The perspectives of former recipients and experts on stigmatization related to electroconvulsive therapy in Denmark: A focus group study

Electroconvulsive therapy in a tertiary Australian mental health facility between 2009 and 2020

BACKGROUND

Despite electroconvulsive therapy being one of the most effective treatments in psychiatry, few studies report trends in the provision of electroconvulsive therapy over time. This study aims to investigate the use of electroconvulsive therapy between 2009 and 2020 in an Australian public tertiary mental health facility, and to describe the electroconvulsive therapy patient population and change in courses of treatment.

METHODS

Routinely collected data for 677 patients who received 1669 electroconvulsive therapy courses of treatment at an Australian public tertiary mental health facility between 2009 and 2020 were examined.

RESULTS

The provision of acute electroconvulsive therapy was stable across the study period; however, the number of maintenance electroconvulsive therapy courses commenced declined over the study. Schizophrenia was the most common indication for index treatment (37.4%). The majority of patients (85.7%) received acute electroconvulsive therapy only. Voluntary provision of electroconvulsive therapy declined over the study period, reducing from 44.9% in 2009 to 16.3% in 2020.

CONCLUSION

Over the study period, there was a significant reduction in the number of maintenance electroconvulsive therapy courses commenced, and a large increase in involuntary treatment. The provision of electroconvulsive therapy was more likely to occur in males with a diagnosis of schizophrenia. Further studies are needed to generate a greater understanding of the factors influencing the provision of electroconvulsive therapy within differing geographical, social and healthcare landscapes.

Perceived Barriers to Using Neurostimulation: A National Survey of Psychiatrists, Patients, Caregivers, and the General Public

OBJECTIVES

Neurostimulation interventions often face heightened barriers limiting patient access. The objective of this study is to examine different stakeholders' perceived barriers to using different neurostimulation interventions for depression.

METHODS

We administered national surveys with an embedded experiment to 4 nationwide samples of psychiatrists (n = 505), people diagnosed with depression (n = 1050), caregivers of people with depression (n = 1026), and members of the general public (n = 1022). We randomly assigned respondents to 1 of 8 conditions using a full factorial experimental design: 4 neurostimulation modalities (electroconvulsive therapy [ECT], repetitive transcranial magnetic stimulation [rTMS], deep brain stimulation [DBS], or adaptive brain implants [ABIs]) by 2 depression severity levels (moderate or severe). We asked participants to rank from a list what they perceived as the top 3 barriers to using their assigned intervention. We analyzed the data with analysis of variance and logistic regression.

RESULTS

Nonclinicians most frequently reported "limited evidence of the treatment's effectiveness" and "lack of understanding of intervention" as their top 2 most important practical barriers to using ECT and TMS, respectively. Compared with nonclinicians, psychiatrists were more likely to identify "stigma about treatment" for ECT and "lack of insurance coverage" for TMS as the most important barriers.

CONCLUSIONS

Overall, psychiatrists' perceptions of the most important barriers to using neurostimulation interventions were significantly different than those of nonclinicians. Perceived barriers were significantly different for implantable DBS and ABI) versus nonimplantable (rTMS and ECT) neurostimulation interventions. Better understanding of how these barriers vary by neurostimulation and stakeholder group could help us address structural and attitudinal barriers to effective use of these interventions.

The ethical imperative of trauma-sensitive care for electroconvulsive therapy (ECT)

BACKGROUND

The empirical literature on the lived experience of electroconvulsive therapy (ECT) is limited, divergent, and largely focused on the experiences of procedures, (adverse) effects, information provision, or decision-making.

AIMS

This study aimed to investigate aspects related to the lived experience and meaning-making of people who have had ECT.

METHOD

In-depth interviews with 21 women (21-65 years old) were analyzed using interpretative phenomenological analysis (IPA).

FINDINGS

A subgroup of nine participants described more negative experiences with ECT. A common factor for these participants was the experience of trauma that remained under-treated. The superordinate themes identified were a lack of trauma-based and recovery-oriented treatment. The rest of the sample (12) expressed more positive experiences with ECT.

CONCLUSIONS

This study suggests that exploring more broadly the impacts of ECT at the long term offers insights that can help design more person-centered services aligned to the needs of the treatment recipients. Educational modules for mental health care staff should include, besides knowledge on the methods' effectiveness, additional evidence about treatment recipients' subjective concerns and the relevance of trauma and recovery-oriented care models.

