A Biopsychosocial Approach to Persistent Post-COVID-19 Fatigue and Cognitive Complaints: Results of the Prospective Multicenter NeNeSCo Study

OBJECTIVE

To evaluate whether psychological and social factors complement biomedical factors in understanding post-COVID-19 fatigue and cognitive complaints. Additionally, to incorporate objective (neuro-cognitive) and subjective (patient-reported) variables in identifying factors related to post-COVID-19 fatigue and cognitive complaints.

DESIGN

Prospective, multicenter cohort study.

SETTING

Six Dutch hospitals.

PARTICIPANTS

205 initially hospitalized (March-June 2020), confirmed patients with SARS-CoV-2, aged ≥18 years, physically able to visit the hospital, without prior cognitive deficit, magnetic resonance imaging (MRI) contraindication, or severe neurologic damage post-hospital discharge (N=205).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Nine months post-hospital discharge, a 3T MRI scan and cognitive testing were performed and patients completed questionnaires. Medical data were retrieved from medical dossiers. Hierarchical regression analyses were performed on fatigue severity (Fatigue Severity Scale; FSS) and cognitive complaints (Cognitive Consequences after Intensive Care Admission; CLC-IC; dichotomized into CLC-high/low). Variable blocks: (1) Demographic and premorbid factors (sex, age, education, comorbidities), (2) Illness severity (ICU/general ward, PROMIS physical functioning [PROMIS-PF]), (3) Neuro-cognitive factors (self-reported neurological symptoms, MRI abnormalities, cognitive performance), (4) Psychological and social factors (Hospital Anxiety and Depression Scale [HADS], Utrecht Coping List, Social Support List), and (5) Fatigue or cognitive complaints.

RESULTS

The final models explained 60% (FSS) and 48% (CLC-IC) variance, with most blocks (except neuro-cognitive factors for FSS) significantly contributing. Psychological and social factors accounted for 5% (FSS) and 11% (CLC-IC) unique variance. Higher FSS scores were associated with younger age (P=.01), lower PROMIS-PF (P<.001), higher HADS-Depression (P=.03), and CLC-high (P=.04). Greater odds of CLC-high were observed in individuals perceiving more social support (OR=1.07, P<.05).

CONCLUSIONS

Results show that psychological and social factors add to biomedical factors in explaining persistent post-COVID-19 fatigue and cognitive complaints. Objective neuro-cognitive factors were not associated with symptoms. Findings highlight the importance of multidomain treatment, including psychosocial care, which may not target biologically-rooted symptoms directly but may reduce associated distress.

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.

Prevalence and trajectories of neuropsychological post-COVID-19 symptoms in initially hospitalized patients

OBJECTIVE

To investigate the prevalence and trajectories of post-COVID-19 neuropsychological symptoms.

DESIGN

Prospective longitudinal multicentre cohort study.

SUBJECTS

A total of 205 patients initially hospitalized with SARS-CoV-2 (COVID-19).

METHODS

Validated questionnaires were administered at 9 months (T1) and 15 months (T2) post-hospital discharge to assess fatigue, cognitive complaints, insomnia, anxiety, depression, and post-traumatic stress symptoms.

RESULTS

Analyses included 184 out of 205 patients. Approximately 50% experienced high cognitive complaints at T1 and T2, while severe fatigue affected 52.5% at T1 and 55.6% at T2. Clinically relevant insomnia scores were observed in 25% of patients at both time-points. Clinically relevant anxiety scores were present in 18.3% at T1 and 16.7% at T2, depression in 15.0% at T1 and 18.9% at T2, and PTSD in 12.4% at T1 and 11.8% at T2. Most symptoms remained stable, with 59.2% of patients experiencing at least 1 persistent symptom. In addition, 31.5% of patients developed delayed-onset symptoms.

CONCLUSION

Post-COVID-19 cognitive complaints and fatigue are highly prevalent and often persist. A subgroup develops delayed symptoms. Emotional distress is limited. Screening can help identify most patients experiencing long-term problems. Future research should determine risk factors for persistent and delayed onset symptoms.

Bidirectional Interplay between Deep Brain Stimulation and Cognition in Parkinson's Disease: A Systematic Review

BACKGROUND

Deep brain stimulation (DBS) is efficacious for treating motor symptoms in Parkinson's disease (PD).

OBJECTIVES

The aim is to evaluate the evidence regarding DBS effectiveness after postoperative cognitive deterioration, the impact of preoperative cognition on DBS effectiveness, and the impact of DBS on cognition.

METHODS

Literature searches were performed on MEDLINE, EMBASE, and CENTRAL (Cochrane library). Primary outcomes were OFF-drug Unified Parkinson Disease Rating Scale Part III score and cognitive test scores.

RESULTS

DBS effectiveness did not differ in patients with postoperative declining compared to stable cognition (n = 5 studies). Preoperative cognition did not influence DBS effectiveness (n = 1 study). DBS moderately decreased verbal fluency compared to the best medical treatment (n = 24 studies), which may be transient.

CONCLUSION

DBS motor effectiveness in PD does not appear to be influenced by cognition. DBS in PD seems cognitively safe, except for a moderate decline in verbal fluency. Further research is warranted. © 2024 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Cognitive and psychiatric outcomes in the GALAXY trial: effect of anaesthesia in deep brain stimulation

BACKGROUND

This study aims: (1) To compare cognitive and psychiatric outcomes after bilateral awake versus asleep subthalamic nucleus (STN) deep brain stimulation (DBS) surgery for Parkinson's disease (PD). (2) To explore the occurrence of psychiatric diagnoses, cognitive impairment and quality of life after surgery in our whole sample. (3) To validate whether we can predict postoperative cognitive decline.

METHODS

110 patients with PD were randomised to receive awake (n=56) or asleep (n=54) STN DBS surgery. At baseline and 6-month follow-up, all patients underwent standardised assessments testing several cognitive domains, psychiatric symptoms and quality of life.

RESULTS

There were no differences on neuropsychological composite scores and psychiatric symptoms between the groups, but we found small differences on individual tests and cognitive domains. The asleep group performed better on the Rey Auditory Verbal Learning Test delayed memory test (f=4.2, p=0.04), while the awake group improved on the Rivermead Behavioural Memory Test delayed memory test. (f=4.4, p=0.04). The Stroop III score was worse for the awake group (f=5.5, p=0.02). Worse scores were present for Stroop I (Stroop word card) (f=6.3, p=0.01), Stroop II (Stroop color card) (f=46.4, p<0.001), Stroop III (Stroop color-word card) (f=10.8, p=0.001) and Trailmaking B/A (f=4.5, p=0.04). Improvements were seen on quality of life: Parkinson's Disease Questionnaire-39 (f=24.8, p<0.001), and psychiatric scales: Hamilton Depression Rating Scale (f=6.2, p=0.01), and Hamilton Anxiety Rating Scale (f=5.5, p=0.02).

