|Year : 2022 | Volume
| Issue : 2 | Page : 113-118
Impact of electroconvulsive education module on knowledge and attitude of caregivers of mentally ill patients toward electroconvulsive therapy
Renish Bhupendra Bhatt1, Parveen Kumar1, Disha Alkeshbhai Vasavada1, Viral Ratnprakash Shah2, Lubna Mohammedrafik Nerli3, Deepak Sachidanand Tiwari1
1 Department of Psychiatry, M.P. Shah Medical College, Jamnagar, Gujarat, India
2 Department of Preventive and Social Medicine, M.P. Shah Medical College, Jamnagar, Gujarat, India
3 Department of Psychiatry and Preventive and Social Medicine, M.P. Shah Medical College, Jamnagar, Gujarat, India
|Date of Submission||12-Feb-2022|
|Date of Decision||04-Apr-2022|
|Date of Acceptance||09-Apr-2022|
|Date of Web Publication||13-Jan-2023|
Dr. Parveen Kumar
2nd Floor, Trauma Building, Department of Psychiatry, G.G. Hospital, Jamnagar - 361 008, Gujarat
Source of Support: None, Conflict of Interest: None
Background: Electroconvulsive therapy (ECT) is a process of passage of an electric current to the patient's brain which induces a grand mal seizure. It is an effective and safe treatment option for many psychiatric disorders. There are a lot of stigmas associated with the use of ECT, which further undermines its acceptance by the general public. Relatives of patients who have more knowledge about ECT and its process of administration have a more positive attitude. Aims and Objective: The current study was used to assess the impact of brief ECT education module on knowledge and attitude toward ECT. Material and Methods: An interventional study was carried out from November 2021 to January 2022 among caregivers of mentally ill patients at a tertiary care center in Jamnagar, Gujarat, India. Consenting caregivers of 18–60 years without any history of psychiatric illness were included in the study. All participants were approached and requested to fill a semistructured pro forma containing demographic details and “knowledge and attitude toward ECT”, before and after the completion of the oral education session. Results: A total of 400 participants participated in the study. Participant's age ranged from 18 to 60 years. Participants have poor knowledge about the mechanism of ECT, its efficacy, and side effects related to it (<50% response). A positive correlation was observed between knowledge and attitude (r = 0.625, P < 0.001). Education has a statistically significant impact on changing attitude. Conclusion: Participants having higher educational qualifications or those having previous history of ECT among close friends or relatives had a positive perception toward ECT. Educational or counseling sessions among caregivers are effective in changing attitude toward ECT.
Keywords: Attitude, electroconvulsive therapy, knowledge, mental illness
|How to cite this article:|
Bhatt RB, Kumar P, Vasavada DA, Shah VR, Nerli LM, Tiwari DS. Impact of electroconvulsive education module on knowledge and attitude of caregivers of mentally ill patients toward electroconvulsive therapy. J Mental Health Hum Behav 2022;27:113-8
|How to cite this URL:|
Bhatt RB, Kumar P, Vasavada DA, Shah VR, Nerli LM, Tiwari DS. Impact of electroconvulsive education module on knowledge and attitude of caregivers of mentally ill patients toward electroconvulsive therapy. J Mental Health Hum Behav [serial online] 2022 [cited 2023 Jun 2];27:113-8. Available from: https://www.jmhhb.org/text.asp?2022/27/2/113/367742
| Introduction|| |
Electroconvulsive therapy (ECT) is a process of passage of an electric current to the patient's brain which induces a grand mal seizure under anesthesia and muscle relaxants to improve the patient's mental status. It is an effective and safe treatment option for many psychiatric disorders such as major depression, bipolar affective disorder, and schizophrenia. Despite its safety and clinical efficacy, there are numerous reports of negative perspectives about ECT among patients and caregivers. There are a lot of stigmas associated with the use of ECT, which further undermines its acceptance by the general public., Primitive practices in the past and negative media coverage contribute to public disapproval. Viewing movie clips that portray ECT as brutal and inhuman generates a more negative attitude. Due to all these factors, ECT has been widely viewed as a terrifying, invasive, and cruel procedure by the lay public.
