|Year : 2014 | Volume
| Issue : 2 | Page : 100-105
Knowledge about and attitude toward electroconvulsive therapy of elderly patients with severe mental disorders
Sandeep Grover, Subho Chakrabarti, Ajit Avasthi
Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
|Date of Web Publication||3-Mar-2015|
Dr. Sandeep Grover
Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
Background: Electroconvulsive therapy (ECT) is quite often used in elderly patients with severe mental disorders. One of the important factors which determine the acceptance of ECT among patients is the knowledge and attitude toward ECT.
Aim: The present study attempted to assess the knowledge about and attitude toward ECT among elderly patients with severe mental disorders who had never received ECT.
Materials and Methods: Knowledge and attitudes regarding ECT were assessed using ECT knowledge and attitude questionnaires, among 102 clinically stable elderly patients with severe mental disorders.
Results: Majority (n = 62; 60.8%) of the patients obtained information mostly from "general word of mouth" or media (n = 23; 22.6%). None of the patients had full knowledge about ECT. Majority of the patients were not aware of the basic facts about ECT. Except for the fact that ECT involves use of electric current and can be given by a doctor, more than two-third of the patients were unaware of the basic facts about the procedure of ECT. Less than half of the patients were aware of the need for informed consent. Knowledge about indications, efficacy, and side effects of ECT was also very poor. In terms of attitude toward ECT, on most (15 out of 16) of the items, positive attitudes toward ECT were found in less than half of the patients (8.8-44.1%). In addition, significant proportions of patients were uncertain about their attitudes to ECT (35.3-66.7%) or had a negative attitude toward ECT (4.9-32.4%). There was significant positive correlation between the total knowledge and attitude score, suggesting that higher knowledge was associated with more positive attitude and vice versa. There was no relationship of total knowledge and total attitude score with demographic and clinical variables.
Conclusions: Elderly patients with severe mental disorders have poor knowledge, and a significant proportion of them have a negative attitude toward ECT. Accordingly, it is important that medical professionals should impart proper information about ECT to elderly patients to increase the acceptability of ECT in this age group who more often respond well to ECT.
Keywords: Attitude, electroconvulsive therapy, elderly, knowledge
|How to cite this article:|
Grover S, Chakrabarti S, Avasthi A. Knowledge about and attitude toward electroconvulsive therapy of elderly patients with severe mental disorders. J Geriatr Ment Health 2014;1:100-5
|How to cite this URL:|
Grover S, Chakrabarti S, Avasthi A. Knowledge about and attitude toward electroconvulsive therapy of elderly patients with severe mental disorders. J Geriatr Ment Health [serial online] 2014 [cited 2019 Jun 16];1:100-5. Available from: http://www.jgmh.org/text.asp?2014/1/2/100/152430
| Introduction|| |
Electroconvulsive therapy (ECT) is possibly the only treatment modality in psychiatry which has stood the test of time and has been found to useful in management of many severe mental disorders in patients with all age groups, including elderly.  Many elderly patients suffering from severe mental disorders have comorbid physical illnesses, presence of which makes selection of various psychotropics difficult. , In such scenario, many a times, clinicians have to consider the use of ECT. However, one of the major limitations which are at times encountered in considering the use of ECT is stigma attached to its use in the general public. ,
Many studies have been done across the globe to assess the knowledge and attitude toward ECT among the patients, their family members and the general public. , These studies, in general, have assessed patients who have received ECT and suggest that there is poor knowledge about ECT among the patients with proportion of patients with full knowledge about ECT varying from 0 to 59%. , Of the various studies done to assess the knowledge and attitude toward ECT among the patients, very few have specifically focused elderly patients. Further, these studies have evaluated the patients who have received ECT. , A recent study evaluated the knowledge and attitude toward ECT of 75 elderly patients with depression who had not received ECT from three different countries (England, Argentina, and Canada). This study suggested that there was a significant difference in knowledge about ECT among the patients from the three different countries. However, a significant difference was not seen for attitude toward ECT.  As is evident from the literature, very few studies have specifically assessed the knowledge and attitude of elderly patients or patients who may have to receive ECT because of their severe mental disorder. Accordingly, the aim of this study was to assess the knowledge and attitude of elderly patients with severe mental disorder.
| Materials and Methods|| |
The study was conducted in the outpatient set-up of a tertiary care multispecialty hospital in India. Participants were recruited after obtaining informed consent, and the study was approved by the Research and Ethics Committee of the Institute.
To be included in the study, the participants were required to be suffering from a severe mental disorder (Schizophrenia, Unipolar depression, Bipolar disorder) and aged more than 60 years, currently clinically stable and able to read Hindi/English. Diagnosis of mental disorders was made as per the ICD-10.  Those with difficulty in reading due to vision problems were excluded. Similarly, those with significant cognitive deficits were excluded.