CONCLUSIONS

This study suggests that the choice between awake and asleep STN DBS does not affect cognitive, mood and behavioural adverse effects, despite a minor difference in memory. STN DBS has a beneficial effect on quality of life, mood and anxiety symptoms.

TRIAL REGISTRATION NUMBER

NTR5809.

Protocol of a randomized controlled trial investigating Deep Brain Stimulation for MOtor symptoms in patients with Parkinson's disease DEmentia (DBS-MODE)

BACKGROUND

Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is an established treatment for disabling motor symptoms of Parkinson's disease (PD) that persist despite optimal pharmacological treatment. Currently, DBS is not performed if there is concomitant significant cognitive impairment based on concerns of cognitive deterioration, higher complication rate and less functional improvement. However, this has not been investigated so far.

METHODS

A single center, prospective, randomized, open-label, blinded end-point (PROBE design) pilot clinical trial is being performed. Patients are eligible for the trial if they have PD dementia (PDD), are able to provide informed consent, and experience disabling motor response fluctuations, bradykinesia, dyskinesia, or painful dystonia, despite optimal pharmacological treatment. In total 44 patients will be randomized to either STN-DBS accompanied by best medical treatment (DBS group) or to best medical treatment alone (BMT group). The primary outcome measure is the change from baseline to 30 weeks on the Movement Disorder Society-Unified Parkinson's Disease Rating Scale part III score in a standardized off-drug phase. The main secondary outcome measures consist of scales assessing cognitive aspects of daily living, neuropsychiatric symptoms and impulsive compulsive disorders. Additional secondary outcome measures include motor signs during on-drug phase, dyskinesia, motor fluctuations, cognitive performance, (severe) adverse events, treatment satisfaction, and caregiver burden. Patients will be followed during 52 weeks after randomization.

DISCUSSION

The Deep Brain Stimulation for MOtor symptoms in patients with Parkinson's disease DEmentia (DBS-MODE) trial directly compares the effectiveness and safety of DBS with BMT in patients with PDD.

TRIAL REGISTRATION

The DBS-MODE trial has been registered in the International Clinical Trial Registry Platform (NL9361) on the 24^th of March 2021 ( https://trialsearch.who.int/Trial2.aspx?TrialID=NL9361 ).

Neurological and (neuro)psychological sequelae in intensive care and general ward COVID-19 survivors

BACKGROUND

COVID-19 affects the brain, leading to long-term complaints. Studies combining brain abnormalities with objective and subjective consequences are lacking. We investigated long-term structural brain abnormalities, neurological-, and (neuro)psychological consequences in COVID-19 patients admitted to the intensive care unit (ICU) or general ward. We aimed to create a multidisciplinary view on the impact of severe COVID-19 on functioning and to compare long-term consequences between ICU and general ward patients.

METHODS

This multicentre prospective cohort study assessed brain abnormalities (3T MRI), cognitive dysfunction (neuropsychological test battery), neurological symptoms, cognitive complaints, emotional distress, and wellbeing (self-report questionnaires) in ICU and general ward (non-ICU) survivors.

RESULTS

101 ICU and 104 non-ICU patients participated 8-10 months post-hospital discharge. Significantly more ICU patients exhibited cerebral microbleeds (61% versus 32%,p<0.001) and had higher numbers of microbleeds (p<0.001). No group differences were found in cognitive dysfunction, neurological symptoms, cognitive complaints, emotional distress, or wellbeing. The number of microbleeds did not predict cognitive dysfunction. In the complete sample, cognitive screening suggested cognitive dysfunction in 41%, standard neuropsychological testing showed cognitive dysfunction in 12%. Sixty-two% reported ≥3 cognitive complaints. Clinically relevant scores of depression, anxiety, and post-traumatic stress were found in 15%, 19%, and 12%, respectively. Twenty-eight% experienced insomnia and 51% severe fatigue.

CONCLUSION

COVID-19 ICU survivors had a higher prevalence for microbleeds but not for cognitive dysfunction compared to general ward survivors. Self-reported symptoms exceeded cognitive dysfunction. Cognitive complaints, neurological symptoms, and severe fatigue were frequently reported in both groups, fitting the post-COVID-19 syndrome.

Long-term Outcome Following Electroconvulsive Therapy for Late-Life Depression: Five-Year Follow-up Data From the MODECT Study

OBJECTIVE

Electroconvulsive therapy (ECT) is the most effective treatment for late-life depression (LLD). Research addressing long-term outcome following an acute course of ECT for LLD is limited. We aimed to describe relapse, cognitive impairment and survival 5 years after a treatment with ECT for severe LLD, and assess the association of clinical characteristics with all three outcome measures.

METHODS

This cohort study was part of the Mood Disorders in Elderly treated with ECT (MODECT) study, which included patients aged 55 years and older with major depressive disorder. Data regarding clinical course, cognitive impairment and mortality were collected 5 years after the index ECT course. We used multivariable Cox proportional hazards models and logistic regression models to assess the association of clinical characteristics with relapse and survival, and cognitive impairment, respectively.

RESULTS

We studied 110 patients with a mean age of 72.9 years. 67.1% of patients who showed response at the end of the index ECT course relapsed, and the included clinical characteristics were not significantly associated with the risk of relapse. 38.8% of patients with available data showed cognitive impairment at five-year follow-up. 27.5% were deceased; higher age and a higher number of previous psychiatric admissions were significantly associated with increased risk of mortality.

CONCLUSIONS

Five-year outcome after a course of ECT for severe LLD seems to be in line with long-term outcome following other acute treatments for severe LLD in terms of relapse, cognitive impairment and survival. Additional studies aimed at improving long-term outcome in severe LLD are warranted.

ECT-related anxiety during maintenance ECT: A prospective study

OBJECTIVE

Despite the established safety of electroconvulsive therapy (ECT), ECT-related anxiety (ERA) remains one of the most distressing complications of ECT. ERA is reported to diminish during an acute course of ECT, but it was never studied during maintenance ECT (M-ECT). Our aim was to study the trajectories of ERA during M-ECT and how they differ from trajectories during the acute course.

