Cognitive change after electroconvulsive therapy in mood disorders measured with the Montreal Cognitive Assessment

The myth of brain damage: no change of neurofilament light chain during transient cognitive side-effects of ECT

Electroconvulsive therapy (ECT) is an effective, safe, and mostly well-tolerated treatment for patients with severe or difficult to treat depression or psychotic disorders. However, a relevant number of patients experience subjective and/or objective cognitive side-effects. The mechanism of these transient deficits is not yet clear. Thus, our study prospectively investigated neurofilament light chain (NfL) concentrations as a highly sensitive biomarker for neuroaxonal damage along with cognitive performance during a course of ECT. Serum NfL concentrations from 15 patients with major depressive disorder receiving ECT were analyzed (1) 24 h before the first ECT, (2) 24 h and (3) 7 days after the last ECT (45 measurements in total). Neuropsychological testing including memory, executive functions and attention was performed at each time-point. NfL concentrations did not change between the three time-points, while a temporary cognitive impairment was found. Even in the subset of patients with the strongest impairment, NfL concentrations remained unchanged. Neuropsychological testing revealed the common pattern of transient cognitive side-effects with reduced performance 24 h post-ECT (global cognition score: p < 0.001; memory: p = 0.043; executive functions: p = 0.002) and return to baseline after 7 days (all p < 0.001). Our study adds to the evidence that neither ECT per se nor the transient cognitive side-effects seem to be associated with an increase of NfL as a marker of neuroaxonal damage. In contrast, we discuss cognitive side effects to be potentially interpreted as a byproduct of ECT's neuroplastic effects.

Reliable Change Indices and Minimum Detectable Change for the Montreal Cognitive Assessment in Electroconvulsive Therapy for Depression

OBJECTIVE

The Montreal Cognitive Assessment (MoCA) is a commonly used brief cognitive screening tool for monitoring adverse cognitive effects of electroconvulsive therapy (ECT). The aim of this study was to examine three statistical methods for detecting reliable change in the MoCA following ECT.

METHODS

In a prospective cohort study, 47 patients (mean age 55.2 [SD = 12.8], 59.6% female) with unipolar or bipolar depression treated with an acute course of brief-pulse ECT (72.3% right unilateral) and 47 depressed controls without ECT exposure were tested on the MoCA at baseline and retested at comparable time intervals. ECT patients' performance was also compared to published normative data from a community-based sample of older adults. We calculated proportions of ECT patients remaining stable, declining, and improving following ECT using practice-corrected reliable change index, standardized regression-based formulas, and minimum detectable change cutoff of ±4 MoCA points.

RESULTS

Using the three methods, 72.3%-78.7% of ECT patients remained stable, 17.0%-23.4% declined, and 4.3% improved in MoCA performance following ECT compared to the two control groups.

CONCLUSIONS

All three methods yield consistent estimates of reliable change in MoCA scores from pre- to post-brief-pulse ECT. The minimum detectable change approach may be the most efficient and accessible method of detecting change due to simplicity of calculation.

Combining Mini-Mental State Examination and Montreal Cognitive Assessment for assessing the clinical efficacy of cholinesterase inhibitors in mild Alzheimer's disease: a pilot study

Current drugs for Alzheimer's Disease (AD), such as cholinesterase inhibitors (ChEIs), exert only symptomatic activity. Different psychometric tools are needed to assess cognitive and non-cognitive dimensions during pharmacological treatment. In this pilot study, we monitored 33 mild-AD patients treated with ChEIs. Specifically, we evaluated the effects of 6 months (Group 1 = 17 patients) and 9 months (Group 2 = 16 patients) of ChEIs administration on cognition with the Mini-Mental State Examination (MMSE), the Montreal Cognitive Assessment (MoCA), and the Frontal Assessment Battery (FAB), while depressive symptoms were measured with the Hamilton Depression Rating Scale (HDRS). After 6 months (Group 1), a significant decrease in MoCA performance was detected. After 9 months (Group 2), a significant decrease in MMSE, MoCA, and FAB performance was observed. ChEIs did not modify depressive symptoms. Overall, our data suggest MoCA is a potentially useful tool for evaluating the effectiveness of ChEIs.