Looking through the lens of stigma: Understanding and anticipating concerns about the responsible development and use of psychiatric electroceutical interventions (PEIs)

Psychiatric electroceutical interventions (PEIs) show promise for treating depression, but few studies have examined stakeholders' views on them. Using interview data and survey data that analyzed the views of psychiatrists, patients, caregivers, and the general public, a conceptual map was created to represent stakeholders' views on four PEIs: electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (TMS), deep brain stimulation (DBS), and adaptive brain implants (ABIs). Stigma emerged as a key theme connecting diverse views, revealing that it is a significant factor in the acceptance and usage of PEIs. Stigma not only discourages seeking mental health services for depression but also inhibits the acceptance of PEIs. Addressing the pervasive and complex effects of stigma highlights the need to change societal attitudes toward mental illnesses and their treatments and to provide support to patients who may benefit from these interventions. The map also demonstrates the value of conceptual mapping for anticipating and mitigating ethical considerations in the development and use of PEIs.

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.

Stigma towards people with mental illness in the Nordic countries - a scoping review

INTRODUCTION

Stigma affects people with mental illness globally, however, it is proposed that stigma is less prevalent in wealthier countries and that people hold more positive attitudes in Northern and Western Europe. Even so, accounts from surveys in Denmark and Sweden reveal that stigma is very much prevalent.

AIM

This scoping review aims to shed light on the body of literature regarding mental-health-related stigma in the Nordic Countries and identify knowledge gaps.

METHODS

We searched four electronic databases in December 2017 and again in June 2020. All types of empirical studies (qualitative, quantitative, and mix-methods) examining the stigma of people with mental illness were included.

RESULTS

In total, 61 studies were included. Overall, findings from the Nordic countries resemble global findings. Studies are primarily descriptive, and mostly survey studies of attitudes toward people with mental illness in the general population. Few studies focus on discrimination, and those who do, measure intended behavior in hypothetical situations rather than actual acts of discrimination in real-life situations. Studies were mostly conducted on a community or organizational level; no studies were identified on a system level. Experienced stigma and discrimination by patients, but also relatives, were a focus in one-third of the studies. Very few studies of interventions to reduce stigma and discrimination were identified.

CONCLUSION

More studies into stigma on a system or institutional level are needed. Ways to measure acts of discrimination should be invented. Furthermore, interventions to reduce stigma and discrimination should be developed, targeting all levels of society.

How Do People Perceive and Adapt to Any Consequences of Electro Convulsive Therapy on Their Daily Lives?

Great controversy surrounds the use of electroconvulsive therapy or ECT. However, it continues to be used internationally. While research on short term effects of ECT abound, there is limited knowledge about long term impacts of ECT on individuals, especially from the lived experience perspective. The aim of this qualitative study was to gain an in-depth understanding of longer-term lived experiences of ECT and how people navigate any impacts on their daily lives. Twenty-three people participated in semi-structured interviews. Data collection and analysis involved an iterative process. Data were coded into four categories: (1) My ECT experience included physical mechanics, decision making, clinic experiences, post ECT support and attitudes and support of others); (2) Direct impacts of ECT on me encompassed both cognitive and emotional impacts; (3) Impacts on my life comprised daily activities, relationships, ongoing health care; and My strategies incorporated fixing or working around the problem, reframing, using support networks, protecting myself and taking control. Insights gleaned through lived experiences have important implications for other service users, direct service providers and those striving for system reforms that embrace more recovery orientated and trauma informed practices.

What are the ethical dilemmas in the decision-making processes of nursing people given electroconvulsive therapy? A critical realist review of qualitative evidence

WHAT IS KNOWN ON THE SUBJECT?: ECT is a treatment which has a long and complicated history. There is no consensus on its effectiveness and there is a great deal of polarized debate as to whether it should be used. MHNs are asked to work with people who are receiving ECT as part of their duties. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The paper seeks to move beyond the polarized arguments and to consider how MHNs can work with people where ECT is being considered or administered as part of their treatment in a manner which satisfies their professional obligations. IMPLICATIONS FOR PRACTICE: MHNs may need to broaden their understanding of ethics beyond the traditional biomedical ethics model of beneficence, non-maleficence, justice and autonomy, as well as improving their understanding of social and political factors which may have an unseen effect of the use of ECT as a treatment in order to meet their professional obligations when working with people being administered ECT. ABSTRACT: INTRODUCTION Electroconvulsive therapy (ECT) has a complex and contentious place in psychiatric care. Mental health nurses (MHNs) are of obligated to be part of this practice despite ethical concerns. Aim To consider the ethical dilemmas and decision-making processes facing MHNs involved in the administration of ECT. Method A critical realist review of the literature surrounding ethical considerations and ECT was undertaken using thematic analysis. Findings Four key themes emerged: the MHN as an advocate and conflict in their role, issues surrounding consent, questionable efficacy and unknown method of action, side effects, and legal issues and clinical guidelines. Discussion Using a critical realist framework for understanding, the decision-making process and ethical considerations are viewed as part of the empirical and actual parts of reality, while the potential for other, unseen causal powers to be at play is acknowledged. Implications for practice MHNs need to ensure they have an adequate ethical underpinning to their practice to enable them to navigate contentious areas of practice such as ECT to practice effectively and preserve safety. This may require moving beyond the traditional biomedical model of ethics. Developing an appreciation of unseen causal factors is also an essential part of MHNs' developing professional competency.

