Patients' Opinions About Electroconvulsive Therapy: What Do Adolescents with Schizophrenia Spectrum Disorders Think?

Abstract

Objective:

The purpose of this study was to assess, in patients with schizophrenia spectrum disorders (SSD) who received electroconvulsive therapy (ECT) prior to the age of 18, their experience, knowledge, and attitudes toward ECT, and to compare the findings with those obtained in adolescents treated only with antipsychotics.

Methods:

Patients diagnosed with SSD (n = 19) and treated with ECT before the age of 18 years (ECT group; n = 19) were compared with a randomly selected group of patients with SSD treated only with antipsychotics (non-ECT group, n = 21). A self-administered questionnaire was used to assess their experience, knowledge, and attitudes.

Results:

Most adolescents in the ECT group thought that the intervention had been helpful (78.9%) and believed that their illness had been worse than ECT or medication (68.4%). Similarly, almost three quarters of these patients did not believe the treatment to be cruel (73.7%) or outdated (73.7%), or that it should be illegal (68.4%). Patients in the non-ECT group often chose “don't know” as their response to the survey questions, and significant differences between the groups were observed. Most patients in both the ECT group (84.2%) and the non-ECT group (80%) said that they would accept the treatment in the future if necessary, there being no differences between the groups in this respect (p = 0.2).

Conclusions:

Most adolescents in the ECT group had positive views about ECT. By contrast, most adolescents in the non-ECT group either did not know or did not have a clear opinion regarding ECT treatment, although they did not have negative views about it.

Introduction

Treatment for early-onset schizophrenia spectrum disorders (SSD) usually consists of antipsychotic treatment, as in the case of adult-onset SSD (Kumra et al. 2008; Mattai et al. 2010; McClellan and Stock 2013). However, in adults with antipsychotic-resistant SSD, electroconvulsive therapy (ECT) has been shown to be a safe and effective treatment (Tharyan and Adams 2005; Chanpattana and Andrade 2006). It has also proved useful in adult patients with catatonia or neuroleptic malignant syndrome (Trollor and Sachdev 1999; Fink and Taylor 2003; Fink 2013).

Indications for ECT treatment in adolescents with SSD are similar to those for adults (American Academy of Child and Adolescent Psychiatry [AACAP]) (Ghaziuddin et al. 2004): Resistance to psychotropic drugs (failure to respond to at least two adequate trials of appropriate psychopharmacological agents), intolerance of medication, contraindications for medication, or a specific clinical indication for ECT such as catatonia or neuroleptic malignant syndrome. Research on ECT in adolescents has shown that it is a safe and effective treatment for treatment-resistant SSD, catatonia, or neuroleptic malignant syndromes (Rey and Walter 1997; Walter and Rey 1997; Bloch et al. 2001; Stein et al. 2004; Suzuki et al. 2006; Bloch et al. 2008; Baeza et al. 2010; de la Serna et al. 2011; Flamarique et al. 2012, 2015). Most studies report only minor side effects, and only a few have reported tardive or prolonged seizures, with complete recovery in all cases (Schneekloth et al. 1993; Ghaziuddin et al 1996; Walter and Rey 1997; Bloch et al. 2008; Baeza et al. 2010; Flamarique et al. 2012). Regarding cognitive side effects, studies in adolescents have found that although they may be present in the short term (Ghaziuddin et al. 2000), they disappear in the long term (Cohen et al. 2000; Ghaziuddin et al. 2000; de la Serna et al. 2011).

Although ECT for adolescents with SSD seems a safe and effective option for resistant or severe cases, it remains underused in this population (Ghaziuddin and Walter 2013; Bernardo and Urretavizcaya 2015). There are several reasons for this, including a lack of knowledge among child psychiatrists about how to prescribe ECT, the limited knowledge regarding cognitive side effects in adolescents, legal restrictions on the use of ECT for adolescents in some countries, and the negative views of the general population and professionals themselves toward this treatment (Ottoson et al. 2004; Ghaziuddin and Walter 2013). Most studies of public opinion, all of them in adult samples, have found that knowledge about ECT appears to be inaccurate, and that people perceive the treatment in a highly negative light (Ghaziuddin and Walter 2013). One telephone survey by Lauber et al. (2005) found that 57% of respondents thought that ECT was harmful and only 1.2% considered it to be helpful (Lauber et al. 2005). Some films depicting ECT have contributed to the negative image of ECT, as most of them do not show the actual ECT procedure (McDonald and Walter 2009). However, not only the general public, but also some child psychiatrists, consider ECT to be a controversial or unethical treatment. Moreover, some studies have shown that child psychiatrists have little knowledge of how to administer or recommend ECT (Walter and Rey 1997; Ghaziuddin et al. 2001). In a random survey of child psychiatrists and psychologists, Ghaziuddin et al. (2001) found that only 16% of them knew a patient who had received the treatment, and 50% reported having minimal knowledge about ECT (Ghaziuddin et al. 2001).