Many studies assess the knowledge and attitude toward ECT among patients, their family members, and the general public. These studies suggest that patients undergoing ECT usually have poor knowledge. Studies have also reported that mentally ill patients who received ECT have more knowledge and a positive attitude and were satisfied with the experience of it.,, Studies reported that after experiencing ECT treatment, both patients and relatives showed a more positive attitude toward ECT., Moreover, relatives of patients who have more knowledge about ECT and its process of administration have a more positive attitude., By adhering to the standard of care, providing education through videos and pamphlets, and improving knowledge, the perception of ECT among patients and caregivers can be improved to ensure better treatment outcomes.
Few Indian studies have assessed the impact of ECT education among caregivers on their knowledge and attitude., Knowledge and attitude among patients and their relatives toward ECT could have a significant impact on the outcome of treatment. Therefore, the current study was used to assess the impact of the “ECT education module” on knowledge and attitude toward ECT and the willingness of caregivers toward ECT.
| Materials and Methods|| |
An interventional study was carried out from November 2021 to January 2022 among caregivers of mentally ill patients attending psychiatric outpatients and indoor services at a tertiary care center in Jamnagar, Gujarat, India. Consenting caregivers of 18–60 years without any history of psychiatric illness were included in the study. All participants were approached and requested to fill a semi-structured pro forma containing the following parts as a part of the pretest: (1) demographic details and (2) knowledge and attitude toward ECT. The scales were translated into the local language (Gujarati) and back-translated to English by a language expert and validated. After the pretest, an oral session of around 45–60 min was conducted using the education module. The oral information session was conducted in the clinic room among caregivers of both outdoor and indoor patients. All oral sessions were conducted by a team of trained psychiatrists, and assessment was done by a different team. Education modules cover the multiple areas such as myths and facts about ECT, historic aspects, the procedure of ECT, consent required during the procedure, indication, mechanism of action, adverse of ECT, and a short-recorded video of ECT procedure. After the completion of the whole module, participants were asked to fill the “Attitude towards ECT” Questionnaire as a part of the posttest.
Demographic details include age, gender, profession, working area, marital status, family education, relation to the mentally ill client, gender of the patient, and history of ECT in a close relative or friend.
Knowledge and attitude toward electroconvulsive therapy
This scale contains two parts: (1) knowledge about ECT and (2) attitude toward ECT.
Knowledge about electroconvulsive therapy
This comprises 30 questions on the different aspects of ECT treatment such as the procedure, informed consent, efficacy of this treatment, and side effects of this treatment. Every question has three options: one option indicates correct knowledge; the other option indicates wrong knowledge; and while the third response of “don't know” again indicates a lack of knowledge and hence was considered wrong. The correct response to any question was given a score of “+1” and wrong responses or “don't know” responses were given a score of “0.” The total knowledge ranges from 0 to 30. The internal reliability of the scale for the current sample was 0.74 using Cronbach's α.
Attitude toward electroconvulsive therapy
This comprises 16 items. Each item has three possible responses: one response suggests a positive attitude, another response suggests a negative attitude, and the third response of “don't know” suggests a neutral attitude. To calculate the total attitude score, positive response, negative response, and neutral response were rated as “+1,” “−1,” and “0,” respectively, which could vary from −16 to +16. The internal reliability of the scale for the current sample was 0.79 using Cronbach's α.
Source of information about electroconvulsive therapy
It was assessed by selecting one of these major sources of information: (1) psychiatrist, (2) other doctor or health-care staff other than a psychiatrist, (3) relative or friends who have experience of ECT, (4) relative or friends who do not have experience with ECT, and (5) TV, news, or movies. The sources of information options were mutually exclusive.
