Awareness and perceptions of electroconvulsive therapy among psychiatric patients: a cross-sectional survey from teaching hospitals in Karachi, Pakistan.

Abstract

Electroconvulsive therapy (ECT) is shown to be effective in many psychiatric illnesses, but its distorted projection by the Pakistani media and its unregulated use by many physicians across the country have adversely affected its acceptability. Given this situation we aimed to assess the awareness and perceptions regarding ECT as a treatment modality among the psychiatric patients.
This was a questionnaire based cross-sectional study carried out at 2 tertiary care hospitals in Karachi, Pakistan.
We interviewed 190 patients of which 140 were aware of ECT. The study showed that the level of education had a significant impact on the awareness of ECT (p = 0.009). The most common source of awareness was electronic and print media (38%), followed by relatives (24%) and doctors (23%). Physical injuries (42%) and neurological (12%) and cognitive disturbances (11%) were the commonly feared side effects. The most popular belief about ECT was that it was a treatment of last resort (56%). Thirty-nine percent thought that ECT could lead to severe mental and physical illness and 37% considered it inhumane. Patients' willingness to receive ECT was dependant on whether or not they were convinced of its safety (p = 0.001) and efficacy (p = 0.0001).
We identified a serious lack of dissemination of information regarding ECT by the psychiatrists and the mental health care providers. This may be the result of an inadequate postgraduate training in Pakistan or just a lack of concern about the mentally ill patients. The media seemed to be the major source of information for our patients. We also saw the prevalence of a variety of myths regarding ECT in our society, which we feel may be responsible for the patients' adverse attitudes. Given the widespread applicability of ECT there is a dire need to dispel these misconceptions and improve its acceptability.

