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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

• Objective: To determine whether patients who have dents endorsed the statement, "I am glad that 1 received
electroconvulsive therapy (ECT) are satisfied with their ECT." Attitude score was significantly higher for the ECT
treatment and demonstrate more favorable attitudes group compared with controls. A higher degree of satisfac-
about ECT compared with controls. tion was associated with a higher level of education and
• Patients and Methods: We developed a 44-item survey younger age.
measuring ECT treatment satisfaction and attitudes. The • Conclusions: Patients who received ECT were satis-
survey was administered to 24 psychiatric inpatients near fied with their treatment and had more favorable attitudes
the end of ECT treatment and 2 weeks later. A modified about it than patients who did not receive this treatment.
survey was administered to 24 outpatient controls who had Mayo Clin Proc. 1999;74:967-971
never received ECT and who were recruited from a psy-
chiatry clinic waiting room.
ECT =electroconvulsive therapy; Ham-D =Hamilton Depres-
• Results: Patients who received ECT had positive atti- sion Scale; MMSE =Mini-Mental State Examination
tudes about it. For example, 21 (91 %) of 24 patient respon-

U sed for 60 years, electroconvulsive therapy (ECT) is


an effective treatment for many psychiatric condi-
tions."Over the years numerous refinements to ECT have
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
made it more efficacious with fewer complications. These many doubt that patients would ever view this treatment
improvements include anesthetic and muscle relaxant use, favorably.
as well as the routine use of electroencephalographic and Information about patient satisfaction with ECT is im-
electrocardiographic monitoring and pulse oximetry. Fur- portant when trying to educate potential patients and their
ther advances include administration of a titrated convul- families about this treatment option. The limited existing
sive stimulus that triggers a seizure at a specific level above literature dates back many years and generally shows that
the patient's measured seizure threshold.r" Clinicians have patients who receive ECT have a positive attitude toward
conducted research, published studies, and developed ex- the treatment and its outcome.>" Relying on these previous
pertise regarding the administration of ECT to patients with studies is inappropriate because of the changes in ECT
a variety of comorbid medical disorders. However, when techniques over the decades, varied study methods, and
ECT is portrayed in the media, typically reference is made lack of a validated survey instrument.
to negative images depicted in the novel and movie One There are at least 3 important reasons to measure satis-
Flew Over the Cuckoo's Nest, without describing modem faction after ECT: (I) patient satisfaction is an increasingly
anesthetic agents and new procedures. As a result, the pub- important component of outcomes assessment; (2) satisfac-
tion data are useful for patients considering ECT treatment;
and (3) a satisfaction survey is an effective quality im-
From the Mayo Medical School (JAG.) and Department of Psychia- provement tool for a particular program. A validated and
try and Psychology(L.E.K.. G.E.S.• TAR., T.S.P.), Mayo Clinic Roch-
ester. Rochester, Minn. reliable questionnaire permits the survey to be adminis-
tered in a standardized fashion over time.
This study was supported in part by grant R10 MH 55484-01A1
from the National Institute of Mental Health (Drs Krahn, Rummans. Measuring patient satisfaction after ECT nonetheless
and Smith). presents a challenge. In particular, the design of a survey
Presented in part at the 1998 Association for Convulsive Therapy and timing of its administration must be done carefully
Annual Meeting. Toronto, Ontario, May 31. 1998, and the 1998 because ECT alters cognition for a brief time. Also compli-
American Psychiatric Association Annual Meeting. Toronto. Ontario,
June 1, 1998.
cating the survey process are potential altered mood and
insight in psychiatric patients after ECT. The present study
Address reprint requests and correspondence to Lois E. Krahn, MD.
Department of Psychiatry and Psychology. Mayo Clinic Rochester, was designed to measure patient satisfaction with ECT
200 First St SW. Rochester, MN 55905. taking into account these factors.
Mayo Clin Proc. 1999;74:967-971 967 © 1999 Mayo Foundation/or Medical Education and Research

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968 Patient Satisfaction With ECT Mayo Clin Proc, October 1999, Vol 74

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 Mostly Not Mostly Definitely
false false sure true true
Your Overall Satisfaction
ECT helps people. 2 3 4 5
People should not be afraid of ECT. 2 3 4 5
ECT is dangerous. 2 3 4 5
Many people are helped by ECT. 2 3 4 5
I am glad that I received ECT. 2 3 4 5
I had to wait too long to be treated on days I received ECT. 2 3 4 5
I felt safe receiving ECT. 2 3 4 5
If my doctor recommended ECT in the future, I would choose to have ECT treatment. 2 3 4 5
I was afraid to receive ECT. 2 3 4 5
ECT was painful. 2 3 4 5
I can remember having a seizure during ECT. 2 3 4 5