Three surveys have been published about the experience and attitudes of adolescents treated with ECT (Walter et al. 1999; Taieb et al. 2001; Kalman et al. 2008). Walter et al. (1999) administered a questionnaire to 26 adolescents who had received ECT, most of whom had presented with a mood disorder at the time of treatment. On average, patients were 17 years old (range 15–18) when first treated with ECT, and they were interviewed 3 years later. Thirteen patients (50%) stated that ECT had been helpful. Patients reported memory impairment and confusion as the most common side effects associated with ECT. Most of them found ECT to be an acceptable treatment and less aversive than the illness for which it was given (73%). In addition, 18 patients (69%) said they would have ECT again if the treatment were advised by their doctor. The results of this survey suggested that recipients of ECT in adolescence have fairly positive attitudes toward ECT, with only three patients expressing strongly negative views (Walter et al. 1999). Taieb et al. (2001) interviewed 10 adolescents who had received ECT for a severe mood disorder before the age of 19 years old, after a mean of 4.5 years (range: 19 months to 9 years). In general, most patients had positive views regarding ECT. All of them reported that ECT had been helpful and 60% said that they would agree to it in the future (Taieb et al. 2001). Lastly, Kalman et al. (2008) surveyed 13 patients after a mean of 4.9 years since their first ECT. Most of these patients had a mood disorder (n = 10), and only three had a diagnosis of SSD. The general attitude toward ECT was positive: 69% reported that ECT was an effective and legitimate treatment and 66.7% believed that it should be used more often (Kalman et al. 2008). The most commonly reported side effects related to ECT in all these studies were memory impairment and confusion (Walter et al. 1999; Taieb et al. 2001; Kalman et al. 2008). Overall, the limited evidence regarding attitudes of adolescent patients who have undergone ECT suggests generally positive views. These attitudes contrast with public opinion about the use of ECT in young people, which tends to be more negative. To our knowledge, there are no published studies exploring opinions regarding ECT among adolescents who received the treatment exclusively for early-onset SSD, and which compare their views with those of peers treated only with medication.

The main aim of the present study was to assess the experience and knowledge of and attitudes toward ECT of patients with SSD who had received ECT prior to the age of 18. A further objective was to compare their knowledge and attitudes with those of a sample of patients with SSD who had been treated only with antipsychotics. We hypothesized that most patients with SSD and treated with ECT would have positive views about ECT, and that their views and attitudes would be more positive than those of patients with SSD treated only with antipsychotics.

Methods

Subjects and procedure

We reviewed all patients diagnosed with SSD (schizophrenia or schizoaffective disorder according to Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision [DSM-IV-TR]) between 2003 and 2012 and who, following admission to the inpatient ward of the Child and Adolescent Psychiatry Department of the Hospital Clinic (Barcelona), had been treated with ECT prior to the age of 18 (American Psychiatric Association 2000). The Hospital Clinic of Barcelona is a tertiary care academic teaching hospital, and, consequently, some of the patients had been referred from other clinics where ECT was not available. Before ECT is performed in this hospital, the ECT committee has to approve the indication for each patient in accordance with the recommendations and criteria of AACAP (Ghaziuddin et al. 2004). Written informed consent for ECT must also be provided by parents or legal guardians.

Of 325 patients hospitalized with a diagnosis of psychosis between 2003 and 2012, 164 were diagnosed with SSD after 1 year of follow-up. Of these 164 patients, 33 were treated with ECT and 131 only with antipsychotics. Of the 33 patients in the ECT group, 3 could not be reached by phone, and 9 refused to participate. A further two patients attended the research appointment but did not then answer the questionnaires; one of them complained about difficulties with concentration, whereas the other patient's parents did not want us to remind him about the period of the illness in which he had been hospitalized and received ECT. Nineteen patients of the group treated with ECT (57.57%) were finally included in the study (ECT group). At the time of interview, a mean of 3.7 years had passed since the last ECT treatment (range, 1–8 years). These patients in the ECT group had been included in a previous study that evaluated the long-term safety and effectiveness of ECT (Flamarique et al. 2015).

The comparison group was selected from among all patients hospitalized with a diagnosis of SSD but who had not undergone ECT during the same time period (n = 131). The stratified randomization method was used to select patients for the comparison group (Suresh 2011). The methodology is further explained in a previous report by our group (Flamarique et al. 2015). The comparison group comprised 21 patients (non-ECT group), and, consequently, the final sample consisted of 40 patients: 19 in the ECT group and 21 in the non-ECT group. The study was approved by the hospital's Ethical Review Board. Follow-up assessments were conducted with all patients who agreed to participate, and written informed consent was given by patients, or by patients and their parents in those still under the age of 18.

Survey

A 41-item self-administered questionnaire was used to assess the experience, knowledge and attitudes toward ECT of patients with SSD who had been treated with ECT prior to the age of 18 (ECT group). This questionnaire is a Spanish translation of the original instrument used by Walter and Rey (Walter et al. 1999), and it was adapted with their permission. From this 41-item questionnaire, 26 items were used to assess the knowledge and attitudes toward ECT of patients with SSD who were treated only with antipsychotics (non-ECT group). This 26 item questionnaire included the same questions as the 41 item questionnaire regarding knowledge and attitudes, because the items removed were those that asked specifically about the patient's personal experience with ECT.

General attitudes toward medication were assessed using the Drug Attitude Inventory (DAI) (Townsend et al. 2009). This is a 10 item self-administered questionnaire designed to assess the attitudes of patients with schizophrenia toward medication. Respondents have to answer “true” or “false” to 10 statements.

