Indian Journal of Social Psychiatry

: 2022  |  Volume : 38  |  Issue : 1  |  Page : 45--51

A study of psychiatrists' attitudes and concerns toward the practice and stigma associated with electroconvulsive therapy

Parth Nagda1, Devavrat Harshe1, Sagar Karia2, Sneha Harshe3, Gurudas Harshe1, Nilesh Shah2, Avinash de Sousa2,  
1 Department of Psychiatry, D. Y. Patil Medical College, Kolhapur, Maharashtra, India
2 Department of Psychiatry, Lokmanya Tilak Municipal Medical College and Hospital, Mumbai, Maharashtra, India
3 Department of Psychiatry, Rajarshi Chhatrapati Shahu Maharaj Government Medical College, Kolhapur, Maharashtra, India

Correspondence Address:
Dr. Sagar Karia
Department of Psychiatry, LTMMC and GH, Sion, Mumbai- 400022, Maharashtra


Background: Electroconvulsive therapy (ECT) has shown to have efficacy and safety in treating psychiatric disorders. Studies have shown psychiatrists harboring negative attitudes about its use. The aim of the study was to assess the attitudes of psychiatrists toward practice and use of ECT and stigma associated with it. Methodology: A self-designed questionnaire was mailed electronically. Participants were asked to rate their attitudes and experience of using ECT in practice, concerns faced during prescribing ECTs, and possible solutions for destigmatization of ECTs. Results: We received 483 valid responses. Majority had positive attitudes toward the current use of ECT. Practicing in a metropolitan city, working in multiple clinics, having a family history of psychiatric illness, and having a member of the family treated with ECTs were associated with significantly more positive attitude and less concern about ECT. Poor socio-occupational strata, poor financial status, poor educational status, diagnosis of psychosis, and history of suicidal illness were associated with better acceptance of ECT by patients and caregivers. Improving undergraduate education in psychiatry and ECT and organizing interactions between patients advised ECT and patients improved with ECT were felt as effective solutions to counter ECT-related stigma by most number of psychiatrists. Conclusions: Psychiatrists in India have positive attitudes toward ECT yet have major concerns about caregiver reactions and patient dropouts while prescribing ECT. Practice location and prior exposure to psychiatric illness and ECT affect attitudes toward ECT. Psychiatrists suggested multiple strategies to reduce stigma associated with ECTs, changing the name of ECT to a nonstigmatizing was one of them.

How to cite this article:
Nagda P, Harshe D, Karia S, Harshe S, Harshe G, Shah N, de Sousa A. A study of psychiatrists' attitudes and concerns toward the practice and stigma associated with electroconvulsive therapy.Indian J Soc Psychiatry 2022;38:45-51

How to cite this URL:
Nagda P, Harshe D, Karia S, Harshe S, Harshe G, Shah N, de Sousa A. A study of psychiatrists' attitudes and concerns toward the practice and stigma associated with electroconvulsive therapy. Indian J Soc Psychiatry [serial online] 2022 [cited 2022 Jun 28 ];38:45-51
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Full Text


Electroconvulsive therapy (ECT) has been used in the management of psychiatric disorder for over 70 years and has demonstrated the efficacy and safety across various studies.[1] It has also been one of the most controversial treatments in psychiatry and is intricately linked to the stigma associated with mental health and psychiatrists.[2] Despite the advent of newer psychotropic medications, ECT still continues to be used in the management of psychiatric and has a place in most treatment algorithms.[3] The stigma associated with ECT use has led to many psychiatrists limiting its use in their patients.[4] The use of ECT varies from nation to nation, and various social, environmental, and academic factors determine the same. This has been demonstrated in the ECT usage pattern and attitude surveys across various countries.[5],[6],[7],[8],[9] Other factors implicated in these variations are legal provisions for the use of ECT, the availability of anesthetists, and the equipment for modified ECT along with the lack of psychiatrists who are trained and experienced in the use of modified ECT.[10] It has been shown in research that social and cultural attitudes toward ECT can make psychiatrists and physicians reluctant to use and refer patients for ECT.[11],[12] It is interesting to note that 4%–52% of psychiatrists across the globe have reported negative attitudes toward ECT and its relevance in the current clinical practice.[13]

The new Mental Health Care Act in India has issued strict regulations on the clinical use of ECT, some of which have faced strong opposition from psychiatrists. The use of ECT would also need greater paperwork which may now add to negative attitudes toward it.[14],[15] In the largest survey on ECT done in India, it was noted that psychiatrists in India have generally positive attitudes toward ECT and use it routinely in their clinical practice.[16] We decide to carry out this survey to assess the attitudes toward the practice of ECT and the stigma associated with it, keeping in light the increased awareness about mental health currently and improved access to mental health services along with the changing mental health laws in India.



