- Email: [email protected]
Patient Satisfaction With Electroconvulsive Therapy
Patient Satisfaction With Electroconvulsive Therapy JESSE
A. GOODMAN, MD;
LOIS
E.
KRAHN, MD; GLENN
E. SMITH,
PHD; TERESA
A. RUMMANS,
MD;
AND THOMAS S. PILEGGI, RN
dents endorsed the statement, "I am glad that 1 received ECT." Attitude score was significantly higher for the ECT group compared with controls. A higher degree of satisfaction was associated with a higher level of education and younger age. • Conclusions: Patients who received ECT were satisfied with their treatment and had more favorable attitudes about it than patients who did not receive this treatment.
• Objective: To determine whether patients who have electroconvulsive therapy (ECT) are satisfied with their treatment and demonstrate more favorable attitudes about ECT compared with controls. • Patients and Methods: We developed a 44-item survey measuring ECT treatment satisfaction and attitudes. The survey was administered to 24 psychiatric inpatients near the end of ECT treatment and 2 weeks later. A modified survey was administered to 24 outpatient controls who had never received ECT and who were recruited from a psychiatry clinic waiting room. • Results: Patients who received ECT had positive attitudes about it. For example, 21 (91 %) of 24 patient respon-
Mayo Clin Proc. 1999;74:967-971
ECT =electroconvulsive therapy; Ham-D =Hamilton Depression Scale; MMSE =Mini-Mental State Examination
U
sed for 60 years, electroconvulsive therapy (ECT) is an effective treatment for many psychiatric conditions."Over the years numerous refinements to ECT have made it more efficacious with fewer complications. These improvements include anesthetic and muscle relaxant use, as well as the routine use of electroencephalographic and electrocardiographic monitoring and pulse oximetry. Further advances include administration of a titrated convulsive stimulus that triggers a seizure at a specific level above the patient's measured seizure threshold.r" Clinicians have conducted research, published studies, and developed expertise regarding the administration of ECT to patients with a variety of comorbid medical disorders. However, when ECT is portrayed in the media, typically reference is made to negative images depicted in the novel and movie One Flew Over the Cuckoo's Nest, without describing modem anesthetic agents and new procedures. As a result, the pub-
lie, potential patients, and even physicians tend to view ECT as archaic and potentially dangerous. Many people suspect that patients undergo ECT as a last resort, and many doubt that patients would ever view this treatment favorably. Information about patient satisfaction with ECT is important when trying to educate potential patients and their families about this treatment option. The limited existing literature dates back many years and generally shows that patients who receive ECT have a positive attitude toward the treatment and its outcome.>" Relying on these previous studies is inappropriate because of the changes in ECT techniques over the decades, varied study methods, and lack of a validated survey instrument. There are at least 3 important reasons to measure satisfaction after ECT: (I) patient satisfaction is an increasingly important component of outcomes assessment; (2) satisfaction data are useful for patients considering ECT treatment; and (3) a satisfaction survey is an effective quality improvement tool for a particular program. A validated and reliable questionnaire permits the survey to be administered in a standardized fashion over time. Measuring patient satisfaction after ECT nonetheless presents a challenge. In particular, the design of a survey and timing of its administration must be done carefully because ECT alters cognition for a brief time. Also complicating the survey process are potential altered mood and insight in psychiatric patients after ECT. The present study was designed to measure patient satisfaction with ECT taking into account these factors.
From the Mayo Medical School (JAG.) and Department of Psychiatry and Psychology(L.E.K.. G.E.S.• TAR., T.S.P.), Mayo Clinic Rochester. Rochester, Minn. This study was supported in part by grant R10 MH 55484-01A1 from the National Institute of Mental Health (Drs Krahn, Rummans. and Smith). Presented in part at the 1998 Association for Convulsive Therapy Annual Meeting. Toronto, Ontario, May 31. 1998, and the 1998 American Psychiatric Association Annual Meeting. Toronto. Ontario, June 1, 1998. Address reprint requests and correspondence to Lois E. Krahn, MD. Department of Psychiatry and Psychology. Mayo Clinic Rochester, 200 First St SW. Rochester, MN 55905. Mayo Clin Proc. 1999;74:967-971
967
© 1999 Mayo Foundation/or Medical Education and Research
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
968
Mayo Clin Proc, October 1999, Vol 74
Patient Satisfaction With ECT
Patient Satisfaction Survey Instructions: Please read each statement below and circle one answer for each statement. Answer each question. If you are unsure about how to answer a question, give the best answer you can. Definitely false
Mostly false
Not sure
Mostly true
Definitely true
Your Overall Satisfaction ECT helps people. People should not be afraid of ECT. ECT is dangerous. Many people are helped by ECT. I am glad that I received ECT. I had to wait too long to be treated on days I received ECT. I felt safe receiving ECT. If my doctor recommended ECT in the future, I would choose to have ECT treatment. I was afraid to receive ECT. ECT was painful. I can remember having a seizure during ECT.
