Public attitudes towards electroconvulsive therapy in the Chuvash Republic

Abstract

Background: Public attitudes towards a given medical procedure can have a significant influence on the employment of that method. Electroconvulsive therapy (ECT) is a medical procedure that has received an exceptionally ambiguous public reception since its inception.

Aim: To survey the level of information about and attitudes towards ECT in a general population sample of the Chuvash Republic of the Russian Federation.

Methods: A randomly selected cohort of 5,373 people was contacted by telephone. The respondents were asked three closed and three open questions.

Results: The response rate was 74.7%. Only 35.2% of those interviewed said they knew anything about ECT. Health professionals and younger respondents were better informed. The two main sources of information about ECT were foreign films and the mass media. The main indication of ECT was thought to be schizophrenia. The majority (63.3%) of the respondents had negative opinions and emotions about ECT.

Conclusion: Limited information about and generally negative attitudes towards ECT were found in the general population of the Chuvash Republic. Gender, age, education level, employment in the health industry, and information source were found to be the determining factors in the knowledge of and attitudes towards ECT.

Keywords

attitude Chuvash Republic electroconvulsive therapy (ECT)knowledge

Introduction

Electroconvulsive therapy (ECT), which was introduced into clinical practice more than 70 years ago (Shorter and Healy, 2007), has remained the most controversial treatment method in psychiatry since its inception. Partly due to its excessive and indiscriminate use in the past (Gazdag et al., 2007) and its distorted portrayal in the mass media (Euba and Crugel, 2009), a balanced view of ECT as a treatment option used in very carefully selected cases and under close ethical scrutiny has not gained wide currency even in medical circles. In most modern treatment guidelines the indication of ECT is mainly restricted to severe, treatment-resistant depression, particularly with high risk of suicide, extreme manic agitation and stupor with refusal of nourishment (American Psychiatric Association, 2001; Royal College of Psychiatrists, 2005). Attitudes towards ECT have been ambiguous even among psychiatrists (Byrne et al., 2006; Dowman et al., 2005, Finch et al., 1999; Gazdag et al., 2004; Golenkov et al., 2010), although attitudes depend on the amount of time spent in clinical practice, medical education, the place and type of employment, and the characteristics of patients seen by the psychiatrist (Gazdag et al., 2004, Golenkov et al., 2010; Hermann et al., 1998). Several other factors have an impact on attitudes towards ECT, including educational programmes (Warnell et al., 2005), ECT training sessions (Chanpattana, 1999; Oldewening et al., 2007) and witnessing a treatment session (Gazdag et al., 2009), all of which have proved to be influential in such attitudes among medical students. Patients who underwent ECT regularly rate their experiences more negatively in patient-led studies (Rose et al., 2003, 2005) than in those initiated by professionals (Malekian et al., 2009; Sienaert et al., 2005) and report a lower rate of satisfaction and higher rate of memory loss in these studies.

A generally negative attitude towards psychiatric patients and psychiatric treatment methods is a worldwide phenomenon (Jorm et al., 2006; Thornicroft, 2006), with the general population being particularly poorly informed about ECT (Lauber et al., 2005; Teh et al., 2007). In the small number of representative studies, predominantly negative attitudes towards ECT have been demonstrated in the general public of Switzerland and Australia (Lauber et al., 2005; Teh et al., 2007). Previous studies have investigated respondents’ views of the use of ECT in schizophrenia and depression and the influence of demographic, psychological, social and cultural factors on attitudes towards ECT (Dowman et al., 2005; Kalayam and Steinhart, 1981; Lauber et al., 2005).

ECT is rarely used in Russia relative to other countries (Nelson, 2005a); Russian hospitals with an ECT department serve only 22.4% of the population. In 2005, 1.43% of inpatients with a psychiatric disorder in the Russian Federation received ECT (Nelson, 2005a). More worryingly, modified ECT was administered in less than 20% of courses in Russia (Nelson, 2005a). The main obstacles to establishing an ECT service are a lack of professional knowledge and equipment. The implementation of more ECT training programmes for mental health professionals is needed, while research studies on ECT in Russia are few and far between (Nelson, 2005a).