Data analysis

Descriptive statistics (percentages, means, and standard deviations) were used to summarize the results. Sociodemographic variables were compared between the two groups using the χ² test or the t test, as appropriate. The Kolmogorov–Smirnov and Levene tests were applied to assess the normality of the sample distribution and the equality of variances. Responses to questions regarding attitudes and knowledge about ECT and medication were also compared between the two groups using Fisher's exact test. All statistical analyses were performed using SPSS 20.0.

Results

Sociodemographic and clinical characteristics of the sample

There were no differences between the groups in terms of gender, diagnosis, age at time of assessment, or duration of illness. However, there were differences in the mean age at symptom onset (p = 0.005), with patients in the ECT group being younger. Comparative sociodemographic data are shown in Table 1. All patients in the sample were outpatients at the time of the follow-up assessment, and none were receiving ECT at this point. All patients, except for two in the ECT group, were receiving pharmacological treatment at follow-up.

Table 1.

Comparison of Sociodemographic and Clinical Variables Between Groups

Sociodemographic and clinical variables	ECT group (n = 19) (mean ± SD)	Non-ECT group (n = 21) (mean ± SD)	t^a/χ²	p value
Gender: male	10 (47.6%)	8 (42.1%)	0.761	0.488
Diagnosis
-Schizoaffective disorder	5	5	0.571	1.00
-Schizophrenia	14	16
Age at symptom onset (years)	14.79 ± 1.43	15.95 ± 0.86	3.062	0.005
Duration of illness (years)	5.68 ± 2.31	4.66 ± 2.35	−1.378	0.176
Age at time of assessment (years)	20.68 ± 2.62	20.76 ± 2.44	0.097	0.924

t test.

ECT, electroconvulsive therapy.

Questions about their experience of ECT (ECT group)

A total of 17 patients (89.5%) reported that they felt better than when they had received ECT. Only 3 (15.8%) patients did not remember the procedure of the treatment, whereas 12 remembered it only “a little” (66.7%). Regarding the reason for being treated with ECT, eight (42.1%) patients believed they had received ECT for schizophrenia, four (21.1%) thought it was for depression, three (15.8%) thought it was for other reasons, and four (21.1%) did not know or did not remember. None of them thought that ECT was given as punishment or to control unacceptable behavior. Most of them were not sure if they had received adequate information from doctors or mental health professionals (n = 11, 57.9%); four (21.1%) said that they had received adequate information, whereas the same number of patients reported the contrary. Eight (42.1%) patients thought, prior to receiving ECT, that it was going to be helpful, whereas four (21.1%) thought the opposite. However, 15 (78.9%) patients stated that it had helped them, 3 (15.8%) did not know or did not remember, and only 1 (5.3%) believed that it had not helped; none of them thought that it had made things worse.

Five patients (26.3%) said that they were not scared before the first session of ECT, five (26.3%) were a little bit scared, and six (31.6%) were very scared. When asked if ECT was more frightening than having something done at the dentist, six (31.6%) believed that it was less frightening, and nine (47.4%) believed that it was more frightening.

Ten (55.6%) patients reported side effects with ECT treatment. The most commonly reported side effects were confusion (n = 9; 47.4%), headache (n = 4; 21.1%), and nausea (n = 3; 15.8%). Regarding side effects related to medication, 11 (57.9%) patients reported some side effects: 7 (36.8%) patients reported confusion, 5 (26.3%) reported headache, and 3 (15.8%) reported nausea with medication. Eight (42.1%) patients reported memory problems associated with ECT, and five also reported memory problems associated with medication (47.4%). Four (21.1%) patients believed that both ECT and medication had improved their memory.

What patients usually found more upsetting about the ECT procedure was the injection. A total of 12 (63.2%) patients stated that the injection was a little or very upsetting, whereas 11 found the whole experience upsetting (57.9%). Waiting for the treatment was reported to be upsetting by six (31.6%) patients. Only 4 (21.1%) patients said that it upset them when people discovered that they had received this treatment, whereas 11 (57.9%) did not find this upsetting at all. When asked if they had tried to hide the fact that they had received this treatment, 14 (73.7%) patients said that they had not tried to hide it, although most of them had only discussed it with relatives (n = 13, 68.4%).

Most patients (n = 13; 68.4%) believed that their illness was worse than the ECT treatment or the medication. One patient (5.2%) believed that the medication was worse than the illness or ECT, and another patient (5.2%) thought that ECT had been worse. Four (21.1%) patients said that they did not know.

Comparison between groups regarding knowledge about ECT

More than half of the patients in both groups said that ECT was a treatment that “uses electric current to induce a seizure,” and that it was mainly used to treat patients with schizophrenia. There were no differences between the groups in this regard. None of the patients in either group thought that ECT was used as punishment or to control behavior, although most of them thought that it is not common for an adolescent to be treated with ECT. Most of them had heard about ECT through health professionals, with no differences between the groups in this respect. Only three patients in the non-ECT group and one in the ECT group had learned about ECT from the media. There were some differences between the groups regarding questions concerning the safety of ECT. Most patients in the ECT group reported that ECT was safe, whereas most patients in the non-ECT group answered “I don't know” to this question. More than half of the patients in the ECT group also thought that ECT did not leave permanent damage, whereas in the non-ECT group the large majority again answered “I don't know” to this question. The number of patients in the ECT group who believed that ECT was not more dangerous than medication was greater than the number who thought it was, whereas in the non-ECT group more than half of the patients said thatthey did not know. Table 2 shows the different questions and answers for both groups regarding knowledge about ECT.