2 2 2 2 2 2 2 2 2 2 2
3 3 3 3 3 3 3 3 3 3 3
4 4 4 4 4 4 4 4 4 4 4
5 5 5 5 5 5 5 5 5 5 5
Your Satisfaction With Results ECT improved the quality of my life. I am very satisfied with the results of my ECT treatment. I am more discouraged since my ECT treatment. I am sleeping worse since my ECT treatment. My appetite is not as good since my ECT treatment. I have more energy since my ECT treatment. I am more confused since my ECT treatment. I am more optimistic since my ECT treatment. I have less physical pain since my ECT treatment. I get along with others better since my ECT treatment.
2 2 2 2 2 2 2 2 2 2
3 3 3 3 3 3 3 3 3 3
4 4 4 4 4 4 4 4 4 4
5 5 5 5 5 5 5 5 5 5
Your Satisfaction With Staff I can remember being in the ECT treatment area. I can remember the people who work in the ECT treatment area. The ECT treatment area provided privacy for me. I was treated with respect by the person who started my IV. I was treated with respect by the person who was with me when I woke up after ECT. I was treated with respect by the people in the room where I received ECT. The ECT treatment area did not provide enough privacy for me.
2 2 2 2 2 2 2
3 3 3 3 3 3 3
4 4 4 4 4 4 4
5 5 5 5 5 5 5
Your Satisfaction With Education Staff spent enough time with me describing ECT. I received the right amount of information about ECT. I received too much information about ECT. I did not receive enough information about ECT. Talking about ECT with my nurses and doctors made me less afraid of ECT. I talked with another patient who had ECT, which made me less afraid to have ECT. I did not know enough about ECT to decide if it was the right treatment. All of my questions about ECT were answered to my satisfaction.
2 2 2 2 2 2 2 2
3 3 3 3 3 3 3 3
4 4 4 4 4 4 4 4
5 5 5 5 5 5 5 5
Your Feelings I feel full of pep and energy most of the time. I feel full oflife. I am a very nervous person. I feel so down in the dumps that nothing can cheer me up. I feel calm and peaceful. I feel downhearted and low. I feel comfortable in groups. I feel tired and worn out most of the time.
2 2 2 2 2 2 2 2
3 3 3 3 3 3 3 3
4 4 4 4 4 4 4 4
5 5 5 5 5 5 5 5
Comments and suggestions. Finally, please identify a way in which you would like to see the treatment you received improved.
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
Patient Satisfaction With ECT
Mayo Clin Proc, October 1999, Vol 74
PATIENTS AND METHODS
Eligible subjects included all psychiatric inpatients who completed a course of ECT between May 1 and July 31, 1997. All patients had a physical examination and electrocardiography before receiving ECT. A Thymatron DG ECT device (Somatics, Inc, Lake Bluff, Ill) was used. The anesthetic medications given to all patients included glycopyrrolate, thiopental, and succinylcholine, administered by an anesthesiologist. The treatment team determined on a case-by-case basis whether to use unilateral or bilateral stimuli. During the first treatment session, a stimulus titration protocol was used to determine seizure threshold, and thereafter patients were treated at 150% and 250% of this setting for bilateral and unilateral treatment, respectively .14 The patients had electrocardiographic and electroencephalographic monitoring and pulse oximetry, with periodic blood pressure checks throughout the procedure and for at least 20 minutes after the procedure until they were hemodynamically stable in the recovery room. The only exclusion criterion was pre-ECT cognitive impairment, identified as a Mini-Mental State Examination (MMSE) score less than 26 (maximum score, 30) or an inability to complete the survey." Controls included consecutive patients seen in the outpatient psychiatric clinic over 2 days. Controls were excluded if they had ever received or been offered ECT. The study was approved by the Institutional Review Board of the Mayo Foundation. Patients were asked to participate while on the hospital unit away from the ECT treatment suite and were advised that their answers would not affect the nature of future psychiatric treatment at the institution. The survey was revised several times after a set of 85 questions was tested and retested with several pilot groups of appropriate patients. The final version of the Patient Satisfaction Survey contained 44 items divided into 5 sections. Answers were scored from 1 to 5. Half of the items were positively phrased and half were negatively phrased. Statements were designed to be understandable, unambiguous, and free of value-laden terms. 16 The questionnaire also encouraged patients to write comments and suggestions about their treatment. Subjects were assured that their responses were confidential. Other data collected from patients receiving ECT included age, sex, level of education, pretreatment psychiatric diagnosis, and pre-ECT and post-ECT Hamilton Depression Scale (Ham-D) and MMSE scores.v-" The preBeT and post-ECT Ham-D and MMSE evaluations for each patient were administered by the same interviewer (2 trained interviewers with good interrater reliability are part of the ECT service). The first ECT surveys were administered the evening before each subject's last ECT treatment