Pre-treatment predictors of cognitive side-effects after treatment with electroconvulsive therapy in patients with depression: A multicenter study

BACKGROUND

Electroconvulsive therapy (ECT) is a highly effective treatment for major depressive episodes (MDE). However, ECT-induced cognitive side-effects remain a concern. Identification of pre-treatment predictors that contribute to these side-effects remain unclear. We examined cognitive performance and individual cognitive profiles over time (up to six months) following ECT and investigated possible pre-treatment clinical and demographic predictors of cognitive decline shortly after ECT.

METHODS

634 patients with MDE from five sites were included with recruitment periods between 2001 and 2020. Linear mixed models were used to examine how cognitive performance, assessed with an extensive neuropsychological test battery, evolved over time following ECT. Next, possible pre-treatment predictors of cognitive side-effects directly after ECT were examined using linear regression.

RESULTS

Directly after ECT, only verbal fluency (animal and letter; p < 0.0001; Cohen's d: -0.25 and -0.29 respectively) and verbal recall (p < 0.0001; Cohen's d: -0.26) significantly declined. However, during three and six months of follow-up, cognitive performance across all domains significantly improved, even outperforming baseline levels. No other pre-treatment factor than a younger age predicted a larger deterioration in cognitive performance shortly after ECT.

LIMITATIONS

There was a substantial amount of missing data especially at 6 months follow-up.

CONCLUSIONS

Our findings show that verbal fluency and memory retention are temporarily affected immediately after ECT. Younger patients may be more susceptible to experiencing these acute cognitive side-effects, which seems to be mostly due to a more intact cognitive functioning prior to ECT. These findings could contribute to decision-making regarding treatment selection, psychoeducation, and guidance during an ECT course.

A Pilot Study of Adjunctive Group Therapy to Enhance Coping With Cognitive Challenges and Support Cognitive Health After Electroconvulsive Therapy

OBJECTIVES

Concerns about the cognitive adverse effects of electroconvulsive therapy (ECT) are common among recipients of the treatment despite its relatively small adverse effects on cognitive functioning. Interventions aimed at remediating or improving coping with cognitive adverse effects of ECT have not been developed. The Enhancing Cognitive Domains after ECT (ENCODE) program is a new group intervention aimed at teaching self-management strategies to cope with the cognitive challenges and associated anxiety that often accompanies ECT.

METHODS

This pilot study used a pretest-posttest design to examine the feasibility and clinical utility of delivering ENCODE to 20 adults who had received ECT in a hospital-based ECT program.

RESULTS

The program was found to be both feasible and acceptable as indicated by the attainment of recruitment targets, high rates of attendance (85% of participants attended at least 5 of the 6 group sessions), and high participant satisfaction ratings (88% reported that ENCODE helped or helped very much to manage their cognitive challenges). The clinical utility of the program was suggested by reductions in depressive symptom severity and subjective memory complaints. Nonsignificant improvements were observed in global cognitive function and cognitive self-efficacy.

CONCLUSIONS

This study provides preliminary evidence for the feasibility and clinical utility of ENCODE based on program demand, strong participant satisfaction, and postgroup reductions in distress and subjective memory complaints.

Medication preventing postictal hypoperfusion and cognitive side-effects in electroconvulsive therapy: A retrospective cohort study

BACKGROUND

Electroconvulsive therapy (ECT) is associated with postictal confusion and cognitive side-effects. In rats, acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs) and calcium antagonists decreased postictal cerebral hypoperfusion along with reduction in postictal symptoms. In this study, in ECT-patients, we explore associations between use of these potentially protective medications and occurrence of postictal confusion and cognitive outcome.

MATERIALS AND METHODS

In this retrospective, naturalistic cohort study, patient-, treatment-, and ECT-characteristics, were collected from medical files of patients treated with ECT for major depressive disorder (MDD) or bipolar depressive episode. To test for associations of use of these medications with occurrence of postictal confusion, 295 patients could be included. Cognitive outcome data were available in a subset of 109 patients. Univariate analyses and multivariate censored regression models were used to test for associations.

