Introduction
Electroconvulsive Therapy (ECT) remains one of the most effective treatments for severe psychiatric disorders, particularly in cases of treatment-resistant depression, acute suicidality, catatonia, and certain conditions during pregnancy where pharmacological interventions pose risks(1,2). Despite its well-documented efficacy, ECT is often met with resistance due to persistent misconceptions, stigma, and inadequate knowledge among patients and their families(3). 
Given that psychiatric patients frequently lack the capacity to provide informed consent, the attitudes and knowledge of their legal guardians or companions play a crucial role in treatment adherence and outcomes (4).
Several studies have highlighted significant gaps in public understanding of ECT. According to a survey by Tang et al in Hong Kong, most patients and relatives viewed ECT as beneficial (5). Despite this positive view, over 60% reported receiving insufficient information before treatment. This lack of information was particularly evident regarding potential side effects, such as transient memory impairment (5). Similarly, Deng et al reported that only 37% of patients and 55% of caregivers in China received adequate explanations about ECT’s risks and benefits, contributing to unwarranted fears (6). 
Family members and legal guardians often serve as decision-makers for psychiatric patients undergoing ECT. However, studies indicate that their knowledge is frequently inadequate. 
In the Iranian context, research by Kheiri et al revealed that a majority of patients’ families had poor knowledge and negative perceptions about ECT, often influenced by media portrayals (7).
Grover et al found that caregivers with prior ECT experience had more favorable attitudes, as they were more likely to receive information directly from psychiatrists (8).
Conversely, first-time companions often relied on unreliable sources, exacerbating anxiety about the procedure. In Iran, Asadi et al demonstrated that companions’ attitudes were significantly influenced by the patient’s prior hospitalization and ECT exposure, emphasizing the need for structured educational interventions (9). Furthermore, a recent study from Iran, conducted by Hosseini et al, examined the experiences of psychiatric trainees with ECT.
They found that while ECT training in Iran is generally available nationwide, its implementation varies. 
Psychiatrists generally held a positive attitude toward the procedure and were actively involved in both observing and administering ECT (10). Cultural beliefs and healthcare system disparities further complicate ECT acceptance. An other study from Iran showed that while patients who had received ECT reported significant satisfaction, public stigma remains a considerable barrier (11). This aligns with findings by Rafoul et al, where healthcare providers held positive views of ECT (12), while family members expressed skepticism, fearing brain damage or death—concerns not supported by mortality data (estimated at 0.002–0.04%)(13). 
A critical barrier to ECT acceptance is the inadequacy of informed consent procedures. Research by Grover et al (8) and Deng et al (6) underscores that simplified, transparent discussions about ECT’s mechanisms, efficacy, and side effects can mitigate fears. For instance, a study in India found that post-educational sessions, caregiver acceptance rates improved by 40% (14). Despite global research on ECT perceptions, few studies in Iran have examined companion-specific knowledge and attitudes, particularly in regions like Gilan, where Shafa Hospital serves as the primary psychiatric referral center.
This study aims to assess the level of knowledge and attitudes toward ECT among companions of patients, identify their primary sources of information and common misconceptions, and evaluate the influence of demographic factors (e.g., education level, prior exposure to ECT) on their perceptions. By addressing these gaps, this study seeks to inform targeted interventions to enhance ECT acceptance and collaboration between families and clinicians, ultimately improving treatment outcomes for psychiatric patients.

Materials and Methods
Study design
This cross-sectional descriptive study was conducted at Shafa Hospital in Rasht, Iran, during 2024. The study population comprised companions of patients referred to the psychiatric clinic for ECT.

Table 1. Demographic characteristics of companions of patients receiving electroshock therapy at shafa hospital in rasht, 2024

Sample size
A convenient sampling method was used to select participants from a list of all companions of ECT patients. The minimum required sample size was estimated to be 361 participants, based on a pilot study of 30 questionnaires (p 37.9%, with a 5% margin of error and 95% confidence level).

Table 2. Concerns about electroshock therapy among companions of patients receiving ECT at shafa hospital in rasht, 2024

Inclusion criteria
Companions aged above 18 or older, fluent in Persian, mentally and physically capable of participating, and willing to provide informed consent.

