favorable attitude toward this treatment modality. In order to increase acceptance of this treatment modality in general public, there is an urgent need to increase knowledge and attitude toward this treatment which is possible only by providing more basic information of ECT to general public and its effectiveness. It has been found that providing general public with basic information about this treatment modality has a significant effect on increasing knowledge of ECT as well as its positive and favorable attitude. The success stories of those patients who have benefitted from ECT will further help in minimizing barriers to acceptance of this treatment modality and increase its awareness among general public., Even though medical interns in our study had a better knowledge and favorable attitude, there were lacunae in certain areas in them. A negative view of ECT among medical and nursing students and doctors and other mental health professionals is translated as a major hindrance in acceptance of this treatment modality by patients and general public, which is further exacerbated by stigma associated with this treatment modality., As discussed earlier, a reason for the negative view in medical students could be the fact that the specific classes about ECT are not a part of basic medical training and therefore a deficit in information exists in various medical professionals. It has been shown that by education and exposure to procedure, the knowledge, favorable attitude, and level of acceptance of ECT in medical students increases significantly.,,,Our study should be viewed with certain limitations in mind. This was a cross-sectional, questionnaire-based study. Although the questionnaire was used previously in Indian studies and the items in it have been derived from several previous studies, the concerns about its validity and reliability still remain. The sample of general public consisted of those who could read and understand the questionnaire and thus our results can’t be generalized. Besides that, sample size was small.
In conclusion, our study found a low knowledge of ECT in general public with less favorable attitude toward this treatment. With a good knowledge of ECT and more favorable attitude in medical students, still there are lacunae in them. However, in both these groups, there was a positive correlation between knowledge and favorable attitude. Hence if we educate and provide information to general public about this treatment, it is expected to increase both knowledge and favorable attitude in them which will be translated as more acceptance of this treatment modality. Similarly, to improve medical students’ knowledge and attitude about ECT, undergraduate medical curriculum should include ECT in theoretical classes and it should be mandatory for medical students to attend at least one ECT session in clinical psychiatry posting.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Wilhelmy S, Rolfes V, Grözinger M, Chikere Y, Schöttle S, Groß D. Knowledge and attitudes on electroconvulsive therapy in Germany: a web based survey. Psychiatry Res 2018;262:407-12.
The UK. Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. Lancet 2003;361:799-808.
Janicak PG, Davis JM, Gibbons RD, Ericksen S, Chang S, Gallagher P. Efficacy of ECT: a meta-analysis. Am J Psychiatry 1985;142:297-302.
Pagnin D, de Queiroz V, Pini S, Cassano GB. Efficacy of ECT in depression: a meta-analytic review. J ECT 2004;20:13-20.
Dowman J, Patel A, Rajput K. Electroconvulsive therapy: attitudes and misconceptions. J ECT 2005;21:84-7.
Igwe MN, Ndukuba AC, Attama CM, Ogbonna PN, Igwe C. Electroconvulsive therapy in the eyes of undergraduate nursing students. Open J Nurs 2014;4:818.
McDonald A, Walter G. Electroconvulsive therapy in biographical books and movies. Electroconvulsive and neuromodulation therapies. Cambridge University Press, New York. 2009 Mar 2:180-95.
Sharma N, Ghai S, Grover S. Knowledge and attitude of nursing students toward electroconvulsive therapy. J Neurosci Rural Pract 2017;8:S7.
] [Full text]
Payne NA, Prudic J. Electroconvulsive therapy part II: a biopsychosocial perspective. J Psychiatr Pract 2009;15:369.
Jorm AF. Mental health literacy: public knowledge and beliefs about mental disorders. Br J Psychiatry 2000;177:396-401.
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.
Lauber C, Nordt C, Falcato L, Rössler W. Can a seizure help? The public’s attitude toward electroconvulsive therapy. Psychiatry Res 2005;134:205-9.
Kerr RA, McGrath JJ, O’kearney RT, Price J. ECT: misconceptions and attitudes. Aust N Z J Psychiatry 1982;16:43-9.
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.
Clothier JL, Freeman T, Snow L. Medical student attitudes and knowledge about ECT. J ECT 2001;17:99-101.
Shah N, Averill PM. Third-year medical students’ understanding, knowledge, and attitudes toward the use of electroconvulsive therapy: a pre-exposure and postexposure survey. J ECT 2009;25:261-4.