Table 2.

Comparison of Knowledge About ECT Between Groups

Questions	ECT group	Non-ECT group	χ²	Fisher's exact test p value
Where did you learn about ECT?
1. From other patients who have had it	1 (5%)	2 (9.1%)	4.578	1
2. From relatives and friends	6 (30%)	2 (9.1%)
3. From doctors and/or other health professionals	10 (50%)	9 (40.9%)
4. From books, radio, TV, and films	1 (5%)	3 (13.6%)
5. Never heard of it / I don't know	2 (10%)	6 (27.3%)
What do you think ECT is?
1. A brain operation	2 (10.5%)	0	5.067	0.191
2. A treatment in which an electric current is used to induce a seizure	12 (63.2%)	14 (66.7%)
3. A form of brain washing	3 (15.8%)	1 (4.8%)
4. A type of punishment	0	0
5. Don't know	2 (10.5%)	6 (28.6%)
What do you understand ECT is usually used for? (tick as many options as needed)			5.242	0.779
1. Treatment of schizophrenia	15 (51.7%)	12 (50%)
2. Treatment of depression	6 (20.7%)	3 (12.5%)
3. Treatment of mania	1 (3.4%)	1 (4.2%)
4. Treatment of another disorder – if so, please specify	3 (10.3%)	9 (40.9%)
5. To control unacceptable behavior	0	0
6. As a punishment	0	0
7. Don't know or can't remember	4 (13.8%)	8 (33.3%)
How common do you think it is for an adolescent to have ECT?			2.338	0.515
1. Rare	10 (52.6%)	12 (57.1%)
2. Common	2 (10.5%)	0
3. Don't know	7 (36.8%)	9 (42.9%)
Do you think that ECT is a safe treatment?			15.993	<0.001
0. No	2 (10.5%)	3 (14.3%)
1. Yes	12 (63.2%)	1 (4.8%)
2. Don't know	5 (26.3%)	17 (81%)
Do you think ECT leaves a person with permanent damage?			14.174	<0.001
0. No	11 (57.9%)	1 (4.8%)
1. Yes	3 (15.8%)	4 (19%)
2. Don't know	5 (26.3%)	16 (76.2%)
Do you think ECT is generally more dangerous than medication?
0. No	7 (36.8%)	1 (4.8%)	6.550	0.044
1. Yes	4 (21.1%)	8 (38.1%)
2. Don't know	8 (42.1%)	12 (57.1%)

ECT, electroconvulsive therapy.

Comparison between groups regarding attitudes toward ECT and medication

Most patients in both groups said that they would accept the treatment in the future for themselves, either right away or if other treatments did not work, there being no differences between the groups in this respect. Most patients in the ECT group would suggest to other people that they accept the treatment if a doctor recommended it, although 15.7% would not accept it under any circumstances. There were no differences between the groups regarding this question.

As for whether ECT should be administered to young people, no differences were found between the groups, with a similar proportion of patients in both groups stating that it should not be given to young people (19–21%). However, there were differences in responses to the questions that asked if ECT was cruel, inhumane, outdated or if it should be illegal. Most patients in the ECT group had positive attitudes toward ECT and thought that it was not cruel or outdated, that it was humane, and that it should not be outlawed. However, most patients in the non-ECT group answered “I don't know” to this question. There were no differences between the groups regarding the legitimacy of the treatment. It is of note that the three patients in the non-ECT group who had learned about the treatment from the media had negative views about it, and two of them thought that it should be illegal. Data for both groups about attitudes toward ECT are shown in Tables 3 and 4.

Table 3.

Comparison of Attitudes Toward ECT Between Groups

Questions	ECT group	Non-ECT group	χ²	Fisher's exact test p value
How soon would you agree to ECT if recommended in the future?
1. Would agree to it right away	6 (31.6%)	2 (10%)	2.786	0.287
2. Would agree to it if medication or other treatments didn't work	10 (52.6%)	14 (70%)
3. Would not agree to it under any circumstances	3 (15.8%)	4 (20%)
If a doctor recommended that a family member or friend have ECT, would you suggest:			1.997	0.577
1. That he/she agree to it right away	4 (21.1%)	2 (9.5%)
2. That he/she agree to it only if medication or other treatments didn't work	8 (42.1%)	7 (33.3%)
3. That he/she not agree to ECT under any circumstances	2 (10.5%)	4 (19%)
4. Don't know	5 (26.3%)	8 (38.1%)
Do you think that ECT should be given to young people?
0. No	4 (21.1%)	4 (19%)	3.041	0.223
1. Yes	8 (42.1%)	4 (19%)
2. Don't know	7 (36.8%)	13 (61.9%)

ECT, electroconvulsive therapy.

Table 4.