Full text

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BioMed Central
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BMC Psychiatry
Open Access
Research article
Awareness and perceptions of electroconvulsive therapy among
psychiatric patients: a cross-sectional survey from teaching
hospitals in Karachi, Pakistan
Mehreen Arshad*1, Ahmad Zafir Arham1, Mansoor Arif1, Maria Bano1,
Ayisha Bashir1, Munira Bokutz1, Maria Maqbool Choudhary1, Haider Naqvi2
and Murad Moosa Khan2
Address: 1Aga Khan University, Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan and 2Department of Psychiatry, Aga Khan University,
Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan
Email: Mehreen Arshad* - mehreena82@yahoo.com; Ahmad Zafir Arham - ahmad.arham@gmail.com;
Mansoor Arif - mansoor.arif@gmail.com; Maria Bano - mariaansari17@hotmail.com; Ayisha Bashir - ayishall@hotmail.com;
Munira Bokutz - ira.alikhan@gmail.com; Maria Maqbool Choudhary - maria.choudhary@gmail.com; Haider Naqvi - haider.naqvi@aku.edu;
Murad Moosa Khan - murad.khan@aku.edu
* Corresponding author
Abstract
Background: Electroconvulsive therapy (ECT) is shown to be effective in many psychiatric illnesses, but
its distorted projection by the Pakistani media and its unregulated use by many physicians across the
country have adversely affected its acceptability. Given this situation we aimed to assess the awareness
and perceptions regarding ECT as a treatment modality among the psychiatric patients.
Methods: This was a questionnaire based cross-sectional study carried out at 2 tertiary care hospitals in
Karachi, Pakistan.
Results: We interviewed 190 patients of which 140 were aware of ECT. The study showed that the level
of education had a significant impact on the awareness of ECT (p = 0.009). The most common source of
awareness was electronic and print media (38%), followed by relatives (24%) and doctors (23%). Physical
injuries (42%) and neurological (12%) and cognitive disturbances (11%) were the commonly feared side
effects. The most popular belief about ECT was that it was a treatment of last resort (56%). Thirty-nine
percent thought that ECT could lead to severe mental and physical illness and 37% considered it inhumane.
Patients' willingness to receive ECT was dependant on whether or not they were convinced of its safety
(p = 0.001) and efficacy (p = 0.0001).
Conclusion: We identified a serious lack of dissemination of information regarding ECT by the
psychiatrists and the mental health care providers. This may be the result of an inadequate postgraduate
training in Pakistan or just a lack of concern about the mentally ill patients. The media seemed to be the
major source of information for our patients. We also saw the prevalence of a variety of myths regarding
ECT in our society, which we feel may be responsible for the patients' adverse attitudes. Given the
widespread applicability of ECT there is a dire need to dispel these misconceptions and improve its
acceptability.
Published: 21 June 2007
BMC Psychiatry 2007, 7:27 doi:10.1186/1471-244X-7-27
Received: 7 December 2006
Accepted: 21 June 2007
This article is available from: http://www.biomedcentral.com/1471-244X/7/27
© 2007 Arshad et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Background
Electroconvulsive therapy (ECT) was introduced in its cur-
rent form by Cerletti and Bini in 1938 [1]. Since then it
has been subjected to controversy and antipathy by the
media and general public alike. Along with an inadequate
post-graduate training in psychiatry, in some developing
countries like Pakistan, it is responsible for the wide-
spread unacceptability of this treatment form among
patients.
The psychiatrist to population ratio is dismally low in
Pakistan. In a recent World Health Organization (WHO)
information facts sheet it was estimated to be 0.2/100,000
[2]. Proper mental health care is provided by only a few
hospitals. There are 2,154 beds available in the Govern-
ment mental health sector. Among these, 943 beds are
allocated in three large custodial centers in the country
[3]. The Governmental budgetary allocation on health
sector is less than 1 % of GNP; mental health allocations
are negligible. It is estimated that private sector accounts
for some 70 % of national expenditure on the provision
of health services [4]. This demand and supply gap is
exploited by the unregulated private health sector, notori-
ous for its use of 'unmodified' ECT (ECT conducted with-
out the use of adequate anesthesia or muscle relaxants,
which can cause fractures, tongue bites, and an enormous
amount of mental and physical anguish [5]). No specific
research has been carried out in Pakistan, but statistics
extrapolated from neighboring India, show that despite
the high risk associated with unmodified ECT, a large
number of psychiatrists continue its use [5]. This has led
to mistrust among the general population about ECT as
an effective treatment modality. Given the unusually high
prevalence of depression in Pakistan, 25% to 66% for
women and 10% to 49% for men in rural areas and 10%
to 25% point prevalence in urban areas [6,7], this distrust
is alarming and requires immediate attention as many
patients may reject an essential treatment due to their mis-
perceptions about ECT.
There is substantial scientific literature on the efficacy and
indication of ECT, and many patients in western countries
have expressed their satisfaction [8-12], but there are few
accounts of how it is viewed by patients, especially in a
developing country like Pakistan. The few studies carried
out, are on the recipients on ECT. Little is known about
the patients' views before they accept the treatment. We
believe it is these views that determine this treatment's
acceptability. Lack of local data on patient's perceptions
has also hampered efforts to advocate adequate ECT serv-
ice utilization.
In view of these facts we designed the study with the
objective to:
1. Assess Awareness regarding ECT among psychiatric
patients
2. Study their Perceptions about ECT
3. Assess the Acceptability of ECT
Methods
Study design and setting
This was a questionnaire based cross-sectional study, car-
ried out over four weeks at 2 tertiary care hospitals in Kara-
chi, Pakistan: Aga Khan University Hospital (AKUH) and
Liaquat National Post-Graduate
(LNPMC). A non-probability, convenient sampling meth-
odology was used.
Medical Center
AKUH is a 500 bed, private hospital, having a 15-bed psy-
chiatric facility. The weekly turnover in the out-patients
department (OPD) is 200–250 patients. LNPMC is an 800
bed, semi-private hospital with a 10-bed psychiatric unit
and a weekly OPD turnover of 140–160 patients.
Questionnaire
The questionnaire was self-developed in order to measure
the various issues that were pertinent to our society. For
this locally published newspapers and magazines were
searched for comments on ECT and its acceptability, and
detailed discussions and peer-review between investiga-
tors and facilitating faculty was carried out.
A team of seven 4th year medical students carried out the
data collection. A standardized Urdu version of the ques-
tionnaire was used for patients who could not understand
English. Patients were recruited from the waiting room
prior to their meeting with the consultant psychiatrist,
and were then interviewed in a separate room to maintain
confidentiality. A brief description of the questionnaire is
given in the next paragraph. The questionnaire itself is
available from the authors.
The socio-demographic details of age, gender, educational
status and the monthly household income were recorded.
Patients were then asked if they had heard about ECT.
Those who responded that they had never heard about
ECT were not questioned any further. Those who were
aware of it were asked what had been their source of infor-
mation and in their opinion, what are the indications and
side-effects of ECT.
In order to evaluate the patients' perceptions and accepta-
bility we asked about their views on the safety of ECT and
if they would agree to undergo ECT if recommended by
their psychiatrists. We also inquired about their confi-
dence in ECT relative to conventional medical treatment.
A review of local literature in print-media helped us in