The study sample comprised all psychiatrists (who have finished their postgraduate (PG) training in psychiatry with a recognized PG degree) and all of whom were members of the Indian Psychiatric Society (IPS), with e-mail addresses being available in the IPS membership directory. Only those psychiatrists working or practicing in India during the study duration were part of the sample.

Study questionnaire development

The study was an online survey, where the participants were assessed cross-sectionally. Institutional ethics committee approval was obtained for the study from D. Y. Patil Medical College, Kolhapur, and Lokmanya Tilak Municipal Medical College, Mumbai.

A core working group was formed consisting of three psychiatrists, all of whom had completed their undergraduate and PG training from institutions which offer ECT services to patients regularly. The core group members practiced general psychiatry and used ECT regularly in their clinical practice. The core group reviewed existing literature on the topic and identified attitudes and concerns about the ECT practice reported commonly in the research literature. These group members also hosted discussions with fellow psychiatrists during the monthly clinical meetings of their local IPS branch and received inputs about the concerns and experiences about patients' acceptance and reactions on prescribing ECTs and possible solutions to address the prevalent stigma about ECT among general public. The group also discussed and identified demographic factors (gender, native place), factors related to education (undergraduate and PG exposure to psychiatry and ECTs), and factors related to clinical practice (city, practice setting, available setup, and academic affiliation) to be included in study questionnaire. The group discussed and debated whether to include items related to familial exposure to psychiatry, mental illness, and ECTs and relevant questions were included in the questionnaire. The developed questionnaire was peer validated by three psychiatrists who had an experience of 10 years or more in the clinical psychiatry which included ECT use, who clinical research experience, and who were also PG teachers. Items with repetitions were deleted and those retained were re-phrased as per the experts' suggestions. The experts also advised to set certain questions with reversed scoring to detect lie responses.

Survey forms and data collection

The final version of the questionnaire was uploaded on Google Forms, a free online platform which creates interactive online forms, which can be shared easily as links via e-mail and phone messages. The link to the online questionnaire was mailed electronically to all psychiatrists, who were the members of the IPS and had shared their e-mail address in the membership directory of IPS. The e-mail contained information about the aim of the study, instructions necessary to access the form on their computer or smartphone, and instructions on how to opt out of the study/stop further e-mails regarding this study.

Reminder mails were sent once every week for the next 12 weeks. Every reminder e-mail mentioned the procedure for opting out of the study and avoiding further reminders. Participants were informed that the study was approved by ethics committees from both study sites. Each e-mail contained the link to the online form. Participants could access the page by clicking on the link and could completely fill the form on their computer as well as on their smartphone browsers.

Participants were informed that clicking on the link would be considered as an informed consent to participate in the study. Each form featured a “submit” button at the end, clicking which the participant's response was logged on the survey page automatically. Responses from all participants were logged on the survey page. The data could only be accessed by the investigators after entering their Google account login credentials. Participants were able to review their response before submission but could not access data once they clicked on the “submit” button. The questionnaires did not contain any field or question which would have disclosed the identity of the participant. Responses logged in Google Forms platform did not keep track of the participant's name or e-mail address, making the survey completely anonymous.

Statistical analysis

Google Forms automatically entered all responses in a spreadsheet, which was used for data analysis. Data were analyzed using a computer-based statistical software (SPSS version 20.0) IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp. Demographic details were analyzed using descriptive statistics. Dichotomous and ordinal variables were analyzed using cross-tabulations and Chi-square test. The statistical significance was assumed at P < 0.05.