Patients fulfilling the inclusion criteria were approached by a social scientist who was not part of the treatment team. He explained the aims and objectives of the study to the patients. Those patients who provided written informed consent were asked to complete the Hindi version of the Knowledge and attitudes questionnaires designed in India.  The knowledge part of the questionnaire has 32 questions which cover various aspects of ECT such as the procedure, informed consent, efficacy/usefulness of ECT, and side effects of ECT. The first item of the knowledge part of the questionnaire also enquires about the primary source of information regarding ECT among the patients. Rest of items of the knowledge part has 3 options, one of which indicates correct knowledge, another option indicates lack of knowledge, and the third option "don't know," which again suggested lack of knowledge. For understanding the level of knowledge all the correct responses to question number 2-32 were given a score "+1" and wrong responses or "don't know" responses were scored as "0." Accordingly, the total knowledge score could vary from 0 to 31.
The attitude part of the questionnaire has 16 items which specifically look at the attitude toward ECT. Each item in attitude questionnaire has three responses-a response suggesting positive attitude, the second response indicating a negative response and a "don't know" response indicating neutral attitude. For calculating the total attitude score, positive attitude response was rated as "+1," negative attitude was rated as "-1" and the neutral response was rated as "0". Accordingly, the total attitude score could vary from -16 to 16.
The current level of functioning was assessed by using Global Assessment of Functioning (GAF) Scale. 
Data were analyzed using SPSS-14 version (Social Science Inc, Chicago). Frequency counts and percentages were calculated for the categorical variables. Means and standard deviations were calculated for continuous variables.
| Results|| |
Profile of patients and relatives
Study included 102 patients. The mean age of the study sample was 64.06 years (standard deviation [SD] - 4.8) with a range of 60-80 years. More than half of the study sample comprised of males (58.8%) and those from the urban background (56.9%). Majority of the patients were married (94%), unemployed (82.4), had a family income of more than Indian rupees 7500. About two-third of the patients were educated up to or less than matric (67.6%) and belonged to the nonnuclear family (68.6%). The results are shown in [Table 1].
Majority of the patients were suffering from affective disorders (94.1%), with unipolar depression being the most common diagnosis (78.4%). The mean GAF score of the study participants was 80.0 (SD - 6.7) with a range of 61-100 indicating that the patient was assessed at a time when they were not in an episode of illness. In accordance with the diagnosis, more than three-fourth of the patients were receiving antidepressant medications, with escitalopram being the most commonly prescribed antidepressant. About one-fourth (25.5%) of the patients were on antipsychotics, and one-sixth (14.7%) were on mood stabilizers. The mean number of medications was 1.95 (SD 0.87) with a range of 1-5 medications. These results are depicted in [Table 2].
Source of information about electroconvulsive therapy
Patients were asked about the primary source from which they had derived their information about ECT. As shown in [Table 3], in more than half of the patients, the primary source of information was "general word of mouth" information. In one-fourth of the patients, the primary source of information in was media (movies, television, newspapers, books, and magazines). Very few patients obtained information from a psychiatrist or physician.
|Table 3: Primary source of information regarding ECT obtained by patients and their relatives |
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Knowledge of electroconvulsive therapy among patients
Knowledge about ECT was assessed using 31-items. Each item had three responses-a correct, an incorrect and a "don't know" response. Incorrect and "don't know" responses on any question were combined while analyzing the data because both signified that the participants were unaware about ECT. No patient had full knowledge about different aspects of ECT. As shown in [Table 4], except for the fact that ECT involves use of electric current and can be given by a doctor, more than two third of the patients were unaware of the basic facts about the procedure of ECT. Less than half of the patients were aware of the need for informed consent. Knowledge about indications of ECT was also very poor, with only 46.1% of the patients being aware that ECT is often used to treat acute psychiatric conditions not responding to medications. Only less than one-fourth of patients were aware of the other details with regards to indications of ECT. Less than one-third of the patients were aware of the various aspects of efficacy and usefulness of ECT. Similarly, proper knowledge about side effects was known to only one-third of the patients.
The mean knowledge score was 7.67 (SD - 5.59) with a range of 0-24 with about three-fourth of the patients (72.5; n = 74) scoring less than 10. Overall, it can be said that knowledge about ECT was poor among the participants.
Attitudes toward electroconvulsive therapy
On most (15 out of 16) of the items, positive attitudes toward ECT were found in less than half of the patients (8.8-44.1%). However, on various items of the scale significant proportions of patients were uncertain about their attitudes ECT (35.3-66.7%) or had a negative attitude toward ECT (4.9-32.4%). These results are shown in [Table 5]. The mean attitude score was 1.87 (SD - 4.69) with a range of −9 to 14. In terms of total score about one-fourth (N = 24; 23.5%) had total score in the negative range, another one-fourth (N = 24; 23.5%) had total score of zero and slightly more than half (N = 54; 52.9%) had mean attitude score in the positive range.