METHODS

Thirty-nine patients with unipolar or bipolar depression, retained for M-ECT after an acute ECT course, were included. ERA was assessed the morning before each ECT session using the ECT-related Anxiety Questionnaire (ERAQ).

RESULTS

ERA remained stable during M-ECT (RC = -0.05 (SE = 0.06), t(8.35) = -0.86, p = 0.42), while ERA declined significantly during the acute course (RC = -0.85 (SE = 0.30), t(33.6) = -2.81, p = 0.0082). During the acute course, patients with a psychotic depression were more anxious at baseline (t(32)= -2.42, p = 0.02), and showed a significant decline in ERAQ scores (RC = -1.65 (SE = 0.46), t(31.6) = -3.56, p = 0.0012), whereas patients with a non-psychotic depression were less anxious at baseline and retained stable ERAQ scores during the acute course (RC = -0.06 (SE = 0.41), t(32.1) = -0.14, p = 0.89). Whereas a correlation (r = 0.48) was noticed between the decline of depression severity and ERA during the acute course, this was not the case during M-ECT.

CONCLUSION

ERA runs a stable course during M-ECT, after having decreased during the acute course. During the acute course, ERA trajectories differed significantly between patients with a psychotic and non-psychotic depression. Decline of depression severity and ERA are significantly connected during the acute course of ECT. Both depression severity and ERA remain stable during M-ECT.

Which residual symptoms predict relapse after successful electroconvulsive therapy for late-life depression?

The risk of relapse following successful acute-phase treatment of late-life depression (LLD), including electroconvulsive therapy (ECT), is substantial. In order to improve reliable prediction of individuals' risk of relapse, we assessed the association between individual residual symptoms following a successful acute course of ECT for LLD and relapse at six-month follow-up. This prospective cohort study was part of the MODECT study, which included 110 patients aged 55 years and older with major depressive disorder. Participants who showed response to the index ECT course were monitored for relapse for six months. We used multivariable stepwise logistic regression models to assess the association between the scores on the 10 individual Montgomery-Åsberg Depression Rating Scale (MADRS) items at the end of the acute ECT course and relapse at six-month follow-up. Of the 80 responders with available six-month follow-up data (58.75% of which had psychotic features at baseline), 36.25% had relapsed. Higher scores on the MADRS items 'reduced sleep' (odds ratio (OR) = 2.03, 95% confidence interval (CI) = 1.11-3.69, p = 0.0214) and 'lassitude' (OR = 1.62, 95% CI = 1.00-2.62, p = 0.0497) at the end of the acute ECT course were significantly associated with increased risk of relapse at six-month follow-up. In conclusion, some residual depressive symptoms, including sleep disturbance and lassitude, may help better identify patients vulnerable to relapse following a successful acute course of ECT for LLD. If these findings can be replicated, studies assessing interventions that target specific residual symptoms may further reduce post-ECT depressive relapse rates.

Study of effect of nimodipine and acetaminophen on postictal symptoms in depressed patients after electroconvulsive therapy (SYNAPSE)

Background

Postictal phenomena as delirium, headache, nausea, myalgia, and anterograde and retrograde amnesia are common manifestations after seizures induced by electroconvulsive therapy (ECT). Comparable postictal phenomena also contribute to the burden of patients with epilepsy. The pathophysiology of postictal phenomena is poorly understood and effective treatments are not available. Recently, seizure-induced cyclooxygenase (COX)-mediated postictal vasoconstriction, accompanied by cerebral hypoperfusion and hypoxia, has been identified as a candidate mechanism in experimentally induced seizures in rats. Vasodilatory treatment with acetaminophen or calcium antagonists reduced postictal hypoxia and postictal symptoms. The aim of this clinical trial is to study the effects of acetaminophen and nimodipine on postictal phenomena after ECT-induced seizures in patients suffering major depressive disorder. We hypothesize that (1) acetaminophen and nimodipine will reduce postictal electroencephalographic (EEG) phenomena, (2) acetaminophen and nimodipine will reduce magnetic resonance imaging (MRI) measures of postictal cerebral hypoperfusion, (3) acetaminophen and nimodipine will reduce clinical postictal phenomena, and (4) postictal phenomena will correlate with measures of postictal hypoperfusion.

Methods

We propose a prospective, three-condition cross-over design trial with randomized condition allocation, open-label treatment, and blinded end-point evaluation (PROBE design). Thirty-three patients (age > 17 years) suffering from a depressive episode treated with ECT will be included. Randomly and alternately, single doses of nimodipine (60 mg), acetaminophen (1000 mg), or water will be given two hours prior to each ECT session with a maximum of twelve sessions per patient. The primary outcome measure is ‘postictal EEG recovery time’, expressed and quantified as an adapted version of the temporal brain symmetry index, yielding a time constant for the duration of the postictal state on EEG. Secondary outcome measures include postictal cerebral perfusion, measured by arterial spin labelling MRI, and the postictal clinical ‘time to orientation’.

Discussion

With this clinical trial, we will systematically study postictal EEG, MRI and clinical phenomena after ECT-induced seizures and will test the effects of vasodilatory treatment intending to reduce postictal symptoms. If an effect is established, this will provide a novel treatment of postictal symptoms in ECT patients. Ultimately, these findings may be generalized to patients with epilepsy.

Trial registration

Inclusion in SYNAPSE started in December 2019. Prospective trial registration number is NCT04028596 on the international clinical trial register on July 22, 2019.

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.

Interrogating Associations Between Polygenic Liabilities and Electroconvulsive Therapy Effectiveness

BACKGROUND

Electroconvulsive therapy (ECT) is the most effective treatment for severe major depressive episodes (MDEs). Nonetheless, firmly established associations between ECT outcomes and biological variables are currently lacking. Polygenic risk scores (PRSs) carry clinical potential, but associations with treatment response in psychiatry are seldom reported. Here, we examined whether PRSs for major depressive disorder, schizophrenia (SCZ), cross-disorder, and pharmacological antidepressant response are associated with ECT effectiveness.

METHODS

A total of 288 patients with MDE from 3 countries were included. The main outcome was a change in the 17-item Hamilton Depression Rating Scale scores from before to after ECT treatment. Secondary outcomes were response and remission. Regression analyses with PRSs as independent variables and several covariates were performed. Explained variance (R²) at the optimal p-value threshold is reported.