RESULTS

Occurrence of severe postictal confusion was not associated with use of acetaminophen, NSAIDs or calcium antagonists (n = 295). Regarding the cognitive outcome measure (n = 109), use of calcium antagonists was associated with higher post-ECT cognitive scores (i.e., better cognitive outcome; β = 2.23; p = 0.047), adjusted for age (β = -0.02; p = 0.23), sex (β = -0.21; p = 0.73), pre-ECT cognitive score (β = 0.47; p < 0.0001), and post-ECT depression score (β = -0.02; p = 0.62), but use of acetaminophen (β = -1.55; p = 0.07) as well as NSAIDs (β = -1.02; p = 0.23) showed no associations.

CONCLUSION

This retrospective study does not find arguments for protective effects of acetaminophen, NSAIDs or calcium antagonists against severe postictal confusion in ECT. As a preliminary finding, the use of calcium antagonists was associated with improved cognitive outcome after ECT in this cohort. Prospective controlled studies are necessary.

Cognitive trajectories during and after electroconvulsive therapy in patients with MDE: Taking different perspectives

Cognitive function during an ECT care pathway is mainly investigated at the group level by analyzing mean cognitive test scores over time. However, there are important inter-individual differences, with some patients experiencing residual invalidating cognitive deficits. This study provides a nuanced examination of cognitive functioning during and after ECT by combining three approaches for data analysis. A cognitive test battery was assessed in seventy-three ECT-treated patients with a Major Depressive Episode (MDE) at up to five time points (baseline, immediately prior to the third session and 1 week, 3 months and 6 months after completion of the index course). Group-level changes in cognitive function were investigated using linear mixed models and individual-level changes were examined using Reliable Change Indices (RCI). The presence of patient subgroups with similar cognitive trajectories was explored using Latent Class Growth Analysis (LCGA). At the group level, there was a temporary deterioration in processing speed, verbal memory and retrograde amnesia during and after index course of ECT. Individual-level analyses revealed considerable variability in cognitive effects of ECT. Three patient classes with a similar cognitive trajectory could be identified, all with a rather parallel courses over time, thus mainly differing in terms of pre-ECT cognitive functioning.

Can brain stimulation enhance cognition in clinical populations? A critical review

Many psychiatric and neurological conditions are associated with cognitive impairment for which there are very limited treatment options. Brain stimulation methodologies show promise as novel therapeutics and have cognitive effects. Electroconvulsive therapy (ECT), known more for its related transient adverse cognitive effects, can produce significant cognitive improvement in the weeks following acute treatment. Transcranial magnetic stimulation (TMS) is increasingly used as a treatment for major depression and has acute cognitive effects. Emerging research from controlled studies suggests that repeated TMS treatments may additionally have cognitive benefit. ECT and TMS treatment cause neurotrophic changes, although whether these are associated with cognitive effects remains unclear. Transcranial electrical stimulation methods including transcranial direct current stimulation (tDCS) and transcranial alternating current stimulation (tACS) are in development as novel treatments for multiple psychiatric conditions. These treatments may also produce cognitive enhancement particularly when stimulation occurs concurrently with a cognitive task. This review summarizes the current clinical evidence for these brain stimulation treatments as therapeutics for enhancing cognition. Acute, or short-lasting, effects as well as longer-term effects from repeated treatments are reviewed, together with potential putative neural mechanisms. Areas of future research are highlighted to assist with optimization of these approaches for enhancing cognition.

National Network of Depression Centers' Recommendations on Harmonizing Clinical Documentation of Electroconvulsive Therapy

