Significantly improved neurocognitive function in major depressive disorders 6 weeks after ECT

Unmasking patient diversity: Exploring cognitive and antidepressive effects of electroconvulsive therapy

BACKGROUND

Electroconvulsive therapy (ECT) is an established treatment for depression, but more data on effectiveness and safety in clinical practice is needed. The aim of this register-based study was to investigate short-term effectiveness and cognitive safety after ECT, evaluated by clinicians and patients. Secondary, we investigated predictors for remission and cognitive decline.

METHODS

The study included 392 patients from the Regional Register for Neurostimulation Treatment in Western Norway. Depressive symptoms and cognitive function were assessed with Montgomery-Åsberg Depression Rating Scale and Mini-Mental State Examination (clinician-rated) and Beck Depression Inventory and Everyday Memory Questionnaire (patient-rated). Assessments were done prior to ECT-series and a mean of 1.7 days after (range 6 days before and 12 days after) end of ECT-series. Paired samples t-tests were extended by detailed, clinically relevant subgroups. Predictors were examined using logistic regression.

RESULTS

Clinician- and patient-rated remission rates were 49.5 and 41.0%, respectively. There was a large reduction in depressive symptoms and a small improvement in cognition after ECT, but we also identified subgroups with non-response of ECT in combination with cognitive decline (4.6% clinician-rated, 15.7% patient-rated). Positive predictors for patient- and clinician-rated remission were increasing age, shorter duration of depressive episode, and psychotic features. Antipsychotic medication at the commencement of treatment and previous ECT-treatment gave higher odds of clinician-rated remission, whereas higher pretreatment subjective depression level was associated with lower odds for patient-rated remission. Clinician-rated cognitive decline was predicted by higher pretreatment MMSE scores, whereas psychotic features, increasing age, and greater pretreatment subjective memory concerns were associated with lower odds for patient-rated cognitive decline.

CONCLUSIONS

Our study supports ECT as an effective and safe treatment, although subgroups have a less favorable outcome. ECT should be considered at an early stage for older patients suffering from depression with psychotic features. Providing comprehensive and balanced information from clinicians and patients perspectives on effects and side effects, may assist in a joint consent process.

Improved Safety of Hybrid Electroconvulsive Therapy Compared With Standard Electroconvulsive Therapy in Patients With Major Depressive Disorder: A Randomized, Double-Blind, Parallel-Group Pilot Trial

Objectives

ECT is a rapid and effective treatment for depression. While efficacy is often remarkable over the initial 3-4 sessions, the efficacy of later sessions is less rapid, and the side-effects, especially cognitive impairment limit its use. To preliminarily compare the efficacy and acceptability of a novel hybrid-ECT (HECT) protocol for patients with major depressive disorder (MDD) with standard ECT, we conducted this pilot trial.

Methods

Thirty patients were randomly assigned to ECT or HECT. Both arms received three ECT sessions (phase 1) but, in phase 2, the HECT arm received low-charge electrotherapy instead of ECT. The primary outcome was the change in 24-item Hamilton depression rating scale (HAMD-24) scores between baseline and the end of treatment. Cognitive function was assessed by repeatable battery for the assessment of neuropsychological status (RBANS), Stroop color word, and orientation recovery tests (ORT). Safety was measured by the drop-out rate and adverse events (AEs). Four visits were conducted at baseline, post-phase 1, post-phase 2, and at 1-month follow-up. Trial registration: Chinese Clinical Trial Registry (http://www.chictr.org.cn/), identifier: ChiCTR1900027701.

Results

Patients in both arms showed significant within-group improvements in HAMD-24, but the between-group differences were non-significant. Participants in the HECT arm outperformed ECT patients for most cognitive tests at the end of treatment or at follow-up. There was a significantly lower AE rate and shorter ORT in phase 2 of the HECT ar.

Conclusion

In this pilot trial, HECT was associated with fewer AEs and better cognitive function including executive and memory function, but its possible similar antidepressive efficacy needs to be further investigated in future.