Exclusion criteria
Included unwillingness to participate or inability to communicate.

Data collection tools
The data collection tool, titled “Questionnaire on Measuring Knowledge and Attitudes Related to ECT”, was extracted from a comprehensive study in 2023 and was completed during a face-to-face interview, provided that consent to participate in the research was obtained (6). After explaining the study objectives and procedures, trained interviewers administered the questionnaire through face-to-face interviews with consenting participants. The questionnaire included three sections: Demographics (gender, age, education level, source of ECT information, family relationship to the patient (Parent, spouse, sibling, child), and history of patient hospitalization), attitude (questions assessing perceptions and concerns about ECT) and knowledge (questions evaluating understanding of ECT’s therapeutic effects, side effects, procedure, and risks). Content validity was confirmed by a panel of 9 faculty members (psychiatry and anesthesiology), with CVR>0.78 and CVI>0.79 for all items. Reliability was confirmed by Cronbach’s alpha (0.66). 

Statistical analysis
The variables analyzed using mean, standard deviation (SD), frequency and a significance level of p<0.05 also 95% confidence interval.

Ethical considerations
This cross-sectional study assessed the knowledge and attitudes toward ECT among companions of psychiatric patients at Shafa Hospital in Rasht, Iran, during 2024. Ethical approval was obtained from the Institutional Review Board (IRB) of Guilan University of Medical Sciences prior to the study commencement (Approval Code: IR.GUMS.REC.1403.022). Informed consent was obtained from all participants, and confidentiality of data was maintained throughout the research.

Results
Out of 400 companions approached, 361 agreed to participate, yielding a response rate of 90.25%. The demographic characteristics of the participants are summarized in table 1. The primary concerns expressed by the companions regarding ECT are presented in table 2. The overall level of knowledge regarding ECT is detailed in table 3. While 67.9% of companions reported having received some information about ECT (p<0.05), only 41.3% felt they had received sufficient overall information (p<0.05). Although 51.5% were informed about its therapeutic effects, fewer were aware of its side effects (28.8%, p<0.05), the specific procedure (19.7%, p<0.05), or the associated risks (23.8%, p<0.05). A strong majority (69.3%, p< 0.05) believed ECT was beneficial for the patient. A substantial majority of companions (83.9%, p<0.05) expressed worry about the treatment. To control for potential confounding variables, a multivariate logistic regression analysis was performed. After adjusting for age, gender, and education level, prior exposure to ECT remained a significant independent predictor of higher knowledge scores [Adjusted Odds Ratio (AOR)=2.85, 95% CI: 1.92–4.24, p<0.001) and more positive attitudes (AOR=2.10, 95% CI: 1.45–3.04, p<0.001). The attitudes of the companions are presented in table 4. Table 5 compares the awareness of ECT between companions based on the patient’s prior exposure to ECT. Companions of patients with prior ECT experience demonstrated significantly greater knowledge across all domains (p<0.05, Chi-square test). Higher education level was significantly associated with lower anxiety regarding ECT (p<0.05, Chi-square test). Table 6 illustrates how the source of information influenced the companions’ awareness. Companions who received information from medical staff had the highest rates of awareness across all knowledge domains (p<0.05, Chi-square test). Despite concerns, 69.3% (p<0.05) viewed ECT as beneficial, and 46.3% considered it safe. Higher education correlated with lower anxiety (p<0.05).

Table 3. Awareness of electroconvulsive therapy (ECT) among companions of patients receiving ECT at shafa hospital in rasht, 2024

 Table 4. Attitudes toward electroconvulsive therapy (ECT) among companions of patients receiving ECT at shafa hospital in rasht, 2024

 Table 5. Awareness of ECT based on previous ECT experience among companions of patients at shafa hospital, rasht (2024)

Table 6. Frequency distribution of responses to awareness questions about electroconvulsive therapy (ECT) by information source among companions of patients receiving ECT at shafa hospital in rasht, 2023