969
and at least 24 hours after the previous treatment. All the surveys were administered by 1 of us (J.A.G.) who was not part of the hospital treatment team or ECT service. The identical survey was mailed to participants at their homes 2 weeks after treatment to follow up their opinions about ECT treatment. The survey was modified before administration to controls because many items addressed the patient's perceptions of the actual ECT experience. Therefore, 5 items were selected from the "Overall Satisfaction" section of the ECT survey that addressed attitude (rather than actual experience). The statements selected were "ECT helps people," "People should not be afraid ofECT," "ECT is dangerous," "Many people are helped by ECT," and "If my doctor recommended ECT in the future, I would choose to have ECT treatment." This modified questionnaire was administered once to controls in the outpatient psychiatry department waiting room. An "Overall Satisfaction" score was generated by the sum of the 44 item scores from the surveys administered to the treated patients. The relationship between the scores resulting from the 2 administrations was evaluated with the Pearson correlation coefficient. Differences between the Ham-D and MMSE scores from the first to second survey were assessed with paired t tests. The relationship between overall satisfaction from the first administration and age, sex, education level, and HamD and MMSE scores before and after ECT was also examined. For those variables that are continuous (age, education level, rating scales), significance was assessed with the Pearson correlation coefficient. For variables that take discrete values (sex), significance was evaluated by analysis of variance. To assess the difference in attitude toward ECT between subjects and controls, an attitude score was calculated for each participant by determining the mean of the 5 items that were asked of both groups. A 2-sample t test was used to assess the statistical significance of the difference of the mean scores between the 2 groups. RESULTS
Fifty-three subjects completed ECT during the study period. Eight were excluded from study participation because of cognitive impairment. Of the 45 eligible subjects, 24 (53%) completed both survey administrations (12 males and 12 females). Five patients refused to participate, and 16 patients (34%) did not complete the follow-up questionnaire. The mean age of the 24 study patients was 58.3 years (SD, 17.6 years; range, 16-78 years). The mean level of education was 12.6 years (SD, 3.5 years; range, 8-20 years). The mean number of ECT treatments was 8.3 (SD, 3.5; range, 2-19). Major depression was the principal psychiatric diagnosis in 22 patients; 1 patient had bipolar
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
970
Mayo Clin Proc , October 1999, Vol 74
Patient Satisfaction With ECT
ECT helps people People should not be afraid of ECT ECT is dangerous Many people are helped by ECT I am glad that I received ECT
I had to wait too long to be treated on days I received ECT I felt safe receiving ECT
If my doctor recommended ECT in the future, I would choose to have ECT treatment I was afraid to receive ECT
ECT was painful I can remember having a seizure during ECT
In hospital
0 2 wee ks post
-J
--l
Definitely false
• •
I
Mostly false
I
Not sure
treatment
Co ntrol
Mostly true
Defi nite ly true
Figure I. Meanresponse to 11 survey items of the"Overall Satisfaction" section of thesurvey by psychiatric inpatientsat the end of the treatment (N=24), 2 weeks after treatment (N=24), and all 5 questions asked of the control outpatients who did not receive electroconvulsive therapy (ECT) (N=24). The 5 response options appearon the x axis. disorder and 1 had dysthymia. Twenty-four eligible contro l patient s completed the modified survey . Responses of ECT patients reflected positive attitudes toward ECT (Figure 1). Data are reported for the "overall satisfaction " component only . For example, 21 (9 1%) of 24 patients endorsed (answered " mostly true" or "definitely true" ) the statement, " I am glad that I received ECT" ; 23 (96%) endorsed the statement , "ECT helps people "; 19 (81%) endorsed the statement, "I felt safe receiving ECT'; and 20 (82%) endorsed the statement, "If my doctor recommended ECT in the future, I would choose to have ECT treatment." The attitude score, comparing responses of patients and controls to the same 5 statements, was significantly higher for the ECT group (4.4 of 5; SO = 0.7) compared with the control group (3.2 of 5; SO =0.9) (P< .OOl). Global satisfaction at the end of treatment correlated with that at 2-week follow-up (r=0.57 ; P=.007). The mean global satisfaction score change from the end of treatment to 2-week follow-up was 1.48 (SO, 21.4), which was not significantly different from O. From the first survey of ECT patients , the correlation between age and global satisfaction was 0.43 (P<.05), and the correlation between education level and global satisfaction was 0.42 (P=.05). The mean Ham-D score at the begin ning of treatment was 27.4 (SO, 7.2) and at the end of treatment was 7.9 (SO,