RESULTS

In the 266 subjects passing quality control, the PRS-SCZ was positively associated with a larger Hamilton Depression Rating Scale decrease in linear regression (optimal p-value threshold = .05, R² = 6.94%, p < .0001), which was consistent across countries: Ireland (R² = 8.18%, p = .0013), Belgium (R² = 6.83%, p = .016), and the Netherlands (R² = 7.92%, p = .0077). The PRS-SCZ was also positively associated with remission (R² = 4.63%, p = .0018). Sensitivity and subgroup analyses, including in MDE without psychotic features (R² = 4.42%, p = .0024) and unipolar MDE only (R² = 9.08%, p < .0001), confirmed the results. The other PRSs were not associated with a change in the Hamilton Depression Rating Scale score at the predefined Bonferroni-corrected significance threshold.

CONCLUSIONS

A linear association between PRS-SCZ and ECT outcome was uncovered. Although it is too early to adopt PRSs in ECT clinical decision making, these findings strengthen the positioning of PRS-SCZ as relevant to treatment response in psychiatry.

Dutch multicentre, prospective follow-up, cohort study comparing the neurological and neuropsychological sequelae of hospitalised non-ICU- and ICU-treated COVID-19 survivors: a study protocol

INTRODUCTION

Owing to the novelty of COVID-19, there are still large knowledge gaps concerning its effect on the brain and the resulting impact on peoples' lives. This large-scale prospective follow-up study investigates COVID-19-associated brain damage, neuropsychological dysfunction and long-term impact on the well-being of patients and their close ones. It is hypothesised that structural brain damage and cognitive dysfunction primarily occur in severely ill patients, as compared with moderately ill patients. Cognitive complaints, emotional distress and impact on well-being are hypothesised to be less dependent on illness severity.

METHODS AND ANALYSIS

For this multicentre study, 200 patients with COVID-19 (100 intensive care unit (ICU) patients and 100 non-ICU patients) formerly hospitalised in one of the six recruiting hospitals during the first European infection wave (ie, March to June 2020) and their close ones will be recruited. At minimally 6 months posthospital discharge, patients will perform a set of neuropsychological tests and are subjected to a 3T MRI scan. Patients and close ones will fill out a set of questionnaires, also at minimally 6 months posthospital discharge and again another 6 months thereafter. Data related to COVID-19 hospitalisation will be extracted from the patients' medical records. MRI abnormalities will ultimately be related to neuropsychological test performance and questionnaire outcomes.

ETHICS AND DISSEMINATION

Ethics approval was granted by the medical research ethics committee of Maastricht University Medical Centre and Maastricht University (NL75102.068.20). The project is sponsored by The Brain Foundation Netherlands. Findings will be presented at national and international conferences, as well as published in peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

NCT04745611.

Managing ECT related cognitive side effects: An individual approach

Electroconvulsive brain stimulation may represent the strongest manipulation available to study brain plasticity in humans. Brain plasticity induced by electroconvulsive brain stimulation, profoundly improves disturbed emotion and motivation in patients with depression. Electroconvulsive therapy (ECT) is a highly effective and safe treatment for psychiatric disorders like severe depression. However, there is ongoing concern about the negative impact of ECT on brain function and cognition that is, surprisingly, only seen in a part of the treated patients. After 80 years of research on ECT, virtually nothing is known about the mechanisms underlying these strong individual differences in cognitive changes induced by ECT. A first step would be to better quantify the pattern and severity of the adverse cognitive outcomes in order to better distinguish patients that suffer from adverse cognitive outcomes from those that do not or even improve. By better distinguishing of these subgroups, a second step towards understanding can be taken: to identify the factors that predict adverse cognitive outcomes. Our research aims to advance understanding of the mechanisms of cognitive plasticity and reveal the pre-treatment profiles that render a patient cognitive vulnerable or resilient.

Disclosure

No significant relationships.

Neurocognitive functioning after electroconvulsive therapy in late-life depression: A 4-year prospective study

OBJECTIVE

Despite the proven efficacy and safety of ECT, there is still concern about the possible cognitive side effects of ECT in older patients. In this study, we aimed to characterize the long-term cognitive effects of ECT in patients with late-life depression (LLD) from before the start until 4 years after the index ECT course.

METHODS

Fourty one patients aged 55 years and older with a unipolar depression, referred for ECT, were included. The neuropsychological test battery was assessed prior to ECT, 6 months, 1 year, 2 years, 3 years, and 4 years after the last ECT session.

RESULTS

We did not find any statistically significant cognitive changes from before the start to 4 years after ending the ECT course. Although we could not detect cognitive changes at group level, we found clinically important differences on an individual level.

CONCLUSION

Cognitive performance in patients with LLD runs a stable course from before the start of ECT until 4 years after the index course. At an individual level, however, both cognitive decline and improvement can be witnessed. Older patients can tolerate ECT and most of them will not experience long-term cognitive side effects.

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

OBJECTIVE

The Montreal Cognitive Assessment (MoCA) is a sensitive and clinically practical test but its usefulness in measuring long-term cognitive effects of ECT is unclear. Using the MoCA, we investigated short- and long-term global cognitive change in ECT-treated patients with a Major Depressive Episode (MDE).

METHOD

We included 65 consecutive ECT-treated patients with MDE, in whom global cognitive functioning was assessed at baseline (T0); during ECT (before the third session; T1); and 1 week (T2), 3 months (T3), and 6 months (T4) after completion of the index course. Changes in MoCA (sub)scores were analyzed using linear mixed models and reliable change indices were computed to investigate individual changes in MoCA total scores.

RESULTS

There was a significant effect of time on MoCA scores (F(4, 230.5) = 4.14, P = 0.003), with an improvement in global cognitive functioning from T3 compared to T1 and T2. At the individual level, 26% (n = 17) of patients showed a significantly worse cognitive functioning at T2 and 12% (n = 8) an improved cognitive functioning compared to T0. For T4, these percentages ameliorated to 8% and 18% respectively.

CONCLUSION

No persistent global cognitive impairment induced by ECT was found at the group level using the MoCA. At the individual level, however, there was clear heterogeneity in the effects of ECT on cognitive functioning. The MoCA is a suitable tool to monitor short- and long-term global cognitive functioning in ECT-treated patients with MDE but in younger patients, potential ceiling effects must be taken into account.

Psychotic late-life depression less likely to relapse after electroconvulsive therapy

BACKGROUND

A substantial number of patients with late-life depression (LLD) that remitted after ECT experience relapse. Identifying risk factors for relapse may guide clinical management to devote attention to those at increased risk. Therefore the current study aims to evaluate which baseline clinical characteristics are related to relapse within six months after successful ECT in patients with severe LLD.

