Assessing Public Attitudes to Electroconvulsive Therapy: Validation of the Modified ECT Attitudes Questionnaire Using a Systematic Analysis

Clinical and Legal Differences in the Use of Involuntary Electroconvulsive Therapy for Life-Threatening Illness Across European Countries

OBJECTIVES

Electroconvulsive therapy (ECT) can be life-saving in situations where patients are at risk of dying from severe manifestations of psychiatric illness. In some of these cases, patients are unwilling/unable to consent to ECT, and involuntary ECT is required. Such use of involuntary ECT varies substantially across European countries for unclear reasons. The aim of this study was to examine clinical and legal differences in this use of involuntary ECT across European countries.

METHODS

A questionnaire based on a case vignette (a 55-year-old female inpatient with psychotic depression at imminent risk of dying from metabolic derangement because of refusal to eat and drink) was sent to an ECT practitioner in each of 31 European countries.

RESULTS

We received responses from ECT practitioners in 18 countries. In 7 of these countries, involuntary ECT could be carried out without approval from others and/or involvement of the court system in the case described in the vignette. Practitioners in the remaining 11 countries responded that they either could not carry out involuntary ECT or would have to meet certain requirements before initiating involuntary ECT (e.g., approval from medical/ethics committee and second opinion from an independent psychiatrist). Notably, the rules regarding involuntary ECT differed for adults and minors (more restrictive for the latter) in 6 of the 18 countries.

CONCLUSIONS

In many European countries, legislation precludes or delays the use of involuntary ECT. Harmonization of the legislation on involuntary ECT across European countries to allow for better access to this potentially life-saving treatment seems warranted.

The differential effects of psychiatrists' and patients' prior experiences on views about psychiatric electroceutical interventions

The aim of this study is to examine ways in which prior experiences and familiarity with psychiatric electroceutical interventions (PEI) shape psychiatrists' and patients' views about these interventions. We administered a national survey, with an embedded experiment, to psychiatrists (n = 505) and adults diagnosed with depression (n = 1050). We randomly assigned respondents to one of 8 conditions using a full factorial experimental design: 4 PEI modalities [ECT, rTMS, DBS, or adaptive brain implants (ABIs)] by 2 depression severity levels [moderate or severe]. We analyzed the survey data with ANOVA and OLS linear regression models. Patients having experience with any PEI reported more positive affect toward, but also greater perceived risk from, their assigned PEI than did patients with no such experience. Psychiatrists who referred or administered any PEI reported more positive affect toward and greater perceived influence on self and perceived benefit from their assigned PEI than did psychiatrists with no such familiarity. Limitations of our study include that our participants were randomly assigned to a PEI, not necessarily to the one they had experience with. Moreover, our study did not directly ask about the kind of experiences participants had with a given PEI. Overall, our survey data shows that greater experience with PEIs elicits more positive affect in both stakeholder groups. Beyond this, prior PEI experience shapes attitudes towards these interventions in complex ways. Further research linking different types of experience with a given PEI would help better understand factors shaping attitudes about specific PEIs.

Response rate and safety of antidepressants combined with electroconvulsive therapy in adolescent depression: Real-world clinical application

BACKGROUND

METHODS: This study included 210 depression patients receiving antidepressants and ECT. The symptoms of depression were examined with the Hamilton Depression Scale (HAMD) and Clinical Global Impressions Scale (CGI) at baseline and the end of treatment. Response and safety were compared among adolescent and adult patients.

RESULTS

For adolescents, the response rate (much improved or very much improved) was 80.9 %, and CGI-Severity (CGI-S), HAMD, and suicide factor scores were significantly changed as compared to baseline (P < 0.001), results of which were similar to the adult group. There were no significant differences in HAMD, CGI scores between adolescent and adult depression before or after treatment (P > 0.05). Notably, adolescents expressed stronger suicidal intent than adults, and ECT observably relieved it. Side effects (memory problems, headache, nausea/vomiting, muscle soreness) in adolescents were not statistically different from those in adults (P > 0.05).

LIMITATIONS

As data were derived from a single center, the generalizability of results may be limited, and the potential factors affecting the efficacy of ECT were not further explored.

CONCLUSION

Antidepressants combined with ECT are associated with high response rate and safety for treating depression, regardless of age. A stronger expression of suicide ideation was observed in depressed adolescents, and side effects of ECT were similar to the adults.