6.6) (P< .OOI). The mean decrease in Ham-D score was 19.2 (SO, 9.8). The mean MMSE score at the beginning of treatment was 27.8 (SO, 2.6) and at the end of treatment was 26.2 (SO = 1.9) (P<.05). There was no significant change in the MMSE score (1.3; SO, 2.65) . DISCUSS ION
The data suggest that ECT patients' posrnve attitudes about ECT persisted at 2 weeks after treatment. The degree of satisfaction may be surprising to the public and nonpsychi atric clinicians as well as to psychiatrists who are ambivalent about ECT . Moreover, ECT patients held significantly more favorable attitudes about ECT than the control group; ECT patien ts' experience with ECT may have altered previously held beliefs that ECT is dangerous or painful. As a consecutive series of outpatients with a variety of psychiatric diagnoses, our control group had limitations. A true control group would have been drawn from inpatients completing pharmacologic treatment for their psychiatric disorder who were not offered ECT. A higher degree of overall satisfaction was associated with a younger age . This is interesting because the "Satisfaction With Results" score, a scale compos ed of 10 items, did not correlate with age. It is possible that the sample was
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
Mayo Clin Proc, October 1999, Vol 74
too small to detect a difference in satisfaction with results by age. Or, while older patients receive similar benefit from ECT, their satisfaction may be diminished by more severe adverse effects. Potential sources of error in the data include selection bias, as patients who chose not to complete the survey may have been less satisfied. The 53% response rate is a possible source of selection bias; with this population of psychiatric patients, however, obtaining high response rates is difficult. If patients are invested in their treatment, their hope that ECT is an effective treatment may inflate their degree of satisfaction. Every attempt was made to administer the survey in a manner in which patients would not feel compelled to answer in a way to please the treatment team. The possibility that mood state alters satisfaction presents another challenge. Patients with recurrence of depressed mood would likely have less positive attitudes about their ECT treatment if surveyed at a time of relapse. Post-ECT confusion may have been an issue for some patients at this point and may account for the number of ECT patients who failed to respond to the second survey. Future research projects to study patient satisfaction with ECT could address many other issues. The study design precluded the involvement of cognitively impaired patients. A future study could enlist family members to complete surveys on patients' behalf or could collect data from all patients regardless of their cognitive status. Another issue for further research is to survey patients who refused ECT to understand their concerns. Additional questions could be incorporated into the questionnaire to examine whether patients with subjective memory impairment have more negative attitudes toward ECT. While the data indicate that patients were satisfied with ECT at the conclusion of treatment and at follow-up 2 weeks later, longer-term follow-up would be valuable to assess satisfaction over time.
ACKNOWLEDGMENT We thank V. Shane Pankratz, PhD, for reviewing the statistical analyses used in this paper.
Patient Satisfaction With ECT
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REFERENCES I. American Psychiatric Association Task Force on Electroconvulsive Therapy. The Practice of Electroconvulsive Therapy: Recommendationsfor Treatment. Training, and Privileging. Washington, DC: American Psychiatric Association; 1990. 2. Weiner RD, Rogers HJ, Davidson JR, Squire LR. Effects of stimulus parameters on cognitive side effects. Ann N Y Acad Sci. 1986; 462:315-325. 3. Abramczuk JA, Rose NM . Pre-anaesthetic assessment and the prevention of post-ECT morbidity . Br J Psychiatry. 1979; 134:582587. 4. Sackeim HA, Prudic J, Devanand DP, et al. Effects of stimulus intensity and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy. N Engl J Med. 1993;328:839846. 5. Mattes JA, Pettinati HM, Stephens S, Robin SE, Willis KW. A placebo-controlled evaluation of vasopressin for ECT-induced memory impairment. Bioi Psychiatry. 1990;27:289-303. 6. Pettinati HM, Tamburello TA, Ruetsch CR, Kaplan FN. Patient attitudes toward electroconvulsive therapy. Psychopharmacol Bull. 1994;30:471-475. 7. Szuba MP, Baxter LR Jr, Liston EH, Roy-Byrne P. Patient and family perspective of electroconvulsive therapy: correlation with outcome. Convuls Ther. 1991;7: 175-183. 8. Baxter LR, Roy-Byrne P, Liston EH, Fairbanks L. The experience of electroconvulsive therapy in the 1980s: a prospective study of the knowledge, opinions, and experience of California electroconvulsive therapy patients in the Berkeley years. Convuls Ther. 1986;2: 179-189. 