Sample size calculation
The sample size required for the current study was calculated using Epi-Info software (Centers for Disease Control and Prevention CDC, Piedmont, North Carolina, United States). The sample size for the current study was estimated at 384; for the proportion sample using 50% anticipated frequency, 5% absolute precision, and 95% confidence interval criteria.
Ethical approval for the present study was obtained from the Institutional Ethics Committee of M.P. Shah Government Medical College and Guru Gobindsingh Hospital, Jamnagar (Ref. no. IEC/Certi/06/01/2022).
Data entry and analysis was done using Microsoft Excel and Statistical Package for the Social Sciences version software (International Business Machines, Armonk, New York, United States). The correct responses of participants have been expressed in terms of frequency and percentage. MannWhitney U-test was applied to find the relation of gender, geographical area, and history of ECT in close relatives or friends, while the KruskalWallis test was for different age groups and education standards of participants with knowledge and attitude toward ECT scores. Pearson's correlation test was used to find the correlation between knowledge and attitude score. P < 0.05 was considered statistically significant.
| Results|| |
A total of 400 participants completed the study. Participants' ages ranged from 18 to 60 years. During the study, 22 caregivers refused to participate. Most of the participants belonged to the Hindu religion 272 (68.0%), followed by Muslims 100 (25.0%) and 28 (7.0%) others.
[Table 1] shows that participants have good knowledge about what is ECT, who can give it, the illness for which it is used, where the stimulus is given, certain investigations, and consent before the procedure. Participants have poor knowledge about who can receive ECT (inpatient and outpatient, pregnant, and elderly), its mechanism, duration of the stimulus, frequency per week and in one course of illness, the duration for which effect lasts, is a permanent cure, and efficacy compared to medication and side effects related to it (<50% response). However, they have average knowledge regarding the facts such as “ECT doesn't worsen the illness” and “given by special machine.”
|Table 1: Correct response of participants toward electroconvulsive therapy (n=400)|
Click here to view
[Table 2] shows that participants with higher education and whose close friends or relatives have taken ECT had statistically significant higher knowledge and positive attitude toward ECT. However, no statistical difference in knowledge and attitude concerning gender, geographical area, age of participants, type of illness, and patient's gender was found. “Mean rank” was calculated by “middle-ranking value” from an ordered list (low to high), giving the lowest rank is 1 and highest rank “n,” the middle rank is (1 + n)/2, which was calculated by using the MannWhitney and KruskalWallis test.
|Table 2: Relation of different variables with knowledge and attitude toward electroconvulsive therapy (n=400)|
Click here to view
[Table 3] shows that participants had a negative attitude toward ECT before education and the educational session has a statistically significant impact on changing attitude. After education, more than 80% agreed that if ECT is needed in the future, they will go and advise relatives about ECT.
|Table 3: Impact of education on attitude toward electroconvulsive therapy (n=400)|
Click here to view
Pearson's correlation test shows a positive relationship between knowledge and attitude toward ECT (r = 0.625, P < 0.001).
Participants who obtained information from a psychiatrist and any other doctor or staff had statistically significant higher knowledge (H = 128.094, P < 0.001) and a positive attitude toward ECT (H = 85.189, P < 0.001) than that of those who got information from TV/news/movies or friends/relatives who have not experienced ECT, as per Kruskal − Wallis test.
| Discussion|| |
The primary aim of the study was to assess the impact of education on knowledge and attitude toward ECT among caregivers of mentally ill patients. The current study observed that before education, participants had poor knowledge about who can receive ECT (inpatient and outpatient, pregnant, and elderly), its procedure, mechanism, and method of ECT. Previously, Dan et al., Kuruvilla et al., and Chavan et al. from India observed that patients and relatives had poor knowledge and acceptance of ECT as treatment. Golenkov et al. among the Chuvash general population observed that there was limited knowledge and generally negative attitudes about ECT. Furthermore, Grover et al. from India observed that a high proportion of participants have poor knowledge and negative attitude toward ECT, and the knowledge and attitude do not differ among those who agree and who refuse ECT.