Your Satisfaction With Results


ECT improved the quality of my life. 2 3 4 5
I am very satisfied with the results of my ECT treatment. 2 3 4 5
I am more discouraged since my ECT treatment. 2 3 4 5
I am sleeping worse since my ECT treatment. 2 3 4 5
My appetite is not as good since my ECT treatment. 2 3 4 5
I have more energy since my ECT treatment. 2 3 4 5
I am more confused since my ECT treatment. 2 3 4 5
I am more optimistic since my ECT treatment. 2 3 4 5
I have less physical pain since my ECT treatment. 2 3 4 5
I get along with others better since my ECT treatment. 2 3 4 5

Your Satisfaction With Staff


I can remember being in the ECT treatment area. 2 3 4 5
I can remember the people who work in the ECT treatment area. 2 3 4 5
The ECT treatment area provided privacy for me. 2 3 4 5
I was treated with respect by the person who started my IV. 2 3 4 5
I was treated with respect by the person who was with me when I woke up after ECT. 2 3 4 5
I was treated with respect by the people in the room where I received ECT. 2 3 4 5
The ECT treatment area did not provide enough privacy for me. 2 3 4 5

Your Satisfaction With Education


Staff spent enough time with me describing ECT. 2 3 4 5
I received the right amount of information about ECT. 2 3 4 5
I received too much information about ECT. 2 3 4 5
I did not receive enough information about ECT. 2 3 4 5
Talking about ECT with my nurses and doctors made me less afraid of ECT. 2 3 4 5
I talked with another patient who had ECT, which made me less afraid to have ECT. 2 3 4 5
I did not know enough about ECT to decide if it was the right treatment. 2 3 4 5
All of my questions about ECT were answered to my satisfaction. 2 3 4 5

Your Feelings
I feel full of pep and energy most of the time. 2 3 4 5
I feel full oflife. 2 3 4 5
I am a very nervous person. 2 3 4 5
I feel so down in the dumps that nothing can cheer me up. 2 3 4 5
I feel calm and peaceful. 2 3 4 5
I feel downhearted and low. 2 3 4 5
I feel comfortable in groups. 2 3 4 5
I feel tired and worn out most of the time. 2 3 4 5

Comments and suggestions.

Finally, please identify a way in which you would like to see the treatment you received improved.

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Mayo Clin Proc, October 1999, Vol 74 Patient Satisfaction With ECT 969

PATIENTS AND METHODS and at least 24 hours after the previous treatment. All the
Eligible subjects included all psychiatric inpatients who surveys were administered by 1 of us (J.A.G.) who was not
completed a course of ECT between May 1 and July 31, part of the hospital treatment team or ECT service. The
1997. All patients had a physical examination and electro- identical survey was mailed to participants at their homes 2
cardiography before receiving ECT. A Thymatron DG weeks after treatment to follow up their opinions about
ECT device (Somatics, Inc, Lake Bluff, Ill) was used. ECT treatment.
The anesthetic medications given to all patients included The survey was modified before administration to con-
glycopyrrolate, thiopental, and succinylcholine, adminis- trols because many items addressed the patient's percep-
tered by an anesthesiologist. The treatment team deter- tions of the actual ECT experience. Therefore, 5 items were
mined on a case-by-case basis whether to use unilateral selected from the "Overall Satisfaction" section of the ECT
or bilateral stimuli. During the first treatment session, a survey that addressed attitude (rather than actual experi-
stimulus titration protocol was used to determine seizure ence). The statements selected were "ECT helps people,"
threshold, and thereafter patients were treated at 150% "People should not be afraid ofECT," "ECT is dangerous,"
and 250% of this setting for bilateral and unilateral treat- "Many people are helped by ECT," and "If my doctor
ment, respectively .14 The patients had electrocardiographic recommended ECT in the future, I would choose to have
and electroencephalographic monitoring and pulse ox- ECT treatment." This modified questionnaire was adminis-
imetry, with periodic blood pressure checks throughout the tered once to controls in the outpatient psychiatry depart-
procedure and for at least 20 minutes after the procedure ment waiting room.
until they were hemodynamically stable in the recovery An "Overall Satisfaction" score was generated by the
room. sum of the 44 item scores from the surveys administered to
The only exclusion criterion was pre-ECT cognitive the treated patients. The relationship between the scores
impairment, identified as a Mini-Mental State Examination resulting from the 2 administrations was evaluated with the
(MMSE) score less than 26 (maximum score, 30) or an Pearson correlation coefficient. Differences between the
inability to complete the survey." Controls included con- Ham-D and MMSE scores from the first to second survey
secutive patients seen in the outpatient psychiatric clinic were assessed with paired t tests.
over 2 days. Controls were excluded if they had ever re- The relationship between overall satisfaction from the
ceived or been offered ECT. The study was approved by first administration and age, sex, education level, and Ham-
the Institutional Review Board of the Mayo Foundation. D and MMSE scores before and after ECT was also exam-
Patients were asked to participate while on the hospital unit ined. For those variables that are continuous (age, educa-
away from the ECT treatment suite and were advised that tion level, rating scales), significance was assessed with the
their answers would not affect the nature of future psychi- Pearson correlation coefficient. For variables that take dis-
atric treatment at the institution. crete values (sex), significance was evaluated by analysis
The survey was revised several times after a set of 85 of variance. To assess the difference in attitude toward
questions was tested and retested with several pilot groups ECT between subjects and controls, an attitude score was
of appropriate patients. The final version of the Patient calculated for each participant by determining the mean of
Satisfaction Survey contained 44 items divided into 5 sec- the 5 items that were asked of both groups. A 2-sample t
tions. Answers were scored from 1 to 5. Half of the items test was used to assess the statistical significance of the
were positively phrased and half were negatively phrased. difference of the mean scores between the 2 groups.
Statements were designed to be understandable, unambigu-
ous, and free of value-laden terms. 16 The questionnaire also RESULTS
encouraged patients to write comments and suggestions Fifty-three subjects completed ECT during the study pe-
about their treatment. Subjects were assured that their re- riod. Eight were excluded from study participation because
sponses were confidential. of cognitive impairment. Of the 45 eligible subjects, 24
Other data collected from patients receiving ECT in- (53%) completed both survey administrations (12 males
cluded age, sex, level of education, pretreatment psychiat- and 12 females). Five patients refused to participate, and 16
ric diagnosis, and pre-ECT and post-ECT Hamilton De- patients (34%) did not complete the follow-up question-
pression Scale (Ham-D) and MMSE scores.v-" The pre- naire. The mean age of the 24 study patients was 58.3 years
BeT and post-ECT Ham-D and MMSE evaluations for (SD, 17.6 years; range, 16-78 years). The mean level of
each patient were administered by the same interviewer (2 education was 12.6 years (SD, 3.5 years; range, 8-20
trained interviewers with good interrater reliability are part years). The mean number of ECT treatments was 8.3 (SD,
of the ECT service). The first ECT surveys were adminis- 3.5; range, 2-19). Major depression was the principal psy-
tered the evening before each subject's last ECT treatment chiatric diagnosis in 22 patients; 1 patient had bipolar