The Future of Neuroscience: Flexible and Wireless Implantable Neural Electronics

Neurological diseases are a prevalent cause of global mortality and are of growing concern when considering an ageing global population. Traditional treatments are accompanied by serious side effects including repeated treatment sessions, invasive surgeries, or infections. For example, in the case of deep brain stimulation, large, stiff, and battery powered neural probes recruit thousands of neurons with each pulse, and can invoke a vigorous immune response. This paper presents challenges in engineering and neuroscience in developing miniaturized and biointegrated alternatives, in the form of microelectrode probes. Progress in design and topology of neural implants has shifted the goal post toward highly specific recording and stimulation, targeting small groups of neurons and reducing the foreign body response with biomimetic design principles. Implantable device design recommendations, fabrication techniques, and clinical evaluation of the impact flexible, integrated probes will have on the treatment of neurological disorders are provided in this report. The choice of biocompatible material dictates fabrication techniques as novel methods reduce the complexity of manufacture. Wireless power, the final hurdle to truly implantable neural interfaces, is discussed. These aspects are the driving force behind continued research: significant breakthroughs in any one of these areas will revolutionize the treatment of neurological disorders.

Efficacy, safety and tolerability of formula-based unilateral vs bilateral electroconvulsive therapy in the treatment of major depression: A randomized open label controlled trial

Electroconvulsive therapy (ECT) remains the most effective treatment of depression, though it is still unclear which of its type is the most beneficial. The aim of this study was to compare the formula-based right unilateral ECT (RUL) with the fronto-temporal bilateral ECT (BT), in terms of their efficacy, safety and tolerability in patients with bipolar or unipolar depression. Ninety-one patients were randomly assigned to either BT (n = 45) or RUL (n = 46) ECT. Brief pulse width (0.5 ms) and a formula-based dosing method were applied. The clinical efficacy was assessed using the Hamilton Depression Rating Scale (HDRS-21).The somatic state was monitored throughout the ECT course and cognitive examination included: general cognitive performance, executive functions, visual-spatial functions, verbal fluency, verbal memory and autobiographical memory. Efficacy outcomes were not found to be significantly different between groups when using higher doses of energy in RUL ECT. Patients in RUL group were less likely to be confused and experienced increased blood pressure. The indices of general cognitive performance and verbal auditory memory were also significantly better this group, while BT ECT did not change these functions. Both ECT types resulted in a decline in the retrieval consistency of autobiographical memory that persists for at least three months and was significantly more marked in BT group as compared to RUL. In conclusion, formula-based RUL ECT does not differ from BT in antidepressant efficacy and has an advantage in terms of safety (lower incidence of increased blood pressure and fewer disturbances of consciousness) and tolerability (impact on cognitive functions).

Association between cognition and suicidal ideation in patients with major depressive disorder: A longitudinal study

BACKGROUND

Suicidal ideation (SI) is common in patients with major depressive disorder (MDD) and often related to cognitive deficits. Limited longitudinal study has shown that cognitive improvement is associated with reduced SI. However, the comparatively study in Chinese depressed patients is still absent. The objective of this study was to explore the specific cognitive deficits in Chinese MDD with SI and investigate the relationship between changes in cognition and change in SI across antidepressant treatment.

METHODS

Three hundred and five patients with MDD received four weeks of antidepressant treatment. The 17-item Hamilton Depression Rating Scale (HAMD-17) and four domains of the MATRICS Consensus Cognitive Battery (MCCB), including speed of processing, working memory, visual learning and verbal learning were measured at baseline and four-week follow-up.

RESULTS

One hundred and thirty patients (42.6%) expressed suicidal ideation. Suicidal patients performed worse on verbal learning than non-suicidal patients. Change in speed of processing domain was negatively associated with change in suicidal scores over time. Logistic regression analysis showed that reduction of SI was associated with improvement of speed of processing.

LIMITATION

The major limitation was that there was no healthy control group in the current study, which might limit the interpretation of cognitive deficits in depressed patients with SI.

CONCLUSIONS

Our findings suggest that suicidal patients performed worse on verbal learning which can potentially serve as a cognitive biomarker of suicide risk in MDD. Moreover, reduced suicidal ideation was associated with improved speed of processing.