The current study observed that participants with higher education and whose close friends or relative have taken ECT had statistically significant higher knowledge and positive attitude toward ECT. Furthermore, participants with higher knowledge about ECT had a more positive attitude toward it. Grover et al. reported that relatives of the ECT-treated group had more knowledge and a positive attitude toward ECT than the non-ECT group. Bustin et al. observed poor knowledge from a sample of three countries and a weak positive correlation between knowledge and attitude. He observed that knowledge is the most influential factor to change the attitude toward ECT. Meena and Samuel among caregivers of mentally ill patients from Madhya Pradesh, India, observed a moderately positive correlation between knowledge and attitude regarding knowledge and attitude regarding ECT. Manoj et al. observed a significant association between education and level of knowledge about ECT. This emphasizes that with an increase in knowledge, there is a development of a positive attitude regarding ECT among caregivers of mentally ill patients.
The current study observed that those participants who attained knowledge from a psychiatrist and any other doctor or staff had more knowledge and a positive attitude toward ECT than those through films or TV. Sienaert observed that movies and TV programs have depicted a negative and inaccurate image of ECT, as a painful and damaging treatment. Grover et al. observed that relatives of mentally ill patients who obtained their information from physicians were more aware and more positive about ECT than those who obtained their information from the media. Similar findings were obtained by Kerr et al., those who were highly educated or had any experience of ECT either personally or through a visited friend or relative showed less fear of procedure and more knowledge. This could be due to better explanation of treatment by doctors or staff leading to fewer misconceptions.
The current study did not observe any difference in knowledge and attitude concerning gender, geographical area, age of participants, type of illness, and patient's gender. Lauber et al. also observed uniform attitude of participants toward ECT as per demographic characteristics and individual or cultural context. Manoj et al. did not observe any significant association between knowledge and other sociodemographic variables such as age, sex, marital status, occupation, and socioeconomic status. However, Bustin et al. reported that knowledge, satisfaction, and attitude toward ECT were influenced by sociocultural and transcultural factors, which are not assessed in the current study.
The current study observed that there is a significant positive change in attitude toward ECT after education related to it. Nagarajan et al. among caregivers of mentally ill patients observed that a single video-assisted teaching program results in significant improvement of both knowledge and attitude. Previously, Sadeghian et al. conducted counseling sessions among the caregivers of mentally ill patients which was effective in reducing the stigma and improving their acceptance of ECT as a safe therapeutic strategy. Shamsaei et al. revealed that short-term educational intervention and counseling decreased the depression, anxiety, and stress level of family caregivers of patients with mental disorders receiving ECT and also improve the emotional outcomes of treatment in the family. Even Takamiya et al. in their study among mentally ill patients and caregivers concluded that with the development of anesthesia and muscle relaxants, modern ECT does not induce strong convulsions, the term electro-”convulsive” therapy to be an inappropriate name and could lead to misconceptions of modern ECT treatments.
The results of the current study suggest that the intervention was effective in improving knowledge and attitude toward ECT. Hence, more information about the basic facts, psychiatric applications, mechanism of action, and procedure to increase the level of awareness and knowledge about ECT improve acceptance among caregivers.
| Conclusion|| |
Participants lack some aspects related to ECT knowledge such as working mechanism, effect, efficacy compared to medication, and side effects related to it. Higher education and knowledge from close friends or relatives have changed their perception toward it. Educational or counseling sessions among caregivers are effective in changing attitude toward ECT and their willingness to undergo ECT for themselves as well as for their relatives if it is indicated as a treatment in future. Hence, more educational interventions are needed to reduce the stigma and thereby improve their acceptance of ECT as a safe therapeutic strategy.
This study was conducted at only one hospital, which limited the generalizability of our results. The study did not assess the nature of the relationship between the caregivers. Further, the absence of a control group and sociocultural and transcultural factors are the major limitations. The study assesses the effect of the intervention immediately after the session; therefore, the persistence of the educational effect on knowledge and attitude scores of the caregivers after a certain time could not be commented on.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Varcarolis E, Halter MJ. In: Halter MJ, editor. Foundations of Psychiatric Mental Health Nursing. A Clinical Approach. 6th
ed. London: Elsevier, Saunders; 2011.