Gazdag G, Takács R, Tolna J, Iványi Z, Ungvari GS, Bitter I. Electroconvulsive therapy in a Hungarian academic centre (1999-2010). Psychiatr Danub 2013;25:366-70.
Tang YL, Jiang W, Ren YP, Ma X, Cotes RO, McDonald WM. Electroconvulsive therapy in China: clinical practice and research on efficacy. J ECT 2012;28:206-12.
Kawoos Y, Wani ZA, Shah IA, Rather YH, Zarger WA, Amin R. Knowledge and attitude of patients and their relatives towards electro-convulsive therapy: a study from a tertiary care centre in Northern India. Int J Res Med Sci 2017;5:2433.
Rajagopal R, Chakrabarti S, Grover S, Khehra N. Knowledge, experience & attitudes concerning electroconvulsive therapy among patients & their relatives. Indian J Med Res 2012;135:201.
Teh SP, Helmes E, Drake DG. A Western Australian survey on public attitudes toward and knowledge of electroconvulsive therapy. Int J Soc Psychiatry 2007;53:247-71.
McFarquhar TF, Thompson J. Knowledge and attitudes regarding electroconvulsive therapy among medical students and the general public. J ECT 2008;24:244-53.
McDonald A, Walter G. Hollywood and ECT. Int Rev Psychiatry 2009;21:200-6.
Matthews AM, Rosenquist PB, McCall WV. Representations of ECT in English-language film and television in the new millennium. J ECT 2016;32:187-91.
Sienaert P. Based on a true story? The portrayal of ECT in international movies and television programs. Brain Stimul 2016;9:882-91.
Grözinger M, Smith ES, Conca A. On the significance of elektroconvulsive therapy in the treatment of severe mental diseases. Wien Klin Wochenschr 2015;127:297-302.
Walter G, McDonald A, Rey JM, Rosen A. Medical student knowledge and attitudes regarding ECT prior to and after viewing ECT scenes from movies. J ECT 2002;18:43-6.
Gazdag G, Kocsis-Ficzere N, Tolna J. Hungarian medical students’ knowledge about and attitudes toward electroconvulsive therapy. J ECT 2005;21:96-9.
Abbas M, Mashrai N, Mohanna M. Knowledge of and attitudes toward electroconvulsive therapy of medical students in the United Kingdom,Egypt, and Iraq: a transcultural perspective. J ECT 2007;23:260-4.
Solomon S, Simiyon M, Vedachalam A. Effectiveness of an educational intervention on medical students’ knowledge about and attitude towards electroconvulsive therapy. Acad Psychiatry 2016;40:295-8.
Aki OE, Ak S, Sonmez YE, Demir B. Knowledge of and attitudes toward electroconvulsive therapy among medical students, psychology students, and the general public. J ECT 2013;29:45-50.
Hoffman GA, McLellan J, Hoogendoorn V, Beck AW. Electroconvulsive therapy: the impact of a brief educational intervention on public knowledge and attitudes. Int Q Community Health Educ 2018;38:129-36.
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]
Flamarique I, Castro-Fornieles J, de la Serna E, Pons A, Bernardo M, Baeza I. Patients’ opinions about electroconvulsive therapy: what do adolescents with schizophrenia spectrum disorders think? J Child Adolesc Psychopharmacol 2015;25:641-8.
Li Y, An FR, Zhu H, Chiu HF, Ungvari GS, Lai KY, Xiang YT. Knowledge and attitudes of patients and their relatives toward electroconvulsive therapy in China. Perspect Psychiatr C 2016;52:248-53.
Aoki Y, Yamaguchi S, Ando S, Sasaki N, Bernick PJ, Akiyama T. The experience of electroconvulsive therapy and its impact on associated stigma: a meta-analysis. Int J Soc Psychiatry 2016;62:708-18.
Maguire S, Rea SM, Convery P. Electroconvulsive therapy-what do patients think of their treatment?. Ulster Med J 2016;85:182.
Pranjkovic T, Degmecic D, Flajsman AM, Gazdag G, Ungvari GS, Kuzman MR. Observing Electroconvulsive therapy changes students’ attitudes: a survey of Croatian medical students. J ECT 2017;33:26-9.
Trenton A, Pelchat R. Medical students’ perceptions of electroconvulsive therapy: the impact of direct exposure. J ECT 2016;32:20-2.
[Table 1], [Table 2]