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compiling a list of 7 common beliefs about ECT. The
patients were then asked which beliefs they held.
A skip pattern was designed to dichotomize the above
responses into those who had received ECT and those
who had not. Recipients of ECT were further asked about
their source of referral, the treatment method and if their
consent had been taken.
Inclusion criteria
• Psychiatric patients, age 16 years and above, either com-
ing for consultation or admitted in the ward at AKUH and
LNPMC.
Exclusion criteria
• Patients who could not speak the national language
(Urdu) or other regional dialects (immigrants without
interpreter).
• Those who were grossly psychotic or acutely manic.
• Those under influence of or being treated for substance
abuse.
Ethical consideration
The study was conducted in compliance with the 'Ethical
principles for medical research involving human subjects'
of Helsinki Declaration. The study protocol was approved
by the Ethical Review Committee (ERC) at AKUH. Verbal
informed consent was taken from our subjects before the
interview. Their personal information (name, residence
and Medical Record number) was not recorded to main-
tain anonymity and confidentiality.
Statistical Methods
The data was analyzed using the SPSS statistical package,
Version 12.0.1 (Chicago, IL, USA). Descriptive statistics
were employed to determine the demographic and clini-
cal variables. Chi square test was utilized at a confidence
interval of 95% to determine if the association between
two variables was real.
Results
Socio-demographic characteristics
A total of 190 subjects were interviewed (151 from AKUH
and 39 from LNPMC). There were an almost equal
number of males (n = 92) and females (n = 98). Sixty-nine
(36%) patients had less than 10 years of education and
121 (64%) were educated beyond that. One hundred and
sixty-five (87%) patients were diagnosed to have various
forms of mood disorders, 3 suffered from substance
abuse, 2 each from somatoform and psychotic disorders
and the rest did not have a working diagnosis. Forty-six
percent (n = 87) of the patients had been on psycho-tropic
medications for more than a year.
Awareness of ECT as a treatment modality
Of all the patients 140 (74%) had heard about ECT and
50 (26%) were unaware of this treatment. The socio-
demographic details of these 2 groups are given in Table
1. Females were seen to be more unaware of this treatment
modality (p = 0.06).
The level of education also had a significant impact on the
awareness of ECT. Forty-two percent (n = 30) of the
patients with an education less than 10 years did not
know about ECT whereas only 22% (n = 27) of patients
with a higher education were unaware of it (p = 0.009).
The most popular sources of information, for patients
who were aware of ECT, were electronic and print media,
relatives and friends (38 %, 24 % and 10 % respectively).
Only 23% of our patients identified doctors as a source.
The majority (86%, n = 120) of these patients were con-
vinced about the effectiveness of ECT as a treatment
modality. However, 86 patients (62%) thought this pro-
Table 1: Socio-demographic Characteristics of patients of
patients who were Aware vs. Unaware of ECT as a treatment
modality
AwareUnaware
N(%)N(%)
Age (Years)
16–25
26–35
36–45
46–55
56–65
> 66
33
33
30
28
12
4
24
24
21
20
9
3
11
13
11
5
5
5
22
26
22
10
10
10
Marital status
Single
Married
Widowed/Divorced
39
97
4
28
69
3
13
36
1
26
72
2
Occupation
Unemployed
Unskilled
Skilled
Businessman
Professional
Housewife
Student
Retired
25
5
7
14
32
41
12
3
18
4
5
10
23
29
9
2
5
0
2
2
8
24
4
2
10
0
4
4
16
48
8
4
Monthly Income (in US$)
< 85
85–160
160–330
330–500
> 500
16
22
22
20
34
11
16
16
14
24
5
8
8
4
10
10
16
16
8
20