Comparison of Attitudes Toward ECT and Medication Between Groups

	Attitudes toward ECT				Attitudes toward medication
Questions	ECT group	Non-ECT group	χ²	Fisher's exact test p value	ECT group	Non-ECT group	χ²	Fisher's exact test p value
Do you think ECT/medication is cruel:			14.590	<0.001
0. No	14 (73.7%)	3 (14.3%)			15 (78.9%)	13 (61.9%)	1.532	0.548
1. Yes	2 (10.5%)	5 (23.8%)			2 (10.5%)	3 (14.3%)
2. Don't know	3 (15.8%)	13 (61.9%)			2 (10.5%)	5 (23.8%)
Do you think ECT/medication is humane:
0. No	3 (15.8%)	4 (19%)	11.026	0.003	2 (10.5%)	1 (4.8%)	3.162	0.258
1. Yes	12 (63.2%)	3 (14.3%)			15 (78.9%)	13 (61.9%)
2. Don't know	4 (21.1%)	14 (66.7%)			2 (10.5%)	7 (33.3%)
Do you think ECT/medication is outdated:
0. No	14 (73.7%)	3 (14.3%)	14.409	<0.001	16 (84.2%)	11 (52.4%)	4.615	0.138
1. Yes	1 (5.3%)	4 (19%)			1 (5.3%)	3 (14.3%)
2. Don't know	4 (21.1%)	14 (66.7%)			2 (10.5%)	7 (33.3%)
Do you think ECT/medication should be outlawed:
0. No	13 (68.4%)	4 (19%)	9.953	0.005	18 (94.7%)	13 (61.9%)	6.389	0.034
1. Yes	1 (5.3%)	3 (14.3%)			0	3 (14.3%)
2. Don't know	5 (47.5%)	14 (66.7%)			1 (5.3%)	5 (23.8%)
Do you think ECT/medication is a legitimate treatment when used in appropriate situations:
0. No	2 (11.1%)	1 (4.8%)	1.776	0.430	1 (5.3%)	0	1.338	0.72
1. Yes	10 (55.6%)	8 (38.1%)			14 (73.7%)	15 (71.4%)
2. Don't know	7 (47.5%)	12 (57.1%)			4 (21.1%)	6 (28.6%)

ECT, electroconvulsive therapy.

Regarding attitudes toward medication, patients' attitudes in both groups were similar and generally positive. Differences were only found when patients were asked if medication should be illegal; none of the patients in the ECT group said that it should be illegal, whereas three (15.3%) in the non-ECT group thought that it should. Data about attitudes toward medication are shown in Table 4. There were no differences between the ECT group (16 ± 2.39) and the non-ECT group (15.93 ± 2.15; t test = −0.80, p = 0.937) regarding the DAI total score, which measures attitudes toward medication.

Patients were given the opportunity to add comments at the end of the questionnaire. More patients in the ECT group found the questionnaire useful than was the case in the non-ECT group (n = 13 vs. n = 5; χ² = 9.288, p = 0.026). One patient said that “thanks to ECT I am perfectly fine now.” Another patient added that he “would like to see the ECT treatment.” Another patient said that “he did not like ECT due to headache, anaesthesia and dizziness.” One patient also added that “some questions were difficult to understand.”

Discussion

The main finding of this study was that most adolescents with SSD and treated with ECT had positive views about the treatment. Moreover, although in the non-ECT group patients either did not know about or did not have a clear opinion regarding ECT treatment, they did not have negative views or misconceptions about it. Most adolescents in the ECT group thought that it had been helpful, and believed that their illness had been worse than ECT treatment. Regarding the comparison between adolescents in the ECT and non-ECT groups, more than half of the patients in both groups had an acceptable degree of knowledge about what the treatment involved. None of them thought that it is used as punishment or to control behavior. Most patients in both groups said that they would accept the treatment in the future, and no differences were observed between the groups in this regard. More than half of the patients in the ECT group thought that it was a legitimate treatment and that it was not cruel or outdated, whereas patients in the non-ECT group did not know what to answer in this respect.

Overall, most of our patients treated with ECT had positive views about the treatment, a finding that is in line with previous surveys of adolescents treated with ECT (Walter et al. 1999; Taieb et al. 2001; Kalman et al. 2008). Studies assessing opinions about ECT in adult patients with SSD treated with ECT have generally found that they have positive views about the treatment (Tang et al. 2002; Virit et al. 2007; Chakrabarti et al. 2010; Rajagopal et al. 2012; Little 2015). By contrast, attitudinal studies of public opinion in adult samples have mainly found highly negative views toward ECT treatment (Jorm et al. 1997; Lauber et al. 2005; Teh et al. 2007; McFarquhar and Thompson 2008). No studies have previously assessed the views about ECT of adolescents with SSD who were treated only with antipsychotics, and only three adolescents treated with ECT in Kalman's study were diagnosed with SSD (Kalman et al. 2008).

As regards the adequacy of information received about ECT, 57.6% of the patients in our ECT group were not sure if they had received adequate information about the treatment. This is consistent with one previous study in which half of the patients did not remember whether explanations had been given (Taieb et al. 2001), but contrasts with the findings of two other studies in which most adolescents thought that they had received adequate information (Walter et al. 1999; Kalman et al. 2008). These results highlight the need for us to address the adequacy of the information given to our patients, and specifically to improve it.

A total of 78.9% of patients in the ECT group stated that ECT had helped them, and only one said that it had not helped. None of them believed that it had made things worse. These results are in line with a previous report in which 100% of patients believed that it had been helpful (Taieb et al. 2001), but differ somewhat from what Walter found: 50% believed that it had been helpful and 11.53% thought that it had made things worse (Walter et al. 1999). Eleven patients (57.9%) in our ECT group said that they were a little bit or very scared before the first session of ECT. This is a very similar percentage to what was found in two previous reports, in which 58–60% of patients said that they had been scared of the treatment (Walter et al. 1999; Taieb et al. 2001). It is possible that a better explanation of the treatment, a visit to the setting in which it will be administered, or talking to other adolescents who have already received the treatment, could help reduce fear of the procedure.

