Reticence towards electroconvulsive therapy: a study of 120 caregivers in a teaching hospital in Tunisia

Introduction

Electroconvulsive therapy (ECT) is rarely practiced in Tunisia. We have tried to explain this lack of use by studying theoretical knowledge, the perception and the attitudes of health professionals towards ECT.

Methods

We conducted a survey in the region of Sfax in Tunisia. It included 120 participants. The latter were divided into four groups, composed of 30 members, in order to compare them: group 1 (psychiatrists); group 2 (neurologists and anaesthetists); group 3 (psychiatric nurses); group 4 (paramedics in the neurological and anaesthesia wards). The surveyed people answered an auto-questionnaire including essentially 16 items: 11 had binary answers (true or false) related to theoretical knowledge about ECT, and five others explored the perception and attitudes concerning this therapy.

Results

Concerning the items exploring theoretical knowledge, 67.5% of people were not able to answer, in conformity with the consensual scientific data, a minimum of 75% questions. The rates were significantly lower among the paramedics (P < 0.001) and those who work outside the psychiatric wards (P = 0.003). The answers of psychiatric caregivers were less frequently incorrect compared to those of non psychiatric ward workers. The latter more frequently thought that the psychiatrists easily resorted to ECT (P = 0.003). The paramedics perceived, more frequently than doctors, the ECT as a violent therapeutic means (P = 0.001), and more frequently refused to give their consent to apply ECT to a relative (P = 0.044). The rate of doctors who refused to give their consent to apply ECT to a relative was statistically higher in group 2 than in group 1 (P = 0.017). Doctors with higher scores in theoretical knowledge, consent more frequently to apply ECT to a member of their families (P = 0.001).

Discussion

The comparison of theoretical knowledge between the two groups of doctors (group 1 versus group 2) revealed significantly more frequent incorrect answers among non-psychiatrists. The latter more frequently had erroneous ideas: that ECT was performed without anaesthesia; that it wasn’t possible to apply it to pregnant women, nor to people suffering from Parkinson's disease, nor as a preventive treatment of recurrence, and that the vital risk was higher with ECT than medical treatments. Compared to the caregivers of group 3, group 4 had significantly more frequent negative attitudes toward ECT; concerning the application without anaesthesia, the lack of tolerance and the over-mortality rate related to ECT. This therapy seems to create an apprehension and a reticence among health professionals, mainly the paramedics and the non-psychiatrists. The lack of valid scientific knowledge concerning ECT allows prejudiced ideas to tarnish the image of this therapy.

Conclusion

Information and training would play a primordial role in the improvement of the perception and attitudes concerning ECT, and lower the reticence towards this therapy, which in spite of its proven efficacy, always maintains a pejorative image.     

Electroconvulsive therapy: a survey of use in the private psychiatric hospital

All 184 member hospitals of the National Association of Private Psychiatric Hospitals (NAPPH) were sent a specially designed 19-item questionnaire regarding their use of electroconvulsive therapy (ECT). Of the 153 respondents, 89 (58%) reported using ECT. Most followed the guidelines delineated in the 1978 American Psychiatric Association Task Force Report.     

Barriers to the use of electroconvulsive therapy in the elderly: a European survey.

A postal survey was carried out to determine the clinical and legal guidelines governing the use of electroconvulsive therapy (ECT) in the countries of the wider Europe. Respondents from 23 of the 33 countries returned completed questionnaires. Considerable variation was found in the availability of ECT, the frequency of its use and associated legal procedures. However, there was a broad consensus with regard to the clinical indications. Access to the treatment was most frequently limited by financial or other resource constraints, political or legal restrictions.     

Features of elderly patients admitted to a general hospital psychiatric unit

Background: Improved management of elderly psychiatric patients requires further identification of their special needs and problems. Methods: We analyzed the characteristics of 1333 consecutive patients admitted to the Psychiatric Center of Yokohama City University Medical Center, a general hospital psychiatric unit, from January 2000 to December 2003. Patients 65 years old or older (the elderly group) accounted for 12.3% of all patients. Results: The duration of admission in elderly patients was significantly longer than in younger patients (less than 65 years old). Admission history and admission type were significantly different between these two groups. Prevalence of dementia or delirium as a primary or secondary diagnosis was significantly greater in the elderly group. About three‐quarters of elderly patients were diagnosed as having a mood disorder (47.6%), or an organic mental disorder (31.1%). A significantly smaller fraction of patients were placed in seclusion in the elderly group than in the younger group, although the fraction of patients who were restrained did not differ between the two groups. A significantly higher fraction of elderly patients was transferred to general medical or surgical wards in the hospital to continue treatment for physical illness. In the elderly group, physical and mental prognoses were poorest in patients with organic mental disorders. Conclusions: Compared with the younger patients, the elderly psychiatric patients showed peculiar features. They were thought to require the treatments that were adapted to meet their needs.     