ABSTRACT

Electroconvulsive therapy (ECT) is a highly therapeutic and cost-effective treatment for severe and/or treatment-resistant major depression. However, because of the varied clinical practices, there is a great deal of heterogeneity in how ECT is delivered and documented. This represents both an opportunity to study how differences in implementation influence clinical outcomes and a challenge for carrying out coordinated quality improvement and research efforts across multiple ECT centers. The National Network of Depression Centers, a consortium of 26+ US academic medical centers of excellence providing care for patients with mood disorders, formed a task group with the goals of promoting best clinical practices for the delivery of ECT and to facilitate large-scale, multisite quality improvement and research to advance more effective and safe use of this treatment modality. The National Network of Depression Centers Task Group on ECT set out to define best practices for harmonizing the clinical documentation of ECT across treatment centers to promote clinical interoperability and facilitate a nationwide collaboration that would enable multisite quality improvement and longitudinal research in real-world settings. This article reports on the work of this effort. It focuses on the use of ECT for major depressive disorder, which accounts for the majority of ECT referrals in most countries. However, most of the recommendations on clinical documentation proposed herein will be applicable to the use of ECT for any of its indications.

The Effects of Baseline Impaired Global Cognitive Function on the Efficacy and Cognitive Effects of Electroconvulsive Therapy in Geriatric Patients: A Retrospective Cohort Study

OBJECTIVES

This study explores the association between baseline impaired global cognitive function and changes in global cognitive function and depression among geriatric patients undergoing acute course electroconvulsive therapy (ECT).

DESIGN

Retrospective cohort study.

SETTING

Single freestanding psychiatric hospital.

PARTICIPANTS

Patients aged 50 and older receiving ECT.

INTERVENTIONS

10 ECT treatments.

MEASUREMENTS

Cognitive assessments with the Montreal Cognitive Assessment (MoCA). Depression assessment with the Quick Inventory of Depressive Symptomatology Self Report 16 item scale (QIDS).

RESULTS

Baseline and follow-up data were available for 684 patients. On average, patients with baseline normal cognition (MoCA ≥26; N = 371) had a decrease in MoCA of -1.44±0.26 points over the course of treatment, while those with baseline impaired global cognitive function (MoCA <26; N = 313) had an increase in MoCA of 1.72±0.25 points. Baseline cognitive status was not associated with a differential response on the QIDS.

CONCLUSIONS

Patients with baseline impaired global cognitive function did not demonstrate a worsening in cognition following ECT, and baseline global cognitive function was not associated with a differential change in depression with ECT. These results suggest that impaired global cognitive function should not be viewed as a contraindication to ECT in geriatric patients.

The anticholinergic burden is not associated with cognitive impairments in patients treated by electroconvulsive therapy for treatment-resistant depression

BACKGROUND

Electroconvulsive therapy (ECT) is the most effective non-pharmacological treatment for treatment-resistant depression (TRD) but can expose to transient cognitive impairments. Understanding factors underlying these cognitive side effects is important. This study investigated the impact of anticholinergic treatments on cognitive performances after ECT courses for TRD in naturalistic condition.

METHODS

Impact of anticholinergic burden (Anticholinergic Impregnation Scale, AIS) on cognitive changes (Montreal Cognitive Assessment, MoCA) adjusted on depression level (Montgomery and Asberg Depression Scale, MADRS) was investigated in 42 patients who received an ECT course between 2017 and 2020 for unipolar or bipolar TRD. Collection of daily treatments given during ECT was carried out via the computerized traceability of treatments validated by nurses.

RESULTS

Among the 31 treatments identified with an anticholinergic score, which represent only 38% of total treatments, the three most frequently given treatments were Lorazepam (47%), Venlafaxine (36%) and Cyamemazine (26%). Delayed recall was the most frequently impaired cognitive function after ECT courses. Using logistic regression, we found no association between the anticholinergic burden and the decrease in cognitive scores after ECT courses, adjusted on MADRS score evolution (p > 0.1). Conversely, improvement in MADRS scores were correlated with improvement in attention MoCA subscores.

LIMITATIONS

This is a retrospective monocentric study with a moderate sample size using anticholinergic scales to calculate the anticholinergic burden without plasma dosage.

CONCLUSION

Anticholinergic treatments did not seem to explain ECT-related cognitive impairments. This warrants further large prospective investigations including different measures of anticholinergic burden.

First Acute-Course Electroconvulsive Therapy for Moderate-to-Severe Depression Benefits Patients With or Without Accompanying Baseline Cognitive Impairment

BACKGROUND

Researchers are increasingly investigating therapeutic response associated with new patient subgroups as a way to improve electroconvulsive therapy (ECT) treatment outcomes and reduce adverse events. This study is the first to examine baseline cognitive impairment status as a predictor of clinical outcome in first acute-course ECT patients.

