Despite the evidence establishing the efficacy of electroconvulsive therapy (ECT), attempts to restrict or stop its use continue (1,2,3). In Texas, public inpatient psychiatric care is provided primarily by the Texas Department of Mental Health and Mental Retardation. The department operates eight psychiatric hospitals, only one of which currently provides ECT. In 1993 the department issued new regulations on the use of ECT as a result of state legislation (4). To examine the possible impact of these changes, we surveyed the attitudes of psychiatrists employed by the department toward ECT use and toward these laws and regulations.
A self-administered mail survey was designed to gather demographic data and information on attitudes toward ECT use and regulation. The survey was distributed in March 1996 to all hospital-based psychiatrists (N=128) through the clinical director of each of the department's eight hospitals. Potential respondents were reminded three times over a period of four months to return completed surveys.
The data were analyzed using descriptive statistics. Differences in age among respondents were tested using the nonparametric Kruskal-Wallis test because of the small numbers of subjects in some of the comparisons. Differences among respondents grouped by experience and demographic characteristics were tested using the two-tailed Fisher's exact test due to the small numbers in some groups. A p value of .05 or less was taken to indicate significance in all tests.
Sixty-seven of the 128 psychiatrists in the sample returned surveys, for a 52.3 percent response rate. However, because not all questions were answered on every survey, reported percentages reflect the number of respondents who answered each item.
Respondents had a mean age of 51±11 years and had a mean of 20±11 years of experience in psychiatry. The majority were male (N=54, or 80.6 percent), had completed a residency in psychiatry (N=65, or 97 percent), and had achieved board certification (N=40, or 59.7 percent).
The majority acknowledged receiving some form of ECT training during their residency (N=61, or 91 percent), and a majority had administered ECT at some point in their professional career (N=57, or 85.1 percent). However, only 23 respondents, or 34.3 percent, reported administering ECT in the last five years. More male respondents than female respondents reported having experience administering ECT (Fisher's exact test, p=.019). Among the respondents who gave their age, those who reported having performed ECT (median age=54 years, N=57) were significantly older than those who had not (median age=39 years, N=9) (Kruskal-Wallis test, p=.05).
Most of the respondents (N=60, or 93.8 percent) felt that ECT should be available to their patients. Nine of the ten psychiatrists who had not administered ECT still agreed with that view. The psychiatrists who had administered ECT were more likely to believe that ECT is safe when used within accepted guidelines and after an acceptable risk-benefit analysis, compared with those who had not administered ECT (84.9 percent versus 50 percent; Fisher's exact test, p= .005). However, none of the respondents felt that ECT is unacceptably dangerous. When asked if they would consider ECT for themselves or a family member, the majority of respondents (N=60, or 92.3 percent)—including those both with and without experience administering ECT—reported that when clinically indicated they would consider the use of ECT.
A majority of respondents perceived ECT as clinically useful in some cases of affective disorder and catatonia. Yet, as a group, they reported referring only four patients for ECT in the six months before the survey, only eight in the preceding year, and just 16 in the previous two years.
Law, policy, and education
A majority of respondents felt that Texas laws and regulations relating to ECT are too restrictive (N=43, or 65.2 percent) and that these restrictions may interfere significantly with good patient care (N=52, or 88.1 percent). The respondents' opinions about the effects on patient care differed significantly based on their prior experience with ECT (Fisher's exact test, p=.03), with more of those with ECT experience reporting concern.
More than a quarter of all respondents (N=19, or 28.4 percent) felt that they did not fully understand the current laws and regulations about ECT. A majority of all respondents (N=62, or 92.5 percent), irrespective of their prior experience with ECT, felt that more professional education about ECT and related laws and regulations is needed. More male psychiatrists (N=52) than female psychiatrists (N= 10) felt that education about ECT needs improvement (Fisher's exact test, p=.07). Psychiatrists who believed more ECT education is needed were significantly older (median age=55 years, N=31) than those who believed ECT education is "so-so" (median age=47.6 years, N=30) or adequate (median age=50 years, N=5) (Kruskal-Wallis test, p=.03).
The important findings in this study are, first, that an overwhelming majority of the responding psychiatrists had ECT training and experience. Most had a clearly positive attitude toward ECT as a safe treatment alternative for their patients, family members, and themselves, regardless of whether they had ever performed ECT.
Second, the responding psychiatrists generally agreed on the diagnoses for which ECT is usually considered to be safe and effective.
Third, the number of referrals for ECT treatment in the past two years reported by respondents seemed low for public psychiatric hospitals. For the period between 1994 and 1997, the average annual rate of use of ECT in Texas was .94 per 10,000 population for both public and private psychiatric hospitals (Shiwach RS, Reed WH, Carmody T, unpublished data, 1998), considerably lower than in other states (5). A low number of referrals and low rate of usage is surprising given the respondents' positive attitudes toward ECT and their apparent knowledge of the diagnoses for which ECT is a clinically accepted treatment.
The results of this survey suggest several factors that may be contributing to the low rate of ECT usage. First, the majority of the responding psychiatrists felt that Texas laws and regulations about ECT are too restrictive. Second, more than a quarter reported that they did not fully understand the current laws and regulations. Third, most respondents felt that professional education about ECT needed improvement. The finding that psychiatrists who were male, older, and more experienced with ECT were more likely to feel the need for improved education suggests that insufficient or inaccurate information about ECT may be limiting referrals.
The likelihood that these factors may be affecting the use of ECT was supported by Fink (3), who argued that attempts by various groups to stop or restrict ECT use through laws and regulations negatively impact the number of referrals for this treatment. Kramer (5) has also suggested that decreased availability of ECT can be associated with regulation. Similar attempts to restrict ECT are illustrated by two unsuccessful bills that were introduced in the 1997 Texas legislative session. One bill would have banned ECT and imposed a criminal penalty for its use. The other would have banned ECT for persons 65 years of age or older (6). Others have suggested that increased education and information about ECT for professionals, patients and their family members, and the general public may result in a more positive attitude toward ECT (1,7,8).
Given the current realities of managed care, the use of treatments with proven efficacy and positive cost-outcome ratios is increasingly critical. Studies have shown that index and maintenance ECT, used when clinically indicated, can result in reduced time spent in the hospital and reduced readmissions (9). Shorter and less frequent hospitalizations would result in considerable cost savings and in improved quality of life for many patients.
The authors thank William H. Reid, M.D., M.P.H., for support during the initiation of the study and Mental Health Connections at Dallas for statistical support.
Dr. Finch, Dr. Sobin, Ms. DeWitt, and Dr. Shiwach are affiliated with the departments of psychiatry and psychology at Terrell State Hospital in Terrell, Texas. Dr. Shiwach is also with the department of psychiatry at the University of Texas Southwestern Medical School in Dallas. Dr. Carmody is with the department of psychiatry and with the academic computing services department at the medical school. Address correspondence to Dr. Finch at the Department of Psychology, Terrell State Hospital, 1200 East Brin, Terrell, Texas 75160 (e-mail, firstname.lastname@example.org).