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According to the American Psychiatric Association (APA) guidelines for the treatment of major depression, electroconvulsive therapy (ECT) should be considered for all forms of moderate-to-severe depression that are unresponsive to pharmacologic treatment (1). To treat bipolar disorder, the Canadian Network for Mood and Anxiety Treatment (CANMAT) guidelines state that ECT should be the first-line treatment for acute mania and mixed-mood states that are characterized by severe behavioural disturbances; it is also the recommended treatment option in either partial responders or nonresponders in rapid-cycling bipolar disorder (2). Further, the APA guidelines for the treatment of bipolar disorder state that ECT is indicated as a treatment for medication nonresponders in acute mania (3). Moreover, it is a first-line treatment for the following: acute mania in pregnancy, neuroleptic malignant syndrome, catatonia, and general medical conditions precluding the use of standard pharmacologic treatment. Likewise, it should be considered a first-line treatment for bipolar depression whenever a rapid response is required (3). Expert consensus guidelines for treating bipolar depression rank ECT as the first choice for bipolar I disorder with psychotic depression (4). With respect to training requirements for this oft-indicated therapy, the 1992 Canadian Psychiatric Association (CPA) position paper on ECT has surprisingly little to say (5). According to the paper, “the educational process should begin in medical school so that graduates have an appreciation of ECT’s role in contemporary psychiatric practice. On the subject of psychiatry residency training, the paper states, “residents in general psychiatric programs should have both didactic teaching and practical experience in the use of ECT.” Further, the paper conveys that “adequate supervision” must be provided when a resident performs ECT (5). Published in 2001, APA guidelines regarding ECT are somewhat more specific concerning resident training. These guidelines advocate 4 hours of didactic lectures that involve theory and mechanisms, indications and contraindications, patient selection and evaluation, consent procedures (including legal ramifications), methods of administration, instrumentation, management of adverse effects, therapeutic outcome evaluation, clinical management posttreatment, and malpractice considerations. In addition, with respect to practical training, the guidelines provide specific recommendations that ensure residents actively participate in at least 10 ECT treatments in at least 3 separate cases that are supervised directly by a staff psychiatrist qualified to administer ECT. Further, each resident should actively participate in the care of at least 2 patients during ECT workup and through a course of ECT. ECT case rounds and conference participation should be actively encouraged. Finally, concerning evaluation, residency training programs should maintain records that include the nature and extent of specific educational experiences related to ECT, as well as evaluations of resident performance and experience (6). Despite these training recommendations, the literature is sparse about their application and efficacy. Few studies exist that have systematically evaluated training in and knowledge of ECT. However, several papers have emerged that look more closely at this issue—perhaps reflecting psychiatry’s growing concern about standards in training in the past 10 years. Lending support to the CPA and APA-recommended training guidelines, Benbow, in a study of medical students, concluded that exposure to ECT training while in medical school resulted in greater knowledge about the indications and side effects of ECT. More importantly, however, this greater knowledge correlated with more positive attitudes about ECT use (7). Szuba and others found similar evidence. In fact, they also found a correlation between greater knowledge and positive attitudes about ECT in a population of junior residents and medical students (8). These studies support the idea that effective and early training programs lead to better knowledge and a more positive attitude toward ECT. Unfortunately, studies of senior residents over the past decade indicate that there are serious shortcomings in effectively applying this principle in psychiatry residency programs. In a study by Jaffe and others, residents attested to significant gaps in their ECT training. Specifically, although most senior residents expressed positive attitudes toward ECT, only 7% expressed confidence in their ability to use it without supervision (9). Goldbloom and Kussin found that, of 156 senior residents in Canadian psychiatric residency training programs who responded to their survey, only 25.3% expressed confidence about their ability to administer ECT (10). Findings in a more recent study by Halliday and Johnson reveal that 60% of the senior residents polled reported that they had not been adequately prepared to administer ECT; an additional 15% were unsure about their ability to administer ECT (11). The results of these surveys indicate a pervasive lack of confidence among senior residents regarding their preparedness to use this important therapeutic modality. This finding is especially significant in light of the remarkable similarities across the groups concerning the extent of training reported. In the Jaffe and others study, residents reported an average of 3.2 hours of didactic lectures on ECT during their residency (ranging from 0 to 12 hours) (9). In the Goldbloom and Kussin study, over one-half of the respondents reported receiving 2 hours or fewer than 2 hours of formal ECT lectures, and 85% of respondents in the Halliday and Johnson study reported the same (10,11). Bedside teaching was less consistent across the studies. Of the residents in the Goldbloom and Kussin study who had performed ECT during their residency, one-half stated that an attending psychiatrist was “rarely or ever present.” Further—and more alarming—was the finding that 19.6% of the senior residents had never administered ECT (10). Similarly, in the Halliday and Johnson study, 55% of the residents who administered ECT indicated that, while they performed ECT, a staff psychiatrist who was trained in the procedure observed only once (11). Given that, in both these studies, a significant proportion of those polled considered that inpatient psychiatry would be a large part of their practice (37.3% in the Goldbloom and Kussin study and 53% in the Halliday and Johnson study), these findings are even more significant (10,11). The Jaffe and others study did not comment on the extent of the bedside supervision by staff (9). Despite the relatively few studies evaluating the extent of residency training programs and ECT administration, a clear trend was evident. Senior residents in their final years of training consistently reported a lack of preparedness concerning their training in ECT. These findings are of significant clinical and pedagogical concern, given clear indications for this essential modality of treatment. In light of the publication of clinical practice guidelines regarding ECT in mood disorders in both Canada and the US, we wondered whether these guidelines have altered resident training in, knowledge of, and attitude toward ECT. This study attempts to answer this question. MethodWe designed a confidential questionnaire to assess the nature of training in, attitude toward, and knowledge of ECT in senior psychiatric residents in Canada. The questionnaire was based heavily on the questionnaire from the Goldbloom and Kussin study (10). However, some modifications were made. With respect to the nature of resident training in ECT, modifications included providing greater variation in allowable responses to get a clearer understanding of the extent of the training. To account for self-directed learning, we added a question that inquired about the number of hours that residents spent reading about ECT. Further, a new question was added pertaining to the number of months spent on an inpatient unit during the residency. This question was added to identify correlations that inpatient experience might have with residents’ attitudes and knowledge. Likewise, we added 2 other questions that assessed residents’ knowledge about the indications and contraindications for ECT. These questions were intended as a brief screen to assess residents’ ECT knowledge. The surveys were sent to the directors of psychiatry residency training programs in all 16 medical schools across Canada, along with a request for distribution to all residents in the last year of their training (postgraduate year 5). With some modifications, the mail survey implementation was based, in part, on the work of Dillman to maximize mail survey response rates (12). This included cover letter design and strategy of the mailings. Then, 3 separate mailings were sent to the programs, each about 2 weeks apart. The first mailing consisted of an introductory letter and a questionnaire. The second mailing comprised a reminder about the first mailing and a notification of our intent to mail out the questionnaire a second time as an attempt to recruit initial nonresponders. The final mailing contained a cover letter and the questionnaire. We included the offer of a $25 gift certificate for a bookstore in the cover letter, which was distributed to residents who provided their mailing address along with their completed questionnaire.
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