9. Freeman CPL, Cheshire KE. Review: attitude studies on electroconvulsive therapy. Convuls Ther. 1986;2:31-42. 10. Freeman CP, Kendell RE. ECT, I: patients' experiences and attitudes. Br J Psychiatry. 1980;137:8-16. 11. Kalayam B, Steinhart MJ. A survey of attitudes on the use of electroconvulsive therapy. Hosp Community Psychiatry. 1981;32: 185-188. 12. Hillard JR, Folger R. Patients' attitudes and attributions to electroconvulsive shock therapy. J Clin Psychol. 1977;33:855-861. 13. Battersby M, Ben-Tovim D, Eden J. Electroconvulsive therapy: a study of attitudes and attitude change after seeing an educational video. Aust N Z J Psychiatry. 1993;27:613-619. 14. Beyer JL, Weiner RD, Glenn MD. Electroconvulsive Therapy: A Programmed Text. 2nd ed. Washington, DC: American Psychiatric Press; 1998:63-78. 15. Folstein MF, Folstein SE, McHugh PRo "Mini-mental state": a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189-198. 16. Streiner DL, Norman GR. Health Measurement Scales: A Practical Guide to Their Development and Use. 2nd ed . Oxford, England: Oxford University Press; 1995. 17. Hamilton M. Development of a rating scale for primary depressive illness. Br J Soc Clin Psychol. 1967;6:278-296.
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
A. GOODMAN, MD;
LOIS
E.
KRAHN, MD; GLENN
E. SMITH,
PHD; TERESA
A. RUMMANS,
MD;
AND THOMAS S. PILEGGI, RN
dents endorsed the statement, "I am glad that 1 received ECT." Attitude score was significantly higher for the ECT group compared with controls. A higher degree of satisfaction was associated with a higher level of education and younger age. • Conclusions: Patients who received ECT were satisfied with their treatment and had more favorable attitudes about it than patients who did not receive this treatment.
• Objective: To determine whether patients who have electroconvulsive therapy (ECT) are satisfied with their treatment and demonstrate more favorable attitudes about ECT compared with controls. • Patients and Methods: We developed a 44-item survey measuring ECT treatment satisfaction and attitudes. The survey was administered to 24 psychiatric inpatients near the end of ECT treatment and 2 weeks later. A modified survey was administered to 24 outpatient controls who had never received ECT and who were recruited from a psychiatry clinic waiting room. • Results: Patients who received ECT had positive attitudes about it. For example, 21 (91 %) of 24 patient respon-
Mayo Clin Proc. 1999;74:967-971
ECT =electroconvulsive therapy; Ham-D =Hamilton Depression Scale; MMSE =Mini-Mental State Examination
U
sed for 60 years, electroconvulsive therapy (ECT) is an effective treatment for many psychiatric conditions."Over the years numerous refinements to ECT have made it more efficacious with fewer complications. These improvements include anesthetic and muscle relaxant use, as well as the routine use of electroencephalographic and electrocardiographic monitoring and pulse oximetry. Further advances include administration of a titrated convulsive stimulus that triggers a seizure at a specific level above the patient's measured seizure threshold.r" Clinicians have conducted research, published studies, and developed expertise regarding the administration of ECT to patients with a variety of comorbid medical disorders. However, when ECT is portrayed in the media, typically reference is made to negative images depicted in the novel and movie One Flew Over the Cuckoo's Nest, without describing modem anesthetic agents and new procedures. As a result, the pub-
lie, potential patients, and even physicians tend to view ECT as archaic and potentially dangerous. Many people suspect that patients undergo ECT as a last resort, and many doubt that patients would ever view this treatment favorably. Information about patient satisfaction with ECT is important when trying to educate potential patients and their families about this treatment option. The limited existing literature dates back many years and generally shows that patients who receive ECT have a positive attitude toward the treatment and its outcome.>" Relying on these previous studies is inappropriate because of the changes in ECT techniques over the decades, varied study methods, and lack of a validated survey instrument. There are at least 3 important reasons to measure satisfaction after ECT: (I) patient satisfaction is an increasingly important component of outcomes assessment; (2) satisfaction data are useful for patients considering ECT treatment; and (3) a satisfaction survey is an effective quality improvement tool for a particular program. A validated and reliable questionnaire permits the survey to be administered in a standardized fashion over time. Measuring patient satisfaction after ECT nonetheless presents a challenge. In particular, the design of a survey and timing of its administration must be done carefully because ECT alters cognition for a brief time. Also complicating the survey process are potential altered mood and insight in psychiatric patients after ECT. The present study was designed to measure patient satisfaction with ECT taking into account these factors.