A recent report from the Chuvash Republic, which is part of the Russian Federation, confirmed health professionals’ negative attitude towards and insufficient knowledge of ECT: medical practitioners frequently opined that ECT causes brain damage; nurses considered it to be a painful procedure and a ‘means of last resort’, and medical students described it as an old-fashioned method that poses a danger to the patient’s life (Golenkov, 2009). To date, no data on the attitudes of the Chuvash general public towards ECT have been collected.

The aim of this study was to explore the knowledge of and attitudes towards ECT in the general populace of the Chuvash Republic.

Methods

A telephone survey organized according to standard recommendations (Walker, 1998) was conducted. There are about 112,000 landline telephone subscribers in Cheboksary, the capital of the Chuvash Republic. Every 20th phone number was selected and those answering were asked to participate in a brief interview (Devyatko, 2002). Only respondents above the age of 16 were included.

In addition to being requested to provide basic sociodemographic data, respondents were asked if they had heard about ECT at all. Those who answered affirmatively were asked an additional five questions about ECT, two of which were closed, requiring an answer of ‘yes’ ‘no’, or ‘I do not know’, and three were open-ended questions, which focused on the source of information, the indications of ECT and the emotions it provoked (Appendix). On the basis of the answers regarding the emotions ECT provoked, respondents were categorized into negative, neutral and positive attitude groups.

The data were analysed using Version 10.0 of the SPSS software package. Descriptive statistical data are given here as means with standard deviation and percentages. Continuous data were compared with t-tests, and categorical variables with χ² tests. When the conditions for the χ² square tests were not met, 2×2 contingency tables were analysed with the two-tailed Fisher’s exact test. Correlation analysis was carried out using Pearson’s test.

Results

The response rate was 74.7% (4,015 out of the 5,373 persons contacted by telephone). Lack of time and unwillingness to participate in the survey were the two main reasons for refusal.

Of the 4,015 respondents (1,822 men and 2,193 women; age: 35+15.05 years; range: 16–89 years), 1,744 (43.4%) had a university degree, 913 (22.7%) had a college degree, 1,358 (33.8%) had completed secondary school; 436 (10.9%) were health professionals comprising 294 doctors and 142 nurses. The high percentage of health professionals in the sample can be explained by the priority given to such individuals in the distribution of landlines in the Chuvash Republic.

Only 1,414 respondents (35.2%) had heard of ECT at all; the highest rate of such knowledge was in the under-50 age group (36%) and the lowest in the over-70 group (12%; Figure 1). There was a significant difference between genders (33.5% vs 36.6%; p = 0.040), with higher representation of females. Health professionals were significantly better informed about ECT than the rest of respondents (83.8% vs 35.2%; p < 0.001), with no difference between doctors and nurses (84.7% vs 83.1%; p = 0.668).

Figure 1.

The percentage of respondents according to age and information about ECT

The respondents who knew nothing at all about ECT had a lower education level (p < 0.001; Table 1) and were older (36.3±15.9 vs 33.8±13.2 years; p < 0.001).

Table 1.

The percentage of respondents according to education level and information about ECT

Education level	Informed	Not informed
University degree	757 (43.4%)	987 (56.6%)
College degree	304 (33.3%)	609 (66.7%)
Secondary school	353 (26.0%)	1,005 (74.0%)

Three hundred and sixty three (25.7%) of the 1,414 in the informed group could name at least one psychiatric disorder as an indication for ECT: schizophrenia (47.9%), depression (11.8%), epilepsy (9.4%), psychoses (8.8%), borderline personality disorder (8.2%), substance dependence (6.1%) and suicidal behaviour (1.7%) were the most frequently mentioned. Significantly more health professionals were able to answer this question (32.2% vs 23.4%; χ² = 10,909; p < 0.001); the most frequently mentioned indications were schizophrenia (p < 0.001), psychoses (p < 0.001) and depression (p < 0.001). Respondents without medical education were more likely to name substance-related disorders (p = 0.047).

Films were the main source of information about ECT for 33.6% of the informed respondents, followed by the mass media (20.2%), friends and acquaintances (18.6%), books (15.3%), medical school or university (4.5%), and the Internet (4%); 3.8% were unable to recall the source. Of the 20 films on the list, the most frequently mentioned were two American films, Requiem for a Dream and One Flew over the Cuckoo’s Nest, and one Russian, The Cage.