Regarding side effects of ECT, the most commonly reported were memory problems and confusion, as in previous studies. Consistent with the findings of Walter, similar side effects were reported in association with medication (Walter et al. 1999). However, fewer patients in our sample reported side effects than in these two previous studies (Walter et al. 1999; Taieb et al. 2001). What patients in our sample found more upsetting about the treatment was the anesthetic injection, as was found in the survey conducted by Taieb et al (2001). Interestingly, most patients in our ECT group were not upset when other people discovered that they had received this treatment, whereas in Walter's report most patients were upset about this (Walter et al. 1999). It is also important to point out that most patients in the ECT group (68.4%) believed that their illness was worse than ECT treatment or medication. This is similar to what Walter et al. found, as 73% of their patients stated that the illness was worse than ECT (Walter et al. 1999).

Regarding the comparison between adolescents in the ECT group and those treated only with antipsychotics (non-ECT group) in terms of their knowledge about ECT, we found no differences in several aspects of knowledge, such as what ECT is, or the source from which information about ECT was obtained. Most patients in both groups understood that ECT consists of a seizure induced by an electric current, this being similar to what Walter found in a sample of adolescents with mood disorder treated with ECT (Walter et al. 1999). Patients in both groups had learnt about ECT mainly from health professionals. The media was only cited as a source of information by one (5.3%) patient in the ECT group and by three (13.6%) patients in the non-ECT group. Interestingly, these latter three cases held negative views about the treatment, with two of them reporting that it should be illegal. In public opinion surveys, most people's knowledge about ECT is reported as coming from the media, and the general public also have more negative views than do our patients (Kerr et al. 1982; O'Shea and McGennis 1983; Teh et al. 2007; McFarquhar and Thompson 2008). Moreover, none of the patients in our sample thought that ECT is used as a punishment or to control behavior. In Walter's report, 8% of patients believed that it is used to control behavior, but several patients (31%) also cited the media as a source of information about ECT, with two of them mentioning the film One Flew Over the Cuckoo's Nest (Walter et al. 1999). It is important to point out that the media does not usually depict the actual ECT procedure (McDonald and Walter 2009). The fact that only one patient in our ECT group had heard about this treatment from the media could be explained by the age of the respondents, similar to that in Walter's report (Walter et al. 1999), but it is also possible that the influence of films such as the one mentioned above has waned over time. A reduced influence of the media might, therefore, imply less negative attitudes toward ECT, as it does not lead to misconceptions or fears.

Regarding the usual indications for ECT, most patients in both our groups believed it is used in schizophrenia, and only a few thought it is used in depression. In Walter's report, the majority stated that depression was a common indication for ECT (Walter et al. 1999). These differences may be explained by the most common diagnosis in each study. With regard to safety, the number of patients in our ECT group who thought the treatment was unsafe was lower than that reported previously (Walter et al. 1999), although in both studies, only a minority of patients stated that ECT was unsafe. In general, adolescents in the non-ECT group did not know or did not have enough knowledge to answer questions such as whether ECT was safe or left permanent damage.

Regarding attitudes toward ECT, the majority of patients in both groups would accept the treatment in the future, either right away or if other treatments did not work, and they would suggest to other people that they agree to it if recommended by a doctor. These results are consistent with what has been found in the literature on adolescents treated with ECT (Walter et al. 1999; Taieb et al. 2001). A minority of our patients (26.3%) thought that ECT should not be given to young people, a finding that is also in line with Walter's report (Walter et al. 1999).

Our results also show that more than half of the patients in the ECT group thought it is not a cruel or outdated treatment, that it should not be outlawed, and that it is a legitimate treatment when used in appropriate situations. These findings are consistent with previous attitudinal studies of adolescents treated with ECT (Walter et al. 1999; Kalman et al. 2008). Patients in our non-ECT group were more likely than those in the ECT group to answer “I don't know” to questions about whether it was a cruel, inhumane, or outdated treatment, or whether it should be outlawed. However, these differences were not observed for the question about the legitimacy of ECT when appropriately used. With regard to opinions about medication, both groups generally had positive views about medication, a finding that is similar to the previous report by Walter et al. (1999). In general, attitudes in the non-ECT group were not negative, although knowledge about the treatment was partial, and some of these patients had never heard of ECT. These findings are consistent with what was found in a sample of adult patients with depression who had received only pharmacological and/or psychological treatment (Sestoft et al. 1998).

The main limitation of this study is the small sample size, reflecting the fact that treatment with ECT is not common in adolescents. A further issue is that patients who did not attend the research interview may have had more negative views about ECT than do those who participated in the study. It is also possible that patients may have had some difficulty recalling the information requested, as in several cases a considerable amount of time had passed since they had received ECT.

The study also has a number of strengths. To our knowledge, it is the first report of attitudes toward ECT in a sample of adolescents with SSD and treated with ECT in which their views are compared with those of patients treated with antipsychotics alone. A further strength is that the control group was randomly selected and matched with the ECT group by age, sex, diagnosis, and duration of illness.

Conclusions

In summary, our data show that most adolescents with SSD and treated with ECT had positive views about the treatment. Furthermore, adolescents treated with antipsychotics only did not generally have negative views about ECT, although some of them had not heard of it or did not have a clear opinion about it.