From the Mayo Medical School (JAG.) and Department of Psychiatry and Psychology(L.E.K.. G.E.S.• TAR., T.S.P.), Mayo Clinic Rochester. Rochester, Minn. This study was supported in part by grant R10 MH 55484-01A1 from the National Institute of Mental Health (Drs Krahn, Rummans. and Smith). Presented in part at the 1998 Association for Convulsive Therapy Annual Meeting. Toronto, Ontario, May 31. 1998, and the 1998 American Psychiatric Association Annual Meeting. Toronto. Ontario, June 1, 1998. Address reprint requests and correspondence to Lois E. Krahn, MD. Department of Psychiatry and Psychology. Mayo Clinic Rochester, 200 First St SW. Rochester, MN 55905. Mayo Clin Proc. 1999;74:967-971
967
© 1999 Mayo Foundation/or Medical Education and Research
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
968
Mayo Clin Proc, October 1999, Vol 74
Patient Satisfaction With ECT
Patient Satisfaction Survey Instructions: Please read each statement below and circle one answer for each statement. Answer each question. If you are unsure about how to answer a question, give the best answer you can. Definitely false
Mostly false
Not sure
Mostly true
Definitely true
Your Overall Satisfaction ECT helps people. People should not be afraid of ECT. ECT is dangerous. Many people are helped by ECT. I am glad that I received ECT. I had to wait too long to be treated on days I received ECT. I felt safe receiving ECT. If my doctor recommended ECT in the future, I would choose to have ECT treatment. I was afraid to receive ECT. ECT was painful. I can remember having a seizure during ECT.
2 2 2 2 2 2 2 2 2 2 2
3 3 3 3 3 3 3 3 3 3 3
4 4 4 4 4 4 4 4 4 4 4
5 5 5 5 5 5 5 5 5 5 5
Your Satisfaction With Results ECT improved the quality of my life. I am very satisfied with the results of my ECT treatment. I am more discouraged since my ECT treatment. I am sleeping worse since my ECT treatment. My appetite is not as good since my ECT treatment. I have more energy since my ECT treatment. I am more confused since my ECT treatment. I am more optimistic since my ECT treatment. I have less physical pain since my ECT treatment. I get along with others better since my ECT treatment.
2 2 2 2 2 2 2 2 2 2
3 3 3 3 3 3 3 3 3 3
4 4 4 4 4 4 4 4 4 4
5 5 5 5 5 5 5 5 5 5
Your Satisfaction With Staff I can remember being in the ECT treatment area. I can remember the people who work in the ECT treatment area. The ECT treatment area provided privacy for me. I was treated with respect by the person who started my IV. I was treated with respect by the person who was with me when I woke up after ECT. I was treated with respect by the people in the room where I received ECT. The ECT treatment area did not provide enough privacy for me.
2 2 2 2 2 2 2
3 3 3 3 3 3 3
4 4 4 4 4 4 4
5 5 5 5 5 5 5
Your Satisfaction With Education Staff spent enough time with me describing ECT. I received the right amount of information about ECT. I received too much information about ECT. I did not receive enough information about ECT. Talking about ECT with my nurses and doctors made me less afraid of ECT. I talked with another patient who had ECT, which made me less afraid to have ECT. I did not know enough about ECT to decide if it was the right treatment. All of my questions about ECT were answered to my satisfaction.
2 2 2 2 2 2 2 2
3 3 3 3 3 3 3 3
4 4 4 4 4 4 4 4
5 5 5 5 5 5 5 5
Your Feelings I feel full of pep and energy most of the time. I feel full oflife. I am a very nervous person. I feel so down in the dumps that nothing can cheer me up. I feel calm and peaceful. I feel downhearted and low. I feel comfortable in groups. I feel tired and worn out most of the time.
2 2 2 2 2 2 2 2
3 3 3 3 3 3 3 3
4 4 4 4 4 4 4 4
5 5 5 5 5 5 5 5
Comments and suggestions. Finally, please identify a way in which you would like to see the treatment you received improved.