METHODS

110 patients with LLD from the prospective naturalistic follow-up Mood Disorders in Elderly treated with Electro-Convulsive Therapy (MODECT) study were included. A total of 73 patients (66.4%) remitted after ECT, six patients had missing information on relapse, rendering to a total sample size of 67 patients. Relapse within six months after ECT was defined as a Montgomery Åsberg Depression Scale (MADRS)-score > 15, readmission or restart of ECT. Logistic regression analyses were conducted to examine the association between baseline clinical characteristics and relapse.

RESULTS

A total of 22 patients (32.8%) experienced a relapse. Patients with psychotic depression were less likely to relapse (odds ratio = 0.32, p = .047), corrected for prior admissions; 76.9% of patients with psychotic depression remained remitted.

LIMITATIONS

Due to its naturalistic design, no firm conclusions can be drawn on the effect of post-ECT treatment.

CONCLUSIONS

Patients with psychotic depression had a lower risk to experience relapse after successful ECT. This result strengthens the hypothesis that psychotic depression might be a specific depression subtype with a favorable ECT outcome up to six months after ECT.

Understanding electroconvulsive therapy-related anxiety: a prospective study

AIMS OF STUDY

Although electroconvulsive therapy (ECT)-related anxiety is experienced by a significant proportion of patients, it remains understudied. Our aim was to study the course of ECT-related anxiety during ECT.

METHODS

Seventy-four patients with unipolar or bipolar depression, referred for ECT, were included. ECT-related anxiety was assessed the morning before each ECT session using the ECT-related Anxiety Questionnaire (ERAQ).

RESULTS

Female patients reported more anxiety than men (F(1,64.6) = 3.95, P = 0.05). Patients with a psychotic depression were more anxious before the start of ECT (F(64.8) = 4.57, P = 0.04), but experienced a significant decrease in ECT-related anxiety (t(63.9) = -3.63, P = 0.0006), whereas patients with a non-psychotic depression remained stable on anxiety during their ECT course (t(63,9) = 0.76, P = 0.45). In addition, we found a significant correlation between the decrease of ECT-related anxiety and the decrease of depression-severity (r = 0.35; P = 0.04).

CONCLUSION

There are individual differences in ECT-related anxiety trajectories during ECT. Both female patients and patients with psychotic depression experienced more ECT-related anxiety before the start of ECT. The severity of ECT-related anxiety decreased significantly in patients with a psychotic depression, but remained stable in patients without a psychotic depression during ECT. In addition, patients who showed a stronger decrease in depression-severity also showed a stronger decrease in ECT-related anxiety. A better understanding of ECT-related anxiety trajectories can help in designing anxiety-reducing interventions.

ECT non-remitters: prognosis and treatment after 12 unilateral electroconvulsive therapy sessions for major depression

BACKGROUND

Depressive disorder causes significant suffering in patients and caregivers worldwide. Electroconvulsive therapy (ECT) is a highly effective antidepressant treatment, but little is known about the prognosis and treatment of patients who do not achieve remission with ECT. We investigated prognosis and treatment of patients with major depression who did not achieve remission after 12 unilateral electroconvulsive therapy sessions.

METHODS

We conducted a retrospective, naturalistic follow-up study. Patients who had previously participated in a double-blind randomized controlled trial that compared brief pulse with ultra-brief pulse ECT and who had not achieved remission after 12 right unilateral (RUL) ECT sessions were selected for this study. We analysed the type of treatments received during the 6-month follow-up and studied the occurrence of remission and response. The primary outcome was remission, defined as a Montgomery-Åsberg Depression Rating Scale score <10.

RESULTS

Eighty-one patients were randomized, of which 18 patients did not remit. Eight of these non-remitters achieved remission during follow-up (44.4%) while 7 did not achieve remission (38.9%). Remission data could not be retrieved for 3 patients (16.7%). Remission was achieved in 6 patients by a combination of continuing unilateral ECT with antidepressants or switching to bilateral ECT.

LIMITATIONS

This is a retrospective study with only a small number of patients. Treatment after RUL ECT non-remission was not standardized.

CONCLUSION

When patients with major depression do not achieve remission after 12 RUL ECT sessions, they have still a reasonable chance of remission within 6 months. Continuing ECT has the best chance of success.

Psychotic depressive subtype and white mater hyperintensities do not predict cognitive side effects in ECT: A systematic review of pretreatment predictors

BACKGROUND

Most studies regarding cognitive side-effects following ECT for treating depression report transient forms of cognitive disturbances. However, a growing number of studies also report considerable differences among individual patients.

OBJECTIVE

The aim of this systematic review was to identify pretreatment patient characteristics for predicting the risk of developing cognitive side-effects following ECT.

METHODS

Online databases PubMed/Medline, Embase, and PsycINFO were searched for articles published from 2002 through May 2019, using the following relevant search terms: #cognitive deficits AND #Electro Convulsive Therapy. Inclusion and exclusion criteria were applied for full-text inclusion. PRISMA guidelines were used.

RESULTS

Our initial search yielded 2155 publications; 16 studies were included. A total of 16 possible predictive factors were identified. Two factors, psychotic features and white matter hyperintensities, were conclusively found to not predict cognitive side-effects following ECT; the remaining 14 factors were inconclusive.

CONCLUSIONS

There is robust evidence that psychotic features and white matter hyperintensities are not predictive of cognitive side-effects following ECT. None of the other 14 factors examined were predictive, however these levels of evidence were weak and therefore inconclusive. Additional studies focusing primarily on pretreatment patient characteristics for predicting cognitive side-effects following ECT are needed, including demographic, clinical, physiological, neurobiological, and genetic factors. Finally, we provide suggestions for future research.

Cognitive functioning, sleep quality, and work performance in non-clinical burnout: The role of working memory

We investigated the relationship between cognitive functioning, work performance, and sleep in non-clinical burnout. In a working population, an online survey was conducted with additional online neuropsychological tests of varying complexity, measuring attention and different components of working memory, of which the coordinating subcomponent the ‘Central Executive’ is thought to be the most vulnerable to stress. Results indicate that non-clinical burnout is associated with more—though not severe—sleep problems, more depressive complaints, impaired work performance, and with both subjective and objective cognitive impairments. Compared with healthy respondents (N = 107), people with non-clinical burnout (N = 17) had a significantly poorer performance on the tests of the visuospatial sketchpad and the Central Executive of the working memory. Our study also indicates that more complex tests may be more sensitive in detecting cognitive dysfunction in non-clinical burnout. Furthermore, a relationship was found between dual-task performance and work performance. Regarding to sleep quality, in our sample of people with non-clinical burnout, there were no severe sleep problems. In the entire sample, however, insomnia was significantly related to subjective, but not objective, cognitive functioning, and also not to work performance.