Basic sociodemographic data and facts

The questionnaire was e-mailed to 4108 members, of which 1314 mails bounced back with a failure to delivery notice. Therefore, we assume that the questionnaire effectively reached 2794 members. We received 495 replies (response rate 17.71%) at the end of 12 weeks. We excluded 12 respondents as they were not practicing in India at the time of the study. Therefore, the study sample consisted of 483 responses. The sample consisted of 377 males (78.1%) and 106 (21.9%) females. The sample had a mean age of 41.96 ± 11.26 years (range: 28–80 years) and a mean experience of 14.31 ± 10.81 years. [Table 1] describes various demographic and professional details of study sample.{Table 1}

Fifty-eight (12%) respondents reported not being posted in psychiatry rotation during their undergraduate training. 281 (58.1%) respondents reported good attendance in psychiatry during their undergraduate training. All the participants reported ECTs being an important part of treatment during their PG training. 319 (66.05%) participants reported their PG department and teachers to be supportive of ECTs. Few psychiatrists were trained during their days on unmodified ECTs, and most were trained using modified ECT. 71 (14.7%) respondents reported having another psychiatrist in family, 157 (32.5%) reported a history of psychiatric illness in their family, and 52 (10.76%) reported a history of a family member having received ECT in the past.

Attitudes toward electroconvulsive therapy and its current use and practice

All the participants used ECT in their practice with varying frequency. Psychiatrists practicing in a single hospital/clinic (χ2 = 27.076, P = 0.001) and those who had a member of their family treated with ECT (χ2 = 9.666, P = 0.046) reported a significantly greater regular use of ECT. Significantly more men (χ2 = 11.551, P = 0.003), those with family history of psychiatric illness (χ2 = 12.290, P = 0.002), and those trained with greater number of ECT sessions per week (χ2 = 24.442, P = 0.007) reported that ECT should not be banned in patients younger than 16 years of age [Table 2].{Table 2}

Significantly more men (χ2 = 18.007, P < 0.001), those using ECTs more regularly (χ2 = 16.209, P = 0.039), those practicing in urban settings (χ2 = 18.382, P = 0.001), those with better attendance in undergraduate psychiatry training (χ2 = 11.802, P = 0.012), those who perceived their teachers supportive of ECT use (χ2 = 12.451, P = 0.014), and those who had a family member having received ECT in the past (χ2 = 6.329, P = 0.042) reported more willingness to accept ECT for themselves or their family members if needed [Table 2].

Negative attitudes toward ECT were also affected by personal factors. Significantly more psychiatrists not using ECTs regularly (χ2 = 41.337, P < 0.001), those with more experience in practice (χ2 = 9.587, P = 0.048), and those who perceived their teachers not supportive of ECT use (χ2 = 18.250, P = 0.001) believed that ECT is no longer necessary with newer psychopharmacological agents. Participants who felt their teachers were not supportive of ECT use also believed that ECT should not be used on humanitarian grounds, despite having superior efficacy (χ2 = 12.599, P = 0.013) [Table 2].

Psychiatrists' concerns toward reactions by patients/caregivers on the suggestion of electroconvulsive therapy as a treatment modality

Significantly more psychiatrists practicing from multiple clinics or hospitals (χ2 = 6.896, P = 0.032), those without any family history of psychiatric illness (χ2 = 3.350, P = 0.040), and those regularly using ECT (χ2 = 16.266, P = 0.039) reported anxiety about losing a patient after prescribing ECT. Psychiatrists practicing in metropolitan and semiurban locales (χ2 = 11.647, P = 0.020) and using ECT less regularly (χ2 = 18.422, P = 0.018) felt that patients might perceive ECTs as an outdated and inhuman treatment modality [Table 3] and [Figure 1]. Psychiatrists using ECTs less regularly (χ2 = 18.554, P = 0.017) reported actually avoiding mentioning ECT to a patient, when they anticipated a negative reaction from the patient or the caregiver.{Table 3}{Figure 1}

Psychiatrists' opinions on strategies to reduce stigma about electroconvulsive therapy

Apart from other initiatives shown in [Table 4], nearly 26% of the participants felt that changing the name of the procedure to a less stigmatizing one would help reduce the stigma associated with the procedure. A total of 126 names were suggested by participants [Table 5], 78% of which did not include the words “electro/electric” and “convulsive” or “shock.”{Table 4}{Table 5}


The survey not only addressed the concerns and attitudes perceived by psychiatrists but also looked at factors that may have been associated with negative attitudes toward ECT. It also explored the psychiatrists' suggestions on countering stigma associated with ECT.