Clinical Significance

It is important to assess the views and experience of patients who undergo ECT in order to demonstrate that patients consider it to be a safe and effective procedure in most cases. This information can help to counteract the stigma associated with this treatment.

Footnotes

Acknowledgments

The authors thank all of the patients and their families for participating. They also thank Garry Walter and Joseph Rey for their permission to use and translate the questionnaires.

Disclosures

Itziar Flamarique, Elena de la Serna, Alexandre Pons, and Josefina Castro-Fornieles affirm that they have no conflicts of interest. Miguel Bernardo received consulting fees from Bristol-Myers Squibb-Otsuka, Janssen-Cilag, and Wyeth. Inmaculada Baeza has been a speaker for Janssen and has received travel support from Otsuka.

References

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision. Washington, DC: American Psychiatric Association; 2000.

Baeza

, Flamarique

, Garrido

, Horga

, Pons

, Bernardo

, Morer

, Lázaro

, Castro-Fornieles

: Clinical experience using electroconvulsive therapy in adolescents with schizophrenia spectrum disorders. J Child Adolesc Psychopharmacol, 20:205–209, 2010.

Bernardo

, Urretavizcaya

: Dignifying electroconvulsive therapy based on evidence [in Spanish]. Rev Psiquiatr Salud Ment, 8:51–54, 2015.

Bloch

, Levcovitch

, Bloch

, Mendlovic

, Ratzoni

: Electroconvulsive therapy in adolescents: Similarities to and differences from adults. J Am Acad Child Adolesc Psychiatry, 40:1332–1336, 2001.

Bloch

, Sobol

, Levkovitz

, Kron

, Ratzoni

: Reasons for referral for electroconvulsive therapy: A comparison between adolescents and adults. Australas Psychiatry, 16:191–194, 2008.

Chakrabarti

, Grover

, Rajagopal

: Electroconvulsive therapy: A review of knowledge, experience and attitudes of patients concerning the treatment. World J Biol Psychiatry, 11:525–37, 2010.

Chanpattana

, Andrade

: ECT for treatment-resistant schizophrenia: A response from the Far East to the UK. NICE report. J ECT, 22:4–12, 2006.

Cohen

, Taieb

, Flament

, Benoit

, Chevret

, Corcos

, Fossati

, Jeammet

, Allilaire

, Basquin

: Absence of cognitive impairment at long-term follow-up in adolescents treated with ECT for severe mood disorder. Am J Psychiatry, 157:460–462, 2000.

de la Serna

, Flamarique

, Castro–Fornieles

, Pons

, Puig

, Andrés–Perpiña

, Lázaro

, Garrido

, Bernardo

, Baeza

: Two-year follow-up of cognitive functions in schizophrenia spectrum disorders of adolescent patients treated with ECT. J Child Adolesc Psychopharmacol, 21:611–619, 2011.

10.

Fink

: Rediscovering catatonia: The biography of a treatable syndrome. Acta Psychiatr Scand, 127(s441):1–47, 2013.

11.

Fink

, Taylor

: Catatonia: A Clinician's Guide to Diagnosis and Treatment. Cambridge: Cambridge University Press; 2003.

12.

Flamarique

, Baeza

, de la Serna

, Pons

, Bernardo

, Castro–Fornieles

: Long-term effectiveness of electroconvulsive therapy in adolescents with schizophrenia spectrum disorders. Eur Child Adolesc Psychiatry, 24:517–24, 2015.

13.

Flamarique

, Castro–Fornieles

, Garrido

, de la Serna

, Pons

, Bernardo

, Baeza

: Electroconvulsive therapy and clozapine in adolescents with schizophrenia spectrum disorders: Is it a safe and effective combination?. J Clin Psychopharmacol, 32:756–766, 2012.

14.

Ghaziuddin

, Kaza

, Ghazi

, King

, Walter

, Rey

: Electroconvulsive therapy for minors: experiences and attitudes of child psychiatrists and psychologists. J ECT, 17:109–117, 2001.

15.

Ghaziuddin

, King

, Naylor

, Ghaziuddin

, Chaudhary

, Giordani

, Dequardo

, Tandon

, Greden

: Electroconvulsive treatment in adolescents with pharmacotherapy-refractory depression. J Child Adolesc Psychopharmacol, 6:259–271, 1996.

16.

Ghaziuddin

, Kutcher

, Knapp

, Bernet

, Arnold

, Beitchman

, Benson

, Bukstein

, Kinlan

, McClellan

, Rue

, Shaw

, Stock

, Kroeger Ptakowski

, Work Group on Quality Issues AACAP: Practice parameter for use of electroconvulsive therapy with adolescents. J Am Acad Child Adolesc Psychiatry, 43:1521–1539, 2004.

17.

Ghaziuddin

, Laughrin

, Giordani: Cognitive side effects of electroconvulsive therapy in adolescents. J Child Adolesc Psychopharmacol, 10:269–276, 2000.

18.

Ghaziuddin

, Walter

: Electroconvulsive therapy in children and adolescents. New York: Oxford University Press; 2013.

19.

Jorm

, Korten

, Rodgers

, Pollitt

, Jacomb

, Christensen

, Jiao

: Belief systems of the general public concerning the appropriate treatments for mental disorders. Soc Psychiatry Psychiatr Epidemiol, 32:468–73, 1997.

