Introduction
Electroconvulsive therapy (ECT) is an effective and common treatment modality in major depression, bipolar affective disorder, and in resistant schizophrenia. But globally and in the Indian subcontinent, despite its widespread usefulness, and acceptance among mental health clinicians, and researchers, stigma about ECT looms a negative outlook among public.1 While Transcranial magnetic stimulation (TMS) has evolved and sought as a day care treatment in the western world, ECT still appears to be very poorly understood as a therapeutic procedure in our population. We studied why ECT is less well understood, accepted, and tends to cause significant anxiety for patients and their family in our setting.
Materials and Methods
To understand this situation better, we chose culturally diverse public and clinical population attending the Department of Psychiatry, GB Pant Hospital, Andaman and Nicobar Islands Institute of Medical Sciences (ANIIMS), Port Blair, the only tertiary care referral hospital of the Union Territory of Andaman and Nicobar Islands. Our observations were from routine clinical interactions of outpatient, inpatient, emergency, and consultation-liaison psychiatric PMI and their families (n-630), over a 3 month period to understand their willingness to consider ECT as a possible psychotherapeutic treatment for their mental health condition if there was an evidence based indication. This random survey included all mental conditions and discussion of their treatment options and multiple responses were invited.
Results
Surprisingly, irrespective of the current psychiatric disorder, we found that 52% (n-327) of PMI and their families raised queries on whether ECT was going to be a component of treatment options for their mental condition, 66% (n-415) wanted to make sure that ECT was not considered at all in their treatment portfolio, and 82% (n-516) were not interested to discuss treatment options, and expressed full faith on the treating mental health professional. Among those with clear indication for ECT as a first-line treatment (n-40) and after being psychoeducated about ECT, and its informed consent process, more than 95% expressed clear anxiety, doubts, hesitation, ambiguity, confusion, and refusal to ECT for reasons quoted as ‘ECT is electric current’, ‘ECT can worsen my mental condition’, ‘ECT can make me crazy’, ‘Oh, anaesthesia is dangerous’, ‘ECT causes memory loss, and damage to the brain’, and ‘I do not want it, I will take medicines only’. Less than 5% openly agreed to ECT by offering to informed consent to the procedure and verbalizing their understanding of the explanation given to them about ECT.
Discussion
Our findings are very important because they demonstrate overwhelming negative attitudes towards ECT,2 unclear if that includes general stigma about mental conditions also. Poor mental health literacy, fearful historical portrayal of ECT in media and popular culture in a negative light, side effects, misinformation that ECT is a form of punishment or a "last resort" treatment, informed consent concerns due to unmodified ECT practices, violation of rights of PMI.3, 4 Stigma towards ECT is the limiting factor in the general acceptability of ECT as a treatment method.5
Literature review shows approaches to tackle this stigma in few ways. Improvement in psychoeducation before, during and after ECT procedure by the mental health team to the PMI and their families could reduce the acceptability component. Further by undertaking public health campaigns to improve mental health literacy, allay fears, apprehension about mental illness and ECT, providing knowledge and training on skills to cope with stigma, could all improve the outlook of ECT in public.6
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