For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
970 Patient Satisfaction With ECT Mayo Clin Proc , October 1999, Vol 74

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 -J


• In hospital
0 2 wee ks post
treatment
I can remember having a
seizure during ECT
--l

I I
• Co ntrol

Definitely Mostly Not Mostly Defi nite ly


false false sure true 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 6.6) (P< .OOI). The mean decrease in Ham-D score was
patient s completed the modified survey . 19.2 (SO, 9.8). The mean MMSE score at the beginning of
Responses of ECT patients reflected positive attitudes treatment was 27.8 (SO, 2.6) and at the end of treatment
toward ECT (Figure 1). Data are reported for the "overall was 26.2 (SO = 1.9) (P<.05). There was no significant
satisfaction " component only . For example, 21 (9 1%) of 24 change in the MMSE score (1.3; SO, 2.65) .
patients endorsed (answered " mostly true" or "definitely
true" ) the statement, " I am glad that I received ECT" ; 23 DISCUSS ION
(96%) endorsed the statement , "ECT helps people "; 19 The data suggest that ECT patients' posrnve attitudes
(81%) endorsed the statement, "I felt safe receiving ECT'; about ECT persisted at 2 weeks after treatment. The degree
and 20 (82%) endorsed the statement, "If my doctor recom- of satisfaction may be surprising to the public and non-
mended ECT in the future, I would choose to have ECT psychi atric clinicians as well as to psychiatrists who are
treatment." The attitude score, comparing responses of pa- ambivalent about ECT . Moreover, ECT patients held sig-
tients and controls to the same 5 statements, was signifi- nificantly more favorable attitudes about ECT than the
cantly higher for the ECT group (4.4 of 5; SO = 0.7) com- control group; ECT patien ts' experience with ECT may
pared with the control group (3.2 of 5; SO =0.9) (P< .OOl). have altered previously held beliefs that ECT is dangerous
Global satisfaction at the end of treatment correlated or painful.
with that at 2-week follow-up (r=0.57 ; P=.007). The mean As a consecutive series of outpatients with a variety of
global satisfaction score change from the end of treatment psychiatric diagnoses, our control group had limitations. A
to 2-week follow-up was 1.48 (SO, 21.4), which was not true control group would have been drawn from inpatients
significantly different from O. From the first survey of ECT completing pharmacologic treatment for their psychiatric
patients , the correlation between age and global satisfac- disorder who were not offered ECT.
tion was 0.43 (P<.05), and the correlation between educa- A higher degree of overall satisfaction was associated
tion level and global satisfaction was 0.42 (P=.05). with a younger age . This is interesting because the "Satis-
The mean Ham-D score at the begin ning of treatment faction With Results" score, a scale compos ed of 10 items,
was 27.4 (SO, 7.2) and at the end of treatment was 7.9 (SO, did not correlate with age. It is possible that the sample was

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Mayo Clin Proc, October 1999, Vol 74 Patient Satisfaction With ECT 971

too small to detect a difference in satisfaction with results REFERENCES


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