Discussion
The findings of this study highlight significant gaps in the knowledge and attitudes of companions of ECT patients at Shafa Hospital in Rasht, Iran, in 2024. Despite the proven efficacy of ECT in treating severe psychiatric conditions, misconceptions and fears persist, particularly regarding memory loss, brain damage, and the safety of the procedure. These concerns are consistent with previous research, which has shown that public perception of ECT is often shaped by outdated stereotypes and media portrayals rather than scientific evidence (15). Present results indicate that nearly half of the companions received information about ECT from healthcare providers, yet a substantial proportion still lacked comprehensive understanding. This aligns with studies by Grover et al, which found that families with prior ECT experience had better knowledge and more positive attitudes, likely due to direct communication with clinicians (16). However, the reliance on non-medical sources such as the internet and social media among first-time companions underscores the need for improved patient education strategies. The study also revealed that companions with higher education levels expressed fewer concerns. This is supported by findings from Shamsaei et al, who emphasized the role of structured pre-ECT counseling in enhancing understanding and reducing anxiety (17).  Furthermore, a positive association exists between prior ECT exposure and reduced fear of either mortality or severe side effects. This finding aligns with studies from high-income countries like the U.S. and other middle-income nations in the region, such as India (3,14).
The high patient volume, compounded by systemic time constraints a challenge across the country is particularly pronounced in regional referral centers such as Shafa Hospital. This is further exacerbated by the lack of comparable private psychiatric referral facilities in the region. These constraints significantly limit the ability of healthcare providers to conduct the detailed, empathetic conversations required to address region-specific misconceptions and beliefs.
When comparing awareness of ECT to other psychiatric treatments, a notable disparity emerges. 
Pharmacological therapies, while also stigmatized, are generally more accepted due to their widespread use and perceived controllability. In contrast, ECT’s more invasive and less understood nature makes it a target for greater skepticism. This is not unique to Iran; studies in Turkey and the Arab world have reported similar public reservations, often rooted in cultural and religious beliefs about the brain and the soul, which are less frequently associated with medication (18,19).
In this regard, the media can play an important role in improving public perceptions of ECT and reducing stigma against it. The media should provide accurate information about a psychiatric patient undergoing ECT. Especially, they show that the procedure is humane and safe, and has excellent recovery (20). A notable limitation of this study is the reluctance of some companions to participate, particularly those with multiple ECT experiences. This may have introduced selection bias, as their perspectives could differ significantly. Future research should explore innovative methods to engage this subgroup, such as anonymous surveys or focus groups.
As demonstrated by studies globally, from Italy (2) to Hong Kong (5), direct information from healthcare providers significantly improves attitudes toward ECT. Consequently, the development of standardized counseling protocols and culturally adapted educational materials for companions-which clearly detail the efficacy and side effects of ECT-is recommended. Enhancing providers’ communication skills through targeted training would also enable them to more effectively address companions’ fears, a strategy endorsed by Shamsaei et al (17). The present study complements and extends these findings by directly assessing the companions’ perspective the key decision-makers. The authors found that this stigma and fear are deeply entrenched among companions, with a significant majority (83.9%) expressing concerns, primarily about memory loss (30.7%) and brain damage (25.4%). This disparity between patient-reported satisfaction and companion apprehension underscores a critical communication gap within the treatment ecosystem. It suggests that positive treatment experiences alone are insufficient to dispel deep-seated societal and cultural fears, emphasizing the need for proactive educational interventions targeting families before and during the treatment process.

Limitations
The small sample size was a limitation of the study.

Conclusion
The findings of this study underscore the critical need for targeted interventions to improve the knowledge and attitudes of companions of patients receiving ECT. Misconceptions and fears, particularly regarding memory loss, brain damage, and procedural safety, persist despite ECT’s well-established efficacy in treating severe psychiatric conditions. Addressing these gaps requires a multifaceted approach centered on education, communication, and community engagement. By adopting these measures, healthcare systems can improve companions’ acceptance of ECT, facilitate informed decision-making, and ultimately enhance treatment outcomes for patients. Future research should explore the long-term impact of such interventions on ECT adherence and patient recovery.

Informed consent
Written consent form was completed by the participants.

Funding
There was no funding source.

Acknowledgement
The authors of this article would like to appreciate the cooperation of all those who participated in this project, especially the patients. This study was approved by the Ethics Committee of Guilan University of Medical Sciences under the code of (IR.GUMS.REC.1403.022).

Conflict of Interest
There was no conflict of interest in this manuscript.