Electroconvulsive therapy "corrects" the neural architecture of visuospatial memory: Implications for typical cognitive-affective functioning

Although electroconvulsive therapy (ECT) is a widely used and effective treatment for refractory depression, the neural underpinnings of its therapeutic effects remain poorly understood. To address this issue, here, we focused on a core cognitive deficit associated with depression, which tends to be reliably ameliorated through ECT, specifically, the ability to learn visuospatial information. Thus, we pursued three goals. First, we tested whether ECT can “normalize” the functional brain organization patterns associated with visuospatial memory and whether such corrections would predict post-ECT improvements in learning visuospatial information. Second, we investigated whether, among healthy individuals, stronger expression of the neural pattern, susceptible to adjustments through ECT, would predict reduced incidence of depression-relevant cognition and affect. Third, we sought to quantify the heritability of the ECT-correctable neural profile. Thus, in a task fMRI study with a clinical and a healthy comparison sample, we characterized two functional connectome patterns: one that typifies trait depression (i.e., differentiates patients from healthy individuals) and another that is susceptible to “normalization” through ECT. Both before and after ECT, greater expression of the trait depression neural profile was associated with more frequent repetitive thinking about past personal events (affective persistence), a hallmark of depressogenic cognition. Complementarily, post-treatment, stronger expression of the ECT-corrected neural profile was linked to improvements in visuospatial learning, a mental ability which is markedly impaired in depression. Subsequently, using data from the Human Connectome Project (HCP) (N = 333), we demonstrated that the functional brain organization of healthy participants with greater levels of subclinical depression and higher incidence of its associated cognitive deficits (affective persistence, impaired learning) shows greater similarity to the trait depression neural profile and reduced similarity to the ECT-correctable neural profile, as identified in the patient sample. These results tended to be specific to learning-relevant task contexts (working memory, perceptual relational processing). Genetic analyses based on HCP twin data (N = 128 pairs) suggested that, among healthy individuals, a functional brain organization similar to the one normalized by ECT in the patient sample is endogenous to cognitive contexts that require visuospatial processing that extends beyond the here-and-now. Broadly, the present findings supported our hypothesis that some of the therapeutic effects of ECT may be due to its correcting the expression of a naturally occurring pattern of functional brain organization that facilitates integration of internal and external cognition beyond the immediate present. Given their substantial susceptibility to both genetic and environmental effects, such mechanisms may be useful both for identifying at risk individuals and for monitoring progress of interventions targeting mood-related pathology.

•

Trait depression and ECT-correctable neural profiles were described in patients.

•

The former was related to rumination and the latter to improved learning after ECT.

•

Their relative expression was linked to subclinical depression in a healthy sample.

•

Twin analyses implied that both profiles are endogenous to working memory contexts.

Subjective memory complaints after electroconvulsive therapy: systematic review

Aims and methodFew studies have looked at subjective memory impairment from electroconvulsive therapy (ECT) after treatment completion. We aimed to systematically review all available evidence for subjective post-treatment effects. RESULTS: We included 16 studies in this review. There was considerable between-study heterogeneity in clinical population, ECT modality and assessment scales used. The most common assessment scale (eight studies) was the Squire Subjective Memory Questionnaire. The majority of studies reported an improvement in subjective memory after ECT, which correlated with improved depression scores. Subjective complaints were fewer in studies that used ultra-brief pulse ECT. Longer pulse widths were associated with more subjective complaints, as was female gender and younger age of treatment in the largest study.Clinical implicationsThere is considerable heterogeneity between studies, limiting meaningful conclusions. Ultra-brief pulse ECT appears to result in fewer subjective complaints.Declaration of interestNone.

Neurognitive function and symptom remission 2 years after ECT in major depressive disorders

BACKGROUND

There is a lack of knowledge of possible cognitive side effects of electroconvulsive therapy (ECT) beyond the first few months after treatment. We aim to describe cognitive effects and symptom remission 2 years after ECT in major depressive disorders.

METHOD

Twenty-seven depression patients were assessed with the MATRICS Consensus Cognitive Battery (MCCB) and the Everyday Memory Questionnaire (EMQ) before and 2 years after ECT. Their scores were compared with those of healthy matches. Depression and remission status were assessed with the Montgomery-Åsberg Depression Rating Scale (MADRS). Main statistical analyses were ANOVAs and linear mixed model tests.

RESULTS

At baseline, the patient group was significantly impaired on 7 of 10 cognitive tests compared to the control group. Two years later, this gap was reduced to impairment on 5 of 10 tests. Within the patient group, neurocognitive function either increased significantly from baseline to follow-up, or there was no change. Two years after ECT, 62.9% of the patients were in remission. Those in remission reported better subjective memory function, but displayed no different neuropsychological test results, compared to the non-remitters.

