Maligned, Underutilized: Education Enhances ECT's Poor Public Image

Patient education explaining the benefits and safety of electroconvulsive therapy (ECT) improves patient acceptance of this effective but much "maligned and underutilized" treatment, new research shows.

The randomized controlled trial of more than 500 patients showed brief psychoeducation, in either video or written format, "markedly improves patient perception and knowledge of ECT and willingness" to receive it, the investigators, led by Jack Tsai, PhD, Yale University School of Medicine in New Haven, Connecticut, write.

"We found that either through a video or informational pamphlet, people who received the educational information had a lot more positive perceptions and knowledge about ECT. They were also more willing to consider ECT as a treatment option," Tsai, associate professor of psychiatry, told Medscape Medical News.

"We also assessed particular attitudes, and I'm not sure if previous studies have been that specific," he added.

The study was published online March 10 in Psychiatric Services.

Poor Public Image

ECT has been shown to be a safe and effective treatment for severe psychiatric conditions, including major depression, mania, and schizophrenia.

As reported previously by Medscape Medical News, early ECT can be an effective option for patients with treatment-resistant depression. The therapy can also benefit children, including those with severe autism who have psychiatric comorbidities.

Yet despite the procedure's proven efficacy and recent technological advancements in the United States, ECT is used in less than 0.5% of individuals with major depression.

This phenomenon is likely due to several factors including negative perceptions and misconceptions of ECT by the public and mental health professionals. The media hasn't helped; American films regularly portray ECT as a brutal and harmful procedure, and one that offers little or no therapeutic benefit.

Given these misconceptions, the investigators believe healthcare professionals have a role to play in educating patients and their families about the procedure.

Previous research shows healthcare providers with experience and knowledge of ECT have more positive attitudes towards the procedure. Nevertheless, only a few studies have examined the efficacy of various psychoeducation tools in promoting knowledge of ECT.

In 2004, researchers found that students who watched an educational ECT video or read an informational pamphlet had improved perceptions and knowledge compared with controls, but neither medium proved superior to the other.

More recent research suggested visual aids are an effective method of informing patients about medical treatments. This finding, along with recent advances in online video production, led Tsai and colleagues to conduct the current study.

"ECT is one of the most robust treatments for severe depression, but seems to be underutilized. So we wanted to see how we can change people's attitudes," he said.

The investigators recruited a national sample of participants via an online platform (Amazon's MTurk) that is widely used by social scientists to recruit participants for studies.

Potential participants were invited to help the investigators "understand attitudes, opinions, and knowledge about treatment for mental disorders."

Selected participants — adults over 18 years old with a positive screen for current depression — were randomized to receive either video education or an informational brochure about ECT.

Prior to the intervention, each of the study participants completed an online baseline survey and then completed a post-intervention survey.

The 8-minute closed-captioned video, which the investigators have posted on YouTube, was designed to offer research regarding the efficacy of ECT and correct common misconceptions. The 4-page online brochure, on the other hand, presented identical information using a direct transcript of the video without images.

Countering Negative Perceptions

Participants completed a questionnaire that included a 6-item perception subscale and a 12-item knowledge subscale.

The study included 556 participants with a wide range of income levels and geographic locations. Although all of the participants screened positive for depression, many others reported they had also been diagnosed with a range of comorbid psychiatric disorders, including anxiety, post-traumatic stress disorder, alcohol use disorder, and bipolar disorder.

Results showed that participants in both groups experienced significant increases with respect to positive perceptions of ECT on all perception items and in the total perception subscale score. Changes in perception scores were generally associated with moderate to large effect sizes. Interestingly, there were no significant differences between groups.

On the other hand, time-interaction effects showed significant differences between the video and pamphlet groups for two items — concerns about the possibility of memory loss and fear of ECT.

Specifically, participants in the brochure group had a significantly greater reduction in concerns about memory loss related to ECT whereas video viewers had a significantly greater reduction in fear of the procedure.

The two media types significantly boosted knowledge of ECT — from 14% to 56% in the video group and 12% to 56% in the brochure group.

In addition, both the video and brochure groups showed significant increases in a willingness to receive ECT treatment, climbing from 31% to 63% among video viewers and from 29% to 56% in participants in the brochure group.

These findings, the investigators note, help demonstrate the negative perceptions that many people — including individuals with depression and other mental illnesses — have regarding ECT.

"Since we didn't find many differences between the two groups, I think this study shows that a lot of people with depression just have a very limited understanding of ECT," Tsai said.

Nevertheless, the researchers were encouraged by the fact that both watching the video and reading the online pamphlet helped change patient perception.

"It almost doesn't matter if it's a video or an informational pamphlet, it's still impactful. Patients' knowledge is so low that any kind of new information really makes a difference," said Tsai.

A Life-Saving Procedure

Commenting on the findings for Medscape Medical News, Charles H. Kellner, MD, adjunct professor of psychiatry at the Medical University of South Carolina, Charleston, who was not involved in the study, explained that any efforts to promote the understanding of ECT among both patients and medical professionals are "laudable".

"ECT probably has the most comprehensive informed-consent process in medicine," Kellner said. "But patients who have never been exposed to ECT, as well as the general population, are still very poorly informed about what it is."

ECT can be a life-saving procedure, said Kellner. "Most patients who get ECT in North America are very seriously psychiatrically ill, and the procedure is dramatically helpful for the majority of those people," he said.

One of the factors impeding the widespread acceptance of ECT is the lack of financial support for educational materials about the procedure, Kellner added. "When a drug company puts out a new drug, there's billions of dollars behind that, but there's no way to promote ECT because there's no money behind it," he said.

Furthermore, said Kellner, the Centers for Medicare & Medicaid Services has never approved reimbursement codes for ECT performed outside the hospital.

"It's a procedure that would lend itself perfectly to be done in an ambulatory surgery center, but it can't be, and there's absolutely no reason for that. If that were ever to get changed, the access to ECT in the US would be greatly increased."

Tsai and Kellner have reported no relevant financial relationships.

Psychiatr Serv. Published online March 10, 2020. Abstract

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