Relationship of knowledge and attitude
There was significant positive correlation between the total knowledge and attitude score (Pearson's correlation coefficient - 0.498, P < 0.001), suggesting that higher knowledge was associated with more positive attitude and vice versa.
Relationship of knowledge and attitude with other variables
There was no relationship of total knowledge and total attitude score with age of the patients, age at onset, and duration of illness.
There was no significant difference in the mean knowledge and attitude scores between the patients of either gender, those belonging to rural or urban background, those educated up to or less than matric or those educated beyond matriculation.
| Discussion|| |
This study attempted to assess the knowledge and attitudes of elderly patients with severe mental disorders toward ECT. In contrast to most of the previous studies in elderly and other age groups, which have focused mainly on the patients who have received ECT, the present study included patients who had never received ECT. Studying this group is important because this group include patients who could form the possible candidates in future to receive ECT. Accordingly understanding their attitude and level of knowledge can help in designing the information to be provided to the patients when these elderly patients are approached for obtaining consent for ECT.
It is suggested that factors like sources of information about ECT and prevailing myths about ECT shape the knowledge and attitude toward ECT. Findings of the present study suggest that the majority of the elderly patients obtain information mostly from "general word of mouth." This is in contrast to previous studies from India, which included adult patients and have shown that the main source of information is media for those who have not received ECT  and the treating doctor for those who had received ECT.  However, it is important to note that overall very few patients in the present study reported obtaining information from the doctors. This finding suggests that treating psychiatrists must be aware of the fact that most of the patients obtain their information about ECT from sources other than the doctors and accordingly while considering they should devote adequate time to provide factual information about ECT to their patients.
The findings of the present study suggest that the elderly patients with severe mental disorders are mostly not aware of the various aspects of ECT. None of the patients had full knowledge about the ECT. Many studies from the developing countries have reported that less than a-quarter of patients (0-23%) have complete or near-complete knowledge and understanding of the procedure of ECT. ,,,, Findings of the present study also suggest that the majority of the patients were unaware of the basic facts about the procedure of ECT, informed consent, indications, effectiveness, and side effects. This finding is in concurrence with many previous studies which have also reported poor knowledge about ECT among patients who have actually undergone ECT. ,,,,,,, The most likely reason for unawareness among patients could be due to lack of access to proper sources of information. This was amply reflected by the fact for about half of the patients the primary source of information was "a general word of mouth" and for another one-fourth the source of information was the media. These findings together suggest that there is a need to increase awareness about the various aspects of ECT among elderly patients. Accordingly, whenever the clinicians have to consider the use of ECT among elderly patients, sufficient time must be spent in providing information to the patient about the exact procedure involved, indication in their case, possible side effects and expected outcome with use of ECT. All efforts must be made to understand the fears and complaints; they must be adequately informed about the possible benefits of ECT and possible risks and side effects, like transient memory problems.
In the present study, in terms of attitude toward ECT, less than half of the patients had a positive attitude on most of the items of the scale. This finding suggests that negative attitude toward ECT is highly prevalent among the elderly patients with severe mental disorders and this can probably influence their decision making when they are approached for ECT as a treatment modality in their case. It can be hypothesized that possibly the negative attitudes are shaped by the socio-cultural factors including media. Further, presence of negative attitude itself acts as a barrier in obtaining knowledge about the treatment and accepting the same. This is reflected by the high level of positive correlation between total knowledge and attitude score in the present study.
In the present study, total knowledge score and total attitude score had no association with sociodemographic variables such as age, gender, urban versus rural locality, and years of education. Similarly, there was no association between the total knowledge and total attitude score and the age of onset and duration of illness. These findings suggest that, in general, the knowledge and attitude toward ECT are not influenced by the demographic and clinical factors.
Taken together the results of the present study suggest that elderly patients who have no experience of ECT derive their knowledge and attitudes about ECT from sources other than the doctors who administer ECT. This not only leads to unawareness about ECT, but also perpetuates negative attitudes about ECT. Accordingly, there is a need for educating patients with psychiatric disorders about ECT. Clinicians should spend enough time in addressing the negative attitude toward ECT and increasing the awareness about ECT among the elderly. In addition, there is a need for developing campaign for the society in large to improve the knowledge about ECT so that the prevalent negative attitudes toward ECT can be addressed. One way of doing this could be by improving the media portrayal of ECT.
Findings of the present study must be interpreted in the light of certain limitations. Present study was limited by small sample size. The present study included elderly mentally ill patients attending a tertiary care hospital and hence the findings cannot be generalized to the general population. Further, the study was limited to a single center. In the present study, most of the patients who participated were suffering from an affective disorder and only very few patients had schizophrenia. We did not study the association of knowledge of ECT and attitude toward ECT with clinical variables like duration of treatment, attitude toward psychiatric treatment per se future studies must attempt to overcome these limitations.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]