Psychiatrists' attitudes about use and relevance of electroconvulsive therapy

A total of 144 (29.9%) of all responders reported rare to never using ECT in their practice. An earlier survey reported up to 13% of psychiatrists not using ECTs in the last 6 months before the survey.[16] Some countries such as Hungary have seen a decline in ECT use by as much as 80% in the last 20 years, while a study from Russia showed that nearly a third of all psychiatrists had never even witnessed an ECT in their career.[6],[7] Reasons for this decline were lack of adequate number of psychiatrists trained in modern ECT procedures, lack of equipment such as anesthetic and ventilation devices in large numbers, and misconceptions about modern ECT such as ECT being extremely painful and being given without a muscle relaxant in those countries. This decline was noted in our study despite the availability of trained workforce and equipment.

Acceptability of electroconvulsive therapy by psychiatrists and patients

Majority of psychiatrists who responded to the survey supported the use of ECT as a first-line treatment, believed that ECT was essential despite availability of newer drugs, and refused to believe that ECTs are being overused. These findings are in conjunction with studies from Russia, Norway, Hungary, United States, Romania, and India.[5],[6],[7],[8],[9],[16]

More than half of the sample (n = 266, 55.07%) felt that ECT should not be banned for use in patients under the age of 16 years. This is a shift in a positive direction compared to a previous Indian survey when only 33% of the psychiatrists felt that ECT should be used in children and adolescents. This increase could be due to research and experience into the efficacy and safety profile of ECT in children and adolescents that has ensued since.[17] Psychiatrists reported that ECT was accepted easily in patients from a rural background and poor socio-occupational strata and those with lower education and poor financial status. A possible explanation for this could be that patients with such factors often engage in paternalism and trust their doctor-blindly and may not go in for a second opinion. They, due to their poor educational status, may have lesser access to online websites and media, which usually portray ECT as barbaric and inhumane.[18]

Interestingly, ECT as a possible treatment for oneself was acceptable to 84% of the participants if indicated, whereas 5% refused this possibility. When asked similar questions, only 32% psychiatrists from Hungary, 47% from Romania, 62% from Russia, and 8% from the United States agreed to receive ECT themselves as a treatment.[5],[6],[7],[9] On a deeper scrutiny, we observed that psychiatrists who were anxious about the relevance of ECT in the current practice were unwilling to accept ECT as a treatment modality. This must be looked at when designing new syllabi and putting modified ECT training as compulsory in PG psychiatry courses while witnessing ECT as compulsory in undergraduate courses.

Concerns reported while prescribing electroconvulsive therapy to patients

Majority of the psychiatrists had a positive attitude toward ECT yet reported difficulties in prescribing the use of ECT to a patient. Major concerns were losing the patient to another doctor (54%), being subjected to bad-mouthing and slander in the community (29%), and the patient perceiving the treatment as inhuman and outdated. More than half (52%) of our sample reported that they always or sometimes avoid mentioning ECTs altogether despite being indicated to a patient if they anticipate a negative reaction from the patient or his/her caregivers.

Psychiatrists who believed that ECTs have become obsolete with newer drugs were significantly more in number to share this belief. This is an important concern that needs to be addressed promptly. Numerous trials including sham studies have shown that all antidepressants and antipsychotics are equally efficacious in treating major psychiatric disorders, such as schizophrenia and depression. ECT has also shown its superior efficacy in resistant cases for depression, schizophrenia, suicidal ideations, catatonia, and even resistant Obsessive Compulsive Disorder (OCD).[19] Therefore, denying the option of such an efficacious and safe treatment alternative to a patient, not on clinical factors, but for the stigma and misconceptions, would be a disservice to a patient.