20.

Kalman

, Luria

, Linder

, Ratzoni

, Levkovitz

, Braw

, Linder

, Bloch

: Electroconvulsive therapy in adolescents: Patient attitudes, satisfaction and informed consent procedures. Int J Child Adolesc Health, 1:199–205, 2008.

21.

Kerr

, McGrath

, O'Kearney

, Price

: ECT: misconceptions and attitudes. Aust N Z J Psychiatry. 16:43–49, 1982.

22.

Kumra

, Oberstar

, Sikich

, Findling

, McClellan

, Vinogradov

, Charles Schulz

: Efficacy and tolerability of second-generation antipsychotics in children and adolescents with schizophrenia. Schizophr Bull, 34:60–71, 2008.

23.

Lauber

, Nordt

, Falcato

, Rössler

: Can a seizure help?. The public's attitude toward electroconvulsive therapy. Psychiatry Res, 134:205–209, 2005.

24.

Little

: Attitudes toward electroconvulsive therapy compared with cardioversion. J ECT, 39:179–181, 2015.

25.

Mattai

, Hill

, Lenroot

: Treatment of early-onset schizophrenia. Curr Opin Psychiatry, 23:304–310, 2010.

26.

McClellan

, Stock

: American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI). Practice parameter for the assessment and treatment of children and adolescents with schizophrenia. J Am Acad Child Adolesc Psychiatry, 52:976–990, 2013.

27.

McDonald

, Walter

: Hollywood and ECT. Int Rev Psychiatry, 21:200–206, 2009.

28.

McFarquhar

, Thompson

: Knowledge and attitudes regarding electroconvulsive therapy among medical students and the general public. J ECT, 24:244–253, 2008.

29.

O'Shea

, McGennis

: ECT: Lay attitudes and experiences—a pilot study. Ir Med J, 76:40–43, 1983.

30.

Ottosson

, Fink

: Ethics in Electroconvulsive Therapy. New York: Routledge; 2004.

31.

Rajagopal

, Chakrabarti

, Grover

, Khehra

: Knowledge, experience & attitudes concerning electroconvulsive therapy among patients & their relatives. Indian J Med Res, 135:201–210, 2012.

32.

Rey

, Walter

: Half a century of ECT use in young people. Am J Psychiatry, 154:595–602, 1997.

33.

Sestoft

, Pederson

, Bendsen

, Hancke

, Larsen

, Mikkelsen

, Undén

, Kreiner

: The effect of electroconvulsive therapy on patients' attitudes to treatment of depression. Nord J Psychiatry, 52:31–37, 1998.

34.

Schneekloth

, Rummans

, Logan

: Electroconvulsive therapy in adolescents. Convuls Ther, 9:158–166, 1993.

35.

Stein

, Kurtsman

, Stier

, Remnik

, Meged

, Weizman

: Electroconvulsive therapy in adolescent and adult psychiatric inpatients—a retrospective chart design. J Affect Disord, 82:335–342, 2004.

36.

Suresh

: An overview of randomization techniques: an unbiased assessment of outcome in clinical research. J Hum Reprod Sci, 4:8–11, 2011.

37.

Suzuki

, Awata

, Takano

, Ebina

, Takamatsu

, Kajiwara

, Ito

, Shindo

, Funakoshi

, Matsuoka

: Improvement of psychiatric symptoms after electroconvulsive therapy in young adults with intractable first-episode schizophrenia and schizophreniform disorder. Tohoku J Exp Med, 210:213–220, 2006.

38.

Taieb

, Flament

, Corcos

, Jeammet

, Basquin

, Mazet

, Cohen

: Electroconvulsive therapy in adolescents with mood disorder: Patients' and parents' attitudes. Psychiatry Res, 104:183–90, 2001.

39.

Tang

, Ungvari

, Chan

: Patients' and their relatives' knowledge of, experience with, attitude toward, and satisfaction with electroconvulsive therapy in Hong Kong, China. J ECT, 18:207–212, 2002.

40.

Teh

, Helmes

, Drake

: A Western Australian survey on public attitudes toward and knowledge of electroconvulsive therapy. Int J Soc Psychiatry, 53:247–73, 2007.

41.

Tharyan

, Adams

: Electroconvulsive therapy for schizophrenia. Cochrane Database Syst Rev, 18:CD000076, 2005.

42.

Townsend

, Floersch

, Findling

: Adolescent attitudes toward psychiatric medication: The utility of the Drug Attitude Inventory. J Child Psychol Psychiatry, 50:1523–31, 2009.

43.

Trollor

, Sachdev

: Electroconvulsive treatment of neuroleptic malignant syndrome: a review and report of cases. Aust N Z J Psychiatry, 33:650–659, 1999.

44.

Virit

, Ayar

, Savas

, Yumru

, Selek

: Patients' and their relatives' attitudes toward electroconvulsive therapy in bipolar disorder. J ECT, 23:255–259, 2007.

45.

Walter

, Koster

, Rey

: Views about treatment among parents of adolescents who received electroconvulsive therapy. Psychiatr Serv, 50:701–702, 1999.

46.

Walter

, Rey

: An epidemiological study of the use of ECT in adolescents. J Am Acad Child Adolesc Psychiatry, 36:809–815, 1997.