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.
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.
Dowman J, Patel A, Rajput K. Electroconvulsive therapy: Attitudes and misconceptions. J ECT 2005;21:84-7.
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.
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.
Brodaty H, Berle D, Hickie I, Mason C. Perceptions of outcome from electroconvulsive therapy by depressed patients and psychiatrists. Aust N Z J Psychiatry 2003;37:196-9.
Goodman JA, Krahn LE, Smith GE, Rummans TA, Pileggi TS. Patient satisfaction with electroconvulsive therapy. Mayo Clin Proc 1999;74:967-71.
Apéria B. Hormone pattern and post-treatment attitudes in patients with major depressive disorder given electroconvulsive therapy. Acta Psychiatr Scand 1986;73:271-4.
Malekian A, Amini Z, Maracy MR, Barekatain M. Knowledge of attitude toward experience and satisfaction with electroconvulsive therapy in a sample of Iranian patients. J ECT 2009;25:106-12.
Kerr RA, McGrath JJ, O'Kearney RT, Price J. ECT: Misconceptions and attitudes. Aust N Z J Psychiatry 1982;16:43-9.
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.
Nagarajan P, Balachandar G, Menon V, Saravanan B. Effect of a video-assisted teaching program about ECT on knowledge and attitude of caregivers of patients with major mental illness. Indian J Psychol Med 2021;43:45-50.
Grover SK, Chakrabarti S, Khehra N, Rajagopal R. Does the experience of electroconvulsive therapy improve awareness and perceptions of treatment among relatives of patients? J ECT 2011;27:67-72.
Rajagopal R, Chakrabarti S, Grover S, Khehra N. Knowledge, experience & attitudes concerning electroconvulsive therapy among patients & their relatives. Indian J Med Res 2012;135:201-10.
] [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]
Kuruvilla T, Fenwick CD, Haque MS, Vassilas CA. Elderly depressed patients: What are their views on treatment options? Aging Ment Health 2006;10:204-6.
Chavan BS, Kumar S, Arun P, Bala C, Singh T. ECT: Knowledge and attitude among patients and their relatives. Indian J Psychiatry 2006;48:34-8.
] [Full text]
Golenkov A, Ungvari GS, Gazdag G. Public attitudes towards electroconvulsive therapy in the Chuvash Republic. Int J Soc Psychiatry 2012;58:289-94.
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 Ment Health Hum Behav 2021;26:92-9.
Meena SK, Samuel J. A study to assess the knowledge and attitude regarding electroconvulsive therapy among caregivers of mentally ill patients in selected government medical college attached hospital and hospital for mental health of Madhya Pradesh state with a view to develop pamphlet on it. Int J Nurs Med Invest 2021;6:61-5.
Manoj Kumar L, Eugin SB. Knowledge and attitude towards ECT among care givers of mentally ill clients and their socio demographic correlates: A cross sectional survey. Asian J Nurs Educ Res 2017;7:12-6.
Sienaert P. Based on a true story? The portrayal of ECT in international movies and television programs. Brain Stimul 2016;9:882-91.
Sadeghian E, Rostami P, Shamsaei F, Tapak L. The effect of counseling on stigma in psychiatric patients receiving electroconvulsive therapy: A clinical trial study. Neuropsychiatr Dis Treat 2019;15:3419-27.
Shamsaei F, Kazemian H, Cheraghi F, Farhadian M. The effect of family teaching on depression, anxiety and stress in caregivers of patients received electroconvulsive therapy. J Ment Health Train Educ Pract 2019;14:289-96.
Takamiya A, Sawada K, Mimura M, Kishimoto T. Attitudes toward electroconvulsive therapy among involuntary and voluntary patients. J ECT 2019;35:165-9.
[Table 1], [Table 2], [Table 3]