Chronotherapy Network Netherlands (CNN)

Information is provided about the Chronotherapy Network Netherlands (CNN).

MMSE Changes During and After ECT in Late-Life Depression: A Prospective Study

OBJECTIVE

There is ongoing concern about the impact of electroconvulsive therapy (ECT) on cognition in patients with late-life depression (LLD), especially in patients for whom pretreatment Mini-Mental State Exam (MMSE) scores are low. Our aim was to examine the evolution of cognitive effects of ECT, using the MMSE in a large group of patients with LLD.

METHODS

One hundred nine patients aged 55 years and older with unipolar depression, referred for ECT, were included in our study. The MMSE was assessed before, during, immediately after, and 6 months after ECT.

RESULTS

MMSE scores improved significantly during the course of ECT and remained stable during the 6-month period after ending ECT for the total group. In the group of patients with a low MMSE score (<24) at baseline, the MMSE score improved significantly during ECT, whereas in the group of patients with a normal MMSE score (≥24) at baseline, the score did not change significantly during ECT. In both groups, MMSE scores still increased slightly after ECT was discontinued.

CONCLUSION

ECT does not cause deleterious cognitive effects, as measured with the MMSE, during and for 6 months after the ECT course in patients with LLD. In the event of a baseline cognitive impairment, MMSE scores tend to improve significantly during and for 6 months after the ECT course. The presence of pretreatment cognitive impairment should not lead clinicians to withhold ECT in older patients with severe depression.

Long-term neurocognitive functioning after electroconvulsive therapy in patients with late-life depression

OBJECTIVE

There is ongoing concern about the possible negative impact of ECT on neurocognitive functioning in older patients. In this study, we aimed to characterize the long-term cognitive effects of ECT in patients with late-life depression, using an extensive neuropsychological battery.

METHODS

A total of 110 patients aged 55 years and older with unipolar depression, referred for ECT were included. The neuropsychological test battery was assessed prior to ECT and 6 months after the last ECT session.

RESULTS

There were no statistically significant group-level changes from baseline to 6 months post-ECT in any of the neuropsychological measurements. Individual differences in cognitive performance were detected using the Reliable Change Index.

CONCLUSION

Patients with late-life depression do not show deleterious cognitive effects 6 months following an ECT index course, although there are considerable differences at an individual level. Clinicians should not hesitate to prescribe ECT in older patients, as most of these patients will tolerate the treatment course and a small group will even experience a cognitive enhancement. However, clinicians should be aware that a small group of patients can experience cognitive side-effects. Further study is needed to predict which patients have a higher risk of developing cognitive side-effects.

Electroconvulsive Therapy for Agitation and Aggression in Dementia: A Systematic Review

OBJECTIVES

Many patients with dementia develop agitation or aggression in the course of their disease. In some severe cases, behavioral, environmental, and pharmacological interventions are not sufficient to alleviate these potentially life-threatening symptoms. It has been suggested that in those cases, electroconvulsive therapy (ECT) could be an option. This review summarizes the scientific literature on ECT for agitation and aggression in dementia.

METHODS

We performed a systematic review in accordance with PRISMA guidelines. A search was conducted in Ovid MEDLINE, EMBASE, and PsycINFO. Two reviewers extracted the following data from the retrieved articles: number of patients and their age, gender, diagnoses, types of problem behavior, treatments tried before ECT, specifications of the ECT treatment, use of rating scales, treatment results, follow-up data, and adverse effects.

RESULTS

The initial search yielded 264 articles, 17 of which fulfilled the inclusion criteria. Of these studies, one was a prospective cohort study, one was a case-control study, and the others were retrospective chart reviews, case series, or case reports. Clinically significant improvement was observed in the majority (88%) of the 122 patients described, often early in the treatment course. Adverse effects were most commonly mild, transient, or not reported.

CONCLUSIONS

The reviewed articles suggest that ECT could be an effective treatment for severe and treatment-refractory agitation and aggression in dementia, with few adverse consequences. Nevertheless, because of the substantial risk of selection bias, the designs of the studies reviewed, and their small number, further prospective studies are needed to substantiate these preliminary positive results.

Vascular risk factors in older patients with depression: outcome of electroconvulsive therapy versus medication

OBJECTIVE

Research suggests that in depression, vascular burden predicts a lower efficacy for medication (MED) and a more favourable outcome for electroconvulsive therapy (ECT). Therefore, we investigated the influence of the following vascular risk factors (VRF): hypercholesterolemia, hypertension, smoking, diabetes mellitus, cardiovascular disease, and cerebral vascular accident/transient ischemic attack, on remission from major depression after ECT versus MED.

METHODS

The study sample consisted of 81 inpatients with a DSM-IV unipolar major depression diagnosis (mean age 72.2 years, SD = 7.6, mean Montgomery-Åsberg Depression Rating Scale score 32.9, SD = 6.2) participating in a randomized controlled trial comparing nortriptyline versus venlafaxine and 43 inpatients (mean age 73.7 years, SD = 7.5, mean Montgomery-Åsberg Depression Rating Scale score 30.6, SD = 7.1) from an randomized controlled trial comparing brief pulse versus ultrabrief pulse ECT. The presence of VRF was established from the medical records. The remission rate of patients with VRF was compared with those of patients without VRF.

RESULTS

The remission rate was 58% (19/33) in the ECT group with ≥1 VRF and 32% (23/73) in the MED group with ≥1 VRF (χ²  = 6.456, p = 0.011). Comparing patients with no VRF versus ≥1 VRF, the remission rate decreased from 80 to 58% (χ²  = 1.652, p = 0.276) in ECT patients and from 38 to 32% (χ²  = 0.119, p = 0.707) in MED patients. Applying different cut-offs for the number of VRFs yielded the same trends. Logistic regression revealed no interaction between VRF and treatment condition.

CONCLUSION

The superior efficacy of ECT over pharmacotherapy in major depression in older age was independent of the presence of VRF. Copyright © 2017 John Wiley & Sons, Ltd.

Cognitive Deficits in Patients With Neuropsychiatric Symptoms: A Comparative Study Between Behavioral Variant Frontotemporal Dementia and Primary Psychiatric Disorders

OBJECTIVE

To compare neuropsychological profiles in behavioral variant frontotemporal dementia (bvFTD) with its most common primary psychiatric differential diagnoses, major depressive disorder (MDD), bipolar disorder (BD), and schizophrenia, in older patients with active symptoms.