LIMITATIONS

Major limitations were low sample size and lack of uniform ECT procedure.

CONCLUSIONS

We found improved neurocognitive function 2 years after ECT. This effect occurred regardless of remission status, suggesting that ECT induces unique cognitive boosting processes.

Patients', Carers', and the Public's Perspectives on Electroconvulsive Therapy

Aims and Method: The aim of this study was to present patients', carers', and the public's perspectives on electroconvulsive therapy (ECT) through a narrative review of the literature. Results: People's perspectives on ECT are often negative due to media and Internet portrayal. Perspectives are influenced by risks, short-term side effects, and the most commonly reported longer-term side effect: memory loss. However, many patients do not report memory loss. Most people who experience ECT and their carers report a positive perspective. In the future, people's perspectives may become more positive with higher service delivery standards and a more balanced, well-informed view of modern ECT presented by the media. However, ECT has risks and side effects, and negative and critical perspectives on the use and effects of ECT will persist. Clinical Implications: Perspectives on ECT are important because of the impact on stigma, patient treatment choice, patient consent, and provision of and referral for ECT.

Long-term Sustained Cognitive Benefits of Vagus Nerve Stimulation in Refractory Depression

BACKGROUND

Treatment-resistant depression (TRD) is a serious chronic condition disabling patients functionally and cognitively. Chronic vagus nerve stimulation (VNS) is recognized for the management of TRD, but few studies have examined its long-term effects on cognitive dysfunction in unipolar and bipolar resistant depression.

OBJECTIVE

The purpose of this study was to assess the course of cognitive functions and clinical symptoms in a cohort of patients treated with VNS for TRD.

METHODS

In 14 TRD patients with VNS, standardized clinical and neuropsychological measures covering memory, attention/executive functions, and psychomotor speed were analyzed prestimulation and up to 2 years poststimulation.

RESULTS

Vagus nerve stimulation patients significantly improved on cognitive and clinical measures. Learning and memory improved rapidly after 1 month of stimulation, and other cognitive functions improved gradually over time. Cognitive improvements were sustained up to 2 years of treatment. At 1 month, improvement in Montgomery-Åsberg Depression Rating Scale scores was not correlated with changes in any of the cognitive scores, whereas at 12 months, the change in Montgomery-Åsberg Depression Rating Scale score was significantly correlated with several measures (Stroop interference, verbal fluency, and Rey-Osterrieth Complex Figure delayed recall).

CONCLUSIONS

In recent years, a growing interest in cognitive dysfunction in depression has emerged. Our results suggest that chronic VNS produces sustained clinical and cognitive improvements in TRD patients, with some mental functions improving as soon as 1 month after the initiation of the VNS therapy. Vagus nerve stimulation seems a very promising adjunctive therapy for TRD patients with cognitive impairment.

Cognitive functioning in patients treated with electroconvulsive therapy

BACKGROUND

Electroconvulsive therapy (ECT) is an effective treatment method for severe mental illnesses. ECT has gone through significant modernization. Side effects of ECT have largely decreased. Temporary disturbance of cognitive performance can be still present as a side effect of electroconvulsive treatment.

METHODS

Cognitive functioning in the sample of patients with severe and acute mental illness treated with electroconvulsive therapy (ECT) was assessed. Basic assessment of cognitive functions was applied in the beginning, in the middle, and at the end of ECT course treatment with the Montreal Cognitive Assessment (MoCA). Complex and detailed testing of cognitive functions using the MATRICS Consensus Cognitive Battery (MCCB) was done at two points in time - within the first week of and then 6 weeks after the end of ECT.

RESULTS

Participants had cognitive deficits at baseline, which were most likely influenced markedly by the psychopathology of the illness itself. The improvement in cognition came together with the reduction in psychopathology; psychopathology scores were significantly reduced during ECT treatment. Compared to the baseline, all scores for cognitive testing were significantly improved but remained low in comparison with the controls. After 6 weeks, there was further significant improvement.

CONCLUSION

Our results confirm the safety and efficacy of ECT in the treatment of severe mental disorders.