The use of electroconvulsive therapy in pregnancy: a review

Treating psychiatric disorders during pregnancy poses a challenge. Both medication and maternal illness may have adverse effect on the fetus and balancing the risks and benefits of symptoms and treatments is crucial. Medications may affect the fetus adversely, especially in the first trimester. Electroconvulsive therapy (ECT) is not known to have adverse fetal effects and therefore may be preferred. A review of the literature and our clinical experience highlight the role of ECT during pregnancy, sometimes offering advantages over pharmacotherapy.     

Special considerations in integrating elderly patients into a general hospital psychiatric unit

Geriatric patients with psychiatric disorders are highly treatable in an acute general hospital setting, but they require special attention in assessment, treatment, and discharge planning. Assessment must include the active involvement of a broad multidisciplinary team led by the psychiatrist. In the treatment process, staff must stay aware of the psychiatric symptoms, which may be obscured by medical problems, and should take therapeutic advantage of the transference issues that an age-mixed population can generate. Discharge planning must attend to resistances and the realistic dilemmas that are unique to the geriatric population. In discussing these issues, the authors describe how a university hospital inpatient unit with a full age range of adult patients adapted its milieu and staffing to treat a larger proportion of geriatric patients.     

Clinical outcome and adverse effects of electroconvulsive therapy in elderly psychiatric patients

We evaluated the short-term outcome and side effects of electroconvulsive treatment (ECT) in a population of elderly psychiatric patients. The material included patients consecutively hospitalized at a psychogeriatric department within a period of 5 years. From a total number of 239 patients, we included 52 treated with ECT (22%). Altogether, 41 patients (79%) improved clinically. Of them, 21 (40%) of the patients went home after the treatment. Twenty patients (38%) developed adverse reactions from the ECT treatment. Impaired memory (14%), confusion (6%), and hypertension (6%) represented the most commonly reported negative reactions secondary to the treatment. The findings from the study support previous assumptions that ECT is effective in the treatment of serious psychiatric disorders in elderly patients. Because of the relative high frequency of side effects, the patients should be selected     

A psychiatric intensive care unit in a psychiatric hospital

This paper describes the operation of a psychiatric intensive care unit in a provincial psychiatric hospital. Its introduction led to a decrease in staff and patient accidents, a decrease in constant observation and seclusion hours, and a decrease in the number of nursing hours lost to injuries at work. It had no effect on nursing absenteeism. The ICU was well liked by nursing staff who preferred to work in its more consistent and controlled environment. In addition, it was also felt that the ward environment in other parts of the hospital became more therapeutic. We therefore conclude that psychiatric ICU's are useful additions to psychiatric settings with important cost and patient care implications.     

The psychiatric acute observation unit in a general hospital

A general hospital based psychiatric acute observation and treatment unit is described, and its operation over a one year period is reviewed. This seven-bed unit is designed to provide constant nursing observation and management, as well as intensive psychiatric treatment, in a secure, safe, and quiet environment for the most acutely psychiatrically ill patients. During the year under review, the unit had 330 admissions. Demographic, clinical, and treatment data are presented, and management of disturbed behavior, staff selection, and acceptance of the unit are discussed.     

Efficacy of electroconvulsive therapy in the treatment of nondepressed psychiatric illness in elderly patients: a review of the literature

Electroconvulsive therapy (ECT) is well established as a safe and effective treatment for several psychiatric disorders. Responsiveness to ECT does not abate with age, and data indicate that the use of ECT in the treatment of psychiatric disorders in the elderly persons has increased in recent decades. Special consideration must be given to the baseline cognitive abilities of an elderly patient prior to treatment with ECT. Much of the literature on the use of ECT in the elderly persons has focused on the treatment of mood disorders, whereas less research has been devoted to its use in the treatment of other psychiatric conditions. Although depressive syndromes remain the most common indication for ECT in the elderly persons, clinicians treating elderly patients should remain aware of the safety and efficacy of this treatment modality with other psychiatric disorders. This review examines the literature on the use of ECT in elderly patients with some common neuropsychiatric disorders including catatonia, bipolar mania, schizophrenia, dementia with behavioral disturbance, and Parkinson's disease.     

Cognitive status of psychiatric patients under maintenance electroconvulsive therapy: a one-year longitudinal study

In recent years, maintenance electroconvulsive therapy (M-ECT) has been a common treatment within psychiatric practice. Little information is available regarding the cognitive risks of this treatment, however. In this study, twenty psychiatric outpatients were assessed during M-ECT and 1 year later on treatment. A comprehensive cognitive battery was administered, and a separate comparison group was used to calculate the Reliable Change Index. Global cognitive measures showed no significant difference in scores over time. Our results concur with those described in case reports and suggest that there is no significant association between cognitive decline and M-ECT.     

The elderly in a mental subnormality hospital: A comparison with the elderly psychiatric patient

Summary Approximately 6 % of the patients in a mental subnormality hospital were over the age of 65, in contrast to 61 % of patients in a psychiatric hospital. The mean time spent in institutional care was 46.4 years for the mentally handicapped individuals. The level of self care of the mentally handicapped patients was generally better than that of the psychiatric patients. 39 % of the mentally subnormal showed psychiatric symptoms when assessed by a standard interview and 42 % did not appear to be in need of hospital care.