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
Patient Satisfaction With ECT
Mayo Clin Proc, October 1999, Vol 74
PATIENTS AND METHODS
Eligible subjects included all psychiatric inpatients who completed a course of ECT between May 1 and July 31, 1997. All patients had a physical examination and electrocardiography before receiving ECT. A Thymatron DG ECT device (Somatics, Inc, Lake Bluff, Ill) was used. The anesthetic medications given to all patients included glycopyrrolate, thiopental, and succinylcholine, administered by an anesthesiologist. The treatment team determined on a case-by-case basis whether to use unilateral or bilateral stimuli. During the first treatment session, a stimulus titration protocol was used to determine seizure threshold, and thereafter patients were treated at 150% and 250% of this setting for bilateral and unilateral treatment, respectively .14 The patients had electrocardiographic and electroencephalographic monitoring and pulse oximetry, with periodic blood pressure checks throughout the procedure and for at least 20 minutes after the procedure until they were hemodynamically stable in the recovery room. The only exclusion criterion was pre-ECT cognitive impairment, identified as a Mini-Mental State Examination (MMSE) score less than 26 (maximum score, 30) or an inability to complete the survey." Controls included consecutive patients seen in the outpatient psychiatric clinic over 2 days. Controls were excluded if they had ever received or been offered ECT. The study was approved by the Institutional Review Board of the Mayo Foundation. Patients were asked to participate while on the hospital unit away from the ECT treatment suite and were advised that their answers would not affect the nature of future psychiatric treatment at the institution. The survey was revised several times after a set of 85 questions was tested and retested with several pilot groups of appropriate patients. The final version of the Patient Satisfaction Survey contained 44 items divided into 5 sections. Answers were scored from 1 to 5. Half of the items were positively phrased and half were negatively phrased. Statements were designed to be understandable, unambiguous, and free of value-laden terms. 16 The questionnaire also encouraged patients to write comments and suggestions about their treatment. Subjects were assured that their responses were confidential. Other data collected from patients receiving ECT included age, sex, level of education, pretreatment psychiatric diagnosis, and pre-ECT and post-ECT Hamilton Depression Scale (Ham-D) and MMSE scores.v-" The preBeT and post-ECT Ham-D and MMSE evaluations for each patient were administered by the same interviewer (2 trained interviewers with good interrater reliability are part of the ECT service). The first ECT surveys were administered the evening before each subject's last ECT treatment
969
and at least 24 hours after the previous treatment. All the surveys were administered by 1 of us (J.A.G.) who was not part of the hospital treatment team or ECT service. The identical survey was mailed to participants at their homes 2 weeks after treatment to follow up their opinions about ECT treatment. The survey was modified before administration to controls because many items addressed the patient's perceptions of the actual ECT experience. Therefore, 5 items were selected from the "Overall Satisfaction" section of the ECT survey that addressed attitude (rather than actual experience). The statements selected were "ECT helps people," "People should not be afraid ofECT," "ECT is dangerous," "Many people are helped by ECT," and "If my doctor recommended ECT in the future, I would choose to have ECT treatment." This modified questionnaire was administered once to controls in the outpatient psychiatry department waiting room. An "Overall Satisfaction" score was generated by the sum of the 44 item scores from the surveys administered to the treated patients. The relationship between the scores resulting from the 2 administrations was evaluated with the Pearson correlation coefficient. Differences between the Ham-D and MMSE scores from the first to second survey were assessed with paired t tests. The relationship between overall satisfaction from the first administration and age, sex, education level, and HamD and MMSE scores before and after ECT was also examined. For those variables that are continuous (age, education level, rating scales), significance was assessed with the Pearson correlation coefficient. For variables that take discrete values (sex), significance was evaluated by analysis of variance. To assess the difference in attitude toward ECT between subjects and controls, an attitude score was calculated for each participant by determining the mean of the 5 items that were asked of both groups. A 2-sample t test was used to assess the statistical significance of the difference of the mean scores between the 2 groups. RESULTS
Fifty-three subjects completed ECT during the study period. Eight were excluded from study participation because of cognitive impairment. Of the 45 eligible subjects, 24 (53%) completed both survey administrations (12 males and 12 females). Five patients refused to participate, and 16 patients (34%) did not complete the follow-up questionnaire. The mean age of the 24 study patients was 58.3 years (SD, 17.6 years; range, 16-78 years). The mean level of education was 12.6 years (SD, 3.5 years; range, 8-20 years). The mean number of ECT treatments was 8.3 (SD, 3.5; range, 2-19). Major depression was the principal psychiatric diagnosis in 22 patients; 1 patient had bipolar
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
970
Mayo Clin Proc , October 1999, Vol 74