Treatment of neurocognitive symptoms in unipolar depression: A systematic review and future perspectives

BACKGROUND

Cognitive symptoms in Major Depressive Disorder (MDD) are persistent and commonly entail neurocognitive impairment and a decline in quality of life. This systematic review gathers the current scientific evidence on therapeutic strategies for neuropsychological impairment in MDD.

METHOD

A systematic search on PubMed, PsycINFO and Clinicaltrials.gov was carried out on December 2016 according to PRISMA using Boolean terms to identify interventions for the treatment of cognitive dysfunction in MDD. Only English-written articles providing original data and focusing in adults with MDD were included with no time restrictions.

RESULTS

A total of 95 studies reporting data on 40 pharmacological and non-pharmacological interventions were included. Interventions were grouped into the following categories: 1) Pharmacological Therapies (antidepressants, stimulants, compounds acting on NMDA receptors, compounds acting on the cholinergic system, compounds showing anti-inflammatory or antioxidant properties, other mechanisms of action), 2) Physical Therapies and 3) Psychological Therapies, 4) Exercise. There are some promising compounds showing a positive impact on cognitive symptoms including vortioxetine, lisdexamfetamine or erythropoietin.

LIMITATIONS

The studies included showed significant methodological differences in heterogeneous samples. The lack of a standardized neuropsychological battery makes comparisons between studies difficult.

CONCLUSION

Current evidence is not sufficient to widely recommend the use of procognitive treatments in MDD although promising results are coming to light.

Neural Response After a Single ECT Session During Retrieval of Emotional Self-Referent Words in Depression: A Randomized, Sham-Controlled fMRI Study

BACKGROUND

Negative neurocognitive bias is a core feature of depression that is reversed by antidepressant drug treatment. However, it is unclear whether modulation of neurocognitive bias is a common mechanism of distinct biological treatments. This randomized controlled functional magnetic resonance imaging study explored the effects of a single electroconvulsive therapy session on self-referent emotional processing.

METHODS

Twenty-nine patients with treatment-resistant major depressive disorder were randomized to one active or sham electroconvulsive therapy session at the beginning of their electroconvulsive therapy course in a double-blind, between-groups design. The following day, patients were given a self-referential emotional word categorization test and a free recall test. This was followed by an incidental word recognition task during whole-brain functional magnetic resonance imaging at 3T. Mood was assessed at baseline, on the functional magnetic resonance imaging day, and after 6 electroconvulsive therapy sessions. Data were complete and analyzed for 25 patients (electroconvulsive therapy: n = 14, sham: n = 11). The functional magnetic resonance imaging data were analyzed using the FMRIB Software Library randomize algorithm, and the Threshold-Free Cluster Enhancement method was used to identify significant clusters (corrected at P < .05).

RESULTS

A single electroconvulsive therapy session had no effect on hippocampal activity during retrieval of emotional words. However, electroconvulsive therapy reduced the retrieval-specific neural response for positive words in the left frontopolar cortex. This effect occurred in the absence of differences between groups in behavioral performance or mood symptoms.

CONCLUSIONS

The observed effect of electroconvulsive therapy on prefrontal response may reflect early facilitation of memory for positive self-referent information, which could contribute to improvements in depressive symptoms including feelings of self-worth with repeated treatments.

Maintained Improvement of Neurocognitive Function in Major Depressive Disorders 6 Months after ECT

Both impaired and improved cognitive function after electroconvulsive therapy (ECT) in major depressive disorder (MDD) patients may occur. We have previously found improved cognitive function 6 weeks after ECT in this group. The aim of this study was to report 6-month follow-up results from the same prospective project monitoring cognitive effects of ECT. Thirty-one patients with MDD were assessed with the MATRICS Consensus Cognitive Battery (MCCB), the Everyday Memory Questionnaire (EMQ), and the Montgomery-Åsberg Depression Rating Scale prior to, 6 weeks, and 6 months after ECT. Compared to baseline, the speed of processing, attention/vigilance, and reasoning/problem solving test results were significantly improved. The depression score was significantly reduced. There were no changes in subjective memory complaint. There was no significant relationship between the EMQ and the MCCB subtests, but a significant correlation between current depression level and the EMQ. Six months after ECT the cognitive improvement reported at 6-week follow-up was maintained and extended. The corresponding decrease in depressive symptoms and stability in subjectively reported memory complaints suggest that the antidepressant effects of ECT do not occur at the expense of cognitive function.