The clinical literature establishing the safety and efficacy of electroconvulsive therapy (ECT) in specific disorders is substantial (1). Although appropriate rates for its use are difficult to estimate, ECT’s popularity waxes and wanes, and some suggest that it is underused, particularly in state hospital and economically disadvantaged populations (2, 3). This underuse may, in part, be related to inadequate education of physicians and continuing controversies about ECT (4, 5). Underuse also may be attributable to inadequate training. Psychiatry residents in one study, for example, did not believe that they had been adequately trained to provide ECT (6), and in a second study, only 7% of graduating psychiatry residents thought that they would be comfortable performing ECT without supervision following graduation (7).
Several studies have examined the attitudes, knowledge, and opinions of patients, physicians, nurses, other mental health professionals, attorneys, psychiatric residents, and medical students toward ECT. Results of these studies are varied. Surveys of ECT patients and their families have shown positive views of ECT, whereas those in nonpatient/family groups have shown more negative attitudes, with the majority of people reporting that their attitudes stemmed from viewing movies in which ECT administration had been depicted (8). ECT and related procedures have been portrayed in many movies, but the representation often has been inaccurate and biased negatively (9).
In general, psychiatrists have been supportive of ECT, but some have been opposed to it, and others have described their knowledge of ECT as inadequate (10—13). Attitudes about ECT among other mental health professionals may be more negative. One survey, for example, found that psychologists and social workers were the least informed about ECT and the most afraid of it (14). Moreover, when given a choice of treatment for severe depression, mental health nurses surveyed favored alternatives to ECT treatment (15).
Research also suggests, however, that the more knowledge and clinical experience a mental health professional has, the more positive their attitudes about ECT will be (16). Nursing students’ knowledge and attitudes of ECT improved after viewing an ECT videotape (17). In the most recent educational intervention study (18), undergraduate students’ ECT knowledge scores were relatively high at baseline (although students had some misconceptions about treatment aspects and side effects). After education (viewing a videotape or reading a pamphlet), students’ knowledge and attitude scores increased significantly.
Surveys of medical students have demonstrated that many had negative attitudes about ECT (19—21) but that perceptions about ECT were more positive following a psychiatric clerkship (22—24). The psychiatry clerkship thus appears to be a good time to effectively counter students’ negative attitudes and stereotypes about ECT.
The most recent APA Task Force Report, The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging, devotes a brief paragraph to medical students, in which the authors recommend both didactic training and observation of ECT directly or on videotape (1). It is not clear, however, whether viewing a videotape is an adequate substitute for direct observation of the procedure. Direct observation may have greater educational effectiveness, because it allows students to interact with ECT patients and ask questions of the staff performing the procedure. (In our program, each junior medical student in their psychiatry clerkship is required to directly observe at least one ECT treatment or, if this is not possible, watch an ECT educational videotape.)
The purpose of the present study was to determine whether live or videotape demonstrations have differential effects on medical students’ knowledge of and attitudes toward ECT. First, we hypothesized that preclerkship knowledge and attitude scores would be relatively low, possibly reflecting misinformation and bias against ECT. Second, we hypothesized that knowledge and attitude scores would rise by the end of the clerkship and that the highest scores would be those of students who witnessed a live (versus a videotaped) demonstration.
Potential subjects were 148 medical students enrolled in their junior-year psychiatry clerkship at a private, southern California medical school. After obtaining approval from the institutional review board, we asked students to participate in this project. A total of 131 agreed, and of those, 122 (82% of the junior-year class)—57 women and 65 men—provided usable pre- and postsurvey responses. After obtaining students’ written participation consent, each was randomly assigned to either the live demonstration or the videotape group. Each student in the live group observed at least two ECT treatments and discussed aspects of ECT with the attending psychiatrist. Each student in the videotape group watched a 30-minute program that contained didactic explanations of ECT procedures and an actual ECT session.
A questionnaire that assessed knowledge of and attitudes toward ECT was administered during orientation to the psychiatry clerkship (before any clinical assignments) and readministered at the end of the 6-week psychiatry rotation. Students also were asked whether they had at their clinical sites followed patients being treated with ECT. Students’ preclinical curriculum included 4 hours of lectures about mood disorders but little education about ECT.