The influence of prior awareness on views about psychiatric electroceutical interventions among non-clinician stakeholders

Psychiatric electroceutical interventions (PEIs) are emerging interventions in the treatment of depression and other mood disorders. The uptake of PEIs is strongly influenced by public, caregiver, and patient views. This study examines the influence of prior awareness and of trust in the medico-scientific establishment with respect to non-clinicians' views on PEI among a cohort of U.S. respondents. About 3098 U.S. caregivers, patients, and members of the general public completed an online survey with an embedded experiment to evaluate PEI views by stakeholder, modality, and disease severity. ANOVA statistical tests and logistic regression models were used to identify significant differences between groups and moderating factors. Overall, respondents had greater awareness of antidepressant medication (73-84%) and psychotherapy (68-76%) than of any PEI, and ECT garnered the most prior awareness (29-40%) within each group. Non-clinical respondents most often used websites or social media as information sources, and the least trusted sources included those with notable financial interests. Considering the low awareness level among non-clinicians, the implementation of programs to target and advance awareness levels about the use of PEIs in depression among this population may contribute to reducing negative views around these interventions. Fostering trust in the medico-scientific establishment may also increase public support for PEIs as well as uptake of these treatment modalities.

Views about neuromodulation interventions for depression by stakeholder group, treatment modality, and depression severity

BACKGROUND

The past few decades have seen the emergence both of new neuromodulation treatment protocols and novel applications of standard neuromodulation interventions in psychiatry. Yet little is known about different stakeholders' views about these interventions.

METHODS

We administered an online survey with an embedded video vignette experiment to four national samples: the general public (N = 1022), caregivers for people with depression (N = 1026), patients living with depression (N = 1050), and board-certified psychiatrists (N = 505). We randomly assigned subjects to one of eight conditions in our full factorial design: four neuromodulation interventions [electroconvulsive therapy, repetitive transcranial magnetic stimulation, deep brain stimulation, or adaptive brain implants] by two depression severity levels [moderate or severe]. In this paper we present results from ANOVA and linear regression models explaining how views about these four neuromodulation interventions-as measured in five attitudinal scales (general affect, perceived influence on self, perceived benefit, perceived risk, and perceived invasiveness)-vary by (1) intervention, (2) depression severity, and/or (3) stakeholder group.

RESULTS

Our results provide evidence that psychiatrists views differ significantly in important ways from other stakeholder groups. Type of intervention also shaped participants' attitudes, including perceptions of invasiveness, effectiveness, and safety.

CONCLUSIONS

Given the differing affective valence among stakeholders and the differences found by modality and stakeholder groups across the different scales, future targeted educational initiatives could be developed to help address key misunderstandings and misinformed perceptions.

Challenging stigma and attitudes towards ECT via an educational video

While electroconvulsive therapy (ECT) is an effective therapeutic modality for the treatment of mental illness, negative attitudes and stigma exist about ECT in the general community and even within health services. Investigating interventions that improve the attitudes of health professionals towards ECT is beneficial as this reduces stigma and increases the acceptability of ECT for consumers. The primary aim of this study was to evaluate the change in attitude of nursing graduates and medical students towards ECT by watching an educational video. The secondary aim was to compare health professional attitudes to those of the general community. An educational video was co-designed with consumers and members of the mental health Lived Experience (Peer) Workforce Team about ECT outlining the procedure, side effects, treatment considerations and lived experiences. Nursing graduates and medical students completed the ECT Attitude Questionnaire (EAQ) prior to and after watching the video. Descriptive statistics, paired samples t-tests and one sample t-tests were completed. One hundred and twenty-four participants completed pre- and post- questionnaires. Attitudes towards ECT significantly improved after watching the video. Positive responses towards ECT increased from 67.09% to 75.72%. Participants in this study reported higher positive attitudes towards ECT than members of the general public before and after watching the intervention. Results indicated that the video educational intervention was effective in improving attitudes towards ECT for nursing graduates and medical students. While the video is promising as an educational tool, further research is required to explore the use of the video in reducing stigma for consumers and carers.