METHODS

Baseline cognitive function at various thresholds and serial depressive symptom severity data from first-time ECT patients were examined using generalized linear mixed-effects models.

RESULTS

Of 1345 patients who met the inclusion criteria, 617 had available data at their third assessment visit (~15th treatment visit). There was a robust improvement in depression symptoms over time (P < 0.0001), and cognitive function was not associated with baseline levels of depressive symptoms or serially measured change in self-reported symptom severity during acute-phase ECT.

CONCLUSIONS

These results indicate that an acute course of ECT for the treatment of moderate-to-severe depression benefits patients with or without accompanying baseline cognitive impairment. These findings may be useful in informing shared decision-making discussions about ECT risks and expected benefits.

Pharmacological interventions to diminish cognitive side effects of electroconvulsive therapy: A systematic review and meta-analysis

OBJECTIVE

The authors conducted a systematic review and meta-analysis of pharmacological interventions to diminish cognitive side effects of ECT.

METHODS

Electronic databases of Pubmed, PsycInfo, Embase and Scopus were searched from inception through 1 April, 2021, using terms for ECT (e.g. electroconvulsive therapy), cognitive outcome (e.g. cogni*) and pharmacological intervention (e.g. calcium channel blocker and general terms, like protein). Original studies with humans receiving ECT were included, which applied pharmacological interventions in comparison with placebo or no additive intervention to diminish cognitive side effects. Data quality was assessed using Risk of Bias and GRADE. Random-effects models were used. PROSPERO registration number was CRD42021212773.

RESULTS

Qualitative synthesis (systematic review) showed 52 studies reporting sixteen pharmacological intervention-types. Quantitative synthesis (meta-analysis) included 26 studies (1387 patients) describing twelve pharmacological intervention-types. Low-quality evidence of efficacy was established for memantine (large effect size) and liothyronine (medium effect size). Very low-quality evidence shows effect of acetylcholine inhibitors, piracetam and melatonin in some cognitive domains. Evidence of no efficacy was revealed for ketamine (very low-quality), herbal preparations with anti-inflammatory properties (very low to low-quality) and opioid receptor agonists (low-quality).

CONCLUSION

Memantine and liothyronine are promising for further research and future application. Quality of evidence was low because of differences in ECT techniques, study populations and cognitive measurements. These findings provide a guide for rational choices of potential pharmacological intervention research targets to decrease the burden of cognitive side effects of ECT. Future research should be more uniform in design and attempt to clarify pathophysiological mechanisms of cognitive side effects of ECT.

Cognitive Adverse Effects of Electroconvulsive Therapy: A Discrepancy Between Subjective and Objective Measures?

OBJECTIVES

The character and duration of cognitive adverse effects of electroconvulsive therapy (ECT) are unclear. This study investigated (1) the sensitivity of a short cognitive test battery to cognitive adverse effects of ECT, (2) the relation between subjective and objective cognitive adverse effects, and (3) patient characteristics associated with more subjective than objective adverse effects.

METHODS

Forty-one patients with unipolar or bipolar depression referred to ECT underwent assessments at baseline, 5 to 7 days post-ECT, and 3 months post-ECT. Patients rated their fear of various aspects of ECT on a visual analog scale. At each assessment, patients were evaluated for depressive symptoms, completed the Screen for Cognitive Impairment in Psychiatry (SCIP) and Trail Making Test-Part B (TMT-B), and rated their cognitive difficulties.

RESULTS

Patients feared cognitive adverse effects and lack of treatment efficacy more than other aspects of ECT. The SCIP and TMT-B revealed transient decline in objective cognition after ECT, which was reversed after 3 months. Patients presented with more subjective than objective cognitive difficulties at baseline and more subjective than objective cognitive adverse effects of ECT. This discrepancy was significantly reduced at follow-up. Younger age and poorer objective cognition pretreatment were associated with more subjective than objective cognitive adverse effects 5 to 7 days after ECT.