METHODS

We included patients from different cohorts with MDD (DSM-IV-TR: 296.20-296.23, 296.30-296.33; n = 42; mean ± SD age, 72.0 ± 8.0 years; female = 57.1%) included from 2002 to 2007, noneuthymic BD (DSM-IV-TR: 296.00-296.06, 296.40-296.46, 296.50-296.56, 296.60-296.66, 296.7; DSM-IV-TR: 296.89; DSM-IV-TR: 296.80; n = 41; age, 71.7 ± 8.8 years; female = 53.7%) included from 2011 to 2015, nonremitted schizophrenia (DSM-IV-TR: 295.10, 295.20, 295.30, 295.60, 295.90; n = 47; age, 67.5 ± 7.1 years; female = 66%) included from 2006 to 2008, or probable/definite bvFTD (n = 173; age, 62.6 ± 8.0 years; female = 39.9%) (Frontotemporal Dementia Consensus criteria) included from 2000 to 2015 and healthy controls (n = 78; age, 71.9 ± 8.0 years; female = 71.8%) included from 2005 to 2007. Neuropsychological tests concerned the domains of attention and working memory, verbal memory, verbal fluency, and executive functioning. Analyses of variance were performed with age, gender, and education level as covariates. Post hoc Bonferroni tests were used to detail group differences.

RESULTS

Compared to the healthy controls, both the bvFTD and primary psychiatric disorder groups showed significant impairment on all cognitive domains. Executive function was more disturbed in all primary psychiatric disorders compared to bvFTD (P < .001). Attention and working memory were significantly better in the bvFTD and schizophrenia groups compared to the MDD and BD groups (P < .001). For verbal memory, the bvFTD group scored significantly higher compared to patients with schizophrenia, BD, or MDD (P < .001). Patients with bvFTD had significantly lower scores on verbal fluency, especially due to Animal Naming, in comparison with the BD group (P < .001); however, these scores were not significantly different from those of MDD or schizophrenia patients.

CONCLUSIONS

Cognitive deficits in bvFTD are less severe than in primary psychiatric disorders with active symptoms. This indicates that in the differential diagnosis of bvFTD, disturbances on tests for cognitive performance do not rule out primary psychiatric diagnoses.

[Doctor, will I get my memory back? Electroconvulsive therapy and cognitive side-effects in daily practice]

BACKGROUND

Patients undergoing or about to undergo electroconvulsive therapy (ECT) are often afraid they will experience negative cognitive side-effects.

AIM

To answer questions that patients and referring clinicians often ask about cognitive problems that can result from ECT.

METHOD

To discuss, on the basis of clinical perception and literature, the cognitive problems resulting from ECT.

RESULTS

The cognitive problems resulting from ect are threefold: short-term postictal confusion (immediately after the treatment), anterograde amnesia and retrograde amnesia. A patient affected by anterograde amnesia, is temporarily less able to remember what he or she has experienced over a period of three months after treatment. The brain of a patient with retrograde amnesia is unable to retrieve or remember information or procedures 'saved' before the treatment took place. More specifically the patient with retrograde amnesia has three main types of problems: semantic memory problems (relating to facts), episodic memory problems (no longer able to retrieve memories concerning non-personal events), and procedural memory problems (no longer able to operate various devices). It is difficult to predict which patients will experience cognitive problems as a result from ect and to what extent. However, the problems are not intensified by maintenance treatment. Factual and autobiographical memory problems following ect-induced retrograde amnesia seems to have a more permanent character. According to the Dutch guidelines for ECT, cognitive side-effects need to be monitored. If patients are monitored before and after ect, they can be given a more targeted psycho-education and eventually a more targeted training course.

CONCLUSION

We conclude that in clinical practice increasing attention is being given to ECT-related cognitive side-effects. Clearly, however, more consideration needs to be given to inter-individual variability. Cognitive monitoring is advisable because the course of the side-effects of ect must be followed and evaluated.

[ResPECT - a decade of Flemish-Dutch ECT research]

BACKGROUND

There is increasing clinical and scientific interest in electroconvulsive therapy (ECT).

AIM

To provide an overview of the main research findings of the Flemish-Dutch research consortium ResPECT.

METHOD

We report on our review of the relevant literature.

RESULTS

Our studies confirm that ECT is one of the most efficient treatments for depression in later life and for depression with psychotic features. Older people with age-related brain pathology can respond well to ECT. It is still preferable to apply a standard pulse-width because this increases the efficacy of the treatment and minimises the cognitive impact. Even vulnerable older people can react favourably to ECT.

CONCLUSION

Recent findings of the ResPECT consortium are providing new insights that are applicable in daily clinical practice. Research into mechanisms of action can also increase our understanding of the pathophysiology of severe depression.

Relapse and long-term cognitive performance after brief pulse or ultrabrief pulse right unilateral electroconvulsive therapy: A multicenter naturalistic follow up

BACKGROUND

Superior cognitive functioning for electroconvulsive therapy (ECT) with right unilateral (RUL) ultrabrief pulse (UBP) stimulation compared to RUL brief pulse (BP) stimulation is not clearly established and long-term data is needed.

METHODS

We conducted a prospective naturalistic follow-up of 87 inpatients from three tertiary psychiatric hospitals. Before these patients entered the follow up phase, they had participated in a RCT comparing twice weekly RUL BP (1.0 ms) with RUL UBP (0.3-0.4 ms) ECT eight times seizure threshold until remission (MADRS < 10), for a maximum of six weeks. Three and six months after the index ECT patients were monitored for relapse and cognitive performance (retrograde amnesia, semantic memory and lexical memory). We compared relapse rate and cognitive performance between RUL BP and RUL UBP stimulation.

RESULTS

Of the 50 patients who remitted after index ECT 44 (24 BP; 20 UBP) were monitored for follow up. Relapse occurred in 25% of the BP group and in 25% of the UBP group (χ(2) = 0.00, p = 1.0) at three-month follow-up; whereas 43.5% of the BP group and 35% of the UBP group relapsed (χ(2) = 0.322, p = 0.57) at six months follow-up. Cognitive assessments (17 BP; 16 UBP) showed no significant differences between BP and UBP groups, except for an advantage for the BP group in the autobiographical incident questions at three months follow-up only (p = 0.04; d = 0.77).

LIMITATIONS

This study may be limited since relapse in a naturalistic follow-up can be influenced by medication and other unknown factors, like social support, medical comorbidity, and psychotherapy. The small numbers of our subgroups hamper statistical significance.