As for attitudes, 895 (63.3%) of the informed respondents expressed negative emotions/attitudes towards ECT, 15.8% were neutral, 11.7% were positive, and 3.1% had no emotional attitude towards the treatment. The harsh or negative words (17.1%) used to characterize emotions included ‘horror’, ‘severe shock’, ‘terrible’, ‘disgust’, ‘indignant’, ‘torture’, ‘mockery’, ‘violence’, ‘nightmare’ and ‘inhumane’, although respondents rarely mentioned banning or restricting ECT. Positive opinions included ‘a good method’, ‘I approve its application’, ‘a necessary, useful procedure’, ‘it helps’ and ‘I am glad that there is an effective treatment for mental disorders’.

When asked about the effectiveness of ECT, 40.7% considered it as an effective treatment modality for psychiatric disorders, whereas 15.6% thought it was ineffective and 43.7% had no firm opinion. A few respondents (3.6%) opined that ECT can decrease ‘aggression’, ‘excitation’, ‘violence’, ‘a lack of balance’ and ‘uncontrollability’, and that it is useful in the ‘severe, long-lasting, extreme stage of mental disorders’ (1.8%).

Twenty-two percent (22%) of the respondents in the informed group said they would approve ECT for a close relative in the case of a severe mental disorder, 46% said they would refuse it and 32% could not answer this question unequivocally; some of the uncertain respondents stipulated that ‘I would agree if doctors could guarantee the improvement’ or ‘Only as a last resort’.

More men than women received information about ECT from films (38.5% vs 30.1%; p < 0.001). Women were more likely to express negative emoitions (67.5% vs 57.8%; p < 0.001), while neutral emotions (18.2% vs 14.1%; p = 0.036) were more common among men. Women more often mentioned psychoses (3.2% vs 1%; p = 0.004) and epilepsy (3.4% vs 1.1%; p = 0.007) as indications for ECT.

Older respondents were more likely to have obtained information about ECT through books (p < 0.001). They were also more likely to consider it to be effective (p < 0.001), to accept its use for their relatives (p < 0.001), and to list substance dependence (p < 0.001) as an indication.

Higher education was associated with the indications of depression (p = 0.013) and psychosis (p = 0.031) and a positive attitude towards ECT (p = 0.027), its effectiveness (p < 0.001) and use for treating a relative (p = 0.001). Films were the most frequent source of information for respondents with a lower level of education (p < 0.001).

Health professionals exhibited a more positive attitude towards ECT (19.61% vs 8.88%; p < 0.001), considered it to be more effective (59.12% vs 34.29%; p < 0.001) and were more likely to approve it for a relative (31.88% vs 18.43%; p < 0.001) compared to the rest of the respondents. The sources of ECT information among health professionals were more likely to be books (38.69% vs 7.07%; p < 0.001) and formal studies (17.16% vs 0.10%; p < 0.001), whereas those in other professions more often turned to the mass media (24.74% vs 7.35%; p < 0.001) and films (40.02% vs 15.25%; p < 0.001) and were more likely to view ECT negatively (64.85% vs 58.85%; p = 0.040).

Comparing doctors and nurses, more doctors considered ECT effective for psychiatric disorders (65.46% vs 45.76%; p < 0.001). Doctors were also more likely to obtain information from books (46.18% vs 22.88%; p < 0.001) and less likely to obtain information from the Internet (1.60% vs 5.93%; p = 0.023).

Finally, the respondents who said they would approve ECT for their relatives were compared with those who said they would refuse it. The indications most commonly identified by the former group were schizophrenia (15.80% vs 11.32%; p < 0.033) and psychoses (4.83% vs 1.54%; p < 0.001), and the majority considered ECT to be effective for psychiatric disorders (83.87% vs 28.62%; p < 0.001). Those who would approve the treatment more frequently received information from books (28.62% vs 11.68%; p < 0.001), whereas films were the main source of information for those who would refuse it (37.14% vs 20.96%; p < 0.001).