CONCLUSIONS

The SCIP and TMT-B are sensitive to cognitive adverse effects of ECT. Patients show more subjective than objective cognitive adverse effects of ECT. These insights can be used clinically to inform patients of treatment choice and expected cognitive consequences.

Individual response to electroconvulsive therapy is not correlated between multiple treatment courses

OBJECTIVES

Electroconvulsive therapy (ECT) effectively treats depressive disorders, but many patients will have subsequent relapses. While some guidelines suggest prior response to ECT is an indication for ECT in a subsequent mood episode, it is unknown whether response to ECT is correlated between treatment courses. This study explores whether response to ECT at a first treatment correlates with response to treatment in a second independent ECT course.

METHODS

Single-center retrospective cohort of patients receiving two different ECT treatment courses between 2011 and 2020 and who self-reported depression symptoms using the Quick Inventory of Depressive Symptomatology (QIDS) at baseline and following treatment #5.

RESULTS

286 patients received two independent ECT series during the study period, of whom 153 received at least 5 treatments in both series. Patients had similar QIDS scores at the start of each treatment series (Pearson's correlation, r = 0.58, p <0.001), but the change in QIDS following 5 ECT treatments was not correlated between series for individual patients (Pearson's correlation, r = 0.083, p = 0.31). In multivariate analyses, change in QIDS was similar for both treatment series, but patients were less likely to receive 5 treatments in the second treatment series.

LIMITATIONS

retrospective cohort cannot control for factors influencing access to repeat ECT treatment CONCLUSIONS: While on average final QIDS score was the same following two independent treatment courses, for individual patients the change in depression symptoms was not correlated between treatment series. Further research is needed to identify factors that may predict longitudinal ECT response.

The utility of the brief ECT cognitive screen (BECS) for early prediction of cognitive adverse effects from ECT: A CARE network study

Although highly effective, electroconvulsive therapy (ECT) often produces cognitive side effects which can be a barrier for patients. Monitoring cognitive side effects during the acute course is therefore recommended to identify patients at increased risk for adverse outcomes. The Brief ECT Cognitive Screen (BECS) is a brief instrument designed to measure emerging cognitive side effects from ECT. The aim of this study was to examine the clinical utility of the BECS for predicting adverse cognitive outcomes in real world clinic settings. The study included data collated from four participating sites in the Clinical Alliance for ECT and Related treatments (CARE) network. The BECS was administered at pre ECT and post 3 or 4 ECT. The primary outcome was a ≥4 point decrease on the Montreal Cognitive Assessment (MoCA) from pretreatment to post ECT. Logistic multiple regression analyses examined the BECS and other relevant clinical and demographic and treatment factors as predictors. The final analysis included 623 patients with diverse indications for ECT including 53.6% with major depression and 33.7% with schizophrenia or schizoaffective disorder. A higher total score on the BECS significantly predicted decline in Total Scores on the MoCA [B = 0.25 (0.08), p = 0.003], though not decline in MoCA Delayed Recall scores (p > 0.1). Other significant predictors included higher pretreatment MoCA Total Scores and female gender for verbal anterograde memory decline. This study confirmed that the BECS has clinical utility for identifying patients with both reduced and increased risk for adverse cognitive outcomes from ECT.

Longitudinal Improvement of Neurocognition after Electroconvulsive Therapy in Bipolar Depression

Electroconvulsive therapy (ECT) is applied to treatment-resistant mood disorders. Its therapeutic effect on neurocognition remains unclear. We report the case of a 55-year-old man with treatment-resistant bipolar depression who underwent ECT series. We longitudinally monitored his neurocognition with the Brief Assessment of Cognition in Schizophrenia-Japanese version (BACS-J). The patient's scores on all of the BACS-J domains except working memory recovered after the ECT series. Interestingly, his verbal memory, motor speed, and executive function recovered 1 month after ECT, whereas his verbal fluency and attention scores recovered approx. 1 year after ECT. The BACS can be useful for monitoring ECT's longitudinal effects on individuals' cognitive recovery. Further studies with a large sample size are needed to confirm our present findings.