Impact of familial exposure to psychiatry and electroconvulsive therapy

Exposure to psychiatry was assessed under three questions, i.e., whether the participants had another psychiatrist in their family, whether the participants had a family history of psychiatric illness, and whether the participants had a member of the family treated with ECTs. Participants with familial exposure to psychiatry, psychiatric illness, and ECT had significantly more positive attitudes toward the current ECT and had significantly lesser concerns and apprehensions while prescribing ECTs. This might again be due to their personal experience about the course and severity of mental illness and experience about safety and efficacy of ECT in mental illnesses. Therefore, they could empathize easily with the patient and psycho-educate about ECT with better conviction. These findings corroborate the argument that positive experience with ECT is associated with positive attitude and less perceived stigma about ECT.[20],[21]

Suggestions to improve electroconvulsive therapy perception and acceptance

Psychiatrists thought that demonstrating ECT to caregivers before consent might help in destigmatization (n = 429, 88.81%). A significant majority (n = 449, 92.97%) thought that organizing interactions with caregivers/patients who have received ECT would help in reducing the fear and stigma about ECT. The reason for this could be the media portrayal and preconceived notions about ECT among the public.[22] Understanding its efficacy and safety by listening to experiences from other patients and relatives might act as a peer-support model, which might make it easier for them to accept ECT as safe and effective.[23]

Majority of the participants believed that undergraduate students should have a demonstration of ECT in their undergraduate training. Psychiatrists also felt that making psychiatry a compulsory subject in undergraduate training would benefit the cause. Currently, the undergraduate training in psychiatry is only two postings each lasting for 15 days. This is too short a time for them to observe the clinical course and progress of a patient being treated with ECT. Many responders in our studies did not have even 1 day of experience in psychiatry at an undergraduate level, and many were not regular in attending the same. Psychiatrists also reported ECT acceptability among medical community to be extremely low. Undergraduate exposure to psychiatry and ECT is vital because prior exposure with ECT sensitizes an individual and is associated with developing positive attitudes about it.[24] Psycho-education about ECT using simple techniques such as showing educational videos has shown to improve the situation drastically.[25]

Participants suggested alternative names for the procedure, but the responses were equivocal about the plausibility of renaming the procedure. Most of them suggested names which were devoid of the word “electro” and “convulsive,” thereby delineating any “harm” or “danger” associated commonly with these words. Most of them were of the opinion of using words such as “light,” “pulse,” “injection,” or “brain activation/brain stimulation” or modulation.

Renaming an illness or a procedure to reduce associated stigma or shock is not a novel strategy. It has been tried with many physical illnesses, e.g., leprosy is often referred to as Hansen's disease while talking to the patients to minimize the shock associated with the diagnosis. Even psychiatry has had its share of renaming an illness to reduce the associated stigma. DSM-5 proposed renaming “mental retardation” to “intellectual disability” as the word “retard” was being used in a derogatory manner.[26] Renaming the treatment is a debatable issue and warrants further discussion.

Strengths and limitations of the study

This only the second study of this kind in India. It evaluates not only negative attitudes and concerns but also explores possible solutions for destigmatization of ECT as reported by psychiatrists. The study has limitations as we had to exclude psychiatrists trained in India and practicing abroad. Psychiatrists who had not updated their e-mail address, who did not check their e-mail regularly, or who were not tech-savvy could not participate in the study. Only 483 responded out of nearly 4108 e-mails that were sent which was dismal and many responses have not been collected.


Majority of the psychiatrists have a positive attitude about the relevance of ECT in clinical practice, despite newer treatment modalities. Psychiatrists also have significant concerns about patient reactions about prescribing ECT. Changes in medical undergraduate training and better patient education modules were identified as ways to counter the stigma by most participants. Demographic factors, professional settings, undergraduate and PG training, and familial exposure to psychiatry affect an individual's attitudes and concerns toward psychiatry. Psychiatrists are entrusted with the vital task of spreading awareness and addressing the stigma about psychiatric illness and mental health. They guard the public against myths, misconceptions, and stigma against mental health issues. It is a matter of concern that psychiatrists could have negative attitudes, stigma, and concerns about using a safe, effective, and time-tested treatment modality. This issue needs to be explored, debated, and discussed on various platforms and a consensus must be reached.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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