History of ECT in Schizophrenia: From Discovery to Current Use

Eighty years ago, schizophrenia was the first indication for electroconulsive therapy (ECT), and likewise ECT was one of the first treatments used for schizophrenia. This paper presents the history of ECT in the treatment of schizophrenia and its evolution, from it's discovery in the 20th century, which is an example of empiricism with a sequence of "shock" therapies. Following this discovery, the use ECT in schizophrenia has been in expansion during several decades, in a context of lack of efficacy of the treatment in schizophrenia. Then, after World War II and the derivative use of ECT in Germany, the use of ECT has decline during several decades. However, in the last decades, the use of ECT in schizophrenia has reemerged. Indeed, among patients in schizophrenia, rates of resistance to treatment have always been and still are high. In 2017, the concept of "ultra-treatment resistant schizophrenia" was defined when clozapine was tried and failed; and ECT, that had been long since abandoned in the treatment of schizophrenia until recent renewed interest, has emerged especially concerning the add-on of ECT to clozapine. However, ECT remains highly stigmatized and underutilized. This article looks at the history of the practice of ECT in schizophrenia with a historical and clinical approach and makes connections between the history of the treatment and its influence on its current recommendation and practice.

Risk Assessment of Electroconvulsive Therapy in Clinical Routine: A 3-Year Analysis of Life-Threatening Events in More Than 3,000 Treatment Sessions

Background: Extensive research has reported that electroconvulsive therapy (ECT) can be highly effective in approximately 80% of patients suffering from depression. Its clinical use is mainly limited by historical objections and the concern about unwanted adverse effects (AEs), including serious and potentially life-threatening adverse events (pLTAEs), induced either by ECT or by anesthesia. Objective risk estimation is, therefore, a decisive factor in determining an indication for ECT. Methods: This paper presents a retrospective analysis of 3-year safety protocols and patient files of 157 patients who received a total of 3,106 ECT applications in a psychiatric inpatient setting at a psychiatric community hospital. This patient group comprises 5.3% of inpatients admitted with comparable diagnoses. Adverse events were analyzed from standardized safety protocols and patient files with a focus on pLTAEs. Results: Adverse events were reported for 30 (19.1%) of the 157 participants during 39 (6.1%) of 641 hospital stays. Serious pLTAEs occurred during three electroconvulsive stimulations in three patients, who needed action through the administration of medication or mechanical respiration. No patient suffered permanent damage to health, and no patient died. The incidence of these and other AEs was independent of sex, age, and diagnosis of patients, and anesthesia medication. Minor AEs occurred more often with higher stimulus doses and an increasing number of treatments. Conclusion: The low incidence rate of 0.097% of serious pLTAEs that require medical action may allow the conclusion that ECT is a rather safe treatment when performed in a controlled setting. The beneficial risk profile of ECT performed in the standard care of psychiatric hospitals suggests a more generous indication of this treatment method. We recommend that ECT facilities collect individual safety data to allow a reliable judgment of their institutional ECT risk profile.

Electroconvulsive Therapy: a Video-Based Educational Resource Using Standardized Patients

OBJECTIVE

Video-based depictions of electroconvulsive therapy (ECT) can be useful for educational purposes, but many of the readily available resources may worsen already stigmatized views of the procedure. Educators' common reliance on such material highlights the paucity of equipoised depictions of modern ECT well suited for the training of health professionals. The authors developed and tested a new educational module enhanced by videotaped depictions of a simulated patient undergoing the consent, treatment, recovery, and follow-up phases of ECT.

METHODS

The didactic intervention interspersed 7 short video clips (totaling 14 min) into a 55-min lecture on treatment-resistant depression. The session, part of an intensive course of preclinical psychiatry, was delivered online through synchronous videoconferencing with Zoom. The primary outcome measure was change in the Questionnaire on Attitudes and Knowledge of ECT (QuAKE).

RESULTS

Fifty-three out of 63 (87%) eligible second-year medical students completed assessments at baseline and after exposure to the didactic intervention. QuAKE scores improved between baseline and endpoint: the Attitudes composite increased from 49.4 ± 6.1 to 59.1 ± 5.7 (paired t 10.65, p < 0.001, Cohen's d 0.69), and the Knowledge composite from 13.3 ± 1.2 to 13.9 ± 0.8 (paired t 3.97, p < 0.001, Cohen's d 0.23).

CONCLUSIONS

These video-based educational materials proved easy to implement in the virtual classroom, were amenable to adaptation by end-use instructors, were well received by learners, and led to measurable changes in students' knowledge of and attitudes toward ECT.