Patient Satisfaction With ECT
ECT helps people People should not be afraid of ECT ECT is dangerous Many people are helped by ECT I am glad that I received ECT
I had to wait too long to be treated on days I received ECT I felt safe receiving ECT
If my doctor recommended ECT in the future, I would choose to have ECT treatment I was afraid to receive ECT
ECT was painful I can remember having a seizure during ECT
In hospital
0 2 wee ks post
-J
--l
Definitely false
• •
I
Mostly false
I
Not sure
treatment
Co ntrol
Mostly true
Defi nite ly true
Figure I. Meanresponse to 11 survey items of the"Overall Satisfaction" section of thesurvey by psychiatric inpatientsat the end of the treatment (N=24), 2 weeks after treatment (N=24), and all 5 questions asked of the control outpatients who did not receive electroconvulsive therapy (ECT) (N=24). The 5 response options appearon the x axis. disorder and 1 had dysthymia. Twenty-four eligible contro l patient s completed the modified survey . Responses of ECT patients reflected positive attitudes toward ECT (Figure 1). Data are reported for the "overall satisfaction " component only . For example, 21 (9 1%) of 24 patients endorsed (answered " mostly true" or "definitely true" ) the statement, " I am glad that I received ECT" ; 23 (96%) endorsed the statement , "ECT helps people "; 19 (81%) endorsed the statement, "I felt safe receiving ECT'; and 20 (82%) endorsed the statement, "If my doctor recommended ECT in the future, I would choose to have ECT treatment." The attitude score, comparing responses of patients and controls to the same 5 statements, was significantly higher for the ECT group (4.4 of 5; SO = 0.7) compared with the control group (3.2 of 5; SO =0.9) (P< .OOl). Global satisfaction at the end of treatment correlated with that at 2-week follow-up (r=0.57 ; P=.007). The mean global satisfaction score change from the end of treatment to 2-week follow-up was 1.48 (SO, 21.4), which was not significantly different from O. From the first survey of ECT patients , the correlation between age and global satisfaction was 0.43 (P<.05), and the correlation between education level and global satisfaction was 0.42 (P=.05). The mean Ham-D score at the begin ning of treatment was 27.4 (SO, 7.2) and at the end of treatment was 7.9 (SO,
6.6) (P< .OOI). The mean decrease in Ham-D score was 19.2 (SO, 9.8). The mean MMSE score at the beginning of treatment was 27.8 (SO, 2.6) and at the end of treatment was 26.2 (SO = 1.9) (P<.05). There was no significant change in the MMSE score (1.3; SO, 2.65) . DISCUSS ION
The data suggest that ECT patients' posrnve attitudes about ECT persisted at 2 weeks after treatment. The degree of satisfaction may be surprising to the public and nonpsychi atric clinicians as well as to psychiatrists who are ambivalent about ECT . Moreover, ECT patients held significantly more favorable attitudes about ECT than the control group; ECT patien ts' experience with ECT may have altered previously held beliefs that ECT is dangerous or painful. As a consecutive series of outpatients with a variety of psychiatric diagnoses, our control group had limitations. A true control group would have been drawn from inpatients completing pharmacologic treatment for their psychiatric disorder who were not offered ECT. A higher degree of overall satisfaction was associated with a younger age . This is interesting because the "Satisfaction With Results" score, a scale compos ed of 10 items, did not correlate with age. It is possible that the sample was
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Mayo Clin Proc, October 1999, Vol 74
too small to detect a difference in satisfaction with results by age. Or, while older patients receive similar benefit from ECT, their satisfaction may be diminished by more severe adverse effects. Potential sources of error in the data include selection bias, as patients who chose not to complete the survey may have been less satisfied. The 53% response rate is a possible source of selection bias; with this population of psychiatric patients, however, obtaining high response rates is difficult. If patients are invested in their treatment, their hope that ECT is an effective treatment may inflate their degree of satisfaction. Every attempt was made to administer the survey in a manner in which patients would not feel compelled to answer in a way to please the treatment team. The possibility that mood state alters satisfaction presents another challenge. Patients with recurrence of depressed mood would likely have less positive attitudes about their ECT treatment if surveyed at a time of relapse. Post-ECT confusion may have been an issue for some patients at this point and may account for the number of ECT patients who failed to respond to the second survey. Future research projects to study patient satisfaction with ECT could address many other issues. The study design precluded the involvement of cognitively impaired patients. A future study could enlist family members to complete surveys on patients' behalf or could collect data from all patients regardless of their cognitive status. Another issue for further research is to survey patients who refused ECT to understand their concerns. Additional questions could be incorporated into the questionnaire to examine whether patients with subjective memory impairment have more negative attitudes toward ECT. While the data indicate that patients were satisfied with ECT at the conclusion of treatment and at follow-up 2 weeks later, longer-term follow-up would be valuable to assess satisfaction over time.
ACKNOWLEDGMENT We thank V. Shane Pankratz, PhD, for reviewing the statistical analyses used in this paper.
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