Recipients' experience with information provision for electroconvulsive therapy (ECT)

BACKGROUND

Despite improvements, studies continue to report unsatisfactory provision of information before, during and after electroconvulsive treatment (ECT).

AIMS

The study explores participants' experiences with information provision about ECT.

METHODS

In-depth interviews with 21 participants (21- 65 year-old) were conducted. Thematic analysis resulted in identification of four themes: pre-treatment knowledge, experience of informed consent, the need for information depth and life after ECT. The study includes user involvement.

RESULTS

Although some participants were satisfied with information provision, the majority experienced an education deficit throughout the treatment period. Their consent was based mostly on oral information, insufficient and unvaried information on official health websites and media. Further, patients reported a lack of follow-up services that can attend to (neuro) psychological concerns.

CONCLUSIONS

Better access to updated factual and narrative information should support patient education and autonomy. Active use of diary writing, better follow-up and more varied representations of experience with ECT in media and health information sites are necessary to educate, improve consent processes and reduce stigma.

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.

Mental Health Nurse experiences of delivering care to severely depressed adults receiving electroconvulsive therapy

WHAT IS KNOWN ON THE SUBJECT?: ECT is a fast-working and potentially life-saving treatment, but it is still considered a controversial treatment choice. Due to lack of knowledge and public stigma, ECT can be an anxiety-inducing treatment for people experiencing severe depression. The nurse's role is to alleviate this anxiety, aid recovery and minimize the risk of relapse. They manage this onerous task ideally through the therapeutic relationship, and use the skills of assessment and risk identification in order to maximize patient outcomes. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: The views of mental health nurses who provide care for adults receiving treatment of ECT for severe depressive illness are in the main positive. The knowledge of and attitude towards ECT among nurses may reflect on patients and influence treatment choice. If stigma is not addressed, then patients will not be appropriately informed regarding their treatment options. Mental health nurses need to engage in reflective practice to ensure that the dignity of the patient is maintained throughout this treatment. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental Health nurses should engage with additional training, formalized clinical supervision and avail of peer support in order to improve confidence, skills and quality of care in the delivery of ECT. Education modules should include a presentation of evidence of effectiveness of ECT as a treatment option. Dialogue among mental healthcare colleagues is important about caring for people presenting for ECT treatment. This will ensure that the mental health nurse can remain cognizant of the potential for patient distress throughout this treatment. ABSTRACT: Background There is a considerable dearth of literature on attitudes towards Electroconvulsive Therapy (ECT) as a treatment for severe depression. Despite being a highly effective treatment, it is still stigmatized even among professionals. Understanding perceptions and knowledge related to ECT treatment among healthcare providers is important for ensuring that treatment can be safely explored as a treatment option with patients. Aim The overall aim of this study is to explore the views of mental health nurses who provide nursing care to people receiving ECT for severe depressive illness in a mental health setting. Methods This is a qualitative study using focus groups (n = 2) with 14 mental health nurses who had a minimum of 3 months experience caring for older adults receiving ECT. Transcripts were subjected to a thematic analysis. Full ethical approval was granted for this study. Results In total, four themes were identified exploring attitudinal changes, managing patient dignity, reflecting changes in practice and managing the unknown. In general, participants experienced ECT as a positive treatment option for adults with severe depressive illness contributing to an enhanced quality of life. Conclusion Findings indicate a desire to improve person-centred care for patients undergoing ECT. Educational support for nurses who work in this area would improve confidence on work practices and lead to improved patient experience. Mental health personnel without direct experience of the treatment should be exposed to educational modules to decrease stigma and to best facilitate informed decision-making among the patient cohort.

The experience of living after ECT: a qualitative meta-synthesis

BACKGROUND

Electroconvulsive therapy (ECT) is a controversial treatment. Research has predominantly focused on clinician assessment of short-term efficacy and, occasionally, on participant experiences of the treatment itself. While service user accounts of the long-term impacts of ECT are reported, they are dispersed throughout the literature and typically tangential to studie's main foci.

AIM

The aim of this study was to synthesise service-user accounts, within peer-reviewed literature, of long-term impacts of ECT in their daily lives.

METHODS

A qualitative meta-synthesis was conducted. A systematic literature search identified qualitative articles meeting the inclusion criteria. Results sections of eligible papers were analysed thematically.

RESULTS

From 16 eligible papers, the review identified 11 long-term impacts, four social influences and five strategies that people employed to navigate these long-term impacts.

CONCLUSION

Limited research has examined long-term experiences of ECT from service-user perspectives. These lived experience perspectives are required to facilitate peer-to-peer learning and assist future service delivery to align with needs of people living with long-term ECT impacts.