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cedure would have serious side effects: injuries (42% of
the patients), neurological impairments (12%), cognitive
disturbances (11%) and pain (8%) being the most com-
mon concerns.
When patients were asked to list all the indications of
ECT, 60% (n = 84) of the patients accurately specified
mood disorders as a major indication. Some commented
on its utility in affective psychosis (26%, n = 36) and
imminent suicide (4%, n = 6). A large number of interest-
ing responses were categorized under "others" (33%, n =
46) including 'vascular spasm', 'dullness of senses', 'brain
cancers', and 'to get rid of old memories'.
Patients' Perceptions about ECT
We found that the majority of our patients (42%, n = 59)
were skeptical of the safety of ECT as a treatment modal-
ity. Twenty-eight percent (n = 39), however, considered it
completely safe, while 12% (n = 17) considered it safe
only when the proper procedural guidelines were fol-
lowed i.e. with anesthesia and muscle relaxants.
When we asked if patients would agree to undergo ECT if
advised by their psychiatrists, 59% (n = 83) said they
would not, whereas the rest were ready to comply.
Patients' willingness was dependant on whether or not
they were convinced of its safety (p = 0.001), and efficacy
(p = 0.0001).
Fourteen percent (n = 20) of our patients had found their
medications to be ineffective and interestingly this group
also had greater awareness of ECT (p = 0.034). We also
inquired about the patients' perception of the relative effi-
cacy of ECT versus the conventional medical treatment,
83% considered medication to be superior.
Common Beliefs
The most commonly held belief among our patients was
that ECT is a treatment of last resort. The prevalence of the
various other beliefs is shown in Table 2. Paradoxically a
significantly greater proportion of patients with an educa-
tion of more than 10 years thought that patients risk total
insanity after ECT (p = 0.03) and that it is often given
unnecessarily (p = 0.02). However, a greater proportion of
patients with an education of less than 10 years consid-
ered ECT to be a permanent cure (p = 0.005). Figure 1
shows the responses for various myths when stratified
according to the level of education. Gender or the source
of information did not have any significant impact on the
prevalence of the various beliefs.
Experience of ECT
Twenty-five patients had received ECT. Twenty-three of
them were advised by a doctor, while 2 had taken it elec-
tively. Sixteen had been given General Anesthesia. Only
11 patients felt the procedure had been appropriately
explained. Consent from the patient or their family had
been taken in 20 cases. Of note patients with an education
of less than 10 years were more likely to complain about
deficiency in the consent process (p = 0.012).
Discussion
We believe this is the first study in Pakistan which took
into account the patients' perspective of ECT. The majority
of our study population was aware of ECT and this
seemed to be related to the patient's gender and education
level.
Patients' Awareness about ECT
As in previous studies, movies and media remained the
most popular source of information [13,14]. And given
the gruesome testimonies of former recipients of ECT that
have often been published [2]; it is no wonder there is
widespread fear of this treatment modality in our society.
Only a few patients had indicated psychiatrists as a source
of information. Since about half the patients were on psy-
chotropic drugs for more than a year and a substantial
majority had chronic disorders, most patients had suffi-
cient contact with their psychiatrist to discuss the option
of ECT. This indicates an unsatisfactory dissemination of
information by the psychiatrists. There are only 150–200
adequately trained psychiatrists in the country. Most are
in private practice and located in major urban areas. Aca-
demic frauds are rampant in the government run public-
sector hospitals. Officials are promoted to the highest
ranks because of their political affiliations. This obviously
has serious repercussions on the teaching and practices of
Table 2: Myths regarding the Electroconvulsive therapy
NumberPatients Beliefs regarding ECTN (%)
1
2
3
4
5
6
7
ECT is a treatment of Last resort
ECT cause severity in Mental and physical illness in the long run
ECT can cause total and irreversible insanity
ECT is a form of torture and an in-humane treatment method
ECT is used unnecessarily by Doctors for exploiting patients financially or otherwise.
ECT renders psychopharmacological treatment in- effective.
ECT is a permanent treatment for mental illnesses.
78 (56)
55 (39)
48 (34)
52 (37)
48 (34)
34 (24)
24 (17)

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Psychiatry in Pakistan. Inadequate training has been cited
as a possible reason in some studies from other countries
[14-18]. Some psychiatrists themselves have shown a neg-
ative attitude against ECT [17], which may influence their
counseling about ECT.
Since there is no qualitative study from Pakistan on the
benefit and efficacy of ECT, we examined this subject from
the patient's perspective. Most of our patients were con-
vinced about the efficacy of ECT, which is somewhat sur-
prising given their main source of information. Most
patients also considered it to have some side effects, espe-
cially injuries. A study on medical students in India
showed similar concerns [14]. In reality, such obstacles
have been overcome with the administration of anesthe-
sia and muscle relaxants. In fact patients who have
received ECT report memory impairment to be the most
worrisome side effect [11,12]. Since only a few trials have
studied the possibility of long-term cognitive impairment
[11], there is a dire need to further investigate this aspect
[22,23].
Mental health legislation in Pakistan is subject to the same
complex judicial rules as so many other areas of social
welfare are. Up until five years ago the judiciary was still
following a modified version of the Lunacy Act of 1912.
So it is no surprise that there are no national guidelines or
protocols for training or clinical use of ECT, and hence no
supervision of the institutes providing ECT. This has
resulted in many patients either undergoing ECT unneces-
sarily or receiving its unmodified version with a conse-
quent high risk of complications. This has made most
patients wary of the procedure. Even though ECT has been
shown to have a considerably good safety profile when
procedural recommendations are followed[20,26].
Patients' Perceptions about ECT
Malpractice of ECT in Pakistan and its inaccurate media
reporting raises certain misperceptions and beliefs which
Prevalence of myths and level of education
Figure 1
Prevalence of myths and level of education.
0
10
20
30
40
50
60
70
Medicines
become
ineffective
Increase in
Physical illness
Total insanityInhumane TxIncrease in
mental illness
Permanent TxUsed as last
resort
Unnecessary Tx
% of pateints
< 10 yrs
> 10 yrs