CONCLUSIONS

Patients that achieved remission after RUL BP or RUL UBP ECT showed similar relapse rates after three and six months. There was no cognitive advantage of UBP over BP ECT in follow up.

CLINICAL TRIALS REGISTRATION

Netherlands trial register www.trialregister.nl registration number NTR1304.

Speed of remission in elderly patients with depression: electroconvulsive therapy v. medication

BACKGROUND

Severe depression can be a life-threatening disorder, especially in elderly patients. A fast-acting treatment is crucial for this group. Electroconvulsive therapy (ECT) may work faster than medication.

AIMS

To compare the speed of remission using ECT v. medication in elderly in-patients.

METHOD

The speed of remission in in-patients with a DSM-IV diagnosis of major depression (baseline MADRS score ≥20) was compared between 47 participants (mean age 74.0 years, s.d. = 7.4) from an ECT randomised controlled trial (RCT) and 81 participants (mean age 72.2 years, s.d. = 7.6) from a medication RCT (nortriptyline v. venlafaxine).

RESULTS

Mean time to remission was 3.1 weeks (s.d. = 1.1) for the ECT group and 4.0 weeks (s.d. = 1.0) for the medication group; the adjusted hazard ratio for remission within 5 weeks (ECT v. medication) was 3.4 (95% CI 1.9-6.2).

CONCLUSIONS

Considering the substantially higher speed of remission, ECT deserves a more prominent position in the treatment of elderly patients with severe depression.

Efficacy and cognitive side effects after brief pulse and ultrabrief pulse right unilateral electroconvulsive therapy for major depression: a randomized, double-blind, controlled study

OBJECTIVE

To compare the efficacy and cognitive side effects of high-dose unilateral brief pulse electroconvulsive therapy (ECT) with those of high-dose unilateral ultrabrief pulse ECT in the treatment of major depression.

METHOD

From April 2007 until March 2011, we conducted a prospective, double-blind, randomized multicenter trial in 3 tertiary psychiatric hospitals. All patients with a depressive disorder according to DSM-IV criteria were eligible. Depression severity was assessed with the Montgomery-Asberg Depression Rating Scale; primary efficacy outcomes were response, defined as a score decrease ≥ 60% from baseline, and remission, defined as a score < 10 at 2 consecutive weekly assessments. Total scores on the Autobiographical Memory Interview and Amsterdam Media Questionnaire were the primary outcome measures for retrograde amnesia. Other cognitive domains included category fluency (semantic memory) and letter fluency (lexical memory). Patients received twice-weekly unilateral brief pulse (1.0 millisecond) or ultrabrief pulse (0.3-0.4 millisecond) ECT 8 times seizure threshold until remission, for a maximum of 6 weeks.

RESULTS

Of the 116 patients, 75% (n = 87) completed the study. Among completers, 68.4% (26/58) of those in the brief pulse group achieved remission versus 49.0% (24/49) of those in the ultrabrief pulse group (P = .019), and the brief pulse group needed fewer treatment sessions to achieve remission: mean (SD) of 7.1 (2.6) versus 9.2 (2.3) sessions (P = .008). No significant group differences were found in the evaluation of the cognitive assessments.

CONCLUSIONS

The efficacy and speed of remission seen with high-dose brief pulse right unilateral ECT twice weekly were superior to those seen with high-dose ultrabrief pulse right unilateral ECT, with equal cognitive side effects as defined by retrograde amnesia, semantic memory, and lexical memory.

TRIAL REGISTRATION

Netherlands National Trial Register number: NTR1304.

Neurocognitive effects after brief pulse and ultrabrief pulse unilateral electroconvulsive therapy for major depression: a review

BACKGROUND

Neurocognitive functioning is well known to be affected after ECT. However quantified data about the severity of the cognitive impairment after ultrabrief pulse and brief pulse ECT are limited, which makes it hard to judge its clinical relevance.

METHODS

To review all prospective studies using right unilateral (ultra) brief pulse index electroconvulsive therapy published up until February 2011 which used at least one instrument for cognitive assessment before and after ECT. The severity and persistence of neurocognitive side effects immediately (one to seven days post ECT), between one and six months and after six months post ECT were assessed by calculating effect sizes using Cohen's d.

RESULTS

Ten studies fulfilled the inclusion criteria and provided detailed information to compute effect sizes. The results indicate loss of autobiographical memory and impairment of verbal fluency, anterograde verbal and non-verbal memory immediately after brief pulse RUL ECT. To a lesser extent impairment of working memory and reduced speed of processing is found. Autobiographical memory is the only domain still being impaired between one and six months post ECT, but improved in this period. Verbal fluency normalized to baseline performance between one and six months post ECT whereas anterograde verbal and non-verbal memory normalized or even improved. Speed of processing improved within six months after ECT. Long-term data on these cognitive domains were not available. Based on two of the ten included studies the results suggest that ultrabrief pulse RUL ECT causes less decline in autobiographical and anterograde memory after ECT than brief pulse RUL ECT.

LIMITATIONS

This review may be limited because of the small number of included studies and due to unreliable effect sizes. Furthermore, few data were available for non-memory domains and cognitive functioning after six months.

CONCLUSIONS

Loss of autobiographical memory is still present between one and six months after unilateral brief pulse ECT. Ultrabrief pulse RUL ECT shows less decline in autobiographical memory. Other neurocognitive impairments after brief pulse RUL ECT seem to be transient.

The effects of ECT on cognitive functioning in the elderly: a review

BACKGROUND

Electroconvulsive therapy (ECT) as a single course or in maintenance form (M-ECT) is an effective treatment in depressed elderly. However, ECT may have adverse effects on cognition.

OBJECTIVE

To review all studies from 1980-2006 on ECT and cognition in the elderly with a minimum age of 55 years or a mean age of 55 years, and with valid measurements of cognition before and after ECT.

RESULTS

Nine out of the 15 eligible studies were focused exclusively on the elderly. Three studies reported verbal learning- and recall problems post ECT, while three studies found positive effects of ECT on memory, speed of processing and concentration. Global cognitive functioning in patients with cognitive impairment improved in all studies. At follow up, most studies reported improvement of cognitive functions. Learning verbal information and executive functioning were impaired in M-ECT patients whereas global cognition remained stable after M-ECT over a year.

CONCLUSIONS

To date research of ECT on cognitive functioning in the elderly is very limited. Small sample size, lack of controls, use of a single screening instrument and a short follow up period may explain the conflicting results. Given the clinical importance, more extensive research on cognition in elderly treated with ECT is urgently needed.