Discussion

This study surveyed the knowledge of and attitudes towards ECT in a large, randomly selected sample of the Chuvash population. The Chuvash Republic is one of the states that make up the Russian Federation. It has a population of about 1.3 million, 500,000 of whom live in the capital, Cheboksary; 67.7% of the population are ethnically Chuvash, 26.5% Russian and 5.8% belong to other ethnic groups. At present, four psychiatric hospitals with 1,200 beds provide inpatient psychiatric care in the state, and there are about 130 psychiatrists employed in the public health system (Golenkov et al., 2010).

The majority (64.8%) of the respondents in this survey knew nothing at all about ECT, despite having a much higher level of education than the general population of the Chuvash Republic, where 16.5% of people hold a university degree, 24.7% are college graduates, and 48.8% have completed secondary school; the figures in the study sample were 43.4%, 22.7%, and 33.8%, respectively.

In addition to being ignorant about ECT, the majority of respondents expressed a negative attitude towards it. As those with a lower education level had more negative attitudes towards ECT, or even did not know what it was, it could be assumed that those without landline telephones, that is, people with low education level and who were not part of the survey, would have similar beliefs.

Two myths about ECT were in particular evidence in this study: ‘It is a forbidden method of treatment’ and ‘It serves as a punishment or a reprisal’ (Nelson, 2005b). The stigma surrounding ECT represents a barrier to its public acceptance viewed as an uncommon and occasionally unavoidable therapeutic intervention (Dowman et al., 2005; Hoffmann-Richter, 1998) underscores the importance of this finding.

The results of the present study differ considerably from those of an Australian survey (Teh et al., 2007) in which more than 60% of the respondents reported some knowledge of ECT, although the attitudes towards the method were negative overall. In a Swiss survey, the proportion of those who knew nothing about ECT was below 50% and three predictors of a negative attitude were identified: younger age, sociocultural traditions, and more frequent contact with psychiatric patients (Lauber et al., 2005).

Slightly more than a quarter (25.7%) of the respondents to this survey claimed to have some knowledge of the indications for ECT. Schizophrenia characterized by severe psychotic symptoms was the most frequently cited indication, a finding reflective of the negative image and associated stigma of ECT. This is not a surprising result because unlike in most contemporary guidelines (American Psychiatric Association, 2001; Royal College of Psychiatrists, 2005), schizophrenia remains the first indication for ECT in Russian psychiatry textbooks (e.g. Korkina et al., 2006). Clinical practice is also in line with the textbooks’ recommendation: in Cheboksary’s State Psychiatric Hospital, more than 90% of ECT is administered for schizophrenia patients (Golenkov et al., 2010).

In accordance with the findings of other studies (McDonald and Walter, 2009), films were found to be the main source of information about ECT in this survey. Films generally depict ECT in a negative light, thereby generating negative attitudes and emotions that lead to refusal of the treatment (McDonald and Walter, 2001). Information received during the course of medical education, in contrast, is generally positive and can significantly improve attitudes among students (Abbas et al., 2007; Chanpattana, 1999; McFarquhar and Thompson, 2008; Oldewening et al., 2007).

Experiencing a favourable treatment response also enhances positive attitudes towards ECT in patients and relatives (Malekian et al., 2009). Educational videos have a similar effect (Battersby et al., 1993; Westreich et al., 1995). ECT is not always effective and also causes mainly transient cognitive disturbances and other adverse effects. Even if the ECT was successful in terms of symptom reduction, it could still leave behind resentment, bitterness and dissatisfaction in the patients depending on the circumstances it was delivered. Therefore, not unexpectedly, there is a discrepancy between patients and mental health professionals’ opinion of and attitude towards ECT (Rose et al., 2003, 2005).

Conclusion

In conclusion, this study has revealed a poor level of knowledge on ECT in the general population of the Chuvash Republic and also confirmed the predominantly negative attitudes towards the treatment. Attitudes towards ECT are significantly influenced by age, gender, education, and the source of information. Educating the public with the aim of developing a more realistic attitude towards ECT, which is in keeping with current scientific views, should be a priority for mental health programmes in the Chuvash Republic.

Footnotes

Appendix

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