ECT knowledge and attitudes were assessed by questionnaire adapted from a previously published study (with permission of the original author (17). ECT knowledge questions were answered true or false. Two examples are: "ECT is used mainly to treat depression" (true) and "The seizure threshold decreases during a course of ECT" (false). ECT attitudes were evaluated by three questions, each of which was rated on a 1 to 4 scale (1 = very uncomfortable, 2 = uncomfortable, 3 = comfortable, and 4 = very comfortable): "How comfortable would you be (a) referring a patient for ECT who has refractory depression, (b) referring a close relative for ECT who has refractory depression, and (c) undergoing ECT yourself if you had a refractory depression?" Students also were asked about the sources of their knowledge and opinions.
To evaluate pre- and postsurvey differences in ECT knowledge and attitudes, we used repeated measures analysis of variance (ANOVA). Instructional method (live versus videotape) was the grouping variable and pre- and postsurvey score was the repeated measure. We conducted one analysis for knowledge and three separate analyses for attitudes.
The sources of students’ knowledge and opinions are shown in t1. Movies and school courses/lectures were the principal sources (1). (Three students marked "Personal experience of ECT," and we are unsure about what they meant by this [we doubt that any of the three had received ECT themselves]. Nevertheless we reran all analyses without these three subjects. The two sets of analyses were very similar.) Students’ pre- and postclerkship knowledge and attitude scores by instructional group are shown in t2. Baseline differences in knowledge and attitude scores by instructional group were not statistically significant. Moreover, comparable numbers of students in the two groups—22 in the live and 21 in the videotape—had followed patients undergoing ECT during the clerkship course. On average, students’ initial knowledge scores were relatively high, that is, well above the scale’s midpoint. Students’ average initial attitude scores were just below the scale’s midpoint.
In the knowledge ANOVA, the clerkship (time) effect was statistically significant (i.e., postscores were higher than pretest scores: F=226.50, df=1, 120, p<0.001) with an effect size (partial eta squared) of 0.65. The group by time interaction effect also was significant (F=5.64, df=1, 120, p<0.05)—pretest scores for students in the live group were slightly lower at pretest than those for students in the videotape group, and they were higher at posttest (the effect size/partial eta squared was only 0.05, however).
In the attitudes ANOVAs, the clerkship effect was statistically significant in all three instances: comfort/patient (F=16.58, df=1, 120, p<001; partial eta squared = 0.12), comfort/family (F=23.49, df=1, 120, p<0.001; partial eta squared = 0.16), and comfort/self (F=23.19, df=1, 120; partial eta squared = 0.16). None of the group by time interactions was significant, however.
ECT knowledge increased, and ECT attitudes became more favorable over the course of the psychiatry clerkship for both instructional groups. Although the knowledge gains were slightly greater for students in the live observation group, the very small effect size (partial eta squared = 0.05) suggests that these two instructional methods were practically equivalent, at least on the measures used in the present study. Preclerkship knowledge scores were higher than expected, however (average score over 13 points out of a possible 20). Given students’ limited exposure to formal ECT instruction prior to the clerkship and that their principal knowledge/opinion source was movies, it is possible that the questions were too easy (although many were technical). Very encouraging were the increases in comfort levels with ECT seen here—and also documented elsewhere (22—24)—over the course of the clerkship.
Among our study’s strengths are research design (true experimental—students were randomly assigned to instructional method groups) and sample size (82% of juniors completed usable pre- and postsurveys). Among its weaknesses are limited generalizability (single-institution study) and the short length of the study (six weeks; no long-term follow up). We cannot say, for example, that the knowledge and attitude scores are stable or that higher scores will affect actual practices. Finally, attitude assessment was limited to willingness to recommend or receive ECT.
Nevertheless, both live demonstration and viewing an ECT videotape appear to be effective ECT teaching methods for medical students. We thus concur with APA task force recommendation that students either see ECT live or view a session on videotape. We continue to encourage live ECT demonstrations for our medical students, for the experience includes opportunities to interact with ECT staff. In cases where live observation is not possible, it is reassuring to know that viewing videotape appears to produce the desired increased knowledge and positive attitude changes.